- Email: [email protected]
Round the World
1168 so present the questions that must be asked are: How long have they had the symptoms ? Have they any sign of complications and if so, could earlier detection have prevented these? Besides the newly diagnosed diabetics, 12 patients are under surveillance because of glycosuria. These patients have a fasting blood-glucose carried out periodically either at the hospital laboratory or with ’Dextrostix ’ (Ames) at the surgery. Unfortunately only 50% cooperated. The remaining 6, though with persistent glycosuria had normal fasting blood-sugars or normal
patient does
glucose-tolerance tests. Of the 20 patients with albuminuria, 5 had congestive cardiac failure, 3 chronic renal disease, and 12 were known hypertensives. Most patients, being with disease processes several elderly, presented this the of blurring survey. Out of the total, aspect 6 had recurrent urinary-tract infection. This does not mean there were no other patients with urinary
Service are provided with the tools for screening, the general practitioner who is anxious to practice preventive medicine is discouraged by the Department’s refusal to supply diagnostic strips as used in the survey free of charge. I thank the clerk to the Wallasey Executive Council, the medical officer of health for Wallasey, the practice nursing sister and my wife (a former health visitor) for help and advice. Requests for reprints should be addressed to 30 Seabank Road, Wallasey, Cheshire L45 7PE. REFERENCES 1. Lancet, 1967, i, 83. 2. Wilson, J. M. G., Jumgner, G. Principles and Practice of Screening for Disease; p. 19. Geneva, 1968. 3. McIlwaine, C. L. K., Smith, A. M. W. Scot. med. J. 1966, 11, 208. 4. Wallace, D. M., Harris, D. L. Lancet, 1965, ii, 332. 5. Sanders, C. Practitioner, 1963, 191, 192. 6. Jameson, R. M. Lancet, 1969, i, 1164.
Round the World
infections
as not all present with albuminuria. For 20 example, pus cells per high-power field will not a cause change of colour in the reagent strip. Tests for haematuria proved most interesting, the most significant findings being: carcinoma of bladder (1), papilloma of bladder (2), and renal stone (1). Each of these patients was symptom-free and the amount of blood present was microscopic, which was detected by the strip tests and confirmed by microscopy. In each case the urine contained no protein. 1 female with haematuria was later found to have a cervical polyp. It is not generally realised that 90% of all cases of bladder tumours present with painless hasmaturia, and that one month’s delay in detection 4 can halve their chances of survival. Microscopic haematuria is more common than has previously been assumed.1i Indeed one hospital recently had referred to it 6 cases of symptomatic microscopic haematuria, discovered by routine testing, that were subsequently diagnosed as tumour in the urinary tract.6 My survey revealed 8 cases of haematuria, confirmed by microscopy, where investigation showed no obvious disease. Several explanations have been offered-local traumatic causes, senile vaginitis, " urethral caruncle or burnt-out glomerulonephritis ". These patients have been labelled " occult lesion " and more detailed follow-up study may reveal the significance of painless haematuria with a negative intravenous pyelogram.
CONCLUSION
It should be
equipment,
possible, given sufficient staff and whole populations every five or
to screen
for such diseases as diabetes, cervical carrenal disease, iron-deficiency anaemia, and cinoma, This would encourage doctors anxious hypertension. to do preventive medicine; the patients would benefit enormously and, if organised with the aid of computers, the programme could be based on properly staffed and equipped health centres within easy reach of district general hospitals. In the absence of a uniform policy, this practice accepts its share of the responsibility and undertakes continuous screening of patients. It seems, however, unforgivable that while other sections of the Health ten years
United States WELFARE CHAOS
In this sombre week, lit by burning R.O.T.C. buildings, there was a minor but significant tragic mishap to the administration’s welfare proposals which had passed the House by a large majority. It was expected that the Senate, rather more liberal than the House in these matters, would accept the proposals-the main foreseen danger being that the benefits might be increased by the Senate to such a point that the President would veto the proposal on financial grounds. However, things turned out differently. The opposition in the Senate turned on two main grounds. The first was that the " incentives " to work were inadequate, and the second that by various means recipients of welfare could, in certain areas, and by various devices, obtain an income that was greater than that of working families. The reason for this is, of course, the great diversity of federal welfare funding agencies and their counterparts in the individual States. Many of the federal welfare schemes do not come under the umbrella of the Department of Health, Education, and Welfare which is to administer the guaranteed-income scheme. By obtaining the maximum benefits from this scheme, by obtaining federal food stamps and other federal benefits, and various State and other allowances, the welfare recipient could, under various if rather peculiar circumstances, boost his income to a considerable extent. Mr. Finch pleaded vainly that he could only control the activities of H.E.W., and that other agencies and what they did were things for which he could not answer. No matter, the Senate sent the proposals back to be reconsidered. Clearly these matters will have to be resolved before the Senate again gets to work on the proposals, but lines of solution are not easy to see. We are faced with a considerable increase in the number of unemployed, further increases are predicted, and a further flood of schoolleavers will aggravate the situation. Summer jobs for students are not easy to find. But apart from this, H.E.W. faces an almost insoluble task unless there is an upheaval in administration at the federal level. Considering that it is responsible for health, education, and welfare, it is already an administrative colossus, and yet in every one of these fields-surely large enough for each to be a separate department-it has to share responsibilities with other federal agencies which it cannot control and which are not
always ready
to cooperate. Not so many years ago, the federal Government’s responsibilities in all these fields were minimal ; now they are enormous, and a crazy patchwork of agencies and funding have been set up-by Congress.
1169
Legislative proposals traditionally come from the executive branch of our Government, and H.E.W. will no doubt do its best and bring forward some new proposals. But Congress might also consider its opportunities: look afresh at the whole of its welfare responsibilities, and take some steps towards rationalisation. In a country full of organisations which advise on rationalisation, streamlining, and efficiency in business, industrial, and even in university fields, it is curious that the federal Government is so unwilling to use this expertise in its own fields of activity. It might help, too, to balance the budget and reduce inflation. COMPUTED LOGIC
I don’t know whether to blame the computers, or the bureaucrats who program them, but between them recently they set my blood boiling. My parents, with the best of intentions, gave me three Christian names. To obscure details, let me call myself Dr. John William Thorton Twerps (I hope I have not taken in vain the name of any colleague). The trouble started when I attempted to licence my new car with the Motor Vehicle Department. The dealer had issued the car to Dr. John Twerps, the insurance cover-note had been made out to Dr. J. W. T. Twerps. The bureaucrat stated that these must be two separate people, and asked to see the licence of my previous car. To my horror, I saw that this was made out to Dr. J. T. Twerps. In a shocked voice, she asked for my driving-licence. When found, this turned out to have been issued to Dr. J. W. Twerps. I was curtly informed that as far as the Motor Vehicle Department was concerned, I was four different people. My plea that all these doctors had the same Social Security number, and lived at the same address, and all had the same computercontrolled driver identification number, was scornfully dismissed. My humble request that all my initials might be put on the documents met with the crushing answer that " the computer could not take it ", and I retired defeated. When the students tire of burning R.O.T.C. buildings I have a suggestion for them. There is only one happy thought. If the Social Security computers are similarly programmed, what a happy day it will be when Dr. J. W. T. Twerps, Dr. John Twerps, Dr. J. T. Twerps, and Dr. J. W. Twerps all receive their Social Security payments.
Parliament Chronically Sick
and Disabled Persons Bill
ONE Bill to reach the Statute Book by the skin of its teeth before Parliament is dissolved will be the Chronically Sick and Disabled Persons Bill. In the report stage of the Bill in the House of Lords on May 20, Lord HUGHES, Minister of State, Scottish Office, rose to make a statement on the proposed Government circular on the needs of the disabled with regard to public transport. He said that discussions had been held, and though no decisions had been made, the matter was certainly in hand. Baroness MASHAM OF ILTON moved an amendment to provide that any patient in hospital who has recently suffered neck or back injuries likely to lead to paralysis, should be transferred to a special spinal unit within 24 hours (or as soon as possible), and " so far as is practicable and reasonable having particular regard to the proper treatment of the patient". She cited cases of two paraplegics who had been admitted to a general hospital, where the facilities and special skills needed to treat this condition had not been available. One of the men had been in the hospital for 19 months, and rehabilitation had not been started. Several speakers supported the amendment. Baroness D’ARCY DE KNAYTH was in sympathy with it, but wanted reassurance that the Tunbridge Committee, set up to investigate rehabilitation centres, should not suggest that
paraplegics be sent to general rehabilitation centres along with people suffering from other forms of disablement. Baroness SEROTA (Minister of State, Department of Health and Social Security), also expressed sympathy with the object of the amendment, but could not recommend it. She said that it would mean issuing directions from the Department to doctors on the clinical care of their patients, and this was unacceptable. She did, however, assure the House that the views contained in the amendment would be brought to the notice of the Tunbridge Committee. The Department intended to ask hospital authorities to ensure that the facilities available at special centres were known to doctors in accident and emergency departments. There " was no need to legislate on this point. Lady Masham very grudgingly " withdrew the amendment. A further amendment was passed, providing for the issue by local authorities of badges for cars with disabled drivers or passengers. Lord Hughes, moving the amendment, said that regulations would be made under the Road Traffic Act 1967 to provide for exemption from parking and waiting restrictions for cars displaying the badges. Badges would also be available to institutions which care for the disabled, for use on their vehicles. One local authority would recognise badges issued by another local authority. Lord SEGAL asked that the badge should be luminous or illuminated, and displayed on the back, as well as the front, of the car. The House expressed some regret that there would not be time to discuss any other amendments, but the Lords agreed that perfection should be sacrificed in the interests of sending the Bill forward for the Royal Assent.
In
England Now
A Running Commentary
by Peripatetic Correspondents
THE professor and I came home by Jumbo; it was a new experience for us both. We were ushered into a vast foyer in the airline terminal building, and here the first decision had be taken: at which of four desks should we reserve our seats ? No. 1 said " First Class " so that was out; the second said " General film-no smoking ". The general film involved someone playing a bassoon. Our feelings about smoking outweighed this disadvantage, but all seats were taken. So that left desks 3 and 4, both of which advertised " Mature film-smoking ". Besides smoking, this involved Elizabeth Taylor. Our seats were directly beneath the cinema screen, and we decided that it was worth$2.50 to rent head-phones to provide distracting music. After a 3Jçhour delay for repairs, the music channels still didn’t work, and we got"back our$2.50. On take-off, a roomy overhead luggage bin that opens with pneumatic ease " disgorged a mackintosh to enshroud a talkative passenger much as one would silence a noisy parrot. An excellent meal was followed by the " mature film " which we saw, but didn’t hear. Unlike the music which didn’t start, the film wouldn’t stop and, as dawn broke over Ireland, Elizabeth Taylor was grinding round for the third time. A minor trouble of this space-age travel is the lavatories: arranged as two pairs with outward-opening doors separated to
cross corridor, it was difficult, and indeed find which was free, for as one bent down to see the rather small sign on the lock, the door was liable to swing open hitting one between the eyes; this could be accompanied by a blow from the rear as the occupant across the corridor attempted to leave. It was all good fun, and our sympathy went out to the cabin staff who tried so hardeven to the extent of searching among 340 passengers to find who had borrowed what appeared to be the only electric razor on board. But next time, an old-fasioned 707 or VC 10, I think.
by a narrow dangerous, to
patient does
glucose-tolerance tests. Of the 20 patients with albuminuria, 5 had congestive cardiac failure, 3 chronic renal disease, and 12 were known hypertensives. Most patients, being with disease processes several elderly, presented this the of blurring survey. Out of the total, aspect 6 had recurrent urinary-tract infection. This does not mean there were no other patients with urinary
Service are provided with the tools for screening, the general practitioner who is anxious to practice preventive medicine is discouraged by the Department’s refusal to supply diagnostic strips as used in the survey free of charge. I thank the clerk to the Wallasey Executive Council, the medical officer of health for Wallasey, the practice nursing sister and my wife (a former health visitor) for help and advice. Requests for reprints should be addressed to 30 Seabank Road, Wallasey, Cheshire L45 7PE. REFERENCES 1. Lancet, 1967, i, 83. 2. Wilson, J. M. G., Jumgner, G. Principles and Practice of Screening for Disease; p. 19. Geneva, 1968. 3. McIlwaine, C. L. K., Smith, A. M. W. Scot. med. J. 1966, 11, 208. 4. Wallace, D. M., Harris, D. L. Lancet, 1965, ii, 332. 5. Sanders, C. Practitioner, 1963, 191, 192. 6. Jameson, R. M. Lancet, 1969, i, 1164.
Round the World
infections
as not all present with albuminuria. For 20 example, pus cells per high-power field will not a cause change of colour in the reagent strip. Tests for haematuria proved most interesting, the most significant findings being: carcinoma of bladder (1), papilloma of bladder (2), and renal stone (1). Each of these patients was symptom-free and the amount of blood present was microscopic, which was detected by the strip tests and confirmed by microscopy. In each case the urine contained no protein. 1 female with haematuria was later found to have a cervical polyp. It is not generally realised that 90% of all cases of bladder tumours present with painless hasmaturia, and that one month’s delay in detection 4 can halve their chances of survival. Microscopic haematuria is more common than has previously been assumed.1i Indeed one hospital recently had referred to it 6 cases of symptomatic microscopic haematuria, discovered by routine testing, that were subsequently diagnosed as tumour in the urinary tract.6 My survey revealed 8 cases of haematuria, confirmed by microscopy, where investigation showed no obvious disease. Several explanations have been offered-local traumatic causes, senile vaginitis, " urethral caruncle or burnt-out glomerulonephritis ". These patients have been labelled " occult lesion " and more detailed follow-up study may reveal the significance of painless haematuria with a negative intravenous pyelogram.
CONCLUSION
It should be
equipment,
possible, given sufficient staff and whole populations every five or
to screen
for such diseases as diabetes, cervical carrenal disease, iron-deficiency anaemia, and cinoma, This would encourage doctors anxious hypertension. to do preventive medicine; the patients would benefit enormously and, if organised with the aid of computers, the programme could be based on properly staffed and equipped health centres within easy reach of district general hospitals. In the absence of a uniform policy, this practice accepts its share of the responsibility and undertakes continuous screening of patients. It seems, however, unforgivable that while other sections of the Health ten years
United States WELFARE CHAOS
In this sombre week, lit by burning R.O.T.C. buildings, there was a minor but significant tragic mishap to the administration’s welfare proposals which had passed the House by a large majority. It was expected that the Senate, rather more liberal than the House in these matters, would accept the proposals-the main foreseen danger being that the benefits might be increased by the Senate to such a point that the President would veto the proposal on financial grounds. However, things turned out differently. The opposition in the Senate turned on two main grounds. The first was that the " incentives " to work were inadequate, and the second that by various means recipients of welfare could, in certain areas, and by various devices, obtain an income that was greater than that of working families. The reason for this is, of course, the great diversity of federal welfare funding agencies and their counterparts in the individual States. Many of the federal welfare schemes do not come under the umbrella of the Department of Health, Education, and Welfare which is to administer the guaranteed-income scheme. By obtaining the maximum benefits from this scheme, by obtaining federal food stamps and other federal benefits, and various State and other allowances, the welfare recipient could, under various if rather peculiar circumstances, boost his income to a considerable extent. Mr. Finch pleaded vainly that he could only control the activities of H.E.W., and that other agencies and what they did were things for which he could not answer. No matter, the Senate sent the proposals back to be reconsidered. Clearly these matters will have to be resolved before the Senate again gets to work on the proposals, but lines of solution are not easy to see. We are faced with a considerable increase in the number of unemployed, further increases are predicted, and a further flood of schoolleavers will aggravate the situation. Summer jobs for students are not easy to find. But apart from this, H.E.W. faces an almost insoluble task unless there is an upheaval in administration at the federal level. Considering that it is responsible for health, education, and welfare, it is already an administrative colossus, and yet in every one of these fields-surely large enough for each to be a separate department-it has to share responsibilities with other federal agencies which it cannot control and which are not
always ready
to cooperate. Not so many years ago, the federal Government’s responsibilities in all these fields were minimal ; now they are enormous, and a crazy patchwork of agencies and funding have been set up-by Congress.
1169
Legislative proposals traditionally come from the executive branch of our Government, and H.E.W. will no doubt do its best and bring forward some new proposals. But Congress might also consider its opportunities: look afresh at the whole of its welfare responsibilities, and take some steps towards rationalisation. In a country full of organisations which advise on rationalisation, streamlining, and efficiency in business, industrial, and even in university fields, it is curious that the federal Government is so unwilling to use this expertise in its own fields of activity. It might help, too, to balance the budget and reduce inflation. COMPUTED LOGIC
I don’t know whether to blame the computers, or the bureaucrats who program them, but between them recently they set my blood boiling. My parents, with the best of intentions, gave me three Christian names. To obscure details, let me call myself Dr. John William Thorton Twerps (I hope I have not taken in vain the name of any colleague). The trouble started when I attempted to licence my new car with the Motor Vehicle Department. The dealer had issued the car to Dr. John Twerps, the insurance cover-note had been made out to Dr. J. W. T. Twerps. The bureaucrat stated that these must be two separate people, and asked to see the licence of my previous car. To my horror, I saw that this was made out to Dr. J. T. Twerps. In a shocked voice, she asked for my driving-licence. When found, this turned out to have been issued to Dr. J. W. Twerps. I was curtly informed that as far as the Motor Vehicle Department was concerned, I was four different people. My plea that all these doctors had the same Social Security number, and lived at the same address, and all had the same computercontrolled driver identification number, was scornfully dismissed. My humble request that all my initials might be put on the documents met with the crushing answer that " the computer could not take it ", and I retired defeated. When the students tire of burning R.O.T.C. buildings I have a suggestion for them. There is only one happy thought. If the Social Security computers are similarly programmed, what a happy day it will be when Dr. J. W. T. Twerps, Dr. John Twerps, Dr. J. T. Twerps, and Dr. J. W. Twerps all receive their Social Security payments.
Parliament Chronically Sick
and Disabled Persons Bill
ONE Bill to reach the Statute Book by the skin of its teeth before Parliament is dissolved will be the Chronically Sick and Disabled Persons Bill. In the report stage of the Bill in the House of Lords on May 20, Lord HUGHES, Minister of State, Scottish Office, rose to make a statement on the proposed Government circular on the needs of the disabled with regard to public transport. He said that discussions had been held, and though no decisions had been made, the matter was certainly in hand. Baroness MASHAM OF ILTON moved an amendment to provide that any patient in hospital who has recently suffered neck or back injuries likely to lead to paralysis, should be transferred to a special spinal unit within 24 hours (or as soon as possible), and " so far as is practicable and reasonable having particular regard to the proper treatment of the patient". She cited cases of two paraplegics who had been admitted to a general hospital, where the facilities and special skills needed to treat this condition had not been available. One of the men had been in the hospital for 19 months, and rehabilitation had not been started. Several speakers supported the amendment. Baroness D’ARCY DE KNAYTH was in sympathy with it, but wanted reassurance that the Tunbridge Committee, set up to investigate rehabilitation centres, should not suggest that
paraplegics be sent to general rehabilitation centres along with people suffering from other forms of disablement. Baroness SEROTA (Minister of State, Department of Health and Social Security), also expressed sympathy with the object of the amendment, but could not recommend it. She said that it would mean issuing directions from the Department to doctors on the clinical care of their patients, and this was unacceptable. She did, however, assure the House that the views contained in the amendment would be brought to the notice of the Tunbridge Committee. The Department intended to ask hospital authorities to ensure that the facilities available at special centres were known to doctors in accident and emergency departments. There " was no need to legislate on this point. Lady Masham very grudgingly " withdrew the amendment. A further amendment was passed, providing for the issue by local authorities of badges for cars with disabled drivers or passengers. Lord Hughes, moving the amendment, said that regulations would be made under the Road Traffic Act 1967 to provide for exemption from parking and waiting restrictions for cars displaying the badges. Badges would also be available to institutions which care for the disabled, for use on their vehicles. One local authority would recognise badges issued by another local authority. Lord SEGAL asked that the badge should be luminous or illuminated, and displayed on the back, as well as the front, of the car. The House expressed some regret that there would not be time to discuss any other amendments, but the Lords agreed that perfection should be sacrificed in the interests of sending the Bill forward for the Royal Assent.
In
England Now
A Running Commentary
by Peripatetic Correspondents
THE professor and I came home by Jumbo; it was a new experience for us both. We were ushered into a vast foyer in the airline terminal building, and here the first decision had be taken: at which of four desks should we reserve our seats ? No. 1 said " First Class " so that was out; the second said " General film-no smoking ". The general film involved someone playing a bassoon. Our feelings about smoking outweighed this disadvantage, but all seats were taken. So that left desks 3 and 4, both of which advertised " Mature film-smoking ". Besides smoking, this involved Elizabeth Taylor. Our seats were directly beneath the cinema screen, and we decided that it was worth$2.50 to rent head-phones to provide distracting music. After a 3Jçhour delay for repairs, the music channels still didn’t work, and we got"back our$2.50. On take-off, a roomy overhead luggage bin that opens with pneumatic ease " disgorged a mackintosh to enshroud a talkative passenger much as one would silence a noisy parrot. An excellent meal was followed by the " mature film " which we saw, but didn’t hear. Unlike the music which didn’t start, the film wouldn’t stop and, as dawn broke over Ireland, Elizabeth Taylor was grinding round for the third time. A minor trouble of this space-age travel is the lavatories: arranged as two pairs with outward-opening doors separated to
cross corridor, it was difficult, and indeed find which was free, for as one bent down to see the rather small sign on the lock, the door was liable to swing open hitting one between the eyes; this could be accompanied by a blow from the rear as the occupant across the corridor attempted to leave. It was all good fun, and our sympathy went out to the cabin staff who tried so hardeven to the extent of searching among 340 passengers to find who had borrowed what appeared to be the only electric razor on board. But next time, an old-fasioned 707 or VC 10, I think.
by a narrow dangerous, to