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What has changed in medical practice Poppy love that patients in 2008 seem to be in so much more pain than in 1988? Personal View Janet Gillespie

I spread out the crumpled note the patient as a sedative and in larger doses as a powerful ber to December 2006 show that prescribing had given me while he spoke: he had been painkiller. People bought it in much the same of rose by 62%, accounting for 25% to the pain clinic “for his back,” and they had way as they buy today: opium was of all prescribing (www.ppa.org.uk/ recommended this to help his pain. If he took more widely available in 1870 than tobacco news/pact-032007.htm). Notably, the note to his (implied) trusty GP, he or she was a century later. Patent medicines such as prescribing rose by 57%. would sort it out for him; and if the treatment Dover’s powder were kept in the kitchen cup- Over my professional lifetime I have was unsuccessful, the pain clinic suggested, he board. Godfrey’s Cordial or Street’s Infants’ ­witnessed the consequences of iatrogenic could be referred to a neurosurgeon for assess- Quietness not only reduced colic in infants ­ dependency, these drugs ment. Mercifully, the trade name was scrawled but made it easier to sedate children so that having originally been promoted as a safer in block capitals. The British National ­Formulary they were indeed “seen and not heard.” The ­substitute for . This was yet another revealed it to be a transdermal intoxicant effects of opium were also appreci- example of the British love of problem solving patch. ated: one Ely brewer added it at source. by substitution: Wellington’s Beer Act (1830) I sat back and considered the matter. It was As early as the 1830s, however, it was recog- promoted beer to solve the misuse of gin, a not an entirely unreasonable suggestion: the nised that opium use reduced life expectancy, drink that was first promoted by William III patient was already taking , tra- and by the 1860s it had become a matter of to reduce the wine trade with France, the old madol, and , with only moderate national concern. A third of all fatal poisonings enemy. So what are we prescribing as control, and his sleep was still disturbed. What were opium related, and accidental poisonings a substitute for? Since the rise in use surprised me was that the opiate prescrip- were so common that information leaflets were clearly predates the “loss” of co-proxamol, is tion had come before a referral for a surgical published to warn of the risks. The 1868 Poi- our prescribing a substitute for action? What ­opinion. sons and Pharmacy Act listed opium as one of has changed in medical practice that patients in In the mid-1980s, when I trained as a gen- 15 poisons whose use became restricted, but 2008 seem to be in so much more pain than in eral practitioner, opiate patches were only it wasn’t until 1920 that Britain had its first for- 1988, when treatments were fewer and ­surgical the proverbial twinkle in a pharmacologist’s mal legislation on the regulation of drugs, with techniques less refined? eye, and use in the community of “Bromp- the Dangerous Drugs Act. Today, we practise Or have the opiates ton cocktail” was considered avant-garde. Ten in the shadow of now become an end in years later, when I left the partnership, syringe Harold Shipman themselves—an easy, drivers and Macmillan nurses had become a and his profli- computer generated routine part of the primary healthcare serv- gate opiate mis- solution with the ice. But that was for terminal care; pain that use. It is somewhat slight annoyance of con- merited further investigation or had a possible paradoxical, then, that stipation and the benefits alternative solution was managed by an appro- prescriptions for opiates are of a mildly sedated patient? priate referral. now computer generated for If so, our profession is at risk of Perhaps part of the reason for this reluctance accuracy and legibility but by this sleepwalking into another iatrogenic to prescribe opiates was the need to handwrite method are less onerous to issue. dependency and forgetting the age old miser- prescriptions for “controlled drugs” in words I recently returned to general practice ies of opiate addiction. and figures. Individual doses were easily after a break of seven years and was My patient and I discussed the pain ­clinic’s remembered: scripts were for small amounts struck by the large number of opiate recommendation and assessed the risks and were therefore often repeated. In the days prescriptions. The NHS’s Prescription and benefits of such an action. He left with before computer searches, a straw poll of the Pricing Division confirms this increase: a prescription for opiates, and I am writ- partners would have produced a complete list from 2000 to 2005 the largest ing to ­expedite his assessment by of all patients taking opiates regularly. increase in painkiller pre- a ­neurosurgeon. That just Opiate prescribing dates back to Sir Tho- scribing was in leaves the matter of our mas Sydenham, who, in the 1660s, promoted , with mor- poppy love. (from the Latin “laudare,” to praise), phine prescription Janet Gillespie is salaried a tincture of opium and . Writing at the increasing by 32% general practitioner, Buntingford end of the 19th century, William Osler called it and patches Medical Centre, Buntingford, “God’s own medicine.” For the first time there nearly sixfold. This Hertfordshire gillespie. was a reliable means of controlling diarrhoeal trend continues: [email protected] symptoms, while in moderate doses it acted data from Octo- Cite this as: BMJ 2008;337:a2334

BMJ | 8 november 2008 | Volume 337 1115 VIEWS & REVIEWS

A fat chance

FROM THE I always enjoyed the university annual eating competi- already exist, and they are neither new nor complex. FRONTLINE tions: five contestants at the zenith of their ability, swal- We need to restore to people’s lives a balance between lowing whole pickled onions or boiled eggs, but only energy input and output. The scale of the problem, how- Des Spence one winner. Gluttony was celebrated, and like many ever, requires a political, not a medical, change. young people I never believed I would gain weight. But We have a decaying and neglected food culture, with times change. Obesity is now common in the young and families offering just readymade meals amid unconvinc- endemic to epidemic in adults. When we won the battle ing excuses of “pressure of time.” But the key problem is for wealth we lost the war of contentment. Doctors have our sedentary life. Current recommendations on activity foolishly rushed into this haemorrhaging of happiness. are woefully low, reflecting a poverty of expectation. Obesity is now a big medical business, with a rapid And the education system is so fevered with targets it is expansion in the number of specialist clinics. Likewise blind to our national disgrace: inactive children. Further- drug companies are active, lurking behind advocacy more, we are so plagued by spectres of mistrust that our groups that endorse drug treatment as a solution to the children are kept virtual prisoners indoors. irresistibly personalised pain of obese people. Recently, An urgent and fundamental change of infrastructure however, , a cannabinoid receptor antagonist and schools policy is needed. We need to create safe anti-obesity drug, joined the long list of withdrawn drugs places for our children to play in, to allow them to cycle, (BMJ 2008;337:a2301). An all too familiar tale was the pedestrianised streets and to restrict car use, along with unforeseen side effects of the drug. education and financial incentives to get people to pre- We must stop the medical advance on obesity and pare food themselves. Medical interventions will serve bring the troops home, for once again we are destabilising only as an irrelevant policy distraction and have a fat self control and personal responsibility. Medicine alone chance of working. cannot solve the problem of obesity, and nor should Des Spence is general practitioner, Glasgow [email protected] it try—obesity is not an illness or syndrome. Solutions Cite this as: BMJ 2008;337:a2432

The bottom line Starting Out “I’ve just passed a 12 inch stool,” to irritable bowel syndrome approach. Time spent regularly Kinesh Patel said the voice over the telephone (gastroenterology seems to have with a patient is largely regarded as with a degree of solemnity more than its fair share). “waste” time that could have been commensurate with such a The bottom line is we’re not very used to see a new referral, thereby statement. “Is that normal?” good at assessing patients’ mental keeping the hallowed “follow-up “Well, I’m not sure,” replied state, let alone offering appropriate to new ratio” (abbreviated, rather the secretary, a little baffled as to treatment for their conditions. It ironically, to FUN) within target. what the appropriate response is much easier to comment matter And while I have no doubt was to such a question, while no of factly on the large ulcerating that such reforms have led to doubt at the same time wondering carcinoma you’ve discovered than shorter waiting times for patients why anyone would bother to to explore environmental influences with organic disease, those with measure a stool, let alone share that on diseases affecting the human debilitating conditions that do not information with anyone else. condition. fit neatly into any pathologically Although such an anecdote Patients with cancer need surgery, proved diagnosis have surely makes us snigger quietly to chemotherapy, and emotional suffered as they are bounced from ourselves, it does illustrate how support, whereas those with hospital to GP and then back again. trusted we are as professionals commoner functional ailments What can we do to solve this that people feel prepared to tell us mainly need just emotional quandary? Taking an interest is an anything and everything. support and reassurance. This important first step—for although It is easy to dismiss what we takes time and effort, often without these conditions are not glamorous perceive as the crazed ramblings of a satisfying tangible result such or popular with clinicians, they patients with functional syndromes as ceremoniously dropping a affect far more people than do the but harder to remember that to neoplastic lesion into a pot with the rarer diseases we often seek. And these patients those symptoms command “Send that to histology.” just in case you were wondering, a are very real. Each specialty has Modern financing structures, 12 inch stool is entirely normal. its own condition that makes such as the NHS’s Payment by Kinesh Patel is junior doctor, London kinesh_ clinicians throw their hands up in Results, do not help encourage [email protected] exasperation: from fibromyalgia a psychologically supportive Cite this as: BMJ 2008;337:a2395

1116 BMJ | 8 november 2008 | Volume 337 VIEWS & REVIEWS

Medical Classics In small town America The Death of Ivan Ilych By Leo Tolstoy There are two doc- ference. “Every- First published in 1886 BETWEEN tors in Winesburg, one in the world In one of his letters Tolstoy defined his novel The Death Ohio, Sherwood THE LINES is Christ,” he says, of Ivan Ilych as “a description of an ordinary death of Anderson’s book Theodore Dalrymple “and they are all an ordinary man.” It is based on the real story of Ivan about a fictional crucified.” Nowa- Ilych Mechnikov, a lawyer who died at the age of 45 from small town in mid- days, of course, we cancer. His younger brother, the Nobel medical laureate dle America. It is all fear lynching by Ilya Ilych Mechnikov, wrote that Tolstoy had given “the best description of fear of death.” an episodic novel coroner’s court and Ivan Ilych, a lawyer in a provincial Russian town, had of loosely con- public inquiry. led a life that was, Tolstoy wrote, “most simple and most nected stories in The other doc- ordinary, and therefore most terrible.” A successful which Anderson tor is Dr Reefy. careerist and head of the family, Ilych one day noticed a depicts the lives of His practice, too, queer taste in his mouth and felt some discomfort in his ordinary people for is exiguous, and left side, accompanied by irritability. His wife demanded whom the American he spends his days that he visit a doctor. But “it was all just as it was in the dream has not come writing things law courts,” Ilych finds: true, partly because down on scraps The doctor put on just the same air towards him as he himself of circumstances of paper and then put on towards an accused person. The doctor said that so and so indicated that there was so and so inside the patient, and partly because screwing them but if the investigation of so and so did not confirm this, of human nature— up into little pills then he must assume that and that. If he assumed that and we are not made for Neither doctor has that he puts in his that, then . . . and so on. To Ivan Ilych only one question was permanent, or even many patients, or pocket or throws important: was his case serious or not? But the doctor ignored that inappropriate question. From his point of view it was not for very prolonged, seems to go in much on to the floor. His the one under consideration, the real question was to decide happiness. for diagnosis, let alone life has been emp- between a floating kidney, chronic catarrh, or appendicitis. The two doctors, treatment tied of meaning Ilych consults several doctors who diagnose different it must be admitted, by the deaths of diseases and administer different treatments. In search are not the finest two women, both of a cure he is prone to irrational behaviour: “One flower of our great profession. Neither patients, with whom he has fallen day a lady acquaintance mentioned a cure affected has many patients or seems to go in in love, and to one of whom he was by a wonder-working icon. Ivan Ilych caught himself much for diagnosis, let alone treat- briefly married before her death. listening attentively and ment. Indeed, Dr Parcival’s qualifica- The other is a woman married to beginning to believe that it had occurred.” Soon he tion as a doctor seems to be in some the town’s hotel keeper, who in her understands that “it’s not doubt: after all, these were the days youth dreamt of romance and adven- a question of appendix (1919) before validation, let alone ture but who has been ground down or kidney, but of life and revalidation, at least in towns such as by everyday banality. Though very . . . death . . . There was Winesburg, Ohio. Dr Parcival says ill, she goes to Dr Reefy not in search light and now there is only that he knows as much of medi- of a cure but because he is the only darkness. I was here cine as anyone in the town, which is man who understands her. Falling in and now I’m going there! about as ambiguous as the famous ref- love, their one moment of passion- Where?” Tolstoy is known for erence once given to a junior doctor: ate embrace is interrupted by an his pejorative and unfair you will be lucky to get this man to employee of the Paris Dry Goods attitude to medical Tolstoy: veracity of depiction work for you. Company Store, above which Dr doctors. All the doctors Dr Parcival doesn’t need patients, Reefy has his office, as he comes up in this novel are shown as hypocrites who constantly lie because he has enough money for his the stairs to deposit a box on the stair- and who are indifferent to Ilych. slender needs. How he came by the well. The lovers never meet again; The death of Ilych from cancer is described in such money is a mystery: he has a rackety their sole moment of human connect- detail that it has been proclaimed the strongest past, and he implies, though never edness is evanescent. The episode is description of this disease in literature. The veracity of the depiction is such that, a Russian professor of actually claims, that he came by his reminiscent of Chekhov’s Lady with medicine said, not only a physician but any third year money in a seriously criminal fashion. the Lapdog. medical student would be able to diagnose the disease It emerges that he is mad (his father Of course, no such thing as hap- as an abdominal cancer localised either in the caecum died in an asylum, at least if he is to pened to Dr Reefy and Mrs Willard or the right kidney. “Every doctor of any specialty should be believed). could happen nowadays, at least not read this story with utmost attention to reveal a sea of One day there is an accident in in the NHS, if for no other reason than horror and doubts experienced by cancer patients,” Winesburg and a child is killed. Dr it is so difficult to get to see the same wrote A T Lidsky in a Russian medical periodical in 1929. Parcival refuses to attend and spends doctor twice. Boleslav Lichterman is senior researcher, Institute for the the rest of his life believing that a Theodore Dalrymple is writer and retired History of Medicine, Russian Academy of Medical Sciences, Moscow [email protected] doctor crowd of townsfolk will one day Cite this as: BMJ 2008;337:a2399 come to lynch him for his cruel indif- Cite this as: BMJ 2008;337:a2400

BMJ | 8 november 2008 | Volume 337 1117 VIEWS & REVIEWS VIEWS & REVIEWS

Review of the Week Lessons from the killing fields A remarkable textbook will allow for the rapid application in surgery of lessons from the wars in Iraq and Afghanistan, finds Jonathan Kaplan

Combat conditions in Iraq and Afghanistan are produc- hours) from 65% to 19%. Another result has been the ing new patterns of wounds. Advances in body armour overturning of established practice in emergency fluid allow soldiers to survive explosions that would previously replacement, concentrating on hypotensive resuscita- have been mortal, though at the expense of limbs ripped tion (up to a systolic blood pressure of 90 mm Hg), with off by blast. The addition of a tourniquet to each soldier’s thawed plasma advocated for the colloid restoration of field kit—and the training to apply it before excessive circulating volume, while crystalloid use is relegated to blood loss—has reduced the death rate through shock the humble task of keeping intravenous lines open. from traumatic amputation by 90%, while ultra-rapid Vividly depicted is the arena in which those decisions evacuation allows soldiers with previously unsurvivable and interventions are made—“the white-hot moments injuries to reach advanced surgical care with vital signs in the surgical theatre where nothing is spared to save still present. One consequence has been bold advances a life.” It is to the credit of the authors and editors that in the treatment of major trauma. Another consequence, despite the imperatives of their work and the pressure perhaps equally dramatic, has been the rewriting of the to deliver effective trauma care under extreme condi- War Surgery in war surgery textbook. tions they have tried to adhere to principles of respect Afghanistan and Iraq: Far from a traditional reference, War Surgery in Afghani- for patients. There are instances when such fastidious- A Series of Cases, stan and Iraq is instead a series of individual case studies ness almost jars. A mortar victim is shown on arrival at 2003-2007 in which treatment decisions and their consequences are a combat support hospital, legs shredded, with medics Eds Shawn Christian followed through to their rigorously analysed conclu- pressing on the avulsed ends of the femoral artery in Nesson, Dave Edmond sions. Cases cover every surgical discipline, crossing ana- each groin. After radical surgery amounting almost to Lounsbury, Stephen P Hetz tomical and specialty boundaries to include neurological, bilateral femoral disarticulation, the pelvis is rephoto- Office of the Surgeon abdominal, thoracic, orthopaedic, faciomaxillary, vascu- graphed, and again during treatment at a military hos- General, US Army, pp 442, $71 lar, and soft tissue injuries. The first case report—a badly pital in the United States. In each image the genitals are Copies may be ordered injured man subjected to complex surgery that occupies covered with a decorous black square, demarcating even through the US the entire surgical team in a forward hospital for hours in this extremity some grade between information and Government Bookstore and empties the blood bank, only for him to die in the poor taste. Later, though, when the man is seen at vari- (www.bookstore.gpo.gov) evacuation helicopter—illustrates the book’s central mes- ous stages of recovery and restoration of mobility, the ISBN: 978-0981822808 sage: damage limitation as the primary intervention. preservation of his modesty seems exactly his due. Rating: Its raw materials are vivid digital camera images and While “host country national” casualties are gener- **** contemporaneous case notes written amid the surgical ally lost to follow-up, an attempt is made to trace the battle. Teleconferencing and computer based tracking progress of each US casualty through tertiary care and of patients have allowed constructive use of this data, rehabilitation, which allows for display and discussion making possible the rapid application of clinical lessons. of advances in these fields as well. Changes in surgi- An example is the principle of damage control resuscita- cal practice towards length preservation in the primary tion, taught in theory for the past decade but prone to amputation have greatly improved eventual function, wide variations of practice. Now, rapid comparisons of with new prostheses that are mouldable to almost any outcomes—and a brisk flow of casualties on which to stump shape. Awareness is growing of the prevalence accumulate an evidence base—are making possible the of mild traumatic brain injury: 29% of battle injured standardisation of what had previously been somewhat patients passing through Walter Reed Army Medical intuitive practices, turning them into scientific princi- Center show some degree of neurocognitive impairment, ples with replicable, consistent results. Such protocols usually through exposure to blast, that may not have are essential to counter the surgeon’s instinct to make been associated with loss of consciousness at the time of things right, to repair all damage, which launches the injury. And the wounded are bringing back new patho- patient along the path of diminishing survival through gens, with multiple drug resistant Acinetobacter baumannii hypothermia, acidosis, and coagulopathy. colonising medical facilities along the evacuation chain Not all the discoveries are new. The use of rapidly from Iraq through European hospitals to tertiary care Vividly depicted cross matched, fresh whole blood as a first line treat- institutions in the US. are “the white-hot ment for haemorrhagic shock was pioneered by Nor- New lessons are being learnt in every aspect of combat moments in the man Bethune in 1936 during the Spanish civil war—but surgical care, and this book is an exemplary and vivid advances in platelet apheresis, together with transfusion document of that evolution. surgical theatre protocols that combine set ratios of blood, platelets, and Jonathan Kaplan is a war zone surgeon and writer, London where nothing is fresh frozen plasma, have greatly reduced mortality after [email protected] spared to save a massive transfusion (10 or more units of blood in 24 Cite this as: BMJ 2008;337:a2394 life”

1118 BMJ | 8 november 2008 | Volume 337