- Email: [email protected]
ON LEARNING THE MEDICAL CRAFT
432
pharmacological
action
can
depend on the
route
of administra-
tion, another may. Dr. Floersheim may be right in his belief that thalidomide has no specific immunosuppressive action (though we have evidence to the contrary to be published shortly), but the validity of his belief cannot be assessed from his experiments. Imperial Cancer Research Fund, Cancer Chemotherapy Unit, Lincoln’s Inn Fields, K. HELLMANN. London, W.C.2.
LONDON’S SKID ROW
SIR,-At the present time, when trends in social-service
rethinking are towards directing welfare to those most genuinely in need, the publication of the inquiry into London’s " Skid Row " by Dr. Edwards and his colleagues of the Alcohol Impact Project of the Institute of Psychiatry (Jan. 29) is most opportune. That there is a group of people who fall through the meshes of current welfare provision is graphically described. yet do not know, however, is the extent of the and for this a quantitative as well as a diagnostic survey is required. The number of such people visiting the casualty departments of hospitals seeking food and shelter in the course of a week must be considerable. Most of these persons, being socially rather than medically sick, are not eligible for admission to general hospitals, and often present themselves at hours when other institutions are unable to accept them. Hostel accommodation is at present inadequate and insufficiently specialised. An attempt to cater for this difficult group in our society has been made for some two years by the Simon Community. This voluntary trust under the directorship of a former probation officer fulfils many of the functions envisaged in the section on Treatment in the special article by Dr. Edwards and his colleagues. It stays close to reality in accepting the need for protracted long-term care, lifelong if need be, and in realising that relapses will be frequent. Members of the Community live, eat, and sleep in the same premises with those they seek to help, and their experience suggests that a man should not be expelled if he begins to drink again but rather that efforts to help him should be redoubled. Observation of the Community in action suggests that it would be difficult to obtain any large body of personnel with the devotion this system requires. Nevertheless it appears that much can be learned from the Community’s experiment, and indeed that it deserves wider recognition and support. With the cooperation of the London borough of Camden further accommodation is to be established, but the Community faces considerable financial difficulty. Further information may be had from Mr. A. Wallich-Clifford, Simon Community Trust, 129,
What
reduce the service we are able to offer to the local community. A reduction in the number of staffed beds seems inevitable, and this can only lead to an increase in the length of time our patients will need to wait before admission to hospital. This state of affairs appears to be more than just a local problem. We are aware that we are competing for scarce national resources, and that staff salaries form a large proportion of Health Service costs. It seems, however, that a stop-go policy applied to the Health Service is leading to a very serious situation in which it is becoming extremely difficult to maintain, let alone improve, the standards of care in our district hospitals. The introduction of modern techniques in nursing care, such as the use of automatic patient monitoring, will enable the nursing staff to care for a greater number of patients more effectively, without losing that personal devotion to the patient which is so much a feature of the nurse in our hospitals. But, until a time is reached when this expensive capital equipment is generally available, we cannot afford arbitrarily to reduce our staff. St. Stephen’s Hospital, M. G. RINSLER. London, S.W.10. "
"
we
problem,
)VtalriPn R "",iI
T nntinn N W S
ANTHONY G. WHITE.
SHORTAGE OF NURSES
SIR,-For many years there has been a shortage of nurses in the hospital service, which has frequently prevented the full utilisation of available beds, and has made impossible the achievement of optimal nursing standards in many hospitals. A recent national recruitment campaign for nursing staff now appears to be successfully attracting larger numbers to the hospital service. At this busy district hospital we have in the past six months reached an approved establishment for nurses, although even this does not permit additional staffing for our new X-ray and cytology departments, and for a surgical-recovery ward which is serving a growing need for an intensive-care unit. For reasons that are not clear we are now faced with a 6°n cut in the number of nurses that the hospital is able to employ. While the present number of nurses has just enabled us to meet our existing commitments, the proposed cut must inevitably
MEDICAL SCHOOLS: MORE OR BIGGER? SIR, Your three leading articles 1clearly state the urgent need for rethinking and reorganising medical education in London. An important first step could be taken now by making use of the facilities already available at this hospital. The Whittington Hospital has a magnificent site within five miles of the centre of London affording ample space for future development; it is one of the largest general hospitals in England, having close to 1200 beds; it has a newly built academic centre with lecture theatres, common-rooms, and a medical library; and it has a well-established extensive programme of postgraduate teaching for specialists in training,
graduates, and general practitioners. type of authority, of the kind you have suggested, representing both the University of London and the Ministry
overseas
A
new
of Health should be
set
up
to
administer
a
coordinated teach-
ing group comprising the Whittington Hospital and an undergraduate teaching hospital. " One [hospital] fulfilling the traditional teaching-hospital role of the regional reference centre for the difficult and the specialised, and the other a district general hospital dealing with the down-to-earth needs of its own neighbourhood. Between these, students might see two different aspects of medicine, equally necessary, equally valid; ..."1 At the same time, the opportunity could be taken to eliminate ...
the undesirable divisions which exist at present between undergraduate and postgraduate teaching, and between research (university) and clinical practice (Health Service). This " well-balanced medical community " could provide a continuing medical education from the basic sciences through to vocational teaching and training for established doctors. Experiment and the trial of new methods are just as essential in medical administration and education as in clinical research. The opportunity to create something new in medicine-a pattern for the future-exists here and now. PETER DAVIES. Whittington Hospital, N.19.
ON LEARNING THE MEDICAL CRAFT SIR,-Professor Hubble’s remarks on medical education (Jan. 1) remind me that my specialty, pathology, can review its role in that process. The present emphasis on microscopic anatomy is time-wasting for teacher and student, and would be better shifted to gross anatomy, at operating and necropsy tables. A revered mentor, Jakob Erdheim, wisely placed great weight on gross anatomical diagnosis, because the physician or surgeon views the bodv and its organs with the naked eye1. Lancet, 1965, 2. ibid. Jan. 22,
ii, 1331. 1966, p. 189; ibid. Jan 29, 1966, p. 243.
433 not
through
the
lens-system
of
a
microscope. Microscopy
takes its proper place in specialty training. Los Angeles, California 90028, S. M. RABSON. United States of America.
FLUORIDATION AND THE COUNCILLORS SIR,-In view of the recent revival of interest in the possible benefits of adding traces of fluoride to our drinking-water, I have taken the trouble to read some of the many published reports about this subject. Hitherto I have thought it a safe and common-sense proposal to add this substance to watersupplies which were deficient in it. I now find that there is a considerable body of authoritative opinion, based upon reliable data, that the procedure is by no means uniformly safe, and that there are serious objections to it. Much of the evidence has appeared in American journals since the publication of the somewhat inconclusive report of the United Kingdom Missionwhich studied an American trial. It seems to me that a new assessment of the evidence is required before local authorities can be expected to comply with the recommendation of the Ministry of Health that they should make up their own minds about the desirability of adding this biologically active element to water-supplies.
’"1-hippuran
right renal autotransplant (arterial internal iliac artery).
renogram from
anastomosis
to
the accumulation of 131I-hippuran in the adjacent bladder; this is demonstrated by the pronounced reduction in countingrate after the bladder is emptied. An intravenous pyelogram 7 months after operation showed normal appearances in both kidneys with no evidence of hydronephrosis. The patient has been followed up for over 2’/z years, and her blood-pressure remains normal; the most recent reading (Dec. 20, 1965) is 120/75. She was married in August, 1965, and now presents us with a further problem-can she embark on a oresnancv ? M. F. A. WOODRUFF Departments of Surgical Science A. DOIG and Medicine, University of Edinburgh K. W. DONALD and Royal Infirmary, B. NOLAN. Edinburgh. to
Institute of Diseases of the Chest,
Brompton Hospital, London, S.W.3.
F. J. PRIME.
RENAL AUTOTRANSPLANTATION
SIR,-The recent correspondence on autotransplantation of the kidney prompts us to report now our use of this procedure in a patient with severe hypertension, instead of waiting as we had intended until a full 3 years had elapsed since the operation. The patient, a 29-year-old staff-nurse, complained of headaches and palpitation for a year; she was found to have bloodpressure readings varying between 220/120 and 240/160 mm. Hg. The intravenous pyelogram and 131I-’Hippuran’ (sodium o-iodohippurate) renogram revealed features of an ischxmic right kidney, and this was later confirmed by a divided renalThe renal plasma-flow p-aminohippurate function test. clearance) was 123 ml. per minute in the right kidney and 393 ml. per minute in the left kidney, and the urinary sodiumexcretion (expressed as a percentage of the filtered sodium load) was 5-5% and 15-5% respectively. Aortography showed evidence of bilateral fibromuscular hyperplasia of the renal arteries. This was much more striking on the right side, where there were multiple areas of severe stenosis involving the renal artery to the point of division into its primary branches. In view of the bilateral renal-artery disease and the good function of the right kidney it seemed desirable to perform a conservative operation to increase the blood-flow to the right kidney. From experience with renal homotransplantation, it seemed that this might best be achieved by dividing the right renal artery and vein, sliding the kidney down to the right iliac fossa,and anastomosing the renal artery end-to-end to the divided internal iliac artery and the renal vein end-to-side to the external iliac vein. This operation was performed on May 27, 1963. The ureter was left intact, because it was felt that with normal ureteric peristalsis and a normal ureterovesical junction it would not matter if the ureter followed a somewhat tortuous course.
The patient made
uncomplicated postoperative recovery, blood-pressure gradually returned to normal over 3 weeks; during this interval serial 1311-hippuran renograms demonstrated a gradual increase in the function of the transplanted organ. The accompanying figure shows normal vascular and secretory phases in the renogram from the autotransplant. The apparent delay in the excretory phase is due an
and her
1 The Fluoridation of Domestic Water Supplies in North America as a Means of Controlling Dental Caries. Report of the United Kingdom Mission. H.M. Stationery Office, 1953. See Lancet, 1963, ii, 127
URINE AND BLOOD UREA IN RENAL FAILURE SIR,-Mr. Chisholm and his colleagues (Jan. 1) demonstrate nicely that the urine-urea: blood-urea (u.u.: B.u.) ratio fails to distinguish satisfactorily between extrarenal uraemia and urxmia caused by intrinsic renal disease. Such a conclusion would be expected from our knowledge of how urea is excreted, particularly when there is extrarenal oliguria. What is surprising is that so many of the workers cited by Mr. Chisholm and his colleagues should have been prepared to ignore this knowledge and to revive a ratio that has been discarded so many times in the past. Mr. Chisholm and his colleagues seem prepared, however, to abandon the use of the blood and urine urea as diagnostic and prognostic aids in renal failure in favour of the response to intravenous fluid replacement, or the central venous pressure. But what is required is a more reliable method of interpreting the blood and urine urea values in relation to one another, particularly when the rate of urine flow is not known precisely. Two possibilities have been suggested. The first,’ based upon experimental work carried out as long ago as 1920,2 is now used in many centres. With a blood-urea of 100 mg. per 100 ml. or over, a urine-urea concentration of below 2-0 g. per 100 ml. indicates intrinsic renal damage, so that fluid therapy should proceed cautiously. Conversely, if the urineurea is above 2-0 g. per 100 ml., fluids may be given fairly freely in the reasonable expectation of promoting a diuresis. The second possibility3 applies only to predicting renal failure after a traumatic event, and establishes 1-1g. of urea per 100 ml. in the first 24-hour urine sample as the level below which renal failure is likely to occur. Both methods rely upon establishing a level of urine-urea which differentiates between the damaged and undamaged kidney in the presence of a urea-load. The level of the blood-urea is immaterial, as long as it is above 100 mg. per 100 ml. for the first method. These two methods do not always give the same conclusions.4 After the lst 24 hours only the first can be applied. Applying it to the data of Mr. Chisholm and his colleagues, it would, correctly, indicate intrinsic renal damage in all their 15 patients with acute renal failure, and normal renal function in 3 of their 6 patients with prerenal urasmia. This is a great deal better than the u.u.: B.u. ratio. The method (like the u.u.: B.u. ratio) does not distinguish chronic renal damage 1. 2. 3 4.
Taylor, W. H. Lancet 1957, ii, 703. Maclean, H., de Wesselow, O. L. V., Br. J. exp. Path. 1920, 1, 63. Molloy, P. J. Lancet, 1962, ii, 696. Taylor, W. H ibid. p. 935.
pharmacological
action
can
depend on the
route
of administra-
tion, another may. Dr. Floersheim may be right in his belief that thalidomide has no specific immunosuppressive action (though we have evidence to the contrary to be published shortly), but the validity of his belief cannot be assessed from his experiments. Imperial Cancer Research Fund, Cancer Chemotherapy Unit, Lincoln’s Inn Fields, K. HELLMANN. London, W.C.2.
LONDON’S SKID ROW
SIR,-At the present time, when trends in social-service
rethinking are towards directing welfare to those most genuinely in need, the publication of the inquiry into London’s " Skid Row " by Dr. Edwards and his colleagues of the Alcohol Impact Project of the Institute of Psychiatry (Jan. 29) is most opportune. That there is a group of people who fall through the meshes of current welfare provision is graphically described. yet do not know, however, is the extent of the and for this a quantitative as well as a diagnostic survey is required. The number of such people visiting the casualty departments of hospitals seeking food and shelter in the course of a week must be considerable. Most of these persons, being socially rather than medically sick, are not eligible for admission to general hospitals, and often present themselves at hours when other institutions are unable to accept them. Hostel accommodation is at present inadequate and insufficiently specialised. An attempt to cater for this difficult group in our society has been made for some two years by the Simon Community. This voluntary trust under the directorship of a former probation officer fulfils many of the functions envisaged in the section on Treatment in the special article by Dr. Edwards and his colleagues. It stays close to reality in accepting the need for protracted long-term care, lifelong if need be, and in realising that relapses will be frequent. Members of the Community live, eat, and sleep in the same premises with those they seek to help, and their experience suggests that a man should not be expelled if he begins to drink again but rather that efforts to help him should be redoubled. Observation of the Community in action suggests that it would be difficult to obtain any large body of personnel with the devotion this system requires. Nevertheless it appears that much can be learned from the Community’s experiment, and indeed that it deserves wider recognition and support. With the cooperation of the London borough of Camden further accommodation is to be established, but the Community faces considerable financial difficulty. Further information may be had from Mr. A. Wallich-Clifford, Simon Community Trust, 129,
What
reduce the service we are able to offer to the local community. A reduction in the number of staffed beds seems inevitable, and this can only lead to an increase in the length of time our patients will need to wait before admission to hospital. This state of affairs appears to be more than just a local problem. We are aware that we are competing for scarce national resources, and that staff salaries form a large proportion of Health Service costs. It seems, however, that a stop-go policy applied to the Health Service is leading to a very serious situation in which it is becoming extremely difficult to maintain, let alone improve, the standards of care in our district hospitals. The introduction of modern techniques in nursing care, such as the use of automatic patient monitoring, will enable the nursing staff to care for a greater number of patients more effectively, without losing that personal devotion to the patient which is so much a feature of the nurse in our hospitals. But, until a time is reached when this expensive capital equipment is generally available, we cannot afford arbitrarily to reduce our staff. St. Stephen’s Hospital, M. G. RINSLER. London, S.W.10. "
"
we
problem,
)VtalriPn R "",iI
T nntinn N W S
ANTHONY G. WHITE.
SHORTAGE OF NURSES
SIR,-For many years there has been a shortage of nurses in the hospital service, which has frequently prevented the full utilisation of available beds, and has made impossible the achievement of optimal nursing standards in many hospitals. A recent national recruitment campaign for nursing staff now appears to be successfully attracting larger numbers to the hospital service. At this busy district hospital we have in the past six months reached an approved establishment for nurses, although even this does not permit additional staffing for our new X-ray and cytology departments, and for a surgical-recovery ward which is serving a growing need for an intensive-care unit. For reasons that are not clear we are now faced with a 6°n cut in the number of nurses that the hospital is able to employ. While the present number of nurses has just enabled us to meet our existing commitments, the proposed cut must inevitably
MEDICAL SCHOOLS: MORE OR BIGGER? SIR, Your three leading articles 1clearly state the urgent need for rethinking and reorganising medical education in London. An important first step could be taken now by making use of the facilities already available at this hospital. The Whittington Hospital has a magnificent site within five miles of the centre of London affording ample space for future development; it is one of the largest general hospitals in England, having close to 1200 beds; it has a newly built academic centre with lecture theatres, common-rooms, and a medical library; and it has a well-established extensive programme of postgraduate teaching for specialists in training,
graduates, and general practitioners. type of authority, of the kind you have suggested, representing both the University of London and the Ministry
overseas
A
new
of Health should be
set
up
to
administer
a
coordinated teach-
ing group comprising the Whittington Hospital and an undergraduate teaching hospital. " One [hospital] fulfilling the traditional teaching-hospital role of the regional reference centre for the difficult and the specialised, and the other a district general hospital dealing with the down-to-earth needs of its own neighbourhood. Between these, students might see two different aspects of medicine, equally necessary, equally valid; ..."1 At the same time, the opportunity could be taken to eliminate ...
the undesirable divisions which exist at present between undergraduate and postgraduate teaching, and between research (university) and clinical practice (Health Service). This " well-balanced medical community " could provide a continuing medical education from the basic sciences through to vocational teaching and training for established doctors. Experiment and the trial of new methods are just as essential in medical administration and education as in clinical research. The opportunity to create something new in medicine-a pattern for the future-exists here and now. PETER DAVIES. Whittington Hospital, N.19.
ON LEARNING THE MEDICAL CRAFT SIR,-Professor Hubble’s remarks on medical education (Jan. 1) remind me that my specialty, pathology, can review its role in that process. The present emphasis on microscopic anatomy is time-wasting for teacher and student, and would be better shifted to gross anatomy, at operating and necropsy tables. A revered mentor, Jakob Erdheim, wisely placed great weight on gross anatomical diagnosis, because the physician or surgeon views the bodv and its organs with the naked eye1. Lancet, 1965, 2. ibid. Jan. 22,
ii, 1331. 1966, p. 189; ibid. Jan 29, 1966, p. 243.
433 not
through
the
lens-system
of
a
microscope. Microscopy
takes its proper place in specialty training. Los Angeles, California 90028, S. M. RABSON. United States of America.
FLUORIDATION AND THE COUNCILLORS SIR,-In view of the recent revival of interest in the possible benefits of adding traces of fluoride to our drinking-water, I have taken the trouble to read some of the many published reports about this subject. Hitherto I have thought it a safe and common-sense proposal to add this substance to watersupplies which were deficient in it. I now find that there is a considerable body of authoritative opinion, based upon reliable data, that the procedure is by no means uniformly safe, and that there are serious objections to it. Much of the evidence has appeared in American journals since the publication of the somewhat inconclusive report of the United Kingdom Missionwhich studied an American trial. It seems to me that a new assessment of the evidence is required before local authorities can be expected to comply with the recommendation of the Ministry of Health that they should make up their own minds about the desirability of adding this biologically active element to water-supplies.
’"1-hippuran
right renal autotransplant (arterial internal iliac artery).
renogram from
anastomosis
to
the accumulation of 131I-hippuran in the adjacent bladder; this is demonstrated by the pronounced reduction in countingrate after the bladder is emptied. An intravenous pyelogram 7 months after operation showed normal appearances in both kidneys with no evidence of hydronephrosis. The patient has been followed up for over 2’/z years, and her blood-pressure remains normal; the most recent reading (Dec. 20, 1965) is 120/75. She was married in August, 1965, and now presents us with a further problem-can she embark on a oresnancv ? M. F. A. WOODRUFF Departments of Surgical Science A. DOIG and Medicine, University of Edinburgh K. W. DONALD and Royal Infirmary, B. NOLAN. Edinburgh. to
Institute of Diseases of the Chest,
Brompton Hospital, London, S.W.3.
F. J. PRIME.
RENAL AUTOTRANSPLANTATION
SIR,-The recent correspondence on autotransplantation of the kidney prompts us to report now our use of this procedure in a patient with severe hypertension, instead of waiting as we had intended until a full 3 years had elapsed since the operation. The patient, a 29-year-old staff-nurse, complained of headaches and palpitation for a year; she was found to have bloodpressure readings varying between 220/120 and 240/160 mm. Hg. The intravenous pyelogram and 131I-’Hippuran’ (sodium o-iodohippurate) renogram revealed features of an ischxmic right kidney, and this was later confirmed by a divided renalThe renal plasma-flow p-aminohippurate function test. clearance) was 123 ml. per minute in the right kidney and 393 ml. per minute in the left kidney, and the urinary sodiumexcretion (expressed as a percentage of the filtered sodium load) was 5-5% and 15-5% respectively. Aortography showed evidence of bilateral fibromuscular hyperplasia of the renal arteries. This was much more striking on the right side, where there were multiple areas of severe stenosis involving the renal artery to the point of division into its primary branches. In view of the bilateral renal-artery disease and the good function of the right kidney it seemed desirable to perform a conservative operation to increase the blood-flow to the right kidney. From experience with renal homotransplantation, it seemed that this might best be achieved by dividing the right renal artery and vein, sliding the kidney down to the right iliac fossa,and anastomosing the renal artery end-to-end to the divided internal iliac artery and the renal vein end-to-side to the external iliac vein. This operation was performed on May 27, 1963. The ureter was left intact, because it was felt that with normal ureteric peristalsis and a normal ureterovesical junction it would not matter if the ureter followed a somewhat tortuous course.
The patient made
uncomplicated postoperative recovery, blood-pressure gradually returned to normal over 3 weeks; during this interval serial 1311-hippuran renograms demonstrated a gradual increase in the function of the transplanted organ. The accompanying figure shows normal vascular and secretory phases in the renogram from the autotransplant. The apparent delay in the excretory phase is due an
and her
1 The Fluoridation of Domestic Water Supplies in North America as a Means of Controlling Dental Caries. Report of the United Kingdom Mission. H.M. Stationery Office, 1953. See Lancet, 1963, ii, 127
URINE AND BLOOD UREA IN RENAL FAILURE SIR,-Mr. Chisholm and his colleagues (Jan. 1) demonstrate nicely that the urine-urea: blood-urea (u.u.: B.u.) ratio fails to distinguish satisfactorily between extrarenal uraemia and urxmia caused by intrinsic renal disease. Such a conclusion would be expected from our knowledge of how urea is excreted, particularly when there is extrarenal oliguria. What is surprising is that so many of the workers cited by Mr. Chisholm and his colleagues should have been prepared to ignore this knowledge and to revive a ratio that has been discarded so many times in the past. Mr. Chisholm and his colleagues seem prepared, however, to abandon the use of the blood and urine urea as diagnostic and prognostic aids in renal failure in favour of the response to intravenous fluid replacement, or the central venous pressure. But what is required is a more reliable method of interpreting the blood and urine urea values in relation to one another, particularly when the rate of urine flow is not known precisely. Two possibilities have been suggested. The first,’ based upon experimental work carried out as long ago as 1920,2 is now used in many centres. With a blood-urea of 100 mg. per 100 ml. or over, a urine-urea concentration of below 2-0 g. per 100 ml. indicates intrinsic renal damage, so that fluid therapy should proceed cautiously. Conversely, if the urineurea is above 2-0 g. per 100 ml., fluids may be given fairly freely in the reasonable expectation of promoting a diuresis. The second possibility3 applies only to predicting renal failure after a traumatic event, and establishes 1-1g. of urea per 100 ml. in the first 24-hour urine sample as the level below which renal failure is likely to occur. Both methods rely upon establishing a level of urine-urea which differentiates between the damaged and undamaged kidney in the presence of a urea-load. The level of the blood-urea is immaterial, as long as it is above 100 mg. per 100 ml. for the first method. These two methods do not always give the same conclusions.4 After the lst 24 hours only the first can be applied. Applying it to the data of Mr. Chisholm and his colleagues, it would, correctly, indicate intrinsic renal damage in all their 15 patients with acute renal failure, and normal renal function in 3 of their 6 patients with prerenal urasmia. This is a great deal better than the u.u.: B.u. ratio. The method (like the u.u.: B.u. ratio) does not distinguish chronic renal damage 1. 2. 3 4.
Taylor, W. H. Lancet 1957, ii, 703. Maclean, H., de Wesselow, O. L. V., Br. J. exp. Path. 1920, 1, 63. Molloy, P. J. Lancet, 1962, ii, 696. Taylor, W. H ibid. p. 935.