1293 in the uncle be significant?1O Perhaps none of these factors are related to the tumour. A search for a history of maternal alcohol consumption during pregnancy in children and young adults with cancer may be helpful. University Affiliated Cincinnati Center for Developmental Disorders, University of Cincinnati Department, of Pediatrics, and Division of
Hematology,
LUSIA HORNSTEIN CAROL CROWE RALPH GRUPPO
Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio 45229, U.S.A.
EARLY DIAGNOSIS OF ANKYLOSING SPONDYLITIS
SIR,-Your editorial (Sept. 17, p. 591) notes the characteristic features of the pain of ankylosing spondylitis: insidious onset, persistence for 3 months, morning stiffness, relief with exercise, and age under 40. Indeed, in our controlled study’ we showed that reliance on these five historical features (selected from seventeen questions) were sensitive (95%) and specific (85%) in the differential diagnosis of 138 patients with back pain attending the Stanford University rheumatology clinic. Nevertheless, a minority of patients with definite ankylosing spondylitis2 may have other less discriminatory symptoms that can suggest mechanical spinal disease. In our study, 17% of 42 patients claimed that the disorder was "caused by an injury", 29% complained of dysaesthesiae in a lower limb, and 41% had pain radiating below the knee. However, features such as these should not deter the physician from an early diagnosis of ankylosing spondylitis, when the other four or five more discriminatory findings are present. A radiograph is diagnostic, and, as you suggest, indiscriminate use of HLA B27 typing is to be avoided. Department of Medicine, Stanford University School of Medicine, Stanford, California 94305, U.S.A.
ANDREI CALIN
WHAT IS NORMAL SERUM MAGNESIUM AND PHOSPHATE? the serum-T4 values reported by Dr MacGregor SIR,-That were (Nov. 26, p. 1129) reported in rnmol/1 and not nmol/1 is not too misleading. What is important, however, is that a serum-magnesium level of 0-85 mmol;1 should be interpreted a indicative of hypermagnesaemia, especially at a time when there is so much conflicting biochemical data relevant to treatment with lithium. Unless the reference range in Dr MacGregor’s laboratory differs appreciably from the usual reference ranges for magnesium, the figure given for serum-magnesium is normal. MacGregor also states that after removal of the parathyroid adenoma the serum-phosphate returned to normal. Was not the preoperative figure (0.88 mmol/1), itself normal? Of the concentrations given only the one for serum-calcium can be considered abnormal. Biochemistry Department, Hospital,
Airedale General
Steeton,
Keighley,
C. SANDERSON
West Yorkshire BD20 6TD
*** This letter has been shown
to
Dr
MacGregor,
whose
reply
follows.-ED. L. are nowadays usually precise but, they sometimes become inflated. When our lithium-
SIR,-Biochemical results like prices, 10. 1.
Fraumeni, J. F., Miller, R. W. J. Pediat. 1967, 70, 129. Calin, A., Porta, J., Fries, J. F., Schurman, L. J. Am.
med. Ass.
2613. 2.
Bennett, P. H. J., Burch, T. A. Bull. rheum. Dis. 1967, 17, 453.
1977, 237,
treated patient was investigated in 1975 the normal range of the serum-magnesium in our laboratory was 0.5-0-8 mmol;1. Lately, and without my knowledge, the upper limit of normal was increased to 1.0 mmol/1. On this reckoning, therefore, the serum-magnesium was normal. Nearly a third of lithiumtreated cases have, however, shown hypermagnesaemia.1 The patient had serum-phosphate levels of 0.30 and 0-35 mmol/1 when her serum-calcium was 3.1and 3.17 mmol/1, before her parathyroid adenoma was excised. The substitution of "m" for "n" in the serum-T4 results was the result of human frailty. St. Luke’s
Hospital, GERALD A. MACGREGOR
Guildford, Surrey GU1 3NT
1. Christiansen,
C., Baastrup, P. C., Transbøl, I. Lancet, 1976, ii, 969.
Commentary from Westminster From Our
Parliamentary Correspondent
The Health Tax
Cigarettes THE Government’s proposal for a cigarette health tax, announced earlier this year by Mr David Ennals, Secretary of State for Social Services, is facing strong opposition both in Brussels and at Westminster. Hopes that the tax would be settled by now have proved optimistic, and a decision this year now depends on a Ministerial meeting in Brussels next week. But further delay is not being ruled out. The proposal is that Britain should be allowed to impose a supplementary health tax on those cigarettes with the highest tar yield, covering about 20% of the market. The result would be a 7p increase on a packet of 20 plain cigarettes. But the plan is being resisted in Brussels where a meeting last week failed to reach any conclusion. The European Commission is said not to like the proposal and very few of our European partners have advanced to such a stage in policy thinking on cigarettes and health. France and Italy both have State monopoly tobacco industries, which present them with particular problems on taxation matters. Now Holland is asking why Britain alone should be given a special derogation to introduce such a tax. The Dutch want to see a general dispensation for every country. At Westminster a number of M.P.S have strongly attacked the idea of bringing the health element into on
taxation. One Conservative has declared that health something which should concern the E.E.C.-although an examination of the Register of M.P.s’ Interests reveals that he is an adviser to British American Tobacco. Other M.P.s with more conspicuous constituency interests in the tobacco industry have criticised the tax for the same reason. They see it as a threat to the industry, its 33 000 employees, the £2250 million a year taxation it pays the Exchequer, and the ,200 million worth of cigarettes it exports every year. For these M.P.s the main consideration is the need to protect the British industry. What is now concerning them is that in pressing for a health tax, the British Government might be persuaded to concede too much in the negotiations on the second stage of harmonising E.E.C. excise duties. The first stage of this harmonisation comes into effect on Jan. 1 and involves changes in the pricing structure which will put up the price of a packet of small matters are not
1294
filter cigarettes by 5p or 6p. The change narrows the gap between the dual elements of taxation-the specific duty relating to the number of cigarettes and the ad-valorem tax based on the retail price. But the result will be to make those cigarettes in the high-tar yield range much more attractive to smokers, in direct contrast to what the Government is trying to achieve. The health tax would offset the disadvantages of harmonisation. But the fact that the negotiations on harmonisation and the health tax are being carried out together inevitably means considerable horse-trading between the countries. The Health Education Council views the negotiations with mixed feelings. It regrets that harmonisation will favour the king-sized cigarettes, but it is delighted that at last taxation is being increased for health reasons. Mr A. C. L. Mackie, the Council’s director-general, told me: "It would be absolutely tragic if smoking gets any cheaper relatively". At the same time the Council still prefers to rely on persuasion rather than taxation to combat smoking, if only because increased taxation puts the less well-off sections of the community at a disadvantage compared with the better-off. The tobacco companies for their part are resigned to a health tax, although they bitterly resent the fact that the tax will probably be based on tar yield. As one executive said: "There is no evidence that tar is the nigger in the woodpile, if there is one". The general expectation is that after much haggling Britain will be allowed to go ahead with a health tax from July next year but to last for only two years. At Westminster this decision would have to be contained in next year’s Budget and included in the Finance Bill. Progress on the tax would go much of the way to satisfying the all-Party Commons Expenditure Committee, which earlier this year called specifically for an annual increase in taxation to reduce cigarette smoking. The members of the committee were not prepared to say that it was more important to keep high revenue and employment than to preserve health. The only remaining doubt for supporters of the health tax concerns the fact that the negotiations are being conducted not by the Department of Health and Social Security but by the Treasury, whose main concerns are normally revenue and employment.
The Medical Defence Societies
as
Insurance
Companies defence societies, fighting a
The medical Government insurance to them into line with companies,1 plan bring are taking their case to the courts. This move follows complete deadlock in negotiations between the Department of Trade and the societies over a Government proposal for the societies to register as insurance companies under the Insurance Companies Act 1974. The Government was concerned that the societies were not adequately provided for claims against their members. Under the 1974 legislation they would have to be reinsured in case claims exceeded their assets. The Government’s legal opinion was that the societies were carrying on business as insurance companies as defined by the legislation. The societies’ legal opinion was that they were not. Negotiations failed to find any solution, so now the
Medical Defence Union has taken the matter to court and a judgment from the Chancery division is awaited next
Medicine and the Law Compensation for Brain-damaged Doctor A 36-year old senior psychiatric registrar working in London was admitted to the Elizabeth Garrett Anderson Hospital for a minor gynaecological operation in 1973. On completion of the operation she was transferred to a recovery room, where she suffered a cardiac arrest. She was in a coma for two weeks, and on regaining consciousness she did not talk, had two epileptic fits, and could not walk. In a rehabilitation unit she recovered the ability to walk a little with help and to speak a few words. Six months thereafter she was said by a consultant neurologist to be suffering from diffuse brain damage producing lack of coordination in all four limbs, to be depressed and withdrawn, and to have difficulty in speaking. Subsequent tests showed that her disabilities were purely organic in origin and due to extensive brain damage caused by the cardiac arrest. In 1974 she was taken to Malaysia to be cared for at home by her mother, who was aged 71. She spent a period in a Singapore hospital where she was found to be depressed, occasionally aggressive, and totally dependent on others in all self-care activities, including feeding, toileting, and grooming. Her condition was said to be the result of gross neurological deficit arising from the brain damage, and it was concluded that she would require maximum personal assistance for the rest of her life, and that she would not be able to function as a doctor. She claimed damages against the area health authority for personal injury, loss, and damage. Mr Justice BRISTOW said that the cardiac arrest had been the result of failure to take reasonable care of the doctor by someone for whom the health authority was vicariously responsible. At the time of the accident the doctor was in mid-career practising in her chosen field of medicine. She had qualified in Singapore in 1963 at the age of 26. In 1971, after starting training in psychiatric medicine in Malaysia, she came to England, where she worked as a clinical assistant before gaining the diploma in psychological medicine. She was appointed to the post of senior registrar in 1972. She was confidently expected to pass the examination for membership of the Royal College of Psychiatrists in 1973. The court could only award a sum of money for the appalling disability from which she was condemned to suffer, but in justice to the health authority as well as to the doctor that sum must be in proportion to awards in other personal injury cases of comparable severity. Her future care was the first priority. On the evidence the court found that her mother would look after her at home for as long as she could, probably seven years, but thereafter she would be sent to England to be cared for in an institution. The appropriate figure for the cost of care at home in Malaysia for seven years was £ 17 500. When she came to England she would be about 47 years old. The present cost of care in an institution in England was in the order of C8000 a year, and £88 000 would be allowed for her care in England. To date the cost of her care was ;8000, out of pocket expenses were £3596, and her loss of earnings were C14 213. Other awards would be £ 84 000 for future loss of earnings, £8000 for loss of pension rights, 20 000 for pain, suffering, and loss of the amenities of life. There would be judgment for £243 309 plus interest and costs against the health authority. Lim
v. Camden and Islington Area Health Authority. Queen’s Bench Division: Bristow, J., Dec. 7, 1977. Counsel and solicitors: Christopher French, Q.c., and George Newman (Coward Chance); John Davies, Q.c., and Peter Scott (J. Tickle
& 1. See Lancet,
1977, i, 1270.
year.
Co.). B. O.
AGYEMAN, Barrister-at-Law
Hematology,
LUSIA HORNSTEIN CAROL CROWE RALPH GRUPPO
Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio 45229, U.S.A.
EARLY DIAGNOSIS OF ANKYLOSING SPONDYLITIS
SIR,-Your editorial (Sept. 17, p. 591) notes the characteristic features of the pain of ankylosing spondylitis: insidious onset, persistence for 3 months, morning stiffness, relief with exercise, and age under 40. Indeed, in our controlled study’ we showed that reliance on these five historical features (selected from seventeen questions) were sensitive (95%) and specific (85%) in the differential diagnosis of 138 patients with back pain attending the Stanford University rheumatology clinic. Nevertheless, a minority of patients with definite ankylosing spondylitis2 may have other less discriminatory symptoms that can suggest mechanical spinal disease. In our study, 17% of 42 patients claimed that the disorder was "caused by an injury", 29% complained of dysaesthesiae in a lower limb, and 41% had pain radiating below the knee. However, features such as these should not deter the physician from an early diagnosis of ankylosing spondylitis, when the other four or five more discriminatory findings are present. A radiograph is diagnostic, and, as you suggest, indiscriminate use of HLA B27 typing is to be avoided. Department of Medicine, Stanford University School of Medicine, Stanford, California 94305, U.S.A.
ANDREI CALIN
WHAT IS NORMAL SERUM MAGNESIUM AND PHOSPHATE? the serum-T4 values reported by Dr MacGregor SIR,-That were (Nov. 26, p. 1129) reported in rnmol/1 and not nmol/1 is not too misleading. What is important, however, is that a serum-magnesium level of 0-85 mmol;1 should be interpreted a indicative of hypermagnesaemia, especially at a time when there is so much conflicting biochemical data relevant to treatment with lithium. Unless the reference range in Dr MacGregor’s laboratory differs appreciably from the usual reference ranges for magnesium, the figure given for serum-magnesium is normal. MacGregor also states that after removal of the parathyroid adenoma the serum-phosphate returned to normal. Was not the preoperative figure (0.88 mmol/1), itself normal? Of the concentrations given only the one for serum-calcium can be considered abnormal. Biochemistry Department, Hospital,
Airedale General
Steeton,
Keighley,
C. SANDERSON
West Yorkshire BD20 6TD
*** This letter has been shown
to
Dr
MacGregor,
whose
reply
follows.-ED. L. are nowadays usually precise but, they sometimes become inflated. When our lithium-
SIR,-Biochemical results like prices, 10. 1.
Fraumeni, J. F., Miller, R. W. J. Pediat. 1967, 70, 129. Calin, A., Porta, J., Fries, J. F., Schurman, L. J. Am.
med. Ass.
2613. 2.
Bennett, P. H. J., Burch, T. A. Bull. rheum. Dis. 1967, 17, 453.
1977, 237,
treated patient was investigated in 1975 the normal range of the serum-magnesium in our laboratory was 0.5-0-8 mmol;1. Lately, and without my knowledge, the upper limit of normal was increased to 1.0 mmol/1. On this reckoning, therefore, the serum-magnesium was normal. Nearly a third of lithiumtreated cases have, however, shown hypermagnesaemia.1 The patient had serum-phosphate levels of 0.30 and 0-35 mmol/1 when her serum-calcium was 3.1and 3.17 mmol/1, before her parathyroid adenoma was excised. The substitution of "m" for "n" in the serum-T4 results was the result of human frailty. St. Luke’s
Hospital, GERALD A. MACGREGOR
Guildford, Surrey GU1 3NT
1. Christiansen,
C., Baastrup, P. C., Transbøl, I. Lancet, 1976, ii, 969.
Commentary from Westminster From Our
Parliamentary Correspondent
The Health Tax
Cigarettes THE Government’s proposal for a cigarette health tax, announced earlier this year by Mr David Ennals, Secretary of State for Social Services, is facing strong opposition both in Brussels and at Westminster. Hopes that the tax would be settled by now have proved optimistic, and a decision this year now depends on a Ministerial meeting in Brussels next week. But further delay is not being ruled out. The proposal is that Britain should be allowed to impose a supplementary health tax on those cigarettes with the highest tar yield, covering about 20% of the market. The result would be a 7p increase on a packet of 20 plain cigarettes. But the plan is being resisted in Brussels where a meeting last week failed to reach any conclusion. The European Commission is said not to like the proposal and very few of our European partners have advanced to such a stage in policy thinking on cigarettes and health. France and Italy both have State monopoly tobacco industries, which present them with particular problems on taxation matters. Now Holland is asking why Britain alone should be given a special derogation to introduce such a tax. The Dutch want to see a general dispensation for every country. At Westminster a number of M.P.S have strongly attacked the idea of bringing the health element into on
taxation. One Conservative has declared that health something which should concern the E.E.C.-although an examination of the Register of M.P.s’ Interests reveals that he is an adviser to British American Tobacco. Other M.P.s with more conspicuous constituency interests in the tobacco industry have criticised the tax for the same reason. They see it as a threat to the industry, its 33 000 employees, the £2250 million a year taxation it pays the Exchequer, and the ,200 million worth of cigarettes it exports every year. For these M.P.s the main consideration is the need to protect the British industry. What is now concerning them is that in pressing for a health tax, the British Government might be persuaded to concede too much in the negotiations on the second stage of harmonising E.E.C. excise duties. The first stage of this harmonisation comes into effect on Jan. 1 and involves changes in the pricing structure which will put up the price of a packet of small matters are not
1294
filter cigarettes by 5p or 6p. The change narrows the gap between the dual elements of taxation-the specific duty relating to the number of cigarettes and the ad-valorem tax based on the retail price. But the result will be to make those cigarettes in the high-tar yield range much more attractive to smokers, in direct contrast to what the Government is trying to achieve. The health tax would offset the disadvantages of harmonisation. But the fact that the negotiations on harmonisation and the health tax are being carried out together inevitably means considerable horse-trading between the countries. The Health Education Council views the negotiations with mixed feelings. It regrets that harmonisation will favour the king-sized cigarettes, but it is delighted that at last taxation is being increased for health reasons. Mr A. C. L. Mackie, the Council’s director-general, told me: "It would be absolutely tragic if smoking gets any cheaper relatively". At the same time the Council still prefers to rely on persuasion rather than taxation to combat smoking, if only because increased taxation puts the less well-off sections of the community at a disadvantage compared with the better-off. The tobacco companies for their part are resigned to a health tax, although they bitterly resent the fact that the tax will probably be based on tar yield. As one executive said: "There is no evidence that tar is the nigger in the woodpile, if there is one". The general expectation is that after much haggling Britain will be allowed to go ahead with a health tax from July next year but to last for only two years. At Westminster this decision would have to be contained in next year’s Budget and included in the Finance Bill. Progress on the tax would go much of the way to satisfying the all-Party Commons Expenditure Committee, which earlier this year called specifically for an annual increase in taxation to reduce cigarette smoking. The members of the committee were not prepared to say that it was more important to keep high revenue and employment than to preserve health. The only remaining doubt for supporters of the health tax concerns the fact that the negotiations are being conducted not by the Department of Health and Social Security but by the Treasury, whose main concerns are normally revenue and employment.
The Medical Defence Societies
as
Insurance
Companies defence societies, fighting a
The medical Government insurance to them into line with companies,1 plan bring are taking their case to the courts. This move follows complete deadlock in negotiations between the Department of Trade and the societies over a Government proposal for the societies to register as insurance companies under the Insurance Companies Act 1974. The Government was concerned that the societies were not adequately provided for claims against their members. Under the 1974 legislation they would have to be reinsured in case claims exceeded their assets. The Government’s legal opinion was that the societies were carrying on business as insurance companies as defined by the legislation. The societies’ legal opinion was that they were not. Negotiations failed to find any solution, so now the
Medical Defence Union has taken the matter to court and a judgment from the Chancery division is awaited next
Medicine and the Law Compensation for Brain-damaged Doctor A 36-year old senior psychiatric registrar working in London was admitted to the Elizabeth Garrett Anderson Hospital for a minor gynaecological operation in 1973. On completion of the operation she was transferred to a recovery room, where she suffered a cardiac arrest. She was in a coma for two weeks, and on regaining consciousness she did not talk, had two epileptic fits, and could not walk. In a rehabilitation unit she recovered the ability to walk a little with help and to speak a few words. Six months thereafter she was said by a consultant neurologist to be suffering from diffuse brain damage producing lack of coordination in all four limbs, to be depressed and withdrawn, and to have difficulty in speaking. Subsequent tests showed that her disabilities were purely organic in origin and due to extensive brain damage caused by the cardiac arrest. In 1974 she was taken to Malaysia to be cared for at home by her mother, who was aged 71. She spent a period in a Singapore hospital where she was found to be depressed, occasionally aggressive, and totally dependent on others in all self-care activities, including feeding, toileting, and grooming. Her condition was said to be the result of gross neurological deficit arising from the brain damage, and it was concluded that she would require maximum personal assistance for the rest of her life, and that she would not be able to function as a doctor. She claimed damages against the area health authority for personal injury, loss, and damage. Mr Justice BRISTOW said that the cardiac arrest had been the result of failure to take reasonable care of the doctor by someone for whom the health authority was vicariously responsible. At the time of the accident the doctor was in mid-career practising in her chosen field of medicine. She had qualified in Singapore in 1963 at the age of 26. In 1971, after starting training in psychiatric medicine in Malaysia, she came to England, where she worked as a clinical assistant before gaining the diploma in psychological medicine. She was appointed to the post of senior registrar in 1972. She was confidently expected to pass the examination for membership of the Royal College of Psychiatrists in 1973. The court could only award a sum of money for the appalling disability from which she was condemned to suffer, but in justice to the health authority as well as to the doctor that sum must be in proportion to awards in other personal injury cases of comparable severity. Her future care was the first priority. On the evidence the court found that her mother would look after her at home for as long as she could, probably seven years, but thereafter she would be sent to England to be cared for in an institution. The appropriate figure for the cost of care at home in Malaysia for seven years was £ 17 500. When she came to England she would be about 47 years old. The present cost of care in an institution in England was in the order of C8000 a year, and £88 000 would be allowed for her care in England. To date the cost of her care was ;8000, out of pocket expenses were £3596, and her loss of earnings were C14 213. Other awards would be £ 84 000 for future loss of earnings, £8000 for loss of pension rights, 20 000 for pain, suffering, and loss of the amenities of life. There would be judgment for £243 309 plus interest and costs against the health authority. Lim
v. Camden and Islington Area Health Authority. Queen’s Bench Division: Bristow, J., Dec. 7, 1977. Counsel and solicitors: Christopher French, Q.c., and George Newman (Coward Chance); John Davies, Q.c., and Peter Scott (J. Tickle
& 1. See Lancet,
1977, i, 1270.
year.
Co.). B. O.
AGYEMAN, Barrister-at-Law
