440
their genes were unchanged. In contrast, in the general population neither mortality rates from this disease nor tobacco consumption fell. The hypothesis that smoking is the major cause of lung cancer does not imply that genetic7 and other factors may not predispose certain smokers to the carcinogenic effects of smoking. But those who publicly assert that people who develop lung cancer were predestined to die from this disease, and that their smoking was irrelevant, do more than ignore the evidence to the contrary: sadly, they may encourage others to smoke cigarettes. Burch has stated that only studies of identical twins with discordant smoking habits will provide a definitive answer to whether the causative or the constitutional hypothesis will explain most cases of the disease. The consequences for being wrong in this matter are serious, and we suspect that doctors will not be attracted by the odds in such a gamble with their patients' lives, even if it is excused by a wish to learn the results of ongoing twin studies which may take decades to complete. 1
Times, 18 August, 1975, p 2. Burch, P R J, Guardian, 22 August, 1975. 3Wald, N, et al, Thorax, 1975, 30, 113. 4Doll, R, and Hill, A B, British Medical Journal, 1964, 1, 1460. 5Doll, R, and Hill, A B, British Medical_Journal, 1952, 2, 1271. " Doll, R,J_ournal of the Royal Statistical Society (Series A), 1971, 134, 133. 7Tokuhata, G, and Lilienfeld, A M,Jrournal of the National Cancer Institute, 1963, 30, 289.
BRITISH MEDICAL JOURNAL
21 AUGUST 1976
previous tendency to these symptoms.4 In this particular study of infectious mononucleosis the identity of the disease was thoroughly proved, but there are grounds for uncertainty about the nature of glandular fever in general, which so easily becomes a convenient label for any febrile illness with lymphadenopathy. Perhaps depression and anxiety call attention to trivial fever and glandular enlargement, or, more probably, a host of unknown viruses may cause glandular-fever-like illnesses with a similar predisposition to psychiatric symptoms. The good rector's exhortation to "keep his spirits up" often proves lamentably inadequate treatment. The medium to long term prognosis may be good, but at the time depression may be profound and the suicidal risk real.4 Explanation and assurance of an eventually complete recovery are important and sometimes sufficient treatment, but a period of treatment with tricyclic antidepressants may be necessary. I 2
3 4
Sayers, D L, The Nine Taylors. London, Gollancz, 1934. Carranza-Acevedo, J, Pharmakopsychiatrie, 1974, 7, 164. Cadie, M, Nye, F J, and Storey, P, British Journal of Psychiatry, 1976, 128, 559. Martini, G A, and Strohmeyer, G, Clinics in Gastroenterology, 1974, 3, 378.
2
Low spirits after virus infections "Tell him to keep his spirits up. Such a nasty depressing complaint...." Thus the rector of Fenchurch St Paul' expressed the common view that influenza and other virus infections predispose to depression, whether immediately or as a late sequel to the illness. As with many firm clinical impressions, proof is remarkably difficult to obtain. Bacterial infections seem to cause depression in proportion to the severity and duration of the illness in a rational and predictable way. It is also no surprise that virus meningoencephalitis predisposes to psychoses. But the strong impression exists that any virus illness may be accompanied by or be succeeded weeks or months later by incapacitating anxiety or depression, though the illness itself may have been mild and without clinical signs to suggest infection of the central nervous system.2 However, this may only show how blunt are the methods for assessing acute disease of the central nervous system. Influenza, infectious mononucleosis, virus hepatitis, and symptomatic herpes simplex infections have all been accused of causing depression, the evidence being perhaps least convincing for herpes simplex.2 An investigation by subjective interview and objective questionnaire of anxiety and depression in unselected patients one year after infectious mononucleosis produced the remarkable finding that women were affected but men were not. This difference in susceptibility to depression and anxiety was evident not only after infection but also before,3 so that the infection seemed to unmask or to exacerbate a pre-existing tendency to these disorders. But to generalise from infectious mononucleosis to all virus infections would be unwise, for profound anxiety and depression have been reported after virus hepatitis in patients without any
Children with appendicitis "When in doubt, take it out" is a well known aphorism relating to the management of patients suspected of having acute appendicitis. As with other useful guidelines, it is best applied by a wise and skilful clinician. Indiscriminate laparotomy every time appendicitis is a possibility would be in no one's best interests. This is particularly so for children, in whom the presentation may be unusual and other conditions readily mimic the symptoms and signs of appendicitis. Appendicitis is rare below the age of 1 year and thereafter increases in prevalence. Although the incidence is lower in preschool children than in children over the age of 5, the morbidity and mortality are higher. This is partly because of the difficulty of obtaining a clear history and of performing a reliable examination on an ill, frightened young child. There are also differences in presentation. In children the classical early central abdominal colic is not always followed by continuous deep pain in the right iliac fossa. Vomiting is usual but not inevitable. There may be diarrhoea, constipation, or no bowel upset at all. The difficulties are compounded by the number of other conditions which may mimic appendicitis. Some, such as intussusception, require laparotomy in their own right; others, such as mesenteric adenitis, may require laparotomy to achieve a definite diagnosis. Others should be diagnosed without laparotomy, among them diabetes mellitus, infectious hepatitis, urinary tract infection from the history and examination of urine, and sickle cell disease by the race and the history. But many will be more difficult to diagnose. In practice gastroenteritis creates much confusion, particularly when the pain precedes either the vomiting or diarrhoea by several hours. It is always worth asking if other members of the family have or have had gastroenteritis recently. Constipation, too, may cause dramatic pain and tenderness in children. A rectal examination, supplemented if necessary by a suppository or disposable enema, should allow the correct
diagnosis. Respiratory tract infections are a frequent cause ofconfusion. Such infections are themselves common, and while any febrile
BRITISH MEDICAL JOURNAL
21 AUGUST 1976
illness may be associated with abdominal pain respiratory infections appear to be particularly likely to cause alimentary symptoms. The textbooks usually refer to right lower lobe pneumonia as being the chief culprit. Nevertheless, a recent report suggests that any basal pneumonia (left or right) can cause symptoms and signs indistinguishable from those of acute appendicitis. Of 250 children presenting with an acute abdomen 12 had a basal pneumonia as the sole cause.' Eight of the children had mild respiratory symptoms and four none at all. Physical findings in the chest were considered normal in all but two of the 12, so that pneumonia was not diagnosed until after x-ray examination. The abdominal pain was severe and sustained, and associated with abdominal tenderness and sometimes absent bowel sounds. This report certainly suggests that in addition to the usual history, examination, and urine tests it is often worth having a chest x-ray film taken of many children presenting with an acute abdomen. The examination should include a good lateral film to display consolidation hidden by the diaphragm in the usual posteroanterior film. When pneumonia is present it will generally be the sole cause of the alimentary symptoms. But it must always be remembered that Winsey and Jones2 reported a series of 114 children with definite appendicitis, of whom eight had respiratory tract signs and two had pneumonia in addition. I 2
Jona, J
Z, and Belin, R P, Archives of Surgery, 1976, 111, 552.
Winsey, H S, and Jones, P F, British Medical3Journal, 1967, 1, 653.
Food and nutrition policies The proposal' by the EEC Commission to tax edible oils so as to make margarine as expensive as butter (of which western Europe has a surplus) would, if carried through, adversely affect the prevention of rickets and osteomalacia,2 the management of hypercholesterolaemia,3 and the nutrition of families with four or more children, whose calorie intake has been falling and now appears to be too low.4 Economists and politicians should take care to obtain sound advice before changing the relative prices of foods, even those that look or taste similar. Despite our outstanding achievements in nutrition during
the second world war Britain has had no integral official food policy since the end of rationing. We do have recommended intakes. These are for calories, protein, six vitamins, and two minerals,5 and the recommendations are now being revised.
Intakes of these nutrients are monitored regularly,6 and it appears to be implicit Government policy to see that most people are able to consume the recommended amounts of these selected nutrients. However, there is more to good nutrition than eating enough riboflavin and vitamin A. The report on recommended intakes5 advises that at least 1000 of our energy (calorie) intake should be provided by protein, but it does not suggest where the remaining 900/ of our food energy should come from. On the average we obtain 12%// of our
energy from protein, 41% from fat, and 46% from carbohydrates,6 and in addition to this another 5-3% per head
of total population now comes from alcoholic drinks.6 Several developing countries have worked out national food and nutrition policies as a part of development planningessential when sections of their populations are malnourished. The food policy and nutrition division of the FAO is providing stimulus and guidance.7 8 In Europe the first country to pro-
441
duce an integrated food and nutrition policy is Norway.'9 10 The Norwegian plan, which is in line with the recommendations of the 1974 World Food Conference, will encourage healthy dietary habits, increase self-sufficiency in food production, and do this in such a way as to stabilise population settlement in the economically weaker areas of the country. The principal change in the Norwegian diet will be a halt in the current increase in meat consumption, a fall in consumption of saturated fat, and a rise in that of cereals and fish-within the Norwegian tradition of meal patterns. In Britain the recent Government White Paper Foodfrom Our Own Resources" did not consider health aspects in its recommendations, which include increased production of milk, beef, and sugar beet. Surely, however, it is not in farmers' long-term interests that future agricultural development should be planned without taking into account its ultimate usenourishing the population. Equally, nutritional advice for large numbers of people (such as that in the report12 of the Royal College of Physicians and British Cardiac Society) must consider the economic and social effects of changes in demand for agricultural produce. Under the catchy title "Eating our way out of debt and disease" Blythe"3 has recently presented the case that Britain ought to be considering seriously a radical new food and nutrition policy, as the Norwegians have done. Nutrition programmes are most unlikely to become realities unless food production, health education, and food pricing are all working in the same direction.'4 Generation of a food and nutrition policy will require collaboration among the Department of Health, the Ministry of Agriculture, the Department of Prices, and the Department of Education as well as representatives of farmers, food manufacturers, and consumer interests. Neither prices nor the consumption patterns of food in Britain are going to stay static. That being so, it would surely be better to try to plan the direction of future change rather than leave matters entirely to chance, politicians, and economists. For example, having abandoned the cod dispute with Iceland, we should be looking at all the implications-the loss of jobs and investment, the change of culinary and dietetic habits, and the loss of nutrients such as iodine. What are the alternatives and how much are we prepared to pay for them? A start could and should be made towards integrating and planning nutrition and food policies in Britain. Furthermore, sensible and regular nutritional advice should be incorporated in the Common Agricultural Policy of the EEC. The Guardian, 10 July, 1975. 2 British Medical3Journal, 1968, 2, 130. Davidson, S, et al, Human Nutrition and Dietetics. Edinburgh, Churchill Livingstone, 1975. 4 Ministry of Agriculture, Fisheries and Food, National Food Survey: Household Food Consumption in the First Quarter of 1974, in Food Facts. London, Ministry of Agriculture, Fisheries and Food, 1976. 5 Department of Health and Social Security, Recommended Intakes of Nutrients for the United Kingdom. Reports on Public Health and Medical Subjects No 120, London, HMSO, 1969. 6Ministry of Agriculture, Fisheries and Food, Household Food Consumption and Expenditure: 1974. Annual Report of the National Food Survey Committee, London, HMSO, 1976. Ganzin, M, Food and Nutrition, 1975, 1, 2. 8 Joy, L, and Payne, P, Food and Nutrition Planning. Nutrition Consultants Theports Series No 35, Rome, FAO, 1975. 9 >sorwegian Ministry of Agriculture, Report to the Storting No 32 (197576), On Norwegian Nutrition and Food Policy. Oslo, Royal Norwegian Ministry of Agriculture, 1975. '0 Eeg-Larsen, N, and 0grim, M E, at Second British Nutrition Foundation Conference, Cambridge, 1-4 April, 1976. 1 Food From Our Own Resources, Cmd 6020. London, HMSO, 1975. 12 Report of a Joint Working Party of the Royal College of Physicians of London and the British Cardiac Society, Prevention of Coronary Heart Disease. Journal of the Royal College of Physicians, 1976, 10, 213. 13 Blythe, C, New Scientist, 1976, 70, 278. 14 Blythe, C, Food Policy, 1976, 1, 91.
their genes were unchanged. In contrast, in the general population neither mortality rates from this disease nor tobacco consumption fell. The hypothesis that smoking is the major cause of lung cancer does not imply that genetic7 and other factors may not predispose certain smokers to the carcinogenic effects of smoking. But those who publicly assert that people who develop lung cancer were predestined to die from this disease, and that their smoking was irrelevant, do more than ignore the evidence to the contrary: sadly, they may encourage others to smoke cigarettes. Burch has stated that only studies of identical twins with discordant smoking habits will provide a definitive answer to whether the causative or the constitutional hypothesis will explain most cases of the disease. The consequences for being wrong in this matter are serious, and we suspect that doctors will not be attracted by the odds in such a gamble with their patients' lives, even if it is excused by a wish to learn the results of ongoing twin studies which may take decades to complete. 1
Times, 18 August, 1975, p 2. Burch, P R J, Guardian, 22 August, 1975. 3Wald, N, et al, Thorax, 1975, 30, 113. 4Doll, R, and Hill, A B, British Medical Journal, 1964, 1, 1460. 5Doll, R, and Hill, A B, British Medical_Journal, 1952, 2, 1271. " Doll, R,J_ournal of the Royal Statistical Society (Series A), 1971, 134, 133. 7Tokuhata, G, and Lilienfeld, A M,Jrournal of the National Cancer Institute, 1963, 30, 289.
BRITISH MEDICAL JOURNAL
21 AUGUST 1976
previous tendency to these symptoms.4 In this particular study of infectious mononucleosis the identity of the disease was thoroughly proved, but there are grounds for uncertainty about the nature of glandular fever in general, which so easily becomes a convenient label for any febrile illness with lymphadenopathy. Perhaps depression and anxiety call attention to trivial fever and glandular enlargement, or, more probably, a host of unknown viruses may cause glandular-fever-like illnesses with a similar predisposition to psychiatric symptoms. The good rector's exhortation to "keep his spirits up" often proves lamentably inadequate treatment. The medium to long term prognosis may be good, but at the time depression may be profound and the suicidal risk real.4 Explanation and assurance of an eventually complete recovery are important and sometimes sufficient treatment, but a period of treatment with tricyclic antidepressants may be necessary. I 2
3 4
Sayers, D L, The Nine Taylors. London, Gollancz, 1934. Carranza-Acevedo, J, Pharmakopsychiatrie, 1974, 7, 164. Cadie, M, Nye, F J, and Storey, P, British Journal of Psychiatry, 1976, 128, 559. Martini, G A, and Strohmeyer, G, Clinics in Gastroenterology, 1974, 3, 378.
2
Low spirits after virus infections "Tell him to keep his spirits up. Such a nasty depressing complaint...." Thus the rector of Fenchurch St Paul' expressed the common view that influenza and other virus infections predispose to depression, whether immediately or as a late sequel to the illness. As with many firm clinical impressions, proof is remarkably difficult to obtain. Bacterial infections seem to cause depression in proportion to the severity and duration of the illness in a rational and predictable way. It is also no surprise that virus meningoencephalitis predisposes to psychoses. But the strong impression exists that any virus illness may be accompanied by or be succeeded weeks or months later by incapacitating anxiety or depression, though the illness itself may have been mild and without clinical signs to suggest infection of the central nervous system.2 However, this may only show how blunt are the methods for assessing acute disease of the central nervous system. Influenza, infectious mononucleosis, virus hepatitis, and symptomatic herpes simplex infections have all been accused of causing depression, the evidence being perhaps least convincing for herpes simplex.2 An investigation by subjective interview and objective questionnaire of anxiety and depression in unselected patients one year after infectious mononucleosis produced the remarkable finding that women were affected but men were not. This difference in susceptibility to depression and anxiety was evident not only after infection but also before,3 so that the infection seemed to unmask or to exacerbate a pre-existing tendency to these disorders. But to generalise from infectious mononucleosis to all virus infections would be unwise, for profound anxiety and depression have been reported after virus hepatitis in patients without any
Children with appendicitis "When in doubt, take it out" is a well known aphorism relating to the management of patients suspected of having acute appendicitis. As with other useful guidelines, it is best applied by a wise and skilful clinician. Indiscriminate laparotomy every time appendicitis is a possibility would be in no one's best interests. This is particularly so for children, in whom the presentation may be unusual and other conditions readily mimic the symptoms and signs of appendicitis. Appendicitis is rare below the age of 1 year and thereafter increases in prevalence. Although the incidence is lower in preschool children than in children over the age of 5, the morbidity and mortality are higher. This is partly because of the difficulty of obtaining a clear history and of performing a reliable examination on an ill, frightened young child. There are also differences in presentation. In children the classical early central abdominal colic is not always followed by continuous deep pain in the right iliac fossa. Vomiting is usual but not inevitable. There may be diarrhoea, constipation, or no bowel upset at all. The difficulties are compounded by the number of other conditions which may mimic appendicitis. Some, such as intussusception, require laparotomy in their own right; others, such as mesenteric adenitis, may require laparotomy to achieve a definite diagnosis. Others should be diagnosed without laparotomy, among them diabetes mellitus, infectious hepatitis, urinary tract infection from the history and examination of urine, and sickle cell disease by the race and the history. But many will be more difficult to diagnose. In practice gastroenteritis creates much confusion, particularly when the pain precedes either the vomiting or diarrhoea by several hours. It is always worth asking if other members of the family have or have had gastroenteritis recently. Constipation, too, may cause dramatic pain and tenderness in children. A rectal examination, supplemented if necessary by a suppository or disposable enema, should allow the correct
diagnosis. Respiratory tract infections are a frequent cause ofconfusion. Such infections are themselves common, and while any febrile
BRITISH MEDICAL JOURNAL
21 AUGUST 1976
illness may be associated with abdominal pain respiratory infections appear to be particularly likely to cause alimentary symptoms. The textbooks usually refer to right lower lobe pneumonia as being the chief culprit. Nevertheless, a recent report suggests that any basal pneumonia (left or right) can cause symptoms and signs indistinguishable from those of acute appendicitis. Of 250 children presenting with an acute abdomen 12 had a basal pneumonia as the sole cause.' Eight of the children had mild respiratory symptoms and four none at all. Physical findings in the chest were considered normal in all but two of the 12, so that pneumonia was not diagnosed until after x-ray examination. The abdominal pain was severe and sustained, and associated with abdominal tenderness and sometimes absent bowel sounds. This report certainly suggests that in addition to the usual history, examination, and urine tests it is often worth having a chest x-ray film taken of many children presenting with an acute abdomen. The examination should include a good lateral film to display consolidation hidden by the diaphragm in the usual posteroanterior film. When pneumonia is present it will generally be the sole cause of the alimentary symptoms. But it must always be remembered that Winsey and Jones2 reported a series of 114 children with definite appendicitis, of whom eight had respiratory tract signs and two had pneumonia in addition. I 2
Jona, J
Z, and Belin, R P, Archives of Surgery, 1976, 111, 552.
Winsey, H S, and Jones, P F, British Medical3Journal, 1967, 1, 653.
Food and nutrition policies The proposal' by the EEC Commission to tax edible oils so as to make margarine as expensive as butter (of which western Europe has a surplus) would, if carried through, adversely affect the prevention of rickets and osteomalacia,2 the management of hypercholesterolaemia,3 and the nutrition of families with four or more children, whose calorie intake has been falling and now appears to be too low.4 Economists and politicians should take care to obtain sound advice before changing the relative prices of foods, even those that look or taste similar. Despite our outstanding achievements in nutrition during
the second world war Britain has had no integral official food policy since the end of rationing. We do have recommended intakes. These are for calories, protein, six vitamins, and two minerals,5 and the recommendations are now being revised.
Intakes of these nutrients are monitored regularly,6 and it appears to be implicit Government policy to see that most people are able to consume the recommended amounts of these selected nutrients. However, there is more to good nutrition than eating enough riboflavin and vitamin A. The report on recommended intakes5 advises that at least 1000 of our energy (calorie) intake should be provided by protein, but it does not suggest where the remaining 900/ of our food energy should come from. On the average we obtain 12%// of our
energy from protein, 41% from fat, and 46% from carbohydrates,6 and in addition to this another 5-3% per head
of total population now comes from alcoholic drinks.6 Several developing countries have worked out national food and nutrition policies as a part of development planningessential when sections of their populations are malnourished. The food policy and nutrition division of the FAO is providing stimulus and guidance.7 8 In Europe the first country to pro-
441
duce an integrated food and nutrition policy is Norway.'9 10 The Norwegian plan, which is in line with the recommendations of the 1974 World Food Conference, will encourage healthy dietary habits, increase self-sufficiency in food production, and do this in such a way as to stabilise population settlement in the economically weaker areas of the country. The principal change in the Norwegian diet will be a halt in the current increase in meat consumption, a fall in consumption of saturated fat, and a rise in that of cereals and fish-within the Norwegian tradition of meal patterns. In Britain the recent Government White Paper Foodfrom Our Own Resources" did not consider health aspects in its recommendations, which include increased production of milk, beef, and sugar beet. Surely, however, it is not in farmers' long-term interests that future agricultural development should be planned without taking into account its ultimate usenourishing the population. Equally, nutritional advice for large numbers of people (such as that in the report12 of the Royal College of Physicians and British Cardiac Society) must consider the economic and social effects of changes in demand for agricultural produce. Under the catchy title "Eating our way out of debt and disease" Blythe"3 has recently presented the case that Britain ought to be considering seriously a radical new food and nutrition policy, as the Norwegians have done. Nutrition programmes are most unlikely to become realities unless food production, health education, and food pricing are all working in the same direction.'4 Generation of a food and nutrition policy will require collaboration among the Department of Health, the Ministry of Agriculture, the Department of Prices, and the Department of Education as well as representatives of farmers, food manufacturers, and consumer interests. Neither prices nor the consumption patterns of food in Britain are going to stay static. That being so, it would surely be better to try to plan the direction of future change rather than leave matters entirely to chance, politicians, and economists. For example, having abandoned the cod dispute with Iceland, we should be looking at all the implications-the loss of jobs and investment, the change of culinary and dietetic habits, and the loss of nutrients such as iodine. What are the alternatives and how much are we prepared to pay for them? A start could and should be made towards integrating and planning nutrition and food policies in Britain. Furthermore, sensible and regular nutritional advice should be incorporated in the Common Agricultural Policy of the EEC. The Guardian, 10 July, 1975. 2 British Medical3Journal, 1968, 2, 130. Davidson, S, et al, Human Nutrition and Dietetics. Edinburgh, Churchill Livingstone, 1975. 4 Ministry of Agriculture, Fisheries and Food, National Food Survey: Household Food Consumption in the First Quarter of 1974, in Food Facts. London, Ministry of Agriculture, Fisheries and Food, 1976. 5 Department of Health and Social Security, Recommended Intakes of Nutrients for the United Kingdom. Reports on Public Health and Medical Subjects No 120, London, HMSO, 1969. 6Ministry of Agriculture, Fisheries and Food, Household Food Consumption and Expenditure: 1974. Annual Report of the National Food Survey Committee, London, HMSO, 1976. Ganzin, M, Food and Nutrition, 1975, 1, 2. 8 Joy, L, and Payne, P, Food and Nutrition Planning. Nutrition Consultants Theports Series No 35, Rome, FAO, 1975. 9 >sorwegian Ministry of Agriculture, Report to the Storting No 32 (197576), On Norwegian Nutrition and Food Policy. Oslo, Royal Norwegian Ministry of Agriculture, 1975. '0 Eeg-Larsen, N, and 0grim, M E, at Second British Nutrition Foundation Conference, Cambridge, 1-4 April, 1976. 1 Food From Our Own Resources, Cmd 6020. London, HMSO, 1975. 12 Report of a Joint Working Party of the Royal College of Physicians of London and the British Cardiac Society, Prevention of Coronary Heart Disease. Journal of the Royal College of Physicians, 1976, 10, 213. 13 Blythe, C, New Scientist, 1976, 70, 278. 14 Blythe, C, Food Policy, 1976, 1, 91.
