978

of dextran. This is supported by a series of observa-tions on normal individuals in America 9 which showedthat sec’ond infusions of dextran four to twenty-three months after the initial infusion were notfollowed by systemic reactions, except in those whohad reacted to the first infusion ; and in these thereactions to the second infusion were not more severethan the reactions to the first. Furthermore, theincidence of positive reactions to the intracutaneousinjection of dextran in people who had previouslybeen given an infusion of dextran was the same as inpersons who had never been given dextran. Thisindicates that infusion of dextran had not givenrise to true sensitivity.

There is still much to be learnt about dextran.Certain strains of L. mesenteroides are poor antibodyproducers in animals ; it would be worth investigatingwhether the corresponding dextrans are only weaklyantigenic or even non-antigenic in man. There isevidence that the antigenic response is influenced bythe chemical structure of the dextran and possiblyalso by its molecular size, and varying the compositionof the medium in which the organism is grown isknown to affect the chemical structure of the dextran

produced. Further study of this aspect would seemworth while. Furthermore, it would be valuable tosecure agreed physical and chemical methods for

characterising the many different dextrans ; manyreports give insufficient information for the dextranto be identified.

In the last five years dextran has been inves-

tigated more intensively than probably any other

plasma substitute ; and the story, in unfolding, hasgradually become more complex. As examination ofthe other plasma substitutes progresses, a similarlyinvolved picture is likely to develop. Some of thenew information about dextran merits careful thought;but the clinical evidence suggests that dextransolutions can be administered safely.

9. Report to National Research Council, Washington, April, 1952.10. College of General Practitioners : First Annual Report, 1953.

See Lancet, Oct. 31, 1953, p. 924.

Facts from General PracticeTwo factors- are helping to secure for general

practice the prominence it has always deserved butwhich it was in danger of losing. One is concern overthe increasing cost of the hospital service and thetardy realisation that, if the general practitioner isto check this drain on national resources by himselfinvestigating and treating illness in its early stages,he must receive both credit and help-includingaccess to investigation departments. The other factoris a new awareness that, in our preoccupation withhospital techniques, we have been neglecting firstcauses in the home and the place of work. Hadresearch into these causes been pursued as vigorouslyas that into the causes of infectious diseases, the totalof our people’s ills might now be less ; and if thisbackwardness is to be ended we shall have to look

largely to the general practitioner, who is better

placed than most to study the influence of heredityand environment on health and disease in the indivi-dual and the family. Here again he needs help ;and he needs, too, the opportunity to cooperate withhis fellows. Fortunately, both are likely to be obtain-able through the College of General Practitioners.lo

But if the family doctor is to make a serious incur-sion into this field, he must know the extent of

morbidity in the population, and the contribution ofeach disease to the total-a subject on which we stillhave little precise information. As a source of thisessential knowledge the experience of general practi-tioners themselves is necessarily imperfect; but it isabout the best we have at the moment. A first

attempt to tap this source is recorded in a report,l1issued this week, in which Dr. W. D. P. LOGAN, chiefmedical statistician of the General Register Office,sets out the results of a year’s experience (from April,1951) in eight widely different practices. The eightpractitioners recorded the date and place of consulta.tions, certificates issued, referral to hospital or else.where, and diagnosis or other reason for consultation.These data have yielded information which, thoughit may not apply to the country as a whole, goessome way to replace impressions by facts.

Reasons for consultation.-The two diseases responsiblefor the largest proportions of consultations were acutenasopharyngitis (common cold) (60-9 consultations per1000) and bronchitis (53-0 per 1000) ; additional to thelatter were acute bronchitis (4-9) and chronic bronchitis(10-8), giving a total for bronchitis of all kinds of about68-7 per 1000. Next came influenza (26-5) and acutetonsillitis (22-1). Other conditions that accounted formore than 10 consultations per 1000 total were asthma(10-5), asthenic reaction (neurasthenia, &c.) (11-1), otitismedia (19-7), hypertension (16-3), pneumonia (12-4),gastritis (11-9), functional gastric disorders (indigestion,&c.) (14’1), gastro-enteritis (12-6), boil and carbuncle(15-6), dermatitis (10-2), muscular rheumatism (16-0), )," rheumatism " (15-0), cough (11-4), and routine antenatalexaminations (19-4).

Respiratory diseases accounted for 24% of all con-sultations ; digestive diseases for 9 % ; diseases of thenervous system and sense organs for 8 % ; circulatory,locomotor, and skin diseases for 7 % each ; infectiousdiseases for 6 % ; and injuries for 5 %. Allergic andendocrine diseases and genito-urinary disease were eachresponsible for 4 % ; the mental and psychoneurosisgroup for 3 % ; and neoplasms, blood diseases, andmaternal complications each for 1 %. Symptoms andsenility accounted for 8 % ; and reasons other thansickness for 5 % of the total.

Sex differences.-Three out of every five consultationsrecorded were in respect of female patients ; but, takingaccount of their larger numbers in the practice popula-tions, this excess was only 25 %.

Place of consultation.-68 % of all consultations weresurgery attendances, 27 % were home visits, and 5%took place elsewhere.

Certificates.-The diseases that accounted for thelargest proportions of certificates (including NationalHealth Insurance, private, and other certificates) were :

Of all certificates issued 29 % were for respiratory diseases-well over twice as many as for diseases of the digestivesystem, which were the next most common reason forissuing a certificate. Certificates for non-medical pur-

11. General Register Office : Studies on Medical and PopulationSubjects, no. 7. General Practitioners’ Records : An analysisof the clinical records of eight practices during the period April1951, to March, 1952. By W. P. D. LOGAN, M.D., PH.D. chiefmedical statistician, General Register Office ; with a forewordby Sir John Charles, M.D., F.R.C.P., chief medical officer of theMinistry of Health. H.M. Stationery Office. Pp. 131. 8s. 6d.

979

poses (e.g., countersigning of claims for family allow-ances, old-age pensions, and tobacco tokens) accountedfor only 0-3% of all certificates issued.Bers.—The most frequent diagnoses for which

"a.t.;Pnt,c W-PT’A rafarrarl trt nm;;nif.::J.1 our p’1’-!fBvifT’f Bvp’T’< ’ &middot;

The conditions for which admission to hospital was mostoften arranged were appendicitis and pneumonia.Number of consultations.-The average number of

consultations during the year per patient on the doctors’lists was 3-4 for males and 4-2 for females.

From these and many other findings tabulated inthe report, Dr. LoGArr concludes that simple data ofthe sort recorded by the eight practitioners are suitablefor statistical analysis. He admits that conscientious

recording was an additional burden on the doctors ;but the weight of this, he feels, was greatest at thestart, and he believes that such a system can be kept

going without undue difficulty even during busyperiods. " There can be little doubt," he says, thatgeneral practitioners’ records " potentially constituteone of the most valuable sources of information onmorbidity." The size and scope of the inquiry mayeventually be increased ; but meanwhile it is beingcontinued on the same lines for a second year. Dr.LoGArr adds two warnings. One is that terminologyand measurement throughout the whole field of mor-bidity statistics are still being developed, and thebest methods of tabulation are undecided. The otheris that doctors who think of embarking on their owncomprehensive analysis should recognise that this is

likely to prove much more burdensome than the

record-keeping itself. Even the General RegisterOffice, with its large resources, seems to have beenquite heavily taxed in analysing the data from thislimited survey.

’

This survey was designed to show what con-

stitutes general practice. But clearly a similar

approach might throw much new light on the sources,extent, and effects of morbidity. It is a strange twistthat has brought the family doctor, who prides himselfon dealing with individual people, to his presentposition in which, in league with a Hollerith machine,he will be handling masses of figures. Perhaps thisfirst account will give him heart for the task.

Annotations

MAN AND DISEASE

THE historical record of man’s early steps towards theunderstanding and treatment of disease may often seemto the student a jumbled and unhelpful story that is oflittle use to him in absorbing present-day teaching. Butcareful study and perceptive interpretation can pickout the threads from this tangled tale and turn it into afascinating introduction to the more familiar events ofrecent years. And this is what Sir Henry Cohen did at theRoyal Society of Medicine last week when, in his presi-dential address to the section of medicine, he discussedthe Evolution of the Concept of Disease.Primitive man was little concerned with the nature or

cause of disease : he concentrated on its cure. Sir Henrypointed out how the earliest remedies were based oncertain doctrines which, though they were crude andsupernatural, had profoundly influenced later thought.There was the doctrine of similars whereby, for example,stewed raven was the cure for greying hair ; the doctrineof signatures which held that distinctive markings on aplant indicated its medicinal properties (thus, yellowcelandine was the thing for jaundice) ; the doctrine of

analogy which drew comparisons between the treatmentof animals and of man ; and the doctrine of contagionwhich attributed a baleful influence to external forcesand which led, among other things, to the popularity ofmoonstone for mental illness. When it came to the

appreciation of the nature of disease, two ideas haddominated man’s thought since earliest times : disease,as a separate entity quite distinct from the individualaffected ; and disease as a deviation from normal.These two views had coexisted until the present day,sometimes overlapping, sometimes one or the other

predominating, according to the philosophy of the timeand the influence of outstanding personalities.The most primitive form of the " entity " idea was the

explanation that disease was caused by a variety of evilspirits, which called for treatment by incantation, burntoffering, and sorcery. These practices could still berecognised from time to time in modern life : the raw

potato carried for the prevention of rheumatism was theequivalent of the primitive amulet ; and Sir Henryrecalled a case in his own experience where the relativesof an Armenian patient had sacrified a pigeon in thebelief that they might thereby instil new life into thedying woman. The notion of diseases as separate entitiesdeveloped from this " demoniacal" concept : and itwas fostered by the careful descriptions of individualillnesses recorded by Hippocrates and later physicians.They all dealt with particular cases, and no attempt atgeneralisation was made until the 9th century A.D. whenRhazes of Persia differentiated between smallpox andmeasles. As many separate diseases became recognised,the idea gained ground and it was given impetus in the17th century by Linnaeus’s Systema Naturae in which heobserved that " there are as many species as there arediverse forms that were created in the beginning," andby Sydenham who declared that diseases were " to bereduced to certain and determinate kinds, with the sameexactness as we see it done by botanic writers in theirtreatises of plants." The entity point of view reached itspeak perhaps, when in 1763, Francois Boissier de Sauvages,botanist and physician (botanist first it seems), groupeddiseases into classes, orders, genera, and species (of whichthere were 2400 in all). This conventional and rationa-listic outlook of A (the patient) plus B (the disease) wasstill apparent, Sir Henry thought, in much of our teachingtoday. It was often responsible for a misguided depen-dence on pathognomonic physical signs and a fondnessfor the penny-in-the-slot diagnosis.The alternative view of disease as a deviation from

normal had its roots in Greece, whose philosophers soughtto generalise from inadequate particulars and to conceivethe whole of Nature without a sufficient knowledge of itsparts. They developed the idea of the four humours-blood, phlegm, yellow bile, and black bile-that was todominate medicine for 2000 years. But it was before thehumours were described that Plato first stressed thediscord of disease, attributing it to abnormal quantity,quality, or position of the four elements of the body.Plato’s views led to the school of thought whose followersGalen called the Dogmatists, and who held the field for a.century after the death of Hippocrates. - They were