- Email: [email protected]
REHABILITATION OF THE TUBERCULOUS
818 As there was no sign of inflammation I did a tubal insufflation and found both tubes blocked. A fortnight later I did a second insufflaton, during which the pressure rose
genesis. to 200
mm.
Hg
and
then abruptly dropped
to
110
mm.
Two hours afterwards the patient complained of shoulder pain, and three weeks later she became pregnant. CASE 2.-A woman of 26 was treated with sulphathiazole, and smears taken during the next two months were free from gonococci. After another three months-having convinced myself by clinical examination, by provocative treatment, and by the sedimentation-rate, that there was no inflammation present-I insufflated the tubes, keeping the pressure below 180 mm. Hg. A fortnight later I repeated the insufflation, allowing the pressure to rise to 200 mm. Hg ; three weeks after this, at a third insufflation, the pressure fell from 180 to 110 mm. Hg and shoulder pain followed, which showed that the tubes had become patent. No conclusions can be drawn from these few cases, but the results seem to justify further investigation on the same lines. It seems to me that no woman with gonorrhoea should be pronounced cured until the tubes have been examined ; and if they are closed, I suggest that tubal insufflation should be undertaken within 3-6 months of the apparent cure, provided that (i) the sedimentation-ra,te is normal ; (ii) the cervical and vaginal secretions have been free from gonococci for at least three months ; (iii) there are no detectable signs of inflammation of the tubes ; and (iv) no focal or general
reaction follows provocative treatment. The pressure should not be allowed to rise higher than 170 mm. Hg during the first insufflation. If there is no local reaction the second insufflation should be performed a fortnight later, when the pressure may be allowed to rise to 200 mm. Hg. E. SCHLEYER.
Wimpole Street, W.I.
FLUORINE
IN DRINKING
WATER
SIR,-Spira and Grimbleby have lately suggested that fluorine can easily be removed from drinking-water by boiling it for 5 minutes (J. Hyg., Camb. 1943, 43, 141). It would be misleading to assume that this is true for all waters. It is in fact extremely difficult to remove fluorine from some samples of water, as many attempts to do so in the United States have shown. We found that the fluorine content in parts per million of tap water from Maldon, Essex, was as follows : as drawn from the tap, 4-5 ; boiled in glass for 5 minutes, 4-5 ; left over calcium carbonate for a day, 3-5 ; left overDoucil ’ water-softener for a day, 4-0. The fluorine content of a hard water from Luxborough, Somerset, was 0-95 p.p.m. before boiling and 0-85 after boiling for 5 minutes. A soft water from Meldon Quarries, near Okehampton, Devon, contained 0-45 p.p.m. before boiling and the same after boiling for 5 minutes. The determinations were made by the zirconium-alizarine colorimetric method, after the precipitation of interfering salts by barium chloride. M. M. MURRAY, D. C. WILSON. Oxford.
DOCTORS AND THE FUTURE SiB;—My friend Dr. Raymond Greene takes you to task, rightly I think, for sitting on the fence in your leader of June 5. He is right also in saying that we must run our own show. Nobody, so far as I know, has suggested that lawyers, for example, should be controlled by persons outside their profession. We must remember, however, that our show comprises not only doctors but also patients, actual or potential ; for that reason our controlling body, corporation or council-call it what you will-must represent laymen as well as doctors, and the best type of lay representative would clearly be of the stuff of which hospital chairmen are madei.e., persons of good repute, of high administrative ability, with a genuine interest in medical service and with no conceivable axes to grind. I agree’ with Dr. Greene that we are unlikely to be able to work happily under either the Ministry of Health or local authorities, but I cannot agree that dictatorships conduce either to administrative efficiency or to the happiness of the masses. Dictatorship has a way of going to the head of the dictator. So far as general practice is concerned. 20 years’ experience has convinced me that what,really matters
is a proper understanding between patient and doctor. The doctor, however tired, must at all-times be prepared to do his best for all patients, however trying. He must laboriously gain their confidence and teach them neither to be absurdly apprehensive about trivial symptoms nor to make frivolous or vexatious demands upon his time or energy. Once such an understanding is established the doctor can snap his fingers at the forces of bureaucracy and his patients will back him up. I can to be in a position imagine nothing more satisfactory than " so you don’t think I to say to a pettifogging inspector, look after my patients properly, don;t you ? Well, go round and tell them so and see what happens to you." L. N. JACKSON. Crediton, Devon.
REHABILITATION OF THE TUBERCULOUS SIR,-It was with keen pleasure that I read Dr. Wollaston’s note in your issue of June 12, more particularly since it emanated from Papworth.’ The policies of Papworth and Preston Hall are (as Dr. JEh A. Pattison says in his recently published Rehabilitation of the Tuberculous) alike except in one very important respect. The late Sir Pendrill Varrier-Jones believed that the tuberculous should be cared for per2iianently in village settlements ; I have taken the view that in the majority of cases of pulmonary tuberculosis who have enjoyed three to five years’ freedom from signs or symptoms of active disease under village settlement conditions, the liability of relapse is very slight. odr policy at Preston Hall has been to encourage such patients to leave the settlement houses in order to make openings for new applicants. In this view I have the support of the majority of my colleagues, including Dr. Pattison, whose experience in the United States has been practical and extensive. Radiological shadows ought never to be taken, by themselves, as a guide to treatment; but radiological shadows considered in relation to the tolerance of a patient over a number of years to graduated exercise under medical supervision constitute a guide which is of the greatest value to those of us engaged in village settlement work and one which is denied to many of our colleagues without similar facilities for assessing " the patient " as distinct from " the disease." The policy of keeping arrested lesions in a state of permanent arrest by perpetual residence in a village settlement is likely to lead to stagnation in the village settlement by limiting the who are in fact suffering admission of further from disease which requires prolonged treatment and the complete -rehabilitation devices which the settlement
patients
provides. Except by the expensive process more
houses,
no new cases can so as are whom there are no
of building more and be taken into the village
settlement long places being occupied by groups of men for longer any solid medical grounds for continued residence in the settlement. Preston Hall, Kent. JOHN B. MCDOUGALL. PROMIN AND PROMANIDE SiR,-Since the publication of the article entitled Tuberculosis treated with Promin in your issue of June 5, I have been informed by Dr. Stanley White thatPromin’ (PDCo) will be designated as’Promanide’ in this country. He also tells me that the strength of the glycerin paint prepared for me by his firm was 20% promanide in 50% glycerin. May I add that this paint was applied for me by Dr. J. Vahrman once or twice daily directly to the affected part of the larynx viewed through a laryngeal mirror. No anoesthetic was needed as the patients soon tolerated the treatment. I should have written viscous rather than oily vehicle as promanide is insoluble in oil, but soluble in glycerin. FREDERICK HEAF. County Hall, S.E.1. The Anglo-Soviet Medical Council have a few spare copies of the Medical Chronicle nublished bv the medical section of VOKS (the USSR for cultural relations with other countries). - The issue available is no. 4, December, 1942) the latest issue so far received. Copies (6d. post free) may be had from the Secretary of the A-SMC, at the Royal Society of Medicine, 1, Wimpole Street, London, Wl.
society
genesis. to 200
mm.
Hg
and
then abruptly dropped
to
110
mm.
Two hours afterwards the patient complained of shoulder pain, and three weeks later she became pregnant. CASE 2.-A woman of 26 was treated with sulphathiazole, and smears taken during the next two months were free from gonococci. After another three months-having convinced myself by clinical examination, by provocative treatment, and by the sedimentation-rate, that there was no inflammation present-I insufflated the tubes, keeping the pressure below 180 mm. Hg. A fortnight later I repeated the insufflation, allowing the pressure to rise to 200 mm. Hg ; three weeks after this, at a third insufflation, the pressure fell from 180 to 110 mm. Hg and shoulder pain followed, which showed that the tubes had become patent. No conclusions can be drawn from these few cases, but the results seem to justify further investigation on the same lines. It seems to me that no woman with gonorrhoea should be pronounced cured until the tubes have been examined ; and if they are closed, I suggest that tubal insufflation should be undertaken within 3-6 months of the apparent cure, provided that (i) the sedimentation-ra,te is normal ; (ii) the cervical and vaginal secretions have been free from gonococci for at least three months ; (iii) there are no detectable signs of inflammation of the tubes ; and (iv) no focal or general
reaction follows provocative treatment. The pressure should not be allowed to rise higher than 170 mm. Hg during the first insufflation. If there is no local reaction the second insufflation should be performed a fortnight later, when the pressure may be allowed to rise to 200 mm. Hg. E. SCHLEYER.
Wimpole Street, W.I.
FLUORINE
IN DRINKING
WATER
SIR,-Spira and Grimbleby have lately suggested that fluorine can easily be removed from drinking-water by boiling it for 5 minutes (J. Hyg., Camb. 1943, 43, 141). It would be misleading to assume that this is true for all waters. It is in fact extremely difficult to remove fluorine from some samples of water, as many attempts to do so in the United States have shown. We found that the fluorine content in parts per million of tap water from Maldon, Essex, was as follows : as drawn from the tap, 4-5 ; boiled in glass for 5 minutes, 4-5 ; left over calcium carbonate for a day, 3-5 ; left overDoucil ’ water-softener for a day, 4-0. The fluorine content of a hard water from Luxborough, Somerset, was 0-95 p.p.m. before boiling and 0-85 after boiling for 5 minutes. A soft water from Meldon Quarries, near Okehampton, Devon, contained 0-45 p.p.m. before boiling and the same after boiling for 5 minutes. The determinations were made by the zirconium-alizarine colorimetric method, after the precipitation of interfering salts by barium chloride. M. M. MURRAY, D. C. WILSON. Oxford.
DOCTORS AND THE FUTURE SiB;—My friend Dr. Raymond Greene takes you to task, rightly I think, for sitting on the fence in your leader of June 5. He is right also in saying that we must run our own show. Nobody, so far as I know, has suggested that lawyers, for example, should be controlled by persons outside their profession. We must remember, however, that our show comprises not only doctors but also patients, actual or potential ; for that reason our controlling body, corporation or council-call it what you will-must represent laymen as well as doctors, and the best type of lay representative would clearly be of the stuff of which hospital chairmen are madei.e., persons of good repute, of high administrative ability, with a genuine interest in medical service and with no conceivable axes to grind. I agree’ with Dr. Greene that we are unlikely to be able to work happily under either the Ministry of Health or local authorities, but I cannot agree that dictatorships conduce either to administrative efficiency or to the happiness of the masses. Dictatorship has a way of going to the head of the dictator. So far as general practice is concerned. 20 years’ experience has convinced me that what,really matters
is a proper understanding between patient and doctor. The doctor, however tired, must at all-times be prepared to do his best for all patients, however trying. He must laboriously gain their confidence and teach them neither to be absurdly apprehensive about trivial symptoms nor to make frivolous or vexatious demands upon his time or energy. Once such an understanding is established the doctor can snap his fingers at the forces of bureaucracy and his patients will back him up. I can to be in a position imagine nothing more satisfactory than " so you don’t think I to say to a pettifogging inspector, look after my patients properly, don;t you ? Well, go round and tell them so and see what happens to you." L. N. JACKSON. Crediton, Devon.
REHABILITATION OF THE TUBERCULOUS SIR,-It was with keen pleasure that I read Dr. Wollaston’s note in your issue of June 12, more particularly since it emanated from Papworth.’ The policies of Papworth and Preston Hall are (as Dr. JEh A. Pattison says in his recently published Rehabilitation of the Tuberculous) alike except in one very important respect. The late Sir Pendrill Varrier-Jones believed that the tuberculous should be cared for per2iianently in village settlements ; I have taken the view that in the majority of cases of pulmonary tuberculosis who have enjoyed three to five years’ freedom from signs or symptoms of active disease under village settlement conditions, the liability of relapse is very slight. odr policy at Preston Hall has been to encourage such patients to leave the settlement houses in order to make openings for new applicants. In this view I have the support of the majority of my colleagues, including Dr. Pattison, whose experience in the United States has been practical and extensive. Radiological shadows ought never to be taken, by themselves, as a guide to treatment; but radiological shadows considered in relation to the tolerance of a patient over a number of years to graduated exercise under medical supervision constitute a guide which is of the greatest value to those of us engaged in village settlement work and one which is denied to many of our colleagues without similar facilities for assessing " the patient " as distinct from " the disease." The policy of keeping arrested lesions in a state of permanent arrest by perpetual residence in a village settlement is likely to lead to stagnation in the village settlement by limiting the who are in fact suffering admission of further from disease which requires prolonged treatment and the complete -rehabilitation devices which the settlement
patients
provides. Except by the expensive process more
houses,
no new cases can so as are whom there are no
of building more and be taken into the village
settlement long places being occupied by groups of men for longer any solid medical grounds for continued residence in the settlement. Preston Hall, Kent. JOHN B. MCDOUGALL. PROMIN AND PROMANIDE SiR,-Since the publication of the article entitled Tuberculosis treated with Promin in your issue of June 5, I have been informed by Dr. Stanley White thatPromin’ (PDCo) will be designated as’Promanide’ in this country. He also tells me that the strength of the glycerin paint prepared for me by his firm was 20% promanide in 50% glycerin. May I add that this paint was applied for me by Dr. J. Vahrman once or twice daily directly to the affected part of the larynx viewed through a laryngeal mirror. No anoesthetic was needed as the patients soon tolerated the treatment. I should have written viscous rather than oily vehicle as promanide is insoluble in oil, but soluble in glycerin. FREDERICK HEAF. County Hall, S.E.1. The Anglo-Soviet Medical Council have a few spare copies of the Medical Chronicle nublished bv the medical section of VOKS (the USSR for cultural relations with other countries). - The issue available is no. 4, December, 1942) the latest issue so far received. Copies (6d. post free) may be had from the Secretary of the A-SMC, at the Royal Society of Medicine, 1, Wimpole Street, London, Wl.
society