THE LANCET, JANUARY 2, I971

decline and to the fact that it involved clinical manifes- tations that were already familiar to obstetricians and p~diatricians and therefore excited no new clinical

interest. Two social phenomena manifested during the years

of this epidemic must be considered for their possible ~etiotogic relevance.

After a temporary wartime restriction, Federal pro- hibidon of alcoholic liquor came into effect with the passage of the Eighteenth Amendment in 1920; the Amendment was repealed in 1933. Tile later years of this period saw tile consumption of an unprecedented amount of liquor produced under uncontrolled and often hazardous conditions. If an mtiological relatio n- ship between neural-tube defects and alcohol con- sumption during this period is to be considered, one must postulate that the responsible agent must have been some abnormal constituent oftl)e liquor--perhaps resulting from the conditions under which the liquor was produced~rather than the alcohol itself, since per-caput alcohol consumption has increased since 1935 ~" while frequency of neural-tube defects has declined. Some support for the linking of neural- tube defects to consumption of some form of alcoholic liquor comes from the observation that these defects are relatively frequent among the Boston Irish and rare among Boston Jews 7--a direction of relationship that parallels common beliefs as to frequency of alco- hol use by members of these ethnic groups. Another relevant observation is that the disparity between rates for the Boston Irish and Jews was much greater during the early 1930s than after 1945. 9

However, prohibition ended in December, 1933, but the highest rate of anencephaly and spina bifida in the two hospitals considered here was during the second half of 1932, when there were 27 affected infants among 2833 births (a rate of almost 1%); in the first half of 1933, the rate dropped to less than half of that observed during the autumn of 1932. This discrepancy becomes even greater when it is considered that the births in the second half of 1932 were conceived early that year or even in 1931. I t is possible that the constituents of illicit alcoholic liquors were changed before the formal repeal of prohibition, although we know of no such change or of any source of information on such a i3ossibility.

Previous work has shown an inverse association between socioeconomic status and this group of mal- formations,~, 7 and the great economic depression, beginning with the financial crash of 1929, shows some relationship to the peak of this epidemic. Again, however, there is a discrepancy in the temporal correspondence, since, at least as measured by rates of unemployment, the depression was at its worst in 1933 and 1934, by which time rates of neural-tube defects had begun to fall. There may be specific relevant features of the depression that peaked before the unemployment-rate, but we have not been able to identify likely candidates.

Whatever a~tiological hypotheses are developed re- garding anencephaly and spina bifida, it is clearly desirable that they accommodate this episode in the

history of this group of malformations. Furthermore, such hypotheses must take account of the fact that these

33

anomalies had the same, or perhaps slightly higher, frequencies during the years 1885-1920 as today.

For permiss ion to ut i l ise records, we are great ly indebted to the adminis t ra t ive and medical staffs of the Boston Hospi ta l for Women and the Providence Lying-In Hospital. For much help in the review we thank the staffs of the two medical-record depa~W.ments. The study was aided by a grant from the William F. Milton fund of Harvard Univexsity.

Requests for reprints should be addressed to B. M.

tlEFEI1ENCES

it. MaeMahon, B., Pugh, T. F., Ingans, T. H. Br. ft. prey. soc. Me& 1953, 7~ 211.

2. Leek, I.~ Rogers, S. C. ibid. 1967~ 21, 177. 3. Yen, S., MacMahon, B. Lancet, 1968~ ii~ 623. 4. PerLrose, L S.jq ment. def. Res. 1957, I , 4. 5. t~dwards~ J. H. Br.'ff. prey. see. Med. 1958, 12, 115. 6. Murphy, D. P. Congenital Malformation. Philadelphia, 1940. 7. lX!aggan, L., MacMahon, B. New Engl. J. Med. 1967, 277, 1119. 8. Gittelsohn, A. M., Milham, S. Bv.] . prey. soc. Med. 1962, 16,153. 9. Naggan, L. Am. J . Bplderedol. 1969~ 89, 15~,

10r McBridi~, W. G. Lancet, 1961, ii, 1358. 11. Lenz, W. ibid. 1962, i, 45. 12,.. National Center for Health Statistics. Vital Statistics of the United

States. ld.S. Government Printing Office. 13. Terris~ M. Am. J . phbL Hhh~ 1967, B7, 2076.

Round the World

United States MONEY N E E D E D FOR UNIVERSITIES

The Carnegie Foundation, having taken a hard look at medical matters and at the needs of the medical schools, has now had an. equally critical look at the finances of the uni- versities and colleges, both public and private. Some are in a good financial state, but these are few; most of those surveyed are either headed for financial disaster or are in deep waters, some Of them being the most famed universi- ties of this country. Other colleges and universities not surveyed are in deep trouble too; they are firing faculty members or not renewing contracts, and economising in every possible way.

The causes are evident--rapidly rising costs, slowly rising revenues. Tuition fees meet only a fraction of the ~otal expenditures, and are in many places high now and can hardly be increased very much. Indeed, many institutions have considerable sums of money laid out in student loans to pay these very fees. Federal support has not risen and State support has risen too slowly. Many legislators have not been looking too favourably at the university students, and some alumni have similar misgivings, but even so alumni support, at least for many universities, has main- tained its astonishingly generous level despite the depression which has eroded endowment income. The great founda- tions seem to be putting their money into the meeting of social needs.

The slowly rising, or maintained, revenue has on the part of the colleges and universities not been matched in alF cases by judicious expansion. The prestige comes from the graduate schools, and these not only are very expensive but have been enormously multiplied, often from direct or indirect Federal aid which has now dried up. Often the graduate schools have drained resources from undergradu- ate teaching and there has been waste, duplication, and overlapping. But what'ever the institutions' sins of omission and commission they have at least tried to provide higher education on a truly massive scale for as many as possible, and it has been a noble experiment. If the results some- times seem disproportionate to the costs, and the universi- ties appear to have been riding the crest of the wave regard- less of the following trough, they have tried. But now it is

34 Tim LANCET, JANUARY 2, 197i~i

only Government money that can provide the means to keep going. At least that is how the Foundation sees it. Dr. Clerk Kerr, the Commission's chairman, declared starkly that higher education here was facing " t h e greatest financial crises it has ever h a d "

AMBULANCE SCANDAL

So much attention has and is being paid to the problems of the high cost of medical care, with particular focus on the hospitals and the payments to physicians, that other equally important elements in the health picture have been rather neglected. After all these years of argument over the Federal role in paying physicians, we have at last got down to the idea that we should do something to clean up our foul air and stinking sewage-laden water. But everywhere we look in the medical scene we see grave deficiencies needing correction. House calls have been largely aban- doned, so that patients have to get themselves to the phy- sician or hospital. Public transport is largely nonexistent, and the alternatives are a car if one is fit enough or an ambulance ff one is seriously sick. The ambulance services are generally appalling. Credit is due to the Chicago Tribune for setting the pace with an account of extortion, inhumanity, brutality, and gross incompetence in the private ambulance services in that city. This led to probings elsewhere, often with equally horrifying exposures. The ambulances tend to be poorly equipped, and manned by quite untrained, or utterly inadequately trained, attendants whose incompetence adds considerably to the morbidity and mortality. In mass disasters they are reported to be more interested in removing the more profitable dead to the undertakers than the un- profitable living to medical care, and as the ambulance service has traditionally in the past been run by the under- takers, usually at a loss, this is perhaps understandable, if unedifying.

In a country where trauma is the major cause of mortality in those aged from 1 year to 37 years--and the costs of trauma are staggering--this is just not good enough. No more research is needed, just the application in skilled hands of the knowledge and tools we have. The problems have been brought to the attention of the not very obser- vant public, and devoted men and women inside and outside the medical field are bringing their talents to bear. Vast improvements have been made. In North Carolina strict enforcement of minimum standards has had two obvious effects: a reduction in road deaths and a flight of undertakers from the field.

Larger questions are raised by these deficiencies in the ambulance services. They are not new-- there have been complaints for many years. Why should they now be publicised ? With traumatic deaths and injuries so common, why did not the insurance companies, which have to bear so large a share of the costs, take up the matter years ago ? Finally, why should the public be so tolerant and so un- critical of these and other abuses ? For good causes the public will provide generously with money, less readily with service. This is a field where public interest, support, and activity has produced excellent results in other, less wealthy countries. Why not here ?

SPLIT ON WELFARE BILL

Conservatives and liberals here agree on the waste, extravagance, and inadequacy of the existing welfare schemes which seem to have been designed to ensure that greater numbers of people go on welfare each year. There has been a 20% rise over the last year to a total of 12.2 mil- lion people on welfare, and the number is guaranteed to rise. Beyond an area of agreement on current inadequacies, t he re i s a vast wasteland of dispute between those (and they are not a small number) who see welfare clients as no-

good idle lie-abouts, and those who think that the resourct~ of the State should be used for all its citizens, even those who have the misfortune to be poor. The Administration, s welfare proposals seem to be completely bogged down i~ Congress because each side insists on trying igo add Pro,

visions to the Bill obnoxious to its opponents. Indeed the conservatives have sought to restore two old provisions ruled unconstitutional by the Supreme Court-:--the man-in the-house and the one-year residency rule--a~ud to place them beyond court challenge, at least by lawyers paid via Federal funds.

Unemployment and low wages compound the problems, Those on welfare include the old and the sick, who should not have to work to keep alive, and the young, who should be being educated. The intermediate group, and probably the largest, is of those who cannot work, being tied to household cares or care of children, and those who cannot find work or can find work only in jobs where the wages ars quite insufficient to meet the needs of the families, No country has a monopoly of such problems, but few countri~ spend as much on them so ineffectually as does this coun~ The conservative/liberal battle in Congress is not shedding much light on the problems, and the financing of individuals and agencies to provide the answers has to date revolved enormous amounts of money without any solutions. And if solutions were provided, would Congress adopt them?

AID FOR THE CITIES

The cry is that the answer to the problems of the citiesj especially that epitome of problems, New York City, more Federal funding. The Federal Government, especiall~ through income-tax, scoops off the most lucr~itive and rapidly growing source of tax money and leaves .to local governments the less lucrative, more expensive t o collecti and more slowly rising, or even sinking, sources of revenue. Property taxes have now become so heavy thal; the public especially in California, but also elsewhere, have been loudly protesting. So the demand is that the Federal Government returns a much larger share of revenues c01. lected to the States and cities whence it comes. New York City, a very lucrative source of Federal Revenue and in very bad shape locally, could conceivably benefit enormously- though the cynic, looking at the Federal Budget, might conclude that there was little to share except deficits.

But with their local sources of revenue strained to the limits, with taxes as high as legally permissible, and with the wealthier sections of the population ensconced, in the independent suburbs, the cities have to turn to the Federal or State Governments for help. Here a new set of complica- tions emerges, and in New York these seem to be setthg the stage for a major clash likely to be repeated elsewhere, However excellent some city administrators may be, decay- ing cities do not attract high-class executives or adminis- trators, and certainly not in the lower ranks of city employees, who may be appointed for political reasons rather than on ability. Laxity in the administration of public funds, to put it politely, has long been a feature of life in the country~ and, in the absence of rigid control, which can in itself bc bureaucratically inhibiting, even the best designed legisla" tion can be used for private ends. It seems that in Ne~ Jersey the mosquito-control legislation has enabled certaill parties to blackmail various contractors and obtain "kicl~" back ". So if the States are to give financial aid to the cities they wish to ensure that it is used, and effectively used, for its intended purposes. Re-elected Governor Rockefella put it bluntly: " There are two big problems, how to get more Federal aid and how does the State ensure that the cities deliver on services ". He added that in his election campaign he had been struck by the frequent complain9 of poor police and poor sanitation services in New york City. I t would seem he has the legislative powers to effect

THE LANCET, JANUARY 2, 1971 35

• °

his purposes. But this clashes with local democracy and home rule in the cities and is sure to be bitterly resisted. Mtich hangs on the outcome• The cities cry for aid, and with good reason; but there would be more sympathy and support if they could be seen to be using fairly, evenly, uniformly, and openly the powers they now have. By and large this has not been demonstrated m the public, and the incessant scandals do not promote public confidence.

Special Articles

C L I N I C A L M E T H O D *

H. A. F. DUDLEY

D¢partment o f Surgery, Monash University, Victoria, Australia

Although a great deal has been written on clinicat method, most of it has concentrated on the way this should be taught rather than on the way it is practised. Studies of the clinician in action have been limited to Stylised situations, 1 or are only just beginning. ~ There are a number of reasons for this: first, the matter is a complex one and has awaited hypotheses that can direct inquiry; second, there is the distinct possibility that, in the context of a clinical encounter, clinicians fed threatened by an eavesdropper, particularly when they may feel guilty because their own efficient methods of pursuing a diagnostic pathway bear such a sma!l resemblance to those they were taught in medical school; third, the experiment is likely to he an untidy one in that the intrusion of the observer cannot help but significantly influence both doctor and patients.

Provisional evidence from the study of surgical resident medical officers in the casualty department of a teaching hospital suggests, at least for this situation, the context of encounter between doctors and patient

will determine the technology of inquiry. This is a Complex verbal cloak for the trite statement that there is always some preconceived notion of what is wrong with a patient because of the circumstances which lead him to seek medical care. A patient will consult a surgeon either spontaneously or at the behest of another doctor because his disorder is thought to lie in a surgical sphere, and the surgeon will use the assumption as his starting point; similarly with the physician, psychiatrist, or any other individual whose work is specialised. Indeed, some assumption is made bY any doctor at the moment of contact with his patient and it is easiest to centre the assumption around the most familiar context.

The result of such a course of action should reveal at once that the patient's problem can or cannot be provisionally assigned to the chosen context. This simple binary decision then permits a progressive narrowing down of the inquiry, designed heuristically to achieve an end-point. I f all patients who presented at the emergency department were asked if they did or did not have abdominal pain, on the assumption that SOme of them really did have an acute abdominal Syndrome, it would be possible to select on the basis of one question a possible-acute-abdomen group and a probably-not-acute-abdomen group. The latter

* In a previous article (Dec. 27~, 1970, p. 1352) Professor Dudley discussed the Clinical Task.--ED. L.

would contain a few patients who belonged in the former and vice versa, so that some checking routine (e.g., supplementary questions on gastrointestinal function) would be required to reassign them. But the first sorting procedure, based upon a single binary d6cision, allows the acute abdomen patient to be focused on and a routine then begun which endeavours to answer simple diagnostic questions such as: " are [here additional features--historical or on examination --which increase the probability of the diagnosis of acute abdomen ? ", " is the lesion progressive ? ", " i s it possible to make a provisional clinicopatho- logical diagnosis ? "

The general thesis, then, is that it probably matters little where inquiry starts as long as the appropriate decision is reached as a result of each response. Thus a negative reply to "have you abdominal pain ? " sets off a different chain of reasoning and therefore of inquiry from that provoked by a positive response. The important feature of this concept,of a valueless starting point is that the interrogator should understand his need to change; it is n o u s e saying " you have not got abdominal pain therefore I am no longer interested in you and you may depart." A value-free starting- point may be achieved by so-called open-ended ques- tions, but this is of course a relative term which has rather been done to death by clinicians as a means of escape from the highly restrictive leading questions of the law court. Any question is leading in that its very posing suggests that there is an answer, or that there is a problem to which the questioner desires to gain access. The only non-leading question that is imagi- nable is a question-mark without a preceding state- ment.

Two objections may be raised to the general argu- ment that has been propounded. First, that starting- points are often, determined either by the patient's spontaneous complaint or by a semi-open-ended question; second, that subsequent to the establishment of a starting-point it is rigid in the extreme to pursue a predetermined pathway aimed at some clearly defined goal. To the first of these it may be replied that the relatively open-ended question is but a way of seeking an entry-point without applying too much pressure to the patient. The patient's choice of entry following a non-leading question may be as right or wrong as the doctor's, and is also conditioned by the context. To the second, the legitimate observation may be made that the clinical encounter is finite. A diagnostician or decision-maker--the words are synonymous--cannot allow the free flow of consciousness to be the only method of gaining information; if he does he must either prolong the encounter indefinitely or become an abstract empiricist, 8 content to v%ave ideas around a body of randomly or goaliessly obtained facts which the patient has chosen to impart to the clinician. I t is true that many clinical encounters are probably terminated too rapidly because of the rejection-stop situation already described in which, when the patient fails to conform to a recognised or preconceived stereotype, the doctor ceases to inquire further; but it is equally possible that many interchanges are prolonged unnecessarily because of failure to use a structured pathway once an entry-point has been achieved.