- Email: [email protected]
RELIEVED GLOOM
1371 do know about CR which published in belongs newspaper April some bare bones,22 but no meat for doctors and scientists to get their teeth into. CR is thought to be dibenz which would have the following
Credit for much of what to
a
we
team
structure:
compound was developed in Britain, almost certainly at Porton, and its biological properties have been explored at Edgewood Arsenal, Maryland; it is not clear whether Porton has done any testing. Biological studies on EA3547, as the Americans call CR, are classified in both countries. The only clues to the nature of this work lie in the titles of Edgewood The
Arsenal technical reports 4455 and 4446. These are, respectively, "EA3547: a clinical and histological study " and Ocular, cutaneous, respiratory, and intratracheal toxicity of solutions of CS and EA3547 in glycol and glycol ether in animals ". CR may be used differently from CS. Its deterrent properties rest in a severe burning sensation in the skin; any effects on the lungs would depend on whether it was used as an aerosol. A further recommendation of the Himsworth Committee was that agents like CS and CR should be tested as if they were drugs, but if, for example, systematic toxicity and metabolic tests have been done they are not covered by the two reports. It would be irresponsible for the Government to brush aside the Himsworth recommendations-and if the findings are to be made public at some time why not now, before any decisions are taken, rather than afterwards when the CR water cannons are already primed ? RELIEVED GLOOM
A GATHERING that has seldom been disposed to seek the silver lining anywhere but in the National Health Service terms of service, the annual representative meeting of the British Medical Association, held this year in Folkestone, was unexpectedly in almost jocund humour last week. With the imminent reorganisation of the N.H.S. (the Bill is back in the Commons this week) and with Sir Paul Chambers’ proposals for the reconstruction of the very Association itself, the scene looked set for some of the mournful tragi-comedy that has in the past been the response to threats of reform. But all was not gloom. The new N.H.S. structure escaped lightly at this late hour in the Bill’s progress; and, though there was a sharp and substantially backed effort from Newcastle upon Tyne to reaffirm an insistence that one-third of the members of all N.H.S. authorities should be elected medical members, it failed by about 40 votes. Mr Walpole Lewin, chairman of the B.M.A. Council, reported that no member of the Lords or the Commons had been discovered who would back such an amendment at the report stage, and the profession, it seemed, would have to be content with the statutoriness of the medical advisory committees. Mr Lewin was in22. Sunday Times, April 22.
clined
to see
reorganisation
as
a
non-starter
unless
much more money was forthcoming for the " grey areas " of preventive medicine, geriatrics, and the care of the mentally ill and the handicapped. Certainly, the case for more support here must be argued unceasingly, but is not the reorganisation another opportunity for the redeployment of existing resources, even if that is a painful process for some doctors ? Whatever N.H.S. structure emerges, it can work well only if those who operate it have the will and the enthusiasm to make it do so; and the district management teams are key bodies. As someone said at Folkestone, these multidisciplinary teams would have undoubted power and, for the first time in the history of the N.H.S., such bodies would have an opportunity for really effective action. There was apprehension about the hours that doctors would have to devote to management when they got closely to grips with it, at the expense perhaps of their clinical But the redistribution of resources must work. include the reallocation of time; and the duties of management should not become a wearying extra.
As for Chambers, the gambit was declined for the moment, in so far as the two existing autonomous committees for general practitioners and for hospital doctors were preserved. The N.H.S. may be unified; the profession’s machinery is to wait. But a cheerful innovation at Folkestone was the granting of autonomous powers to the Hospital Junior Staffs Group Council to act on all matters relating solely to N.H.S. junior hospital staff. It is to be hoped that forecasts of a shining new era in the representation of junior doctors will be fulfilled. The cautious will await developments; but there is no doubt that the efforts of those who championed this cause, through the Junior Hospital Doctors’ Association and in other ways, have gained ground. Two matters of particular concern to junior hospital doctors are the indifferent standards of much residential accommodation and the high risks of certain posts, such as those involving work in dialysis units and accident flying-squads, where compensation for death or incapacity is nothing like adequate: the Secretary of State has promised to make suggestions on this subject any day now. Dr J. C. Cameron, Chairman of the General Medical Services Committee, was unhappy about misrepresentation in the Press and elsewhere of the profession’s attitude towards Government proposals for the extension of family-planning advice and supplies provided by the National Health Service. Doctors had been portrayed as saboteurs of the plan, and that was never their intent; but they drew the line at becoming " points for contraceptive of issue " or slot-machines supplies, when no medical supervision of the health of the user was necessary. The meeting was warned that if sheaths were to be provided on N.H.S. prescription, that would mean another 20 million prescriptions a year, as well as the distasteful imposition of " young bucks " and prostitutes and their clients swarming into the doctor’s consulting-room. Representatives were sufficiently alarmed by this prospect to instruct the G.M.S. Committee to negotiate a separate contract for family-planning services (many preferred the word " contraceptive ", which they "
"
1372
meaning something more restricted than family planning) for general practitioners willing to provide such service, " such contract to recognise special skills "; and the Council of the Association, in its discussions with the Departments of Health, should make it quite clear to the Ministers that general practitioners were not prepared to be involved in the prescribing of contraceptive devices on form EClO when no medical supervision of the health of the user is called for ". Though an attempt to make all plain by adding the words " as, for example, in the use of the condom " got nowhere, the message will carry to the Ministers, who can hardly have failed to recognise it long ago. Thus, provided a bit more money is forthcoming through a separate contract, partly perhaps to help the general practitioner fortify his surgery against the clamour of the undesirables, then the profession is ready to go along with Sir Keith Joseph’s " revolution ", which, after all, will only bring the N.H.S. family-planning service more or less into line with long-declared B.M.A. policy. Every year, it seems, the representative meeting has a jolly session with merit awards for N.H.S. consultants and the ghastly secrecy of the system; but it has never worked itself to the point of recommending revelation of who gets what. What happened this year to promote a reversal of policy in so far as disclosure to the profession went ? Was it the result of the referendum on distinction awards, carried out on the instructions of the 1971 meeting, and the plea that the majority thus revealed should have their democratic way ? The questions asked included "should names of holders be published ?". Of consultants receiving awards, only 33% of those answering said " yes ". From those not receiving awards, the "yes" answers made up 71 %. The overall figures were 44% for continued non-publication and 56° for disclosure. Despite the old warnings about the dread comparisons that would
saw
as
wholesome who were
"
follow the appearance of merit lists leaked to the local paper, the meeting boldly voted by the necessary twothirds majority that " merit awards be renegotiated and their secrecy within the profession be abolished ". Again, there was a little financial element to the motion, but the rest of it was evidently not to the liking of the medical establishment, who will be pondering the next move.
ACUPUNCTURE ANALGESIA
THE upsurge of interest in acupuncture
reflects,
in part, the deep-seated desire felt by most people for a greater understanding of the Chinese and their country; but at a more personal level it also reflects the fact that too many patients in the West are still forced to seek unorthodox remedies for disabilities which Western medicine has failed to cure. Acupuncture is only one of the nine branches of traditional Chinese medicine, and is believed to owe its origins to the Yellow Emperor who reigned about 2600 B.C. Basically, it is the treatment of ailments by puncturing certain vital points distributed along well-defined Once the needles are inserted they energy paths. apparently need to be agitated, usually by manual
rotation, for the duration of the treatment. The method has survived virtually unchanged for more than 4000 years and, indeed, about the only concession modern progress has been the use of a small electric stimulator to apply a pulsatile current to the needles as a substitute for manual rotation. With such a history it is difficult to accept the theory that indoctrination and ideological faith inspired by the teachings of Chairman Mao is the greatest single factor in the success of the method. However, on a more general basis the possibility that acupuncture depends on some form of hypnosis deserves to be Like hypnosis, acupuncture seems to considered. need a period of preparation, and it is this time factor that has restricted the use of hypnosis in Western medicine. But in a country where drugs and equipment are scarce and where many villages rarely see an orthodox physician it is not surprising that the peasants, thrown back on their own resources, have adopted this essentially simple technique. After all, the healing power of attention and sympathy is not confined to the Far East, and there is ample evidence that most patients, given time, are susceptible to hypnosis. Nevertheless, many observers are convinced that hypnosis plays no part. If this is right, some alternative explanation is needed, and the necessity for maintaining a more or less continuous stimulus through the needles may provide a clue. For years it has been known that awareness of pain can be suppressed by increasing the input of sensory stimuli from other receptors, and the gate control theory of pain appreciation1 was put forward to explain this effect. Shealy’s battery-operated dorsal-column stimulator2 for management of intractable pain was based on this theory, and the relief provided by acupuncture could have a similar explanation. The importance of an intact nervous system for successful acupuncture analgesia is emphasised by two papers in the March Chinese Medical Journal.3 Workers from the Peking Medical College studied the effect of acupuncture on the pain threshold of human skin and showed that when acupuncture was applied to the affected limbs of hemiplegic patients the pain threshold on the healthy side was unaffected, whereas in normal subjects the pain threshold was increased by 65-95%. The second paper describes an electrophysiological study of spinal reflexes : investigators from the Hsii Yi Country Peoples Hospital concluded that artificial reinforcement of large-fibre activity under acupuncture anaesthesia might suppress small-fibre activity enough to produce surgical analgesia. These observations, if they are substantiated, will represent considerable progress in elucidation of the mode of action of acupuncture, and perhaps also in understanding the pain mechanism. Whether or not acupuncture analgesia has anything to offer in the management of patients for surgery remains to be seen. But the minor renaissance of acupuncture in the West has led to reappraisal of old theories and new experiments to explore its mode of action. Only good can come from this.
to
Melzack, R., Wall, P. D. Science, 1965, 150, 971. Shealy, C. N., Mortimer, J. T., Reswick, J. B. Anesth. Analg. 1967, 46, 489. 3. Chinese med. J. 1973, no. 3, p. 33 and p. 35 (abstr.). 1. 2.
Credit for much of what to
a
we
team
structure:
compound was developed in Britain, almost certainly at Porton, and its biological properties have been explored at Edgewood Arsenal, Maryland; it is not clear whether Porton has done any testing. Biological studies on EA3547, as the Americans call CR, are classified in both countries. The only clues to the nature of this work lie in the titles of Edgewood The
Arsenal technical reports 4455 and 4446. These are, respectively, "EA3547: a clinical and histological study " and Ocular, cutaneous, respiratory, and intratracheal toxicity of solutions of CS and EA3547 in glycol and glycol ether in animals ". CR may be used differently from CS. Its deterrent properties rest in a severe burning sensation in the skin; any effects on the lungs would depend on whether it was used as an aerosol. A further recommendation of the Himsworth Committee was that agents like CS and CR should be tested as if they were drugs, but if, for example, systematic toxicity and metabolic tests have been done they are not covered by the two reports. It would be irresponsible for the Government to brush aside the Himsworth recommendations-and if the findings are to be made public at some time why not now, before any decisions are taken, rather than afterwards when the CR water cannons are already primed ? RELIEVED GLOOM
A GATHERING that has seldom been disposed to seek the silver lining anywhere but in the National Health Service terms of service, the annual representative meeting of the British Medical Association, held this year in Folkestone, was unexpectedly in almost jocund humour last week. With the imminent reorganisation of the N.H.S. (the Bill is back in the Commons this week) and with Sir Paul Chambers’ proposals for the reconstruction of the very Association itself, the scene looked set for some of the mournful tragi-comedy that has in the past been the response to threats of reform. But all was not gloom. The new N.H.S. structure escaped lightly at this late hour in the Bill’s progress; and, though there was a sharp and substantially backed effort from Newcastle upon Tyne to reaffirm an insistence that one-third of the members of all N.H.S. authorities should be elected medical members, it failed by about 40 votes. Mr Walpole Lewin, chairman of the B.M.A. Council, reported that no member of the Lords or the Commons had been discovered who would back such an amendment at the report stage, and the profession, it seemed, would have to be content with the statutoriness of the medical advisory committees. Mr Lewin was in22. Sunday Times, April 22.
clined
to see
reorganisation
as
a
non-starter
unless
much more money was forthcoming for the " grey areas " of preventive medicine, geriatrics, and the care of the mentally ill and the handicapped. Certainly, the case for more support here must be argued unceasingly, but is not the reorganisation another opportunity for the redeployment of existing resources, even if that is a painful process for some doctors ? Whatever N.H.S. structure emerges, it can work well only if those who operate it have the will and the enthusiasm to make it do so; and the district management teams are key bodies. As someone said at Folkestone, these multidisciplinary teams would have undoubted power and, for the first time in the history of the N.H.S., such bodies would have an opportunity for really effective action. There was apprehension about the hours that doctors would have to devote to management when they got closely to grips with it, at the expense perhaps of their clinical But the redistribution of resources must work. include the reallocation of time; and the duties of management should not become a wearying extra.
As for Chambers, the gambit was declined for the moment, in so far as the two existing autonomous committees for general practitioners and for hospital doctors were preserved. The N.H.S. may be unified; the profession’s machinery is to wait. But a cheerful innovation at Folkestone was the granting of autonomous powers to the Hospital Junior Staffs Group Council to act on all matters relating solely to N.H.S. junior hospital staff. It is to be hoped that forecasts of a shining new era in the representation of junior doctors will be fulfilled. The cautious will await developments; but there is no doubt that the efforts of those who championed this cause, through the Junior Hospital Doctors’ Association and in other ways, have gained ground. Two matters of particular concern to junior hospital doctors are the indifferent standards of much residential accommodation and the high risks of certain posts, such as those involving work in dialysis units and accident flying-squads, where compensation for death or incapacity is nothing like adequate: the Secretary of State has promised to make suggestions on this subject any day now. Dr J. C. Cameron, Chairman of the General Medical Services Committee, was unhappy about misrepresentation in the Press and elsewhere of the profession’s attitude towards Government proposals for the extension of family-planning advice and supplies provided by the National Health Service. Doctors had been portrayed as saboteurs of the plan, and that was never their intent; but they drew the line at becoming " points for contraceptive of issue " or slot-machines supplies, when no medical supervision of the health of the user was necessary. The meeting was warned that if sheaths were to be provided on N.H.S. prescription, that would mean another 20 million prescriptions a year, as well as the distasteful imposition of " young bucks " and prostitutes and their clients swarming into the doctor’s consulting-room. Representatives were sufficiently alarmed by this prospect to instruct the G.M.S. Committee to negotiate a separate contract for family-planning services (many preferred the word " contraceptive ", which they "
"
1372
meaning something more restricted than family planning) for general practitioners willing to provide such service, " such contract to recognise special skills "; and the Council of the Association, in its discussions with the Departments of Health, should make it quite clear to the Ministers that general practitioners were not prepared to be involved in the prescribing of contraceptive devices on form EClO when no medical supervision of the health of the user is called for ". Though an attempt to make all plain by adding the words " as, for example, in the use of the condom " got nowhere, the message will carry to the Ministers, who can hardly have failed to recognise it long ago. Thus, provided a bit more money is forthcoming through a separate contract, partly perhaps to help the general practitioner fortify his surgery against the clamour of the undesirables, then the profession is ready to go along with Sir Keith Joseph’s " revolution ", which, after all, will only bring the N.H.S. family-planning service more or less into line with long-declared B.M.A. policy. Every year, it seems, the representative meeting has a jolly session with merit awards for N.H.S. consultants and the ghastly secrecy of the system; but it has never worked itself to the point of recommending revelation of who gets what. What happened this year to promote a reversal of policy in so far as disclosure to the profession went ? Was it the result of the referendum on distinction awards, carried out on the instructions of the 1971 meeting, and the plea that the majority thus revealed should have their democratic way ? The questions asked included "should names of holders be published ?". Of consultants receiving awards, only 33% of those answering said " yes ". From those not receiving awards, the "yes" answers made up 71 %. The overall figures were 44% for continued non-publication and 56° for disclosure. Despite the old warnings about the dread comparisons that would
saw
as
wholesome who were
"
follow the appearance of merit lists leaked to the local paper, the meeting boldly voted by the necessary twothirds majority that " merit awards be renegotiated and their secrecy within the profession be abolished ". Again, there was a little financial element to the motion, but the rest of it was evidently not to the liking of the medical establishment, who will be pondering the next move.
ACUPUNCTURE ANALGESIA
THE upsurge of interest in acupuncture
reflects,
in part, the deep-seated desire felt by most people for a greater understanding of the Chinese and their country; but at a more personal level it also reflects the fact that too many patients in the West are still forced to seek unorthodox remedies for disabilities which Western medicine has failed to cure. Acupuncture is only one of the nine branches of traditional Chinese medicine, and is believed to owe its origins to the Yellow Emperor who reigned about 2600 B.C. Basically, it is the treatment of ailments by puncturing certain vital points distributed along well-defined Once the needles are inserted they energy paths. apparently need to be agitated, usually by manual
rotation, for the duration of the treatment. The method has survived virtually unchanged for more than 4000 years and, indeed, about the only concession modern progress has been the use of a small electric stimulator to apply a pulsatile current to the needles as a substitute for manual rotation. With such a history it is difficult to accept the theory that indoctrination and ideological faith inspired by the teachings of Chairman Mao is the greatest single factor in the success of the method. However, on a more general basis the possibility that acupuncture depends on some form of hypnosis deserves to be Like hypnosis, acupuncture seems to considered. need a period of preparation, and it is this time factor that has restricted the use of hypnosis in Western medicine. But in a country where drugs and equipment are scarce and where many villages rarely see an orthodox physician it is not surprising that the peasants, thrown back on their own resources, have adopted this essentially simple technique. After all, the healing power of attention and sympathy is not confined to the Far East, and there is ample evidence that most patients, given time, are susceptible to hypnosis. Nevertheless, many observers are convinced that hypnosis plays no part. If this is right, some alternative explanation is needed, and the necessity for maintaining a more or less continuous stimulus through the needles may provide a clue. For years it has been known that awareness of pain can be suppressed by increasing the input of sensory stimuli from other receptors, and the gate control theory of pain appreciation1 was put forward to explain this effect. Shealy’s battery-operated dorsal-column stimulator2 for management of intractable pain was based on this theory, and the relief provided by acupuncture could have a similar explanation. The importance of an intact nervous system for successful acupuncture analgesia is emphasised by two papers in the March Chinese Medical Journal.3 Workers from the Peking Medical College studied the effect of acupuncture on the pain threshold of human skin and showed that when acupuncture was applied to the affected limbs of hemiplegic patients the pain threshold on the healthy side was unaffected, whereas in normal subjects the pain threshold was increased by 65-95%. The second paper describes an electrophysiological study of spinal reflexes : investigators from the Hsii Yi Country Peoples Hospital concluded that artificial reinforcement of large-fibre activity under acupuncture anaesthesia might suppress small-fibre activity enough to produce surgical analgesia. These observations, if they are substantiated, will represent considerable progress in elucidation of the mode of action of acupuncture, and perhaps also in understanding the pain mechanism. Whether or not acupuncture analgesia has anything to offer in the management of patients for surgery remains to be seen. But the minor renaissance of acupuncture in the West has led to reappraisal of old theories and new experiments to explore its mode of action. Only good can come from this.
to
Melzack, R., Wall, P. D. Science, 1965, 150, 971. Shealy, C. N., Mortimer, J. T., Reswick, J. B. Anesth. Analg. 1967, 46, 489. 3. Chinese med. J. 1973, no. 3, p. 33 and p. 35 (abstr.). 1. 2.