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structured follow-up notes in the case-sheet. Theletter can be used without applying the Weed systemfully to the ward case-sheets. A problem list is all thatis required to operate the discharge-letter system at aminimum level.

The notes on active problems should be brief yet containthe important clinical findings and laboratory resultsnecessary for the continuing management of the

patient. They should be composed in the ward on theday before the patient’s discharge. At this time each

problem should be considered critically and briefnotes made which would subsequently be transferredto the discharge letter.When the patient is discharged the case-sheet will

therefore contain a reason for referral, an updatedproblem list, a list of drugs, and concise notes on theactive problems. These can all be easily transferred tothe discharge letter by a secretary. No dictation is

required and delay in sending the letter is thus reducedto a minimum.

DISCUSSION

One of the ways in which the medical professioncould improve patient care is by keeping better casenotes. A doctor with the keenest clinical acumen is oflittle value to his patients if he does not record his

findings clearly and accurately so that others mayunderstand them. Many hospitals are now introducingthe problem-oriented approach in an effort to achievecase-records which are concise, meaningful, and easilyread by any doctor.The communication problem between doctors is

not confined to hospitals. The hospital physician andprimary-care physician must be able to exchange infor-mation in the most efficient manner possible if theyare to maintain optimum patient care. In a specialistclinic the efficient exchange of information is facilitatedby the new letter described by Boyle et al. We hopethat the proposed letter will further improve communi-cation. Its success will be measured by the speed withwhich it can be dispatched after the patient’s discharge,ideally within 24 hours, and by its acceptability to theprimary-care physician. Both these aspects will be

kept under continuing review.REFERENCES

1. Weed, L. L. Medical Records, Medical Education, and PatientCare. Cleveland, Ohio, 1971.

2. Boyle, C. M., Alexander, W. D., Stevenson, J. G. Lancet, 1973, i, 249.

In England Now

In this era research proposals involving human experi-mentation are submitted to careful review, usually includingan informed-consent form approved by the applicant’shospital experimental committee. The problem hingeson the word " informed ". At a recent grant reviewmeeting a proposal from South-East Asia put this problemin sharp focus:INFORMED CONSENT FORM, TO BE USED BY SUBJECTS IN RESEARCH

PROPOSAL

I agree to participate in research project to determine theincidence of occult venous thromboembolism after I receive anexperimental Birth Control Pill, consenting to monthly intra-venous administration of 110 microcuries of 12’1 Fibrinogen asa diagnostic test.

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Letters to the Editor

PAIN IN HÆMOPHILIA

SIR,-Mr Harvey (April 7, p. 776) draws attention to thelack of suitable analgesics available to suppress the painof hxmophilic arthropathy. His plea for haemophiliacsto be allowed to choose between a more active shorter life

by the use of strong analgesics or a lengthy, dependent,pain-wrecked condition without them is eloquently made.But such a choice does not exist. HsEmophilic arthropathy isa chronic condition, and the regular administration of

powerful analgesics is not compatible with a normal activelife-short or long. Within months, not years, all drugspowerful enough to suppress severe pain completelybegin to impair concentration; work becomes erratic;driving dangerous; and social contact increasingly difficult.Moreover, all such drugs are addictive in the sense that theeffective pain-killing dose goes up steadily and with it theseverity of disabling side-effects. That every possibleeffort must be made to alleviate the pain of hxmophiliacsis not in question, and trying to play down the ordeal iscertainly no help. But nor does it help to adopt an all tooeasy cavalier attitude of " pain-killers are there to kill

pain "-and it is the latter mistake which is both graver inits consequences and far more common.

In this Haemophilia Centre, when dealing with severepain due to an acute hasmarthrosis or muscle hasmatomawe use intravenous pentazocine (’ Fortral’) 30 mg. pluspromazine (’ Sparine’) 25 mg., as suggested to us sometime back by Dr G. I. C. Ingram. For the constant andsevere pain of arthropathy we ring the changes between’DF 118’, dextropropoxyphene (’Doloxene’), and oralpentazocine (in spite of the disadvantages outlined in

your editorial of April 7). Patients with persistent arthriticpain are seen by the orthopoedic surgeon and appropriatemeasures (which often do help) are taken. The importanceof the patient living within his own physical capacity is

always stressed. To live a reasonably inactive life neednot in any way imply that the life is inadequate.

I am not complacent, nor am I satisfied with the anal-gesics that are available; nor do I feel censorious when

patients ask for drugs. However, having lived with someof the problems of at least six patients, all of whom havebecome addicted to hard drugs as the result of medicalprescriptions, I am far more firm in my refusal to allow

myself and my juniors to seek this easy way out than Iwas even three or four years ago.

SIR,-We write in support of Mr Harvey’s plea and yourown reasoned arguments for more effective analgesia inhaemophilia. In a survey 1 which we conducted among 42haemophiliacs attending two hxmophilia centres, painwas defined as a " problem " in 22; and the most frequentcomplaint which the patients made about their previoustreatment was that insufficient analgesia had been given.Sometimes this was because of the unimaginative insistenceon

" within four hours " rules and the like, and sometimes,understandably, for fear of inducing drug dependence;but probably much of the difficulty arose because it is notusually realised that, for the patient, the major symptomof hxmophilia is pain.However, as you say, the problem is not easy. You

mention the possibility of renal papillary necrosis and

KATHARINE M. DORMANDY.

The Hæmophilia Centre,Royal Free Hospital,North Western Branch,

Lawn Road,London NW3 2XJ.

1. Frommer, E., Ingram, G. I. C. Practitioner, 1969, 202, 413.

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hepatotoxicity after prolonged analgesic medication.There is indeed the danger of drug addiction, although wefeel that you overrate the danger with dihydrocodeine.We have found the greatest problem to be the developmentof an emotional dependence on analgesics, associated witha lowering of the pain threshold, especially in adolescentsand young adults. The phenomenon has been extreme inonly a few patients, who are those who come most oftenfor specific early treatment of early spontaneous " bleeds "-i.e., painful episodes presenting before the developmentof objective signs, such as local heat or swelling. Some

may have a concurrent depressive illness which is treatable,but we believe that most of these patients have reallybecome addicted to being doctored, because they, or

possibly their families, lack the emotional resources to dealunaided with haemophilia along with all the other slings andarrows of outrageous fortune. We agree with Mr Harvey,and with you, that analgesics must be adequately providedfor hxmophiliacs; but the irony is not lost on us that readyaccess to analgesics may allow some hxmophiliacs to

retreat from a fully responsible approach to their difficulties,and so fail to develop their emotional resources to the full.We ourselves believe that this is the lesser evil, but do notminimise the doctor’s responsibility for trying to help eachpatient to find the right balance between independence andaccepting help. In the nature of things this will not beeasy, and a success-rate of less than 100% is not necessarilyevidence of analgesic abuse; nor should the doctor feelthat his management has failed because some patientscontinue to be dependent upon him.Department of Child Psychiatryand Department of Hæmatology,

St. Thomas’ Hospital,London SE1 7EH.

EVA A. FROMMERG. I. C. INGRAM.

NUTRITION : A PRIORITY IN AFRICAN

DEVELOPMENT

SIR,-Whilst I share Professor Vahlquist’s concern

(March 31, p. 716) about the need to arouse interest in theproblem of malnutrition, some of his comments have simplyserved to increase my feeling that the subject of nutritionand national development deserves a much more criticaland analytical approach than was accorded to it by manyof the contributors to the Dag Hammarskjold Foundationseminar.

It seems that Bo Vahlquist’s concern is directed towardstwo main questions: (1) the relationship between nutritionand health standards for the whole population, and " de-velopment " in terms of G.N.P. increase; and (2) the specialneeds of children and the necessity for intervention pro-grammes of a

" short-cut " nature to combat child mal-nutrition.

Clearly these issues cannot be regarded as entirelyseparate. Are we really to believe that it makes sense toeliminate malnutrition and to ensure physical and mentaldevelopment in children when " In most African nationsthe goal of materially increasing the production of alreadyexisting staple foods may take generations to reach"?The fallacy is to assume so easily that improved standardsfor the whole population can only be achieved through anincrease in G.N.P. If that, as yet, unproven assumptionwas reinforced in the minds of the politicians and civil-servants attending the seminar, then this was indeed adisservice to the cause of development. In fact, as BoVahlquist himself says in his letter, the " quality of life "concept is gaining increasing adherence in African countries,and this does hold promise that more attention could bepaid to the use of resources to eliminate poverty andconcomitant malnutrition as a primary aim, G.N.P. growthbeing regarded as of secondary importance. It is in this

context that the cost-benefit approach to nutrition needsto be subjected to a very critical appraisal, precisely be-cause the issues raised are essentially those of social values:present consumption versus investment for the future,food given to children now or to factory workers now.Cost-benefit analysis tends to distract from the value

judgments involved in these resource allocation situationsby reducing them to numerical " profitability

" calculations.The real issues are just what value society is prepared toput upon healthy and active lives for both adults andchildren.The second of the two questions, that of child malnutri-

tion, in so far as it can logically be separated from the first,is very much bound up with the idea of

" short-cut "

nutrition intervention programmes of the public-healthtype. The philosophy of these is that one of the symptomsof poverty and social deprivation in a community-i.e.,malnutrition in infants-could perhaps be suppressed by arelatively cheap and universal programme analogous to

immunisation against an infectious disease. The dangerof overemphasis of this approach lies precisely in its attrac-tions for politicians and administrators, who correctlysee that it avoids the underlying social issues and causes,the problems of poverty, of inadequate demand, of ignor-ance, dirt, and disease.Even so, there might be some point if these measures

were known to be effective, but there is pitifully little toshow for the results of the many field trials of the past 30

years or so.There are at least three essential preconditions for the

success of a " short-cut " type of intervention:

(1) The nature of the problem must be correctly diag-nosed as due to an imbalance of nutrients-primarily to thelack of a particular nutrient (e.g., protein or vitamin A)rather than an inadequate intake of otherwise reasonablybalanced food.

(2) There must be evidence that money spent on theprogramme will be more cost-effective in reducing infantmortality and improving morbidity than more conventionalpublic-health activities aimed at reducing chronic levelsof infection.

(3) There must be a delivery system which will givewidespread coverage to the target population.

Certainly these three preconditions have not been demon-strated in any African community to date. The first is

obviously basic. If the problem is inadequate quantity offood, then distribution and demand stimulation (income/employment generation) policies are the relevant strategies.The history of the past 10 years or so is one of increasingdoubts by many nutritionists of the validity of the theorythat primary protein deficiency is the cause of most mal-nutrition in infants. These doubts even find expression inthe name now widely adopted " protein-energy malnu-trition " to cover even such conditions as kwashiorkor:the implication being that in practice there is always anelement of quantitative as well as qualitative deficit. Thelevels of protein and of energy requirements suggestedby successive W.H.O./F.A.O. committees since 1963show that the proportion of protein in diets adequate forthe needs of children aged one year and over is verysimilar to that required by adults, and would be providedby any cereal-based diet (at less than one year, mothersreceiving adequate energy diets can provide sufficientsupplements in the form of breast milk). Practical demon-stration of the " more of the same kind of food " rather thanprotein supplements approach, which these estimates

suggest, is given, for example, by the work of Begum et al. Iin India, who have shown that two-year-old children canachieve American standards of growth velocity when given

1. Begum, A., Radhakrishnan, A. N., Pereira, S. M. Am. J. clin. Nutr.1970, 9, 1175.