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THE CLAIM
181 a compound in which a methyl group has been substituted for the p-amino group, show that it has a similar hypoglycaemic action when given by mouth to rats, dogs, rabbits, and men. In diabetic patients the results and indications for its successful also very much the same ; but unlike use are sulphanyl butylurea it has only a slight bacteriostatic action. The way in which these substances produced hypoglycsemia is still obscure. The various possibilities have lately been reviewed by BEST.12 Neither clinical observations nor experimental findings in hypophysectomised and adrenalectomised animals have pointed to a direct action on these glands. Thyroid function, as measured with radio-iodine, may be depressed in diabetic patients after the administration of these substances, and enlargement of the thyroid in the rat has been noted after large doses.1o 13 The sulphanyl-urea compounds can apparently reduce the blood-sugar level only in patients who can secrete some endogenous insulin.14 The suggestion that they act on the «-cells of the pancreas has not been confirmed ; and no consistent changes have been found in these cells in either animals or patients who had had the drugs.9 15 Another possibility is that the sulphanyl ureas are non-competitive inhibitors of an enzyme, insulinase, responsible for the destruction
orinase),
’
Best, C. H. Ibid, p. 957. Kinsell, L. W., Brown, F. R., Friskey, R. W., Michaels, G. D. Science, 1956, 123, 585. 14. Wrenshall, G. A., Best, C. H. Canad. med. Ass. J. 1956, 74, 12. 13.
968. 15.
Ferner, H., Runge, W.
Dtsch. med. Wschr.
1956, 81, 331.
Annotations THE CLAIM the text of the Joint Negotiating in favour of a 24% rise in payments to general practitioners and hospital medical staff in the National Health Service. The basis of this case is that, since doctors joined the service on the promise of remuneration at a particular level in relation to the rewards of comparable work, the Government have an obligation to maintain that level : they made a contract with the profession, and, if they allow the purchasingpower of doctors to decline steadily in relation to that of the rest of the community, they will break their contract and in so doing will damage the service and its usefulness to the public. Essentially, this is true. It is fair to add, however, that-though they did it slowly, reluctantly, and sometimes inadvertently-successive Governments did eventually produce a settlement which was generally equitable in terms of the 1951 value of money. If inflation had not continued (indeed quickened), there would have now been no cause for complaint ; and this illustrates the fact that doctors have at least as much reason as other citizens for desiring the end of a process which alters the meaning of all financial agreements within a few months of their being reached. Failing radical treatment of inflation, the Joint Negotiating Committee are right in insisting that the pay of doctors should be periodically adjusted according to the fall in the value of money and the rise in most other people’s incomes. LTnfortunately, however, we have to recognise that no Government has yet conceded that medical remuneration should rise’ automatically with the cost of living, and that sueh a device can reasonably be resisted on the ground that it isa form of symptomatic treatment which, if generally adopted, must exacerbate the economic ON p. 189
Committee’s
we
publish
case
of insulin..16-18
But in-vitro experiments have not demonstrated inhibition of insulinase activity in concentrations that might reasonably be expected to occur in vivo.19 A further explanation is that the rate of formation and liberation of insulin from the pancreas may be increased,2O 21 but such changes are very hard to measure and they must be studied indirectly. In animal experiments, liver glycogen is increased after the administration of sulphanyl urea, whereas muscle glycogen remains unchanged. Insulin, on the other hand, produces a substantial increase in muscle glycogen, and there is thus a difference in the action of the two agents.9 10 There is evidence that sulphanyl urea reduces the hexose-6-phosphatase of the liver 22 and also the rate of absorption of glucose from the intestine.23 These actions contribute to a reduction in the blood-sugai level, though other factors may also be at work. No measurable amounts of sulphanyl urea have been found to accumulate in any organs ; and tolylsulphonyl urea labelled with 35S is not incorporated in the insulin molecule.99 From the observations reported so far, it seems likely that one of the primary sites of action of these compounds is the enzyme systems in the liver. 16. Mirsky, I. A., Diengott, D., Dolger, H. Science, 1956, 123, 583. 17. Mirsky, I. A. Metabolism, 1956, 5, 138. 18. Mirsky, I. A., Perisutti, G., Diengott, D. Ibid, p. 156. 19. Vaughan, M. Science, 1956, 123, 885. 20. Loubatières, A. Pr. méd. 1955, 63, 1701. 21. Ashworth, M. A., Haist, R. E. Canad. med. Ass. J. 1956, 74, 975. 22. Hawkins, R., Ashworth, M. A., Haist, R. E. Ibid, p. 972. 23. Friedlich, T. L., Ashworth, M. A., Hawkins, R. D., Haist, R. E. Ibid, p. 973.
illness.
Moreover
if
the
present
Government
are
genuinely determined to halt inflation, and believe that their present measures will do it, they can hardly be expected to welcome the committee’s argument that the doctors’ claim-since it asks merely for fulfilment of a contract-does not come within the scope of the Chancellor’s appeal for restraint. Having had a sharp reply which cannot have been wholly unexpected, the Joint Negotiating Committee may decide to press their claim at once, by whatever means they can. Or, having registered the claim, they may seek discussions on a more amicable if less immediate level. Or, postponing the general claim for a period, they may urge the Government at least to consider what can be done without delay to mitigate particular hardships. Whatever course they decide on, they will have the support of all their colleagues in believing that doctors in the N.H.S. should not indefinitely accept a relative decline in their remuneration. Some of us may add that, so long after the service started, its machinery ought to be such as will award suitable pay without continual contests.
DENTAL CARIES IN AFRICA slogan " clean teeth don’t decay," which used to hang in some dental waiting-rooms twenty years or so ago, is unfortunately no more than a half-truth. Regular and efficient cleaning will slightly reduce the incidence of caries, but it is one only of many factors. We have lately discussed2 the part played in the production of dental caries by different types of foodstuffs. The amount and kind of sugars in the diet have been investigated, and these researches show sufficient agreement to suggest that dietary control could help A recent study3 of young African to reduce caries. THE
1. See Lancet, July 21, 1956, p. 151. 2. Ibid, July 7, 1956, p. 27. 3. Welbourn, H. F. East Afr. med. J.
1956, 33, 181.
orinase),
’
Best, C. H. Ibid, p. 957. Kinsell, L. W., Brown, F. R., Friskey, R. W., Michaels, G. D. Science, 1956, 123, 585. 14. Wrenshall, G. A., Best, C. H. Canad. med. Ass. J. 1956, 74, 12. 13.
968. 15.
Ferner, H., Runge, W.
Dtsch. med. Wschr.
1956, 81, 331.
Annotations THE CLAIM the text of the Joint Negotiating in favour of a 24% rise in payments to general practitioners and hospital medical staff in the National Health Service. The basis of this case is that, since doctors joined the service on the promise of remuneration at a particular level in relation to the rewards of comparable work, the Government have an obligation to maintain that level : they made a contract with the profession, and, if they allow the purchasingpower of doctors to decline steadily in relation to that of the rest of the community, they will break their contract and in so doing will damage the service and its usefulness to the public. Essentially, this is true. It is fair to add, however, that-though they did it slowly, reluctantly, and sometimes inadvertently-successive Governments did eventually produce a settlement which was generally equitable in terms of the 1951 value of money. If inflation had not continued (indeed quickened), there would have now been no cause for complaint ; and this illustrates the fact that doctors have at least as much reason as other citizens for desiring the end of a process which alters the meaning of all financial agreements within a few months of their being reached. Failing radical treatment of inflation, the Joint Negotiating Committee are right in insisting that the pay of doctors should be periodically adjusted according to the fall in the value of money and the rise in most other people’s incomes. LTnfortunately, however, we have to recognise that no Government has yet conceded that medical remuneration should rise’ automatically with the cost of living, and that sueh a device can reasonably be resisted on the ground that it isa form of symptomatic treatment which, if generally adopted, must exacerbate the economic ON p. 189
Committee’s
we
publish
case
of insulin..16-18
But in-vitro experiments have not demonstrated inhibition of insulinase activity in concentrations that might reasonably be expected to occur in vivo.19 A further explanation is that the rate of formation and liberation of insulin from the pancreas may be increased,2O 21 but such changes are very hard to measure and they must be studied indirectly. In animal experiments, liver glycogen is increased after the administration of sulphanyl urea, whereas muscle glycogen remains unchanged. Insulin, on the other hand, produces a substantial increase in muscle glycogen, and there is thus a difference in the action of the two agents.9 10 There is evidence that sulphanyl urea reduces the hexose-6-phosphatase of the liver 22 and also the rate of absorption of glucose from the intestine.23 These actions contribute to a reduction in the blood-sugai level, though other factors may also be at work. No measurable amounts of sulphanyl urea have been found to accumulate in any organs ; and tolylsulphonyl urea labelled with 35S is not incorporated in the insulin molecule.99 From the observations reported so far, it seems likely that one of the primary sites of action of these compounds is the enzyme systems in the liver. 16. Mirsky, I. A., Diengott, D., Dolger, H. Science, 1956, 123, 583. 17. Mirsky, I. A. Metabolism, 1956, 5, 138. 18. Mirsky, I. A., Perisutti, G., Diengott, D. Ibid, p. 156. 19. Vaughan, M. Science, 1956, 123, 885. 20. Loubatières, A. Pr. méd. 1955, 63, 1701. 21. Ashworth, M. A., Haist, R. E. Canad. med. Ass. J. 1956, 74, 975. 22. Hawkins, R., Ashworth, M. A., Haist, R. E. Ibid, p. 972. 23. Friedlich, T. L., Ashworth, M. A., Hawkins, R. D., Haist, R. E. Ibid, p. 973.
illness.
Moreover
if
the
present
Government
are
genuinely determined to halt inflation, and believe that their present measures will do it, they can hardly be expected to welcome the committee’s argument that the doctors’ claim-since it asks merely for fulfilment of a contract-does not come within the scope of the Chancellor’s appeal for restraint. Having had a sharp reply which cannot have been wholly unexpected, the Joint Negotiating Committee may decide to press their claim at once, by whatever means they can. Or, having registered the claim, they may seek discussions on a more amicable if less immediate level. Or, postponing the general claim for a period, they may urge the Government at least to consider what can be done without delay to mitigate particular hardships. Whatever course they decide on, they will have the support of all their colleagues in believing that doctors in the N.H.S. should not indefinitely accept a relative decline in their remuneration. Some of us may add that, so long after the service started, its machinery ought to be such as will award suitable pay without continual contests.
DENTAL CARIES IN AFRICA slogan " clean teeth don’t decay," which used to hang in some dental waiting-rooms twenty years or so ago, is unfortunately no more than a half-truth. Regular and efficient cleaning will slightly reduce the incidence of caries, but it is one only of many factors. We have lately discussed2 the part played in the production of dental caries by different types of foodstuffs. The amount and kind of sugars in the diet have been investigated, and these researches show sufficient agreement to suggest that dietary control could help A recent study3 of young African to reduce caries. THE
1. See Lancet, July 21, 1956, p. 151. 2. Ibid, July 7, 1956, p. 27. 3. Welbourn, H. F. East Afr. med. J.
1956, 33, 181.