- Email: [email protected]
WHERE ARE THE TEACHERS OF COMMUNITY MEDICINE?
575 administered examinations of achievement and intellectual function. Had our patient been reported at age 3, he would have been evidence for the association of mental retardation and thymic aplasia. From this case, it seems that the delayed development is a function of the repeated insults rather than the underlying disorder. Obviously more data are required before any reliable conclusions may be drawn. Children’s Diagnostic and Study Branch, W. EDWIN DODSON National Institute of Child Health, and Human Development, National Institutes of Health, Bethesda, Maryland 20014.
DUANE ALEXANDER MATTI AL-AISH FELIX DE LA CRUZ.
WHERE ARE THE TEACHERS OF COMMUNITY MEDICINE? SIR,-Many words used by doctors lend themselves to different interpretation. Social medicine, community medicine -even the word medicine itself-can all have different meanings in different contexts. I should therefore like to put another point of view apart from the one expressed by Professor McKeown (March 1, p. 463). The shortage of teachers (particularly in the London schools), which was the main theme of the paper by Professor Morris and Dr. Warren (Feb. 1, p. 249), is acknowledged by all who are close to this field, but it receives scant attention from others who play an important part in undergraduate education. One reason may be the uncertainty that exists in the minds of some physicians and surgeons about the meaning of social medicine and the confusion between it and medical social work. Furthermore, even though most teachers of the subject have, as Professor McKeown said, a reasonably consistent idea of what they mean by social medicine, it should be pointed out that this consistency is not found in the variety of titles which are used to describe the appropriate departments of the different medical schools in
COXSACKIE A7 VIRUS AND POLIOMYELITIS IN VACCINEES Kitamura and colleagues (March 1, p. 465) SIR,-Dr. remind us of the problems of interpretation of poliomyelitis developing after poliovirus vaccination. Their communication, like that of Stolley et al.l reporting poliomyelitis after contact with a vaccinee, illustrates the variety of laboratory investigations required in such cases and shows some of the difficulties of interpretation which may arise. Now that poliomyelitis due to virulent " wild " poliovirus has become unusual, it is appropriate in such cases to attempt to exclude infection with Coxsackie A7 virus, the next most important enterovirus causing paralysis. Because routine tissue-cultures usually fail to detect this virus, its isolation requires inoculation of newborn mice, as in one of the above reported cases.l Several serological tests for antibodies to Coxsackie A7 virus are available,2 but for routine purposes it is convenient to include the tissue-culture-adapted strain,3 with the battery of polioviruses in the neutralisation tests. By these methods Coxsackie A7 infection was found in the Glasgow area in cases of paralytic disease developing shortly after administration of inactivated4 and live oral2 poliovaccine. It is comforting to note that Coxsackie A7 virus has shown no tendency to become more prevalent in this area since the epidemic of 1959.4 Since the outbreak of 19632 it has been isolated in this laboratory from only 9 children in 1967 and 1 child in 1968 (5 boys and 5 girls: 2 aged under one year, 2 aged two years, and 1 each aged three, four, five, six, seven, and twelve years). None was paralysed; 9 had aseptic meningitis (1 complicated by acute ataxia) and 1 whooping cough. Glasgow University Department of Infectious Diseases, Ruchill Hospital, Glasgow N.W.
N. R. GRIST.
Britain.
Recently, teaching hospitals, some of which tended to be aloof from the communities in which they were situated, have accepted responsibility for providing specialist and other services for their local populations, and thus serve their communities. This breach of the ramparts surrounding the ivory towers was an important step towards ending the demarcation between " hospital " and " community ". Against this background it seems that the term " community medicine " can be applied to that department of a medical school where certain academic disciplines are based. A community-medicine department should be concerned with teaching and research in three broad areas: epidemiology and biostatistics; preventive medicine, including health education, with particular reference to communities ; organisation of medical care, consisting of two components-(a) health and related services and their changing structures, functions, and interrelationships, and (b) the interaction between society (including family, home, and work), the patient, and his illness. Some parts of these subdivisions are included in the general teaching of medicine itself, and a department of community medicine should not assume a monopoly position but should collaborate with teachers in many fields, especially those giving clinical services. The term *’ community medicine " may seem ambiguous at present, but, with the trend towards a new interpretation of " hospital and community ", it seems reasonable to expect that its use to mean " the specialty practised by epidemiologists and by administrators of medical services-e.g., medical officers of local authorities, central health or other government departments, hospital boards or industries-and by the staffs of the corresponding academic departments "may receive general recognition. Under these circumstances this definition should cover the study of health and related services for communitiesincluding inpatient services. Guy’s Hospital Medical School, London S.E.1. J. A. D. ANDERSON. 1.
Royal Commission on Medical Education 1965-68. Report; H.M. Stationery Office, 1968.
para. 133.
BLOOD-POTASSIUM IN PATIENTS UNDERGOING HÆMODIALYSIS SiR,—The correspondence in your columns between Dr. Boucher and Dr. Strunin (Jan. 4, p. 55), Dr. Seedat (Jan. 11, p. 104), and Mr. Ram and Mr. Chisholm (Feb. 1, p. 260), has prompted these comments. Most investigators interested in the area of carbohydrate metabolism and potassium have long since agreed that there is no correlation between levels of serum and total-body potassium. We thank Dr. Seedat5 for confirming our published datathat patients with chronic urasmia have decreased levels of total exchangeable body potassium. We have also pointed out that abnormalities of carbohydrate metabolism in such patients are due to the delayed release of pancreatic insulin, which is potassium-dependent. With the return of values for total-body potassium to normal, insulin release occurs earlier in time and in greater amounts, and carbohydrate metabolism returns towards normal. Other data from our laboratory, as yet unpublished, show that the disappearance-rate of glucose from the plasma of patients undergoing chronic hsmodialysis is dependent upon the concentration of potassium used in the dialysate, regardless of the level of the patient’s serum-potassium. The higher the concentration of potassium used in the dialysate, the more rapid is the glucose-disappearance rate. The reverse is true if the potassium concentration is low. All patients studied had low total-body-potassium values and all had hyperkalaemia. Manipulations of dialysate concentrations of urea did not, per se, affect glucose-disappearance rates. Stolley, P. D., Joseph, J. M.. Allen, J. C., Deane, G., Janney, J. H. Lancet, 1968, i, 661. 2. Grist, N. R. ibid. 1965, ii, 261. 3. Habel, K., Loomis, L. N. Proc. Soc. exp. Biol. Med. 1957, 95, 597. 4. Combined Scottish Study. Br. med. J. 1961, ii, 597. 5. Seedat, Y. K. Lancet, 1968, ii, 1166. 6. Spergel, G., Bleicher, S. J., Goldberg, M., Adesman, J., Goldner, M. G. Metabolism, 1967, 16, 581. 1.
DUANE ALEXANDER MATTI AL-AISH FELIX DE LA CRUZ.
WHERE ARE THE TEACHERS OF COMMUNITY MEDICINE? SIR,-Many words used by doctors lend themselves to different interpretation. Social medicine, community medicine -even the word medicine itself-can all have different meanings in different contexts. I should therefore like to put another point of view apart from the one expressed by Professor McKeown (March 1, p. 463). The shortage of teachers (particularly in the London schools), which was the main theme of the paper by Professor Morris and Dr. Warren (Feb. 1, p. 249), is acknowledged by all who are close to this field, but it receives scant attention from others who play an important part in undergraduate education. One reason may be the uncertainty that exists in the minds of some physicians and surgeons about the meaning of social medicine and the confusion between it and medical social work. Furthermore, even though most teachers of the subject have, as Professor McKeown said, a reasonably consistent idea of what they mean by social medicine, it should be pointed out that this consistency is not found in the variety of titles which are used to describe the appropriate departments of the different medical schools in
COXSACKIE A7 VIRUS AND POLIOMYELITIS IN VACCINEES Kitamura and colleagues (March 1, p. 465) SIR,-Dr. remind us of the problems of interpretation of poliomyelitis developing after poliovirus vaccination. Their communication, like that of Stolley et al.l reporting poliomyelitis after contact with a vaccinee, illustrates the variety of laboratory investigations required in such cases and shows some of the difficulties of interpretation which may arise. Now that poliomyelitis due to virulent " wild " poliovirus has become unusual, it is appropriate in such cases to attempt to exclude infection with Coxsackie A7 virus, the next most important enterovirus causing paralysis. Because routine tissue-cultures usually fail to detect this virus, its isolation requires inoculation of newborn mice, as in one of the above reported cases.l Several serological tests for antibodies to Coxsackie A7 virus are available,2 but for routine purposes it is convenient to include the tissue-culture-adapted strain,3 with the battery of polioviruses in the neutralisation tests. By these methods Coxsackie A7 infection was found in the Glasgow area in cases of paralytic disease developing shortly after administration of inactivated4 and live oral2 poliovaccine. It is comforting to note that Coxsackie A7 virus has shown no tendency to become more prevalent in this area since the epidemic of 1959.4 Since the outbreak of 19632 it has been isolated in this laboratory from only 9 children in 1967 and 1 child in 1968 (5 boys and 5 girls: 2 aged under one year, 2 aged two years, and 1 each aged three, four, five, six, seven, and twelve years). None was paralysed; 9 had aseptic meningitis (1 complicated by acute ataxia) and 1 whooping cough. Glasgow University Department of Infectious Diseases, Ruchill Hospital, Glasgow N.W.
N. R. GRIST.
Britain.
Recently, teaching hospitals, some of which tended to be aloof from the communities in which they were situated, have accepted responsibility for providing specialist and other services for their local populations, and thus serve their communities. This breach of the ramparts surrounding the ivory towers was an important step towards ending the demarcation between " hospital " and " community ". Against this background it seems that the term " community medicine " can be applied to that department of a medical school where certain academic disciplines are based. A community-medicine department should be concerned with teaching and research in three broad areas: epidemiology and biostatistics; preventive medicine, including health education, with particular reference to communities ; organisation of medical care, consisting of two components-(a) health and related services and their changing structures, functions, and interrelationships, and (b) the interaction between society (including family, home, and work), the patient, and his illness. Some parts of these subdivisions are included in the general teaching of medicine itself, and a department of community medicine should not assume a monopoly position but should collaborate with teachers in many fields, especially those giving clinical services. The term *’ community medicine " may seem ambiguous at present, but, with the trend towards a new interpretation of " hospital and community ", it seems reasonable to expect that its use to mean " the specialty practised by epidemiologists and by administrators of medical services-e.g., medical officers of local authorities, central health or other government departments, hospital boards or industries-and by the staffs of the corresponding academic departments "may receive general recognition. Under these circumstances this definition should cover the study of health and related services for communitiesincluding inpatient services. Guy’s Hospital Medical School, London S.E.1. J. A. D. ANDERSON. 1.
Royal Commission on Medical Education 1965-68. Report; H.M. Stationery Office, 1968.
para. 133.
BLOOD-POTASSIUM IN PATIENTS UNDERGOING HÆMODIALYSIS SiR,—The correspondence in your columns between Dr. Boucher and Dr. Strunin (Jan. 4, p. 55), Dr. Seedat (Jan. 11, p. 104), and Mr. Ram and Mr. Chisholm (Feb. 1, p. 260), has prompted these comments. Most investigators interested in the area of carbohydrate metabolism and potassium have long since agreed that there is no correlation between levels of serum and total-body potassium. We thank Dr. Seedat5 for confirming our published datathat patients with chronic urasmia have decreased levels of total exchangeable body potassium. We have also pointed out that abnormalities of carbohydrate metabolism in such patients are due to the delayed release of pancreatic insulin, which is potassium-dependent. With the return of values for total-body potassium to normal, insulin release occurs earlier in time and in greater amounts, and carbohydrate metabolism returns towards normal. Other data from our laboratory, as yet unpublished, show that the disappearance-rate of glucose from the plasma of patients undergoing chronic hsmodialysis is dependent upon the concentration of potassium used in the dialysate, regardless of the level of the patient’s serum-potassium. The higher the concentration of potassium used in the dialysate, the more rapid is the glucose-disappearance rate. The reverse is true if the potassium concentration is low. All patients studied had low total-body-potassium values and all had hyperkalaemia. Manipulations of dialysate concentrations of urea did not, per se, affect glucose-disappearance rates. Stolley, P. D., Joseph, J. M.. Allen, J. C., Deane, G., Janney, J. H. Lancet, 1968, i, 661. 2. Grist, N. R. ibid. 1965, ii, 261. 3. Habel, K., Loomis, L. N. Proc. Soc. exp. Biol. Med. 1957, 95, 597. 4. Combined Scottish Study. Br. med. J. 1961, ii, 597. 5. Seedat, Y. K. Lancet, 1968, ii, 1166. 6. Spergel, G., Bleicher, S. J., Goldberg, M., Adesman, J., Goldner, M. G. Metabolism, 1967, 16, 581. 1.