1136

detecting and preventing cardiovascular disease in-

creases, so the market for screening will expand.Those who reject the Turner and Ball approach willhave to produce the evidence soon.

COSMETIC SURGERY

SOME years ago there was anxiety among plasticsurgeons lest they be regarded as mere practitionersof the art of face-lifting; and the word " recon-structive " was introduced (not too successfully) todescribe their branch of surgery-or that part of itwhich commanded general approbation. Rozner 1

has raised some problems that involve both patientand doctor.The patients always include a high proportion who

are unhappy, neurotic, or unbalanced, and who seeksurgical correction of largely imaginary defects; forthese the real need is psychiatric guidance. Manypatients are unaware of the basic distinction betweena true deformity, congenital or acquired, and insidiousbut universal facial changes due to advancing years.Moreover, there commonly appears the devious

patient who claims (say) that his nose aches, when hisreal concern is to have it reshaped. Finally, somepeople have visions of physical perfection, of WalterMitty proportions, that are impossible of fulfilment.The patient may be asked, when making an appoint-

ment with the surgeon, to bring a letter from her orhis own doctor, but nevertheless arrives empty-handed. When questioned, the answer is that the

patient particularly wishes the family doctor to knownothing about the matter, or, alternatively, that theG.P. has been consulted and was unhelpful or evenhostile. The busy family doctor has his own problems.He may not envisage the plastic surgeon (in Rozner’svivid phrase) as " a psychiatrist with a knife "; and hemay not realise the nightmare facing a vulnerableschoolboy whose bat ears attract cruel attention.

Moreover, discrimination is essential if the G.P. is notto fail in his duty towards really needy people. Suc-cessful surgery to reduce massive breasts or improvetheir shape has long been practised; but there areimportant distinctions. The girl of 20, whose hugeand heavy breasts are clearly a social embarrassmentand an orthopaedic liability which will plague her fordecades, presents an indication for operation that isnot shared by the woman of 40 who detects a degreeof mammary sag that (did she but know it) is virtuallyuniversal. To operate on the latter type of case maybe permissible for psychic reasons; but the formerconstitutes an indication, as positive as permanentfacial paralysis or hypospadias, which none shoulddispute.The specialist’s problems are formidable. He must

listen with unusual patience to tales that are morethan twice-told. He must select, even from amongneurotic patients, those whose condition will be

helped, or even transformed, by surgery; and hemust firmly reject, in face of often violent pressure,those who are unbalanced. Surgery for such people,pitiful though their plight may be, may lead to tragedy.

1. Rozner, L. Med. J. Aust. 1973, ii, 573.

The specialist has a further difficulty-an ethical one.In private practice the plastic surgeon, possiblycontrary to his own bent, is presented with an alarm-ingly high proportion of middle-aged patientsdemanding surgical relief for symptoms of senescencewhich are fairly trivial and certainly common. Yieldingto the temptation to carry out surgery " on demand

"

may be justified in particular circumstances; but thesituation puts a certain strain on professional integrity.

Patients cannot be expected to assess themselves,but a sympathetic hearing will go a long way towardsgaining their confidence and persuading them thatthe operation suggested is prudent-or the reverse.Of course, the patient is usually avid for surgery, sothe temptation to make the offer (all venal considera-tions apart) is hard to resist. Importunity may winthrough exhaustion. In this tricky and relativelynew field balanced judgments should become betterestablished, but this will be possible only if communi-cation between doctor and patient continues to

improve.

NEW SMOKE OVER COVENTRY" WE would not be satisfied about test marketing

Planet in this small way unless we thought it wassafer than existing cigarettes." 1 Thus Courtaulds

justified the launching last week of’ Planet’, a cigarettecontaining 50% synthetic tobacco. The nature of thematerial has not been disclosed (unlike that of theI.C.I. product 2), nor do we know what tests have beendone on it; but this statement seems disingenuous.The Hunter Committee, appointed to examine justthese materials, opposed the launch on the ground thatmore tests were needed. No doubt the Committeewanted to be sure that smokers would not be exposedto a toxic hazard not present in the smoke from naturaltobacco. 2 And it seems that Courtaulds found the

pace too slow.

That one of the principal firms of the U.K. should,in 1973, be diversifying into tobacco products seemssad; and that the company chooses to bypass measuresdesigned to protect the public is sadder. The companyought to have been told that any change in the chemicalinput to man is liable to have both desirable andundesirable consequences, and that some of these canbe identified by laboratory tests when these are

pursued to the limit. Courtaulds should have waitedfor the completion of tests.

Perhaps Courtaulds’ new cigarette will be too

unpalatable to sell. If so, no more need be said; forthe competitors are sticking to the Hunter rules.But if ’ Planets ’ do prove acceptable in Coventry,where the test marketing is taking place, Courtauldshave a resounding duty at once to mount adequateepidemiological investigations. Such investigationswould be greatly aided by restriction of marketing, forseveral years, to clearly defined areas. For the companyto do less, after last week’s events, would be a scandal.

1. Times, Nov. 3.2. Lancet, 1973, i, 1226.