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STREPTOCOCCAL INFECTION IN A SCHOOL
220
years’ experience knows that for every visit where the doctor’s presence is essential there are nineteen others which a registered nurse or even an experienced housewife could deal with. Unfortunately the responsibility for assessing the urgency of a call is the doctor’s and the doctor’s alone. He alone will pay if he delays in response to a call and the patient suffers. So he visits and visits and visits. Dr. Patrick Wood (Jan. 19), writing on The Future of General Practice, feels that the visiting list is an integral part of British medicine and makes British medical practice what it is. His survey of the American scene answers some of the questions implied by Dr. Rorie’s report. He seems much concerned for the unvisited American patients but does not make a case that they suffer by having to travel to the doctor instead of having the doctor visit them. It is refreshing to read the two views and to learn that successful general practice can be conducted without a visiting list. Whatever the American system, what hope has the British G.P. with 3000 patients of organising routine check-ups, cervical smears, breast examinations, minor surgery, minor psychiatry, and so forth? What chance has he of doing sound preventive medicine when wholly preoccupied by ill-health? True, there are a few dedicated souls who do not know fatigue and seek no recreation from medicine except more medicine, who manage to do these things, but they can scarcely number 100 out of the 20,000 principals in practice here. If the Government is not prepared to improve general practice by providing buildings, equipment, and nursing and clerical help, and by rewarding skill, it can still, without extra
charge
to
the
Treasury, improve practice by
a
policy of discouraging excessive house visiting. If a homenursing service is to be the policy, it should be staffed by nurses and not qualified medical practitioners. In our Welfare State, practically every family has a car or a close friend or relative willing to provide transport. The long visiting list is a relic of the days when the horse was the only means of getting about and when only the wealthy could afford something on four wheels. Nowadays, transport of the sick to the surgery should be the rule rather than the exception. Visiting by the doctor is uneconomical use of a trained man, and as such is as out of date as the Ark. E. C. ATKINSON. A THOUSAND OUTPATIENTS
SIR,-There are two aspects of Dr. Priest’s paper1 that seem to have escaped him and your correspondents. Firstly, it is unlikely that his thousand is a representative sample of those who go to their family doctor with a
problem within the scope of a general medical outpatient department. Some of the thousand will come to outpatients for a confirmatory opinion, but most (probably) will be those whose problems the general practitioner has failed
solve. This failure may be due to lack of inclinaor of facilities for special investigation, but it follows that Dr. Priest’s implied criticisms of general practice are not valid since they are largely based on observation of the comparative failures. The successes of diagnosis and treatment in general practice never reach a hospital. Secondly, self-respecting family doctors, who dislike having their work done for them, sometimes well done, and sometimes not so well done, by hospital doctors, will to
tion, of skill, of knowledge,
1.
Lancet, 1962, ii, 1043.
not
send
opinion
a
to a
patient about whom they desire a second specialist who does too much following up. B. D. MORGAN WILLIAMS.
STREPTOCOCCAL INFECTION IN A SCHOOL
SIR,-Iwas extremely interested in School Doctor’s letter of Jan. 12. He has all my sympathy. For two terms (autumn, 1961, and spring, 1962) I had a similar strepto. coccal infection (Lancefield A) in one of the preparatory schools which I look after. Most of these cases were of pharyngitis, but there were two cases of lymphangitis and cellulitis. Several patients relapsed after adequate penicillin treatment. There was some improvement in the relapse-rate when treatment
changed to sulphamethoxazole (’ Gantanol’) (a longacting sulphonamide), but the epidemic only gradually subsided by the end of March.
was
The water and milk supplies were examined, with negative results, and the advice of the public-health authority was
sought. Mass swabbing was not done because it was felt certain that carriers would be found, and probably the carrier popula. tion would differ from day to day. A thorough airing of dormitories and bedding was done as opportunity allowed. An anxious watch was kept for complications, but fortu. nately none occurred, except in the case of the school doctor himself! No further case has occurred since May, 1962. I have a strong impression that oral penicillin treatment has in some way impaired the body’s natural production of immunity. This was not so in the days soon after the late war when sulphonamide treatment was my routine for such cases in schools. It is also advisable to have children with chronically infected tonsils seen by an E.N.T. surgeon and swabbed. I am suspicious that they often start such an epidemic and may well keep it going. St. Leonards-on-Sea, Sussex.
H. S. BRODRIBB.
USE OF THE UMBILICAL VEIN FOR TRANSFUSION OF NEWBORN BABIES
SIR,-From six years’ experience of the method in Edinburgh and Belfast we support Professor Wilkinson’s advocacy (Jan. 12, p. 86) of the use of the umbilical vein for infusion in neonatal surgery.
Although the method of insertion he describes is valuable, it is more often practicable and desirable before operation to insert the drip through the base of the umbilical cord directly into the sectioned vein exposed by a bold two-thirds transection of the cord. This takes less than a minute, and a drip already in position -has not been found to embarrass exposure, since most intraabdominal conditions in the early neonatal period are accessible through a transverse incision above and to the right of the umbilicus or through a transverse incision below the umbilicus. The umbilical route, too, has been found to be the one of choice for infusion in thoracic operations. We prefer a graduated cannula, with rounded tip and lateral opening. Nylon is distinctly better than polyethylene. (An appliance of this type has, of course, much wider applications in gavage, aspiration, and catheterisation.) We agree that the greatest advantages, apart from the ease of insertion, are the suitability for rapid transfusion, and for the giving of anaesthetic drugs during operation, but we have found a need for postoperative intravenous infusion more often than Professor Wilkinson, and we have used this method fairly widely over preoperative and postoperative periods. Objections have been raised about the danger of infection. We have found no significant local or disseminated infection attributable to the umbilical drip site, and this is possibly because of the eversion of the umbilical-cord/skin junction and the very slight tissue trauma incurred in erection. In fact,
years’ experience knows that for every visit where the doctor’s presence is essential there are nineteen others which a registered nurse or even an experienced housewife could deal with. Unfortunately the responsibility for assessing the urgency of a call is the doctor’s and the doctor’s alone. He alone will pay if he delays in response to a call and the patient suffers. So he visits and visits and visits. Dr. Patrick Wood (Jan. 19), writing on The Future of General Practice, feels that the visiting list is an integral part of British medicine and makes British medical practice what it is. His survey of the American scene answers some of the questions implied by Dr. Rorie’s report. He seems much concerned for the unvisited American patients but does not make a case that they suffer by having to travel to the doctor instead of having the doctor visit them. It is refreshing to read the two views and to learn that successful general practice can be conducted without a visiting list. Whatever the American system, what hope has the British G.P. with 3000 patients of organising routine check-ups, cervical smears, breast examinations, minor surgery, minor psychiatry, and so forth? What chance has he of doing sound preventive medicine when wholly preoccupied by ill-health? True, there are a few dedicated souls who do not know fatigue and seek no recreation from medicine except more medicine, who manage to do these things, but they can scarcely number 100 out of the 20,000 principals in practice here. If the Government is not prepared to improve general practice by providing buildings, equipment, and nursing and clerical help, and by rewarding skill, it can still, without extra
charge
to
the
Treasury, improve practice by
a
policy of discouraging excessive house visiting. If a homenursing service is to be the policy, it should be staffed by nurses and not qualified medical practitioners. In our Welfare State, practically every family has a car or a close friend or relative willing to provide transport. The long visiting list is a relic of the days when the horse was the only means of getting about and when only the wealthy could afford something on four wheels. Nowadays, transport of the sick to the surgery should be the rule rather than the exception. Visiting by the doctor is uneconomical use of a trained man, and as such is as out of date as the Ark. E. C. ATKINSON. A THOUSAND OUTPATIENTS
SIR,-There are two aspects of Dr. Priest’s paper1 that seem to have escaped him and your correspondents. Firstly, it is unlikely that his thousand is a representative sample of those who go to their family doctor with a
problem within the scope of a general medical outpatient department. Some of the thousand will come to outpatients for a confirmatory opinion, but most (probably) will be those whose problems the general practitioner has failed
solve. This failure may be due to lack of inclinaor of facilities for special investigation, but it follows that Dr. Priest’s implied criticisms of general practice are not valid since they are largely based on observation of the comparative failures. The successes of diagnosis and treatment in general practice never reach a hospital. Secondly, self-respecting family doctors, who dislike having their work done for them, sometimes well done, and sometimes not so well done, by hospital doctors, will to
tion, of skill, of knowledge,
1.
Lancet, 1962, ii, 1043.
not
send
opinion
a
to a
patient about whom they desire a second specialist who does too much following up. B. D. MORGAN WILLIAMS.
STREPTOCOCCAL INFECTION IN A SCHOOL
SIR,-Iwas extremely interested in School Doctor’s letter of Jan. 12. He has all my sympathy. For two terms (autumn, 1961, and spring, 1962) I had a similar strepto. coccal infection (Lancefield A) in one of the preparatory schools which I look after. Most of these cases were of pharyngitis, but there were two cases of lymphangitis and cellulitis. Several patients relapsed after adequate penicillin treatment. There was some improvement in the relapse-rate when treatment
changed to sulphamethoxazole (’ Gantanol’) (a longacting sulphonamide), but the epidemic only gradually subsided by the end of March.
was
The water and milk supplies were examined, with negative results, and the advice of the public-health authority was
sought. Mass swabbing was not done because it was felt certain that carriers would be found, and probably the carrier popula. tion would differ from day to day. A thorough airing of dormitories and bedding was done as opportunity allowed. An anxious watch was kept for complications, but fortu. nately none occurred, except in the case of the school doctor himself! No further case has occurred since May, 1962. I have a strong impression that oral penicillin treatment has in some way impaired the body’s natural production of immunity. This was not so in the days soon after the late war when sulphonamide treatment was my routine for such cases in schools. It is also advisable to have children with chronically infected tonsils seen by an E.N.T. surgeon and swabbed. I am suspicious that they often start such an epidemic and may well keep it going. St. Leonards-on-Sea, Sussex.
H. S. BRODRIBB.
USE OF THE UMBILICAL VEIN FOR TRANSFUSION OF NEWBORN BABIES
SIR,-From six years’ experience of the method in Edinburgh and Belfast we support Professor Wilkinson’s advocacy (Jan. 12, p. 86) of the use of the umbilical vein for infusion in neonatal surgery.
Although the method of insertion he describes is valuable, it is more often practicable and desirable before operation to insert the drip through the base of the umbilical cord directly into the sectioned vein exposed by a bold two-thirds transection of the cord. This takes less than a minute, and a drip already in position -has not been found to embarrass exposure, since most intraabdominal conditions in the early neonatal period are accessible through a transverse incision above and to the right of the umbilicus or through a transverse incision below the umbilicus. The umbilical route, too, has been found to be the one of choice for infusion in thoracic operations. We prefer a graduated cannula, with rounded tip and lateral opening. Nylon is distinctly better than polyethylene. (An appliance of this type has, of course, much wider applications in gavage, aspiration, and catheterisation.) We agree that the greatest advantages, apart from the ease of insertion, are the suitability for rapid transfusion, and for the giving of anaesthetic drugs during operation, but we have found a need for postoperative intravenous infusion more often than Professor Wilkinson, and we have used this method fairly widely over preoperative and postoperative periods. Objections have been raised about the danger of infection. We have found no significant local or disseminated infection attributable to the umbilical drip site, and this is possibly because of the eversion of the umbilical-cord/skin junction and the very slight tissue trauma incurred in erection. In fact,