- Email: [email protected]
INSTITUTE OF GENERAL PRACTICE?
1054
formation reduces the specificity of the input, and then exchanges impulses with both the cerebral cortex and the spinal cord. The information going from the reticular formation to the cerebral cortex activates the cortex, and the amount of activating traffic is reduced during sleep. If there is a block in the direct path to the cerebral cortex, wakefulness results; but if the block lies between the reticular formation and the cerebral cortex there is excessive sleepiness.3Certain drugs probably affect sleep by their action on the reticular formation; amphetamine stimulates it and barbiturates depress it.3 Adrenaline also causes alertness; and in sleep both the plasma concentration and the urinary excretion of adrenaline are lowered. Since adrenaline is one of the products released as a result of increased sympathetic stimulation, it is easy to see how anxiety can cause wakefulness by an adrenaline-maintained activity of the reticular formation, and the anxious man cannot let his cerebral cortex rest. We are liable to forget that sensory impulses arise not only from our skin, ears, and eyes but also from within the organism. Yet we have all had an occasional bad night because of an overactive gastrointestinal tract after an injudicious meal or an infection. There are other equally important sensory paths of which we are less aware, such as those from the muscle spindles and the baroreceptors. The muscle paths supply information about skeletal muscle tension, and when the spindles are unstretched they transmit very few impulses and cause no disturbance. In the waking state there are always some impulses from the spindles; and, in anxiety, tension is far greater and it is liable to persist, so that the sensory input from the muscles diminishes the chances of
sleep.
Bonvallet, M., Dell, P., Hiebel, G. Electroenceph. clin. Neurol. 6, 119. 7. Nakao, H., Ballin, H. M., Gellhorn, E. ibid. 1956, 8, 413.
lie in the central nervous system, or in a change in the reactivity of the baroreceptors. Further, in the elderly there may be subtle changes in the oxygen supply to the central nervous system (it is reportedthat in the vertebral, basilar, and internal carotid arteries stenosis may begin as early as the fourth decade). If the blood-vessels to the central nervous system are narrowed, the blood-pressure may have to be continually adjusted to ensure an adequate circulation to the vital areas; these unconscious reflexes could disturb sleep, perhaps because of an increase in sympathetic activity. These ideas are highly speculative, though not improbable. We know far too little about the need for sleep and of the biochemical changes associated with sleep or its lack. One interesting practical point emerges from TILLER’S work.2 The elderly patients who benefited least from the increased bed rest were those who had come to depend on sedative drugs, although the drugs were withdrawn for a month before the observations began. This leads to the not surprising conclusion that it may be a mistake to become dependent on drugs, because they may induce some longlasting or radical change. If drugs ultimately prove necessary for the relief of insomnia, there is much to be said for fairly frequent changes from one drug to another of different chemical constitution.
Annotations INSTITUTE OF GENERAL PRACTICE?
WRITING
The baroreceptors are concentrates in two main areas -in the carotid sinuses and in the aortic arch; and a number of similar receptors are scattered in many different regions. The receptors are, in fact, tension receptors for the vascular system: for instance, when the pressure in the carotid artery rises, the number of nerve impulses passing to the central nervous system increases, and the result is a reflex series of events which tend to counteract the rise in blood-pressure. It has been found that distension of the carotid sinus within physiological limits leads to a progressive reduction in cerebral cortical activity, and the appearance of an E.E.G. pattern like that of sleep. The effect is independent of the reflexly induced hypotension. In reverse, a reduction in carotid-sinus pressure, as by acetylcholine, reduces the impulse traffic from the baroreceptors and gives rise to cerebral cortical excitation. Thus the baroreceptors seem to exert a homoeostatic effect on the cerebral cortex as well as on blood-pressure,7 and in both instances the effect looks like a process of inhibition. In Bali the medicine men induce longlasting sleep, accompanied by slowing of the pulse and respiration, by massaging the neck over the carotid sinus.3 Sleep induction by a rise in blood-pressure cannot be a simple uncomplicated reflex, and in what way a raised blood-pressure in the elderly does, or 6.
could, disturb sleep rhythm is not clear. The fault could
says
on
as a
hospital physician, Dr. Robert Kemp
p. 1025 that the time has
come to
get rid of
our
deepseated preference for treating illness in a hospital bed. Such beds ought to be kept for those who really need them, and instead of multiplying their number we should look to a future in which the welfare authority and the general practitioner take over much of what hospitals are now doing. To fulfil this policy would mean a major reallocation of resources, which has not even begun; and, as things stand today, the general practitioner could hardly be asked to undertake more work rather than less. But Dr. Kemp is right, and we should at least be preparing for a more rational future in which domiciliary medicine has more emphasis. Yet, despite interminable discussions, the bases of policy are still undecided. Opinions remain sharply divided between those who believe that practitioners must preserve their status as independent contractors and those who want general practice to be merged in the medical service as a whole 9; between those who see the practitioner as a hospital-oriented physician and those who see him as more and more concerned with the mental and social aspects of medicine; between those who think he will be most useful as a specialised member of a group and those who think his work essentially individual. At what is perhaps the psychological moment comes a proposal from Prof. J. N. Morris and Dr. John Fry that an Institute of General Practice should be created which could arrange some of the experiments needed if possible, 8.
1954, 9.
Dickinson, C. J. in Hypertension: Second Hahnemann Symposium on Hypertensive Disease (edited by A. N. Brest and J. H. Moyer); p. 103. London, 1962. Lancet, Sept. 19, 1964, p. 627.
1055
before decisions are reached. Though the College of General Practitioners has a fine record of epidemiological and clinical research, operational studies of the type and on the scale now required have not been undertaken. Planned experiment is required, for example, on the means whereby general practice may be best associated with local-authority and hospital services, and on the role of the practitioner (and his actual or potential auxiliaries) in
domiciliary care. For such purposes we need, if possible, experimental models in the community, whose working can be assessed by trained staff with the necessary time and facilities. Another side of general practice demanding investigation is the development of its preventive function by the use of screening techniques in a far larger way than at
discarded,
and
readopted
with success,
failure, and
occasional disaster. All have their limitations, difficulties, and complications; and all their successes. Among recent suggestions, Fegan’s continuous compression technique for injection1 is, we hear, winning further support. But every method demands careful attention to detail in execution and aftercare. Electrocoagulation is perhaps the least controllable and has not found popularity in this country. Politowski et al.,2in a recent report1 from Poland, seem to support electrocoagulation; but thirddegree skin burns in 8 of their 231 patients points to a serious objection. For the most part, careful ligation and stripping gives very satisfactory results with a low complication-rate. The operation demands inpatient management for at least twenty-four hours postoperatively; and major varicose tributaries of the saphenous system may require separate obliteration by sclerosant at the time of operation or later.
present. Professor Morris and Dr. Fry also see the proposed institute as giving a lead in the systematic vocational training of future practitioners. They believe that doctors going into this work should have full-time training for several months, aimed at giving them the essentials of WOMEN IN MEDICINE general and social medicine as these are seen outside the The institute (staffed at the centre by a medical hospital. THE shortage of doctors has directed attention to the director, two or three other doctors, a statistician, and a lost potential among medically qualified women. While sociologist) would have the part-time service of active they are single, women are accepted in the profession with practitioners; and their practices in different parts of the equanimity; but, for lack of part-time work, marriage and country would contribute both to the varied teaching and the rearing of a family often end their medical career. The to the operational research. At present it is far from clear number of unemployed medical wives in this country who what good general practice is: one cannot assume that the are anxious to return to work has been put as high as 5000. best of existing practices " necessarily represent the On the other hand, an offer by the Medical Women’s optimum, however soundly they are based on tradition, Federation to help married women graduates to find common sense, experience, and devotion ". Practices are appropriate jobs attracted only 40 or 50 replies. But, needed where an attempt would be made to reach, and to whatever the size of the problem, there is much to suggest formulate, the kind of standards that a professorial unit in that this country, though desperately short of doctors, is a teaching hospital tries to reach in its own subject. The yet not making full use of the women it has trained. This described at failure was considered by Sir Brian Windeyer, dean of the Guys Hospital very interesting developments in our last issue are another move in the same direction. Middlesex Hospital Medical School, in an address given In their memorandum 10 Professor Morris and Dr. Fry to the Federation on Nov. 4. In many of the London medical schools, he said, the point out that the evolving health and welfare services present new possibilities, but that the concept of com- proportion of women in the yearly student intake had munity care rests on many untested and unrecognised remained close to the compulsory minimum of 15%. assumptions-" those about the resources, organisation, Since there seemed to be fewer A-level failures among the and development of general practice being crucial ". The girls provisionally accepted, roughly 20% of the eventual necessary facts about general practice are often missing, entry might be female. By contrast, of the initial applicaand those that exist are not followed up sufficiently. This tions for admission, 1 in 3 came from a woman. At this is all too true; and the new institute could be the means of first hurdle of a medical career it could not be pretended solving problems which have become as urgent as any in that the sexes had equal opportunity, and lately it had been British medicine. Hence we hope that the idea will be questioned whether even the present inequitable proporfully but quickly explored, in the hope of giving it early tion of places should be assigned to women. The Ministry had recommended a 10% increase in the entry to meet the reality. VARICOSE VEINS national demand for medical manpower; and, by and THAT fashions change so often in the treatment of large, a man was more likely to continue in practice. A varicose veins is due more to faults in the application of small survey of women graduating from the Middlesex methods than in the methods themselves. There is always Hospital showed that roughly half were doing full-time clinical work, a third part-time work, and the remainder an accompanying defect in the deep vein system of the leg, and its persistence entails a certain amount of " recur- none at all. This return per place taken was, Sir Brian felt, If married women doctors were to stay in too low. rence no matter how thorough or apparently effective initial treatment may be. Whatever operative method is practice, he believed that something would have to be used, the first essential is to locate and ligate accurately done to encourage them. all demonstrably incompetent communications between Many women might wish to take up medicine again the deep and superficial leg veins. This done, the remainwhen their children went away to school, but at present ing varices, which the patient may see or feel, should be there was a lack of refresher courses. Admittedly, to eliminated or reduced as far as is practical and safe. Striparrange suitable courses would not be easy, but attachment ping, multiple interruption, multiple excision, sclerosing to the staff of local district hospitals seemed a promising injection, internal abrasion, and electrocoagulation are approach. The cost would be well worth meeting, for the among the many methods that have been tried, adopted, nation had contributed largely to the training of these "
10. They write from the Department of Social and Preventive Medicine, London Hospital Medical College, Turner Street, London, E.1.
1. 2.
Fegan, W. G. Lancet, 1963, ii, 109. Politowski, M., Szpak, E., Marszalek, Z. Surgery, 1964, 56,
355.
formation reduces the specificity of the input, and then exchanges impulses with both the cerebral cortex and the spinal cord. The information going from the reticular formation to the cerebral cortex activates the cortex, and the amount of activating traffic is reduced during sleep. If there is a block in the direct path to the cerebral cortex, wakefulness results; but if the block lies between the reticular formation and the cerebral cortex there is excessive sleepiness.3Certain drugs probably affect sleep by their action on the reticular formation; amphetamine stimulates it and barbiturates depress it.3 Adrenaline also causes alertness; and in sleep both the plasma concentration and the urinary excretion of adrenaline are lowered. Since adrenaline is one of the products released as a result of increased sympathetic stimulation, it is easy to see how anxiety can cause wakefulness by an adrenaline-maintained activity of the reticular formation, and the anxious man cannot let his cerebral cortex rest. We are liable to forget that sensory impulses arise not only from our skin, ears, and eyes but also from within the organism. Yet we have all had an occasional bad night because of an overactive gastrointestinal tract after an injudicious meal or an infection. There are other equally important sensory paths of which we are less aware, such as those from the muscle spindles and the baroreceptors. The muscle paths supply information about skeletal muscle tension, and when the spindles are unstretched they transmit very few impulses and cause no disturbance. In the waking state there are always some impulses from the spindles; and, in anxiety, tension is far greater and it is liable to persist, so that the sensory input from the muscles diminishes the chances of
sleep.
Bonvallet, M., Dell, P., Hiebel, G. Electroenceph. clin. Neurol. 6, 119. 7. Nakao, H., Ballin, H. M., Gellhorn, E. ibid. 1956, 8, 413.
lie in the central nervous system, or in a change in the reactivity of the baroreceptors. Further, in the elderly there may be subtle changes in the oxygen supply to the central nervous system (it is reportedthat in the vertebral, basilar, and internal carotid arteries stenosis may begin as early as the fourth decade). If the blood-vessels to the central nervous system are narrowed, the blood-pressure may have to be continually adjusted to ensure an adequate circulation to the vital areas; these unconscious reflexes could disturb sleep, perhaps because of an increase in sympathetic activity. These ideas are highly speculative, though not improbable. We know far too little about the need for sleep and of the biochemical changes associated with sleep or its lack. One interesting practical point emerges from TILLER’S work.2 The elderly patients who benefited least from the increased bed rest were those who had come to depend on sedative drugs, although the drugs were withdrawn for a month before the observations began. This leads to the not surprising conclusion that it may be a mistake to become dependent on drugs, because they may induce some longlasting or radical change. If drugs ultimately prove necessary for the relief of insomnia, there is much to be said for fairly frequent changes from one drug to another of different chemical constitution.
Annotations INSTITUTE OF GENERAL PRACTICE?
WRITING
The baroreceptors are concentrates in two main areas -in the carotid sinuses and in the aortic arch; and a number of similar receptors are scattered in many different regions. The receptors are, in fact, tension receptors for the vascular system: for instance, when the pressure in the carotid artery rises, the number of nerve impulses passing to the central nervous system increases, and the result is a reflex series of events which tend to counteract the rise in blood-pressure. It has been found that distension of the carotid sinus within physiological limits leads to a progressive reduction in cerebral cortical activity, and the appearance of an E.E.G. pattern like that of sleep. The effect is independent of the reflexly induced hypotension. In reverse, a reduction in carotid-sinus pressure, as by acetylcholine, reduces the impulse traffic from the baroreceptors and gives rise to cerebral cortical excitation. Thus the baroreceptors seem to exert a homoeostatic effect on the cerebral cortex as well as on blood-pressure,7 and in both instances the effect looks like a process of inhibition. In Bali the medicine men induce longlasting sleep, accompanied by slowing of the pulse and respiration, by massaging the neck over the carotid sinus.3 Sleep induction by a rise in blood-pressure cannot be a simple uncomplicated reflex, and in what way a raised blood-pressure in the elderly does, or 6.
could, disturb sleep rhythm is not clear. The fault could
says
on
as a
hospital physician, Dr. Robert Kemp
p. 1025 that the time has
come to
get rid of
our
deepseated preference for treating illness in a hospital bed. Such beds ought to be kept for those who really need them, and instead of multiplying their number we should look to a future in which the welfare authority and the general practitioner take over much of what hospitals are now doing. To fulfil this policy would mean a major reallocation of resources, which has not even begun; and, as things stand today, the general practitioner could hardly be asked to undertake more work rather than less. But Dr. Kemp is right, and we should at least be preparing for a more rational future in which domiciliary medicine has more emphasis. Yet, despite interminable discussions, the bases of policy are still undecided. Opinions remain sharply divided between those who believe that practitioners must preserve their status as independent contractors and those who want general practice to be merged in the medical service as a whole 9; between those who see the practitioner as a hospital-oriented physician and those who see him as more and more concerned with the mental and social aspects of medicine; between those who think he will be most useful as a specialised member of a group and those who think his work essentially individual. At what is perhaps the psychological moment comes a proposal from Prof. J. N. Morris and Dr. John Fry that an Institute of General Practice should be created which could arrange some of the experiments needed if possible, 8.
1954, 9.
Dickinson, C. J. in Hypertension: Second Hahnemann Symposium on Hypertensive Disease (edited by A. N. Brest and J. H. Moyer); p. 103. London, 1962. Lancet, Sept. 19, 1964, p. 627.
1055
before decisions are reached. Though the College of General Practitioners has a fine record of epidemiological and clinical research, operational studies of the type and on the scale now required have not been undertaken. Planned experiment is required, for example, on the means whereby general practice may be best associated with local-authority and hospital services, and on the role of the practitioner (and his actual or potential auxiliaries) in
domiciliary care. For such purposes we need, if possible, experimental models in the community, whose working can be assessed by trained staff with the necessary time and facilities. Another side of general practice demanding investigation is the development of its preventive function by the use of screening techniques in a far larger way than at
discarded,
and
readopted
with success,
failure, and
occasional disaster. All have their limitations, difficulties, and complications; and all their successes. Among recent suggestions, Fegan’s continuous compression technique for injection1 is, we hear, winning further support. But every method demands careful attention to detail in execution and aftercare. Electrocoagulation is perhaps the least controllable and has not found popularity in this country. Politowski et al.,2in a recent report1 from Poland, seem to support electrocoagulation; but thirddegree skin burns in 8 of their 231 patients points to a serious objection. For the most part, careful ligation and stripping gives very satisfactory results with a low complication-rate. The operation demands inpatient management for at least twenty-four hours postoperatively; and major varicose tributaries of the saphenous system may require separate obliteration by sclerosant at the time of operation or later.
present. Professor Morris and Dr. Fry also see the proposed institute as giving a lead in the systematic vocational training of future practitioners. They believe that doctors going into this work should have full-time training for several months, aimed at giving them the essentials of WOMEN IN MEDICINE general and social medicine as these are seen outside the The institute (staffed at the centre by a medical hospital. THE shortage of doctors has directed attention to the director, two or three other doctors, a statistician, and a lost potential among medically qualified women. While sociologist) would have the part-time service of active they are single, women are accepted in the profession with practitioners; and their practices in different parts of the equanimity; but, for lack of part-time work, marriage and country would contribute both to the varied teaching and the rearing of a family often end their medical career. The to the operational research. At present it is far from clear number of unemployed medical wives in this country who what good general practice is: one cannot assume that the are anxious to return to work has been put as high as 5000. best of existing practices " necessarily represent the On the other hand, an offer by the Medical Women’s optimum, however soundly they are based on tradition, Federation to help married women graduates to find common sense, experience, and devotion ". Practices are appropriate jobs attracted only 40 or 50 replies. But, needed where an attempt would be made to reach, and to whatever the size of the problem, there is much to suggest formulate, the kind of standards that a professorial unit in that this country, though desperately short of doctors, is a teaching hospital tries to reach in its own subject. The yet not making full use of the women it has trained. This described at failure was considered by Sir Brian Windeyer, dean of the Guys Hospital very interesting developments in our last issue are another move in the same direction. Middlesex Hospital Medical School, in an address given In their memorandum 10 Professor Morris and Dr. Fry to the Federation on Nov. 4. In many of the London medical schools, he said, the point out that the evolving health and welfare services present new possibilities, but that the concept of com- proportion of women in the yearly student intake had munity care rests on many untested and unrecognised remained close to the compulsory minimum of 15%. assumptions-" those about the resources, organisation, Since there seemed to be fewer A-level failures among the and development of general practice being crucial ". The girls provisionally accepted, roughly 20% of the eventual necessary facts about general practice are often missing, entry might be female. By contrast, of the initial applicaand those that exist are not followed up sufficiently. This tions for admission, 1 in 3 came from a woman. At this is all too true; and the new institute could be the means of first hurdle of a medical career it could not be pretended solving problems which have become as urgent as any in that the sexes had equal opportunity, and lately it had been British medicine. Hence we hope that the idea will be questioned whether even the present inequitable proporfully but quickly explored, in the hope of giving it early tion of places should be assigned to women. The Ministry had recommended a 10% increase in the entry to meet the reality. VARICOSE VEINS national demand for medical manpower; and, by and THAT fashions change so often in the treatment of large, a man was more likely to continue in practice. A varicose veins is due more to faults in the application of small survey of women graduating from the Middlesex methods than in the methods themselves. There is always Hospital showed that roughly half were doing full-time clinical work, a third part-time work, and the remainder an accompanying defect in the deep vein system of the leg, and its persistence entails a certain amount of " recur- none at all. This return per place taken was, Sir Brian felt, If married women doctors were to stay in too low. rence no matter how thorough or apparently effective initial treatment may be. Whatever operative method is practice, he believed that something would have to be used, the first essential is to locate and ligate accurately done to encourage them. all demonstrably incompetent communications between Many women might wish to take up medicine again the deep and superficial leg veins. This done, the remainwhen their children went away to school, but at present ing varices, which the patient may see or feel, should be there was a lack of refresher courses. Admittedly, to eliminated or reduced as far as is practical and safe. Striparrange suitable courses would not be easy, but attachment ping, multiple interruption, multiple excision, sclerosing to the staff of local district hospitals seemed a promising injection, internal abrasion, and electrocoagulation are approach. The cost would be well worth meeting, for the among the many methods that have been tried, adopted, nation had contributed largely to the training of these "
10. They write from the Department of Social and Preventive Medicine, London Hospital Medical College, Turner Street, London, E.1.
1. 2.
Fegan, W. G. Lancet, 1963, ii, 109. Politowski, M., Szpak, E., Marszalek, Z. Surgery, 1964, 56,
355.