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Action against Rheumatic Diseases

THE LANCET.LONDON: SATURDAY, SEPTEMBER 29, 1945

A NEw Minister is surveying the health of the coun-try, and it is probable that he will place chronic" rheumatism" on the list of high priorities. Itwould be natural for an ex-miner from the Ebbw Valeto take a realistic view of Public Enemy No. 1 of thecoal (and other) industries. The necessary first step,however, was taken by his predecessor Mr. WILLINK,when in May, 1944, he added a sub-committee onchronic rheumatic disease to his Standing MedicalAdvisory Committee, and instructed this body toexamine with all speed the practical possibilitiesof fighting rheumatism more effectively. This

they did, under the chairmanship of Prof. HENRYCOHEN, and their plan in essentials followed the oneput forward by the Empire Rheumatism Council in1941 and published over the signature of LordHORDER as Rheumatism a Plan for National Action.The new proposals had to be put aside for the momentbecause of the lack of medical personnel, but the

period of cold storage, we may hope, is soon coming toan end ; and already, we are told, the Government’sdecision to tackle not onlv diseases that kill but alsothose that cripple has acted as a stimulus to othernations. In the words of Dr. RALPH PEMBERTON,president of the Pan-American Rheumatism League," it will influence thought everywhere."The plan is based on the need to concentrate the

more specialised facilities which are essential for

diagnosis or treatment in many early cases of chronicrheumatism and arthritis. For this purpose thecreation of a special department in a principal hospitalin every region is advocated. This will be in chargeof a physician who will have access to all the hospitalresources, such as radiography, laboratory facilities,and (not least) the opinion of his colleagues-notablythe orthopaedists. Around this regional nucleus therewill be an outer circle of smaller clinics whose staff and

equipment will be less specialised : these will servemainly as treatment centres and will refer their moreobscure diagnostic problems to the hospital centre.Such a scheme has the merit of making full use of theservices of physicians with special knowledge andexperience of "

rheumatology," and of avoidingadditional pressure on the physical-medicine depart-ments of hospitals. It should also provide favourablesurroundings, and large opportunities for much-neededresearch under university auspices. An experimentaltrial of the scheme, early this year, in one or twosectors of the Emergency Medical Service did notmeet with great success, because both medical andnursing staff were insufficient ; but we understandthat in Manchester a special committee has recom-mended that an institute shall be set up for the studyof bone and joint pathology in the rheumatic diseases,while in Liverpool and in Leeds arrangements are to bemade between the voluntary and municipal hospitalswhich should result in diagnostic centres beingestablished, with beds in which patients can stay as

long as may be necessary, and in which research will beundertaken under the auspices of the professor ofmedicine. In London no teaching hospital has yetfollowed the example of the West London Hospital,which in 1938 set up a department on lines similar tothose of the present scheme ; but at least one of the’Big Twelve now has this project under consideration.

The prominence of chronic rheumatism as a cause of .

sickness and absence in industry has attracted theattention of other Government departments, includingthe Ministry of Labour, and the Ministry of Fuel andPower, and of the Industrial Health Research Board.There is reason to hope that the universities, throughtheir teaching hospitals, will in the near future join inthe establishment of the special centres proposed bythe Ministry of Health and that voluntary organisa-tions interested in medical research will supportinvestigation in such centres. We must now try tofulfil the prophecy of the Times when the campaignagainst rheumatism opened :

" As it grows in strengthit will spread over the whole country, and from itssuccess the nation is likely to reap substantialadvantage."

Surgery in Ulcerative ColitisIT is to be hoped and indeed confidently expected

that the surgical treatment of ulcerative colitis is butan interim measure which will be discarded when amore thorough understanding is reached of this

distressing complaint. Its aetiology is still far fromclear. There is a stage of the disease when the pictureis one of infected ulceration, but the lack of confirma-tion for BARGEN’S- diplococcus, and the failure ofattempts to find other specific causative agents havecast doubt on infection as a prime factor, though treat-ment with the " sterilising

"

sulphonamides, especiallywhen combined with penicillin,! has sometimes beensuccessful-perhaps, as it does in amoebic dysentery,because it holds secondary invaders in check. That

deficiency may play a part is supported by MoRTONGILL’S experience with fresh and dried pigs’ intestine,both of which, given by mouth, led to improvement insome cases. The association of the complaint withemotional instability, and the tendency of emotionalcrises to precipitate recurrences, suggest some inherentsensitivity or diathesis, while allergy has also beencalled on to account for the patients’ susceptibility,although the stimulus to which they over-react is notapparent.3 None of these avenues of investigationlooks like leading to a surgical goal, but, while they arebeing explored, surgery, though difficult and uncertain,can tide many patients over a bad patch, prevent othersfrom relapsing, and save the lives of some.

Surgery has been adopted for three purposes inulcerative colitis : (1) to promote easy access of medica-ments and wash-out fluids to the colon ; (2) to rest theinflamed and ulcerated bowel ; and (3) to extirpatethe seat of the disease. The first of these has largelybeen superseded, for even if it is desirable to wash outthe bowel, which is doubtful, this can be done adequatelyfrom the rectum although not with the same certaintyas through an appendical or caecal opening. If the

appendix is unsuitable and caecostomy is performedinto potentially or actually diseased bowel, the resultsmay be horrible, for the patient in addition to passing

1. Hargreaves, W. H. Lancet, July 21, 1945, p. 68.2. Morton Gill, A. Ibid, Aug. 18, 1945, p. 202.3. Hardy, T. L. Ibid, 1945, i, 519, 553.