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PREVENTION OF BURNS AND SCALDS
438 have had to do. That would, in my opinion, be excellent, but I have the gravest doubts whether the modern " planner " would be prepared to leave that amount of freedom in his circumscribed world. A. PINEY. London, W.1.
generation
PARA-AMINOSALICYLIC ACID IN TUBERCULOSIS SiR,-In the following case of tuberculous ulceration of the tongue and epiglottis, a dramatic result was obtained by administration of p-aminosalicylic acid. A man of 42 was admitted under my care on Dec. 18, 1947, with bilateral tuberculous disease of the lungs. There was a small tuberculous ulcer at the tip and a larger ulcer on the right margin of the tongue ; the epiglottis was free of disease. The patient was The sputum contained tubercle bacilli. submitted to a general sanatorium regime. Locally the tongue was treated with 10% Promanide ’ spray, and the marginal ulcer was cauterised by Mr. W. H. Bradbeer. At the end of March, 1948, he was discharged to attend to urgent business. His weight, which had been 9 st. 12 lb. on admission, was now 9 st. 13 lb. He
readmitted on Oct. 14, weighing 9 st. 2 lb. His general condition had deteriorated. The ulcer at the tip of the tongue had healed but the marginal ulcer was larger and was intensely painful ; the epiglottis was now ulcerated and swallowing was extremely difficult. On Nov. 5 he began to take by mouth the sodium salt of p-aminosalicylic acid in a mixture containing to each 3 g. of the drug 1 drachm of syr. aurantii and water to 1/2 oz. The patient received five doses of 3 g. between 6 A.M. and 6 P.M., with a single dose of 6 g. at 9 r.M. Locally, the ulcers were sprayed twice daily with a 10% solution of the drug. was
’
Within three days the pain subsided and appetite returned. The ulcers steadily decreased in size. By the beginning of April, 1949, the tongue had healed firmly and the ulcer of the epiglottis appeared to be quiescent. Clinically and radiologically the pulmonary lesions were unchanged. The sputum, which had been negative for tubercle bacilli on Dec. 13, 1948, was positive on Feb. 14 and again negative on April 27. The patient was discharged on May 5, weighing 9 st. 13 lb.
In
experience p-aminosalicylic acid, prescribed gives rise to very few troublesome symptoms ; nausea and diarrhaea have always been transient and have subsided promptly when the medicine was discontinued for 48 hours. In my opinion the preparation may be safely administered in the home, and I suggest that early cases awaiting admission to a sanatorium should receive a course of it while having my
in the way described here,
bed rest at home.
GEORGE T. ALLERTON.
Torquay.
PREVENTION OF BURNS AND SCALDS
SiR,-In your issue of July 30 Dr. and Mrs. Colebrook discussed prevention of burns and scalds in the home. They did not mention one very dangerous practice-i.e., the use of inflammable materials for " home work " on partly finished factory articles such as rubber and crepe soled footwear. One young woman in my experience lost her life from the accidental " spillage " of a solution supplied to her husband for " home work," and now a greater disaster has occurred in Bristol from the spilling of a solution for fixing heels to shoes’! It should be possible-and it certainly seems desirable home work." -to forbid the use of rubber solution in "
Unfortunately it is always a temptation for those on a low rate of pay to take up easy " home work " such as the finishing of rubber shoes, to help out their earnings. It is not realised how high a risk attaches to the process. It may be all right in a properly designed and equipped factory where all the workers are properly trained, but should be Drohibited in the home. FRANK MARSH. Epping, Essex. 1.
Evening Standard, Aug. 25, p. 1.
THYROID SURGERY
SIR,-In the absence of Mr..piercy, who is in Canada, I should like to acknowledge on his behalf as well as my own, Dr. Friedmann’s kind reference in your issue of Aug. 20 to our recent article (July 23). May I assure " him that we are not ignorant of the existence of pseudotuberculous " or giant-cell " thyroiditis, or of the fact that in the past it must have often been mistaken for As a matter of fact, it tuberculosis of the thyroid ? was only the realisation of the already unconscionable length of our article which prevented us at the last moment from making a brief reference to the condition and thus forestalling the criticism which we were certain would otherwise be forthcoming. The sections were examined and reported on by pathologists with great experience in thyroid histology. "
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J. W. LINNELL.
London, W.1.
WHY NOT GENERAL PRACTICE?
SiR,—Our hearts are uplifted by your leading article last week with its vision of what might be, only to be cast into despair by the realisation of reality. In fact, the shape of things is being determined by a school of consultant thought which is imbued with the idea of " (not sick people) into their segregating all cases specialised pigeon-holes, and appointing teams of experts to cope with each resultant fraction. In this scheme the general practitioner has no place except as a preliminary sorting clerk. Specialisation has developed to the point where the gynaecologists are not prepared to allow a general surgeon to remove an ovary. (The South-West Metropolitan regional hospital board is giving effect to this by concentrating all gynoecological cases into one hospital.) In blunter English, they want wardsful of wombless women, with no subject of conversation but their mutual sterility. The psychiatrists, of course, will soon point out the danger of this, and the logical conclusion will be reached when trigonometry teachers with traumatised tibiae all go to Tooting, where they can talk about tangents. This process is well known in the industrial world, where it is called " breaking down thejob," and is the fundamental basis of mass production. A prototype car may be the perfection of thoughtful design, but the individual product often has irritating defects because parts were fixed by people with no responsibility for the whole. Is this to happen to medicine ?1 The only people with a whole view are the general physician and the general practitioner. The first is nearly extinct ; the second is being gradually throttled. We suffer from the type of specialist who thinks himself omniscient, and to whom the mighty are very ready to listen. He sees all the G.P.’s mistakes but none of his good work, so has an unbalanced idea of his value. The G.P. himself is in a, far better position to get a balanced view of the work of the specialist and is not naive enough to imagine that the specialist never makes mistakes. These Olympians, in fact, are not infallible ; they too are human. But this degradation of the G.P. is no remote danger. It is in progress. In my town we have one of the finest It has a visiting consultant G.P. hospitals in the country. staff from London teaching hospitals, who nevertheless like working with us. Our consultative outpatient department is of inestimable value, both to our patients and to us as doctors. Our wards are happy, because our patients are neighbours who have many subjects of mutual interest. All this, built up over many years, is to end. It is to end, not because of the ignorance of some non-professional committee, but because the medical advisory committee to the regional hospital board (who should be hanging their heads in shame) is imbued with this conception of "
generation
PARA-AMINOSALICYLIC ACID IN TUBERCULOSIS SiR,-In the following case of tuberculous ulceration of the tongue and epiglottis, a dramatic result was obtained by administration of p-aminosalicylic acid. A man of 42 was admitted under my care on Dec. 18, 1947, with bilateral tuberculous disease of the lungs. There was a small tuberculous ulcer at the tip and a larger ulcer on the right margin of the tongue ; the epiglottis was free of disease. The patient was The sputum contained tubercle bacilli. submitted to a general sanatorium regime. Locally the tongue was treated with 10% Promanide ’ spray, and the marginal ulcer was cauterised by Mr. W. H. Bradbeer. At the end of March, 1948, he was discharged to attend to urgent business. His weight, which had been 9 st. 12 lb. on admission, was now 9 st. 13 lb. He
readmitted on Oct. 14, weighing 9 st. 2 lb. His general condition had deteriorated. The ulcer at the tip of the tongue had healed but the marginal ulcer was larger and was intensely painful ; the epiglottis was now ulcerated and swallowing was extremely difficult. On Nov. 5 he began to take by mouth the sodium salt of p-aminosalicylic acid in a mixture containing to each 3 g. of the drug 1 drachm of syr. aurantii and water to 1/2 oz. The patient received five doses of 3 g. between 6 A.M. and 6 P.M., with a single dose of 6 g. at 9 r.M. Locally, the ulcers were sprayed twice daily with a 10% solution of the drug. was
’
Within three days the pain subsided and appetite returned. The ulcers steadily decreased in size. By the beginning of April, 1949, the tongue had healed firmly and the ulcer of the epiglottis appeared to be quiescent. Clinically and radiologically the pulmonary lesions were unchanged. The sputum, which had been negative for tubercle bacilli on Dec. 13, 1948, was positive on Feb. 14 and again negative on April 27. The patient was discharged on May 5, weighing 9 st. 13 lb.
In
experience p-aminosalicylic acid, prescribed gives rise to very few troublesome symptoms ; nausea and diarrhaea have always been transient and have subsided promptly when the medicine was discontinued for 48 hours. In my opinion the preparation may be safely administered in the home, and I suggest that early cases awaiting admission to a sanatorium should receive a course of it while having my
in the way described here,
bed rest at home.
GEORGE T. ALLERTON.
Torquay.
PREVENTION OF BURNS AND SCALDS
SiR,-In your issue of July 30 Dr. and Mrs. Colebrook discussed prevention of burns and scalds in the home. They did not mention one very dangerous practice-i.e., the use of inflammable materials for " home work " on partly finished factory articles such as rubber and crepe soled footwear. One young woman in my experience lost her life from the accidental " spillage " of a solution supplied to her husband for " home work," and now a greater disaster has occurred in Bristol from the spilling of a solution for fixing heels to shoes’! It should be possible-and it certainly seems desirable home work." -to forbid the use of rubber solution in "
Unfortunately it is always a temptation for those on a low rate of pay to take up easy " home work " such as the finishing of rubber shoes, to help out their earnings. It is not realised how high a risk attaches to the process. It may be all right in a properly designed and equipped factory where all the workers are properly trained, but should be Drohibited in the home. FRANK MARSH. Epping, Essex. 1.
Evening Standard, Aug. 25, p. 1.
THYROID SURGERY
SIR,-In the absence of Mr..piercy, who is in Canada, I should like to acknowledge on his behalf as well as my own, Dr. Friedmann’s kind reference in your issue of Aug. 20 to our recent article (July 23). May I assure " him that we are not ignorant of the existence of pseudotuberculous " or giant-cell " thyroiditis, or of the fact that in the past it must have often been mistaken for As a matter of fact, it tuberculosis of the thyroid ? was only the realisation of the already unconscionable length of our article which prevented us at the last moment from making a brief reference to the condition and thus forestalling the criticism which we were certain would otherwise be forthcoming. The sections were examined and reported on by pathologists with great experience in thyroid histology. "
-
---
-
J. W. LINNELL.
London, W.1.
WHY NOT GENERAL PRACTICE?
SiR,—Our hearts are uplifted by your leading article last week with its vision of what might be, only to be cast into despair by the realisation of reality. In fact, the shape of things is being determined by a school of consultant thought which is imbued with the idea of " (not sick people) into their segregating all cases specialised pigeon-holes, and appointing teams of experts to cope with each resultant fraction. In this scheme the general practitioner has no place except as a preliminary sorting clerk. Specialisation has developed to the point where the gynaecologists are not prepared to allow a general surgeon to remove an ovary. (The South-West Metropolitan regional hospital board is giving effect to this by concentrating all gynoecological cases into one hospital.) In blunter English, they want wardsful of wombless women, with no subject of conversation but their mutual sterility. The psychiatrists, of course, will soon point out the danger of this, and the logical conclusion will be reached when trigonometry teachers with traumatised tibiae all go to Tooting, where they can talk about tangents. This process is well known in the industrial world, where it is called " breaking down thejob," and is the fundamental basis of mass production. A prototype car may be the perfection of thoughtful design, but the individual product often has irritating defects because parts were fixed by people with no responsibility for the whole. Is this to happen to medicine ?1 The only people with a whole view are the general physician and the general practitioner. The first is nearly extinct ; the second is being gradually throttled. We suffer from the type of specialist who thinks himself omniscient, and to whom the mighty are very ready to listen. He sees all the G.P.’s mistakes but none of his good work, so has an unbalanced idea of his value. The G.P. himself is in a, far better position to get a balanced view of the work of the specialist and is not naive enough to imagine that the specialist never makes mistakes. These Olympians, in fact, are not infallible ; they too are human. But this degradation of the G.P. is no remote danger. It is in progress. In my town we have one of the finest It has a visiting consultant G.P. hospitals in the country. staff from London teaching hospitals, who nevertheless like working with us. Our consultative outpatient department is of inestimable value, both to our patients and to us as doctors. Our wards are happy, because our patients are neighbours who have many subjects of mutual interest. All this, built up over many years, is to end. It is to end, not because of the ignorance of some non-professional committee, but because the medical advisory committee to the regional hospital board (who should be hanging their heads in shame) is imbued with this conception of "