Medicine is news. There is constant public interest in health and disease; in medical miracles and in breakthroughs; in medical disasters, failures and malpraxis ; in deficiencies and defects ofhealth services; and in the rising costs ofhealth care. Medicine is 'big business'. Physicians co me out near the top money earners in most medical care systems. In the Uni ted Kingdom the National Health Service (NHS) now costs over [6000 million a year ($ ro 800 million), a free service that costs every British man, woman and child [120 a year ($216) in direct and indirect taxes. But this is less than the [500 ($900) a year that medical care costs each person in USA and West Germany. In developed countries health care costs are approaching ro% ofthe gross national product (GNP). It is big business also in that in Britain the NHS is one of the largest employers; about I million Britons work as employees of the NHS, caring for the other 54 millions and in the USA the numbers are 5 million caring for 2. 5 millions. The provision of health services is full of problems and dilemmas. These problems and dilemmas cross all' national boundaries. All countries share the same problems and dilemmas. Problems of objectives, of standards, of effectiveness and efficiency, and problems of relations between the medical profession, the public and govern ment. Medical care still is full of mystique.

Part one of the book presents the gastrointestinal problems that commonly face the general practitioner. Emphasis is placed on analysis of clinical data and how this may provoke the most profitable lines of investigation. Many of the investigation and treatment protocols are within the scope of general practice, but hospital management is also included. It was possible to deal with common oesophageal diseases under the heading of oeso phageal problems in Part 1. In contrast, it proved impossible to discuss adequately all of the common diseases affecting other organs of the digestive system under the problem headings. For this reason, a fuller ac count of many common alimentary diseases is provided in Part two. M. L.-5. K. G. D. W. 9 Series Foreword This series of books is designed to help general practitioners. So are other books. What is unusual in this instance is their collec tive authorship; they are written by specialists working at district general hospitals. The writers derive their own experi ence from a range of cases less highly selected than those on which textbooks are traditionally based. They are also in a good position to pick out topics which they see creating difficulties for the practitioners of their district, whose personal capacities are familiar to them; and to concentrate on contexts where mistakes are most likely to occur. They are all well-accustomed to working in consultation."

Over several years working in a district general hospital as a physician with a cardiological interest, the common problems in this field are clearer. This knowledge has come through normal out-patient clinic referrals, care of in-patients, and by working in a domiciliary consultative capacity. The problems that concern family physicians nowadays are somewhat different from the problems of two or three decades ago. The accent now is very much on the implications of hypertensive and ischaemic heart disease. Rheumatic fever is rarely seen, though its sequelae may still be discovered. Hence the approach of this book is to the common problems of today in family practice, and the book is not intended to be a reference text book of cardiology. It does not include references because it has been written from personal experience gained from the treatment and management of patients with common cardiac problems. It is hoped that it will be of value primarily to family physicians because it has been written in an attempt to fill a need as measured by the problems that are referred to specialists in the cardiological field. It may prove of value to those medical students and nurses who wish to consider medical problems in a practical way, that is from the ways that cardiac problems present in practice.

This series of books is designed to help general practitioners. So are other books. What is unusual in this instance is their collec tive authorship; they are written by specialists working at district general hospitals. The writers derive their own experi ence from a range of cases less highly selected than those on which textbooks are traditionally based. They are also in a good position to pick out topics which they see creating difficulties for the practitioners of their district, whose personal capacities are familiar to them; and to concentrate on contexts where mistakes are most likely to occur. They are all well-accustomed to working in consultation. All the authors write from hospital experience and from the viewpoint of their specialty. There are, therefore, matters important to family practice which should be sought not within this series, but elsewhere. Within the series much practical and useful advice is to be found with which the general practitioner can compare his existing performance and build in new ideas and improved techniques. These books are attractively produced and I recommend them."

The purpose of this book is to clarify the use of antibiotics in the management of the eommon respiratory illnesses seen in general practiee. The underlying philosophy, whieh embraees the avoidanee of unneeessary use, is that proper use entails a full understanding of the nature of the illness. The eoneept of seleetive antibiotie use reeognizes that respiratory illnesses eommonly eomprise multiple illness features, and that some of these features have a viral cause and some a bacterial one. In assessing antibiotic need, eaeh feature or eomponent part of an illness may be evaluated individually, so enabling adecision for antibiotie use in the illness as a whole. The nature of eaeh individual illness feature with its antibiotic indication is diseussed in sueeessive ehapters, and this aecumulated knowledge is of value in managing the more eomplex PUO and flu-like illnesses whieh are diseussed at the end of the book. The first two ehapters eneompass the principles of antibiotic use and the relationship between antibiotie preseribing and various states of the patient, e.g. allergy, pregnaney ete. An attempt has been made to justify every reeommendation or decision, and non-antibiotic management is diseussed where relevant.

One of the eXCltmg challenges of medicine has been the reaching of decisions based on less than complete evidence. As undergraduates in teaching hospitals future physicians are taught to think in clear and absolute black and white terms. Diagnoses in teaching hospitals all are based on supportive positive findings of in vestigations. Treatment follows logically on precise diagnosis. When patients die the causes of death are confirmed at autopsy. How very different is real life in clinical practice, and particularly in family medicine. By the very nature of the common conditions that present diagnoses tend to be imprecise and based on clinical assessment and interpretation. Much of the management and treatment of patients is based on opinions of individual physicians based on their personal expenences. Because of the relative professional isolation offamily physicians within their own practices, not unexpectedly divergent views and opinions are formed. There is nothing wrong in such divergencies because there are no clear absolute black and white decisions. General family practice functions in grey areas of medicine where it is possible and quite correct to hold polarized distinct opinions. The essence of good care must be eternal flexibility and readiness to change long-held cherished opinions. To demonstrate that with many issues in family medicine it is possible to have more than one view I selected 10 clinical and II non -clinical topics and invited colleagues and fellow-practitioners to enter into a debate-in-print."

In writing this short monograph on 'Problems in Peripheral Vascular Disease', I have tried to steer a course between a simplistic dogmatic approach more appropriate to an under graduate text, and a detailed specialist treatise of interest only to vascular surgeons. Although arterial surgery has been performed for centuries, the main indications in the past were to deal with the effects of trauma and aneurysm formation. The development of arterio graphy and the ability to see arterial blocks and stenoses allowed surgeons to carry out increasingly sophistidated operations for an enlarging range of pathological conditions. Even today, arterial surgery continues to develop, and although we are often dealing with the 'surgery of ruins', a successful outcome is just as rewarding for surgeon and patient alike. In this book I have also included a discussion on venous problems including a note about recent developments in direct surgery of the deep veins of the lower limb which could be a re warding field of endeavour for the vascular surgeon. The original descriptions by Buerger and Raynaud are taken from 'Classic Descriptions of Disease' by Ralph H. Major. While reviewing my own surgical practice, I have had the pleasure of reading once again the publications of H.H.G. Eastcott (arterial surgery), J.T. Hobbs (varicose veins), G.L. Hill (Buerger's disease), Adrian Marston (intestinal ischaemia), Martin Bimstingl (vasospastic disorders) and C.H. Hawkes (lumbar canal stenosis)."

This third edition of the Beecham Manual has its origins in a manual produced by Selwyn Carson for his general practice in Christchurch, New Zealand. He produced loose-leaf sets of instructions for his practice team and colleagues. Beecham Research Laboratories of New Zealand did a great service for the medical profession by publishing and distributing Dr Carson's manual there. The British version of the Beecham Manual had different objectives. The vocational training programme needed basic resources and the British Manual was created as an easy to read reference book on common prob lems and methods in general practice. The first and second editions met with enthusiastic approval from princi pals, trainers and trainees. This third edition follows the same general format but has been completely revised and updated and includes many new additions. The five sections are: o planned care of definable population and other groups o principles of teaching and learning o emergencies and their management o psychiatry o clinical care of common conditions We have kept to simple, clear and brief presentations of our conjoint views based on our experiences in our own practices. We dedicate this third edition to our colleagues involved in caring, learning and teaching. They may not agree with us completely but we hope that we will make them consider our suggestions and use them for thought, debate and discussion. We hope also that it will be used as a work book for the whole practice team."

The topics chosen for discussion represent the most common problems referred by family doctors to chest clinics. It was taken for granted that the reader will be familiar with the symptoms, signs, and natural history of respiratory diseases, so that the stress is on differential diagnosis and treatment. Tuberculosis once occupied nearly all the time of chest physicians. At present weeks go by without a single case presenting itself. There has been no comparable improvement in cancer of the lung, which remains one of the most intract able problems. Asthma was seldom referred to out-patient clinics when the disease was regarded as more unpleasant than dangerous. The hazards of severe attacks and the advan tages of liaison with a hospital department are now widely recognized. A similar change of attitude to the management of chronic bronchitis brought many new patients to the chest clinics in place of the vanishing tuberculous population. Some uncommon pulmonary diseases are included: allergic alveolitis, because of the importance of early diagnosis, and sarcoidosis in order to discourage unnecessary treatment. The book is intended to be a practical guide and is not a critical review. This might serve as an excuse for its didactic style and the exclusion of controversial subjects. Some statements are repeated at more than one place in order to help readers who wish to consult individual chapters bearing on some current problem. Source references are omitted and are replaced by a short list of books recommended for further reading."

DDDDDDDDDDDD Effective management logically follows accurate diagnosis. Such logic often is difficult to apply in practice. Absolute diagnostic accuracy may not be possible, particularly in the field of primary care, when management has to be on analyis of symptoms and on knowledge of the individual patient and family. This series follows that on Problems in Practice which was concerned more with diagnosis in the widest sense and this series deals more defini tively with general care and specific treatment of symptoms and diseases. Good management must include knowledge of the nature, course and outcome of the conditions, as well as prominent clinical features and as sessment and investigations, but the emphasis is on what to do best for the patient. Family medical practitioners have particular difficulties and advantages in their work. Because they often work in professional islation in the com munity and deal with relatively small numbers of near-normal patients their experience with the more serious and more rare conditions is restricted. They find it difficult to remain up-to-date with medical advances and even more difficult to decide on the suitability and application of new and rela tively untried methods compared with those that are 'old' and well proven. Their advantages are that because of long-term continuous care for their patients they have come to know them and their families well and are able to become familiar with the more common and less serious diseases of their communities."

WHY WE MUST PRACTISE TRANSCULTURAL MEDICINE Health professionals and GPs should concern themselves with ethnicity, religion and culture as much as with the age, sex and social class of their patients. Transcultural medicine is the knowledge of medical and communication encounters between a doctor or health worker of one ethnic group and a patient of another. It embraces the physical, psychological and social aspects of care as well as the scientific aspects of culture, religion and ethnicity without getting involved in the politics of segregation or integration. English general practitioners and health professionals tend to regard everyone as English, and to assume that all patients have similar needs. Would that it were as simple as that! For economic reasons - based on supply and demand - the mass migration of working populations from the new Commonwealth countries, along with their dependent relatives (including their parents) to Britain took place during one decade - the 1960s. Broadly speaking, the workers were in their thirties and forties, and their dependent parents were in their fifties and sixties. All these will, of course, be 30 years older in the 1990s.

JOHN JOHN FRY FRY All All examinations examinations create create problems problems and and stresses stresses in in examinees. examinees. The The examination examination for for the the Membership Membership of of the the Royal Royal College College of of General General Practitioners Practitioners is is no no exception. exception. Although Although the the examiners examiners state state that that their their objectives objectives are are to to pass pass candidates candidates wherever wherever and and whenever whenever possible, possible, nevertheless nevertheless the the failure failure rate rate remains remains con sistently sistently at at 30% 30% plus plus of of those those taking taking the the examination. examination. The The reasons reasons for for failure failure fall fall into into a a number number of of groups. groups. The The candidate candidate may, may, through through over-confidence, over-confidence, not not have have prepared prepared for for the the examination. examination. He He may may have have assumed assumed that that it it is is not not necessary necessary to to read, read, learn learn and and digest digest data, data, facts facts and and experience experience on on general general practice. practice. How How wrong wrong that that is, is, he he will will discover discover when when he he sits sits the the exam. exam."

DDDDDDDDDDDDD Effective management logically follows accurate diagnosis. Such logic often is difficult to apply in practice. Absolute diagnostic accuracy may not be possible, particularly in the field of primary care, when management has to be on analysis of symptoms and on knowledge of the individual patient and family. This series follows that on Problems in Practice which was concerned more with diagnosis in the widest sense and this series deals more definitively with general care and specific treatment of symptoms and diseases. Good management must include knowledge of the nature, course and outcome of the conditions, as well as prominent clinical features and assess is on what to do best for the ment and investigations, but the emphasis patient. Family medical practitioners have particular difficulties and advantages in their work. Because they often work in professional isolation in the com munity and deal with relatively small numbers of near-normal patients their experience with the more serious and more rare conditions is restricted. They find it difficult to remain up-to-date with medical advances and even more difficult to decide on the suitability and application of new and rela tively untried methods compared with those that are 'old' and well proven. Their advantages are that because of long-term continuous care for their patients they have come to know them and their families well and are able to become familiar with the more common and less serious diseases of their communities."

John P. Horder, President, 1980-82 The first 30 years of the College have been an exciting experience for those most closely involved. Some have already passed on, but this account has been written soon enough for many of the actors to be historians. Future members of the College will be grateful to them for what they have written, as well as for what they did as a remarkably determined and harmonious team. Students of twentieth century medicine in this country will also be grateful for a first-hand account of the development of an institution which has been closely associated with, and partly responsible for, important changes in medical care and education. Those who read these pages may wonder how the builders of this young College could have found time to do much general practice. They did. The three editors of this history, which covers 25 years, and the general practitioner members of the Steering Committee all ran large practices, in which they worked very hard throughout that time. Most of their work for the College was done during off-duty hours, weekends and holidays. The College could not have developed as it did, had they not been personally concerned with the practical problems and needs of clinical medicine. This is also true of many of the contributors. It is impossible to mention everyone who deserves credit. The editors hope that they may be forgiven for any serious omissions.

This book is a personal testimony of faith in the future and in the progression to better health and a better life. It is the testament of a rough and ready measuring device - a practising physician who sought to compare and contrast three systems of medical care to see what can be distilled from them to help us all in achieving better services for medical care. Medical care as a human and civic right is the con cern of us all. Seeking to live longer and in good health we depend on medical, social and welfare services to attain this goal. Yet it is quite obvious that there are limits and dilemmas that prevent anything but an unsatisfactory compromise. The resources that are available cannot meet all the calls. How then can we make the best use of the resources that we have? This must be the theme for this book. What can we learn from each other for the com mon good? Since we all are facing the same common prob lems, how do we go about resolving them? For example, how do the medical care services in the USSR, USA and UK cope with an acute heart attack, with a middle-aged woman with depression, with a brain-damaged child, with a road accident or with a case of measles? These are the common human factors involved."

The fact that there are special problems in the care of the elderly in the community is ample justification for writing a separate volume on the subject. The knowledge that there are increasing numbers of older people in virtually every country in the world makes it all the more important that the family physician should have sympathy with and understanding of the problems of them, since they are lilcely to make up a significant part of his worlcload and, increasingly, will take up more of his time and energy. There is a progressive amount of disability with advancing years, and this is particularly true of those aged 75 years and over. Increasing age is associated with serious impairment of hearing and vision, senses which younger people take for granted. Old age sees the arrival of major diseases of middle age with much greater frequency, such as ischaemic heart and cerebrovascular disease, diabetes mellitus and osteoarthritis. There are other disorders that are virtually confined to the elderly, such as fractures of the femoral neck, Paget's disease and myeloma. We now know that the disintegration of the con ducting tissue of the heart is largely an age-related phenomenon. Ageing processes affect every major organ system in the body and the impairment of physiological perfor mance resulting from these affects the elderly individual's response to infections, disease and environmental changes in complex ways that are not seen in younger people."

The aim of this book is to give a short and practical account of the problems related to the ear, nose and throat. The presenta tion is orientated towards arriving at a diagnosis based on the presenting symptoms and signs and aid the management of the case. While it is specifically intended for those who have not had the opportunity of devoting much time to the subject, I hope that it may be of some service to the more experienced practitioner. Padman Ratnesar Farn boro ugh, 1984 7 Series Foreword This series of books is designed to help general practitioners. So are other books. What is unusual in this instance is their collective authorship; they are written by specialists working at district general hospitals. The writers derive their own experience from a range of cases less highly selected than those on which textbooks are traditionally based. They are also in a good position to pick out topics which they see creating diffi culties for the practitioners of their district, whose personal capacities are familiar to them; and to concentrate on contexts where mistakes are most likely to occur. They are all well accustomed to working in consultation.

One of the few real and lasting benefits of international medical meetings is the opportunity to meet, talk, gossip and get to know colleagues from other countries. So it was that we met, talked and planned at WONCA (World Organization of National Colleges and Academies and Academic Associa tions of General Practitioners/Family Physicians) meetings at Montreux and New Orleans. We realized that although we worked in different places and in different practices 'primary health care' was essentially the same the world over. Our roles, our problems, our clinical content, our challenges and objectives were similar whether we work in Europe, North America, Australasia, South Africa or developing countries. With such similarities we asked ourselves - 'why not share our common experiences for mutual benefits?' The question developed into an idea and the idea into this book. We started by selecting what we considered were important topics and then we invited friends and colleagues to join us in putting our experiences and beliefs from years of practice to readers from all over the world to demonstrate our common concerns and to learn from one another."

For many years we have known that dental caries is one of the most common diseases of mankind. Only few people have sound teeth till the end of life. Formerly we thought that the only possibility to keep our teeth in good state was to go to the dentist regularly. Since we know how complicated our nutrition is we know too that we have to regard the composition of our food as a principal factor influencing the state of our teeth. The trace-elements e. g. play an important role. Studies with tracers during the last decades have shown that the minerals are metabolized very actively by living organisms. Thus research in our laboratory, together with Prof. SIZOO and Prof. OOLS, has demon strated that intravenously injected radio-active phosphorus has disap peared from the blood already half an hour after injection. Even the hard dental substance participates in this active metabolism."

1 Shepherd Coronary artery disease, the most important cause of death in the United Kingdom, kills about 200 000 Britons each year. Many victims are struck down out of the blue and in the prime of an active working life. Others survive the fIrst attack but are so debilitated by it that they are compelled to fall back on the efforts of their family and the Social and Health Services for their future survival. The epidemic proportions of the problem and the burden which it places on the community at large has led many health care professionals to reassess their attitudes to heart disease prevention. In the past, the clinician's attention has been directed primarily at the treatment of established ischaemic heart disease rather than focussing on forestalling its appearance by attempting to tackle those life-style habits within the population which appear to predispose to it. A number of recent developments make this approach hard to sustain. First, there is now convincing evidence that action taken against cigarette smoking, hyper tension and hypercholesterolaemia offers signifIcant protection to the individual. Secondly, effective and apparently safe antihypertensive and lipid-lowering agents have recently become available to the practicing clinician. Thirdly, developments in computer technology and laboratory equipment manufacture have brought the measurement of coronary risk factors right into the primary health care setting. And, last, but not least, political attitudes towards prevention now favour the enthusiastic general practitioner with an interest in anticipating and averting the development of degenerative diseases like atherosclerosis."

Psychology and Diabetes Care: A Practical Guide is a concise handbook for the practicing diabetes clinician who is interested in gaining a better understanding of his patients, and in learning simple skills and tips to manage patients more effectively. It identifies and explores key psychological interventions in diabetes care in order to help healthcare professionals support their patients effectively. Edited by an expert on the psychology of diabetes, and with contributions from a group of specialists in diabetes psychology, this book contains a myriad of insights into how to understand and treat the type 1 or type 2 diabetes patient.

Legal action involving doctors, either as defendants or expert witnesses, has greatly increased over the past decade and few can now remain aloof from this aspect of their profession. Written by doctors (including five Council Members of the Medical Defence Union of Great Britain) and lawyers, this practical guide offers clear and comprehensive advice to all concerned. Part I discusses how to write medical reports, especially when consent is required or confidential information is involved. Part II covers contentious issues in various clinical specialties which repeatedly arise in litigation; well-known examples are cases involving whiplash injuries or perinatal brain damage. In Part III lawyers discuss the medico-legal problems of the solicitor's role, court testimony and medical negligence. This book is a valuable reference to all members of the medical profession. Lawyers, officials and others outside the medical profession who come into contact with medical litigation but have limited medical knowledge will find much helpful information.

TO ACUPUNCTURE A Practical Guide for GPs and other Medical Personnel Peter Pearson, MBBS, MRCGP, DRCOG The Medical Centre, Yateley, Cambedey, Surrey GU17 7LS Publisht;d in. the UK and Europe by MTP Press Limited Falcon House Lancaster, England British Library Cataloguing in Publication Data Pearson, Peter An introduction to acupuncture: a practical guide for GPs and other medical personnel. 1. Acupuncture I. Title 615. 8'92 RM184 ISBN-13: 978-94-010-7935-8 e-ISBN-13: 978-94-009-3199-2 DOl: 10. 1007/978-94-009-3199-2 Published in the USA by MTPPress A division of Kluwer Academic Publishers 101 Philip Drive Norwell, MA 02061, USA Copyright (c) 1987 MTP Press Limited Softcover reprint of the hardcover 1st edition 1987 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior permission from the publishers. CONTENTS Preface 7 Acknowledgements 8 1 What is acupuncture? 9 2 Local dysfunction of channels 13 3 The channels and points 15 4 Technique 37 5 Specific conditions 45 6 Systemic treatment 53 7 Other forms of acupuncture 65 8 Academic considerations 73 9 Further information 79 References 83 Index 87 PREFACE Several years ago, a patient consulted me, and requested 'aquapuncture'. This sounded more like an underwater sexual activity than anything else, but I confessed ignorance! Several more requests highlighted my complete lack of knowledge of this subject and stimulated me into activity.

In a relatively short period of time two-dimensional echo cardiography has become the most important non-invasive diagnostic tool in the daily practice of a pediatric cardiologist who predominantly deals with congenital structural heart disease in neonates and infants. Consequently, one-dimensional M-mode echocardiography has lost most of its importance particularly in this field. Therefore, an atlas showing exclusively two-dimensional echocardiograms of the most common and some less frequently occurring malformations appeared to be a useful addition to the existing literature. The confinement to two dimensional imaging alone allowed an elaborate presentation of the various defects with more than 200 selected still frames and many additional explanatory drawings and diagrams. The material was collected from patients who were referred to the Department of Pediatric Cardiology of the Wilhelmina University Children's Hospital in Utrecht during a period of about 2 years. The two-dimensional echocardiographic findings were correlated with cardiac catheterization data and/or surgical procedures and/or post mortem investigations. The necessary echocardiographic equipment was aquired with financial aid from the Dutch Heart Foundation. We are indebted to Mrs. J. W. Wetselaar for her outstanding artwork. We also thank P. D. Woltema and F. J. van Waert for the photographic reproductions, Jacomine Bosma for preparing and type-setting the entire manuscript and Dr. N. Middleton for critically reading the English text. G. J. van Mill, M. D. A. J. Moulaert, M. D. E. Harinck, M. D. CONTENTS 1. Introduction and the normal heart Introduction The normal heart 2 2."