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SMOKING
678
The very mention of these subjects makes it obvious that modern public-health practice cannot be successfully carried out in isolation: it requires serious cooperation, not only between the branches of our profession but with a host of outside agencies as well. The society’s council includes a number of doctors who are not themselves in the public-health service, and its minutes show the great importance it attaches to representation on other bodies, lay and medical, and to joint meetings to discuss matters of common interest. Similarly, many of the fellows themselves are making every effort to increase collaboration with their colleagues in the hospitals and in general practice. The barriers, indeed, are breaking down at last, and this is one of the most hopeful aspects of post-war public health. Let us trust that the years of disappointment are over, and that the Society will prove as adventurous at the beginning of its second century as it was at the beginning of its first.
home
nurses.
Annotations
’’
1.
Lancet, 1954, i. 409.
been made. programme
objectivity.
For instance, in a recent B.B.C. television doctor set out the facts with admirable Beyond such individual efforts, the Central
a
Health E(Iuct.tion might suitably issue for distribution by general practitioners; and the British Medical Association might again use the occasion of its annual representative meeting-always closely watched by the lay press--to rehearse the facts. If such approaches prove ineffective doctors might band themselves together to bring home the risks to their patients. This would be a fine exercise in preventive iiiedicine-aiid incidentally in public spirit. Few patients with bronchial carcinoma could then say they had not been told how this might have been averted. Council
for
pamphlets
ILEOSTOMY BETWEEN 1928 and 1952. 871 patients were treated for ulcerative colitis at the Lahey (’linic, 413 (47%) being submitted to surgery; during this period the mortality for the ileostomy fell from 8to 5%. Dr. Neil Swinton gave these figures ill a discussion by the proctology section of the Royal Society of Medicine on May 2. He dealt. more with an analysis, by Colcock and Mathiesen, of their more recent cases: between 1946 and 1954, 307 patients were submitted to ileostomy and colectomy ; including operative and late deaths the mortality was 11% (34)—a fi,_,tire which closely matched that given by Mr. B. X. Brooke of 12%(15 deaths in 126 patients). Dr. Swinton and Mr. Brooke agreed that intestinal obstruction was a common sequel; this complication developed after discharge from hospital in 58 of 307Lahey Clinic patients and in 9 of llr. Brooke’s
fully
SMOKING
ON Monday the Minister of Health was questioned in the House of Commons about the association between tobacco-smoking and lung cancer. The tenor of his replies (see p. 696) was profoundly unsatisfactory. He might have used the occasion to state the danger categorically and to undertake to bring this to the notice of the public by other means. Instead he refused to initiate a publicity campaign and suggested that the extent of the problem should be neither minimised nor exaggerated." Within an hour the tobacco companies had issued a smoke-screen thick enough to obscure even a much plainer statement. If any other poison sold for public consumption were believed to be causing some thousands of deaths each vear, its sale would be suppressed. One reason whv this step has not been taken in the case of tobacco is that any Government initiating such a measure would fall on the ii-iorrow : as a nation we are tobacco-addicted. A second reason is that if the Treasury were denied the sum of £707 million a year now being yielded by the tobacco duty our fiscal policy would have to be radically re-shaped. There is at present no chance - or, as the smokers among us would put it, no risk-that the sale of tobacco will be controlled. But this does not signify that we should accept the status quo. In London nearly all those engaged in the long-term effects of tobacco on health or specialising in the treatment of lung cancer gave up smoking some time ago. We must not rest content until the whole community has understood the facts that have led this small group to change their habit. Occasional1 statements in Parliament do not reach, or are not long remembered by, most people. In 1954 the then Minister of Health issued a warning1 which was hardly less explicit than that uttered this week. Yet since then we have all often heard well-edueated people ask whether there " is anything in this tobacco scare." Their ignorance may be due partly to reluctance to learn ; but partly without doubt it is due to the mortal unwillingness to accept anything which has not been said again and again. A decision to control the sale of tobacco would be administrative-in other words, political. But a decision to impress the hazards on the public may properly be regarded as medical. Such a campaign would yield
investigating
rapid results : heavy smoking bears none of the stigma of heavy drinking, and an exchange of cigarettes is as much part of the established social order as an exchange of handclasps. But a useful start has already
no
12(j
patients. *
The ileal stoma calls for considerable care at the initial operation, and the technique of its construction is evidently becoming standardised. In all centres the importance of fixation of the mesentery in order to avoid ileostomy prolapse or recession is appreciated. At the Lahey Clinic, as elsewltere,a separate stab-wound is now found to be more satisfactory than the main incision for accommodating the stoma; eversion of the mucosa and direct suture to skin is also becoming widely practised. Complications such as fistula, prolapse, and recession, which render the stoma inetlicient, call for operative revision ; a further operation for excision of the whole or part of the buwel provided an opportunity for such revision in 9, and a separate operation was required in 4, of 106 cases in which Mr. Brooke did the
original ileostomy.
electrolvte balance is of vital importance reducing mortality after ileostomy. Sodium is lost in direct proportion to the volume output, which may be as much as 3 litres in twenty-four hours shortly after operation, decreasing to 500 ml. later ; Brooke has found its concentration to be roughly 300 m.eq. per litre, falling to 150 m.eq. per litre from the long-established stoma. Accordingly sodium requirements can be estimated from the daily volume excreted through the ileostomy. When the atuma is efficient, so that an adherent bag may be applied to it, patients express satisfaction with an ileostomy, even five years or more after its institution ; and they remain at full and arduous work. Nevertheless some maintain that an ileostomy is unnecessary. Mr. Stanley Aylett has undertaken ileorectal anastomosis in 38 patients, of whom 1 died ; he has found that the state of the rectum improves after anastomosis, though healing, judged histologically, is not perfect. This finding is supported by the experiences of Mr. Lawrence Abel and Mr. A. Dickson Wright. A sharp division of opinion The maintenance of in
The very mention of these subjects makes it obvious that modern public-health practice cannot be successfully carried out in isolation: it requires serious cooperation, not only between the branches of our profession but with a host of outside agencies as well. The society’s council includes a number of doctors who are not themselves in the public-health service, and its minutes show the great importance it attaches to representation on other bodies, lay and medical, and to joint meetings to discuss matters of common interest. Similarly, many of the fellows themselves are making every effort to increase collaboration with their colleagues in the hospitals and in general practice. The barriers, indeed, are breaking down at last, and this is one of the most hopeful aspects of post-war public health. Let us trust that the years of disappointment are over, and that the Society will prove as adventurous at the beginning of its second century as it was at the beginning of its first.
home
nurses.
Annotations
’’
1.
Lancet, 1954, i. 409.
been made. programme
objectivity.
For instance, in a recent B.B.C. television doctor set out the facts with admirable Beyond such individual efforts, the Central
a
Health E(Iuct.tion might suitably issue for distribution by general practitioners; and the British Medical Association might again use the occasion of its annual representative meeting-always closely watched by the lay press--to rehearse the facts. If such approaches prove ineffective doctors might band themselves together to bring home the risks to their patients. This would be a fine exercise in preventive iiiedicine-aiid incidentally in public spirit. Few patients with bronchial carcinoma could then say they had not been told how this might have been averted. Council
for
pamphlets
ILEOSTOMY BETWEEN 1928 and 1952. 871 patients were treated for ulcerative colitis at the Lahey (’linic, 413 (47%) being submitted to surgery; during this period the mortality for the ileostomy fell from 8to 5%. Dr. Neil Swinton gave these figures ill a discussion by the proctology section of the Royal Society of Medicine on May 2. He dealt. more with an analysis, by Colcock and Mathiesen, of their more recent cases: between 1946 and 1954, 307 patients were submitted to ileostomy and colectomy ; including operative and late deaths the mortality was 11% (34)—a fi,_,tire which closely matched that given by Mr. B. X. Brooke of 12%(15 deaths in 126 patients). Dr. Swinton and Mr. Brooke agreed that intestinal obstruction was a common sequel; this complication developed after discharge from hospital in 58 of 307Lahey Clinic patients and in 9 of llr. Brooke’s
fully
SMOKING
ON Monday the Minister of Health was questioned in the House of Commons about the association between tobacco-smoking and lung cancer. The tenor of his replies (see p. 696) was profoundly unsatisfactory. He might have used the occasion to state the danger categorically and to undertake to bring this to the notice of the public by other means. Instead he refused to initiate a publicity campaign and suggested that the extent of the problem should be neither minimised nor exaggerated." Within an hour the tobacco companies had issued a smoke-screen thick enough to obscure even a much plainer statement. If any other poison sold for public consumption were believed to be causing some thousands of deaths each vear, its sale would be suppressed. One reason whv this step has not been taken in the case of tobacco is that any Government initiating such a measure would fall on the ii-iorrow : as a nation we are tobacco-addicted. A second reason is that if the Treasury were denied the sum of £707 million a year now being yielded by the tobacco duty our fiscal policy would have to be radically re-shaped. There is at present no chance - or, as the smokers among us would put it, no risk-that the sale of tobacco will be controlled. But this does not signify that we should accept the status quo. In London nearly all those engaged in the long-term effects of tobacco on health or specialising in the treatment of lung cancer gave up smoking some time ago. We must not rest content until the whole community has understood the facts that have led this small group to change their habit. Occasional1 statements in Parliament do not reach, or are not long remembered by, most people. In 1954 the then Minister of Health issued a warning1 which was hardly less explicit than that uttered this week. Yet since then we have all often heard well-edueated people ask whether there " is anything in this tobacco scare." Their ignorance may be due partly to reluctance to learn ; but partly without doubt it is due to the mortal unwillingness to accept anything which has not been said again and again. A decision to control the sale of tobacco would be administrative-in other words, political. But a decision to impress the hazards on the public may properly be regarded as medical. Such a campaign would yield
investigating
rapid results : heavy smoking bears none of the stigma of heavy drinking, and an exchange of cigarettes is as much part of the established social order as an exchange of handclasps. But a useful start has already
no
12(j
patients. *
The ileal stoma calls for considerable care at the initial operation, and the technique of its construction is evidently becoming standardised. In all centres the importance of fixation of the mesentery in order to avoid ileostomy prolapse or recession is appreciated. At the Lahey Clinic, as elsewltere,a separate stab-wound is now found to be more satisfactory than the main incision for accommodating the stoma; eversion of the mucosa and direct suture to skin is also becoming widely practised. Complications such as fistula, prolapse, and recession, which render the stoma inetlicient, call for operative revision ; a further operation for excision of the whole or part of the buwel provided an opportunity for such revision in 9, and a separate operation was required in 4, of 106 cases in which Mr. Brooke did the
original ileostomy.
electrolvte balance is of vital importance reducing mortality after ileostomy. Sodium is lost in direct proportion to the volume output, which may be as much as 3 litres in twenty-four hours shortly after operation, decreasing to 500 ml. later ; Brooke has found its concentration to be roughly 300 m.eq. per litre, falling to 150 m.eq. per litre from the long-established stoma. Accordingly sodium requirements can be estimated from the daily volume excreted through the ileostomy. When the atuma is efficient, so that an adherent bag may be applied to it, patients express satisfaction with an ileostomy, even five years or more after its institution ; and they remain at full and arduous work. Nevertheless some maintain that an ileostomy is unnecessary. Mr. Stanley Aylett has undertaken ileorectal anastomosis in 38 patients, of whom 1 died ; he has found that the state of the rectum improves after anastomosis, though healing, judged histologically, is not perfect. This finding is supported by the experiences of Mr. Lawrence Abel and Mr. A. Dickson Wright. A sharp division of opinion The maintenance of in