important parts of the national economy. Secondly the insurance contribution of individuals will become so great that it will remove demand from important sectors of the economy by reducing the money in the pockets of the population. Thirdly the insurance contributions of employers will raise the prices of their goods and services so as to make them uncompetitive with imports (this is thought to be happening already in the United States in respect of motor cars). A highly automated and efficient manufacturing industry producing consumer goods at low cost and using relatively little manpower will obviously allow a higher proportion of the GNP to be devoted to health care before reaching the level of maximum stimulation, as shown in fig 2. These are the characteristics of present-day industry and this probably explains why health-care expenditure has been able to continue to increase gradually and without detriment in all advanced countries. TRYING THE EXPERIMENT?
hypothesis only be proved or disproved by experiment. It is Government power to increase directly the GNP of this beyond can
country but it is within its power Fig 2-Hypothetical effect devoted The
increasing the proportion
peaks A,B,C are determined by efficiency of other parts of the economy,
less efficient economy and C
Government policy is preventing the economic characteristics of the UK from rising along the regression line in fig I towards comparable countries in which such Government pressures are either unknown or ineffective. Perhaps we should be making major efforts to take health care out of Government expenditure and establish it on the basis of compulsory health insurance. This would not detract from the important principle of medical care being free to the person who is ill, which is a characteristic feature of all developed countries and not just the NHS. An insurance-based system would allow health authorities to have an income based on work done rather than a fixed allocation as at present. Healthservice workers (including doctors) could continue to be paid by salary and regional planning could continue to ensure a relatively even spread of resources with access to medical care for all the
expenditure. If the Government decides to do so either by direct action or by devolving control to an insurance organisation then it will be interesting to see whether the GNP rises. Cochrane suggests that we should increase the GNP by buying British, improving management, and avoiding strikes. Over the past few years strikes have considerably diminished and management is thought to have improved, but there has been no significant rise in the GNP. Perhaps the best way of buying British goods and services is to invest in health care. This cannot be done overnight since a large organisation can change only slowly and more work in the NHS (irrespective of its means of finance) can only be performed with more facilities (which need building) and more staff (who need training). A planned or unplanned increase could bring about major improvements not only to the health service but to the economy as a whole.
Before Our Time
population. We must differentiate between health-care activity being good for patients and health-care activity being good for the economy. It has been well established by Maxwell3 that there is little or no relationship between health-care expenditure and the health status of the population. Patients can be treated equally well in huts or antiquated hospitals as in modern hospitals even though they would probably express a desire for the latter. Britain tends to lag behind in many areas of high technology in medicine-for example, computers and CT scanning. Although much high technology in medicine is of marginal value and although patients can be treated
perfectly well without computers and CT scans, this type ofmedical care is of great economic importance to the suppliers of advanced high technology equipment. Furthermore, a strong home market is essential to the development of exports. There is no doubt a limit to which health-care expenditure stimulates the GNP in a similar way to which venous return stimulates cardiac output. The regression line in fig 1 can probably be extended into a curve similar to that of Starling’s law*, as in fig 2. Once health-care expenditure increases above about 10% of the GNP then it will probably have three major detrimental effects upon the national economy, ultimately leading to a reduction in the GNP. Firstly, the health service will absorb large amounts of highly skilled and semi-skilled manpower to the detriment of other 3. Maxwell R. Health Care the Growing Dilemma. New York: McKinsey
Co Inc 1974
that the energy of contraction (of the heart) is proportionate to the initial length of the cardiac muscle fibres. It is based on the observation that increasing the volume and pressure of blood returning to the heart stimulates a more forceful contraction of the heart with an increase in the cardiac output, but if continued beyond a certain point it will lead to heart failure. In other words, increasing the input leads to a greater increase in the output, but only up to a point.
AN 18th CENTURY AMPUTATION
SURGERY in the days before anaesthesia was nasty, brutish, and-if you were lucky-short. Patients were held down or strapped to the table; nowadays such grim proceedings seem to be the stuff of nightmares rather than reality. And if our adult forbears suffered grievously under the knife, for children the terrors must have been
staggering. Until recently I had never chanced upon a description ofa major operation performed on a child in the pre-anaesthesia era. At a book sale last year I purchased a manuscript notebook entitled An Account of the Illness and Death of Lady Anne Dawson Drawn up by her Sister Lady Louisa Clayton and Presented by her to Master Dawson the Only Surviving Child of Lady Anne. Some 63 pages are devoted to Lady Anne’s rather protracted demise (faintly reminiscent of Mimi in La Boheme) which finally occurred on March 1, 1769, from, appparently, consumption; another 46 pages concern themselves with gloomy poems and sundry prose broodings on death and eternity; and the last 9 pages are an Extract of a Letter from Miss R to Lady L (.Lady Louisa Clayton?]. This last entry gives the following account of the removal of a young girl’s leg. *
I have lately heard such a pretty anecdote of a sweet little girl of 9 years old that I must give it you as I think it may interest your little ones.
Lady S’s second daughter Laura had been for months confined at 1.
(d.1769) were daughters of
Fermor, Countess of Pomfret (d.1761) who, according to DNB,
although an "excellent wife and mother. .exposed herself to constant ridicule by wishing to pass for a learned woman." Lady Louisa Clayton was married to Sir William Clayton, Bt, and Lady Anne Dawson to Thomas Dawson, later Viscount Cremorne
1075 Clifton with
in her knee. Mr
her, and a surgeon from London, when at length they pronounced i necessary to amputate her leg else she would [lose] her life. Lady [S would not bear the thought of her child suffering such and preferre( losing her; however after some days she made up her mind t4 consent to it and two more surgeons from London were sent for. Sh said the day before they were to arrive Laura was to be told of it. M Baynton told Lady S he could not break it to the dear child. Lady ! said she would take it upon herself to do that and accordingly wen into Laura’s room; and after speaking to her most affectionately fo some time, broke it to her. The sweet child showed no agitation no alarm when her mother said "My love do you think me very cruel t( take this resolution?" "No, Mamma, you could not help it.’ "Would you prefer dying, my love?" "Yes, Mamma, for then should be happy," but pausing added, "that would be taking my fat4 into my own hands and I could not expect that God would suppor me in dying; God demands my leg, not my life." This happy composure was not transitory-it lasted all that dayl! night. She told her mother, "Mamma, do you remember the day yot stayed at home from church with me and talked with me about God from that day I have thought much about Him, and loved Him, & it is that now supports me, and will support me during tht operation-pray for me. I will not ask you to stay in the room; i1 would not be good for you, but perhaps Rowe (the housekeeper) wil be so good." The next day, Thursday in Passion week, the foui surgeons arrived. Lady S went into Laura’s room to acquaint her The child shed some tears upon hearing it was so near, but soor recovering her wonted composure said, "Mamma, pray for me that 1 may glorify God by patience and that it may do good to Mr Bayntor to see what God can do." Laura was taken out of bed and placec upon a table; when they went to cover her eyes, she said "you neec not do that. I will keep them shut but if you like it, do." They bounc on the handkerchief and began the operation which the dear chilc bore without a word until the end when she gave one cry of Oh when the great artery was taken up. To show how much she was supported even in body, a few flowers which she held between hei fingers remained unmoved during the operation. After it was over, Mr Baynton was expressing his astonishment at her composure & calmness. She said "There should not have been one Oh! Good God supported me; two texts comforted me during the operation’-’through much tribulation you must enter into the Kingdom of Heaven’ & ’if we suffer with Him we shall reign with Him’." Emily B saw her five days after the operation eating an orange in bed as if nothing had happened. Laura said she would not change her situation or have back her leg. She expressed great delight to think it took place in Passion week, by suffering thus to be made like her Saviour. Thus out of the mouth of a babe was God glorified. Laura goes on well. This not only shows what divine grace can do, but is an evidence of prayer for the child being answered. Lady S at one time despaired of her, her natural temper was so volatile. *
What are we to make of all this? Obviously the power of faith and prayer over pain, although an unbeliever might uncharitably suggest that the child was in shock or a toxaemic state before or shortly after the operation began; however, the eyewitness account suggests that the child was completely rational, and so does her rapid postoperative recovery. Was she too self-possessed for a nineyear old? Could such a young girl utter such sentiments under such grim conditions? Possibly-after all, those who admire the life and
precocious writings of Marjorie Fleming (1803-11) (whose life,
Sir Leslie Stephen recorded in the Dictionary of National Biography, "is probably the shortest to be recorded in these volumes, and certainly she is one of the most charming characters") will recognise a kindred spirit. Department of Anatomy, UCLA School of Medicine, Center for the Health Sciences, Los Angeles, California 90024
L. R. C. AGNEW
2 Probably Thomas Baynton (1761-1820), the noted Bristol surgeon. His Descriptive Account ofa NewMethodofTreatingOldUlcersoftheLegsfirstappearedin 1797, with a second edition in 1799, both editions being published in Bristol.
Round the World From our
India MIXED RESPONSE TO
THE proposed withdrawal ofclioquinol by Ciba-Geigy has evoked a mixed response among doctors in India. An interview-based survey published by the Madras daily, The Hindu (July 26), revealed that while many general practitioners believed the withdrawal to be "unwarranted", senior professors are divided in their opinions. Two heads of departments of gastroenterology in leading teaching institutes have been quoted as saying that when safe and effective alternatives exist, it is preferable to avoid using a drug whose harmful side-effects have been documented in other countries. Other senior doctors, including the president of the Indian Medical Association, have taken the stand that since such side-effects have not been "reported" in India, there is no need to stop using a drug known to be a cheap and effective antiamoebic in a country where amoebiasis is widespread. A paper on "the clioquinol controversy" circulated last year by the Voluntary Health Association of India argued that no systematic study had been done to detect and monitor side-effects, a task rendered the more difficult by over-the-counter sales of the many available brands, widely self-prescribed as routine anti-diarrhoeals. In April a talk on the dangers of clioquinol by Dr Olle Hansson, the Swedish physician, at the All India Institute of Medical Sciences in New Delhi was widely reported in the press and provoked a Parliamentary question in May. The Health Ministry replied that it did not plan to ban the drug; but its listing as a prescription drug is supposed to be an adequate safeguard against unmonitored use. Since in actual practice this norm is not being observed, VHAI has called for warnings written in language comprehensible to the lay consumer. There are over 50 brands of hydroxyquinoline drugs; and some "enzyme" tablets are said to include clioquinol as an ingredient. Since there is no official ban on clioquinol the withdrawal of Ciba-Geigy’s product will not affect the sale of other brands.
United States COMPUTER VERSUS COMPUTER
WHEN the computerised records of patients at the SloanKettering Memorial Cancer Center were broken into, the consequences were reported to include administrative chaos and such deletion of records as to cause serious loss both of data and money. We were told that no patients were harmed (they could have been, for the computer records broken into were those for the monitoring of the treatment of cancer patients). Not only had the system been broken into but it had also been reprogrammed to reveal the secret passwords of other users. The director programmed the computer to tell the intruder to desist but since then there have been more than twenty attempts to make use of the computer records. In Madison, two reporters showed Wisconsin’s Attorney General how, using the home computer with a telephone link, they could obtain from the State’s computers information on income-tax refunds, welfare payments, and other confidential information, a demonstration the Attorney General described as "scary". All the youthful intruders so far identified and willing to talk noted how lax was security in nearly all the institutions they tapped into. The intruders cannot be brought before the courts except on secondary charges, improper use of telephone lines or not paying for computer services. Wisconsin, as it happens, has a State law prohibiting unauthorised access to computers, but it is not easy to see how it could be enforced. There are no Federal laws. We are promised more efficient computers, to work more rapidly, to store more data, and generally to be more efficient if not intelligent. But human intelligence with time and determination may still be able to enter them, to steal their information, and perhaps to reprogramme them to deny that they have been rifled. That is the worry; perhaps much of the information even in secret secure computers has by now been stolen.