1342 The Government has not accepted the Royal Commission’s recommendation that regional health authorities might become directly accountable to Parliament. Such a bold change would, in the Government’s view, be inconsistent with the statutory accountability to Parliament of the Secretary of State. The paper also rejects the proposal to abolish family-practitioner committees, though compromise legislation will be introduced to make it possible for one such committee to cover more than one district health authority, if that be judged a good arrangement. A question-mark hangs over the future of community health councils. The Government invites views on whether or not the councils should be retained once the new district authorities are established. Next year community health councils will cost ,E4 million and the Government would naturally like to save that sum. (It hopefully sees an eventual ,30 million annual saving in the whole streamlining of administration.) The argument against community health councils is that the districts would be closer to local services than the existing areas, so the councils might not be needed. On the other hand, it is a pity to sacrifice Sir Keith Joseph’s principle of a separation of consumer representation from management. Members of community health councils have often shown a greater commitment to the N.H.S. than members of authorities have been able to display. The layman may be better placed to declare what he wishes the N.H.S. to do for the people than to pronounce on how it should be managed. The consultative paper pictures changes in management as well as in structure. The same prospect of more delegation to local judgement was envisaged in 1974, but it never truly happened. Since regions would nominate a preponderance of members on new district authorities, how much better would the reformed structure be in securing the long-sought delegation? The planning system, too, may be simplified. Planning is a part of good management, not something apart. If districts are to be entrusted with the management of their affairs in other respects, then they might as well be given the opportunity to find more of their own ways towards .effective planning. But the hazard in increased local autonomy and a playing-down of wider planning is that the development of services for the elderly and the mentally handicapped and the improvement of primary care and prevention may suffer. The medical advisory machinery is also being reviewed and prepared for simplification. The advisory structure in the Trent region, set out as appendix J to the report of the Royal Commission, was an illustration of how desperately elaborate such machinery can become. If the medical advisory machinery has not worked or is incapable of working, the management reasons must be closely and quickly examined-without the delay involved in the assembly and cogitation of the working party now to be established. The new districts would be told to ensure that each sizeable hospital or group of hospitals had a senior administrator and a senior nurse with authority to run it in consultation with the medical staff. They would be directly accountable to district headquarters, without any intervening level of management. The supporting services within a hospital, such as catering, domestic, and engineering, would be accountable to the hospital ad-
changes.
ministrator and not to functional managers at district. Such arrangements will appeal to those who have complained, since 1974, that no-one has been able to take decisions at hospital level. They will not appeal to the functional managers. It is not clear what is to be the executive function of the district hospital in relation to planning. The general stress of the paper is undoubtedly on encouragement for the hospital as the most important element in the reconstructed service, but the document is at its vaguest about how this is going to come about. WHEEZING AT THE SWIMMING POOL SWIMMING is often cited as the one sport which asthmatic children can manage without troublesome exercise-induced wheeze. This observation still awaits confirmation by a strictly controlled physiological study, but, if true, it fits well with modern ideas about the pathogenesis of exercise-induced asthma. In 1977 several groups produced evidence to suggest that exercise caused worse asthma if done in cold or dry conditions,1-3 findings which led McFadden and Ingram4 to postulate that the stimulus for asthma is linked to heat exchange across respiratory epithelium. This means that cold dry conditions are most likely to be associated with asthma on exercise, and hot, humid ones least so. Indeed, one study showed a complete absence of bronchospasm when subjects were exercised in air warmed to 5 body temperature and fully saturated with water vapour. Whilst the atmosphere of indoor swimming pools has for asthmatics the desirable features of warmth and humidity, there is unfortunately a quite unrelated factor at work in the opposite direction-namely, chlorine used for sterilisation. Traditionally chlorine gas is pumped into public pools according to the number (and dirtiness) of its occupants. Chlorine is always noticeable by smell and taste, and concentrations can rise enough to cause conjunctivitis and bronchial irritation. Surprisingly, frank asthmatic attacks are seldom reported by children using chlorinated pools, but a report from Manchester details asthma in three children who were using a newly opened pool.6 All three had positive skin prick tests, but no history of asthma. This particular pool was sterilised by chlorine dioxide generated on site, a method which will be increasingly used as direct chlorination, with its attendant risks to technical staff, is phased out. Although chlorine dioxide in correct concentration is odourless and non-irritating, the children involved in the Manchester episode all smelt "chlorine" strongly. Small private pools also depend mainly on chlorine for sterilisation, usually supplied as sodium or calcium hypochlorite, but there may be a move towards nonchlorine-containing sterilising compounds as these become cheaper and more effective. When recommend1. Bar-Or O, Neuman I, Dotan R. Effects of dry and humid climates on exercise-induced asthma in children and preadolescents. J Allergy Clin Immunol 1977; 60: 163-68. 2. Chen WY, Horton DJ. Heat and water loss from the airways and exerciseinduced asthma. Respiration 1977; 34: 305-13. 3. Strauss RH, McFadden ER, Ingram RH, Jaeger JJ. Enhancement of exercise-induced asthma by cold air. N Engl J Med 1977; 297: 743-47. 4. McFadden ER, Ingram RH. Exercise induced asthma; observations on the initiating stimulus. N Engl J Med 1979; 301: 763-69. 5. Strauss RH, McFadden ER, Ingram RH. Influence of heat and humidity on the airway obstruction induced by exercise in asthma. J Clin Invest 1978; 61: 433-40. 6. Mustchin CP, Pickering CAC. "Coughing water": bronchial hyperactivity induced by swimming in a chlorinated pool. Thorax 1979; 34: 682-83.
1343
ing swimming
to
asthmatic children, doctors and others
should bear in mind the potential hazard of bronchial irritation by chlorine. But the risks are probably small in relation to the benefits of sterilisation.
MINDS UNDER THE FLIGHTPATH NO-ONE ought to have to live under the narrow landing corridor to a major airport, but a lot of housing, much of it in the public sector, is so sited. Near London’s Heathrow classroom teaching can be interrupted, lipreading is a useful skill, and subsidies have to be provided for soundproofing buildings. A preliminary communication, published exactly ten years ago, suggested
that stress from exposure to aircraft was reflected in increased admissions to hospital for mental illness. Noise annoys,2 and the din of jet engines is no exception, but the notion that illness severe enough to warrant inpatient psychiatric care might ensue came as a surprise. The first attempt to confirm these findings was by Gattoni and Tarnopolsky ;3 a couple of chi-squared values get near the magic figure when the data are rearranged to suit the original hypothesis, but that is all. Now Tarnopolsky and his colleagues have published a further chapter in the Hounslow/Heathrow/Springfield Hospital saga4 as part of a Medical Research Council programme under the direction of Prof. Michael Shepherd. The latest inquiry is more thorough than the one by Abey-Wickrama et al.,’ and it is on a much larger scale than anything that has gone before. The three studies based on Springfield admissions differ greatly in the way residence, hospital catchment, and noise boundaries were handled. Another negative result would not have been surprising, but instead we get in the third inquiry4 a highly significant trend in the reverse direction-more noise, lower admission-rates. Tarnopolsky and his coworkers do not seem to know what to make of this finding. They warn against drawing conclusions from "exploratory research", yet this was not a pilot study but a careful investigation based on a population of about a million people and covering forty times as many admissions and twice the duration of the earlier studies. Dr Tarnopolsky has kindly provided us with a copy of a paper,5 given at a congress in Freiburg last year, which provides a further twist to the tale. Admissions to the Holloway Sanatorium at Virginia Water, a hospital about one-sixth the size of Springfield and serving a population under the baleful influence of the airport but much more rural in character, support the noise hypothesis for first admissions of single people and for all admissions except for the noisiest zone where the population at risk is small and we are advised to ignore the aberration. Even after a decade of research, therefore, it is not possible to say whether aircraft noise can seriously damage the psyche-indeed it is doubtful if anything 1.
Abey-Wickrama I, a’Brook MF, Gattoni FEG, Herridge CF. Mental hospital admissions and aircraft noise. Lancet 1969; ii: 1275-77.
2. Editorial. Noise, annoyance, and mental health. Lancet 1977; i: 1090. 3. Gattoni F, Tarnopolsky A. Aircraft noise and psychiatric morbidity. Psychol Med 1973; 3: 515-20. 4. Jenkins LM, Tarnopolsky A, Hand DJ, Barker SM. Comparison of three studies of aircraft noise and psychiatric hospital admissions conducted in the same area. Psychol Med 1979; 9: 681-93. 5. Hand DJ, Tarnopolsky A, Barker SM, Jenkins LM. Relationships between psychiatric hospital admissions and aircraft noise: a new study. In: Proceedings of Third International Congress on Noise as a Public Health Problem. (In press.)
useful can be learned from further retrospective studies based on one airport and relating to the early 1970s (even the largest study covers no admissions after Dec. 31, 1972). Intuitively, it would seem unlikely that two populations, one living right under the jets and one further off, would be the same in every respect other than exposure to aircraft noise, but this is difficult to check on at a distance of seven years or more. The problem of social matching is made even harder by the fact that demographic risk factors for psychiatric illness come in unusual packages (an unemployed graduate living on his own, for example). Furthermore, admission or community care for a mental problem is nowadays as likely to be determined on social as on medical grounds; nor can the question of immigrant communities around Heathrow be neglected. more
COLONIC COMPLICATIONS OF ACUTE PANCREATITIS "AcuTE pancreatitis is the most terrible of all the calamities that occur in connection with the abdominal viscera," proclaimed Sir Berkeley Moynihan1 in 1925. This opinion has been supported by an ever-increasing list of complications both intra-abdominal and extra-
abdominal.22 The incidence of primary acute pancreatitis in the United Kingdom varies greatly from year to year,3 but overall the disease seems to be increasing, particularly when associated with alcohol or drugs. Unless this increase is due to very mild forms of pancreatitis, there is likely to be an increase in the complications seen. Abscess and pseudocyst are the commonest intra-abdominal complications; damage to the colon (obstruction, fistula, bleeding, or stricture) is rare, but often life-threatening. (The watery-diarrhoea syndrome with varied serum levels of intestinal polypeptides might also be added to the colonic complications.4 Abcarian and his colleagues5 have reviewed 65 published case reports of colonic complications of acute pancreatitis, together with 10 of their own cases managed in a three-year period in Cook County Hospital, Chicago. This represented 1% of the total number of patients admitted with acute pancreatitis (predominantly alcoholic) during that same period. It is surprising that such colonic complications are not more common since the transverse mesocolon is an intimate anterior relation of the pancreas. 2 of the 10 Chicago patients died, and this creditably low mortality rate was attributed to a high index of clinical suspicion coupled with early aggressive surgery, particularly for colonic bleeding and fistula. Several useful clinical lessons emerge from this paper. The older patients (over 50 years) with mild pancreatitis may have pseudo-obstruction of the colon which must not be mistaken for malignant obstruction or ischaemic colitis; they have a good prognosis. Pseudocysts, inflammatory masses and abscesses must be carefully monitored by repeated clinical examination, ultrasonography, and barium studies to 1. 2.
Moynihan B. Acute pancreatitis. Ann Surg 1925; 81: 132-42. Carey LC. Extra-abdominal manifestations of acute pancreatitis. Surgery 1979; 86: 337-42.
3. Bourke JB. Variation in annual incidence of primary acute pancreatitis in Nottingham 1969-74. Lancet 1975; ii: 967-69. 4. Burbige, EJ, Manning, RJ, Belber JP. Watery diarrhea syndrome with elevated levels of vasoactive intestinal polypeptide associated with pancreatitis and pancreatic pseudocyst. Am J Gastroenterol 1978; 70: 136-40. 5. Abcarian H, Eftaiha M, Kraft AR, Nyhus LM. Colonic complications of acute
pancreatitis. Arch Surg 1979: 114: 995-1001.
changes.
ministrator and not to functional managers at district. Such arrangements will appeal to those who have complained, since 1974, that no-one has been able to take decisions at hospital level. They will not appeal to the functional managers. It is not clear what is to be the executive function of the district hospital in relation to planning. The general stress of the paper is undoubtedly on encouragement for the hospital as the most important element in the reconstructed service, but the document is at its vaguest about how this is going to come about. WHEEZING AT THE SWIMMING POOL SWIMMING is often cited as the one sport which asthmatic children can manage without troublesome exercise-induced wheeze. This observation still awaits confirmation by a strictly controlled physiological study, but, if true, it fits well with modern ideas about the pathogenesis of exercise-induced asthma. In 1977 several groups produced evidence to suggest that exercise caused worse asthma if done in cold or dry conditions,1-3 findings which led McFadden and Ingram4 to postulate that the stimulus for asthma is linked to heat exchange across respiratory epithelium. This means that cold dry conditions are most likely to be associated with asthma on exercise, and hot, humid ones least so. Indeed, one study showed a complete absence of bronchospasm when subjects were exercised in air warmed to 5 body temperature and fully saturated with water vapour. Whilst the atmosphere of indoor swimming pools has for asthmatics the desirable features of warmth and humidity, there is unfortunately a quite unrelated factor at work in the opposite direction-namely, chlorine used for sterilisation. Traditionally chlorine gas is pumped into public pools according to the number (and dirtiness) of its occupants. Chlorine is always noticeable by smell and taste, and concentrations can rise enough to cause conjunctivitis and bronchial irritation. Surprisingly, frank asthmatic attacks are seldom reported by children using chlorinated pools, but a report from Manchester details asthma in three children who were using a newly opened pool.6 All three had positive skin prick tests, but no history of asthma. This particular pool was sterilised by chlorine dioxide generated on site, a method which will be increasingly used as direct chlorination, with its attendant risks to technical staff, is phased out. Although chlorine dioxide in correct concentration is odourless and non-irritating, the children involved in the Manchester episode all smelt "chlorine" strongly. Small private pools also depend mainly on chlorine for sterilisation, usually supplied as sodium or calcium hypochlorite, but there may be a move towards nonchlorine-containing sterilising compounds as these become cheaper and more effective. When recommend1. Bar-Or O, Neuman I, Dotan R. Effects of dry and humid climates on exercise-induced asthma in children and preadolescents. J Allergy Clin Immunol 1977; 60: 163-68. 2. Chen WY, Horton DJ. Heat and water loss from the airways and exerciseinduced asthma. Respiration 1977; 34: 305-13. 3. Strauss RH, McFadden ER, Ingram RH, Jaeger JJ. Enhancement of exercise-induced asthma by cold air. N Engl J Med 1977; 297: 743-47. 4. McFadden ER, Ingram RH. Exercise induced asthma; observations on the initiating stimulus. N Engl J Med 1979; 301: 763-69. 5. Strauss RH, McFadden ER, Ingram RH. Influence of heat and humidity on the airway obstruction induced by exercise in asthma. J Clin Invest 1978; 61: 433-40. 6. Mustchin CP, Pickering CAC. "Coughing water": bronchial hyperactivity induced by swimming in a chlorinated pool. Thorax 1979; 34: 682-83.
1343
ing swimming
to
asthmatic children, doctors and others
should bear in mind the potential hazard of bronchial irritation by chlorine. But the risks are probably small in relation to the benefits of sterilisation.
MINDS UNDER THE FLIGHTPATH NO-ONE ought to have to live under the narrow landing corridor to a major airport, but a lot of housing, much of it in the public sector, is so sited. Near London’s Heathrow classroom teaching can be interrupted, lipreading is a useful skill, and subsidies have to be provided for soundproofing buildings. A preliminary communication, published exactly ten years ago, suggested
that stress from exposure to aircraft was reflected in increased admissions to hospital for mental illness. Noise annoys,2 and the din of jet engines is no exception, but the notion that illness severe enough to warrant inpatient psychiatric care might ensue came as a surprise. The first attempt to confirm these findings was by Gattoni and Tarnopolsky ;3 a couple of chi-squared values get near the magic figure when the data are rearranged to suit the original hypothesis, but that is all. Now Tarnopolsky and his colleagues have published a further chapter in the Hounslow/Heathrow/Springfield Hospital saga4 as part of a Medical Research Council programme under the direction of Prof. Michael Shepherd. The latest inquiry is more thorough than the one by Abey-Wickrama et al.,’ and it is on a much larger scale than anything that has gone before. The three studies based on Springfield admissions differ greatly in the way residence, hospital catchment, and noise boundaries were handled. Another negative result would not have been surprising, but instead we get in the third inquiry4 a highly significant trend in the reverse direction-more noise, lower admission-rates. Tarnopolsky and his coworkers do not seem to know what to make of this finding. They warn against drawing conclusions from "exploratory research", yet this was not a pilot study but a careful investigation based on a population of about a million people and covering forty times as many admissions and twice the duration of the earlier studies. Dr Tarnopolsky has kindly provided us with a copy of a paper,5 given at a congress in Freiburg last year, which provides a further twist to the tale. Admissions to the Holloway Sanatorium at Virginia Water, a hospital about one-sixth the size of Springfield and serving a population under the baleful influence of the airport but much more rural in character, support the noise hypothesis for first admissions of single people and for all admissions except for the noisiest zone where the population at risk is small and we are advised to ignore the aberration. Even after a decade of research, therefore, it is not possible to say whether aircraft noise can seriously damage the psyche-indeed it is doubtful if anything 1.
Abey-Wickrama I, a’Brook MF, Gattoni FEG, Herridge CF. Mental hospital admissions and aircraft noise. Lancet 1969; ii: 1275-77.
2. Editorial. Noise, annoyance, and mental health. Lancet 1977; i: 1090. 3. Gattoni F, Tarnopolsky A. Aircraft noise and psychiatric morbidity. Psychol Med 1973; 3: 515-20. 4. Jenkins LM, Tarnopolsky A, Hand DJ, Barker SM. Comparison of three studies of aircraft noise and psychiatric hospital admissions conducted in the same area. Psychol Med 1979; 9: 681-93. 5. Hand DJ, Tarnopolsky A, Barker SM, Jenkins LM. Relationships between psychiatric hospital admissions and aircraft noise: a new study. In: Proceedings of Third International Congress on Noise as a Public Health Problem. (In press.)
useful can be learned from further retrospective studies based on one airport and relating to the early 1970s (even the largest study covers no admissions after Dec. 31, 1972). Intuitively, it would seem unlikely that two populations, one living right under the jets and one further off, would be the same in every respect other than exposure to aircraft noise, but this is difficult to check on at a distance of seven years or more. The problem of social matching is made even harder by the fact that demographic risk factors for psychiatric illness come in unusual packages (an unemployed graduate living on his own, for example). Furthermore, admission or community care for a mental problem is nowadays as likely to be determined on social as on medical grounds; nor can the question of immigrant communities around Heathrow be neglected. more
COLONIC COMPLICATIONS OF ACUTE PANCREATITIS "AcuTE pancreatitis is the most terrible of all the calamities that occur in connection with the abdominal viscera," proclaimed Sir Berkeley Moynihan1 in 1925. This opinion has been supported by an ever-increasing list of complications both intra-abdominal and extra-
abdominal.22 The incidence of primary acute pancreatitis in the United Kingdom varies greatly from year to year,3 but overall the disease seems to be increasing, particularly when associated with alcohol or drugs. Unless this increase is due to very mild forms of pancreatitis, there is likely to be an increase in the complications seen. Abscess and pseudocyst are the commonest intra-abdominal complications; damage to the colon (obstruction, fistula, bleeding, or stricture) is rare, but often life-threatening. (The watery-diarrhoea syndrome with varied serum levels of intestinal polypeptides might also be added to the colonic complications.4 Abcarian and his colleagues5 have reviewed 65 published case reports of colonic complications of acute pancreatitis, together with 10 of their own cases managed in a three-year period in Cook County Hospital, Chicago. This represented 1% of the total number of patients admitted with acute pancreatitis (predominantly alcoholic) during that same period. It is surprising that such colonic complications are not more common since the transverse mesocolon is an intimate anterior relation of the pancreas. 2 of the 10 Chicago patients died, and this creditably low mortality rate was attributed to a high index of clinical suspicion coupled with early aggressive surgery, particularly for colonic bleeding and fistula. Several useful clinical lessons emerge from this paper. The older patients (over 50 years) with mild pancreatitis may have pseudo-obstruction of the colon which must not be mistaken for malignant obstruction or ischaemic colitis; they have a good prognosis. Pseudocysts, inflammatory masses and abscesses must be carefully monitored by repeated clinical examination, ultrasonography, and barium studies to 1. 2.
Moynihan B. Acute pancreatitis. Ann Surg 1925; 81: 132-42. Carey LC. Extra-abdominal manifestations of acute pancreatitis. Surgery 1979; 86: 337-42.
3. Bourke JB. Variation in annual incidence of primary acute pancreatitis in Nottingham 1969-74. Lancet 1975; ii: 967-69. 4. Burbige, EJ, Manning, RJ, Belber JP. Watery diarrhea syndrome with elevated levels of vasoactive intestinal polypeptide associated with pancreatitis and pancreatic pseudocyst. Am J Gastroenterol 1978; 70: 136-40. 5. Abcarian H, Eftaiha M, Kraft AR, Nyhus LM. Colonic complications of acute
pancreatitis. Arch Surg 1979: 114: 995-1001.
