98 MORE DOCTORS OR MORE ANCILLARIES ? Sir,-Your excellent leading article last week raises one of the most important problems for the future of medical practice under the N.H.S. in this country. Since, as you rightly assume, it is all-important that we shall maintain the standards of medical training, it seems to be inevitable that more and more of the techniques of medicine and surgery must gradually be decentralised on to the ancillary medical professions. This is probably a legitimate form of " dilution." The central problem at present inherent in this tendency is, as you suggest, to determine at this stage whether these professions shall be regarded for this purpose as " daughter " or " sister " professions of medicine. It was presumably in recognition of the need to face this problem that the Ministry of Health in 1950 set up the eight Cope Committees.- Important majority and minority reports were published embodying their findings and recommendations about eighteen months ago. Since then little or nothing further has been heard of the matter. This is a very unsettling situation both for us and also for the members of the ancillary professions. It has led to some members of the latter being encouraged by this interregnum to plan for autonomous status within the N.H.S. In view of your statement that " the proper use of ancillaries is a major issue on which doctors ought to be forming a considered opinion," it would seem desirable that the authorities should proceed to the next step, which is presumably to draft a Bill based upon the findings of the Cope report, and submit it for further discussion in Parliament. W. S. C. COPEMAN. ...
CLINICAL STUDY OF ADRENOCHROME
SiR,-The interesting letter by Dr. Srinivasan (Oct. 4) prompts us to make a few comments. Our experiments in the same field led us to consider the action of the products of oxidation of adrenaline upon the adrenal cortex of rats and men. We found that intraperitoneal injection trihydroxy-N-methylindol (T.H.N.I.), and
of adrenochrome, semicarbazone of adrenochrome (adrenoxyl), in doses of 100 g. per 100 g. body-weight to intact male rats, produced biochemical and hsematological signs of adrenal hyperactivity 1--i.e., adrenal ascorbic-acid depletion, decrease of adrenal cholesterol, and a fall in the level of circulating eosinophils. The action of 100 g. of each of these substances is, however, less than that of l-adrenaline in doses of 20 jjLg. per 100 g. body-weight. The semicarbazide chlorhydrate and the semicarbazone of glucose are inactive in the same doses. Thus, adrenal stimulation by adrenoxyl does not seem to depend on the semicarbazone radical, as was suggested by Gabe and Parrot.2
As adrenoxyl does not enhance the effects of adrenaline, then the stimulation of the adrenal cortex by the doses used in our experiments is not due to this sympathicomimetic hormone. JMoreover, the action of adrenaline does not depend on the oxidation products because adrenaline is active in a smaller dose.
excretion of reducing steroids and 17estimated in patients who had had an intravenous injection of 1 mg. of adrenochrome twice daily for five to ten days, and in other patients who had had 9 mg. of adrenoxyl (h 3 doses) every twenty-four hours for three successive days. No significant change was found in the urinary excretion of the steroids, and regular decrease in though there was a the circulating eosinophils. This discrepancy between animal and clinical experiments may be due to too small a dose in man, and further investigation may decide The
Cauwenberge, H., Lecomte, J., Fischer, P., Vliers, M., Goblet, J. Arch. int. Pharmacodyn. (in the press). 2. Gabe, M., Parrot, J. L. C.R. Acad. Sci., Paris, 1951, 232, 2255.
But there is no disagreement between animal and clinical experiments with salicylates in large doses, and our results with salicylates 3 suggest that it is aspirin which is in fact the " poor man’s cortisone." H. VAN CAUWENBERGE J. LECOMTE. Department of Internal Medicine and Medical Laboratory of Pathology and Chemical Research, University of Liége, Belgium.
CHRONIC OTITIS MEDIA
SIR,-I must have expressed myself badly at the
Royal Society of Medicine for your reporter to have misinterpreted me (Dec. 20, p. 1208). I do not believe in failure of pneumatisation of the mastoid bone, because radiography shows the presence of diploitic cells as the apophysis develops. Somehow some of these come to communicate with the antrum, forming the pneumatic cells. Then a non-suppurative otitis media passing up from the respiratory tract results in a condensing periostitis under the mucosa which is also the internal periosteum of these cavities. According to the number and severity of such inflammations the mastoid process may be modified from the normal cellular type into the so-called diploitic type or the sclerosed mastoid. This "’
must, I think, be the process that
causes these anomalies. but various bits may be produce ; pieced together. First, there is the occasional unilateral sclerosed mastoid. Anatomical variations such as these cannot be called normal. Nature does not build symmetrical bilateral structures in that way. Then again the otologist whose work was concerned almost entirely with the acute inflammations, as mine was, did not come across any other than cellular mastoids under adult or late adolescent life. Nor does he see them by radiography. It was in the ’20s that this first taught us that the normal mastoid is a cellular structure ; and that the patterns of the cells in the two sides, though not identical, are similar one to another. I have often confirmed this by using the radiogram of the normal mastoid to tell me how far I must go when operating on the diseased side, finding, more than once, cells in the squama of the temporal bone of which there was no sign in the blurred photography of disease, or going downwards and back. wards or up into the area where posterior and middle fossae of the base of the skull meet on their lateral
Evidence is hard to
aspects. Sometimes, from isolated
years ago the first mastoid X-ray taken at the North-eastern Hospital, not to decide whether a mastoid operation should be done but to study otitis media. And there was the bad side " all blurred in distinction with the clearly outlined cells on the otherand this within forty-eight hours of the first symptom. It exploded the old hypothetical pathology of successive jumps: and in course of time the xnodern concept of inflammation of the middle-ear cleft took its place. Twenty years later the boy became one of my last dressed The old plate had been destroyed, but a new one showed the cells on the two sides with patterns similar-but not identical :l because the cells in the side that had been inflamed were= smaller than those on the other, with thicker walls between them. One other case I had. A young lady of the W.R.N.S had been sent back from Algiers for operation, with the diagnosis of mastoiditis. The depth of the meatus wasso acutely tender that I wondered whether she had ever had an inflammation of the middle-ear cleft at all or whether the con dition might not be an otitis externa kept up by the irritating drops that had been used. And so a radiogram was taken and there was a cellular mastoid as clear as the one sometimes sees on the background of an said to her : Haveyou ever had anything wrong with the other ear ? " and she answered Oh yes!I had it bad once
3. Roskam, J., Vivario, R., Van Cauwenberge, H., Heusghem, Bull. Acad. Méd., Belg. 1951, 16, 561. Betz, H. 4. Van Cauwenberge, H., Betz, H. Lancet, 1952, i, 1083.
99 when I was quite a little girl " ; and she described a typical On that side the radiogram case of acute otitis media. showed the cells with patterns similar to the other-but again not identical, because all the cells were smaller, with thicker walls between them. If each practising otologist finds one such case in the course of his career we may, in a century or so, have a respectable body of evidence in favour of this hypothesis.
T. B. LAYTON.
very little to say that 50% of the milk consumed community is from non-attested herds if in fact the bulk of this 50% is adequately heat-treated before means
unless of course, Mr. Pitcher intends to ingestion of killed tubercle bacilli can produce immunity. For this there is, so far as I know, not a scrap of evidence. D. B. BRADSHAW
argue that the
BOVINE TUBERCULOSIS AND HUMAN TUBERCULOSIS
SIR,—Mr. Pitcher’s thesis (Dec. 6) is,
first approxiruns thus :
infections due to the bovine tubercle bacillus will increase the number of people susceptible to both types, and, other things being equal, will lead to an increased incidence of pulmonary tuberculosis. Mr. Pitcher’s figures purport to show that this theoretical possibility has been realised in Scotland.
Before considering Mr. Pitcher’s data, let us remember that bovine tuberculosis is not to be regarded merely as a beneficent immuniser against infection by the human bacillus: bovine tuberculosis was estimated to have caused some 2600 deaths in 1931. Mr. Pitcher’s tables compare notifications for 11 counties in two quinquennia. In his first table the second quinquennium is virtually the same for all counties, but for the first quinquennium he chooses five different periods. I do not wish to suggest that Mr. Pitcher has misled us by choosing the periods to support the thesis. No doubt his choice was governed by availability of data, but he should certainly try to show that his results have not been sophisticated thereby. It seems to me that at least the first table contains The last column, errors of simple arithmetic. increase or decrease," seems to have been calculated as a simple difference, and this would be legitimate if, as is probable, the populations of the counties did not alter greatly If my assumption be between the two quinquennia. correct, then the last column figures for West Lothian and Dumbarton should read + 119 and + 12 respectively. It may be that Mr. Pitcher has made his calculation by some other method, in which case the figure which he gives for Dumbarton may be correct, but that for West Lothian is certainly wrong on any basis of computation. Finding the rates for Glasgow incredible, I have taken the liberty (which I hope Dr. Laidlaw will forgive) of extracting the real figures from the annual reports of the Glasgow medical officer of health. They are as follows : "
that the notifications per 152 and 247 respectively, and
not 2 and 3 as Mr. Pitcher states. It is possible that the terms " new registrations of pulmonary tuberculosis and " notifications are not quite synonymous ; for example, the first term might include " transfers in," but this could not account for the gross discrepancy. Apart from the unreliability of the data there is a fundamental defect in the logic of Mr. Pitcher’s argument. The immunological consideration which underlies his argument is whether or not living tubercle bacilli are ingested. The extent to which a milk-supply is pasteurised or sterilised is, therefore, of the first importance. It "
mation, perfectly logical. The argument (1) Pulmonary tuberculosis is due almost exclusively to infection by the human type of tubercle bacillus. (2) There is a high degree of cross-immunity between human and bovine tuberculosis. Therefore, a diminution in
It follows from these
Deputy Medical Officer of Health.
THOMAS DRUMMOND SHIELS Kt., M.C., M.B., Edin. Sir Drummond Shiels, who died in London on Jan. 1, had made a career for himself in politics as well as medicine : and he had used his experience in each calling to enrich his work for the other. He was born in Edinburgh in 1881 and when he left school began work as a photographer. During the .1914-18 war, while in command of a trench-mortar battery, he was mentioned in despatches and was awarded the M.C. and the
he returned to Edinburgh and began to study medicine, taking his M.B. in 1924. Meanwhile he had been elected to the Edinburgh town council, and in the year he graduated he also became a Labour member of Parliament for East Edinburgh. His political advancement was rapid. In 1927 he was appointed a member of the Royal Commission on constitutional reform in Ceylon. Two years later he became Parliamentary under-secretary for [Walter Stoneman India, and later to the Colonial Office. After he lost his seat in Parliament in the 1931 election he became secretary to the British Social Hygiene Council, a post for which his judgment and turn for lucid exposition well fitted him. But the decision not to seek re-election to Parliament had been a hard one, and he eagerly seized the opportunity, when it arose, to join the staff of the Empire Parliamentary Association. As deputy secretary of that body he was brought back to the atmosphere of Westminster in which he thrived, and which gave scope for his genial personality. In 1946 he was appointed public relations officer to the Post Office, and in the same year he also became a member of the Colonial Economic and Development Council. He was vice-president of the Royal Empire Society, on whose council he had served for many years, he was also a -member of the governing body of the He was British Postgraduate Medical Federation. knighted in 1939. R. F. writes : " The Clydesiders considered Drummond Shiels’s views to be pale pink, but they never questioned the honesty and sincerity of purpose of their Edinburgh colleague. The inevitable ins-and-outs of the politician’s life meant for him hardship and financial stringency, but he never complained, and he always showed those qualities of toleration, loyalty, and humour for which In speech he was slow, he was held in general esteem. deliberate, and almost ponderous, but he never took himself too seriously. If his demeanour was grave, his smile at once removed all trace of the funereal. His manner was tactful and persuasive, but that jowl of his denoted dour persistence : his humour was pawky rather than sly, for there was nothing but good nature behind it. At home in any company, he never forgot that he was a Scot : and when he presided over his fellow-exiles at the dinner of the London Burns Club in 1951, we little guessed that his life of public service and private kindliness was so near its end." Sir Drummond Shiels’s first wife died in 1948. In 1950 he married Miss Gladys Buhler, M.B.E., who survives him with the daughter of his first marriage.