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Notes and News

QUACKBUSTERS OF YORE

NOTHING excites the righteous wrath of the physician so much asthe quack. But to the public, the distinction between doctor andquack can sometimes be blurred, as emerged when TheodorMyersbach came to London in the second half of the 18th centuryand established a wealthy practice based on urine-gazing. Althoughuroscopy-diagnosis and prognosis from scrutiny of the patient’surine-had fallen into disrepute by this time, it had its roots inantiquity, and clients flocked to Myersbach with their flasks. Hedispensed various potions, some anodyne and some containingquantities of opium or lead, which attracted the hostile attention ofan eminent physician, John Coakley Lettsome. Lettsome

proceeded via the press to try to expose the "pisse prophet" as anignorant swindler. Columns of newsprint were given over toacrimonious debate between interested parties. But, over themonths, the doctor seems to have unwittingly dented the image ofhis own profession. For, to the public, Lettsome and Myersbachwere "two chips of one log"-the doctor doing no more thandefending his own market by slinging mud at the opposition.

In a book1 charting the career of the charlatan and mountebank inEngland, a neat analogy is drawn: the quack is to the doctor like thehack is to the poet. The author, Roy Porter, senior lecturer in thesocial history of medicine, Wellcome Institute for the History ofMedicine, spans the mid-17th to the mid-19th centuries, a periodwhich takes in the early years of The Lancet. Its founder, ThomasWakley, outspoken doctor and coroner, spearheaded a campaign torid the profession and the nation of the "satanic system of

quackery". Nostrums, such as Macleod’s Bread Pills, whichcontained nothing but bread and were sold by a physician at StGeorge’s Hospital, and Morison’s Vegetable Pills, marketed by abusinessman who dubbed himself the Hygeist, made the pages ofThe Lancet ring with thundering zeal.Medical registration (1858) ensured the dominance of the

physician, and the Pharmacy Act (1868) took the punch out ofpatent remedies. But, as quackery was eclipsed by modemmedicine, and Porter comes to the end of his entertaining narrative,he concludes that the gulf between quackery and pre-modernmedicine was perhaps not so great as commonly perceived and wasrooted more in differences in showmanship than anything else.He suggests that, to understand the enduring appeal of the

irregular healer, we must "discard the stereotype of the quack’scustomers as ’gulls"’. Despite medical supremacy, the

contemporary doctor still has to defend rational practice. With all itsastonishing achievements, medicine is unable to help some patients,who turn to the alternative practitioners of today who offer hope.

THE BURDEN OF HUNTINGTON’S DISEASE

AN insightful television programme can portray in a sensitive waythe enormous personal and social burden of Huntington’s disease.A pity, then, that A Family Apart (BBC 2, Aug 23) was marred bysuch descriptions of the disorder as "a total destroyer of individualsand families" and "a disease which causes the slow and irreversibledestruction of a human being". Although there is no specifictreatment for Huntington’s disease, good medical and social

management has much to offer. To say that people afflicted with thedisease are "beyond help" is likely to arouse needless anxiety inaffected families.

Sensational programmes about serious medical disorders

inevitably stir up emotions that television is unable to deal with(although in this instance a contact telephone number wasprovided). The Institute of Medical Genetics, Cardiff, receivedseveral telephone inquiries from anxious family members after

1. Health for Sale: Quackery in England 1660-1850. By Roy Porter. ManchesterUniversity Press. 1989. Pp 280. £19.95.

transmission, one of them from a man whose affected brother hadbecome suicidal after seeing the "hopelessness of the diagnosis".Television cannot be a substitute for unhurried and careful

counselling, which fosters a climate of trust. Emotions are far betterreleased in this setting than in front of an unresponsive televisionscreen.

The programme ended on a justifiable note of optimism: cloningof the abnormal gene, which will probably be achieved in the nextfive years, could lead to a more rational and effective approach totherapy. In the meantime, however, predictive testing has raisedunexpected difficulties, some of which are discussed in two articlesin this week’s issue (pp 601 and 603).

SPIN-OFFS FROM SPACE

THREE scientist-astronauts who participated in the US spaceshuttle Challenger flight in November, 1985, have reproduced thesymptoms of space sickness.1 They lay supine in a centrifuge andsubjected themselves to an acceleration of 3 g. During the 5-6 hourperiod of readjusting to the normal environment they noted thesame symptoms that they had experienced when adjusting fromnormal to zero gravity during the Spacelab mission. The full rangeof symptoms from "not being sick" to "acute sickness" was

reproduced, and the symptoms reflected the individual differencesobserved in space. Research into the causes and treatment of spaceand motion sickness will be facilitated by the availability of a methodof reproducing these unpleasant manifestations.

Other results may bring surprises: it has been shown that theimmune system is more active at increased gravity and almostinactive when gravity is absent.2 Experiments in a centrifuge havemany potential spin-offs.

NEUTRON THERAPY

US National Cancer Institute support for neuron therapy is onthe wane, as a ten-year$70 million programme draws to a close.From next year NCI will find extra money to see four trials throughto completion, but at a much reduced level of funding. Further, themoney will be tied to patient accrual, to encourage a speedyconclusion to the studies. The August, 1989, issue of the AmericanJournal of Clinical Oncology seems unlikely to convert the

previously uncommitted clinician into an eager writer of referralletters. Of nine papers in AJCO, four are reviews, these being onneutron therapy for lung, head and neck, bladder, and prostatecancer, the indications for which trials are still in progress; DrSandra Zink and her colleagues review the history of neutrontherapy research in the United States;’ and four groups reportoriginal data. The bankruptcy of a US firm supplying cyclotrons formedical use threw the whole programme into disarray, and theAmerican trial that everyone has been waiting for-on fast neutronsin head-and-neck cancer-will not be completed until 1993, unlessrecruitment at the only non-US site (Merseyside, UK) quickens thepace. So far results achieved at Hammersmith Hospital, London,have not been matched,’ and late toxicity remains a concern. Thepaper on a particular variety of head-and-neck malignancy,advanced salivary gland tumours, strikes the only note of realoptimism in this AJCO collection: "Available evidenceoverwhelmingly supports the role of fast neutron radiation as thetreatment of choice for advanced inoperable, unresectable andrecurrent salivary gland cancers".5 The rate of severe late

complications in the studies reviewed by Koh et al3 (one a smallcontrolled trial) was 19%.

1. Ockels WJ, Furrer R, Messerschmit F. Space sickness on earth. Nature 1989; 340:681-82.

2. Lorenzi G, Fuchs-Bislin P, Cogoli A. Effects of hypergravity on "whole blood"cultures of human lymphocytes. Aviat Space Environ Med 1986; 57: 1131-35.

3. Zink S, Antoinc J, Mahoney FJ. Fast neutron therapy clinical trials in the UnitedStates. AJCO 1989; 12: 277-82.

4. Wells G, Koh W-J, Pelton J, et al. Fast neutron teletherapy in advanced epidermoidhead and neck cancer: a review. AJCO 1989; 12: 295-99.

5. Koh W-J, Laramore G, Griffin T, et al. Fast neutron radiation for inoperable andrecurrent salivary gland cancers. AJCO 1989; 12: 316-19.

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PRIVET, KEEP OUT

Sept 4-11 is Privet Out Week in the Auckland area of NewZealand-a time when zealous environmentalists are urgingresidents to uproot, cut down, or spray every privet bush in sight.Four species of privet, none of them native, are found in NewZealand, and, encouraged by the warm moist climate, they arespreading fast, posing a threat to parks, gardens, and-moreseriously-to areas of native bush, where they are smothering theyoung plants. Conservationists are worried that the invading specieswill eventually displace certain native ones and even becomerecognised, mistakenly, as native plants themselves. The campaignto eradicate privet has every chance of success, for New Zealanderscare deeply about their environment. The environmentalists’ handhas been strengthened by claims that privet is also a health hazard.Privet has long been suspected of causing asthma and hayfever, andan Auckland doctor has now claimed to have proof of thisassociation.1 When Dr Harry Rae, of Auckland’s Green LaneHospital, used a fan to blow pollen from a concealed privet busharound a room, some of his asthmatic patients responded withairways constriction; the whirring fan alone elicited no response.Sceptics say that privet pollen is too heavy to be inhaled in normalcircumstances, but many asthmatics are convinced that their illnessis aggravated by proximity to privet in summer.

WHAT’S IN A NAME?

FOR readers whose command of Latin extends little further thanthe occasional ung(uentum), mitte, or gutt(ae), we commend thefollowing lines, presented in the style of a medieval annunciationcarol.

Tunica mucosa linguaePapilla ductus parotidaeSulcus corporis callosi

Gyri temporales transversiPlica umbilicalis lateralis

Vestibulum bursae omentalisMusculiRima orisDiastema

Valvula semilunaris dextraNucleus ventralis anterior

Serious anatomists and many others will be relieved to learn thatthe sixth edition of the Nomina Anatomicae (which contains withinits covers third editions of two more nominas, histologica andembryologica) is set out in a far more systematic fashion. On thisoccasion, we applaud the decision of the International AnatomicalNomenclature Committee not to include an index, which wouldhave been an unnecessary encumbrance; an English translation ofcontents is provided for those less familiar with the Latin tongue.

REAL SAVINGS?

SINCE 1984 all health authorities have been required to identifythe amount of savings made through cost-improvementprogrammes (CIPs). The savings are said to be additional resourcesfor service development over and above any new money allocated tothe NHS. The 900 million a year claimed by the Government tohave been generated by CIPs is impressive, but, according to asurvey3 of these programmes, the figure is so imprecise as to makethe certainty with which it is cited at national level a source ofconcern. The report also concluded that an overstatement of actual

savings must account in part for the severe funding problems facedby many health authorities in recent years.The survey, conducted jointly by the Institute of Health Service

Management, the King’s Fund Institute, and the NationalAssociation of Health Authorities, examined how three healthdistricts formulated their CIPs and calculated the savings. A

1. New Zealand Herald Aug 19.2. Nomina anatomica. 6th ed. Edinburgh: Churchill Livingstone. 1989. Pp 200. £30.

ISBN 0-443040850.3. Efficiency in the NHS. A Study of Cost Improvement Programmes. London: King’s

Fund Institute. 1989. Pp 84. £3.95.

regional health authority was also studied to assess how CIPs aremonitored and audited.As defined by the Government, CIPs should not include

cost-saving measures that produce service reductions, but thesurvey revealed lack of uniformity between districts in their

assessment of the impact of a particular programme on servicelevel--eg, one district included ward closures over Christmas andEaster as a CIP, whereas another regarded it as a service reduction.

Other points contributing to the imprecision of the figures werethe exclusion of capital costs in the calculations and the assumptionthat savings from CIPs are recurrent. The survey also found thatregional health authorities did not always challenge questionableitems included in CIPs to the point that they were withdrawn fromthe programme.The report says that the Department of Health is not unaware of

the issues that are causing concern about CIPs-these were broughtup in 1986 by the National Audit Office and the Public AccountsCommittee-and it is now in the third stage of its own study of therealism of CIP targets, the implementation of the programmes, andthe review process.

University of CambridgeA professorship of molecular parasitology has been endowed by

Glaxo Holdings with a capital sum and grants totalling 1 1 1 million.The endowment is designed to improve understanding of some ofthe major health problems facing the third world.

Immunisation CoverageThe World Health Organisation’s Expanded Programme on

Immunisation has announced that, for the first time, immunisationcoverage for the world has reached the two-thirds mark (67%) for athird dose of poliovaccine for children reaching the age of 1 year.Third-dose coverage for diphtheria, pertussis, and tetanus (DPT)stands at 66%; for BCG 71%, and for measles vaccine 61%.However, only 25% of pregnant women received a second dose oftetanus toxoid.

Fred L. Soper Award

The Pan American Health and Education Foundation (PAHEF)has established the Fred L. Soper Award for articles in the healthsciences, especially those of special relevance to Latin America orthe Caribbean, or both. The award is given in recognition of DrSoper, Director of the Pan American Health Organisation from1947 to 1959, for his outstanding contributions to health in theAmericas. The first award will be made during 1990, andapplications must be received by 31 March, 1990. Applicationsshould be sent to the Executive Secretary, PAHEF, 525 23rd StreetNW, Washington, DC 20037, USA.

Corrections

Sex Ratio of Infants following Assisted Reproduction.-In this letter by DrW. H. James (Aug 19, p 446) the end of the first sentence should have read:"... reported that 13 of 14 babies bom after gamete intrafallopian transfer(GIFT) were boys".

Predictive Testing for Huntington’s Disease with Linked DNA Markers.-Fig 2 in this article by Prof D. J. H. Brock and colleagues (Aug 26, p 463) wasreproduced incorrectly. The correct figure is shown below.