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THE ELEVEN PRINCIPLES
207
Letters
to
THE ELEVEN
the Editor PRINCIPLES
SiR,—The report of the Representative Committee to
its constituent bodies should receive our warmest support. I suggest three points of importance in its " General Principles " calling for amendment. (1) Surely "The health of the people depends primarily "
well as their opportunity, to help themselves. There is far too much talk of what the community must do for the individual, as compared with what the individual can and should do for himself. The words ... and upon the will of the people to help themselves " should be added. (10) Is "the central administrative structure ... con. cerned only with civilian health services " to be a Ministry of Health, stripped of its responsibility for local government and housing ? If so, local authorities will look to other departments for guidance ; and health will again become the Cinderella of local government. Why not call this central administration the Ministry of Health and strengthen it as suggested in the report ?*? I ’*’ Locally, new administrative bodies ... should be representative... in appropriate numbers, of the local medical profession...." Are these bodies to supplant the county and county borough councils and the local sanitary authorities ? If so, they must be elected by public vote and will not be representative of the local medical profession. If not, they will not have the power of the local authority, its officers And its purse; they will be yet another extra body to complicate and delay matters. Local government cannot be split up between health matters and others. The expected reform of local government will, it is hoped, provide bodies, elected by the people and directly responsible to them, who will be more and more influenced’by the other " local medical advisory committees," rightly proposed in this report. The more medical men in local, as in national, government the better. But do not let us tinker with the democratic system, however faulty, of elective government, local or national, giving the people the doctoring they want, in favour of a corporative exception, redolent of Mussolini. FRANCIS FREMANTLE. Hatfield, Herts. on
their will,
as
’
SULPHONAMIDE RESISTANCE SiR,-In your leader of July 10 the statement is made that " an organism which has become resistant to one sulphonamide is correspondingly resistant to all the others." Two years ago I had arrived at a similar conclusion, but I recognised that further investigation From this further investigation it now was necessary. seems that mv earlier conclusion was incorrect. Seven strains of haemolytic streptococci which were resistant to sulphanilamide were tested by the ditchplate method (Fleming,2 Colebrook & Francis 1) against four sulphonamides as shown in the following table. The figures indicate the width of the zone in which the growth was suppressed by the different compounds
(millimetres)
:-
*
1.
Sensitive control.
Colebrook, L. and Francis, A. E. J. Path. Bact. 1941. 53, 2. Fleming, A. Proc. R. Soc. Med. 1940-41, 34, 342.
155.
The results show that, of the seven strains resistant to sulphanilamide, only one was resistant to all four drugs and that six of the seven were sensitive to sulphathiazole (2-5 mg. per 100 c.cm)-a concentration which is easily obtained in the circulating blood with the
usual dosage.
So far as it goes, this evidence suggests that sulphathiazole is the drug of choice in dealing with resistant strains. Only one, out of 37 strains tested so far, has proved .resistant to this drug in a concentration of 20 mg. per 100 c.cm. Other evidence bearing on this question, which cannot profitably be discussed here, suggests that there is much to be learned yet about this property of sulphonamide-fastness and that we should do well to avoid too definite conclusions. LEONARD COLEBROOK. Glasgow. THE
TEACHING OF MEDICAL STUDENTS
SIR,-I feel sure most clinicians will agree with Dr. Geoffrey Evans that in the teaching of medical students
" disease must be the first concern." Preventive and social medicine, in so far as they are not mere political catch-words, are related to environmental factors which should be the proper concern of Government (in which term is included the Ministry of Health and Public Medical Services) and over which the practising physician can exercise but little control. Nevertheless the basis upon which preventive medicine exists and progresses is the experience gained in the treatment of the sick throughout the ages, and the recent fall in the death-rate, as shown by the latest returns of the Registrar-General, is attributable largely to the use of the sulphonamide compounds’, rather than to improved sociological conditions. The diagnosis and treatment of disease is an exacting and whole-time occupation of immense importance to the individual and to the nation. Man is a cyclical animal born to decay and perish, and in the New World, whether it be brave or otherwise, death in his varied and stealthy forms will be ever knocking at the door. He who wishes to become proficient in clinical medicine will be wise if he make no attempt to serve two masters; his vision must be focused on the patient, unobscured by the misty ambiguities of " social medicine " and " positive health "-phrases, to tell truth, which smack more of the politician than the scientist, characterised rather by their slogan appeal to the unthinking than by their relation to any intellectual concept. MacNair Wilson sums up the position well in his British Medici7ce: "Medicine however stands or falls by its practice. It is clinical or it is nothing and the work done at the bedside is the foundation as it is also the measure of its success." The cynic might add that medicine is clinical or it is-
politics. GORDON BURTON. Sawbridgeworth. GAS GANGRENE IN THE MIDDLE EAST SIR,-Your leading article of July 31 states that a fatality of 50% shows how little progress we have made in 25 years. Is the explanation possibly to be found in your statement that " The best prophylactic of gas gangrene is early and radical surgery " ? J. F. Kelly and D. A. Dowell in Roentgen Treatment of Infections (Year Book Publishers, 1942, p. 148) show a mortality of 11-5% in 364 cases. Having some little experience in the X-ray therapy of inflammatory conditions-but not of gas gangrene-I brought the matter to the notice of the appropriate authorities some twelve months ago, and suggested that a lorry or an aeroplane should be equipped with a suitable X-ray apparatus so that a controlled investigation into the value of X-ray therapy in’ The gas gangrene might be carried out in the field. replies received from both British and American Army authorities were unfavourable. I don’t know whether any of the 58 men who died in the Middle East could have been saved by radiotherapy, but neither will anybody know until it is tried. RALPH PHILLIPS. St. Bartholomew’s Hospital, E.C.!. * In the war the British Army of the ** early days considered the provision of mobile X-ray equipment for the treatment of gas gangrene in the forward areas. Such mobile units would need to work in front of the casualty clearing stations to be effective in fulminating
Letters
to
THE ELEVEN
the Editor PRINCIPLES
SiR,—The report of the Representative Committee to
its constituent bodies should receive our warmest support. I suggest three points of importance in its " General Principles " calling for amendment. (1) Surely "The health of the people depends primarily "
well as their opportunity, to help themselves. There is far too much talk of what the community must do for the individual, as compared with what the individual can and should do for himself. The words ... and upon the will of the people to help themselves " should be added. (10) Is "the central administrative structure ... con. cerned only with civilian health services " to be a Ministry of Health, stripped of its responsibility for local government and housing ? If so, local authorities will look to other departments for guidance ; and health will again become the Cinderella of local government. Why not call this central administration the Ministry of Health and strengthen it as suggested in the report ?*? I ’*’ Locally, new administrative bodies ... should be representative... in appropriate numbers, of the local medical profession...." Are these bodies to supplant the county and county borough councils and the local sanitary authorities ? If so, they must be elected by public vote and will not be representative of the local medical profession. If not, they will not have the power of the local authority, its officers And its purse; they will be yet another extra body to complicate and delay matters. Local government cannot be split up between health matters and others. The expected reform of local government will, it is hoped, provide bodies, elected by the people and directly responsible to them, who will be more and more influenced’by the other " local medical advisory committees," rightly proposed in this report. The more medical men in local, as in national, government the better. But do not let us tinker with the democratic system, however faulty, of elective government, local or national, giving the people the doctoring they want, in favour of a corporative exception, redolent of Mussolini. FRANCIS FREMANTLE. Hatfield, Herts. on
their will,
as
’
SULPHONAMIDE RESISTANCE SiR,-In your leader of July 10 the statement is made that " an organism which has become resistant to one sulphonamide is correspondingly resistant to all the others." Two years ago I had arrived at a similar conclusion, but I recognised that further investigation From this further investigation it now was necessary. seems that mv earlier conclusion was incorrect. Seven strains of haemolytic streptococci which were resistant to sulphanilamide were tested by the ditchplate method (Fleming,2 Colebrook & Francis 1) against four sulphonamides as shown in the following table. The figures indicate the width of the zone in which the growth was suppressed by the different compounds
(millimetres)
:-
*
1.
Sensitive control.
Colebrook, L. and Francis, A. E. J. Path. Bact. 1941. 53, 2. Fleming, A. Proc. R. Soc. Med. 1940-41, 34, 342.
155.
The results show that, of the seven strains resistant to sulphanilamide, only one was resistant to all four drugs and that six of the seven were sensitive to sulphathiazole (2-5 mg. per 100 c.cm)-a concentration which is easily obtained in the circulating blood with the
usual dosage.
So far as it goes, this evidence suggests that sulphathiazole is the drug of choice in dealing with resistant strains. Only one, out of 37 strains tested so far, has proved .resistant to this drug in a concentration of 20 mg. per 100 c.cm. Other evidence bearing on this question, which cannot profitably be discussed here, suggests that there is much to be learned yet about this property of sulphonamide-fastness and that we should do well to avoid too definite conclusions. LEONARD COLEBROOK. Glasgow. THE
TEACHING OF MEDICAL STUDENTS
SIR,-I feel sure most clinicians will agree with Dr. Geoffrey Evans that in the teaching of medical students
" disease must be the first concern." Preventive and social medicine, in so far as they are not mere political catch-words, are related to environmental factors which should be the proper concern of Government (in which term is included the Ministry of Health and Public Medical Services) and over which the practising physician can exercise but little control. Nevertheless the basis upon which preventive medicine exists and progresses is the experience gained in the treatment of the sick throughout the ages, and the recent fall in the death-rate, as shown by the latest returns of the Registrar-General, is attributable largely to the use of the sulphonamide compounds’, rather than to improved sociological conditions. The diagnosis and treatment of disease is an exacting and whole-time occupation of immense importance to the individual and to the nation. Man is a cyclical animal born to decay and perish, and in the New World, whether it be brave or otherwise, death in his varied and stealthy forms will be ever knocking at the door. He who wishes to become proficient in clinical medicine will be wise if he make no attempt to serve two masters; his vision must be focused on the patient, unobscured by the misty ambiguities of " social medicine " and " positive health "-phrases, to tell truth, which smack more of the politician than the scientist, characterised rather by their slogan appeal to the unthinking than by their relation to any intellectual concept. MacNair Wilson sums up the position well in his British Medici7ce: "Medicine however stands or falls by its practice. It is clinical or it is nothing and the work done at the bedside is the foundation as it is also the measure of its success." The cynic might add that medicine is clinical or it is-
politics. GORDON BURTON. Sawbridgeworth. GAS GANGRENE IN THE MIDDLE EAST SIR,-Your leading article of July 31 states that a fatality of 50% shows how little progress we have made in 25 years. Is the explanation possibly to be found in your statement that " The best prophylactic of gas gangrene is early and radical surgery " ? J. F. Kelly and D. A. Dowell in Roentgen Treatment of Infections (Year Book Publishers, 1942, p. 148) show a mortality of 11-5% in 364 cases. Having some little experience in the X-ray therapy of inflammatory conditions-but not of gas gangrene-I brought the matter to the notice of the appropriate authorities some twelve months ago, and suggested that a lorry or an aeroplane should be equipped with a suitable X-ray apparatus so that a controlled investigation into the value of X-ray therapy in’ The gas gangrene might be carried out in the field. replies received from both British and American Army authorities were unfavourable. I don’t know whether any of the 58 men who died in the Middle East could have been saved by radiotherapy, but neither will anybody know until it is tried. RALPH PHILLIPS. St. Bartholomew’s Hospital, E.C.!. * In the war the British Army of the ** early days considered the provision of mobile X-ray equipment for the treatment of gas gangrene in the forward areas. Such mobile units would need to work in front of the casualty clearing stations to be effective in fulminating