646 to the many possible dietary influences on alimentary cancer, it emphasises the "complex interactions of different factors, which encourage the weaving of intellectual cats-cradles of hypotheses and counter-hypotheses". Epidemiological studies are more feasible, but may be expensive, and this report doubts their cost-effectiveness. More may be gleaned from family studies: for example, twins and man-and-wife studies can help to distinguish between environmental and genetic causal factors. The authors of the summary were enthusiastic about a laboratory search for carcinogens, and pick out for special mention the nitrosamines, which are known to be carcinogenic and which can be produced from the nitrates and nitrites used in food preservatives. They praise the work on gut bacteria (particularly, nuclear dehydrogenation clostridia [N.D.C.] which may manufacture carcinogens and, while epidemiological studies on the population’s gut bacteria are progressing, they believe that a systematic laboratory examination should be undertaken of the various dehydrogenated sterols produced by
ing
N.D.C.
In the realm of diagnosis, screening of the symptomfree population is not encouraged, but uneasiness is voiced at delays in diagnosis of those with symptoms. In mentioning experience in the United States with faecal occult-blood testing (often by patients themselves), the report does not point out that this is a test widely used at the bedside by American physicians, while in Great Britain it is wrongly regarded as a laboratory investigation, which increases its cost considerably. Exfoliative cytology is praised as a possibly effective method of screening high-risk groups, though the abbreviated report fails to clarify how this is to be done and what the difficulties are in patient-acceptability. Carcinoembryonic antigen has an airing, and it must be wondered whether the Medical Research Council has not missed the boat in setting up a trial to ask what value it has in the diagnosis and management of early recurrent rectal cancer. We would predict the answer to be "very little". Nevertheless, the search for chemical markers of malignancy is rightly encouraged, though the dream of a screening test for cancer done on a few ml of blood is obviously far from reality. For the non-researching clinician the passages on therapy are useful. The wide variations in results from different centres certainly need explaining. If one centre can produce a five-year survival of 41% for gastric cancer, why cannot all the others do so? The haphazardness of studies of chemotherapy and radiotherapy in these diseases is well illustrated. Because proper controlled trials are arduous and time-consuming to set up, the suggestion is that interested centres might form semi-permanent links (as have the British Breast Group) so that, once such questions as definition, staging, and data collection have been ironed out, whole series of trials could easily be mounted. All over the country there are clinicians sufficiently motivated to participate but lacking the time, resources, and number of patients to do the trials on their own. They only need coordinating for useful inquiries to be conducted, and the superiority of British studies of clinical management over North American ones (for reasons related to health-care systems) makes it important for this initiative to be taken.
CARDIAC REHABILITATION IT is 25 years since Levine and Lown’ challenged the dogma of prolonged immobilisation for patients with acute myocardial infarction by proposing their "armchair treatment". Until then, patients were kept in bed for 6 weeks or longer, partly on the grounds that a firm myocardial scar was not formed for at least 6 weeks,2 and partly because of the curious observation that rupture of the myocardium was more common in mental-
hospital patients,3 presumably because they were mentally deranged and would not stay in bed. Since then the period of confinement to bed and hospital has become progressively shorter, and now it is generally advocated (and backed by evidence from controlled studies4-6) that mobilisation for patients with uncomplicated infarction should start on the 3rd and 4th day, leading to discharge home after 8-10 days. For the few patients whose infarction is complicated by cardiac failure, mobilisation should be delayed, but even for them it is usually unnecessary to delay discharge much beyond 2 weeks. At the same time it is becoming recognised that the natural history of the disease demands that patients with infarction should be admitted to hospital as early as possible and that paramedical staff rather than medical practitioners may be best fitted to organise this and to give emergency treatment during the very acute stage.’ Thus the rationale of hospital treatment for infarction has been strengthened by the knowledge that most of the lethal complications arise in the very acute stage and that recovery from uncomplicated infarction is rapid. After discharge from hospital the most important aim for the patient is a return to normal, productive, and happy life. Undoubtedly cardiac rehabilitation should start in the coronary-care unit, where the patient can nearly always be told truthfully that the early dangerous phase of his illness is over and that rapid recovery is expected. When this positive and reassuring idea is repeated by doctors and nurses during the patient’s stay in hospital and subsequently, patients rarely fail to become fully rehabilitated and to return to work within 4 to 8 weeks of the infarct. Thus, for most patients cardiac rehabilitation is merely a component of good medi8 cal management. Much has been written about
more detailed aspects of cardiac rehabilitation, and two new publications describe the proceedings of a conference on rehabilitation9 and the results of a controlled triapo in which the prognosis of 180 patients given physical training starting 10 weeks after the infarct was compared with that of 200 patients who had no physical training but performed a monthly ergometric test. This trial failed to showany significant effect on mortality or recurrent infarction in the trainers after 31 months, although both death and 1. Levine, S. A., Lown, B. J. Am. med. Ass. 1952, 148, 1365. 2. Mallory, G. K., White, P. D., Sakedo-Salgar, J. Am. Heart J. 1939, 18, 647. 3. Jetter, W., White, P. D. ibid. 1944, 21, 783. 4. Tucker, H. H., Carson, P. H. M., Bass, N. M., Sharratt, G. P., Stock,J.P P Br. med. J. 1973, i, 10. 5. Chatuverdi, N. C., Walsh, M. V., Evans, S. A., Munro, P., Boyle, D. M. Barber, J M. Br. Heart J. 1974, 36, 533. 6. Hayes, M. J., Morris, G. K., Hampton, J. R. ibid. p. 395. 7. White, N. M., Parker, W. S., Binning, R. A., Kimber, E. R., Ead, H W., Chamberlain, D. A. Br. med. J. 1973, iii, 618. 8. Seldon, W. A. Bibl. cardiol. 1977, no. 36, p. 118. 9. Critical Evaluation of Cardiac Rehabilitation (edited by J. J. Kellerman and H. Denolin). Bibl. cardiol. 1977, no. 36. 10. Palatsi, I. Acta med. scand. 1976, suppl. no. 599.
647
reinfarction tended
to
be less
common
than in the
con-
trols.
Many of the benefits of rehabilitation and exercise training are psychological rather than physiological: undoubtedly the quality of life is improved, if not its quantity. Thus, exercise training and rehabilitation cannot really be subjected to controlled trials because the plaeffect is an essential part of the treatment." Nevertheless, the proven safety of exercise training in ischaemic heart-disease, which has been demonstrated in many inquiries, together with its obvious benefits to physical and merital,health, make it desirable for most patients after myocardial infarction. Whether this is carried out in groups or alone, or is reinforced by group discussion as in an anti-coronary club, will depend on local resources, enthusiasms, and social cebo
(psychological)
customs.
PREGNANCY IN THE HEAVY DRINKER VERY few proven human teratogens it
are
known, and
of a shock when, in the early 1970s, David W. Smith and his colleagues in Seattle described, in a series of reports in The Lancet, a complex of abnormalities in infants born to mothers who drank heavily during their pregnancies. Even now the existence of a "fetal alcohol syndrome" is not universally accepted; there is no firm epidemiological base for calculation of the risk; and suggestions that termination of pregnancy should be discussed with or even urged on pregnant women who persist in drinking heavily are controversial. Now a group from Boston has produced a clearer picture, in a large series; of the early problems likely to be faced by an infant born to an alcohol abuser.’ Interpretation of the findings is blurred by the fact that, for various reasons; less than half the eligible pregnancies have been followed up and by the fact that the obstetric population seen at the Boston City Hospital is a high-risk one (more than a third of the babies born there are sent to intensive care). All the same the message is clear enough: "... there is a definitively increased risk to offspring of women who drink heavily during pregnancy", and this risk is manifest in abnormalities of growth and neurological assessment and in frequency of congenital anomalies (though no case of the fetal alcohol syndrome was found). 42 infants were born to heavy drinkers, defined as drinking at least 45 ml of absolute alcohol daily and in fact imbibing a daily average of 174 ml. The comparison groups were moderate or only very occasional drinkers. By almost every criterion the heavy drinkers’ babies were worse off-notably in frequency of hypotonia and jitteriness in the neurological assessment, in prematurity, low birth-weight, and small head circumference, and in frequency of major, minor, and multiple congenital anomalies. Termination apart, the only feasible preventive action is for the mother to cut down on her drinking. Twothirds of the women who did so in the Boston series had normal babies while all but 2 of the babies born to the 27 heavy drinkers who did not change their habits were 11. 1
abnormal. With such high risks of perinatal problems thought might, in desperation, be given to disulfiram. Pregnancy is a contraindication to the use of this drug, and on p. 664 Dr Nora and her colleagues report two cases of limb-reduction defects in babies born to women who took disulfiram while pregnant.
came as
something
Strasser, T Bibl. cardiol. 1977, no. 36, p. 99. Ouellette, E M., Rosett, H. L., Rosman, N. P., Weiner, Med. 1977, 297, 528.
L. New
Engl. J.
IS THE MEDICAL PROFESSION INEVITABLY PATRIARCHAL? IN the
hope of gaining more information on attitudes in medicine, Savage and Wilson1 sent 350 questionnaires to a random selection of doctors in Great to women
Britain drawn from the British Medical Association’s address system. Only a third of the questionnaires were returned, with rather less usable, so the findings must be viewed with some caution. Not surprisingly, a greater proportion of women than men replied, and the expected results emerged. The woman respondents believed that, though sex discrimination had been absent at medical school, they had suffered when they applied for hospital posts. Their main complaints were the lack of crche facilities at work and difficulty in obtaining domestic help at home. In general they saw themselves as especially well suited to branches of clinical practice such as obstetrics, gynaecology, paediatrics, family planning, sexual and marriage guidance counselling, venereology, geriatrics, and psychiatry. A booklet published by the Royal College of Physicians2 again draws attention to themethods whereby women doctors can train in part-time posts to become consultants,3 and encourages them to choose the shortage specialties-for example, geriatrics, psychiatry, ,
anaesthetics, or accident and emergency. Women docthey marry and have children, are temporarily at a disadvantage because of their multiple roles as doctor; wife, and mother; but the Department of Health is striving not to lose them completely during this phase.4 Manpower needs apart, do married women have anything special to contribute? An optimist would say that, with their family activities, they will be skilled at the practical and emotional aspects of caring; that they will not be forced into the male mould; and they might even do something to counter the trend towards officehours mentality, as the profession ponders selling its
tors, when
soul for cash or units of medical time. The different career prospects of men and women doctors are due to psychological and physiological factors as well as social ones. Only the last are susceptible to change. GoldbergS argues that most males are impelled by their hormones to seek dominance to a far greater extent than females and that it is this that leads to more men in the highest positions of authority. Yet attitudes too are important. As more women qualify in medicine, let us hope they will be properly represented on policymaking committees. -
1. Savage, R., Wilson, A. Jl R. Coll. gen. Practitioners, 1977, 27, 363. 2. Part-time Postgraduate Training in Medicine: report of the Standing Committee of the Royal College of Physicians, April, 1977. 3. The employment of women doctors. HM (69) 6. Department of Health and Social Security, 1969. 4. Women doctors’ retainer scheme. HM (72) 42. Department of Health and Social Security, 1972. 5. Goldberg, S. The Inevitability of Patriarchy. London, 1977.
ing
N.D.C.
In the realm of diagnosis, screening of the symptomfree population is not encouraged, but uneasiness is voiced at delays in diagnosis of those with symptoms. In mentioning experience in the United States with faecal occult-blood testing (often by patients themselves), the report does not point out that this is a test widely used at the bedside by American physicians, while in Great Britain it is wrongly regarded as a laboratory investigation, which increases its cost considerably. Exfoliative cytology is praised as a possibly effective method of screening high-risk groups, though the abbreviated report fails to clarify how this is to be done and what the difficulties are in patient-acceptability. Carcinoembryonic antigen has an airing, and it must be wondered whether the Medical Research Council has not missed the boat in setting up a trial to ask what value it has in the diagnosis and management of early recurrent rectal cancer. We would predict the answer to be "very little". Nevertheless, the search for chemical markers of malignancy is rightly encouraged, though the dream of a screening test for cancer done on a few ml of blood is obviously far from reality. For the non-researching clinician the passages on therapy are useful. The wide variations in results from different centres certainly need explaining. If one centre can produce a five-year survival of 41% for gastric cancer, why cannot all the others do so? The haphazardness of studies of chemotherapy and radiotherapy in these diseases is well illustrated. Because proper controlled trials are arduous and time-consuming to set up, the suggestion is that interested centres might form semi-permanent links (as have the British Breast Group) so that, once such questions as definition, staging, and data collection have been ironed out, whole series of trials could easily be mounted. All over the country there are clinicians sufficiently motivated to participate but lacking the time, resources, and number of patients to do the trials on their own. They only need coordinating for useful inquiries to be conducted, and the superiority of British studies of clinical management over North American ones (for reasons related to health-care systems) makes it important for this initiative to be taken.
CARDIAC REHABILITATION IT is 25 years since Levine and Lown’ challenged the dogma of prolonged immobilisation for patients with acute myocardial infarction by proposing their "armchair treatment". Until then, patients were kept in bed for 6 weeks or longer, partly on the grounds that a firm myocardial scar was not formed for at least 6 weeks,2 and partly because of the curious observation that rupture of the myocardium was more common in mental-
hospital patients,3 presumably because they were mentally deranged and would not stay in bed. Since then the period of confinement to bed and hospital has become progressively shorter, and now it is generally advocated (and backed by evidence from controlled studies4-6) that mobilisation for patients with uncomplicated infarction should start on the 3rd and 4th day, leading to discharge home after 8-10 days. For the few patients whose infarction is complicated by cardiac failure, mobilisation should be delayed, but even for them it is usually unnecessary to delay discharge much beyond 2 weeks. At the same time it is becoming recognised that the natural history of the disease demands that patients with infarction should be admitted to hospital as early as possible and that paramedical staff rather than medical practitioners may be best fitted to organise this and to give emergency treatment during the very acute stage.’ Thus the rationale of hospital treatment for infarction has been strengthened by the knowledge that most of the lethal complications arise in the very acute stage and that recovery from uncomplicated infarction is rapid. After discharge from hospital the most important aim for the patient is a return to normal, productive, and happy life. Undoubtedly cardiac rehabilitation should start in the coronary-care unit, where the patient can nearly always be told truthfully that the early dangerous phase of his illness is over and that rapid recovery is expected. When this positive and reassuring idea is repeated by doctors and nurses during the patient’s stay in hospital and subsequently, patients rarely fail to become fully rehabilitated and to return to work within 4 to 8 weeks of the infarct. Thus, for most patients cardiac rehabilitation is merely a component of good medi8 cal management. Much has been written about
more detailed aspects of cardiac rehabilitation, and two new publications describe the proceedings of a conference on rehabilitation9 and the results of a controlled triapo in which the prognosis of 180 patients given physical training starting 10 weeks after the infarct was compared with that of 200 patients who had no physical training but performed a monthly ergometric test. This trial failed to showany significant effect on mortality or recurrent infarction in the trainers after 31 months, although both death and 1. Levine, S. A., Lown, B. J. Am. med. Ass. 1952, 148, 1365. 2. Mallory, G. K., White, P. D., Sakedo-Salgar, J. Am. Heart J. 1939, 18, 647. 3. Jetter, W., White, P. D. ibid. 1944, 21, 783. 4. Tucker, H. H., Carson, P. H. M., Bass, N. M., Sharratt, G. P., Stock,J.P P Br. med. J. 1973, i, 10. 5. Chatuverdi, N. C., Walsh, M. V., Evans, S. A., Munro, P., Boyle, D. M. Barber, J M. Br. Heart J. 1974, 36, 533. 6. Hayes, M. J., Morris, G. K., Hampton, J. R. ibid. p. 395. 7. White, N. M., Parker, W. S., Binning, R. A., Kimber, E. R., Ead, H W., Chamberlain, D. A. Br. med. J. 1973, iii, 618. 8. Seldon, W. A. Bibl. cardiol. 1977, no. 36, p. 118. 9. Critical Evaluation of Cardiac Rehabilitation (edited by J. J. Kellerman and H. Denolin). Bibl. cardiol. 1977, no. 36. 10. Palatsi, I. Acta med. scand. 1976, suppl. no. 599.
647
reinfarction tended
to
be less
common
than in the
con-
trols.
Many of the benefits of rehabilitation and exercise training are psychological rather than physiological: undoubtedly the quality of life is improved, if not its quantity. Thus, exercise training and rehabilitation cannot really be subjected to controlled trials because the plaeffect is an essential part of the treatment." Nevertheless, the proven safety of exercise training in ischaemic heart-disease, which has been demonstrated in many inquiries, together with its obvious benefits to physical and merital,health, make it desirable for most patients after myocardial infarction. Whether this is carried out in groups or alone, or is reinforced by group discussion as in an anti-coronary club, will depend on local resources, enthusiasms, and social cebo
(psychological)
customs.
PREGNANCY IN THE HEAVY DRINKER VERY few proven human teratogens it
are
known, and
of a shock when, in the early 1970s, David W. Smith and his colleagues in Seattle described, in a series of reports in The Lancet, a complex of abnormalities in infants born to mothers who drank heavily during their pregnancies. Even now the existence of a "fetal alcohol syndrome" is not universally accepted; there is no firm epidemiological base for calculation of the risk; and suggestions that termination of pregnancy should be discussed with or even urged on pregnant women who persist in drinking heavily are controversial. Now a group from Boston has produced a clearer picture, in a large series; of the early problems likely to be faced by an infant born to an alcohol abuser.’ Interpretation of the findings is blurred by the fact that, for various reasons; less than half the eligible pregnancies have been followed up and by the fact that the obstetric population seen at the Boston City Hospital is a high-risk one (more than a third of the babies born there are sent to intensive care). All the same the message is clear enough: "... there is a definitively increased risk to offspring of women who drink heavily during pregnancy", and this risk is manifest in abnormalities of growth and neurological assessment and in frequency of congenital anomalies (though no case of the fetal alcohol syndrome was found). 42 infants were born to heavy drinkers, defined as drinking at least 45 ml of absolute alcohol daily and in fact imbibing a daily average of 174 ml. The comparison groups were moderate or only very occasional drinkers. By almost every criterion the heavy drinkers’ babies were worse off-notably in frequency of hypotonia and jitteriness in the neurological assessment, in prematurity, low birth-weight, and small head circumference, and in frequency of major, minor, and multiple congenital anomalies. Termination apart, the only feasible preventive action is for the mother to cut down on her drinking. Twothirds of the women who did so in the Boston series had normal babies while all but 2 of the babies born to the 27 heavy drinkers who did not change their habits were 11. 1
abnormal. With such high risks of perinatal problems thought might, in desperation, be given to disulfiram. Pregnancy is a contraindication to the use of this drug, and on p. 664 Dr Nora and her colleagues report two cases of limb-reduction defects in babies born to women who took disulfiram while pregnant.
came as
something
Strasser, T Bibl. cardiol. 1977, no. 36, p. 99. Ouellette, E M., Rosett, H. L., Rosman, N. P., Weiner, Med. 1977, 297, 528.
L. New
Engl. J.
IS THE MEDICAL PROFESSION INEVITABLY PATRIARCHAL? IN the
hope of gaining more information on attitudes in medicine, Savage and Wilson1 sent 350 questionnaires to a random selection of doctors in Great to women
Britain drawn from the British Medical Association’s address system. Only a third of the questionnaires were returned, with rather less usable, so the findings must be viewed with some caution. Not surprisingly, a greater proportion of women than men replied, and the expected results emerged. The woman respondents believed that, though sex discrimination had been absent at medical school, they had suffered when they applied for hospital posts. Their main complaints were the lack of crche facilities at work and difficulty in obtaining domestic help at home. In general they saw themselves as especially well suited to branches of clinical practice such as obstetrics, gynaecology, paediatrics, family planning, sexual and marriage guidance counselling, venereology, geriatrics, and psychiatry. A booklet published by the Royal College of Physicians2 again draws attention to themethods whereby women doctors can train in part-time posts to become consultants,3 and encourages them to choose the shortage specialties-for example, geriatrics, psychiatry, ,
anaesthetics, or accident and emergency. Women docthey marry and have children, are temporarily at a disadvantage because of their multiple roles as doctor; wife, and mother; but the Department of Health is striving not to lose them completely during this phase.4 Manpower needs apart, do married women have anything special to contribute? An optimist would say that, with their family activities, they will be skilled at the practical and emotional aspects of caring; that they will not be forced into the male mould; and they might even do something to counter the trend towards officehours mentality, as the profession ponders selling its
tors, when
soul for cash or units of medical time. The different career prospects of men and women doctors are due to psychological and physiological factors as well as social ones. Only the last are susceptible to change. GoldbergS argues that most males are impelled by their hormones to seek dominance to a far greater extent than females and that it is this that leads to more men in the highest positions of authority. Yet attitudes too are important. As more women qualify in medicine, let us hope they will be properly represented on policymaking committees. -
1. Savage, R., Wilson, A. Jl R. Coll. gen. Practitioners, 1977, 27, 363. 2. Part-time Postgraduate Training in Medicine: report of the Standing Committee of the Royal College of Physicians, April, 1977. 3. The employment of women doctors. HM (69) 6. Department of Health and Social Security, 1969. 4. Women doctors’ retainer scheme. HM (72) 42. Department of Health and Social Security, 1972. 5. Goldberg, S. The Inevitability of Patriarchy. London, 1977.
