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ANTIBIOTICS AND THE COMMON COLD
471 determining Scotland’s continuing status, in European terms, as obstetric poor relation. For the organisation of consultant practice in this way removes from many areas, in which it operates in its more extreme forms, one of the great safeguards of the National Health Service-namely, the provision for general practitioners and their patients of the real alternatives of clinically independent consultants free to compete as equals. It seems likely that consultants in England and Wales, with their democratic tradition, will reject the proposal1 that chairmen of divisions be appointed by regional boards, unless it be accompanied by proper safeguards, such as provision that the chairman’s powers be clearly defined and strictly limited, with the office subject to automatic rotation at intervals between different consultant members of the division. As to Scotland, with its very different authoritarian tradition, one is less optimistic. While its report2 pays lip service to the need for the democratisation of consultant relationships, there is a powerful lobby concerned to resist such change. For the consultant-inadministrative-charge system is dear to two groups-consultants in administrative charge themselves and whole-time medical administrators. To the former, the system commends itself because the exercise of petty power has a certain fascination for all of us, and theirs is power with perquisites-successful projection of the " big doctor " image has economic advantages whether in private practice or by way of merit award. To the latter, the system appeals because it is the perfect answer to the perennial problem which confronts the administrator in his dealings with any group of clinicians organised on a basis of equality: no longer is there the need to seek the compromise, or establish the consensus; difference of opinion and diversity of view are dealt with in that most effective of ways-simply by suppressing them. It is not surprising, then, to find that the Scottish report, after arguing the case for abandonment of the consultant-in-administrative-charge system, makes provision for exceptions to this general recommendation. " In clinical specialties with close community relationships ... it may often be desirable for a consultant in administrative charge to continue to be appointed." No reasons are offered, and what, after all, is a specialty " with close community relationships " ? If this latter phrase means anything it has to do with a given group of beds drawing their occupants from a given geographical area. The size of the latter is not specified. The formula is capable of an elasticity of interpretation such as shall no doubt enable our administrators in Scotland to include any and every specialty at will, without overtaxing their exegetic ingenuity. There is a danger, then, that this report will serve only to entrench the existing hierarchical arrangements to the benefit of a few consultants but to the great deteriment of most consulPlus ça change, tants and all hospital patients in Scotland. plus c’est la même chose. an
E. MACDONALD.
A NEW LOOK AT THE D.P.H. SIR,-Ishould like to comment on your remarks about the future of the medical officer of health in your leading article
(Feb. 17, p. 345). Whilst I agree that it seems possible that many M.O.H.S will join regional-hospital-board administrative medical officers in a unified Health Service, I hope that some will remain to carry on and extend their present epidemiological functions. A case can be made out for a national epidemiological service 5 as part of a unified Health Service; this would need the skill and experience in epidemiology which many M.o.H.s possess. "
the M.o.H. should be reinvented " in two distinct roles: (1) medical administrator; (2) epidemiologist. Finally, I think that many public-health doctors would find it difficult to accept the suggestion that they should become " a kind of medical Ombudsman ". Health Department, N. S. GALBRAITH. Newham.
Perhaps
5.
Galbraith,
N. S. Publ.
Hlth, Lond. 1968, 81,
221.
SiR,ŅIshould like to convey my appreciation of your leader (Feb. 17, p. 345). To me the most interesting part was its look into the future, since I am personally a strong supporter of the proposals in the Porritt report or of some similar arrangement whereby the separate strands of the National Health Service would be brought together in local units of manageable size. These would no doubt be hospital-centred and might very well correspond in many cases to the present areas of hospital management committees. My own proposal would be that the post of medical officer of health should be converted into that of consultant epidemiologist, to be attached to each of these combined units. I envisage that his terms of reference would be very much what you have described, being concerned with epidemiology in its widest sense and with the assessment of the value of all forms of treatment, whether in hospital or otherwise. Not only therefore would the epidemiologist be responsible for preventive medicine, but also he would provide a feed-back of information about long-term results of therapy. Presumably in such circumstances he would still be interested in environmental hygiene, and to that end would be seconded to local authorities in the area as their adviser, though remaining all the time the employee of the new health authority. This incidentally would allow the chief public-health inspector, who would presumably remain a local-government official, to become the personage whose position he has so long coveted-a chief official in his own right. County Borough Health Department, Archer Street, Darlington, Yorks. JOSEPH V. WALKER.
ANTIBIOTICS AND THE COMMON COLD SIR,-I have read with interest your annotation (Feb. 3, p. 240), in which you comment on Banks’ article in the Medical Officer. With some of your points I am in complete agreement, but I wish to take issue with you on the
following: 1. "... risk of producing antibiotic-resistant strains of organisms." This is admittedly most important in antibiotic therapy in general, but, as Dr. Banks noted last week (p. 425), your reference to the Tees-side outbreak due to Escherichia coli is beside the point: the antibiotics and the bacteria concerned are entirely different. I showed1 that the question of resistance was considered before any work was carried out at all. Tests were repeatedly made, even to the extent of obtaining practically sterile sputum cultures owing to deliberate overdosage; in each case the flora of the individual returned to normal within days of discontinuance of the antibiotic, the maximum time noted being within a fortnight. 2. "... the early common cold should have no more than symptomatic treatment. Antibiotics should be reserved for significant added infection by organisms of known sensitivity." The problem of sensitivity was also gone into in my papery It is agreed that when possible sensitivity tests should always be carried out, not only for the common cold, but in medicine generally. But it is not generally understood that treatment of the common cold is, from the beginning, an urgent matter if worth-while results are to be obtained. The virus has begun its depressant effect on resistance before symptoms have appeared, and there is no time for sensitivity tests. One must therefore give an antibiotic which is, from study of the known bacteriology of many patients, most likely to produce the effect.
The whole question boils down to this: why is it assumed that the treatment of the common cold is purely a virus affair and therefore in the province of virologists alone ? The virus (or virus group) is after all only one of the originators of the common cold. The old-fashioned threshing mill using dusty corn could produce as severe, long-lasting, and typical a cold as any virus, though non-infective and confined to those using the mill. The fact is that the common cold (with its sequelx) is produced by any agent that will reduce resistance to an auto-induced bacterial infection. Essentially the problem is now not " Shall we use antibiotics ? " but " How do we control their use ?".
J. MORRISON RITCHIE. 1.
Ritchie, J.
M.
Lancet, 1958, i, 618; ibid.
p. 699.
E. MACDONALD.
A NEW LOOK AT THE D.P.H. SIR,-Ishould like to comment on your remarks about the future of the medical officer of health in your leading article
(Feb. 17, p. 345). Whilst I agree that it seems possible that many M.O.H.S will join regional-hospital-board administrative medical officers in a unified Health Service, I hope that some will remain to carry on and extend their present epidemiological functions. A case can be made out for a national epidemiological service 5 as part of a unified Health Service; this would need the skill and experience in epidemiology which many M.o.H.s possess. "
the M.o.H. should be reinvented " in two distinct roles: (1) medical administrator; (2) epidemiologist. Finally, I think that many public-health doctors would find it difficult to accept the suggestion that they should become " a kind of medical Ombudsman ". Health Department, N. S. GALBRAITH. Newham.
Perhaps
5.
Galbraith,
N. S. Publ.
Hlth, Lond. 1968, 81,
221.
SiR,ŅIshould like to convey my appreciation of your leader (Feb. 17, p. 345). To me the most interesting part was its look into the future, since I am personally a strong supporter of the proposals in the Porritt report or of some similar arrangement whereby the separate strands of the National Health Service would be brought together in local units of manageable size. These would no doubt be hospital-centred and might very well correspond in many cases to the present areas of hospital management committees. My own proposal would be that the post of medical officer of health should be converted into that of consultant epidemiologist, to be attached to each of these combined units. I envisage that his terms of reference would be very much what you have described, being concerned with epidemiology in its widest sense and with the assessment of the value of all forms of treatment, whether in hospital or otherwise. Not only therefore would the epidemiologist be responsible for preventive medicine, but also he would provide a feed-back of information about long-term results of therapy. Presumably in such circumstances he would still be interested in environmental hygiene, and to that end would be seconded to local authorities in the area as their adviser, though remaining all the time the employee of the new health authority. This incidentally would allow the chief public-health inspector, who would presumably remain a local-government official, to become the personage whose position he has so long coveted-a chief official in his own right. County Borough Health Department, Archer Street, Darlington, Yorks. JOSEPH V. WALKER.
ANTIBIOTICS AND THE COMMON COLD SIR,-I have read with interest your annotation (Feb. 3, p. 240), in which you comment on Banks’ article in the Medical Officer. With some of your points I am in complete agreement, but I wish to take issue with you on the
following: 1. "... risk of producing antibiotic-resistant strains of organisms." This is admittedly most important in antibiotic therapy in general, but, as Dr. Banks noted last week (p. 425), your reference to the Tees-side outbreak due to Escherichia coli is beside the point: the antibiotics and the bacteria concerned are entirely different. I showed1 that the question of resistance was considered before any work was carried out at all. Tests were repeatedly made, even to the extent of obtaining practically sterile sputum cultures owing to deliberate overdosage; in each case the flora of the individual returned to normal within days of discontinuance of the antibiotic, the maximum time noted being within a fortnight. 2. "... the early common cold should have no more than symptomatic treatment. Antibiotics should be reserved for significant added infection by organisms of known sensitivity." The problem of sensitivity was also gone into in my papery It is agreed that when possible sensitivity tests should always be carried out, not only for the common cold, but in medicine generally. But it is not generally understood that treatment of the common cold is, from the beginning, an urgent matter if worth-while results are to be obtained. The virus has begun its depressant effect on resistance before symptoms have appeared, and there is no time for sensitivity tests. One must therefore give an antibiotic which is, from study of the known bacteriology of many patients, most likely to produce the effect.
The whole question boils down to this: why is it assumed that the treatment of the common cold is purely a virus affair and therefore in the province of virologists alone ? The virus (or virus group) is after all only one of the originators of the common cold. The old-fashioned threshing mill using dusty corn could produce as severe, long-lasting, and typical a cold as any virus, though non-infective and confined to those using the mill. The fact is that the common cold (with its sequelx) is produced by any agent that will reduce resistance to an auto-induced bacterial infection. Essentially the problem is now not " Shall we use antibiotics ? " but " How do we control their use ?".
J. MORRISON RITCHIE. 1.
Ritchie, J.
M.
Lancet, 1958, i, 618; ibid.
p. 699.