cardiorespiratory disease and in those who have undergone multiple abdominal operations. Although patients with acute complications of gall stone disease can be managed by laparoscopic cholecystectomy, even surgeons expert at the technique treat few such patients. At the Middlesex Hospital we have a separate experience of percutaneous cholecystolithotomy from that reported by Mr S G Chiverton and colleagues at the London Clinic2 (misquoted by Mr A E Stuart'). Of the 96 patients who have undergone percutaneous cholecystolithotomy, 28% were referred because surgery entailed a high risk and they were therefore unsuitable for laparoscopic cholecystectomy. Sixteen per cent of the patients presented with an acute complication of gall stone disease. Percutaneous drainage of the acutely inflamed gall bladder rapidly relieved symptoms and, after percutaneous cholecystolithotomy, resulted in complete resolution usually with a return of normal gall bladder function. In elderlv people with gall bladders jaundice due to bile duct stones may be managed by endoscopic sphincterotomy and stone extraction without additional treatment for the stones. Only 15% of these patients develop further symptoms that require treatment.4 Apart from patients at high risk and those with acute complications of gall stone disease, some patients who are suitable for surgery do not wish to undergo cholecystectomy despite the risk of developing recurrent stones. Of the patients referred to our gall stone clinic over the past two years, almost 200 have been assessed for non-operative treatment at their own request or because they were at high risk or elderly. We have found that 77% are suitable for percutaneous cholecystolithotomy, which contrasts with selection for other non-operative methods. Patients are offered percutaneous cholecystolithotomy, extracorporeal shockwave lithotripsy, laparoscopic cholecystectomy, or minicholecystectomy. Whether laparoscopic cholecystectomy, minicholecystectomy, or even a minimally invasive method proves to be the preferable treatment, there will be an increasing requirement for the specialist with experience of all the above techniques to offer a personalised approach to the varied presentation of biliary tract stones. S CHESLYN-CURTIS R C G RUSSELL Middlesex Hospital, London WIN 8AA I Coleman J, Spangenberger W, Paul A, Klein J, Troidl H. Percutaneous cholecystolithotomy. Br Med J 1990;301:120.
(14 July.) 2 Chiverton SG, Inglis JA, Hudd C, Kellett MJ, Russell RCG, Wickham JEA. Percutaneous cholecystolithotomy: the first 60 patients. BrMedJ 1990;300:1310-2. (19 May.) 3 Stuart AE. Percutaneous cholecystolithotomy. Br Med 7
1990;301:120-1. (14 Julv.) Theis B, et al. Do patients need a cholecystectomy following endoscopic sphincterotomy for bile duct stones? Gut 1989;30:A1506.
4 Vaira D, Ainley CC,
Trauma of the spine and spinal cord SIR, -Mr Andrew Swain and colleagues describe radiological features of injuries to the cervical spine and, in particular, they discuss the presence of swelling of the prevertebral soft tissue.' It is important, however, to realise the limitations of this radiological sign. It occurs in only roughly half of all fractures of the cervical spine and even less commonly in fractures of the posterior vertebral elements.2' Enlargement of the prevertebral space is also seen in about a fifth of soft tissue injuries to the cervical spine without bony injury and is of no prognostic importance in such patients.4
340
The presence of swelling of the prevertebral soft tissue does not indicate the presence of a cervical spine fracture, and its absence does not exclude the possibility of such an injury; this sign should therefore be interpreted with caution. K A MILES
Addenbrooke's Hospital, Cambridge CB2 2QQ I Swain A, Dove J, Baker H. Trauma of the spine and spinal cord: 2. BrMedJ 1990;301:110-13. (14 July.) 2 Miles KA, Finlay D. Is prevertebral soft tissue swelling a useful sign in injury of the cervical spine? Injurv 1988;19:177-9. 3 Templeton PA, Young JWR, Mirvis SE, Buddemeyer EV. The value of retropharyngeal soft tissue measurements in trauma of the adult cervical spine. Skeletal Radiol 1987;16:98. 4 Miles KA, Maimaris C, Finlay D, Barnes M. The incidence and prognostic significance of radiological abnormalities in soft tissue in'juries of the cersical spine. Skeletal Radiol
1988;17:493-6.
Serological abnormalities in bird fancier's lung SIR,-We would like to comment on the Lesson of the Week by Dr Zarir Udwadia and colleagues on bird fancier's lung. ' It is not clear if the serological tests were complement fixation tests (although this is implied in the discussion), and the chlamydia antigen used is not specified. We were surprised that the presence of high antibody titres to four antigenically distinct organisms in a single serum specimen should have prompted a diagnosis of atypical pneumonia. The likely pathogen is not stated. Multiple infection with four organisms is unlikely. The authors imply that cross reactivity to yolk sac may have caused the raised titres. Influenza A and B viruses and chlamydia group B are usually derived from egg material but Mycoplasma pneumoniae is not.2 Unless the last antigen had (unusually) been derived from egg material, cross reactivity with yolk sac could not account for the raised mycoplasma titre. Innate anticomplementary activity of serum may give rise to false positive results in complement fixation tests. The authors do not state if control tests were performed to exclude this possibility. The use of amoxycillin and clavulanic acid to treat atypical pneumonia is unusual. Erythromycin or tetracycline would be the usual choice.4 In conclusion, we believe that the presence of high titres of antibody to four organisms made a diagnosis of atypical pneumonia unlikely and that an alternative explanation could have been sought from the outset. DERMOT P MAHER BARBARA A CROSSE
Seacroft Hospital, Leeds LS14 6UH I Udwadia ZF, Wright MJ, 1\cIntosh LG, Leitch AG. Confusing serological abnormalities in bird fancier's lung. Br Mled J
1990;300:1519. (9 June.) 2 McGee ZA, Taylor-Robinson D. Mvcoplasmas. In: Braude Al, et al, eds. Infectious diseases and medical microbiolov. 2nd ed. Philadelphia: W B Saunders, 1986:456-60. 3 Osebuld JW. Immunological diagnosis. In: Hoeprich PD, ed. Infectious diseases. 3rd ed. New York: Harper and Row, 1983:157-65. 4 Crompton GK, Grant IWB, NIcHardy GJR. Diseases of the respiratory system. In: Mlacleod J, ed. Davidson's principles and
practice of medicine. 14th ed. Edinburgh: Churchill Livingstone, 1984:202-77.
AUTHOR'S REPLY,-All the serological tests were complement fixation tests, the chlamydia antigen being psittacosis CF antigen supplied by the Central Public Health Laboratory (microbiological reagents and quality control). All complement fixation tests were carried out strictly according to the standard protocol,' and this included standard control tests to rule out innate anticomplementary activity of the serum. We are well aware that mycoplasma antigen is not
egg derived, and the reference quoted in our article2 makes it clear that it was influenza A and B viruses and chlamydia we were referring to. Finally, we agree with Drs Maher and Crosse that erythromycin is the antibiotic of choice for atypical pneumonia. Our article merely served to highlight the bewildering non-specific rises in viral and antibody titres that may, on occasion, accompany extrinsic allergic alveolitis and that compound the difficulty in distinguishing this from pneumonia. ZARIR F UDWADIA
South Cleveland Hospital, Cleveland TS4 3BW I Broadstreet CMP, Taylor CED. Complement fixation tests. Monthly Bulletin of the Ministry of Health and Public Health L aboratory Service 1962;21:%-lOO. 2 Taylor AJN, Taylor P, Bryant DH, Longbottom JL, Pepys J. False positive complement fixation tests with respiratory virus preparations in bird fanciers with allergic alveolitis. Thorax 1977;32:563-6.
SIR,-The confusing serology in bird fancier's lung described by Dr Zarir F Udwadia and colleagues is simply a consequence of polyclonal B cell stimulation.' This is a general feature of the alveolitides and may be important in helping to understand the more basic aspects of immunopathogenesis. The raised serum titres to respiratory viruses reported in acute bird fancier's lung have a similar profile to those in farmer's lung and are not simply due to antibody against egg antigens from virus cultures. These patients can also have very high total IgG concentrations, which we have shown to be polyclonal by isoelectric focusing, and the concentrations correlate quantitatively with the specific IgG antibody titre against avian antigens measured by radioimmunoassay.2 These observations prompted us to look at cellular immunity in 43 pigeon breeders with acute alveolitis (manuscript in preparation). Phenotypic analysis of peripheral blood lymphocytes with a range of monoclonal antibodies showed normal B cell numbers but increased T cell numbers in 21 patients consisting of raised CD4+ as well as CD8 + cells. The numbers of CD8 + cells in patients correlated with T cell numbers. In vitro lymphocyte proliferation assays (18 patients and 18 controls) showed that pigeon serum contained a potent non-specific cellular mitogenic component as well as a specific antigenic component recognised by the patients' antibodies. Thus the response to inhaled antigens in bird fancier's lung is more comprehensive than just specific antibody production and includes non-specific inflammation shown by raised total IgG concentrations and raised lymphocyte and natural killer cell counts, presumably induced by proinflammatory cytokines. We would suggest that these subjects are a valuable identifiable group in whom to study pulmonary immunology. FRANCES BRITTON CHARLES McSHARRY GAVIN BOYD Royal Infirmary, Glasgow G4 OSF I Udwadia ZF, Wright MJ, McIntosh LG, Leitch GA. Confusing serological abnormalities in bird fancier's lung. Br Med J7 1990;300:1519. (9 June.) 2 MicSharrv C. Immunological studies in extrinsic allergic alveolitis. Glasgow: University of Glasgow, 1984. (PhD thesis.)
Effect of maternal and child health on mortality SIR, - Dr Vincent Fauveau and colleagues' confirm what is known by many health workers from the developing world-namely, that effective provision of basic health care does reduce mortality'. This is a very important message.
BMJ
VOLUME 301
11
AUGUST
1990
In a prospective study of 640 consecutive hospital and clinic deliveries at Jane Furse Memorial Hospital, Lebowa, South Africa, in 1988 the perinatal mortality rate was 60/1000 births. One third of these deaths were considered easily avoidable: they were associated with failure to detect and treat severe anaemia and syphilis and the failure to refer patients with pre-eclampsia in the early stages. After these defects in care were identified it proved fairly easy to design and implement intervention strategies to try to prevent such deaths. Antenatal care was reorganised, standing orders for the management of antenatal problems were issued, the midwives were trained, and village clinics were supported. A comparative prospective study of 2193 consecutive deliveries in the seven months after implementation of the strategies found that the perinatal mortality rate had fallen to 40/1000 and deaths considered easily avoidable had been eliminated (ninth conference on priorities in perinatal care in South Africa, University of Witwatersrand, March 1990). The general standard of care improved appreciably. With an annual delivery of 4000, 80 perinatal deaths are prevented each year. The value of such work is that it proves that preventive measures can measurably reduce mortality. Health workers battling under enormous workloads should take heart and ensure that their curative and preventive strategies are balanced. I agree with Dr Fauveau and colleagues that much can be done while awaiting improved socioeconomic conditions. D WILKINSON
Newquay TR7 IDA 1 Fauveau V, Wojtyniak Bn Chakraborty J, et al. The effect of maternal and child health and family planning services on mortality: Is prevention enough? Br Med J 1990;301:103-7. (14 July.)
Low back pain: comparison of chiropractic and hospital outpatient treatment SIR,-It is perhaps surprising that despite the recent correspondence regarding their paper on back pain' Dr T W Meade and colleagues continue to assert that their results "make it necessary to consider the availability of chiropractic to NHS patients now."' Their study shows that one of the two treatment groups derived more long term benefits.2 The fact, however, that there were other important variables in addition to the availability or otherwise of chiropractic seems to have been largely ignored in the conclusions. The consequence of this is that the media have transmitted the simplified message that chiropractic heals backs without the necessary caveats that should have been more clearly presented in the original paper. This, I believe, has not helped the cause of manipulation. As a doctor trained in medical manipulation I am well aware of its potential benefits in treating musculoskeletal pain. It is not, however, a universal cure, and there already exist several competing schools of manipulative technique, each laying claim for special consideration. The specialty oforthopaedic medicine, which integrates manipulation into a structured medical framework, offers a sensible way forward. A department of orthopaedic medicine, run by Dr Cyriax, existed for many years at St Thomas's Hospital. It acquired a good international reputation, and its work is still recognised and quoted. Similar centres currently exist in Europe and North America. If manipulation is to be introduced into the NHS it should be properly planned. The ideal would be through departments of orthopaedic medicine set
BMJ
VOLUME 301
1 1 A'UGUST 1990
up in a few key centres, with suitable research facilities.3 To give precedence on the basis of this paper to one particular school of manipulation is unwarranted; nor is it helpful to the future development of a therapeutic technique that has much to offer prospective patients. ADAM A WARD
Royal London Homoeopathic Hospital, London WC IN 3HR 1 Correspondence. Low back pain: comparison of chiropractic and hospital outpatient treatment. Br Med J 1990;300:1647-50. (23 June.) 2 Meade TW, Dyer S, Browne W, Townsend J, Frank AO. Low back pain of mechanical origin: randomised comparison of chiropractic and hospital outpatient treatment. Br Med J 1990;300:1431-7. (2 June.) 3 Ward A. A limited role for manipulation? Br Med J 1987;294: 311.
SIR,-There can be no satisfaction gained in any quarter from the correspondence generated by the paper by Dr T W Meade and colleagues.' In April 1981, on behalf of the British Chiropractic Association, I approached Dr Meade, as the director of a prestigious Medical Research Council unit, about the possibility of a randomised controlled trial of our treatment for low back pain. The association's motives for doing this should be known and are as follows. Firstly, the association was unhappy with the legislative safeguards for the standards of practice and found the medical profession's representatives unwilling to undertake any dialogue about this because the effectiveness of chiropractic treatment was unproved. This impasse had to be overcome before initiatives towards obtaining statutory backing for standards of care and professional competence could hope to overcome medical opposition. Secondly, it was clear that growing public interest in heterodox medicine would make a clinical trial inevitable at some stage. The difficulty in designing such a trial made it necessary that it be approached with absolute evenhandedness and by someone with the ability to follow a close argument. In short, a flawed trial would have been worse than no trial at all. It was on the advice of the then chief scientist to the Department of Health and Social Security in the light of this that an approach to the Medical Research Council was made. Thirdly, at the time considerable pressure was being applied by groups of patients, who felt certain that if chiropractic could only "prove itself' all would be well for their interests. During the trial the chiropractors had many anxious moments, not least of which was when an article was published in The Times in 1985 quoting Dr Meade as listing as a possible consequence of an unfavourable outcome for chiropractic the restriction ofits practice. In the event chiropractors and patients with back pain can take no comfort from the response to the trial as it appears in your columns. Most of those commenting seem to have done so with irritation and apparently on impulse. Thus after eight years of work and many thousands of pounds spent on research few besides the authors themselves have so far exhibited a constructive attitude to the results. Surely a paper with such socioeconomic implications deserves to be read more carefully. A BREEN Anglo-European College of Chiropractic, Bournemouth BH5 2DF 1 Meade TW, Dyer S, Browne W, Townsend J, Frank AO. Low back pain of mechanical origin: randomised comparison of chiropractic and hospital outpatient treatment. Br Med J 1990;300:1431-7. (2 June.)
SIR,-I would like to take issue with Dr T W Meade and colleagues over their trial of treatment for back pain. The results do not bear the conclusion they wish to make,' and it is those conclusions
rather than the results that have captured the attention of the media. I pointed out to Dr Meade at the beginning of the trial that they were in danger of promoting chiropractic instead of a treatment modalityhigh velocity manipulation. This treatment is performed by many therapists but only chiropractors were included in the trial. It is also available in many hospital departments; I run such a clinic in one of the chosen centres, but again this was excluded from the trial. As "opponents" for the chiropractors Dr Meade and colleagues chose the hard pressed physiotherapists, who do not specialise in back treatments or necessarily use manipulation. They have many other priority groups to deal with and physiotherapy is only one of the many departments available in hospitals to treat back pain. Once again, none of these were included. That the chiropractors were working in the private sector, with funding, and had a vested interest in a positive result and that they were compared with physiotherapists working within the much more restrictive conditions of the NHS is further evidence of bias. I believe that the results from such a protocol cannot be taken seriously. Even with this favourable loading the chiropractors' results were only marginally better than those of the physiotherapists, and they gave their patients almost twice as many treatments. There is, however, a need for a properly constructed trial of manipulative treatment as the questions about it remain largely unanswered. BRIAN GURRY Plympton, Plymouth PL7 3DE I Meade TW, Dyer S, Browne W, Townsend J, Frank AO. Low back pain of mechanical origin: randomised comparison of chiropractic and hospital outpatient treatment. Br Med J
1990;300:1431-7. (2 June.)
AUTHORS' REPLY,-Dr Ward has misrepresented our results and provides a good example of the need, referred to by Mr Breen, for more careful consideration of what we actually said. We made it very clear that the trial was a comparison of two policies: chiropractic and hospital outpatient management. We ourselves pointed out that both (particularly hospital management) consist of several components. In each case one of these was manipulation. The relative effectiveness of different manipulative techniques is certainly a high priority for further trials. Until these have been carried out, however, it is premature for Dr Ward to suggest particular methods or administrative arrangements. Meanwhile, patients who cannot afford chiropractic privately can reasonably claim that they are being denied an effective treatment through the NHS. Provision of this treatment does not need to await full and detailed knowledge of which component is responsible for its value. Dr Gurry suggests lack of specialisation by physiotherapists as a possible explanation for the superiority of chiropractic, and earlier correspondents have made similar comments. ' Clearly, the role of general practitioners and others with special interests and skills should be taken into account in planning further studies. There was no question of actively excluding Dr Gurry's clinic from our trial, which was concerned with chiropractic in chiropractic clinics and with hospital management. In considering the extent to which chiropractic was more effective than hospital management, we should reiterate the distinction between the percentage point nature of the Oswestry scale and comparison of the two approaches expressed in percentage terms. By the last method at two and three years the benefit due to chiropractic was about 70% and 100% respectively more than the sum of spontaneous improvement and of any treatment effect in the
341
(14 July.) 2 Chiverton SG, Inglis JA, Hudd C, Kellett MJ, Russell RCG, Wickham JEA. Percutaneous cholecystolithotomy: the first 60 patients. BrMedJ 1990;300:1310-2. (19 May.) 3 Stuart AE. Percutaneous cholecystolithotomy. Br Med 7
1990;301:120-1. (14 Julv.) Theis B, et al. Do patients need a cholecystectomy following endoscopic sphincterotomy for bile duct stones? Gut 1989;30:A1506.
4 Vaira D, Ainley CC,
Trauma of the spine and spinal cord SIR, -Mr Andrew Swain and colleagues describe radiological features of injuries to the cervical spine and, in particular, they discuss the presence of swelling of the prevertebral soft tissue.' It is important, however, to realise the limitations of this radiological sign. It occurs in only roughly half of all fractures of the cervical spine and even less commonly in fractures of the posterior vertebral elements.2' Enlargement of the prevertebral space is also seen in about a fifth of soft tissue injuries to the cervical spine without bony injury and is of no prognostic importance in such patients.4
340
The presence of swelling of the prevertebral soft tissue does not indicate the presence of a cervical spine fracture, and its absence does not exclude the possibility of such an injury; this sign should therefore be interpreted with caution. K A MILES
Addenbrooke's Hospital, Cambridge CB2 2QQ I Swain A, Dove J, Baker H. Trauma of the spine and spinal cord: 2. BrMedJ 1990;301:110-13. (14 July.) 2 Miles KA, Finlay D. Is prevertebral soft tissue swelling a useful sign in injury of the cervical spine? Injurv 1988;19:177-9. 3 Templeton PA, Young JWR, Mirvis SE, Buddemeyer EV. The value of retropharyngeal soft tissue measurements in trauma of the adult cervical spine. Skeletal Radiol 1987;16:98. 4 Miles KA, Maimaris C, Finlay D, Barnes M. The incidence and prognostic significance of radiological abnormalities in soft tissue in'juries of the cersical spine. Skeletal Radiol
1988;17:493-6.
Serological abnormalities in bird fancier's lung SIR,-We would like to comment on the Lesson of the Week by Dr Zarir Udwadia and colleagues on bird fancier's lung. ' It is not clear if the serological tests were complement fixation tests (although this is implied in the discussion), and the chlamydia antigen used is not specified. We were surprised that the presence of high antibody titres to four antigenically distinct organisms in a single serum specimen should have prompted a diagnosis of atypical pneumonia. The likely pathogen is not stated. Multiple infection with four organisms is unlikely. The authors imply that cross reactivity to yolk sac may have caused the raised titres. Influenza A and B viruses and chlamydia group B are usually derived from egg material but Mycoplasma pneumoniae is not.2 Unless the last antigen had (unusually) been derived from egg material, cross reactivity with yolk sac could not account for the raised mycoplasma titre. Innate anticomplementary activity of serum may give rise to false positive results in complement fixation tests. The authors do not state if control tests were performed to exclude this possibility. The use of amoxycillin and clavulanic acid to treat atypical pneumonia is unusual. Erythromycin or tetracycline would be the usual choice.4 In conclusion, we believe that the presence of high titres of antibody to four organisms made a diagnosis of atypical pneumonia unlikely and that an alternative explanation could have been sought from the outset. DERMOT P MAHER BARBARA A CROSSE
Seacroft Hospital, Leeds LS14 6UH I Udwadia ZF, Wright MJ, 1\cIntosh LG, Leitch AG. Confusing serological abnormalities in bird fancier's lung. Br Mled J
1990;300:1519. (9 June.) 2 McGee ZA, Taylor-Robinson D. Mvcoplasmas. In: Braude Al, et al, eds. Infectious diseases and medical microbiolov. 2nd ed. Philadelphia: W B Saunders, 1986:456-60. 3 Osebuld JW. Immunological diagnosis. In: Hoeprich PD, ed. Infectious diseases. 3rd ed. New York: Harper and Row, 1983:157-65. 4 Crompton GK, Grant IWB, NIcHardy GJR. Diseases of the respiratory system. In: Mlacleod J, ed. Davidson's principles and
practice of medicine. 14th ed. Edinburgh: Churchill Livingstone, 1984:202-77.
AUTHOR'S REPLY,-All the serological tests were complement fixation tests, the chlamydia antigen being psittacosis CF antigen supplied by the Central Public Health Laboratory (microbiological reagents and quality control). All complement fixation tests were carried out strictly according to the standard protocol,' and this included standard control tests to rule out innate anticomplementary activity of the serum. We are well aware that mycoplasma antigen is not
egg derived, and the reference quoted in our article2 makes it clear that it was influenza A and B viruses and chlamydia we were referring to. Finally, we agree with Drs Maher and Crosse that erythromycin is the antibiotic of choice for atypical pneumonia. Our article merely served to highlight the bewildering non-specific rises in viral and antibody titres that may, on occasion, accompany extrinsic allergic alveolitis and that compound the difficulty in distinguishing this from pneumonia. ZARIR F UDWADIA
South Cleveland Hospital, Cleveland TS4 3BW I Broadstreet CMP, Taylor CED. Complement fixation tests. Monthly Bulletin of the Ministry of Health and Public Health L aboratory Service 1962;21:%-lOO. 2 Taylor AJN, Taylor P, Bryant DH, Longbottom JL, Pepys J. False positive complement fixation tests with respiratory virus preparations in bird fanciers with allergic alveolitis. Thorax 1977;32:563-6.
SIR,-The confusing serology in bird fancier's lung described by Dr Zarir F Udwadia and colleagues is simply a consequence of polyclonal B cell stimulation.' This is a general feature of the alveolitides and may be important in helping to understand the more basic aspects of immunopathogenesis. The raised serum titres to respiratory viruses reported in acute bird fancier's lung have a similar profile to those in farmer's lung and are not simply due to antibody against egg antigens from virus cultures. These patients can also have very high total IgG concentrations, which we have shown to be polyclonal by isoelectric focusing, and the concentrations correlate quantitatively with the specific IgG antibody titre against avian antigens measured by radioimmunoassay.2 These observations prompted us to look at cellular immunity in 43 pigeon breeders with acute alveolitis (manuscript in preparation). Phenotypic analysis of peripheral blood lymphocytes with a range of monoclonal antibodies showed normal B cell numbers but increased T cell numbers in 21 patients consisting of raised CD4+ as well as CD8 + cells. The numbers of CD8 + cells in patients correlated with T cell numbers. In vitro lymphocyte proliferation assays (18 patients and 18 controls) showed that pigeon serum contained a potent non-specific cellular mitogenic component as well as a specific antigenic component recognised by the patients' antibodies. Thus the response to inhaled antigens in bird fancier's lung is more comprehensive than just specific antibody production and includes non-specific inflammation shown by raised total IgG concentrations and raised lymphocyte and natural killer cell counts, presumably induced by proinflammatory cytokines. We would suggest that these subjects are a valuable identifiable group in whom to study pulmonary immunology. FRANCES BRITTON CHARLES McSHARRY GAVIN BOYD Royal Infirmary, Glasgow G4 OSF I Udwadia ZF, Wright MJ, McIntosh LG, Leitch GA. Confusing serological abnormalities in bird fancier's lung. Br Med J7 1990;300:1519. (9 June.) 2 MicSharrv C. Immunological studies in extrinsic allergic alveolitis. Glasgow: University of Glasgow, 1984. (PhD thesis.)
Effect of maternal and child health on mortality SIR, - Dr Vincent Fauveau and colleagues' confirm what is known by many health workers from the developing world-namely, that effective provision of basic health care does reduce mortality'. This is a very important message.
BMJ
VOLUME 301
11
AUGUST
1990
In a prospective study of 640 consecutive hospital and clinic deliveries at Jane Furse Memorial Hospital, Lebowa, South Africa, in 1988 the perinatal mortality rate was 60/1000 births. One third of these deaths were considered easily avoidable: they were associated with failure to detect and treat severe anaemia and syphilis and the failure to refer patients with pre-eclampsia in the early stages. After these defects in care were identified it proved fairly easy to design and implement intervention strategies to try to prevent such deaths. Antenatal care was reorganised, standing orders for the management of antenatal problems were issued, the midwives were trained, and village clinics were supported. A comparative prospective study of 2193 consecutive deliveries in the seven months after implementation of the strategies found that the perinatal mortality rate had fallen to 40/1000 and deaths considered easily avoidable had been eliminated (ninth conference on priorities in perinatal care in South Africa, University of Witwatersrand, March 1990). The general standard of care improved appreciably. With an annual delivery of 4000, 80 perinatal deaths are prevented each year. The value of such work is that it proves that preventive measures can measurably reduce mortality. Health workers battling under enormous workloads should take heart and ensure that their curative and preventive strategies are balanced. I agree with Dr Fauveau and colleagues that much can be done while awaiting improved socioeconomic conditions. D WILKINSON
Newquay TR7 IDA 1 Fauveau V, Wojtyniak Bn Chakraborty J, et al. The effect of maternal and child health and family planning services on mortality: Is prevention enough? Br Med J 1990;301:103-7. (14 July.)
Low back pain: comparison of chiropractic and hospital outpatient treatment SIR,-It is perhaps surprising that despite the recent correspondence regarding their paper on back pain' Dr T W Meade and colleagues continue to assert that their results "make it necessary to consider the availability of chiropractic to NHS patients now."' Their study shows that one of the two treatment groups derived more long term benefits.2 The fact, however, that there were other important variables in addition to the availability or otherwise of chiropractic seems to have been largely ignored in the conclusions. The consequence of this is that the media have transmitted the simplified message that chiropractic heals backs without the necessary caveats that should have been more clearly presented in the original paper. This, I believe, has not helped the cause of manipulation. As a doctor trained in medical manipulation I am well aware of its potential benefits in treating musculoskeletal pain. It is not, however, a universal cure, and there already exist several competing schools of manipulative technique, each laying claim for special consideration. The specialty oforthopaedic medicine, which integrates manipulation into a structured medical framework, offers a sensible way forward. A department of orthopaedic medicine, run by Dr Cyriax, existed for many years at St Thomas's Hospital. It acquired a good international reputation, and its work is still recognised and quoted. Similar centres currently exist in Europe and North America. If manipulation is to be introduced into the NHS it should be properly planned. The ideal would be through departments of orthopaedic medicine set
BMJ
VOLUME 301
1 1 A'UGUST 1990
up in a few key centres, with suitable research facilities.3 To give precedence on the basis of this paper to one particular school of manipulation is unwarranted; nor is it helpful to the future development of a therapeutic technique that has much to offer prospective patients. ADAM A WARD
Royal London Homoeopathic Hospital, London WC IN 3HR 1 Correspondence. Low back pain: comparison of chiropractic and hospital outpatient treatment. Br Med J 1990;300:1647-50. (23 June.) 2 Meade TW, Dyer S, Browne W, Townsend J, Frank AO. Low back pain of mechanical origin: randomised comparison of chiropractic and hospital outpatient treatment. Br Med J 1990;300:1431-7. (2 June.) 3 Ward A. A limited role for manipulation? Br Med J 1987;294: 311.
SIR,-There can be no satisfaction gained in any quarter from the correspondence generated by the paper by Dr T W Meade and colleagues.' In April 1981, on behalf of the British Chiropractic Association, I approached Dr Meade, as the director of a prestigious Medical Research Council unit, about the possibility of a randomised controlled trial of our treatment for low back pain. The association's motives for doing this should be known and are as follows. Firstly, the association was unhappy with the legislative safeguards for the standards of practice and found the medical profession's representatives unwilling to undertake any dialogue about this because the effectiveness of chiropractic treatment was unproved. This impasse had to be overcome before initiatives towards obtaining statutory backing for standards of care and professional competence could hope to overcome medical opposition. Secondly, it was clear that growing public interest in heterodox medicine would make a clinical trial inevitable at some stage. The difficulty in designing such a trial made it necessary that it be approached with absolute evenhandedness and by someone with the ability to follow a close argument. In short, a flawed trial would have been worse than no trial at all. It was on the advice of the then chief scientist to the Department of Health and Social Security in the light of this that an approach to the Medical Research Council was made. Thirdly, at the time considerable pressure was being applied by groups of patients, who felt certain that if chiropractic could only "prove itself' all would be well for their interests. During the trial the chiropractors had many anxious moments, not least of which was when an article was published in The Times in 1985 quoting Dr Meade as listing as a possible consequence of an unfavourable outcome for chiropractic the restriction ofits practice. In the event chiropractors and patients with back pain can take no comfort from the response to the trial as it appears in your columns. Most of those commenting seem to have done so with irritation and apparently on impulse. Thus after eight years of work and many thousands of pounds spent on research few besides the authors themselves have so far exhibited a constructive attitude to the results. Surely a paper with such socioeconomic implications deserves to be read more carefully. A BREEN Anglo-European College of Chiropractic, Bournemouth BH5 2DF 1 Meade TW, Dyer S, Browne W, Townsend J, Frank AO. Low back pain of mechanical origin: randomised comparison of chiropractic and hospital outpatient treatment. Br Med J 1990;300:1431-7. (2 June.)
SIR,-I would like to take issue with Dr T W Meade and colleagues over their trial of treatment for back pain. The results do not bear the conclusion they wish to make,' and it is those conclusions
rather than the results that have captured the attention of the media. I pointed out to Dr Meade at the beginning of the trial that they were in danger of promoting chiropractic instead of a treatment modalityhigh velocity manipulation. This treatment is performed by many therapists but only chiropractors were included in the trial. It is also available in many hospital departments; I run such a clinic in one of the chosen centres, but again this was excluded from the trial. As "opponents" for the chiropractors Dr Meade and colleagues chose the hard pressed physiotherapists, who do not specialise in back treatments or necessarily use manipulation. They have many other priority groups to deal with and physiotherapy is only one of the many departments available in hospitals to treat back pain. Once again, none of these were included. That the chiropractors were working in the private sector, with funding, and had a vested interest in a positive result and that they were compared with physiotherapists working within the much more restrictive conditions of the NHS is further evidence of bias. I believe that the results from such a protocol cannot be taken seriously. Even with this favourable loading the chiropractors' results were only marginally better than those of the physiotherapists, and they gave their patients almost twice as many treatments. There is, however, a need for a properly constructed trial of manipulative treatment as the questions about it remain largely unanswered. BRIAN GURRY Plympton, Plymouth PL7 3DE I Meade TW, Dyer S, Browne W, Townsend J, Frank AO. Low back pain of mechanical origin: randomised comparison of chiropractic and hospital outpatient treatment. Br Med J
1990;300:1431-7. (2 June.)
AUTHORS' REPLY,-Dr Ward has misrepresented our results and provides a good example of the need, referred to by Mr Breen, for more careful consideration of what we actually said. We made it very clear that the trial was a comparison of two policies: chiropractic and hospital outpatient management. We ourselves pointed out that both (particularly hospital management) consist of several components. In each case one of these was manipulation. The relative effectiveness of different manipulative techniques is certainly a high priority for further trials. Until these have been carried out, however, it is premature for Dr Ward to suggest particular methods or administrative arrangements. Meanwhile, patients who cannot afford chiropractic privately can reasonably claim that they are being denied an effective treatment through the NHS. Provision of this treatment does not need to await full and detailed knowledge of which component is responsible for its value. Dr Gurry suggests lack of specialisation by physiotherapists as a possible explanation for the superiority of chiropractic, and earlier correspondents have made similar comments. ' Clearly, the role of general practitioners and others with special interests and skills should be taken into account in planning further studies. There was no question of actively excluding Dr Gurry's clinic from our trial, which was concerned with chiropractic in chiropractic clinics and with hospital management. In considering the extent to which chiropractic was more effective than hospital management, we should reiterate the distinction between the percentage point nature of the Oswestry scale and comparison of the two approaches expressed in percentage terms. By the last method at two and three years the benefit due to chiropractic was about 70% and 100% respectively more than the sum of spontaneous improvement and of any treatment effect in the
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