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ANOXIA AND RENAL FUNCTION
362
Letters
to
the Editor
CHALLENGE TO THE MEDICAL ACT
SiR,—At the second reading in the House of Commons of the National Insurance (Industrial Injuries) Bill on
Feb. 18 a number’of Socialist back-benchers proposed amendment to clause 85 in which a definition was given that the term " medical practitioner used in the Bill " means a registered medical practitioner." The amendment sought to insert at the end of that description the words " or such person or class of persons as the Minister may prescribe " ; and " the Minister," the clause states, " means the Minister of National Insurance." The effect of this amendment would have been to transfer to the Ministerof National Insurance that part of the function of the General Medical Council entrusted tq-it- by the Medical Act of 1858, which made the council " the sole authority to determine those persons who an
"
could be regarded as having undergone an adequate professional training to practise medicine." The official list’kept by this body, known as " the Medical Register," contains " the names of those persons, and only of those persons, who have fulfilled the conditions and training demanded." The purpose of this office performed by the General Medical Council is to protect the public by giving it knowledge of persons who have the qualifications to practise medicine.
The amendment would have the effect of entrusting the temporary Minister of National Insurance with the responsibility of making decisions now made exclusively by a statutory body with nearly a century of experience behind it, consisting of persons having a special and direct knowledge of the practice of medicine in its various branches, as well as of lay persons appointed by the Privy Council. The motion was disallowed by the Speaker as covering But at ground which had been previously dealt with. the third reading the Member who had taken the initiative in proposing the amendment, undeterred by his failure, pressed the Minister to reopen the question. The Minister met this request with the rather ominous suggestion that the proposal would be more appropriately made in the consideration of the new Health Bill so soon to make its debut in the House of Commons. A similar power to that sought by the motion cited was given to the Minister of Health by a clause slipped into the Nurses Act, 1943, by which he could " authorise the use by specified persons of specified names or titles containing the wordnurse’" (vide section 6). By Statutory Order no. 638, May 31, 1945, the Minister, taking advantage of that clause, made a regulation authorising the recognition of so-called " Christian Science nurses " on an equality with registered nurses. The nursing profession is in proper revolt against this development ; and when the matter came under debate (Hansard, Oct. 17, 1945) it was freely stated that this obnoxious regulation was one explanation of the present critical shortage of nurses. This precedent should surely be a warning to the medical profession and to the public. To throw the Medical Register open to any person or persons whom a Minister, having no personal knowledge or experience of medical training, might regard as qualified for admission to it, would be to introduce chaos such as prevailed before the enactment of the epochmaking Medical Act, 1858. House of Commons, E. GRAHAM-LITTLE. London, S.W.1. ANOXIA AND RENAL FUNCTION SiR,-The article by Maegraith, Havard, and Parsons in THE LANCET of Sept. 8, 1945 (p. 293), aroused considerable discussion in your columns and elsewhere, and for this reason alone will probably do much to further our knowledge of renal function. In suggesting that a common cause underlies - the functional renal failures which may complicate so many different diseases they have attempted to put down on paper a matter which has been occupying our attention for at least 12 years. We have, however, never con- vinced ourselves that all the renal failures we have observed had the same pathological background. Maegraith and his colleagues have incriminated anoxia. But it is difficult to see why anoxia alone should bring about a fall in the physical process of glomerular filtra-
tion, and if anoxia is the underlying cause of the functional renal failure why should the syndrome be encountered in uncompensated alkalosis ? In this condition, as met with in clinical practice, there need be no haemoconcentration, no disorganisation of the circulation, and no fall of blood-pressure. Why therefore should there be any reduced oxygen supply to the kidney, and, if the alkalosis itself is held to interfere with the utilisation of oxygen by the tubules, why should there be a fall in the glomerular filtration-rate ? The authors themselves are clearly in a difficulty about the cause of the renal failure in alkalosis, and their own admirable, if limited, work on the subject has not helped them to clarify the matter. The retention of sodium, which they record experimentally (Lancet, Dec. 1, 1945, p. 761), is difficult to explain in the presence of a glomerular filtration-rate twice as high as normal. When, moreover, they have to postulate " alterations in renal haemodynamics so that the blood-flow favours the glomeruli at the expense of the tubules " and a " redistribution of blood-flow through the kidney " to explain the increased glomerular filtration-rates which they observed in the early stages of experimental alkalosis, it is difficult anatomically to visualise such changes in the mammalian kidney, in which the tubules have no separate blood-supply. An alteration in the glomerular membrane or a fall in the colloidal osmotic pressure of the plasma would seem to be much more reasonable explanations of the rise in glomerular filtration-rate. Without wishing, therefore, in any way to belittle the contribution of Maegraith and his colleagues of the Army Malaria Research Unit to renal physiology, we believe it is not yet time to try to find a single explanation for this interesting and widespread syndrome. One may yet be found ; but at this stage we prefer to keep an open mind as to cause, and to concentrate on the collection of facts. R. A. MCCANCE. Department of Experimental Medicine, D. A. K. BLACK. University of Cambridge. CHEMOTHERAPY OF THE COMMON COLD Sm,—Searching the literature for experiments on insufflation of the sulphonamides into the nose to alleviate acute coryza we found that since Delafield, Straker, and Topley1 described their trial of antiseptic snuff in 1941, six papers had been published dealing with over 700 such treatments with no greater complication than a transient local skin rash in three patients. Macro- and micro-crystals had been used and dosages from as high as " ... a thick chalky Bhn ... covering " the nasal mucous membrane and laryngo-pharynx ..." 0-3 g. daily for three days." One experiment down to involved blowing the powders into the trachea. Pressed for time, and with only one insufflator, we decided to use macrocrystalline sulphathiazole with men under battle training who reported sick with a cold without other signs of infection. One puff of powder was directed up each nostril thrice daily for three days and for a further two days if symptoms had not abated. By careful weighings it was found that each puff delivered 0-09 g. The total treatment therefore averaged about 2-0 g. We were unable to do a control group with inert powder. The presence or absence of the following clinical points was noted before, during, and after treatment: "
nasal blockage, cough, earache, throat, the amount of nasal discharge, and the loss of smell (tested by bottled scent). In seven weeks
temperature, headache, sore
77
men were
retain the
treated. No special effort in the nose.
was
made to
powder
From our own experience and patients’ reports the nasal congestion was lessened in about an hour and ability to breathe through the nose at night was felt as a considerable relief. Of the 77 men treated, 72 remained on duty ; 5 had temperatures of 99° F and were put to bed, but lost their symptoms and returned to duty in less than five days. Among the 72 on duty, 10 had five days’ treatment before losing their symptoms ; the rest had three days’ treatment. One exception was a man who developed a septic finger and was not free from symptoms after seven days’ treatment. Three patients had labial herpes and one this after three days’ treatment. No complications ensued in any patient.
developed
1.
Delafield, M. E., Straker, E., Topley, W. W. C. Brit. med. J. 1941, i, 145.
Letters
to
the Editor
CHALLENGE TO THE MEDICAL ACT
SiR,—At the second reading in the House of Commons of the National Insurance (Industrial Injuries) Bill on
Feb. 18 a number’of Socialist back-benchers proposed amendment to clause 85 in which a definition was given that the term " medical practitioner used in the Bill " means a registered medical practitioner." The amendment sought to insert at the end of that description the words " or such person or class of persons as the Minister may prescribe " ; and " the Minister," the clause states, " means the Minister of National Insurance." The effect of this amendment would have been to transfer to the Ministerof National Insurance that part of the function of the General Medical Council entrusted tq-it- by the Medical Act of 1858, which made the council " the sole authority to determine those persons who an
"
could be regarded as having undergone an adequate professional training to practise medicine." The official list’kept by this body, known as " the Medical Register," contains " the names of those persons, and only of those persons, who have fulfilled the conditions and training demanded." The purpose of this office performed by the General Medical Council is to protect the public by giving it knowledge of persons who have the qualifications to practise medicine.
The amendment would have the effect of entrusting the temporary Minister of National Insurance with the responsibility of making decisions now made exclusively by a statutory body with nearly a century of experience behind it, consisting of persons having a special and direct knowledge of the practice of medicine in its various branches, as well as of lay persons appointed by the Privy Council. The motion was disallowed by the Speaker as covering But at ground which had been previously dealt with. the third reading the Member who had taken the initiative in proposing the amendment, undeterred by his failure, pressed the Minister to reopen the question. The Minister met this request with the rather ominous suggestion that the proposal would be more appropriately made in the consideration of the new Health Bill so soon to make its debut in the House of Commons. A similar power to that sought by the motion cited was given to the Minister of Health by a clause slipped into the Nurses Act, 1943, by which he could " authorise the use by specified persons of specified names or titles containing the wordnurse’" (vide section 6). By Statutory Order no. 638, May 31, 1945, the Minister, taking advantage of that clause, made a regulation authorising the recognition of so-called " Christian Science nurses " on an equality with registered nurses. The nursing profession is in proper revolt against this development ; and when the matter came under debate (Hansard, Oct. 17, 1945) it was freely stated that this obnoxious regulation was one explanation of the present critical shortage of nurses. This precedent should surely be a warning to the medical profession and to the public. To throw the Medical Register open to any person or persons whom a Minister, having no personal knowledge or experience of medical training, might regard as qualified for admission to it, would be to introduce chaos such as prevailed before the enactment of the epochmaking Medical Act, 1858. House of Commons, E. GRAHAM-LITTLE. London, S.W.1. ANOXIA AND RENAL FUNCTION SiR,-The article by Maegraith, Havard, and Parsons in THE LANCET of Sept. 8, 1945 (p. 293), aroused considerable discussion in your columns and elsewhere, and for this reason alone will probably do much to further our knowledge of renal function. In suggesting that a common cause underlies - the functional renal failures which may complicate so many different diseases they have attempted to put down on paper a matter which has been occupying our attention for at least 12 years. We have, however, never con- vinced ourselves that all the renal failures we have observed had the same pathological background. Maegraith and his colleagues have incriminated anoxia. But it is difficult to see why anoxia alone should bring about a fall in the physical process of glomerular filtra-
tion, and if anoxia is the underlying cause of the functional renal failure why should the syndrome be encountered in uncompensated alkalosis ? In this condition, as met with in clinical practice, there need be no haemoconcentration, no disorganisation of the circulation, and no fall of blood-pressure. Why therefore should there be any reduced oxygen supply to the kidney, and, if the alkalosis itself is held to interfere with the utilisation of oxygen by the tubules, why should there be a fall in the glomerular filtration-rate ? The authors themselves are clearly in a difficulty about the cause of the renal failure in alkalosis, and their own admirable, if limited, work on the subject has not helped them to clarify the matter. The retention of sodium, which they record experimentally (Lancet, Dec. 1, 1945, p. 761), is difficult to explain in the presence of a glomerular filtration-rate twice as high as normal. When, moreover, they have to postulate " alterations in renal haemodynamics so that the blood-flow favours the glomeruli at the expense of the tubules " and a " redistribution of blood-flow through the kidney " to explain the increased glomerular filtration-rates which they observed in the early stages of experimental alkalosis, it is difficult anatomically to visualise such changes in the mammalian kidney, in which the tubules have no separate blood-supply. An alteration in the glomerular membrane or a fall in the colloidal osmotic pressure of the plasma would seem to be much more reasonable explanations of the rise in glomerular filtration-rate. Without wishing, therefore, in any way to belittle the contribution of Maegraith and his colleagues of the Army Malaria Research Unit to renal physiology, we believe it is not yet time to try to find a single explanation for this interesting and widespread syndrome. One may yet be found ; but at this stage we prefer to keep an open mind as to cause, and to concentrate on the collection of facts. R. A. MCCANCE. Department of Experimental Medicine, D. A. K. BLACK. University of Cambridge. CHEMOTHERAPY OF THE COMMON COLD Sm,—Searching the literature for experiments on insufflation of the sulphonamides into the nose to alleviate acute coryza we found that since Delafield, Straker, and Topley1 described their trial of antiseptic snuff in 1941, six papers had been published dealing with over 700 such treatments with no greater complication than a transient local skin rash in three patients. Macro- and micro-crystals had been used and dosages from as high as " ... a thick chalky Bhn ... covering " the nasal mucous membrane and laryngo-pharynx ..." 0-3 g. daily for three days." One experiment down to involved blowing the powders into the trachea. Pressed for time, and with only one insufflator, we decided to use macrocrystalline sulphathiazole with men under battle training who reported sick with a cold without other signs of infection. One puff of powder was directed up each nostril thrice daily for three days and for a further two days if symptoms had not abated. By careful weighings it was found that each puff delivered 0-09 g. The total treatment therefore averaged about 2-0 g. We were unable to do a control group with inert powder. The presence or absence of the following clinical points was noted before, during, and after treatment: "
nasal blockage, cough, earache, throat, the amount of nasal discharge, and the loss of smell (tested by bottled scent). In seven weeks
temperature, headache, sore
77
men were
retain the
treated. No special effort in the nose.
was
made to
powder
From our own experience and patients’ reports the nasal congestion was lessened in about an hour and ability to breathe through the nose at night was felt as a considerable relief. Of the 77 men treated, 72 remained on duty ; 5 had temperatures of 99° F and were put to bed, but lost their symptoms and returned to duty in less than five days. Among the 72 on duty, 10 had five days’ treatment before losing their symptoms ; the rest had three days’ treatment. One exception was a man who developed a septic finger and was not free from symptoms after seven days’ treatment. Three patients had labial herpes and one this after three days’ treatment. No complications ensued in any patient.
developed
1.
Delafield, M. E., Straker, E., Topley, W. W. C. Brit. med. J. 1941, i, 145.