URINARY INFECTIONS IN GENERAL PRACTICE

1184 since they have found a loss of only 27 consultant and senior academic pathologists over a two-year period. ’I’o this needs to be added the loss due to retirement and premature death which will almost certainly be a much larger number during the next few years. Because of this the loss of 54-67 senior registrars, registrars, and junior academics during their survey period is more serious. It is, therefore, probable that many senior posts in pathology will remain unfilled. It is especially unfortunate that most of these "unfillable" posts will be where they are badly needed-in the smaller hospitals whose work loads could not possibly allow, in the present economic circumstances, the replacement of two "general" pathologists by four specialist pathologists and, therefore, by anyone at all since general pathologists are no longer being trained.

no

Department of Chemical Pathology, Walton and Fazakerley Hospitals, Merseyside L9 7AL

Glasgow

reassuring

better way now to find these facts than by controlled clinical trial. There is a higher morality which demands that even players of inspired hunches should follow a method which will enable them to report their results in a way that their colleagues can understand and accept so that not one patient anywhere will fail to get any benefit that results at the very first possible moment. Dr Street and any others who put science second can argue all they like, but they cannot relieve the rest of us of the moral and legal need to have scientifically acceptable evidence for preferring a new treatment over what we have been doing before, and not just belief in sombody else’s convictions. Department of Materia Medica, University of Glasgow, Stobhill General Hospital,

G.

G21 3UW

J. ADDIS

I. J. L. GOLDBERG

URINARY INFECTIONS IN GENERAL PRACTICE FINANCING THE HEALTH SERVICE

SIR,-In my view the lack of finances in the Health Service present is to a great extent due to the very significant numbers of extra administrators appointed, often perhaps of not a very high calibre or educational achievement, in the reorganised Health Service. It is no consolation to N.H.S. patients and workers alike that the new N.H.S. was initiated by the Heath Government and actually uncritically implemented by the newly formed Wilson Government of 1974. The large new cadre of administrators actually takes workers-for example, cooks, doctors, nurses, therapists, stokers-away from their work to serve on endless committees which sometimes give the impression of being set up in order to justify the new administrators’ posts. There appears to be no recognised financial structure at district level. One of the two districts to which I am attached, serving the elderly for a population of 500 000, was over ;600 000 overspent during the last financial year. Surely there must have been a gross lack of budgetary monitoring for this at

to

SIR Large quantities of antibacterial agents are prescribed for symptoms of urinary infection in general practice, often without bacteriological confirmation or before the laboratory report is received. The distribution of organisms causing infection in domiciliary and in hospital practice is different, but few large studies have been undertaken. 12 Furthermore, in only one were age and sex differences mentioned.2 We have identified all organisms isolated in pure culture in significant numbers from mid-stream urine (M.S.U.) specimens sent to the laboratory by general practitioners during the three months January to March, 1976. 846 organisms were identified by standard methods;’ a further 10, in which identification proved difficult, were identified by the Computer Trials Laboratory (Central Public Health Laboratory). 162 infections occurred in 147 males and 694 in 664 females. The following organisms were identified: No. % Organism Coagulase-negative staphylococci Streptococcus fiecalis

happen.

then insisted upon and one is always told that they wiil not affect patient services. In practice, however, cuts generally start with the "Cinderella" services, such as my own, and to begin with they have shown themselves in: (1) a tortoiselike approach in carrying out admittedly expensive recommendations of a newly appointed fire officer for geriatric inpatient wards on the first and second floors built at the turn of the century; and (2) the "postponing implementation", "freezing", "deferring", what-you-will of a sister’s post for a geriatric ward, yet all Government documents suggest that the resources are actually going to be redistributed towards the services for the elderly, amongst others. Is the Department of Health really serious in trying to keep the N.H.S. a going concern or are they interested only in maintaining or increasing the enormously top heavy 9-to-5 MondayCuts

Klebsiella spp. Acinetobacter spp. Pseudomonas œruginosa Lancefield group-B hzmolytic Cttrobacter spp.

are

through-Friday unproductive bureaucracy? West Middlesex

streptococci

Staphylococcus aureus Enterobacter spp. Proteus vulgaris Serratia marcescens Yeasts

Morganella morganii Alcaligenes spp. Ps. pseudoalcaligenes *69 strains t36 strains

Total late or non-lactose-fermenting. were novobiocin resistant.

50t 29 23 13 12 9 6 6 5 3 2 2 1 1 1 856

72.0 9.0 60 33 2.7

70

were

78% of these organisms were isolated in counts of greater than 108/1 (definite infection) and 22% in counts of 107-108/l (probable infection). The distribution of the in the two categories.

organisms was the same

When the

Hospital,

organisms were analysed for age and sex groups striking differences were observed. Proteus spp. accounted for 41.5% (E. coli 34%) of the 41 infections in boys

some

Isleworth, Middlesex TW7 6AF

616* 77

Escherichia colt Proteus mirabilis

JAMES ANDREWS

up to fifteen years of age, whereas E. coli accounted for 79% (Proteus spp. 6-6%) of the 137 infections in girls. In males over the age of fifteen E. coli predominated, accounting for 78 TREATMENT OF BRONCHIAL CARCINOMA

SIR,-The hide of the sacred cow of prospective randomised trials would be a lot less impermeable to the stones of Dr Street (March 27, p. 702) if he could show us any good reason to believe that "following your own hunch" will not leave the dying patients of 1976 very much worse off than with standard treatment. The truth about the treatment of lung cancer can only be established by careful attention to facts, and there is

(65%) of the 120 infections. We have observed these differences on a previous occasion.4 Secondly, coagulase-negative staphylococci (29 of which were novobiocin resistant and McAllister, T. A., Percival, A., Alexander, J. G., Boyce, J. M. H., Dulake, C., Wormald, P. J. Postgrad. med. J. 1971, 47, suppl. p. 7. 2. Meers, P. D. J. Hyg., Camb. 1974, 72, 229. 3. Cowan, S. T. Manual for the Identification of Medical Bacteria. London, 1.

1974. 4. Maskell, R.,

Pead, L., Hallett, R. J. Br. J. Urol. 1975, 47, 691.

1185 be micrococcus 3 or 5) were the second pathogens in females between the ages of sixteen and thirty-five, and accounted for 35 (13%) of the 263 infections in this group. This has also been reported by Meers.2 The low incidence of Klebsiella spp. is also interesting. Only 23 of the 106 lactose-fermenting organisms not showing the characteristic colonial appearance of,. coli proved to be Klebsiella, and this organism cannot be identified on colonial appearance. 12 (52%) of the Klebsiella infections were in patien over the age of fifty-five years. Although the true incidence of urinary infection cannot be deduced from the number of M.S. u. specimens sent to the laboratory, a considerable number of infections in males were seen. Up to age fifteen the ratio of male to female infection was z 3; it fell to 1/17.5 between sixteen and thirty-five years and to 1/1-9after that. Urinary infection in males seems to be more common before the age of prostatic hypertrophy than is often believed. Furthermore our results show that the age and sex of the patient should be taken into account when prescribing treatment for urinary infection. Nitrofurantoin, which is ineffective against Proteus spp. in vivo, should not be used as the drug of choice in boys, and nalidixic acid and oxolinic acid, which have little or no activity against gram-positive organisms, should be avoided in young women.

therefore presumed

to

commonest

We thank the

Computer Trials Laboratory for their assistance. JOHN CRUMP Public Health Laboratory,

LINDA PEAD ROSALIND MASKELL

St Mary’s General Hospital, Portsmouth PO3 6AQ

CHEMOTHERAPY AFTER MASTECTOMY

SIR,-We agree

with the

general

comment made

by

Ur

Bonadonna and

Dr Rossi (March 27, p. 697) on the letter by Dr Donovan and his colleagues on adjuvant cyclophosphamide treatment in operable breast cancer (Jan. 3, p. 42). Furthermore we feel, that the role of cyclophosphamide itself should

be reconsidered. Bonadonna et al. suggest’ that the cyclophosphamide, methotrexate, fluorouracil regimen (CMF) could be made less toxic by replacing cyclophosphamide with chlorambucil. However, this step is hampered by the lack of information on the activity of this drug in breast cancer. This was reported in only one study.2 At the present time it would be very difficult, if not impossible, to obtain new data on the activity of a single drug m breast cancer, since combination chemotherapy is the treatment of choice in advanced disease. For this reason we feel that some of our results3 could be of interest in the debate on the best combination chemotherapy to be used as adjuvant treatment in operable breast cancer. Brunner et al. reported the results of three prospective, controlled cooperative clinical studies in metastatic breast cancer. These were conducted between 1966 and 1972 by the Swiss Group for Clinical Cancer Research (S.A.K.K.). In the first of these three studies, 62 women were randomly allocated either to a combination of chlorambucil and methotrexate or to a combination of cyclophosphamide and methotrexate. The two groups showed no significant difference in the rate of the objective tumour regression (52% v. 49%). Also the distributions within the different categories of remission degree were almost identical. These results suggest a similar activity of cyclophosphamide and chlorambucil in breast cancer. In our opinion, this is an interesting finding, since a direct comparison between the two drugs is hardly possible any more today. Based upon these data as well as a pilot study in St. Gallen (one of the S.A.K.K. members), the S.A.K.K. has now started 1 Bonadonna, G., and others New Engl J. Med. 1976, 294, 405. 2 Moore, G , and others Cancer Chemother Rep. 1968, 52, 661 3 Brunner, K. W., and others Cancer, 1975, 36, 1208.

an

adjuvant protocol in breast ’Leukeran’).

cancer

using

LMF

(L =

chlorambucil.

Data Centre, Swiss Group for Clinical Cancer Research, 1205 Geneva, Switzerland

F. CAVALLI P. ALBERTO F. JUNGI G. MARTZ

HOW DOES BLOOD-PRESSURE CAUSE STROKE?

SIR,-Dr Ross Russell’s hypothesis’ made interesting read-

ing. Stroke among

our

as a complication of hypertension is common hypertensive population. Those afflicted are, in

younger than their counterparts in Europe and America. Our entire hypertensive population is also younger than the same population among Caucasians. The complications of hypertension most commonly seen here are cardiac failure, renal failure, and cerebrovascular accidents, in that order of frequency. Reviews from Lagos2 and Ibadan3 have shown that cerebral infarction following cerebral thrombosis is the commonest of the three accidents—haemorrhage, thrombosis, and embolism. I suspect that this may be due to an artefact. These patients are more likely to survive and thus to present in hospital. There is also the general belief, especially in this part of the country, that traditional methods of therapy for strokes are more successful than treatment in hospital. As a result, only a fraction of patients come to hospitals. In fact the acute episodes seen in our hospital within hours of onset are generally in the younger age-group. They are very often admitted in coma, and a diagnosis of cerebral haemorrhage or subarachnoid haemorrhage is usual. The role of potassium in the pathogenesis of hypertensive complications makes an interesting study. The normal range of serum-potassium in Nigeria is givenas 3.0-4.8mmol/l, which is lower than the accepted normal elsewhere. The effect of hypokalaemia on the musculature (skeletal, myocardial, and smooth) is well known. I have studied cerebrospinal fluid electrolytes, with special reference to potassium, in strokes and "non-strokes" (mainly patients with meningitis and other conditions necessitating lumbar puncture). Of 20 cases, 8 were strokes. 2 of the 8 had subarachnoid haemorrhage without hypertension. The potassium in the 6 strokes ranged from 2.22 to 2.6 mmol/l; in the others it ranged from 2.6 to 3.2 mmol/1. Only fluids free from blood were examined. Serum-electrolytes were all in the normal range. Does the weakening of smooth muscle caused by hypokalmmia contribute in anyway to the pathological process in the cerebral arterioles? We know that in hypertension the terminal branches of cerebral arterioles show areas of dilatation which must correspond to weak spots in the musculature of the arteriole tree. Leakage through these areas has been advanced as the cause of hypertensive encephalopathy.5 It is my belief that variation in potassium level contributes to cardiac failure, which is the main complication of the disease among regular attenders at my hypertension clinic. I always give potassium supplements in increased dosage to these patients, though the plasma-potassium may be normal at the time. The use of diuretics alone in the treatment of hypertension produces hypokalaemia in my experience, though contrary reports have appeared.b ’Good control of blood-pressure

general,

1. Ross Russell, R. W. Lancet, 1975, ii, 1283. 2. Dada, T. O., Johnson, F. A., Araba, A. B., Adegbite, S. A. West Afr. med. J. 1969, 18, 95. 3. Osuntokun, B. O., Odeku, E. L., Adeloye, R. B. A. ibid. 1969, 19, 160. 4. Department of Chemical Pathology, University College Hospital, University of Ibadan, Nigeria. November, 1971. Normal Laboratory Values of Clini-

cal Importance. 5. Giese, J Cited by Byrom, F. B. Lancet, 1973, i, 766. 6. Dargie, H. J., Boddy, K., Kennedy, A. C., King, P. C., Read, P. R., Ward, D. M. Br med. J 1974, iv, 316. 7. Wilkinson, P. R., Issler, H., Hesp, R., Raftery, E. B. Lancet, 1975, i, 759.