- Email: [email protected]
THE FUTURE OF GENERAL PRACTICE
486 factors concerned with the contractile mechanism of uterine muscle, he has nevertheless been cautious in defining the exact quantitative role of oestrogen in human myometrial disorders. Uterine volume is another factor which may be important in determining the state of myometrial function after fcetal death. Csapo et al.were able to initiate labour by the intraamniotic injection of 500 ml. of 5% dextrose in water in two cases where considerable reduction of uterine volume had occurred after foetal death, and there is already a certain amount of evidence concerning the basic role of uterine volume in determining the onset of labour in both rabbit and human
pregnancy.2 Queen Charlotte’s Maternity Hospital, London, W.6.
CARL WOOD.
M. H. GHANEM MOUFID H. FAHMI A. TANIOUS.
Alexandria, Egypt.
IATROGENIC " suffix -genic is used indiscriminately to "
SiR,łThe
causing " (atherogenic, carcinogenic, mutagenic, pathogenic, pyrogenic) or " caused by" (agnogenic, cryptogenic, iatrogenic, neurogenic, psychogenic); and there is haemogenic shock ", shock caused not by blood but by loss of it.
mean "
"
AND FIBRINOLYTIC ACTIVITY SiR,łWe would like to report on the effect of phenformin (D.B.I.) on fibrinolytic activity of the blood. Fearnley et al.3 reported that, after injection of 20 units of soluble insulin in 4 diabetic patients, an initial decrease in fibrinolytic activity was followed by a rapid rebound increase when the blood-glucose was at its lowest level. This resulted probably from adrenaline release. On the other hand the same workers later reportedthat sulphonylurea (tolbutamide and chloropropamide) increased the fibrinolytic activity in 7 out of 18 non-diabetics suffering from thromboembolic
PHENFORMIN
significantly affect the fibrinolytic activity either by reduction, as with insulin, or by increase, as with sulphonylurea.
(D.B.I.)
What is worse,
some
of the words
are
used in both
senses.
" Ewing used the termosteogenic ’ to indicate that the tumor is of osseous genesis but other writers use it to mean that it forms bone tissue ... many recent writers prefer to use the non-committal term ’osteosarcoma’." )I In medicine, cause and effect are often hard to distinguish, and it is intolerable that ill-conceived words should increase the confusion. Dr. Arie and Mr. Cronin (Jan. 27) would discard " iatrogenic ", and many pathologists would discard " osteogenic "; I believe that lucidity would be served by our discarding all words of this class-preferably before someone hits on the idea of labelling inherited disorders " genogenic ". Faulkner Hospital, D. M. Boston,
Mass.
JACKSON.
THE FUTURE OF GENERAL PRACTICE
Actual and mean rates of fibrinolysis before and after administration for fifteen days of soluble insulin and 100 mg. phenformin daily to 14 diabetics.
disease. Unlike the effect with insulin, this effect was unrelated to the blood-sugar level. We have determined the fibrin lysed per hour before and after administration of phenformin. The percentage of fibrin lysed after six and twelve hours was estimated by the quantitative method of Bide11.5&a cute; Three and a half hours after a single oral dose of 50 mg. of
phenformin no significant changes in fibrinolytic activity (p < 0.2) or blood-sugar (p < 0.3) was observed in 6 diabetics compared with 4 normal controls. Similarly no significant change in fibrinolytic activity was observed in 14 diabetics. Activity was estimated in 14 diabetics after a fifteen-day course of combined soluble insulin and 100 mg. phenformin (see figure). An insignificant increase in fibrinolytic activity was observed in the 4 patients who had a relatively greater drop in their blood-sugars (34-3% to 22-5%).
experience we have found that the brief long-continued administration of phenformin does not
In this limited or 1.
Csapo, A., Jaffin, H., Kerenyi, T., Lipman, J., Wood, C. published.
To be
2. Csapo, A., Lloyd-Jacob, M. Amer. J. Obstet. Gynec. (in the press). 3. Fearnley, G. R., Vincent, C. T., Chakrabarti, R. Lancet, 1959, ii, 1067. 4. ibid. 1960, ii, 622. 5. Bidwell, E., Biochem. J. 1953, 55, 497.
SIR,-Iwas cheered to read that others share my conviction that general practice is truly a specialty in its own right. The picture of the general practitioner drawn by Dr. Cardew (Feb. 3) and Dr. Stark Murray (Feb. 17) is that of a front-line defender against illness, whether physical or otherwise. This picture is not an abstract one, for such can be found, even in 1962, in many parts of the country. Being a third-rate consultant, or even a junior hospital medical officer, is really a distraction from his proper work, which requires his full attention. To do this work efficiently, he needs two things. First, ability to recognise which patients will be best treated by himself and which will benefit from specialised advice. This ability is necessarily founded upon up-to-date general medical knowledge. It is here that he should gain the invaluable help of his local consultants, year-round seminars being a more effective way to provide him with this knowledge than occasional intensive courses of lectures and case demonstrations. Secondly, he must have full access to all those diagnostic routines which are within his own ability to interpret authoritatively. Such considerations prompt some further comments. Writers, in growing numbers, during the past few years have warned of the danger lest-in the vast machine which is the National Health Service-the primary needs of the patient may be largely overlooked. How good for all our patients it would be if three wise men " could ponder their needs, and how they might be met! Such small " thinking units" have a way of getting to the root of a problem in a way often denied to larger committees. Just how much the patient’s needs can be ignored is vividly shown in the structure and administration of the maternity medical services. The views of the Treasury, the local health authorities, the hospital boards, and, quite often, the consultants are given due weight and consideration. The needs of the person most concerned (the patient) are best understood by the person most intimately known (the general practitioner), yet he it is whose representations are most consistently ignored by officialdom. But these thoughts run quite counter to current trends. 1. Aegerter, E., Kirkpatrick, J. A. Orthopedic Diseases; p. 449, Philadelphia, 1958. "
487
Letters to The Lancet release one’s tension, but do they affect policies in any degree whatsoever ? Is it too late to save the man outlined by your previous correspondents, or is the take-over bid already accepted though not yet divulged ? I rather think it is. G. F. TRIPP. Dartford, Kent. NEW FIBRINOLYTIC AND ANTICOAGULANT ENZYME
SIR,-It was with great interest that I read the preliminary communication1 about the enzyme isolated from Pseudomonasfluorescens, because recently we observed that Ps. aeruginosa possessed fibrinolytic activity. None of the standard textbooks on bacteriology mention the ability of pseudomonas of any species to produce fibrinolysin. The fibrinolysin we described2 resembles in many ways that isolated by Adamis from Ps. fluorescens. One important difference, however, is that the aeruginosa enzyme is heat-stable. Our work
was
first described to the Indian Association of Patho1959.
logists in Poona on Dec. 18,
Department of Pathology, Mahatma Gandhi Memorial Medical Indore, India.
College,
ARVIND G. BHAGWAT.
OLD AGE IS NOT A DISEASE am SIR,-I very loth to criticise the article of Jan. 13 by Dr. Robert Kemp, but I feel that, as no-one else seems to have offered criticism during the month which has followed its publication, I ought to do so. In the first place, he says that to the medical officer of health
patient " is a name a long way down the waiting-list for hostel accommodation ". This suggests that the medical officer of health is in control of hostel accommodation. As secretary of the welfare group of the Society of Medical Officers of Health, I know that, in the majority of cases, the welfare services are not administered by the medical officer of health. Most medical officers of health I know, at any rate in the smaller boroughs, do not think of the old people in their area as merely names either on or off a waiting-list, but take a great personal interest in them. Dr. Kemp also says, " it is not for doctors to preach on the right and wrong way to grow old, but most of the troubles of old age are due to personal mismanagement ...". Health education, which is an important and continuing function of any medical officer of health and his staff, attempts to do just the
this.
J. ADRIAN GILLET Civic Centre, Dagenham, Essex.
Secretary, Welfare Group, Society of Medical Officers of Health.
ADRENALINE AND SCHIZOPHRENIA
SiR,—The following
case
tion with adrenaline and annotation of Jan. 27.
may be of interest in
connec-
schizophrenia, discussed in
your
A 50-year-old man, a nurse in a mental hospital, received prophylactic tetanus antitoxin a short time after an accidental head wound. An immediate anaphylactic reaction developed, with severe hypotension, convulsions, and loss of consciousness. I injected 1 mg. of adrenaline subcutaneously and he soon recovered completely. I was surprised by an obvious change in the patient’s attitude some minutes after recovery. He was exaggeratedly preoccupied with his slight wound, showed terrible anxiety, and finally expressed the conviction that the people in the room were speaking about him, about his death, and were making plans directed against him. Despite the apparent narrowing of his attention, he noted each person who entered or left the room and gave strange interpretations of each movement. After an 1. 2.
D. M. Lancet, 1961, ii, 1070. Rangam, C. M., Gupta, J. C., Bhagwat, R. R., Bhagwat, A. G. Ind. J. med. Res. 1961, 49, 232.
Adamis,
work and had slight amnesia for the He was known to be an anxious emotional person and he had had a gastrectomy for duodenal ulcer. hour he wanted
to return to
suspicion-anxiety period.
I am inclined to link this paranoid reaction to the adrenaline injection in a predisposed person-he was working in a situation not free from anxiety and among aggressive people, and at the time of the injection he was in a state of temporary cerebral anoxia. EDGAR PICK. Jerusalem. THE NEW HOSPITALS
SiR,—Thinking of hospitals up and down this country which I worked in or visited as a General Nursing Council examiner, and a few in which I was employed in China, I would incorporate in the new ones to be built: (a) Many more
washbasins in the wards-as many as one to beds-in neat recesses but very near the beds. (b) Well-designed changing-rooms for non-resident nurses attached to every ward and department. Built-in furniture for each nurse should include a drawer big enough to hold a week’s supply of clean uniform, a container for discarded uniform, a locker for outdoor clothing and shoes, and draw-curtains for privacy when changing. (c) Small " homely " nurses’ homes for the few nurses still resident. A mere cubby hole of a bedroom would do, but opening from it would be a comfortable private sitting-room and the means for making light meals. These individual, private sitting-rooms could be furnished by the occupant. (d) Instead of a single room for " matron’s office ", my ideal hospital would have a suite with a comfortable private waitingroom, a small sitting-room (reasonably sound-proof) where the matron could talk privately to her nurses or ancillary staff, and a small dining-room where she could entertain official visitors. every
two
Wonderful architecture and shining will not alone attract nursing staff.
expensive equip-
ment
Burton-in-Lonsdale, Lancashire.
11. JC MARIE . IE A. A SIMPSON. SMPSON
.
CHRONIC TETANY AND MAGNESIUM DEPLETION SIR,-Iread with great interest Dr. Durlach’s letter1 and I agree with most of his ideas. But there is one
phrase that could lead to misunderstanding-namely, French papers ". Indeed, although many studies from my laboratory were issued in France, the first publications appeared in Belgium (in Dutch or French). And precisely those studies, started in 1956described for the first time the " low magnesium tetany " syndrome as the most common form of tetany 3-5 and proved the efficacy of the treatment 36 proposed. Our delimitation of this syndrome with its electromyographic changes and hypomagnesxmia was comfirmed7 a year later by Durlach and others. The works of Turpin, Klotz, Contamin, Vallee, Hannah, and others describe interesting aspects regarding hypocalcsemia and hypomagnesaemia, including new evidence about this syndrome. Magnesium oxide gave the best results. In our opinion several magnesium salts can be used until the best treat"
ment
is found.
Laboratory of Electromyography, N. ROSSELLE. University of Louvain, Belgium. 1. Durlach, J. Lancet, 1961, i, 282. 2. Rosselle, N., De Doncker, K. Belg. T. Geneesk. 1957, 13, 265. 3. Rosselle, N., De Doncker, K. Acta. clin. belg. 1959, 14, 162; Pathol. Biol. 1959, 7, 1835. 4. De Doncker, K., Rosselle, N. J. Physiol. 1959, 51, 39. 5. Rosselle, N., De Doncker, K. Rev. franc. Et. clin. biol. 1960, 5, 1018. 6. Rosselle, N., De Doncker, K. Brux. méd. 1960, 40, 1625. 7. Durlach, J., Lebrun, R. Ann. Endocr., Paris, 1960, 21, 244.
pregnancy.2 Queen Charlotte’s Maternity Hospital, London, W.6.
CARL WOOD.
M. H. GHANEM MOUFID H. FAHMI A. TANIOUS.
Alexandria, Egypt.
IATROGENIC " suffix -genic is used indiscriminately to "
SiR,łThe
causing " (atherogenic, carcinogenic, mutagenic, pathogenic, pyrogenic) or " caused by" (agnogenic, cryptogenic, iatrogenic, neurogenic, psychogenic); and there is haemogenic shock ", shock caused not by blood but by loss of it.
mean "
"
AND FIBRINOLYTIC ACTIVITY SiR,łWe would like to report on the effect of phenformin (D.B.I.) on fibrinolytic activity of the blood. Fearnley et al.3 reported that, after injection of 20 units of soluble insulin in 4 diabetic patients, an initial decrease in fibrinolytic activity was followed by a rapid rebound increase when the blood-glucose was at its lowest level. This resulted probably from adrenaline release. On the other hand the same workers later reportedthat sulphonylurea (tolbutamide and chloropropamide) increased the fibrinolytic activity in 7 out of 18 non-diabetics suffering from thromboembolic
PHENFORMIN
significantly affect the fibrinolytic activity either by reduction, as with insulin, or by increase, as with sulphonylurea.
(D.B.I.)
What is worse,
some
of the words
are
used in both
senses.
" Ewing used the termosteogenic ’ to indicate that the tumor is of osseous genesis but other writers use it to mean that it forms bone tissue ... many recent writers prefer to use the non-committal term ’osteosarcoma’." )I In medicine, cause and effect are often hard to distinguish, and it is intolerable that ill-conceived words should increase the confusion. Dr. Arie and Mr. Cronin (Jan. 27) would discard " iatrogenic ", and many pathologists would discard " osteogenic "; I believe that lucidity would be served by our discarding all words of this class-preferably before someone hits on the idea of labelling inherited disorders " genogenic ". Faulkner Hospital, D. M. Boston,
Mass.
JACKSON.
THE FUTURE OF GENERAL PRACTICE
Actual and mean rates of fibrinolysis before and after administration for fifteen days of soluble insulin and 100 mg. phenformin daily to 14 diabetics.
disease. Unlike the effect with insulin, this effect was unrelated to the blood-sugar level. We have determined the fibrin lysed per hour before and after administration of phenformin. The percentage of fibrin lysed after six and twelve hours was estimated by the quantitative method of Bide11.5&a cute; Three and a half hours after a single oral dose of 50 mg. of
phenformin no significant changes in fibrinolytic activity (p < 0.2) or blood-sugar (p < 0.3) was observed in 6 diabetics compared with 4 normal controls. Similarly no significant change in fibrinolytic activity was observed in 14 diabetics. Activity was estimated in 14 diabetics after a fifteen-day course of combined soluble insulin and 100 mg. phenformin (see figure). An insignificant increase in fibrinolytic activity was observed in the 4 patients who had a relatively greater drop in their blood-sugars (34-3% to 22-5%).
experience we have found that the brief long-continued administration of phenformin does not
In this limited or 1.
Csapo, A., Jaffin, H., Kerenyi, T., Lipman, J., Wood, C. published.
To be
2. Csapo, A., Lloyd-Jacob, M. Amer. J. Obstet. Gynec. (in the press). 3. Fearnley, G. R., Vincent, C. T., Chakrabarti, R. Lancet, 1959, ii, 1067. 4. ibid. 1960, ii, 622. 5. Bidwell, E., Biochem. J. 1953, 55, 497.
SIR,-Iwas cheered to read that others share my conviction that general practice is truly a specialty in its own right. The picture of the general practitioner drawn by Dr. Cardew (Feb. 3) and Dr. Stark Murray (Feb. 17) is that of a front-line defender against illness, whether physical or otherwise. This picture is not an abstract one, for such can be found, even in 1962, in many parts of the country. Being a third-rate consultant, or even a junior hospital medical officer, is really a distraction from his proper work, which requires his full attention. To do this work efficiently, he needs two things. First, ability to recognise which patients will be best treated by himself and which will benefit from specialised advice. This ability is necessarily founded upon up-to-date general medical knowledge. It is here that he should gain the invaluable help of his local consultants, year-round seminars being a more effective way to provide him with this knowledge than occasional intensive courses of lectures and case demonstrations. Secondly, he must have full access to all those diagnostic routines which are within his own ability to interpret authoritatively. Such considerations prompt some further comments. Writers, in growing numbers, during the past few years have warned of the danger lest-in the vast machine which is the National Health Service-the primary needs of the patient may be largely overlooked. How good for all our patients it would be if three wise men " could ponder their needs, and how they might be met! Such small " thinking units" have a way of getting to the root of a problem in a way often denied to larger committees. Just how much the patient’s needs can be ignored is vividly shown in the structure and administration of the maternity medical services. The views of the Treasury, the local health authorities, the hospital boards, and, quite often, the consultants are given due weight and consideration. The needs of the person most concerned (the patient) are best understood by the person most intimately known (the general practitioner), yet he it is whose representations are most consistently ignored by officialdom. But these thoughts run quite counter to current trends. 1. Aegerter, E., Kirkpatrick, J. A. Orthopedic Diseases; p. 449, Philadelphia, 1958. "
487
Letters to The Lancet release one’s tension, but do they affect policies in any degree whatsoever ? Is it too late to save the man outlined by your previous correspondents, or is the take-over bid already accepted though not yet divulged ? I rather think it is. G. F. TRIPP. Dartford, Kent. NEW FIBRINOLYTIC AND ANTICOAGULANT ENZYME
SIR,-It was with great interest that I read the preliminary communication1 about the enzyme isolated from Pseudomonasfluorescens, because recently we observed that Ps. aeruginosa possessed fibrinolytic activity. None of the standard textbooks on bacteriology mention the ability of pseudomonas of any species to produce fibrinolysin. The fibrinolysin we described2 resembles in many ways that isolated by Adamis from Ps. fluorescens. One important difference, however, is that the aeruginosa enzyme is heat-stable. Our work
was
first described to the Indian Association of Patho1959.
logists in Poona on Dec. 18,
Department of Pathology, Mahatma Gandhi Memorial Medical Indore, India.
College,
ARVIND G. BHAGWAT.
OLD AGE IS NOT A DISEASE am SIR,-I very loth to criticise the article of Jan. 13 by Dr. Robert Kemp, but I feel that, as no-one else seems to have offered criticism during the month which has followed its publication, I ought to do so. In the first place, he says that to the medical officer of health
patient " is a name a long way down the waiting-list for hostel accommodation ". This suggests that the medical officer of health is in control of hostel accommodation. As secretary of the welfare group of the Society of Medical Officers of Health, I know that, in the majority of cases, the welfare services are not administered by the medical officer of health. Most medical officers of health I know, at any rate in the smaller boroughs, do not think of the old people in their area as merely names either on or off a waiting-list, but take a great personal interest in them. Dr. Kemp also says, " it is not for doctors to preach on the right and wrong way to grow old, but most of the troubles of old age are due to personal mismanagement ...". Health education, which is an important and continuing function of any medical officer of health and his staff, attempts to do just the
this.
J. ADRIAN GILLET Civic Centre, Dagenham, Essex.
Secretary, Welfare Group, Society of Medical Officers of Health.
ADRENALINE AND SCHIZOPHRENIA
SiR,—The following
case
tion with adrenaline and annotation of Jan. 27.
may be of interest in
connec-
schizophrenia, discussed in
your
A 50-year-old man, a nurse in a mental hospital, received prophylactic tetanus antitoxin a short time after an accidental head wound. An immediate anaphylactic reaction developed, with severe hypotension, convulsions, and loss of consciousness. I injected 1 mg. of adrenaline subcutaneously and he soon recovered completely. I was surprised by an obvious change in the patient’s attitude some minutes after recovery. He was exaggeratedly preoccupied with his slight wound, showed terrible anxiety, and finally expressed the conviction that the people in the room were speaking about him, about his death, and were making plans directed against him. Despite the apparent narrowing of his attention, he noted each person who entered or left the room and gave strange interpretations of each movement. After an 1. 2.
D. M. Lancet, 1961, ii, 1070. Rangam, C. M., Gupta, J. C., Bhagwat, R. R., Bhagwat, A. G. Ind. J. med. Res. 1961, 49, 232.
Adamis,
work and had slight amnesia for the He was known to be an anxious emotional person and he had had a gastrectomy for duodenal ulcer. hour he wanted
to return to
suspicion-anxiety period.
I am inclined to link this paranoid reaction to the adrenaline injection in a predisposed person-he was working in a situation not free from anxiety and among aggressive people, and at the time of the injection he was in a state of temporary cerebral anoxia. EDGAR PICK. Jerusalem. THE NEW HOSPITALS
SiR,—Thinking of hospitals up and down this country which I worked in or visited as a General Nursing Council examiner, and a few in which I was employed in China, I would incorporate in the new ones to be built: (a) Many more
washbasins in the wards-as many as one to beds-in neat recesses but very near the beds. (b) Well-designed changing-rooms for non-resident nurses attached to every ward and department. Built-in furniture for each nurse should include a drawer big enough to hold a week’s supply of clean uniform, a container for discarded uniform, a locker for outdoor clothing and shoes, and draw-curtains for privacy when changing. (c) Small " homely " nurses’ homes for the few nurses still resident. A mere cubby hole of a bedroom would do, but opening from it would be a comfortable private sitting-room and the means for making light meals. These individual, private sitting-rooms could be furnished by the occupant. (d) Instead of a single room for " matron’s office ", my ideal hospital would have a suite with a comfortable private waitingroom, a small sitting-room (reasonably sound-proof) where the matron could talk privately to her nurses or ancillary staff, and a small dining-room where she could entertain official visitors. every
two
Wonderful architecture and shining will not alone attract nursing staff.
expensive equip-
ment
Burton-in-Lonsdale, Lancashire.
11. JC MARIE . IE A. A SIMPSON. SMPSON
.
CHRONIC TETANY AND MAGNESIUM DEPLETION SIR,-Iread with great interest Dr. Durlach’s letter1 and I agree with most of his ideas. But there is one
phrase that could lead to misunderstanding-namely, French papers ". Indeed, although many studies from my laboratory were issued in France, the first publications appeared in Belgium (in Dutch or French). And precisely those studies, started in 1956described for the first time the " low magnesium tetany " syndrome as the most common form of tetany 3-5 and proved the efficacy of the treatment 36 proposed. Our delimitation of this syndrome with its electromyographic changes and hypomagnesxmia was comfirmed7 a year later by Durlach and others. The works of Turpin, Klotz, Contamin, Vallee, Hannah, and others describe interesting aspects regarding hypocalcsemia and hypomagnesaemia, including new evidence about this syndrome. Magnesium oxide gave the best results. In our opinion several magnesium salts can be used until the best treat"
ment
is found.
Laboratory of Electromyography, N. ROSSELLE. University of Louvain, Belgium. 1. Durlach, J. Lancet, 1961, i, 282. 2. Rosselle, N., De Doncker, K. Belg. T. Geneesk. 1957, 13, 265. 3. Rosselle, N., De Doncker, K. Acta. clin. belg. 1959, 14, 162; Pathol. Biol. 1959, 7, 1835. 4. De Doncker, K., Rosselle, N. J. Physiol. 1959, 51, 39. 5. Rosselle, N., De Doncker, K. Rev. franc. Et. clin. biol. 1960, 5, 1018. 6. Rosselle, N., De Doncker, K. Brux. méd. 1960, 40, 1625. 7. Durlach, J., Lebrun, R. Ann. Endocr., Paris, 1960, 21, 244.