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FUTURE OF GENERAL PRACTICE
416
Annotations FUTURE OF GENERAL PRACTICE How can we modify this Act to preserve more of the past of general practice ?" has been the loudest question lately in medical gatherings. It is refreshing to turn to Prof. Robert Platt’s remarks on the future of general practice, made in a recent address. He looks to the Act, and to the profession operating it, to make possible great improvements. He has the courage to say " there is a great deal wrong with general practice," and to list its faults. The doctor has insufficient time to do his job well. He works too much in professional isolation. There is no recognised standard in general practice ; that is to say, a practitioner’s work is so screened from the eyes of his colleagues that he lacks the stimulus of knowing that it will -be judged. He complains of an inferior status vis-a-vis the specialist. Finally, he has not been trained on proper lines. The Act is capable of adjusting the numbers of doctors to the amount of work that is to be done in a way that " private enterprise " never did. Platt sees no harm in basic salary combined with tapered capitation fee as a means to that end. In the health centres there is a remedy for professional isolation ; a doctor will talk shop, with mutual advantage, to another doctor in the same health centre, where he would, for prestige’ sake, have remained silent in the presence of a competitor, and he will know that at any time his case-records may have to be made available to his colleagues. These are powerful and unbureaucratic encouragements to maintaining a high standard of work. The status difficulty has its roots in the bias of medical education. Platt holds it ridiculous that the practitioner of the future is trained wholly by the specialist. Surely he is right. Even if the content of this training were altogether appropriate, the respectful student could not help emerging from it with the impression that specialists are a superior order of beings. So they are, in some respects ; but mostly they are not, in others. If the "
staff included some competent general practitioners, broad in their outlook and wise in their experi-
teaching
of men, able to look the specialists in the face and their bubbles on occasion, the student’s perspective would be truer, and the short-sighted stampede of the young into specialism would cease. To this end Platt offers the same suggestion as we did 2-namely, that one or more health centres should be established as an integral part of every teaching school. The members of their staffs should be chosen for their ability to conduct general practice well, and for their capacity to teach the students who (singly for preference) would accompany them throughout their working day. We can think of no single innovation which could do more than this to raise the standard and realise the true function of general practice in the next generation.
found that it took four seconds to reach a wound in the foot, seven seconds to reach the skin, and a whole minute to reach the bone-marrow (none reached compact bone). On the other hand, the dye was removed much more quickly from the marrow than the soft tissues; in less than three minutes it disappeared from the marrow, whereas it was visible for ten minutes in the skin. Studying the minute anatomy of the long bones they found that the nutrient artery describes many curves before entering the bone, and, after dividing into ascending and descending branches which run through the marrow, it ends in wide blood-spaces close to the epiphyses ; these blood-spaces are in close contact with veins of wide calibre and very thin walls. This arrangement of blood-vessels reduces the pressure and speed of circulation in the arteries, and enables the, veins to carry substances quickly away from the blood-spaceshence the efficacy of therapeutic injections into the marrow. The slowness of the flow through the nutrient arteries is supported by the measurements of blood-flow in the normal humerus made by Edholm et awl.4 From their figures it is estimated that the amount of blood normally flowing through the whole skeleton probably does not exceed 100 c.cm. a minute, though it may be vastly more in Paget’s disease. Though all the long bones have a highly efficient venous drainage, the sternum is the bone of choice for transfusions and infusions because of its convenient situation, because it has excellent- short venous connexions, through the internal mammary and innominate veins, with the superior vena cava, and because the compact part of the bone is very thin and easily pierced with the needle, the site of election being the upper part of the manubrium. The firm anchorage that the sternum gives for the needle was found useful in North Africa, wounded were transported long distances with an intrasternal drip-transfusion running. It can also be made use of in the continuous administration of penicillin. Thus Giraud and Desmonts 5 injected 20,000 units of penicillin, in 250 c.cm. of serum, in two hours by this route, and two days later gave 40,000 units in 250 c.cm. of serum in five hours without encountering any difficulties.
plethysmograph
where
ence
prick
BLOOD-FLOW IN
BONE
THE failure of their many attempts at obtaining arteriograms of bone vessels in living subjects led Lamas and his colleagues3 to investigate the intra-osseous circulation. They argued that a relatively slow bloodstream would be expected because none of the three physiological functions of the long bones-mechanical support of the body, storage of calcium salts, and hsemopoiesis—need a rapid circulation; hsemopoiesis and calcium storage are in fact facilitated by a slow bloodstream. Nor does movement of a bone, unlike that of muscle, require an extra supply of blood. When a dye was injected into the external iliac arteries of dogs they 1. Publ. Hlth, Lond. January, 1947, p. 99. 2. Lancet, Feb. 8, p. 228. 3. Lamas, A., Amado, D., Da Costa, J. C. 5, 241.
ADSORPTION OF ENDOGENOUS TOXINS FEw now believe that the various toxic chemicals, such as indole, skatole, tyramine, guanidine, putrescine, &c., formed by the decomposition of protein in the large bowel cause systemic disease or even the symptoms associated with constipation, though it has lately been suggested that their action may be partly responsible for the degenerative changes of old age. Most prefer to think that the barrier offered by the bowel wall and the detoxicating action of the liver together form an efficient protection’ against intoxication.6 Nevertheless, since the substances are responsible for the unpleasant odour of faeces, their removal would be a great blessing to patients who are incontinent or have an artificial anus. Kaolin and activated charcoal have been much used for the purpose, but neither has provided the
complete
Edholm, O. G., Howarth, S., McMichael, J. Clin. Sci. 1945, 5, 249 ; see Lancet, 1946, ii, 568. Giraud, G., Desmonts, T. Pr. méd. 1946, 54, 51. 6. Best. C. H., Taylor, N. B. Physiological Basis of Medica Practice, London, 1943, p. 851. 7. Martin, G. J., Wilkinson, J. Arch. Biochem. 1947, 12, 95. 4.
5.
Amatus lusitanus, 1946,
answer.
The ideal adsorbent should be completely effective in removing odour but should not interfere with intestinal synthesis of vitamins or with the absorption of foodstuffs and drugs. Martin and Wilkinsontried to find a suitable adsorbent which will adsorb the toxic chemicals in the pH range of the gut. They found thatAmberlite IR-4,’ a synthetic resin, was very effective against indole and skatole, while all the amines tested (putrescine, cadaverine, tyramine, histamine, and guanidine)
Annotations FUTURE OF GENERAL PRACTICE How can we modify this Act to preserve more of the past of general practice ?" has been the loudest question lately in medical gatherings. It is refreshing to turn to Prof. Robert Platt’s remarks on the future of general practice, made in a recent address. He looks to the Act, and to the profession operating it, to make possible great improvements. He has the courage to say " there is a great deal wrong with general practice," and to list its faults. The doctor has insufficient time to do his job well. He works too much in professional isolation. There is no recognised standard in general practice ; that is to say, a practitioner’s work is so screened from the eyes of his colleagues that he lacks the stimulus of knowing that it will -be judged. He complains of an inferior status vis-a-vis the specialist. Finally, he has not been trained on proper lines. The Act is capable of adjusting the numbers of doctors to the amount of work that is to be done in a way that " private enterprise " never did. Platt sees no harm in basic salary combined with tapered capitation fee as a means to that end. In the health centres there is a remedy for professional isolation ; a doctor will talk shop, with mutual advantage, to another doctor in the same health centre, where he would, for prestige’ sake, have remained silent in the presence of a competitor, and he will know that at any time his case-records may have to be made available to his colleagues. These are powerful and unbureaucratic encouragements to maintaining a high standard of work. The status difficulty has its roots in the bias of medical education. Platt holds it ridiculous that the practitioner of the future is trained wholly by the specialist. Surely he is right. Even if the content of this training were altogether appropriate, the respectful student could not help emerging from it with the impression that specialists are a superior order of beings. So they are, in some respects ; but mostly they are not, in others. If the "
staff included some competent general practitioners, broad in their outlook and wise in their experi-
teaching
of men, able to look the specialists in the face and their bubbles on occasion, the student’s perspective would be truer, and the short-sighted stampede of the young into specialism would cease. To this end Platt offers the same suggestion as we did 2-namely, that one or more health centres should be established as an integral part of every teaching school. The members of their staffs should be chosen for their ability to conduct general practice well, and for their capacity to teach the students who (singly for preference) would accompany them throughout their working day. We can think of no single innovation which could do more than this to raise the standard and realise the true function of general practice in the next generation.
found that it took four seconds to reach a wound in the foot, seven seconds to reach the skin, and a whole minute to reach the bone-marrow (none reached compact bone). On the other hand, the dye was removed much more quickly from the marrow than the soft tissues; in less than three minutes it disappeared from the marrow, whereas it was visible for ten minutes in the skin. Studying the minute anatomy of the long bones they found that the nutrient artery describes many curves before entering the bone, and, after dividing into ascending and descending branches which run through the marrow, it ends in wide blood-spaces close to the epiphyses ; these blood-spaces are in close contact with veins of wide calibre and very thin walls. This arrangement of blood-vessels reduces the pressure and speed of circulation in the arteries, and enables the, veins to carry substances quickly away from the blood-spaceshence the efficacy of therapeutic injections into the marrow. The slowness of the flow through the nutrient arteries is supported by the measurements of blood-flow in the normal humerus made by Edholm et awl.4 From their figures it is estimated that the amount of blood normally flowing through the whole skeleton probably does not exceed 100 c.cm. a minute, though it may be vastly more in Paget’s disease. Though all the long bones have a highly efficient venous drainage, the sternum is the bone of choice for transfusions and infusions because of its convenient situation, because it has excellent- short venous connexions, through the internal mammary and innominate veins, with the superior vena cava, and because the compact part of the bone is very thin and easily pierced with the needle, the site of election being the upper part of the manubrium. The firm anchorage that the sternum gives for the needle was found useful in North Africa, wounded were transported long distances with an intrasternal drip-transfusion running. It can also be made use of in the continuous administration of penicillin. Thus Giraud and Desmonts 5 injected 20,000 units of penicillin, in 250 c.cm. of serum, in two hours by this route, and two days later gave 40,000 units in 250 c.cm. of serum in five hours without encountering any difficulties.
plethysmograph
where
ence
prick
BLOOD-FLOW IN
BONE
THE failure of their many attempts at obtaining arteriograms of bone vessels in living subjects led Lamas and his colleagues3 to investigate the intra-osseous circulation. They argued that a relatively slow bloodstream would be expected because none of the three physiological functions of the long bones-mechanical support of the body, storage of calcium salts, and hsemopoiesis—need a rapid circulation; hsemopoiesis and calcium storage are in fact facilitated by a slow bloodstream. Nor does movement of a bone, unlike that of muscle, require an extra supply of blood. When a dye was injected into the external iliac arteries of dogs they 1. Publ. Hlth, Lond. January, 1947, p. 99. 2. Lancet, Feb. 8, p. 228. 3. Lamas, A., Amado, D., Da Costa, J. C. 5, 241.
ADSORPTION OF ENDOGENOUS TOXINS FEw now believe that the various toxic chemicals, such as indole, skatole, tyramine, guanidine, putrescine, &c., formed by the decomposition of protein in the large bowel cause systemic disease or even the symptoms associated with constipation, though it has lately been suggested that their action may be partly responsible for the degenerative changes of old age. Most prefer to think that the barrier offered by the bowel wall and the detoxicating action of the liver together form an efficient protection’ against intoxication.6 Nevertheless, since the substances are responsible for the unpleasant odour of faeces, their removal would be a great blessing to patients who are incontinent or have an artificial anus. Kaolin and activated charcoal have been much used for the purpose, but neither has provided the
complete
Edholm, O. G., Howarth, S., McMichael, J. Clin. Sci. 1945, 5, 249 ; see Lancet, 1946, ii, 568. Giraud, G., Desmonts, T. Pr. méd. 1946, 54, 51. 6. Best. C. H., Taylor, N. B. Physiological Basis of Medica Practice, London, 1943, p. 851. 7. Martin, G. J., Wilkinson, J. Arch. Biochem. 1947, 12, 95. 4.
5.
Amatus lusitanus, 1946,
answer.
The ideal adsorbent should be completely effective in removing odour but should not interfere with intestinal synthesis of vitamins or with the absorption of foodstuffs and drugs. Martin and Wilkinsontried to find a suitable adsorbent which will adsorb the toxic chemicals in the pH range of the gut. They found thatAmberlite IR-4,’ a synthetic resin, was very effective against indole and skatole, while all the amines tested (putrescine, cadaverine, tyramine, histamine, and guanidine)