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PERFORATION OF INTESTINE BY FISH-BONE
536 This B.P.C. grade of sodium original papers. &bgr;-glycerophosphate does contain a little of the oc form, but Velazquez states that this too is effective. The possibility that the substance decomposes on autoclaving has also been investigated, but it appears to be stable. the
The unavoidable conclusion is, therefore, that sodium is of no use inthe treatment of abortion and has no effect on the contracting full-term uterus. D. C. A. BEVIS St. Mary’s Hospitals for women
&bgr;-glycerophosphate
Senior Registrar.
and Children, Manchester.
PERFORATION a
OF
INTESTINE
BY
FISH-BONE
SIR,—Mr. Travers’s article last week calls to my mind similar case operated on by me.
consulting me in December, 1944, the elderly man, had persistent pain in the abdomen followed by a swelling immediately to the right of the umbilicus. This swelling had diminished and then reappeared. He had a very deep umbilicus, and I concluded that the swelling was due to cellulitis with suppuration in an hour-glass umbilicus. Appropriate treatment was ordered and I did not see him again until June, 1945, when there was an obvious abscess in the same situation. Immediately before incising this, I ventured a guess that a foreign body might be present. A small amount of pus was evacuated, and, on exploring the cavity with a finger, the foreign body, which was a flat and springy fish-bone 1/8 in. wide and 1 in. long, was removed. The wound healed normally. For six weeks before
patient,
a
stout
Obviously
this bone must have
perforated
the small
intestine, causing the abdominal pain of which the
patient complained, and peritoneum and fasciæ.
had managed to perforate the The patient had no recollection of having swallowed this bone. EDRIC WILSON. Plymouth. CONCENTRATION OF DIPHTHERIA ANTITOXIN IN CORD BLOOD
interested in the article by Miss Barr, SIR,—I Mr. Glenny, and Dr. Randall in your issue of Aug. 20. For reasons pointed out elsewhereone may assume that diphtheria antitoxin is a univalent antibody, and that therefore its concentration in the cord serum and the maternal serum should be equal. In fact, the data given by Miss Barr and her colleagues in table 11 fulfil this expectation. In their conclusion, however, the authors state : " The antitoxin content of cord blood was very appreciably higher than that of antenatal samples of the mother’s blood taken during labour." The reason for the discrepancy between the conclusion and the actual findings can be found in the body of the article, where the authors claim that the method of titrating antitoxin used by them has an error of less than 10%. Actually, serological titrations ordinarily have a minimum error of about 100%, and only by doing multiple titrations and averaging the results can the error be reduced to 50%. If the authors’ conclusions were correct, then it should be possible to take the same samples blind-that is, with no indication of which is the cord blood and which is the maternal blood -and by repeating the titrations to identify the samples correctly. Had this experiment been tried by the authors they would have found that they could not really differentiate the cord serum from the maternal serum, showing that the titres of antitoxin in the cord serum and the maternal serum are not significantly different. In five cases where the antitoxin titrations were repeated on the baby’s serum only 1-5 days after birth, lower titres were obtained which agreed more closely with the maternal titres, demonstrating the existence of a relatively large experimental error. A. S. WIENER. New York. was
1.
Wiener, A.
S.
Ann.
Allergy, 1948, 6, 293.
WHY NOT GENERAL PRACTICE?
SiR,-Your admirable leader of Aug. 27 expresses the
thoughts of many, and calls attention to matters of vital importance for the future development of medicine in this country. The prestige of the profession will depend ultimately on the general practitioner and not on the specialist. To debase him is to debase the medical profession. Health today is an urgent social problem, and the practice of medicine calls for more than technical efficiency. The hospitals in general must remain the centres for salvage and research. They accumulate the severe, the rare, and the little understood cases, and are staffed by specialists who have never been in general practice and too frequently have little understanding of its problems. They tacitly assume that the keen men will become specialists and the rest go into general practice ; and their teaching often reflects this attitude. It is primarily for this reason that the average student leaves hospital woefully ill-prepared for general practice. To restore the balance and raise the prestige of the general practitioner you suggest the establishment of chairs of general practice. Surely the need would be met if before specialist status were granted, particularly for any post entailing teaching, a certain length of time had to be spent in general practice. Similarly, before entering general practice the new graduate should hold several hospital posts. In this way there would be more balance in teaching and more unity in the profession. The specialists would bring to their posts a sound knowledge of social problems and human understanding gained from general practice, and through their leadership raise the vocation of medicine to new heights of service to humanity. The present tendency to which the ill-prepared implementation of the National Health Service has given impetus, is for the general practitioner to be overwhelmed by a mass of people with trivial or imaginary ailments, many of them demanding specialist opinion. With no facilities for handling this mass, the inevitable result is that a large number of ill-assorted and unsorted cases reach the specialist clinics and hospitals. There the waiting-list for appointments increases and the specialists in turn are deprived of the opportunity for efficient work by overwhelming numbers. The only hope of improvement is in the provision of health centres where the general practitioner may have facilities for examination and diagnosis and opportunity for thorough work. Most of these centres will, for many years to come, have to be improvised, but that would have the merit of allowing the best type to be worked out in practice. These centres would, moreover, be foci from which future specialists might, by their example, set standards for general medicine and restore the unity of the medical profession which present tendencies
endanger. Farnham Royal, Bucks.
M. E. M. HERFORD.
SIR,—The proposal to establish a College or Faculty of General Practicerevealed not only dissatisfaction with graduate and postgraduate medical education but also some confusion about the practice of medicine itself. Having spent many years in general practice, and also
postgraduate education, I want to suggest that a coinmission of inquiry should be appointed to consider these problems. The following questions should be asked. What is general practice, and what should it be ? How and why does it differ from specialist practice ? "
How should these two branches of medicine be related What, if any, special skills do G.P.S those skills be taught? If so, how, by ‘? Can require ? " whom, and at what stage in the career of the G.r. ?" to each other ?
1. Lancet,
1949, i, 372, 415,
458.
The unavoidable conclusion is, therefore, that sodium is of no use inthe treatment of abortion and has no effect on the contracting full-term uterus. D. C. A. BEVIS St. Mary’s Hospitals for women
&bgr;-glycerophosphate
Senior Registrar.
and Children, Manchester.
PERFORATION a
OF
INTESTINE
BY
FISH-BONE
SIR,—Mr. Travers’s article last week calls to my mind similar case operated on by me.
consulting me in December, 1944, the elderly man, had persistent pain in the abdomen followed by a swelling immediately to the right of the umbilicus. This swelling had diminished and then reappeared. He had a very deep umbilicus, and I concluded that the swelling was due to cellulitis with suppuration in an hour-glass umbilicus. Appropriate treatment was ordered and I did not see him again until June, 1945, when there was an obvious abscess in the same situation. Immediately before incising this, I ventured a guess that a foreign body might be present. A small amount of pus was evacuated, and, on exploring the cavity with a finger, the foreign body, which was a flat and springy fish-bone 1/8 in. wide and 1 in. long, was removed. The wound healed normally. For six weeks before
patient,
a
stout
Obviously
this bone must have
perforated
the small
intestine, causing the abdominal pain of which the
patient complained, and peritoneum and fasciæ.
had managed to perforate the The patient had no recollection of having swallowed this bone. EDRIC WILSON. Plymouth. CONCENTRATION OF DIPHTHERIA ANTITOXIN IN CORD BLOOD
interested in the article by Miss Barr, SIR,—I Mr. Glenny, and Dr. Randall in your issue of Aug. 20. For reasons pointed out elsewhereone may assume that diphtheria antitoxin is a univalent antibody, and that therefore its concentration in the cord serum and the maternal serum should be equal. In fact, the data given by Miss Barr and her colleagues in table 11 fulfil this expectation. In their conclusion, however, the authors state : " The antitoxin content of cord blood was very appreciably higher than that of antenatal samples of the mother’s blood taken during labour." The reason for the discrepancy between the conclusion and the actual findings can be found in the body of the article, where the authors claim that the method of titrating antitoxin used by them has an error of less than 10%. Actually, serological titrations ordinarily have a minimum error of about 100%, and only by doing multiple titrations and averaging the results can the error be reduced to 50%. If the authors’ conclusions were correct, then it should be possible to take the same samples blind-that is, with no indication of which is the cord blood and which is the maternal blood -and by repeating the titrations to identify the samples correctly. Had this experiment been tried by the authors they would have found that they could not really differentiate the cord serum from the maternal serum, showing that the titres of antitoxin in the cord serum and the maternal serum are not significantly different. In five cases where the antitoxin titrations were repeated on the baby’s serum only 1-5 days after birth, lower titres were obtained which agreed more closely with the maternal titres, demonstrating the existence of a relatively large experimental error. A. S. WIENER. New York. was
1.
Wiener, A.
S.
Ann.
Allergy, 1948, 6, 293.
WHY NOT GENERAL PRACTICE?
SiR,-Your admirable leader of Aug. 27 expresses the
thoughts of many, and calls attention to matters of vital importance for the future development of medicine in this country. The prestige of the profession will depend ultimately on the general practitioner and not on the specialist. To debase him is to debase the medical profession. Health today is an urgent social problem, and the practice of medicine calls for more than technical efficiency. The hospitals in general must remain the centres for salvage and research. They accumulate the severe, the rare, and the little understood cases, and are staffed by specialists who have never been in general practice and too frequently have little understanding of its problems. They tacitly assume that the keen men will become specialists and the rest go into general practice ; and their teaching often reflects this attitude. It is primarily for this reason that the average student leaves hospital woefully ill-prepared for general practice. To restore the balance and raise the prestige of the general practitioner you suggest the establishment of chairs of general practice. Surely the need would be met if before specialist status were granted, particularly for any post entailing teaching, a certain length of time had to be spent in general practice. Similarly, before entering general practice the new graduate should hold several hospital posts. In this way there would be more balance in teaching and more unity in the profession. The specialists would bring to their posts a sound knowledge of social problems and human understanding gained from general practice, and through their leadership raise the vocation of medicine to new heights of service to humanity. The present tendency to which the ill-prepared implementation of the National Health Service has given impetus, is for the general practitioner to be overwhelmed by a mass of people with trivial or imaginary ailments, many of them demanding specialist opinion. With no facilities for handling this mass, the inevitable result is that a large number of ill-assorted and unsorted cases reach the specialist clinics and hospitals. There the waiting-list for appointments increases and the specialists in turn are deprived of the opportunity for efficient work by overwhelming numbers. The only hope of improvement is in the provision of health centres where the general practitioner may have facilities for examination and diagnosis and opportunity for thorough work. Most of these centres will, for many years to come, have to be improvised, but that would have the merit of allowing the best type to be worked out in practice. These centres would, moreover, be foci from which future specialists might, by their example, set standards for general medicine and restore the unity of the medical profession which present tendencies
endanger. Farnham Royal, Bucks.
M. E. M. HERFORD.
SIR,—The proposal to establish a College or Faculty of General Practicerevealed not only dissatisfaction with graduate and postgraduate medical education but also some confusion about the practice of medicine itself. Having spent many years in general practice, and also
postgraduate education, I want to suggest that a coinmission of inquiry should be appointed to consider these problems. The following questions should be asked. What is general practice, and what should it be ? How and why does it differ from specialist practice ? "
How should these two branches of medicine be related What, if any, special skills do G.P.S those skills be taught? If so, how, by ‘? Can require ? " whom, and at what stage in the career of the G.r. ?" to each other ?
1. Lancet,
1949, i, 372, 415,
458.