TRAINING DISTRICT MEDICAL OFFICERS

491

EJACULATION IN MALE RHESUS MONKEYS SIR,—Dr. Wiener’s interesting suggestion (Aug. 13), that the transmission of sexual information from the female monkey to the male may be by olfactory cues, is supported by work currently in progress and briefly reported elsewhere.’ Observamade on the sexual behaviour of ovariectomised rhesus monkeys after the local application of very small quantities of cestrogen (5 ug. per day) to their genitalia. Application restricted to the hormone-sensitive area of specialised skin " surrounding the external genitalia (the sexual skin ") restored the vivid red colour of the intact animal, but induced slight changes in the low sexual activity of the male. Vaginal smears taken during this procedure showed the vaginal epithelium to be unaffected. But when oestrogen in the same dose was introduced into the vaginal lumen, there was considerable stimulation of the male’s sexual activity, and mounting and ejaculation occurred frequently. The vaginal smears in this experiment resembled those from animals given large doses of oestrogen systemically. Alteration in some hormone-dependent quality within the vagina, and not changes in the female’s behaviour2 " or in the appearance of the sexual skin ", seems therefore to transmit information on the female monkey’s sexual attractiveness to the male. Experiments are in progress with anosmic males to test whether (as seems most likely) an olfactory mechanism is involved. The widespread use of perfume as a sexual attractant in our own species suggests that similar mechanisms, modified by social conventions, may operate in

of coronary-artery disease and thromboembolism. Dr. Maddocks and Dr. Vines have some information

Perhaps these

on

matters.

Holy Name of Jesus Hospital, Gadsden, Alabama.

J. H. ROGERS.

nons were

man.

Two further factors must be considered before these results on rhesus monkeys are applied more generally. Firstly, the extremely dominant position occupied by the male rhesus monkey over the female is greater than in some other species of monkeys, such as the langur3 or howler,4 and in these the females’ behaviour may have greater influence. Secondly, the smdies upon monkeys cited by Dr. Wiener were carried out upon temporarily isolated pairs of individuals, and social factors were therefore excluded: these themselves substantially modify basic neuroendocrine mechanisms. Department of Anatomy, University Medical School, Birmingham 15.

J. HERBERT.

A NEW REMEDY FOR MIGRAINE treatment of migraine with described in his letter last week, acidophilus, makes me wonder whether this organism replaces intestinal putrefactive anaerobes to such an extent as to influence alimentary tyramine tolerance,5 and whether a change in pH has this effect. J. P. CRAWFORD.

SIR,—Professor Ask-Upmark’s

Lactobacillus

CHRONIC INFECTION AND BLOOD-PRESSURE SIR,-The excellent article by Dr. Maddocks and Dr. Vines (July 30) raises the subject of the effect of chronic infection on degenerative vascular disease in general. I have maintamed that chronic or repeated infection has a beneficial effect on the incidence of coronary-artery disease, and thromboembolism generally, by virtue of changes in plasma-proteins :consisting of increase in globulins (including fibrinogen) and decrease in albumin.These changes, I believe, result in a relative in-vivo hypocoagulable state of the blood ". Pernaps a better term would be a relative hypothromboic state. Throughout the world, populations such as the one studied by Dr. Maddocks and Dr. Vines have shown low incidences ’‘

1. Herbert, J. Excerpta med. Int. Cong. Ser. 1966, 111, 212. 2. Herbert, J., Michael, R. P. Acta. endocr., Copenh. 1965, suppl. 100, p 173.

Jay, P. in Primate Behavior (edited by I. DeVore). New York, 1965. Carpenter, C. R. ibid. 5. Crawford, J. P. Medical News, July 31, 1964. 6. Rogers, J. H. Lancet, 1963, i, 175; ibid. 1964, i, 114. 3 4.

DIURETICS IN RESPIRATORY FAILURE SIR,-In their article (July 30) Dr. Noble and his co-workers state that in their cases 1 and 2 oedema followed the rise of P aC02, and that this observation was compatible with the suggestion of Campbell and Short1 " that the oedema of ’cor pulmonaleis secondary to the respiratory failure ". But slight ankle cedema had been noted earlier in case 2 when the PC02 was only 37-5 mm. Hg, and in both cases fluid retention before significant oedema appeared might have preceded the development of hypercapnia. In ambulant and non-cedematous patients with chronic bronchitis attending this clinic, tests of ventilatory capacity have suggested that hypercapnia may be related to superadded restriction of ventilation rather than to further airflow obstruction,23 and there was some evidence that such restriction might have been associated with fluid retention.3 Reduced compliance in chronic airways obstruction has been found not only with œdema,4 5 but also in chronic hypercapnia without cedema.6It seems possible that fluid retention in the chest (lungs, chest wall) might produce superadded restriction of ventilation, which initiates the hypercapnia before oedema occurs.

Finchley Chest Clinic, 980 High Road,

J. J. SEGALL.

London N.20.

TRAINING DISTRICT MEDICAL OFFICERS SIR,-My objective in using the term " rural medicine ″7 was not to introduce a new discipline but to focus attention on a little-known type of physician-the district medical officerand his needs in training. He is vitally important to the progress of health in the underprivileged countries, which contain three-fifths of the world’s population. In most of these countries the responsibility for organising and delivering health services to the majority of the people rests on but a few of their qualified physicians-namely, district medical officers. Not only are physicians in these countries scarce, but for the most part they are concentrated in the larger urban centres where the practice of medicine bears a striking similarity to that in any large provincial town in an industrialised country. District medical officers may be few but their importance in delivering health services to the rural majority cannot be overstated. The district medical officer is as much in need of special consideration in training programmes as the general practitioner or the specialist. He needs to be trained as the " super generalist," and to learn how to make the greatest impact with inadequate funds, personnel, and facilities in the face of an overwhelming demand. At present he learns his job, or never learns it, through experience. Neither under-

graduate

nor

postgraduate training adequately

prepares him

for the job. If through the use of the phrase " rural medicine " I have been able to focus some attention on him and his needs, then I am content. I agree with Dr. Robertson (Aug. 13) in his plea for the non-proliferation of a multiplicity of terms having similar meanings. I do not propose to enter a semasiological discussion as to which term is most appropriate. I have, however, two observations. Firstly, in postgraduate study, the field of study and the nomenclature of the award should bear a relation 1. 2. 3. 4. 5. 6.

Campbell, E. J. M., Short, D. S. Lancet, 1960, i, 1184. Segall, J. J. ibid. 1965, ii, 546. Segall, J. J., Butterworth, B. A. Scand. J. resp. Dis. (in the press). Cherniack, R. M. J. clin. Invest. 1956, 35, 394. Hammond, J. D. S. Clin. Sci. 1957, 16, 481. Kahana, L. M., Aronovitch, M., Place, R. Am. 87, 699.

7.

Fendall,

N. R. E.

Lancet, 1966, i, 1097.

Rev. resp. Dis.

1963,

492

another-e.g., one studies public health and is awarded diploma of public health. Secondly, just as surgery may be subdivided into such specialties as neurosurgery and abdominal surgery, so may public health be divided for the sake of emphasis into its various branches. I maintain that the art of practising medicine in the rural areas of underprivileged countries is a special field of competency, and one worthy of special consideration by to one a

medical educators of such countries. If one is to cavil at terms one may as well cavil at the use of the terms tropical diseases and tropical medicine, for many of the diseases covered by these terms were not always confined to the tropics-for example, cholera, plague, and malaria. Perhaps with the present changing pattern poliomyelitis may be transferred from textbooks of medicine to textbooks of tropical medicine. But the term " tropical medicine " has served to focus attention on the need to apply public-health to the underprivileged areas. I hope that the term practices " rural medicine " will likewise serve to focus attention on the needs of the rural areas of the underprivileged territories, and the training of district medical officers. Population Council, N. R. E. FENDALL. New York, New York 10017.

PRESCRIBING BY NURSING STAFF SIR,-Mr. Ross’s description of a safer system of supply and storage of medicines in hospitals (Aug. 6) will interest all those concerned with this important subject. Since he has taken so much trouble to make drug treatment safer and more accurate, however, it is to be regretted that he gives tacit approval to " sister’s medications (e.g., antacids, laxatives, and mild

analgesics) ". For reasons you have previously discussed, there ought not be " sister’s medications "-a view also held by the subcommittee of the Central Health Services Council,2 and endorsed by the Ministry of Health.3 Modern drug treatment is a very complex subject. There is no such thing as a " simple " or " mild " medicament. Prescribing is for doctors. It never has been, and never will be, the duty of a nurse. to

D. M. DAVIES.

TETRACYCLINES AND THE TEETH SIR,—Since Shwachman and Schuster4 drew attention to dental lesions occurring in children treated with tetracycline, many similar cases have been reported, inter alia, by Waltman and Hilton.Õ Two kinds of lesions have been described: (1) pigmentation, which can vary between yellow and brown, the gradation probably depending upon which tetracycline preparation was used and the time since treatment was given; and (2) enamel defects, where the degree of severity is probably connected also with the choice of preparation. Oxytetracycline has throughout given the lowest frequency of lesions and also the least unbecoming discoloration-a pale yellow which, moreover, becomes still lighter with age.5-7 The cause of the dental lesions has proved to be the deposition of tetracycline during the stage of development, when the circulation and consequently the metabolism is rapidly decreased-i.e., during the mineralisation phase. Finally tetracycline cannot be liberated and becomes fixed and a calcium salt for the remaining lifetime of the tooth. Mineral1. Lancet, 1963, i, 758. 2. Central Health Services Council: Report of the Joint Subcommittee on the Control of Dangerous Drugs and Poisons in Hospitals. H.M. Stationery Office, 1958. 3. Ministry of Health circular H.M. (58) 17. 4. Shwachman, H., Schuster, A. Pediat. Clins N. Am. 1956, 3, 295. 5. Wallman, I. S., Hilton, H. B. Lancet, 1962, i, 827; ibid. 1962, ii, 720, 6. Kienitz, M. in Praxis der Antibioticatherapie im Kinderalter (edited by Marget and M. Kienitz). Stuttgart, 1964. 7. Weyman, J. Br. dent. J. 1965, 118, 289.

isation is completed at 1 year of age in milk teeth and at years of age in permanent teeth. For the effect to occt treatment must have been given before these ages. The dent lesions reported, however, are almost exclusively in milk teett Only single cases have been described where permanent teet

frequency are available. In connection with a follow-up investigation of children with appendicitis complicated by peritonitis, who were post operatively treated with oxytetracycline (’ Terramycin’ Pfizer), the occurrence of any effect on the teeth was studied Only those children were included in the investigation wh( were treated before they were 7 years old and who were oBe 12 at the time of the follow-up, when teething was over, aec the teeth were therefore available for inspection. Out of 124 children 84 were investigated, and only 1 (12‘ of these showed tetracycline lesions. This was a 2-year-oi; girl who, after appendectomy, was given intravenously 12 mg, of terramycin per kg. body-weight per 24 hours for only 4 days-i.e., a dose which was much lower than the average in our subjects. At 12 years of age the general condition of her teeth was bad, with unmistakably tetracycline-induce.1 enamel defects, and yellowish-white pigmentation onal anterior premolars. No fluorescence was observed. There were no other causes to account for the lesions, such as furthcr tetracycline treatment, erythroblastosis fretalis, traumata, or were

affected, and no data

on

;

infections. The parents had not observed the actual lesions due to tetracycline, which indicates that these had not caused any appreciable cosmetic inconvenience. The parents of 15 of the children stated that they had observed the discoloration of their children’s teeth. 12 of these children were investigated, but no effect of tetracycline could be observed. Two cussion

questions on

appear to be of

lesions caused by

special interest tetracycline:

in the dis-

1. Will the children whose milk teeth are affected also havelenbnanin their permanent teeth Theoretically this is probable, but so far this has not been reported. There should be no difficulty in obtaining information on this, since there are still so many cases with affected milk teeth. 2. What practical consequences do the overt lesions give rise to’ Discoloration may be widespread and extremely disfiguring in severc cases, which, however, are probably rare. When there is only pigmentation the occurrence of caries seems to be normal, although in such cases enamel brittleness has been described.5-7 When there are enamel defects, which can range from small cavities to total aplasia, quite naturally the frequency of caries is increased. It has been stated that the occurrence of lesions of mill teeth as a result of treatment with oxytetracycline is infrequent This investigation shows that lesions of the permanent teet"

result of oxytetracycline are rare. In view of the gre3i advantages of the preparation, the risk of dental lesions should as a

prevent its use in suitable cases. Department of Surgery, Kronprinsessan Lovisas Barnsjukhus, Stockholm K, Sweden.

not

ULF GÄSTRIN STAFFAN JOSEPHSON

EPIDEMICS OF ACUTE LEUKÆMIA

SIR,—I have read your editorial (July 23) with great interss and I am glad to say that I have confirmed Dowsett’s findings in 53 leukaemia children treated in the pasdiatric department( Rome University in the years 1944-58.2 There were no clusters, with the exception of some cases = , the suburbs, on the borderline between Rome and the surrounding Campagna, a situation which resembles that:: Niles, a suburb of Chicago, described by Heath et al.3 the reasons for the suburban clustering of cases of childhen

-

leukaemias was a

are

striking

clear. As in Dowsett’s cases, however, ther preference for the same streets or their affuents not

in different years. Your conclusion-that physicians in charge of patients acute leuksemia should deepen their histories in order to ’" 1. 2. 3.

Dowsett, E. G. Br. J. Cancer, 1966, 20, 16. Fischer, F. Arch. ital. Pediat. Pueric. 1963, 23, 81. Heath, C. W., Jr., Hasterlik, R. J. Am. J. Med. 1963, 34, 796