UNDER TENSION
1
748 Furthermore, what is meant by the phrase " Required -house-physician, A or B2 " ? Does it mean that this is a first appointment open to newly qualified practi- tipners, unless an ex-Serviceman or registrar with an M.R.C.P. cares to apply ? Or, more charitably, does it mean that a post normally of B2 status is found difficult to fill and offered to A practitioners ? . To many, I said, this issue is dead. To me, and to many other newly qualified men, it is very much alive. A. B. BLOOD FOR TRANSFUSION SIR,-In view of the recent correspondence and last week’s leading article on this subject, I think it is worth recording that recently we obtained 30 pints of group-O blood from the North London Blood Transfusion Depot for the purpose of exsanguination transfusion. We are particularly indebted to the director of this unit for his help in supplying this large quantity at short notice. St. Bartholomew’s Hospital, London, E.C.1. I. P. MACDOUGALL Chief Assistant. NITROUS OXIDE SUPPLIED BY PRACTITIONERS IN MIDWIFERY SERVICE SIR,—There appears to be confusion about the supply to general practitioners of cylinders of nitrous-oxide gas for analgesic purposes in maternity cases under the National Health Service. As the National Birthday Trust is particularly interested in the provision of analgesia to women confined in their own homes, approach was made to the Ministry of Health for guidance in the matter; and the following is from the Ministry’s reply : " The position is that if a doctor is engaged by the patient to give maternity medical service under part iv pf the Act, he is in the same position as any doctor giving general medical service under part iv. He may write prescriptions or may himself supply any drug personally administered’- e.g., nitrous .oxide. For drugs so supplied he will receive payment from the executive council on presentation of a claim on E.c.10 to the executive council. " If the doctor is called in by a midwife in emergency, he is not giving maternity medical service under part iv of the National Health Service Act but is giving services under the Midwives- Act, 1918. He receives a fee which includes the supply of necessary drugs and dressings, except that he gets extra payment for certain expensive drugs named in part 2 of the schedule to s.i. 1453 of 1948. In such cases, the patient would have a midwife in attendance and, as you know, midwives are supplied by the local health authority with cylinders of nitrous oxide. Many, but not all, doctors have cylinders but some may not have realised that when giving maternity service under part iv they can be paid for any nitrous oxide they supply themselves." 57, Lower Belgrave Street, London, S.W.I. D. V. RIDDICK Secretary, National Birthday Trust Fund. MEDICAL RESEARCH IN AFRICA SIR,—I am very glad that your correspondent of Oct. 16 (p. 624) has called attention to the attitude (or lack of it) of the Colonial Office to the immense medical problems of Africa. I note that he makes no reference to venereal diseases, but in this respect the official attitude seems to be much the same as in others. During 1944 and 1945, as Command venereologist and- dermatologist to the British Army in East Africa, I devoted fifteen months to the study of the special problems of venereal diseases in these territories. The war saw an enormous increase in the incidence of venereal diseases in East Africa, and at the same time provided means by which that increase was likely to go on. In this respect the V.D. problem has an urgency not presented by such a condition as malnutrition, which was pre- sumably not changed very much in recent years. It is also comparatively remediable ; yaws has been virtually " stamped out " in many districts, and comparable medical " campaigns " on a larger scale would do much to control the spread of venereal diseases. Three times since the end of the war have I tried to induce the Colonial Office to show an interest in the problem. I have submitted a survey of some 3000 words, called twice at the Colonial Office, and written letters ; but I have never detected any spark of real interest. My correspondents in Kenya are still unable to tell me of any material steps which have been taken to cope with the situation in that country. . No doubt, as your correspondent says, there is a shortage of personnel to do the work ; but I am not satisfied that this is the reason why so little has been done. The official mind does not seem to be appalled at so many tasks and so few people to carry them out : -. its attitude more resembles indifference, which can only result from a lack of appreciation of the importance of the work or from apathy. So long, of course, as this is the attitude of Whitehall the field workers of the Colonial Medical Service will be frustrated in their work; and, if they are good doctors, many of them will leave the service as soon as they can. Meanwhile, what of our trusteeship of the Africans ? London, W.1. F. R. BETTLEY. UNDER TENSION SIR,—In his letter on Oct. 23, Dr. West insinuates that because I admit the obvious fact that the Muscovite rulers wish to destroy non-Communist States, I must therefore be a warmonger intent on a preventive war against the U.S.S.R. This is a very serious charge, which I deny. In everyday life, a man who is threatened by a homicidal paranoiac neither reflects, while awaiting the mortal stroke, that it takes all sorts to make a world, nor decides to murder him first. He does the common- sense thing. If he lives in an ordered and policed State, he calls on the police to protect him, and he no doubt hopes that psychiatrists will cure the paranoiac of his mental aberration in due course. If, on the other hand, he lives in a State without police, law- courts, or psychiatrists, he collects trusted friends and fortifies his house. This is my logical counter to Muscovite threats. I am fortunately able to answer Dr. West’s whimsical question about what voices are to be heard in the U.S.S.R. In the Stalin-Tito exchanges, Stalin writes that the idea that there can be " peaceful development of capitalist elements alongside Socialism is a rotten and opportunist theory." Stalin also said, in the same Tito-Cominform controversy : " Communist parties can live and develop only in open warfare against the enemies of Com- munism." Dr. West’s counter to these bloodthirsty threats seems to be that’no-one is really to blame and that it will all be the same in 40 years. Very whimsical. very. A mighty droll and fantastical fellow, ’pon my word. Bridlington. P. D. H. CHAPMAN. STAPHYLOCOCCAL ENTERITIS DURING STREPTOMYCIN THERAPY SIR,—At the end of the case-report admirably presented by Mr. Kramer on Oct. 23, I was surprised to find in the summary the suggestion that " the Staph. aureus, already present elsewhere in the body, was rendered streptomycin-resistant by the small amount of the drug absorbed from the gut." In the absence of proven facts the subject is one for speculation ; but it is of great clinical importance. My experience is limited to penicillin, about which similar suggestions are frequently made. I find regu- larly after giving normal dosage of penicillin for 2 or 3 days in proper cases and failing to obtain improvement. that a characteristic defervescence by crisis is obtained by doubling or quadrupling the dose. I would submit that clinical experience in this and other ways is against the theory of education of a bacterial strain to immunity to penicillin. By an interesting coincidence, in the same number of THE LANCET Dr. Barber and Dr. Rozwadowska- Dowzenko find " that it has not so far been possible to train a staphylococcus in vitro to destroy penicillin." Furthermore, in Mr. Kramer’s case, the staphylococcus causing conjunctivitis was present on the face and was therefore being ingested before penicillin or streptomycin was administered. Why then did it not cause the fatal enteritis at that stage ? Is it suggested that small doses of streptomycin not only produced insensitivity to the drug but enhanced the virulence ? I believe Mr. Kramer’s second suggestion to be nearer the truth-" that elimination of the normal intestinal flora may have contributed to the establishment ofthestaphylo-
Transcript of UNDER TENSION
748
Furthermore, what is meant by the phrase " Required-house-physician, A or B2 " ? Does it mean that thisis a first appointment open to newly qualified practi-tipners, unless an ex-Serviceman or registrar with anM.R.C.P. cares to apply ? Or, more charitably, does itmean that a post normally of B2 status is found difficultto fill and offered to A practitioners ?
. To many, I said, this issue is dead. To me, and tomany other newly qualified men, it is very much alive.
A. B.
BLOOD FOR TRANSFUSION
SIR,-In view of the recent correspondence and lastweek’s leading article on this subject, I think it is worthrecording that recently we obtained 30 pints of group-Oblood from the North London Blood Transfusion Depotfor the purpose of exsanguination transfusion. We areparticularly indebted to the director of this unit for hishelp in supplying this large quantity at short notice.
St. Bartholomew’s Hospital,London, E.C.1.
I. P. MACDOUGALLChief Assistant.
NITROUS OXIDE SUPPLIED BY PRACTITIONERSIN MIDWIFERY SERVICE
SIR,—There appears to be confusion about the supplyto general practitioners of cylinders of nitrous-oxidegas for analgesic purposes in maternity cases under theNational Health Service. As the National BirthdayTrust is particularly interested in the provision ofanalgesia to women confined in their own homes, approachwas made to the Ministry of Health for guidance in thematter; and the following is from the Ministry’s reply :
" The position is that if a doctor is engaged by the patientto give maternity medical service under part iv pf the Act,he is in the same position as any doctor giving general medical
service under part iv. He may write prescriptions or mayhimself supply any drug personally administered’-e.g., nitrous .oxide. For drugs so supplied he will receivepayment from the executive council on presentation of aclaim on E.c.10 to the executive council.
" If the doctor is called in by a midwife in emergency, heis not giving maternity medical service under part iv of theNational Health Service Act but is giving services underthe Midwives- Act, 1918. He receives a fee which includes the
supply of necessary drugs and dressings, except that he getsextra payment for certain expensive drugs named in part 2of the schedule to s.i. 1453 of 1948. In such cases, the
patient would have a midwife in attendance and, as youknow, midwives are supplied by the local health authoritywith cylinders of nitrous oxide. Many, but not all, doctorshave cylinders but some may not have realised that whengiving maternity service under part iv they can be paid forany nitrous oxide they supply themselves."
57, Lower Belgrave Street,London, S.W.I.
D. V. RIDDICK
Secretary,National Birthday Trust Fund.
MEDICAL RESEARCH IN AFRICA
SIR,—I am very glad that your correspondent ofOct. 16 (p. 624) has called attention to the attitude (orlack of it) of the Colonial Office to the immense medicalproblems of Africa. I note that he makes no referenceto venereal diseases, but in this respect the officialattitude seems to be much the same as in others.
During 1944 and 1945, as Command venereologist and-dermatologist to the British Army in East Africa, Idevoted fifteen months to the study of the specialproblems of venereal diseases in these territories. Thewar saw an enormous increase in the incidence of venerealdiseases in East Africa, and at the same time providedmeans by which that increase was likely to go on. Inthis respect the V.D. problem has an urgency not presentedby such a condition as malnutrition, which was pre-sumably not changed very much in recent years. It isalso comparatively remediable ; yaws has been virtually" stamped out " in many districts, and comparablemedical " campaigns " on a larger scale would do muchto control the spread of venereal diseases.
Three times since the end of the war have I tried toinduce the Colonial Office to show an interest in theproblem. I have submitted a survey of some 3000words, called twice at the Colonial Office, and writtenletters ; but I have never detected any spark of realinterest. My correspondents in Kenya are still unable to
tell me of any material steps which have been taken tocope with the situation in that country. .
No doubt, as your correspondent says, there is a
shortage of personnel to do the work ; but I am notsatisfied that this is the reason why so little has beendone. The official mind does not seem to be appalledat so many tasks and so few people to carry them out : -.its attitude more resembles indifference, which can onlyresult from a lack of appreciation of the importance ofthe work or from apathy. So long, of course, as this isthe attitude of Whitehall the field workers of the ColonialMedical Service will be frustrated in their work; and,if they are good doctors, many of them will leave theservice as soon as they can.
Meanwhile, what of our trusteeship of the Africans ?London, W.1. F. R. BETTLEY.
UNDER TENSION
SIR,—In his letter on Oct. 23, Dr. West insinuatesthat because I admit the obvious fact that the Muscoviterulers wish to destroy non-Communist States, I musttherefore be a warmonger intent on a preventive waragainst the U.S.S.R. This is a very serious charge,which I deny. In everyday life, a man who is threatenedby a homicidal paranoiac neither reflects, while awaitingthe mortal stroke, that it takes all sorts to make a world,nor decides to murder him first. He does the common-sense thing. If he lives in an ordered and policedState, he calls on the police to protect him, and heno doubt hopes that psychiatrists will cure the paranoiacof his mental aberration in due course. If, on theother hand, he lives in a State without police, law-courts, or psychiatrists, he collects trusted friends andfortifies his house.
This is my logical counter to Muscovite threats. Iam fortunately able to answer Dr. West’s whimsicalquestion about what voices are to be heard in the U.S.S.R.In the Stalin-Tito exchanges, Stalin writes that the ideathat there can be " peaceful development of capitalistelements alongside Socialism is a rotten and opportunisttheory." Stalin also said, in the same Tito-Cominformcontroversy : " Communist parties can live and developonly in open warfare against the enemies of Com-munism." Dr. West’s counter to these bloodthirstythreats seems to be that’no-one is really to blame andthat it will all be the same in 40 years. Very whimsical.very. A mighty droll and fantastical fellow, ’pon myword.
Bridlington. P. D. H. CHAPMAN.
STAPHYLOCOCCAL ENTERITIS DURINGSTREPTOMYCIN THERAPY
SIR,—At the end of the case-report admirablypresented by Mr. Kramer on Oct. 23, I was surprised tofind in the summary the suggestion that " the Staph.aureus, already present elsewhere in the body, wasrendered streptomycin-resistant by the small amount ofthe drug absorbed from the gut."
In the absence of proven facts the subject is one forspeculation ; but it is of great clinical importance.My experience is limited to penicillin, about whichsimilar suggestions are frequently made. I find regu-larly after giving normal dosage of penicillin for 2 or 3days in proper cases and failing to obtain improvement.that a characteristic defervescence by crisis is obtainedby doubling or quadrupling the dose. I would submitthat clinical experience in this and other ways is againstthe theory of education of a bacterial strain to immunityto penicillin.By an interesting coincidence, in the same number of
THE LANCET Dr. Barber and Dr. Rozwadowska-Dowzenko find " that it has not so far been possible totrain a staphylococcus in vitro to destroy penicillin."Furthermore, in Mr. Kramer’s case, the staphylococcuscausing conjunctivitis was present on the face and wastherefore being ingested before penicillin or streptomycinwas administered. Why then did it not cause the fatalenteritis at that stage ? Is it suggested that small dosesof streptomycin not only produced insensitivity to thedrug but enhanced the virulence ?
I believe Mr. Kramer’s second suggestion to be nearer thetruth-" that elimination of the normal intestinal floramay have contributed to the establishment ofthestaphylo-
