- Email: [email protected]
STUDENTS SHOW THE WAY
145 Was this to be a resignation issue ? That put the motion, which was promptly replaced by paid another, almost equally odd, which was carried. This repeated a recent declaration by the Association’s council that the profession could no longer accept collective responsibility for the preservation of those standards of medical care which a modern community should expect under the National Health Service. The public may reasonably ask whether doctors are still prepared to
Gibson. to
accept individual responsibility. A tremendous row was precipitated by the efforts of a young lady to distribute to representatives copies of On-Call, the newspaper of the Junior Hospital Doctors’ Association, which has been using very robust tactics in its efforts to remind the B.M.A. that it has not always done everything it could for young doctors. At first it was announced that the B.M.A. would break off its discussions with the J.H.D.A. because of the harsh attacks on the B.M.A. But finally the meeting passed a motion deprecating the attacks on B.M.A. leaders and suggesting that discussions continue, provided the J.H.D.A. disowned the distribution of On-Call at the meeting. An apology was forthcoming and the hypertensive attack was over. Discussions between the two Associations will continue.
TUMOUR-PRODUCING ADENOVIRUSES
THE oncogenic activity of some human adenoviruses in newborn hamsters has led to much speculation about their role in human tumours. One important question is whether all adenoviruses should be considered as potentially oncogenic or whether there is some character besides ability to produce tumours that might serve to distinguish oncogenic from non-oncogenic viruses. Latner and his colleaguessuggested that isoenzyme patterns might be used, but Fujinaga and Green2 have now shown that non-oncogenic, and weakly and highly oncogenic, types of adenovirus can be distinguished by the character of the R.N.A. they induce in tumour cells. The highly oncogenic adenovirus types are 12, 18, and 31, and they produce tumours in most hamsters in 1-2 months, whereas the weakly oncogenic types 7, 14, 16, and 21 produce tumours only rarely and after 4-18 months. Tritiumlabelled virus-specific R.N.A. from tumour cells produced by highly oncogenic adenoviruses hybridises with D.N.A. extracted from all such viruses but not with D.N.A. from weakly oncogenic or non-oncogenic types. Similarly, weakly oncogenic viruses show a relationship with each other but not with other adenoviruses. Similar relationships are shown by the demonstration of homology between D.N.A. extracted from the virus types of the two oncogenic groups. These results suggest that there is a specific nucleotide sequence responsible for carcinogenesis which is not present in non-oncogenic strains of adenovirus. Highly oncogenic adenoviruses also share certain virus-specific T antigens, and weakly oncogenic viruses have another common T antigen which is also present in two adenovirus types (4 and 11) not yet found to be oncogenic.3 So far, these antigens have not been detected in human tumours, but this may be because attempts to do so have been complicated by non-specific 1.
Latner,
A.
I., Gardner, P. S., Turner, D. M., Brown, J. O. Lancet,
1964, i, 197. 2. 3.
Fujinaga, K., Green, M. Proc. natn. Acad. Sci. U.S.A. 1967, 57, 637. Huebner, R. J. First International Conference on Vaccines Against Viral and Rickettsial Disease of Man. P.A.H.O./W.H.O. 73-80. Washington, D.C., 1967.
reactions between human tissues and antibodies to T antigens in the sera of tumour-bearing hamsters. Similar difficulties are found in the detection of avian leucosisvirus antigens in infected chick embryo cells-the socalled COFAL test.4 Hamsters bearing Rous sarcoma, and probably other virus-induced tumours, have antibodies in their sera which react non-specifically with tissue homogenates. These non-specific reactions make detection of the specific antigens difficult, but in the avian lecosis-virus system the problem is overcome by passaging the virus-containing cells in vitro.5 A similar passaging technique might be used for human tumours. An alternative method would be to attempt to hybridise the protein-labelled R.N.A. from human tumours with D.N.A. from highly and weakly oncogenic advenoviruses, as worked out by Fujinaga and Green.2
STUDENTS SHOW THE WAY
Is a sixth-former considering a career in medicine really able to make a rational choice ? To do this, he must know much more about medicine than did his predecessors. To help provide this information, the students’ union of St. Mary’s Hospital, London, held a conference for sixth-formers and schoolmasters on July 3. The conference opened with a detailed description of the medical training timetable. Next came a symposium in which specialists covered general practice, hospital practice, mental health, community medicine, and medical research. These contributions showed effectively that medicine ranges much wider than hospital and general practice. Then followed over an hour’s keen questioning from the sixth-formers. Is general practice boring because interesting patients must be referred ? How can a doctor serve most effectively in a developing country ? What rewards, other than financial, can private practice offer ? Later the guests met doctors and students informally over coffee. After a series of well-arranged visits to hospital and medical-school departments, the meeting was rounded off by students talking on their life and activities. Surprisingly, hardly any other comparable conference has been held-there was one at the London Hospital earlier this summer. The initiative of the students at St. Mary’s in themselves organising this meeting is admirable : they saw a gap, and they acted to fill it. The image of the hearty, unthinking medical student dies hard; this kind of action may hammer one more nail in its coffin. The need for the conference was clear: for the 110 places, over 500 applications arrived from all over the country; and visitors showed a real and disturbing ignorance of medical education-in particular, the girls seemed unaware of the special difficulties they would face
(regrettably, some speakers painted an over-optimistic picture of openings for women doctors). The great majority of the sixth-formers had never been into a medical school and had only a vague idea of what a medical career actually entailed; and most were unaware of the relative merits of various medical schools. They com; plained that facts were very hard to obtain. Such criticisms should be taken seriously. If bright sixth-formers do not truly appreciate the scope and depth of medicine, then fewer of them will choose career. Already many schoolmasters tend to 4. 5.
a
medical their
urge
Sarma, P. S., Turner, M. C., Huebner, R. J. Virology, 1964, 23, 313. Furminger, I. G. S. Paper to British Society for Immunology, April, 1967.
146 able pupils to take up pure rather than biological sciences. If this trend is to be halted, the medical profession must improve its information services. Today, many an applicant has to rely on limited and subjective information from doctor contacts, an overworked careers master, and recent school-leavers. Armed with an array of impressively formal medical-school prospectuses, a sixth-former will still feel that he has little idea of what it is like to be a medical student. If every medical school incorporated a conference like that at St. Mary’s into its yearly timetable, medicine would be more certain of attracting the right people for the right reasons.
more
rise to difficulties of diagnosis: it usually occurs as a terminal illness in a patient with another serious, often neoplastic, conditions There can, however, be little doubt that in bacterial endocarditis the most common cause of a sterile blood-culture is previous administration of an antibiotic, and no patient with fever and a heartmurmur should be treated with an antibiotic until bloodcultures have been made. Not more than five or six cultures are necessary,4 and these may be done over a period of 24 or 48 hours if further delay in treatment is
give
thought unjustifiable. A MEANINGLESS COMPARISON
BACTERIAL ENDOCARDITIS
RATIONAL treatment of bacterial endocarditis depends on the identification of the infecting organism,1 and
persistently sterile blood-cultures (which are by no means uncommon) merely confuse the issue. Hampton and Harrison,2 reviewing 107 patients treated for bacterial endocarditis at the United Oxford Hospitals between 1955 and 1965, found that 59% had positive and 41% negative blood-cultures. The groups with positive and negative cultures were similar in age and sex distribution and, in most respects, in histories, physical signs, and laboratory findings. In the culture-negative group, however, significantly more patients had a history of illness for more than 3 months before admission to hospital, and (probably related to this longer illness) anxmia was more frequent than in those with positive cultures. Embolic phenomena and breathlessness or heart-failure were also commoner in the negative group. Except in 3 cases, there did not seem to have been any significant delay in starting treatment in the patients with negative cultures; delay in treatment, when it did happen, seemed to be due more to failure to consider a diagnosis of bacterial endocarditis than to the fact that cultures were sterile. 50% of the positive group and 67% of the negative group had been given antibiotics either at home or in hospital before blood-cultures were taken, and, although this difference did not reach statistical significance, Hampton and Harrison think that prior administration of antibiotics was an important factor in the failure to obtain positive blood-cultures. Most other workers are agreed on this point,3-5 although Blount found positive cultures in as many treated patients as untreated. Antibiotics may cause a’ change in the characteristics of the infecting: organism, with the production of L-phase bacteria, which 8 are more difficult to isolate than the usual form.7 Sterile cultures may also be due to the presence of an organism, such as brucella,9 which does not grow easily in conventional culture media. Rickettsial endocarditis should be considered in any patient with persistently negative blood-cultures: although the organism cannot be cultured, a simple serological test can confirm the diagnosis.1O Non-bacterial thrombotic endocarditis may 1. 2. 3. 4. 5.
6. 7. 8. 9. 10.
Lancet, 1967, i, 605. Hampton, J. R., Harrison, M. J. G. Q. Jl Med. 1967, 36, 167. Hall, B., Dowling, H. F. Med. Clins N. Am. 1966, 50, 159. Lerner, P. I., Weinstein, L. New Engl. J. Med. 1966, 274, 323. Rabinovich, S., Evans, J., Smith, I. M., January, L. E. Ann. intern. Med. 1965, 63, 185. Blount, J. G. Am. J. Med. 1965, 38, 909. Godzeski, C. W., Brier, G., Griffith, R. S., Black, H. R. Nature, Lond. 1965, 205, 1340. Mattman, L. H., Mattman, P. E. Archs intern. Med. 1965, 115, 315. Peery, T. M., Belter, L. F. Am. J. Path. 1960, 36, 673. Grist, N. R., Ross, C. A. C., Sommerville, R. G. Lancet, 1967, i, 727.
PARTS of the
of Health’s latest annual report 148) read like a company prosfor the National Health Service in it 1966, says, pectus : " there has been a striking measure of success." Social historians of a later century, turning the yellowing pages of this report, may be pardoned for concluding that last year marked the opening of a medical Elysium on the shores of the United Kingdom. But the social historians can take care of themselves: anyhow they will probably be aware that it is in the nature of the Elephant to trumpet. What is inexcusable in the report-because it may deceive those who are yet alive-is that it once more prominently sets current and projected hospital capital expenditure against expenditure in the years before the 1939-45 war. Last year expenditure was " in real terms 63% above pre-war ". Splendid. But what does this mean ? The report absentmindedly fails to record with equal prominence that in the pre-war years, when most of the voluntary hospitals were tottering towards bankruptcy, capital expenditure was at a low ebb;" that for over two decades after 1939 construction of per" manent hospitals was virtually at a standstill; that, in real terms, each hospital bed now costs more; and that the population has increased and is expected to increase further. Comparison of current expenditure with that in the 1930s is no more meaningful (and it is a good deal A shipping more misleading) than with that in the 1630s. company which has to replace old vessels does not congratulate itself on its surge of new investment: it tells its shareholders how soon they may expect to possess a seaworthy fleet. Likewise the Ministry should frankly declare how far the current ten-year building programme will go towards meeting the proved need for new
(briefly referred
Ministry
to on p.
hospitals. REVERSING THE BRAIN DRAIN
IT is no secret that British doctors are emigrating to North America in sizeable numbers. Equally it is no secret that, of those who emigrate, a fair proportionpossibly about a third-return to the United Kingdom within a few years. To ease the way of any who contemplate re-crossing the Atlantic from West to East, the Ministry of Health is in October despatching to the United States and Canada a Board which will interview those interested. Among the attractions of the Ministry’s scheme are payment of fares (including those of the family) for selected applicants and guaranteed appointments for three years.
Inquiries
may be addressed to Dr. R. H.
Barrett, Ministry of
Health, Elephant and Castle, London S.E.l. 11.
MacDonald, R. A., Robbins, S.
L. Ann. intern. Med.
1957, 46, 255.
Gibson. to
accept individual responsibility. A tremendous row was precipitated by the efforts of a young lady to distribute to representatives copies of On-Call, the newspaper of the Junior Hospital Doctors’ Association, which has been using very robust tactics in its efforts to remind the B.M.A. that it has not always done everything it could for young doctors. At first it was announced that the B.M.A. would break off its discussions with the J.H.D.A. because of the harsh attacks on the B.M.A. But finally the meeting passed a motion deprecating the attacks on B.M.A. leaders and suggesting that discussions continue, provided the J.H.D.A. disowned the distribution of On-Call at the meeting. An apology was forthcoming and the hypertensive attack was over. Discussions between the two Associations will continue.
TUMOUR-PRODUCING ADENOVIRUSES
THE oncogenic activity of some human adenoviruses in newborn hamsters has led to much speculation about their role in human tumours. One important question is whether all adenoviruses should be considered as potentially oncogenic or whether there is some character besides ability to produce tumours that might serve to distinguish oncogenic from non-oncogenic viruses. Latner and his colleaguessuggested that isoenzyme patterns might be used, but Fujinaga and Green2 have now shown that non-oncogenic, and weakly and highly oncogenic, types of adenovirus can be distinguished by the character of the R.N.A. they induce in tumour cells. The highly oncogenic adenovirus types are 12, 18, and 31, and they produce tumours in most hamsters in 1-2 months, whereas the weakly oncogenic types 7, 14, 16, and 21 produce tumours only rarely and after 4-18 months. Tritiumlabelled virus-specific R.N.A. from tumour cells produced by highly oncogenic adenoviruses hybridises with D.N.A. extracted from all such viruses but not with D.N.A. from weakly oncogenic or non-oncogenic types. Similarly, weakly oncogenic viruses show a relationship with each other but not with other adenoviruses. Similar relationships are shown by the demonstration of homology between D.N.A. extracted from the virus types of the two oncogenic groups. These results suggest that there is a specific nucleotide sequence responsible for carcinogenesis which is not present in non-oncogenic strains of adenovirus. Highly oncogenic adenoviruses also share certain virus-specific T antigens, and weakly oncogenic viruses have another common T antigen which is also present in two adenovirus types (4 and 11) not yet found to be oncogenic.3 So far, these antigens have not been detected in human tumours, but this may be because attempts to do so have been complicated by non-specific 1.
Latner,
A.
I., Gardner, P. S., Turner, D. M., Brown, J. O. Lancet,
1964, i, 197. 2. 3.
Fujinaga, K., Green, M. Proc. natn. Acad. Sci. U.S.A. 1967, 57, 637. Huebner, R. J. First International Conference on Vaccines Against Viral and Rickettsial Disease of Man. P.A.H.O./W.H.O. 73-80. Washington, D.C., 1967.
reactions between human tissues and antibodies to T antigens in the sera of tumour-bearing hamsters. Similar difficulties are found in the detection of avian leucosisvirus antigens in infected chick embryo cells-the socalled COFAL test.4 Hamsters bearing Rous sarcoma, and probably other virus-induced tumours, have antibodies in their sera which react non-specifically with tissue homogenates. These non-specific reactions make detection of the specific antigens difficult, but in the avian lecosis-virus system the problem is overcome by passaging the virus-containing cells in vitro.5 A similar passaging technique might be used for human tumours. An alternative method would be to attempt to hybridise the protein-labelled R.N.A. from human tumours with D.N.A. from highly and weakly oncogenic advenoviruses, as worked out by Fujinaga and Green.2
STUDENTS SHOW THE WAY
Is a sixth-former considering a career in medicine really able to make a rational choice ? To do this, he must know much more about medicine than did his predecessors. To help provide this information, the students’ union of St. Mary’s Hospital, London, held a conference for sixth-formers and schoolmasters on July 3. The conference opened with a detailed description of the medical training timetable. Next came a symposium in which specialists covered general practice, hospital practice, mental health, community medicine, and medical research. These contributions showed effectively that medicine ranges much wider than hospital and general practice. Then followed over an hour’s keen questioning from the sixth-formers. Is general practice boring because interesting patients must be referred ? How can a doctor serve most effectively in a developing country ? What rewards, other than financial, can private practice offer ? Later the guests met doctors and students informally over coffee. After a series of well-arranged visits to hospital and medical-school departments, the meeting was rounded off by students talking on their life and activities. Surprisingly, hardly any other comparable conference has been held-there was one at the London Hospital earlier this summer. The initiative of the students at St. Mary’s in themselves organising this meeting is admirable : they saw a gap, and they acted to fill it. The image of the hearty, unthinking medical student dies hard; this kind of action may hammer one more nail in its coffin. The need for the conference was clear: for the 110 places, over 500 applications arrived from all over the country; and visitors showed a real and disturbing ignorance of medical education-in particular, the girls seemed unaware of the special difficulties they would face
(regrettably, some speakers painted an over-optimistic picture of openings for women doctors). The great majority of the sixth-formers had never been into a medical school and had only a vague idea of what a medical career actually entailed; and most were unaware of the relative merits of various medical schools. They com; plained that facts were very hard to obtain. Such criticisms should be taken seriously. If bright sixth-formers do not truly appreciate the scope and depth of medicine, then fewer of them will choose career. Already many schoolmasters tend to 4. 5.
a
medical their
urge
Sarma, P. S., Turner, M. C., Huebner, R. J. Virology, 1964, 23, 313. Furminger, I. G. S. Paper to British Society for Immunology, April, 1967.
146 able pupils to take up pure rather than biological sciences. If this trend is to be halted, the medical profession must improve its information services. Today, many an applicant has to rely on limited and subjective information from doctor contacts, an overworked careers master, and recent school-leavers. Armed with an array of impressively formal medical-school prospectuses, a sixth-former will still feel that he has little idea of what it is like to be a medical student. If every medical school incorporated a conference like that at St. Mary’s into its yearly timetable, medicine would be more certain of attracting the right people for the right reasons.
more
rise to difficulties of diagnosis: it usually occurs as a terminal illness in a patient with another serious, often neoplastic, conditions There can, however, be little doubt that in bacterial endocarditis the most common cause of a sterile blood-culture is previous administration of an antibiotic, and no patient with fever and a heartmurmur should be treated with an antibiotic until bloodcultures have been made. Not more than five or six cultures are necessary,4 and these may be done over a period of 24 or 48 hours if further delay in treatment is
give
thought unjustifiable. A MEANINGLESS COMPARISON
BACTERIAL ENDOCARDITIS
RATIONAL treatment of bacterial endocarditis depends on the identification of the infecting organism,1 and
persistently sterile blood-cultures (which are by no means uncommon) merely confuse the issue. Hampton and Harrison,2 reviewing 107 patients treated for bacterial endocarditis at the United Oxford Hospitals between 1955 and 1965, found that 59% had positive and 41% negative blood-cultures. The groups with positive and negative cultures were similar in age and sex distribution and, in most respects, in histories, physical signs, and laboratory findings. In the culture-negative group, however, significantly more patients had a history of illness for more than 3 months before admission to hospital, and (probably related to this longer illness) anxmia was more frequent than in those with positive cultures. Embolic phenomena and breathlessness or heart-failure were also commoner in the negative group. Except in 3 cases, there did not seem to have been any significant delay in starting treatment in the patients with negative cultures; delay in treatment, when it did happen, seemed to be due more to failure to consider a diagnosis of bacterial endocarditis than to the fact that cultures were sterile. 50% of the positive group and 67% of the negative group had been given antibiotics either at home or in hospital before blood-cultures were taken, and, although this difference did not reach statistical significance, Hampton and Harrison think that prior administration of antibiotics was an important factor in the failure to obtain positive blood-cultures. Most other workers are agreed on this point,3-5 although Blount found positive cultures in as many treated patients as untreated. Antibiotics may cause a’ change in the characteristics of the infecting: organism, with the production of L-phase bacteria, which 8 are more difficult to isolate than the usual form.7 Sterile cultures may also be due to the presence of an organism, such as brucella,9 which does not grow easily in conventional culture media. Rickettsial endocarditis should be considered in any patient with persistently negative blood-cultures: although the organism cannot be cultured, a simple serological test can confirm the diagnosis.1O Non-bacterial thrombotic endocarditis may 1. 2. 3. 4. 5.
6. 7. 8. 9. 10.
Lancet, 1967, i, 605. Hampton, J. R., Harrison, M. J. G. Q. Jl Med. 1967, 36, 167. Hall, B., Dowling, H. F. Med. Clins N. Am. 1966, 50, 159. Lerner, P. I., Weinstein, L. New Engl. J. Med. 1966, 274, 323. Rabinovich, S., Evans, J., Smith, I. M., January, L. E. Ann. intern. Med. 1965, 63, 185. Blount, J. G. Am. J. Med. 1965, 38, 909. Godzeski, C. W., Brier, G., Griffith, R. S., Black, H. R. Nature, Lond. 1965, 205, 1340. Mattman, L. H., Mattman, P. E. Archs intern. Med. 1965, 115, 315. Peery, T. M., Belter, L. F. Am. J. Path. 1960, 36, 673. Grist, N. R., Ross, C. A. C., Sommerville, R. G. Lancet, 1967, i, 727.
PARTS of the
of Health’s latest annual report 148) read like a company prosfor the National Health Service in it 1966, says, pectus : " there has been a striking measure of success." Social historians of a later century, turning the yellowing pages of this report, may be pardoned for concluding that last year marked the opening of a medical Elysium on the shores of the United Kingdom. But the social historians can take care of themselves: anyhow they will probably be aware that it is in the nature of the Elephant to trumpet. What is inexcusable in the report-because it may deceive those who are yet alive-is that it once more prominently sets current and projected hospital capital expenditure against expenditure in the years before the 1939-45 war. Last year expenditure was " in real terms 63% above pre-war ". Splendid. But what does this mean ? The report absentmindedly fails to record with equal prominence that in the pre-war years, when most of the voluntary hospitals were tottering towards bankruptcy, capital expenditure was at a low ebb;" that for over two decades after 1939 construction of per" manent hospitals was virtually at a standstill; that, in real terms, each hospital bed now costs more; and that the population has increased and is expected to increase further. Comparison of current expenditure with that in the 1930s is no more meaningful (and it is a good deal A shipping more misleading) than with that in the 1630s. company which has to replace old vessels does not congratulate itself on its surge of new investment: it tells its shareholders how soon they may expect to possess a seaworthy fleet. Likewise the Ministry should frankly declare how far the current ten-year building programme will go towards meeting the proved need for new
(briefly referred
Ministry
to on p.
hospitals. REVERSING THE BRAIN DRAIN
IT is no secret that British doctors are emigrating to North America in sizeable numbers. Equally it is no secret that, of those who emigrate, a fair proportionpossibly about a third-return to the United Kingdom within a few years. To ease the way of any who contemplate re-crossing the Atlantic from West to East, the Ministry of Health is in October despatching to the United States and Canada a Board which will interview those interested. Among the attractions of the Ministry’s scheme are payment of fares (including those of the family) for selected applicants and guaranteed appointments for three years.
Inquiries
may be addressed to Dr. R. H.
Barrett, Ministry of
Health, Elephant and Castle, London S.E.l. 11.
MacDonald, R. A., Robbins, S.
L. Ann. intern. Med.
1957, 46, 255.