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TEACHING OF SOCIAL AND PREVENTIVE MEDICINE
286 Prior to the start of prophylaxis, beta haemolytic streptococci should be eradicated by proper treatment of the patient. (See methods of penicillin therapy reeommended above.)
seen.-
Hom Long Should Prophylaxis be Continuet In children, at least to the age of eighteen ; in all those above this age, for at least five years from their last attack. Should Prophylaxis be Contircued During the Summer t Yes. PROPHYLACTIC METHODS
Sulphadiazine This drug has the advantage of being easy to administer, inexpensive, and effective (other newer sulphonamides are probably equally effective). Although resistant streptococci have appeared during mass prophylaxis in
the
armed
forces, this is
rare
in
civilian
populations. 0 - 5 to I - 0 g. taken each morning throughout The smaller dose is to be used in children under
Dosage.-From the year.
sixty pounds. Toxic reactions.-These are infrequent and are usually minor. in any patient being given prophylaxis with sulphonamides consider all rashes and sore throats as possible toxic reactions to the drug, especially if they occur in the first eight weeks of prophylaxis. The chief toxic reactions are : Skin eruptions : (a) Morbilliform, much like measles. Continue drug with caution. (b) Urticarial. Best discontinue treatment. (c) Scarlatiniform, often associated with sore throat and fbver. Unsafe to continue drug. Blood reactions : Leucopenia. Discontinue if white blood-count falls below 4000 and polynuclear neutrophils below 35% because of possible agranulocytosis which is often associated with sore throat and a rash. Because of these reactions, weekly white blood-counts are advisable for the first two months of prophylaxis. (The use of sulphonamides therapeutically for any reason in this period should be preceded by a white blood-count.) The occurrence of agranulocytosis after eight weeks of continuous prophylaxis with sulphonamides is extremely rare.
However,
&mid ot;
Penicillin
Although experience with oral penicillin for the prophylaxis of rheumatic fever is more limited than that with the sulphonamides, the antibiotic promises to be a safe and effective prophylactic agent. Oral penicillin has the desirable characteristics of beingbactericidal for haemolytic streptococci and of rarely producing serious toxic reactions. It has the disadvantages of being more costly than sulphadiazine and because of the need of giving it on an empty stomach, of being somewhat more difficult to administer. Oral penicillin represents an alternative drug for rheumatic fever prophylaxis. It is especially important to use this agent for those who do not tolerate sulphadiazine. Dosage.-Although other routines of administration may satisfactory, the following schedules are suggested : 200,000 to 250.000 units two times daily is recommended. Since penicillin is best absorbed on an empty stomach, the time of administration should be 1/22 to 1 hour before a meal or at bedtime. A single dose of 200,000 to 230,000 units before prove
breakfast is less preferable. Toxic reactions.-(1) Urticaria. (2) Reactions similar to serum sickness-they include fever and joint pains and may be mistaken for rheumatic fever. (3) Angioneurotic oedema. Although many individuals who have had reactions to penicillin can subsequently take the drug without trouble, it is safer not to use penicillin, if the reaction has been severe and particularly if angioneurotic oedema has occurred. A.c.T.H. or cortisone, be cautious that other not masked since the prophylactic dose is to treat such concurrent illnesses as pneumonia or
t In patients receiving infections
are
inadequate meningitis. -
TEACHING OF SOCIAL AND PREVENTIVE MEDICINE THE Royal College of Physicians, through its Social and Preventive Medicine Committee, has been re-examining methods of teaching social and preventive medicine and comparing present conditions with those described in the committee’s first interim report of 1943.1 The progress report published last month observes that chairs of social or preventive medicine have now been created in almost every provincial university, thus going far towards fulfilling the committee’s earlier hope that every medical school would eventually have a department of social and preventive medicine. PROVINCIAL SCHOOLS
Turning first to the provincial medical schools, the committee found that almost everywhere the number of hours’ teaching directly devoted to social medicine had been doubled ; and in general the curriculum in social medicine is spread over the three clinical years. Some departments are directed by a whole-time professor who has one or more active medical omcers of health on his staff, others are directed by a medical officer of health as part-time professor or lecturer, with whole-time university lecturers carrying out most of the teaching programme. There is remarkably little difference between the two arrangements, the report continues, and one way or the other " the programmes of the different provincial schools show an encouraging improvement," although " a detailed examination suggests that in some of them there are still serious gaps in teaching practice." The importance of occupational health and industrial medicine is generally accepted, but some schools are unable to give these subjects as much teaching- time as they would wish. Personal hygiene and environmental hygiene have a place in the undergraduate curriculum of every provincial school, but the amount of time devoted to them is relatively small. The report commends the statistical departments which are appearing within, or in close association with, some departments of social medicine. " Theoretical statistics is a subject often included in the social medicine curriculum, but more as a matter of convenience than on grounds of compelling logic. As a rule, however, there is no alternative provision for teaching this subject, and in the absence of a separate Statistical Department, the attachment of a Statistical Section to a Department of Social Medicine is usually a good working
arrangement." LONDON
SCHOOLS
The arrangements in London are very different, partly because the schools do not have to give postgraduate teaching in public health, which is provided by the London School of Hygiene and Tropical Medicine and by the Royal Institute of Public Health. Apart from of formal lectures for undergraduates, the courses London schools aim to teach by integrating social aspects of illness with clinical subjects and pathology. The report quotes the dean of one London school : " Social medicine cannot and should not be taught to the undergraduate student as a special subject." It seems that no undergraduate schools in London are undertaking sociomedical research in the way that many of the provincial schools are doing. The committee conclude : " it appears that generally speaking the consolidation of social’medicine as a subject in the curriculum in London lags behind the best provincial arrangements.... Epidemiology in the wide sense does not appear to be treated systematically at any point in many London schools." -
-
1. See
Lancet, 1943, ii, 546.
seen.-
Hom Long Should Prophylaxis be Continuet In children, at least to the age of eighteen ; in all those above this age, for at least five years from their last attack. Should Prophylaxis be Contircued During the Summer t Yes. PROPHYLACTIC METHODS
Sulphadiazine This drug has the advantage of being easy to administer, inexpensive, and effective (other newer sulphonamides are probably equally effective). Although resistant streptococci have appeared during mass prophylaxis in
the
armed
forces, this is
rare
in
civilian
populations. 0 - 5 to I - 0 g. taken each morning throughout The smaller dose is to be used in children under
Dosage.-From the year.
sixty pounds. Toxic reactions.-These are infrequent and are usually minor. in any patient being given prophylaxis with sulphonamides consider all rashes and sore throats as possible toxic reactions to the drug, especially if they occur in the first eight weeks of prophylaxis. The chief toxic reactions are : Skin eruptions : (a) Morbilliform, much like measles. Continue drug with caution. (b) Urticarial. Best discontinue treatment. (c) Scarlatiniform, often associated with sore throat and fbver. Unsafe to continue drug. Blood reactions : Leucopenia. Discontinue if white blood-count falls below 4000 and polynuclear neutrophils below 35% because of possible agranulocytosis which is often associated with sore throat and a rash. Because of these reactions, weekly white blood-counts are advisable for the first two months of prophylaxis. (The use of sulphonamides therapeutically for any reason in this period should be preceded by a white blood-count.) The occurrence of agranulocytosis after eight weeks of continuous prophylaxis with sulphonamides is extremely rare.
However,
&mid ot;
Penicillin
Although experience with oral penicillin for the prophylaxis of rheumatic fever is more limited than that with the sulphonamides, the antibiotic promises to be a safe and effective prophylactic agent. Oral penicillin has the desirable characteristics of beingbactericidal for haemolytic streptococci and of rarely producing serious toxic reactions. It has the disadvantages of being more costly than sulphadiazine and because of the need of giving it on an empty stomach, of being somewhat more difficult to administer. Oral penicillin represents an alternative drug for rheumatic fever prophylaxis. It is especially important to use this agent for those who do not tolerate sulphadiazine. Dosage.-Although other routines of administration may satisfactory, the following schedules are suggested : 200,000 to 250.000 units two times daily is recommended. Since penicillin is best absorbed on an empty stomach, the time of administration should be 1/22 to 1 hour before a meal or at bedtime. A single dose of 200,000 to 230,000 units before prove
breakfast is less preferable. Toxic reactions.-(1) Urticaria. (2) Reactions similar to serum sickness-they include fever and joint pains and may be mistaken for rheumatic fever. (3) Angioneurotic oedema. Although many individuals who have had reactions to penicillin can subsequently take the drug without trouble, it is safer not to use penicillin, if the reaction has been severe and particularly if angioneurotic oedema has occurred. A.c.T.H. or cortisone, be cautious that other not masked since the prophylactic dose is to treat such concurrent illnesses as pneumonia or
t In patients receiving infections
are
inadequate meningitis. -
TEACHING OF SOCIAL AND PREVENTIVE MEDICINE THE Royal College of Physicians, through its Social and Preventive Medicine Committee, has been re-examining methods of teaching social and preventive medicine and comparing present conditions with those described in the committee’s first interim report of 1943.1 The progress report published last month observes that chairs of social or preventive medicine have now been created in almost every provincial university, thus going far towards fulfilling the committee’s earlier hope that every medical school would eventually have a department of social and preventive medicine. PROVINCIAL SCHOOLS
Turning first to the provincial medical schools, the committee found that almost everywhere the number of hours’ teaching directly devoted to social medicine had been doubled ; and in general the curriculum in social medicine is spread over the three clinical years. Some departments are directed by a whole-time professor who has one or more active medical omcers of health on his staff, others are directed by a medical officer of health as part-time professor or lecturer, with whole-time university lecturers carrying out most of the teaching programme. There is remarkably little difference between the two arrangements, the report continues, and one way or the other " the programmes of the different provincial schools show an encouraging improvement," although " a detailed examination suggests that in some of them there are still serious gaps in teaching practice." The importance of occupational health and industrial medicine is generally accepted, but some schools are unable to give these subjects as much teaching- time as they would wish. Personal hygiene and environmental hygiene have a place in the undergraduate curriculum of every provincial school, but the amount of time devoted to them is relatively small. The report commends the statistical departments which are appearing within, or in close association with, some departments of social medicine. " Theoretical statistics is a subject often included in the social medicine curriculum, but more as a matter of convenience than on grounds of compelling logic. As a rule, however, there is no alternative provision for teaching this subject, and in the absence of a separate Statistical Department, the attachment of a Statistical Section to a Department of Social Medicine is usually a good working
arrangement." LONDON
SCHOOLS
The arrangements in London are very different, partly because the schools do not have to give postgraduate teaching in public health, which is provided by the London School of Hygiene and Tropical Medicine and by the Royal Institute of Public Health. Apart from of formal lectures for undergraduates, the courses London schools aim to teach by integrating social aspects of illness with clinical subjects and pathology. The report quotes the dean of one London school : " Social medicine cannot and should not be taught to the undergraduate student as a special subject." It seems that no undergraduate schools in London are undertaking sociomedical research in the way that many of the provincial schools are doing. The committee conclude : " it appears that generally speaking the consolidation of social’medicine as a subject in the curriculum in London lags behind the best provincial arrangements.... Epidemiology in the wide sense does not appear to be treated systematically at any point in many London schools." -
-
1. See
Lancet, 1943, ii, 546.