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MURDER AT THE CROSS-ROADS
1204 MURDER AT THE CROSS-ROADS
SIR,-How fascinating it is to read of the two types of general practitioner-the utility practitioner described by Dr. Geiringer (May 16) as the end-product of the N.H.S. and the " non-utility practitioner described by Dr. Clyne (May 30) as the doctor who has been able to acquire the special skill " to understand and use human relationships on the medical level " !i The recognition of these two types of.practitioner was, in fact, made earlier than May this year by that profound observer, Plato, about 350 B.C. (Laws, 720): "
"
"
"
Did you ever observe that there are two classes of patients in states, slaves and freemen; and the slave-doctors run about and cure the slaves, or wait for them in the dispensaries-practitioners of this sort never talk to their patients individually, or let them talk about their own individual complaints ? The slave-doctor prescribes what mere experience suggests, as if he had exact knowledge; and when he has given his orders, like a despot, he rushes off with equal assurance to some other servant who is ill; and so relieves the master of the house of the care of his invalid slaves. But the other doctor, who is a freeman, attends and practises upon freemen; and he carries his enquiries far back, and goes into the nature of the disorder; he talks with the patient and with his friends, and is at once getting information from the sick man, and also instructing him as far as he is able, and he will not prescribe for him until he has first convinced him; at last, when he has brought the patient more and more under his persuasive influences and set him on the road to health, he attempts to effect a cure."
The " utility practitioner " can only be displaced when, as Dr. Clyne points out, the specific skill of general practice is taught at undergraduate and postgraduate levels, and is studied as a proper scientific discipline. H. STEPHEN PASMORE. London, W.8.
SIR,-In studying Dr. Geiringer’s article the first thing that must strike any reader is " How long ago was it written ? ", for a good deal of what he says is now not true. For example, we have a very active and influential
College of General Practitioners which has done a great deal to raise the standard of general practice in the past few years. Dr. Geiringer then goes on to say that " One of the major flaws of the service is payment by capitation fee ", and suggests as a remedy some form of fee for service. In your leader you refer to one of two alternative methods: either Sir Frank Newsam’s case system or the late W. J. Braithwaite’s system of " items of illness ". No mention has been made of an alternative method first put forward by me in your columns in 1947,1 or a similar scheme which first appeared in the Medical World Newsletter of Nov. 10, 1950. The main "
proposals briefly were: expense factor, length-of-service factor, special-skills or higher-degrees factor, difficult-areas factor, and capitation fee. Thus, the capitation fee would no longer be the main source of remuneration. Surely either of these is worthy of serious consideration. I put forward later proposals last year.2 To my mind either of these has none of the objections that pertain to the fee-for-service system. My suggestions would go a long way towards meeting many of Dr. Geiringer’s objections, since income would no longer depend on heads only "; and the G.P. of the future would acquire that priceless asset, time to do his work properly. Dr. Geiringer asks " is general practice really necessary ? Surely the answer is an unqualified " yes ". Family doctors will always be necessary, for the patient must have a doctor who "
"
’
will see him as a whole and over a number of years, and as a human being rather than a scientific entity. Towards the end of a long life I have seen far too much of what happens when cases fall into the hands of men with " one-track minds ". If the G.P. has the time and the will to do all the work for which he was trained himself without constant referals to hospital, if he has the time to write suitable notes on cases so sent, 1. Lancet, 1947, i, 380. 2. ibid. 1958, i, 1125.
and also the time to meet his consultant colleagues over his cases, Dr. Geiringer may never fear that the G.P. will ever play second fiddle to the hospital staff, because I can assure him that the G.r.’s relationship with his consultant colleagues will be of the friendliest.
HAROLD LEESON.
Worthing.
A DELAYED AMBULANCE
SiR,—This case (May 30, p. 1145) interests me because (soon as possible) was written by the woman clerk at the ambulance depot to denote an urgent call. This was SAP
done for a short while in confusion. SAP can mean
practice but soon led to anything from " as soon as to conveniently possible " something really urgent. Now, our
secretaries have strict instructions that a call for a doctor is either " urgent " or has no qualification. Since this rule was instituted, we have had no confusion about the urgency of a call. Perhaps the ambulance service in question might consider this amendment to their our
nresent custom.
R. A. MURRAY SCOTT.
Leeds.
TREATMENT OF ORGANOPHOSPHORUS
SIR,-There is
now
POISONING convincing clinical evidence for the
pyridine-2-aldoxime methiodide (P.A.M.) in the of poisoning by the organophosphorus insecticide, parathion, and experimental evidence of the value of P.A.M. and other oximes in poisoning of animals by other anticholinesterase insecticides, especially in combination with atropine therapy. value of
treatment
Both the methiodide (P.A.M.) and the more soluble methane sulphonate (P2S) are available in this country as laboratory chemicals, but inquiries in late 1958 showed that no ready-touse pharmaceutical preparation existed in North America or this country. Supplies of P.A.M. have therefore been obtained from Japan in ampoules ready for immediate use. This preparation has been extensively and successfully used in that country, for the treatment of parathion poisoning. Supplies of P.A.M. have been located at the following establishments of this Company, all of which are situated in areas of considerable insecticide usage: Harston, Cambridge Staplehurst, Kent (Harston 312, day and night) (Headcorn 213) Feering, Essex Fakenham, Norfolk (Kelvedon 257) (Fakenham 2313) Metheringham, Lincs. Lichfield, Staffs. (Lichfield 3228) (Metheringham 206) These supplies are available on request to any practitioner encountering organophosphorus poisoning. The Medical Division, C.D.E.E. (Ministry of Supply), Porton, Wilts (Idmiston 211), also operates an emergency service for the treatment of any cases of organophosphorus insecticide poisoning.2 The recommended specific therapy of such cases is a combination of atropine, P.A.M. (or P2S), and supportive measures. Initially, atropine sulphate should be given (intravenously or intramuscularly) in doses of 2 mg. (gr. to be repeated every 30-60 minutes until the patient is obviously fully atropinised or is improving. P.A.M. should be administered intravenously as soon as possible, in doses of 1 g. (i.e., two 20 ml. ampoules each containing 0-5 g.). This dose of P.A.M. may be doubled in very severe cases, or repeated after 30 minutes if no real improvement has occurred. A rather dramatic improvement is likely in all severe and responsive cases after the first injection. A " maintenance dose " of P.A.M. may be given intramuscularly or subcutaneously where signs of poisoning tend to
persist.
Supportive measures may need to include intravenous or intramuscular barbiturates for intense excitement or restlessness, postural drainage for bronchial hypersecretion, and 1. 2.
Davies, D. R., Green, A. L. Brit. J. industr. Med. 1959, 16, 128. Lancet, May 9, 1959, p. 981.
SIR,-How fascinating it is to read of the two types of general practitioner-the utility practitioner described by Dr. Geiringer (May 16) as the end-product of the N.H.S. and the " non-utility practitioner described by Dr. Clyne (May 30) as the doctor who has been able to acquire the special skill " to understand and use human relationships on the medical level " !i The recognition of these two types of.practitioner was, in fact, made earlier than May this year by that profound observer, Plato, about 350 B.C. (Laws, 720): "
"
"
"
Did you ever observe that there are two classes of patients in states, slaves and freemen; and the slave-doctors run about and cure the slaves, or wait for them in the dispensaries-practitioners of this sort never talk to their patients individually, or let them talk about their own individual complaints ? The slave-doctor prescribes what mere experience suggests, as if he had exact knowledge; and when he has given his orders, like a despot, he rushes off with equal assurance to some other servant who is ill; and so relieves the master of the house of the care of his invalid slaves. But the other doctor, who is a freeman, attends and practises upon freemen; and he carries his enquiries far back, and goes into the nature of the disorder; he talks with the patient and with his friends, and is at once getting information from the sick man, and also instructing him as far as he is able, and he will not prescribe for him until he has first convinced him; at last, when he has brought the patient more and more under his persuasive influences and set him on the road to health, he attempts to effect a cure."
The " utility practitioner " can only be displaced when, as Dr. Clyne points out, the specific skill of general practice is taught at undergraduate and postgraduate levels, and is studied as a proper scientific discipline. H. STEPHEN PASMORE. London, W.8.
SIR,-In studying Dr. Geiringer’s article the first thing that must strike any reader is " How long ago was it written ? ", for a good deal of what he says is now not true. For example, we have a very active and influential
College of General Practitioners which has done a great deal to raise the standard of general practice in the past few years. Dr. Geiringer then goes on to say that " One of the major flaws of the service is payment by capitation fee ", and suggests as a remedy some form of fee for service. In your leader you refer to one of two alternative methods: either Sir Frank Newsam’s case system or the late W. J. Braithwaite’s system of " items of illness ". No mention has been made of an alternative method first put forward by me in your columns in 1947,1 or a similar scheme which first appeared in the Medical World Newsletter of Nov. 10, 1950. The main "
proposals briefly were: expense factor, length-of-service factor, special-skills or higher-degrees factor, difficult-areas factor, and capitation fee. Thus, the capitation fee would no longer be the main source of remuneration. Surely either of these is worthy of serious consideration. I put forward later proposals last year.2 To my mind either of these has none of the objections that pertain to the fee-for-service system. My suggestions would go a long way towards meeting many of Dr. Geiringer’s objections, since income would no longer depend on heads only "; and the G.P. of the future would acquire that priceless asset, time to do his work properly. Dr. Geiringer asks " is general practice really necessary ? Surely the answer is an unqualified " yes ". Family doctors will always be necessary, for the patient must have a doctor who "
"
’
will see him as a whole and over a number of years, and as a human being rather than a scientific entity. Towards the end of a long life I have seen far too much of what happens when cases fall into the hands of men with " one-track minds ". If the G.P. has the time and the will to do all the work for which he was trained himself without constant referals to hospital, if he has the time to write suitable notes on cases so sent, 1. Lancet, 1947, i, 380. 2. ibid. 1958, i, 1125.
and also the time to meet his consultant colleagues over his cases, Dr. Geiringer may never fear that the G.P. will ever play second fiddle to the hospital staff, because I can assure him that the G.r.’s relationship with his consultant colleagues will be of the friendliest.
HAROLD LEESON.
Worthing.
A DELAYED AMBULANCE
SiR,—This case (May 30, p. 1145) interests me because (soon as possible) was written by the woman clerk at the ambulance depot to denote an urgent call. This was SAP
done for a short while in confusion. SAP can mean
practice but soon led to anything from " as soon as to conveniently possible " something really urgent. Now, our
secretaries have strict instructions that a call for a doctor is either " urgent " or has no qualification. Since this rule was instituted, we have had no confusion about the urgency of a call. Perhaps the ambulance service in question might consider this amendment to their our
nresent custom.
R. A. MURRAY SCOTT.
Leeds.
TREATMENT OF ORGANOPHOSPHORUS
SIR,-There is
now
POISONING convincing clinical evidence for the
pyridine-2-aldoxime methiodide (P.A.M.) in the of poisoning by the organophosphorus insecticide, parathion, and experimental evidence of the value of P.A.M. and other oximes in poisoning of animals by other anticholinesterase insecticides, especially in combination with atropine therapy. value of
treatment
Both the methiodide (P.A.M.) and the more soluble methane sulphonate (P2S) are available in this country as laboratory chemicals, but inquiries in late 1958 showed that no ready-touse pharmaceutical preparation existed in North America or this country. Supplies of P.A.M. have therefore been obtained from Japan in ampoules ready for immediate use. This preparation has been extensively and successfully used in that country, for the treatment of parathion poisoning. Supplies of P.A.M. have been located at the following establishments of this Company, all of which are situated in areas of considerable insecticide usage: Harston, Cambridge Staplehurst, Kent (Harston 312, day and night) (Headcorn 213) Feering, Essex Fakenham, Norfolk (Kelvedon 257) (Fakenham 2313) Metheringham, Lincs. Lichfield, Staffs. (Lichfield 3228) (Metheringham 206) These supplies are available on request to any practitioner encountering organophosphorus poisoning. The Medical Division, C.D.E.E. (Ministry of Supply), Porton, Wilts (Idmiston 211), also operates an emergency service for the treatment of any cases of organophosphorus insecticide poisoning.2 The recommended specific therapy of such cases is a combination of atropine, P.A.M. (or P2S), and supportive measures. Initially, atropine sulphate should be given (intravenously or intramuscularly) in doses of 2 mg. (gr. to be repeated every 30-60 minutes until the patient is obviously fully atropinised or is improving. P.A.M. should be administered intravenously as soon as possible, in doses of 1 g. (i.e., two 20 ml. ampoules each containing 0-5 g.). This dose of P.A.M. may be doubled in very severe cases, or repeated after 30 minutes if no real improvement has occurred. A rather dramatic improvement is likely in all severe and responsive cases after the first injection. A " maintenance dose " of P.A.M. may be given intramuscularly or subcutaneously where signs of poisoning tend to
persist.
Supportive measures may need to include intravenous or intramuscular barbiturates for intense excitement or restlessness, postural drainage for bronchial hypersecretion, and 1. 2.
Davies, D. R., Green, A. L. Brit. J. industr. Med. 1959, 16, 128. Lancet, May 9, 1959, p. 981.