- Email: [email protected]
ULCERATIVE COLITIS
215
Disabilities and How to Live with Them ULCERATIVE COLITIS I REMEMBER well, as a 15-year-old high school student, the day I first passed blood in my stool. I told my parents and they sent me immediately to our family doctor. He made his diagnosis easily: "Young man, you have got some haemorrhoids". He gave me a prescription for suppositories and off I went. About two weeks later the blood loss became greater and I consulted the doctor again. The man remained firm in his original opinion, but sent me to a specialist. There I met the rectoscope for the first time. I felt hopeless, helpless, and awful. The posture required for this examination is not only embarrassing but is also difficult to maintain for a long time. To undergo rectoscopy is very tiresome-I have had over forty-because you have to starve for a day or more and it may be necessary to have a laxative enema as well. The sigmoidoscopy takes about an hour and it is normally difficult to pass the whole instrument, and many biopsy specimens have to be taken. I think that the examining doctors are often unaware of how it really feels to undergo all this, especially when an illness is in an acute phase. A doctor who has had such an examination himself may understand the patient better and carry out the examination more sympathetically. I think that doctors and/or students should undergo a number
of similar
unpleasant procedures during training.
At the time of my first sigmoidoscopy I was told that I had proctitis-an inflamed rectum-and only learned two years later that in fact I had ulcerative colitis. I was given sulphasalazine tablets and suppositories, and was put on a strict diet: no fats, oils, fatty meat or fish, wholemeal products, nuts, currants, raw food, cabbage, onion, milk, alcoholic drinks, spices, tobacco, and much besides. These limitations are not inconsiderable, but when it is for the good of your health you can bear it more easily. However, I did not expect any improvement. It is usual for doctors to suggest that a light, low-fat diet is necessary. Sometimes, however, a spastic colon and a hard stool, which can cause intestinal damage, may result. Wholemeal products are as necessary for colitis sufferers as they are for healthy people. I have even heard about a colitis patient who was free from symptoms during the war, in the winter of 1944-45, when predominantly turnips and bulbs were eaten.
J, Speirits K The rapid increase of heroin-addiction in Glasgow during 1981. Background paper 2, 1981, University of Glasgow Ratcliffe RAW Misuse of drugs in Scotland 1977-1979. Hlth Bull 1981; 39: 125-28. The deadly addiction of solvent sniffing. Glasgow Herald, Sept. 16, 1981: 9. Lush M. Oliver jS, Watson JM. The analysis of blood in cases of suspected solvent abuse with a review of results during the period October, 1977, to july, 1979. Forensic toxicology London: Croom Helm, 1980 304-13 Watling R Identification of larger fungi Amersham, Bucks Hulton Educational
1 Ditton 2
3 4
5
Publications Lid , 1973: 114-15. Mushrooms and toadstools. a field guide Oxford: Oxford University Press, 1979 84-85. 7 Hyde C, Glancy G, Omerod P, Hall D, Taylor GS Abuse of indigenous psilocybin mushrooms A new fashion and some psychiatric complications Br J Psychiat 1978; 132: 602-04 8 McDonald A Mushrooms and madness: hallucinogenic mushrooms and some psycho-
6
Kibby G
9
Cooper R
pharmacological implications. Can J Psychiat 1980, 25: 586-94 A guide to British psilocybin mushrooms London Red Shift Books, 1980.
22-23 10 Vale A, Meredith T. Poisonous plants and mushrooms. Med Int (UK ed) 1981; 1, 9: 108-11 11 Cooke RC Fungi, man and his environment. London: Longman, 1977: 132. 12 Benjamin C Persistent psychiatric symptoms after eating psilocybin mushrooms. Br Med J 1979, i 1319-1320 13. Mills PR. Lesinskas D, Watkinson G The danger of hallucinogenic mushrooms Scot
Most colitis patients know when and which foods and drinks disagree with them. In my own case chocolate, alcoholic drinks, and spices are the main culprits. After two years of chronic colitis I had an acute exacerbation and at last was admitted to hospital for observation. They examined me inside out. I had laxative enemas, rectoscopies, X-rays, blood tests, tests of nutritional status, and gastric acid tests-everything you can imagine! Owing to the poor resorptive capacity of my large intestine I was given vitamins and ferrous fumarate. I was now told that I had ulcerative colitis-60 cm of inflamed, reddish mucosa. I was treated with corticosteroid tablets and enemas. In a few weeks the disease was in good remission. I was surprised, therefore, a few months later when I again started to pass much bloody mucus. The medical staff had failed to tell me that I was suffering from a chronic disease with acute exacerbations. For the past 10 years my treatment has varied. During acute phases, when there was much blood loss, I was given prednisone and high dose sulphasalazine. During quiet, chronic stages I was given a maintenance dose of sulphasalazine. Some doctors now think that it does not matter whether low dose treatment is given or not. They think that an exacerbation can occur at any time; only its severity can be diminished. Sulphasalazine can cause an allergic reaction and also haemolysis when taken chronically. The side-effects of long term prednisone are well known, but, besides these, prednisone enemas often cause embarrassing borborygmi and flatulence. Recently I discovered that these symptoms are partly caused by the diuretic added to the enema. The enema also increases the amount of mucus secretion and is therefore actually causing inflammation. Self-administration of an enema, avoiding air bubbles, is difficult, especially for young people in awkward situations such as while on holiday or with friends. Suppositories, on the other hand, are small and convenient, there is no need to bring them to body heat before use, and, unlike enemas, there is no difficulty with overnight retention. It strikes me that, during the past fifteen years, there has been no appreciable change in treatment-prednisone and suphasalazine are still given for acute colitis. During an acute phase of colitis, when the urge to defaecate can be great, sphincter control is almost absent. It is better, therefore, not to wear white trousers in summer. A man who met with such an accident while shopping, asked a passer-by
Med J 1979; 24: 316-17 14 Cooles P. Abuse of the mushroom 15. Peden NR, Bissett AF, Macaulay
Panaeolus foenisecii.
Br
Med J 1980; i:
446-47.
KEC, Crooks J, Pelosi AJ. Clinical toxicology of "magic mushroom" ingestion. Postgrad Med J 1981; 57: 543-45 £30 an oz. toadstool. Sunday Times, Nov 20, 1977: 2
16. 17. Festival of the
new hippies Observer, Sept. 14, 1980: 3. 18. Magic hippies to be moved on Scotsman, Sept. 8, 1981: 4 19. The magic mushroom craze that could end in tragedy. Glasgow Herald, Sept. 8, 1978: 7. 20. Release Collective Hallucinogenic mushrooms. London: Release Publications Limited, 1979. 21. Gottlieb A. Legal highs a concise encyclopaedia of legal herbs and chemicals with psychoactive properties London: Greenham and Gotto, 1981. 22 Editorial. Mushroom poisoning. Lancet 1980. ii: 351-52. 23. Phillips R Mushrooms and other fungi of Great Britain and Europe, London. Pan Books, 1981 173 24 Buck RW. Mushroom poisoning since 1924 in the United States Mycologia 1961; 53: 537-38 25. Sniffing damage permanent Glasgow Herald, Sept. 4, 1981 3. 26 King MD, Day RE, Oliver JS, Lush M, Watson JM Solvent encephalopathy. Br Med J 1981, ii. 663-65. 27. Hallucinatory fungi not illegal, judge rules. Times, April 14, 1976 4. 28. Magistrate baffled over drug in mushroom Times, Dec 29, 1977: 2. 29 R v Goodchild. [1977] 2 A11 ER 163-67. 30. Plath S. The colossus. London: Heinemann, 1960: 34-35
216
physical well-being, or on my working life. The worst psychological stress for me occurs when I am, for example, out of my family circle and circumstances do not allow me to comply with my diet. So, lifestyle is important. You normally have to defaecate at least daily, and are reminded of your disabilities every time. That is upsetting and gives rise to feelings which in turn affect the colitis and complete a vicious circle. The most important determinant of well-being, therefore, is a good state of mind: as the Bible says (Proverbs) "a happy heart benefits the recovery".
call a taxi because he felt "unwell": the feeling in such situations is one of great unhappiness. Lately, I have had some trouble free periods, alternating with episodes of mucus secretion and bleeding. It is not clear to me why and when an attack occurs. It does not necessarily seem to be related to stress, to a delicate state of health, or to eating the wrong foods, although these influences may exacerbate the colitis or prolong the acute episode. All chronic diseases can be accompanied by psychological effects. However, I do not think that in my own case such effects have made a significant impact on my mental or
to
Round the World From
our
Correspondents
United States FAITH, HOPE, AND CHARITY
be said that the people need all these virtues at the they survey the actions of the Administration and the effects on the economy. The faith of some, especially of those of conservative mind, is still high, but others are much distressed by heresy in high places. It has long been an article of faith for many that the cause of inflation is Federal Budget deficits and that once the Budget is balanced all will be well. The President himself has strongly endorsed this view, and so prevalent has it been that one can hardly remember any President who did not promise to balance the Budget, even if the activities of most of them have resulted in greater imbalance. Imagine then the cries of the faithful when one of the members of the Council of Economic Advisors told a conservative assembly that Federal Budget deficits do not have much impact on inflation. In fact, he made no bones about it, saying, to an audience that just could not believe its ears, "the simple relationship between deficits and inflation is as close to being empty as can be perceived". This utterance brought heavy rebuke from higher up, just as that ex-divinity student, Mr Stockman, the President’s closest economic adviser, was chastised for openly avowing his own honest doubts about the likely success of the very measures he was urging the President to accept. But the heretics are growing and it seems that the Secretary of the Treasury also holds that Federal deficits are not the main cause of inflation. Faith told us that, with cuts in corporate and personal taxes, great sums of money would be freed to be invested, to secure industrial growth, more jobs, and so on. Well, the cuts are coming, but the money freed seems to be going into saving and retirement funds, to take advantage of the high interest rates, and so industries are closing, jobs get scarcer, unemployment rises sharply, Federal expenditure grows, as receipts diminish and the postulated Federal deficits grow ever larger. Savage cuts in welfare and education expenditures have been made and there is not much room for further economy. The aged have made clear their adamant opposition to reduced social security. So the only place for massive cuts is in the military budget, which many feel would be all the better for cutting. Hope that the Administration’s policies will succeed is thus fading. The President and his Administration are placing both faith and hope in charity to fill the holes in the nets of social welfare torn by the welfare cuts. As these cuts and the winter cold and blizzards bite, causing severe hardships to many, the chorus of complaints is rising. Many social and religious leaders are starting to criticise in savage terms the series of economies. The only reply so far is that an advisory body has been set up to explain to those communities who seek help in the solution of some social problem how some other community has been successful.
It
might
moment,
as
CONGRESS AND THE FOREIGN MEDICAL GRADUATE
There has been
a
roller-coaster series of pronouncements about
F. J. ZIJLSTRA
The Netherlands
a
grievous lack of physicians in many areas, alternating with dismal talk of massive overproduction of physicians and consequent unemployment. Many immigrant physicians have taken posts which U.S.-trained physicians are unwilling to accept, especially in the inner city hospitals, in the mental hospitals, and in custodial units. In many city hospitals a very high proportion of the medical staff are foreign medical graduates. Protests at this dependence on the importing of large numbers of medical staff have intensified. Since 1976, Congress has been trying to stem the flow and now, it seems, it has given final notice that all hospitals are to stop depending on foreign physicians. Congress tried this before and roused a storm of protests from a host of States, hospitals, and institutions heavily dependent on such staff. The latest measure, amending the Immigration and Nationality Act, requires all such immigrants to pass the visa qualifying examination. Failure to pass will, after December, 1983, preclude employment in any capacity. How this is going to work is unclear, and how these posts are to be filled is not spelled out. The restrictions do not apply to U.S. citizens who get their medical qualifications abroad; and such graduates will clearly be needed. The Association of American Medical Colleges is anxious to suppress the overseas medical schools that have sprung up to train U.S. citizens who are unable to obtain medical degrees in their own country. The tactics adopted have been criticised as bringing little credit to the A.A.M.C. and its constituents. Now these actions seem incompatible with the desires of Congress. MORE ON ASBESTOS
ASBESTOS-RELATED diseases are in the news again, and rather disconcerting news it is. In an effort to reduce malpractice claims, the law in New York State was changed to impose a three-year statute of limitations on the filing of personal injury suits. It was a laudable decision with excellent intent, and reasonable as long as the three years started when the injury came to light. But in an extraordinary, unexplained, and unexpected decision, the New York State Court of Appeals has ruled for asbestosis that the three years starts when the asbestos is inhaled, without specifying whether this starts when the victim begins or ceases to inhale asbestos. It is usually many years before any asbestos-related disease develops to the point where it can be diagnosed. The assailed companies, such as Johns-Manville, who are faced
with some 400 suits a month, may feel some relief; but the decision, if upheld, or if the legislature declines to intervene (the Court did suggest it was the "appropriate forum"), the decision will be a terrible blow to the many victims of this disease. The route to the U.S. Supreme Court seems to be blocked by a recent decision of that Court dealing with attempts to sue the producers of the defoliant, agent orange, and its toxic ingredient, dioxin, to which servicemen were exposed in south-east Asia. The alleged ill effects became evident years after exposure and suits in many States are barred by statutes of limitations. So the veterans sought relief through the Federal Courts, and this approach has been blocked by a majority decision of the Supreme Court. Where we shall go from here in the case of asbestos is uncertain, but the decision is unjust to the sufferers. As one lawyer says, "right now, in New York State, you have to start the suit before you are ill"-and that is going to be difficult.
Disabilities and How to Live with Them ULCERATIVE COLITIS I REMEMBER well, as a 15-year-old high school student, the day I first passed blood in my stool. I told my parents and they sent me immediately to our family doctor. He made his diagnosis easily: "Young man, you have got some haemorrhoids". He gave me a prescription for suppositories and off I went. About two weeks later the blood loss became greater and I consulted the doctor again. The man remained firm in his original opinion, but sent me to a specialist. There I met the rectoscope for the first time. I felt hopeless, helpless, and awful. The posture required for this examination is not only embarrassing but is also difficult to maintain for a long time. To undergo rectoscopy is very tiresome-I have had over forty-because you have to starve for a day or more and it may be necessary to have a laxative enema as well. The sigmoidoscopy takes about an hour and it is normally difficult to pass the whole instrument, and many biopsy specimens have to be taken. I think that the examining doctors are often unaware of how it really feels to undergo all this, especially when an illness is in an acute phase. A doctor who has had such an examination himself may understand the patient better and carry out the examination more sympathetically. I think that doctors and/or students should undergo a number
of similar
unpleasant procedures during training.
At the time of my first sigmoidoscopy I was told that I had proctitis-an inflamed rectum-and only learned two years later that in fact I had ulcerative colitis. I was given sulphasalazine tablets and suppositories, and was put on a strict diet: no fats, oils, fatty meat or fish, wholemeal products, nuts, currants, raw food, cabbage, onion, milk, alcoholic drinks, spices, tobacco, and much besides. These limitations are not inconsiderable, but when it is for the good of your health you can bear it more easily. However, I did not expect any improvement. It is usual for doctors to suggest that a light, low-fat diet is necessary. Sometimes, however, a spastic colon and a hard stool, which can cause intestinal damage, may result. Wholemeal products are as necessary for colitis sufferers as they are for healthy people. I have even heard about a colitis patient who was free from symptoms during the war, in the winter of 1944-45, when predominantly turnips and bulbs were eaten.
J, Speirits K The rapid increase of heroin-addiction in Glasgow during 1981. Background paper 2, 1981, University of Glasgow Ratcliffe RAW Misuse of drugs in Scotland 1977-1979. Hlth Bull 1981; 39: 125-28. The deadly addiction of solvent sniffing. Glasgow Herald, Sept. 16, 1981: 9. Lush M. Oliver jS, Watson JM. The analysis of blood in cases of suspected solvent abuse with a review of results during the period October, 1977, to july, 1979. Forensic toxicology London: Croom Helm, 1980 304-13 Watling R Identification of larger fungi Amersham, Bucks Hulton Educational
1 Ditton 2
3 4
5
Publications Lid , 1973: 114-15. Mushrooms and toadstools. a field guide Oxford: Oxford University Press, 1979 84-85. 7 Hyde C, Glancy G, Omerod P, Hall D, Taylor GS Abuse of indigenous psilocybin mushrooms A new fashion and some psychiatric complications Br J Psychiat 1978; 132: 602-04 8 McDonald A Mushrooms and madness: hallucinogenic mushrooms and some psycho-
6
Kibby G
9
Cooper R
pharmacological implications. Can J Psychiat 1980, 25: 586-94 A guide to British psilocybin mushrooms London Red Shift Books, 1980.
22-23 10 Vale A, Meredith T. Poisonous plants and mushrooms. Med Int (UK ed) 1981; 1, 9: 108-11 11 Cooke RC Fungi, man and his environment. London: Longman, 1977: 132. 12 Benjamin C Persistent psychiatric symptoms after eating psilocybin mushrooms. Br Med J 1979, i 1319-1320 13. Mills PR. Lesinskas D, Watkinson G The danger of hallucinogenic mushrooms Scot
Most colitis patients know when and which foods and drinks disagree with them. In my own case chocolate, alcoholic drinks, and spices are the main culprits. After two years of chronic colitis I had an acute exacerbation and at last was admitted to hospital for observation. They examined me inside out. I had laxative enemas, rectoscopies, X-rays, blood tests, tests of nutritional status, and gastric acid tests-everything you can imagine! Owing to the poor resorptive capacity of my large intestine I was given vitamins and ferrous fumarate. I was now told that I had ulcerative colitis-60 cm of inflamed, reddish mucosa. I was treated with corticosteroid tablets and enemas. In a few weeks the disease was in good remission. I was surprised, therefore, a few months later when I again started to pass much bloody mucus. The medical staff had failed to tell me that I was suffering from a chronic disease with acute exacerbations. For the past 10 years my treatment has varied. During acute phases, when there was much blood loss, I was given prednisone and high dose sulphasalazine. During quiet, chronic stages I was given a maintenance dose of sulphasalazine. Some doctors now think that it does not matter whether low dose treatment is given or not. They think that an exacerbation can occur at any time; only its severity can be diminished. Sulphasalazine can cause an allergic reaction and also haemolysis when taken chronically. The side-effects of long term prednisone are well known, but, besides these, prednisone enemas often cause embarrassing borborygmi and flatulence. Recently I discovered that these symptoms are partly caused by the diuretic added to the enema. The enema also increases the amount of mucus secretion and is therefore actually causing inflammation. Self-administration of an enema, avoiding air bubbles, is difficult, especially for young people in awkward situations such as while on holiday or with friends. Suppositories, on the other hand, are small and convenient, there is no need to bring them to body heat before use, and, unlike enemas, there is no difficulty with overnight retention. It strikes me that, during the past fifteen years, there has been no appreciable change in treatment-prednisone and suphasalazine are still given for acute colitis. During an acute phase of colitis, when the urge to defaecate can be great, sphincter control is almost absent. It is better, therefore, not to wear white trousers in summer. A man who met with such an accident while shopping, asked a passer-by
Med J 1979; 24: 316-17 14 Cooles P. Abuse of the mushroom 15. Peden NR, Bissett AF, Macaulay
Panaeolus foenisecii.
Br
Med J 1980; i:
446-47.
KEC, Crooks J, Pelosi AJ. Clinical toxicology of "magic mushroom" ingestion. Postgrad Med J 1981; 57: 543-45 £30 an oz. toadstool. Sunday Times, Nov 20, 1977: 2
16. 17. Festival of the
new hippies Observer, Sept. 14, 1980: 3. 18. Magic hippies to be moved on Scotsman, Sept. 8, 1981: 4 19. The magic mushroom craze that could end in tragedy. Glasgow Herald, Sept. 8, 1978: 7. 20. Release Collective Hallucinogenic mushrooms. London: Release Publications Limited, 1979. 21. Gottlieb A. Legal highs a concise encyclopaedia of legal herbs and chemicals with psychoactive properties London: Greenham and Gotto, 1981. 22 Editorial. Mushroom poisoning. Lancet 1980. ii: 351-52. 23. Phillips R Mushrooms and other fungi of Great Britain and Europe, London. Pan Books, 1981 173 24 Buck RW. Mushroom poisoning since 1924 in the United States Mycologia 1961; 53: 537-38 25. Sniffing damage permanent Glasgow Herald, Sept. 4, 1981 3. 26 King MD, Day RE, Oliver JS, Lush M, Watson JM Solvent encephalopathy. Br Med J 1981, ii. 663-65. 27. Hallucinatory fungi not illegal, judge rules. Times, April 14, 1976 4. 28. Magistrate baffled over drug in mushroom Times, Dec 29, 1977: 2. 29 R v Goodchild. [1977] 2 A11 ER 163-67. 30. Plath S. The colossus. London: Heinemann, 1960: 34-35
216
physical well-being, or on my working life. The worst psychological stress for me occurs when I am, for example, out of my family circle and circumstances do not allow me to comply with my diet. So, lifestyle is important. You normally have to defaecate at least daily, and are reminded of your disabilities every time. That is upsetting and gives rise to feelings which in turn affect the colitis and complete a vicious circle. The most important determinant of well-being, therefore, is a good state of mind: as the Bible says (Proverbs) "a happy heart benefits the recovery".
call a taxi because he felt "unwell": the feeling in such situations is one of great unhappiness. Lately, I have had some trouble free periods, alternating with episodes of mucus secretion and bleeding. It is not clear to me why and when an attack occurs. It does not necessarily seem to be related to stress, to a delicate state of health, or to eating the wrong foods, although these influences may exacerbate the colitis or prolong the acute episode. All chronic diseases can be accompanied by psychological effects. However, I do not think that in my own case such effects have made a significant impact on my mental or
to
Round the World From
our
Correspondents
United States FAITH, HOPE, AND CHARITY
be said that the people need all these virtues at the they survey the actions of the Administration and the effects on the economy. The faith of some, especially of those of conservative mind, is still high, but others are much distressed by heresy in high places. It has long been an article of faith for many that the cause of inflation is Federal Budget deficits and that once the Budget is balanced all will be well. The President himself has strongly endorsed this view, and so prevalent has it been that one can hardly remember any President who did not promise to balance the Budget, even if the activities of most of them have resulted in greater imbalance. Imagine then the cries of the faithful when one of the members of the Council of Economic Advisors told a conservative assembly that Federal Budget deficits do not have much impact on inflation. In fact, he made no bones about it, saying, to an audience that just could not believe its ears, "the simple relationship between deficits and inflation is as close to being empty as can be perceived". This utterance brought heavy rebuke from higher up, just as that ex-divinity student, Mr Stockman, the President’s closest economic adviser, was chastised for openly avowing his own honest doubts about the likely success of the very measures he was urging the President to accept. But the heretics are growing and it seems that the Secretary of the Treasury also holds that Federal deficits are not the main cause of inflation. Faith told us that, with cuts in corporate and personal taxes, great sums of money would be freed to be invested, to secure industrial growth, more jobs, and so on. Well, the cuts are coming, but the money freed seems to be going into saving and retirement funds, to take advantage of the high interest rates, and so industries are closing, jobs get scarcer, unemployment rises sharply, Federal expenditure grows, as receipts diminish and the postulated Federal deficits grow ever larger. Savage cuts in welfare and education expenditures have been made and there is not much room for further economy. The aged have made clear their adamant opposition to reduced social security. So the only place for massive cuts is in the military budget, which many feel would be all the better for cutting. Hope that the Administration’s policies will succeed is thus fading. The President and his Administration are placing both faith and hope in charity to fill the holes in the nets of social welfare torn by the welfare cuts. As these cuts and the winter cold and blizzards bite, causing severe hardships to many, the chorus of complaints is rising. Many social and religious leaders are starting to criticise in savage terms the series of economies. The only reply so far is that an advisory body has been set up to explain to those communities who seek help in the solution of some social problem how some other community has been successful.
It
might
moment,
as
CONGRESS AND THE FOREIGN MEDICAL GRADUATE
There has been
a
roller-coaster series of pronouncements about
F. J. ZIJLSTRA
The Netherlands
a
grievous lack of physicians in many areas, alternating with dismal talk of massive overproduction of physicians and consequent unemployment. Many immigrant physicians have taken posts which U.S.-trained physicians are unwilling to accept, especially in the inner city hospitals, in the mental hospitals, and in custodial units. In many city hospitals a very high proportion of the medical staff are foreign medical graduates. Protests at this dependence on the importing of large numbers of medical staff have intensified. Since 1976, Congress has been trying to stem the flow and now, it seems, it has given final notice that all hospitals are to stop depending on foreign physicians. Congress tried this before and roused a storm of protests from a host of States, hospitals, and institutions heavily dependent on such staff. The latest measure, amending the Immigration and Nationality Act, requires all such immigrants to pass the visa qualifying examination. Failure to pass will, after December, 1983, preclude employment in any capacity. How this is going to work is unclear, and how these posts are to be filled is not spelled out. The restrictions do not apply to U.S. citizens who get their medical qualifications abroad; and such graduates will clearly be needed. The Association of American Medical Colleges is anxious to suppress the overseas medical schools that have sprung up to train U.S. citizens who are unable to obtain medical degrees in their own country. The tactics adopted have been criticised as bringing little credit to the A.A.M.C. and its constituents. Now these actions seem incompatible with the desires of Congress. MORE ON ASBESTOS
ASBESTOS-RELATED diseases are in the news again, and rather disconcerting news it is. In an effort to reduce malpractice claims, the law in New York State was changed to impose a three-year statute of limitations on the filing of personal injury suits. It was a laudable decision with excellent intent, and reasonable as long as the three years started when the injury came to light. But in an extraordinary, unexplained, and unexpected decision, the New York State Court of Appeals has ruled for asbestosis that the three years starts when the asbestos is inhaled, without specifying whether this starts when the victim begins or ceases to inhale asbestos. It is usually many years before any asbestos-related disease develops to the point where it can be diagnosed. The assailed companies, such as Johns-Manville, who are faced
with some 400 suits a month, may feel some relief; but the decision, if upheld, or if the legislature declines to intervene (the Court did suggest it was the "appropriate forum"), the decision will be a terrible blow to the many victims of this disease. The route to the U.S. Supreme Court seems to be blocked by a recent decision of that Court dealing with attempts to sue the producers of the defoliant, agent orange, and its toxic ingredient, dioxin, to which servicemen were exposed in south-east Asia. The alleged ill effects became evident years after exposure and suits in many States are barred by statutes of limitations. So the veterans sought relief through the Federal Courts, and this approach has been blocked by a majority decision of the Supreme Court. Where we shall go from here in the case of asbestos is uncertain, but the decision is unjust to the sufferers. As one lawyer says, "right now, in New York State, you have to start the suit before you are ill"-and that is going to be difficult.