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CHLORIDES IN CEREBROSPINAL FLUID
723
blood, which
noted some months ago,1 has than ever. " I was told of a " for sale the other day," said an agent; I could practice have sold it for certain to any of several dozen doctors. The first one I offered it to bought it the next day." These unemployed doctors are not a true surplus ; there This was are not too many but too few in practice. inevitable during the war because other claims came first, but today there is no such excuse. Several ways of ending this artificial separation of doctor from patient have been proposed. It has been suggested, for example, that the limit of 2500 on the number of patients which a doctor may have on his panel list should be reimposed. This may commend itself as just and reasonable ; but it is not enough. If, before 1948, the public is to have the fullest possible generalpractitioner service, those now in practice must be further persuaded to- share work of which they have more than enough with those that have none. A correspondent of the Manchester Guardian (Nov. 11) suggests an announcement that compensation under the Act will be paid at 1947-48 (not 1939) values, which would, he thinks, lead many doctors to employ assistants to enlarge their practices. The final alternative is active support from the Government. The Minister is understandably more reluctant to subsidise the general than the specialist, because the immediate benefits in training, and the remote advantage for the new service, are less obvious. But these doctors are mostly of the younger generation, and without any practical knowledge of civilian general practice. When the service comes -into being the demands on the country’s practitioners may be greater than ever before, owing to the large number of patients who for the first time will be offered free medical attention. It would help the service to get off to a good start if, in the meantime, these doctors were trained for their responsibilities by an apprenticeship under those who already have experience of practice. The future service, we are told, is to concern itself more with preventive methods. For their success these depend on genuine understanding between the publichealth and the clinical services-an understanding which has hitherto not been as close and cordial as it might. The Minister might therefore like to encourage some of those for whom a place in practice is not immediately found to spend the coming months gaining first-hand experience in the various departments of public health ; he would thus be assured of a group of general practitioners having a particular understanding and sympathy for preventive practice. Those that are not absorbed into practice should certainly not be left to kick their heels until they are needed, as they will be, to help in the operation of the Act ; to rest content with this continued unemployment is to accede to the attitude that the general practitioner needs no special knowledge or experience beyond what he has gained from undergraduate training and casual. hospital appointments. new
become
more
we
pronounced
practitioner
CHLORIDES IN CEREBROSPINAL FLUID THERE still seems to be some doubt about the interpretation of chloride levels in the cerebrospinal fluid (C.s.F.) in the diagnosis of meningitis. Honor Smith,l in her recent paper to the Tuberculosis Association, rightly emphasised that there is no level characteristic of
tuberculous
meningitis. Nearly twenty years
2 ago, Linder and Carmichael c.s.F. chlorides in meningitis was associated with a fall in the serum of plasma chlorides, and the same approximate relationship between C.s.F. and plasma chlorides has been shown to hold for other conditions. For example, a low level of
demonstrated that the fall in the
1.
Lancet, 1946, i, 968. 1. See Lancet, Oct. 12, p. 528. 2. Linder, G. C., Carmichael, E. A.
Biochem. J. 1928, 22, 46.
serum
chlorides is
common
in
nephritis
and constant in
alkalosis, and in the latter condition the lowest
c.s.F.
chloride levels of all are met with. In infection in general, and in tuberculosis in particular, there is often- a fall in the serum chlorides, and this is mirrored in the low C.S.F.’ chlorides, irrespective of whether there is meningitis or not. In the " meningism " associated with lobar pneumonia and other conditions c.s.F. chlorides of 650 mg. per 100 ml. and lower may be met with without any evidence of meningeal infection. In true meningitis, as shown by raised protein and cell contents of the c.s.., there is usually, though not invariably, a fall in the chloride level of the serum and hence of the C.S.F., and this fall is usually, though again not invariably, greater in tuberculous than in nontuberculous meningitis, but the difference is a statistical one and may be misleading in an individual case. Allott 3 has shown that in about 50% of cases of tuberculous meningitis there is a C.S.F. chloride level of 640 mg. per 100 ml. or lower on first examination, whereas for nontuberculous meningitis the 50% level is 675 mg. per 100 ml. Very low c.s.F. chloride levels are commoner in tuberculous than in non-tuberculous meningitis, - and Allott found 25% of tuberculous but only 5% of nontuberculous meningitis cases with levels below 600 mg. per 100 ml. on admission to hospital. The cytology of the cerebrospinal fluid in the two main forms of meningitis is usually distinctive, the pyogenic form containing numerous polymorphs and the tuberculous form predominantly lymphocytes. But difficulties are sometimes met with here also, since in the early stages of tuberculous meningitis there may be only a slight rise in the cell content and more than half the cells may be polymorphs-a finding similar to that in poliomyelitis and virus encephalomeningitis. Tubercle bacilli can be found in smears in a fair proportion of cases of tuberculous meningitis if the C.s.F. is examined repeatedly, and they can be grown in culture from the majority, though, owing to the slow growth of the tubercle bacillus, the culture result is often obtained only after the patient’s death. Notwithstanding these difficulties, the characters of the c.s.F. tend to " change towards the " typical finding of high lymphocytes and very low chlorides as the disease progresses ; and most cases -can be diagnosed with certainty by repeated examinations, even if the first specimen of fluid givesequivocal results. ’
SCIENTIFIC LIAISON BETWEEN NATIONS UNTIL the first world war, science had been considered to be above the battle. The example usually given is that of Sir Humphry Davy visiting France at the height of the Napoleonic wars, and being honoured by Napoleon himself. From 1914 to 1918, however, the scientist was found to be such a vitally important part of the nation’s war effort that this scientific internationalism broke down completely ; only medicine escaped, and the doctor was still expected to treat friend and enemy alike. Between the two wars attempts were made by various organisations, notably the League of Nations, to bring together scientists from all countries, and the last few months has seen a heartening revival in such attempts-for example, the British-Swiss Medical Conference and the International Medical Conference in In a special number of Chronica Botanica, London. published in the autumn of last year, B. Cannon and R. M. Field review the aims and methods of international scientific relations, both past and future. Their memorandum starts by emphasising that " war is a great stimulus to national, and to limited international, cooperative scientific research in most of the applied sciences." " What is needed today, to quote Joseph Needham, is an attempt to combine the methods 3.
Allott, E.
N.
Proc. R. Soc. Med. 1945,
38, 275.
blood, which
noted some months ago,1 has than ever. " I was told of a " for sale the other day," said an agent; I could practice have sold it for certain to any of several dozen doctors. The first one I offered it to bought it the next day." These unemployed doctors are not a true surplus ; there This was are not too many but too few in practice. inevitable during the war because other claims came first, but today there is no such excuse. Several ways of ending this artificial separation of doctor from patient have been proposed. It has been suggested, for example, that the limit of 2500 on the number of patients which a doctor may have on his panel list should be reimposed. This may commend itself as just and reasonable ; but it is not enough. If, before 1948, the public is to have the fullest possible generalpractitioner service, those now in practice must be further persuaded to- share work of which they have more than enough with those that have none. A correspondent of the Manchester Guardian (Nov. 11) suggests an announcement that compensation under the Act will be paid at 1947-48 (not 1939) values, which would, he thinks, lead many doctors to employ assistants to enlarge their practices. The final alternative is active support from the Government. The Minister is understandably more reluctant to subsidise the general than the specialist, because the immediate benefits in training, and the remote advantage for the new service, are less obvious. But these doctors are mostly of the younger generation, and without any practical knowledge of civilian general practice. When the service comes -into being the demands on the country’s practitioners may be greater than ever before, owing to the large number of patients who for the first time will be offered free medical attention. It would help the service to get off to a good start if, in the meantime, these doctors were trained for their responsibilities by an apprenticeship under those who already have experience of practice. The future service, we are told, is to concern itself more with preventive methods. For their success these depend on genuine understanding between the publichealth and the clinical services-an understanding which has hitherto not been as close and cordial as it might. The Minister might therefore like to encourage some of those for whom a place in practice is not immediately found to spend the coming months gaining first-hand experience in the various departments of public health ; he would thus be assured of a group of general practitioners having a particular understanding and sympathy for preventive practice. Those that are not absorbed into practice should certainly not be left to kick their heels until they are needed, as they will be, to help in the operation of the Act ; to rest content with this continued unemployment is to accede to the attitude that the general practitioner needs no special knowledge or experience beyond what he has gained from undergraduate training and casual. hospital appointments. new
become
more
we
pronounced
practitioner
CHLORIDES IN CEREBROSPINAL FLUID THERE still seems to be some doubt about the interpretation of chloride levels in the cerebrospinal fluid (C.s.F.) in the diagnosis of meningitis. Honor Smith,l in her recent paper to the Tuberculosis Association, rightly emphasised that there is no level characteristic of
tuberculous
meningitis. Nearly twenty years
2 ago, Linder and Carmichael c.s.F. chlorides in meningitis was associated with a fall in the serum of plasma chlorides, and the same approximate relationship between C.s.F. and plasma chlorides has been shown to hold for other conditions. For example, a low level of
demonstrated that the fall in the
1.
Lancet, 1946, i, 968. 1. See Lancet, Oct. 12, p. 528. 2. Linder, G. C., Carmichael, E. A.
Biochem. J. 1928, 22, 46.
serum
chlorides is
common
in
nephritis
and constant in
alkalosis, and in the latter condition the lowest
c.s.F.
chloride levels of all are met with. In infection in general, and in tuberculosis in particular, there is often- a fall in the serum chlorides, and this is mirrored in the low C.S.F.’ chlorides, irrespective of whether there is meningitis or not. In the " meningism " associated with lobar pneumonia and other conditions c.s.F. chlorides of 650 mg. per 100 ml. and lower may be met with without any evidence of meningeal infection. In true meningitis, as shown by raised protein and cell contents of the c.s.., there is usually, though not invariably, a fall in the chloride level of the serum and hence of the C.S.F., and this fall is usually, though again not invariably, greater in tuberculous than in nontuberculous meningitis, but the difference is a statistical one and may be misleading in an individual case. Allott 3 has shown that in about 50% of cases of tuberculous meningitis there is a C.S.F. chloride level of 640 mg. per 100 ml. or lower on first examination, whereas for nontuberculous meningitis the 50% level is 675 mg. per 100 ml. Very low c.s.F. chloride levels are commoner in tuberculous than in non-tuberculous meningitis, - and Allott found 25% of tuberculous but only 5% of nontuberculous meningitis cases with levels below 600 mg. per 100 ml. on admission to hospital. The cytology of the cerebrospinal fluid in the two main forms of meningitis is usually distinctive, the pyogenic form containing numerous polymorphs and the tuberculous form predominantly lymphocytes. But difficulties are sometimes met with here also, since in the early stages of tuberculous meningitis there may be only a slight rise in the cell content and more than half the cells may be polymorphs-a finding similar to that in poliomyelitis and virus encephalomeningitis. Tubercle bacilli can be found in smears in a fair proportion of cases of tuberculous meningitis if the C.s.F. is examined repeatedly, and they can be grown in culture from the majority, though, owing to the slow growth of the tubercle bacillus, the culture result is often obtained only after the patient’s death. Notwithstanding these difficulties, the characters of the c.s.F. tend to " change towards the " typical finding of high lymphocytes and very low chlorides as the disease progresses ; and most cases -can be diagnosed with certainty by repeated examinations, even if the first specimen of fluid givesequivocal results. ’
SCIENTIFIC LIAISON BETWEEN NATIONS UNTIL the first world war, science had been considered to be above the battle. The example usually given is that of Sir Humphry Davy visiting France at the height of the Napoleonic wars, and being honoured by Napoleon himself. From 1914 to 1918, however, the scientist was found to be such a vitally important part of the nation’s war effort that this scientific internationalism broke down completely ; only medicine escaped, and the doctor was still expected to treat friend and enemy alike. Between the two wars attempts were made by various organisations, notably the League of Nations, to bring together scientists from all countries, and the last few months has seen a heartening revival in such attempts-for example, the British-Swiss Medical Conference and the International Medical Conference in In a special number of Chronica Botanica, London. published in the autumn of last year, B. Cannon and R. M. Field review the aims and methods of international scientific relations, both past and future. Their memorandum starts by emphasising that " war is a great stimulus to national, and to limited international, cooperative scientific research in most of the applied sciences." " What is needed today, to quote Joseph Needham, is an attempt to combine the methods 3.
Allott, E.
N.
Proc. R. Soc. Med. 1945,
38, 275.