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AMPHETAMINE

SIR,—May I suggest that Dr. Howard’s case (Jan. 4),in which the possibility of a coincidental remission ofsymptoms on withdrawal of amphetamine cannot beruled out, does not provide grounds for his opinion thatmore cases of idiosyncrasy are observed with ampheta-mine than with other drugs ? In fact, I submit, theliterature inclines the other way. There have beenremarkably few published reports of idiosyncrasy tothis drug, and in a recent survey Bett 1 states that " thegreat preponderance of competent clinical opinion favoursthe view that the incidence of undesirable reactionscomplicating Benzedrine ’ therapy in normal dosagerange is negligible and that the few cases reported in theliterature are usually traceable to indiscriminate or

unsupervised use."T. C. BLACK.Menley & James Ltd., London, S.E.5.

PERITONEAL DIALYSIS

SiR,—I was interested to read of the use of peritonealdialysis by Mr. Reid and his colleagues (Nov. 23, p. 749)in a case of anuria treated by renal decapsulation. Youwill note the recovery of 7 g. of urea from the peritonealefflux. (It should be emphasised that measurement ofurea excretion is only a convenient way of measuring theexcretion of all diffusible retention products.) Althoughmore urea escaped in the unrecovered fluid which leakedout, it is not likely that the total extracted during thethree days of saline drip exceeded the 20-24 g. per daywhich continuous peritoneal irrigation - achieves. Evenat this rate, the uraemic patient must be treated for notless than three or four days before substantial clinicalimprovement is manifest. Had the urea excretion viathe kidney after decapsulation been measured, a validestimate of the comparative benefits of decapsulationversus dialysis would have been possible. The evidenceas far as it goes leaves little doubt that dialysis contri-buted only a very small benefit and that decapsulationbrought about recovery.We are apprehensive that peritoneal dialysis will

be discredited unless the precautions we have latelydescribed with respect to the correct formula and thecontrol of peritonitis-an ever-present danger-areadopted. In a number of cases the method has failedbecause of incorrect technique, neglect of the principlesof fluid balance, or poor choice of case. Our publishedreports consider the type of tube and the fluid formulasto be used as well as the diffusion processes involvedin peritoneal dialysis, the problem of oedema, &c. Webelieve these problems are not insurmountable, whereasthat of peritonitis may well prove to be. We are nowimproving the method so as to eliminate, or at leastreduce to a minimum, the possibility of infection fromextraperitoneal sources. Once this has been achieved the-occurrence of peritonitis will be traceable to invasionfrom the gut, and if this proves to be the case the methodmay well have to be discarded. The usual invader isBact. coli when penicillin, alone or with sulphonamides,is used. We had hoped that when streptomycin becameavailable in sufficient quantity to maintain a bacterio-static concentration throughout the period of irrigationthis organism would come under control. But we havenow learnt that streptomycin prophylactically has the

. disadvantage of inducing increasing resistance in Bact.coli. Chemotherapy alone, even including streptomycin,will not prevent or cure Bact. coli peritonitis.A number of otherwise salvageable patients will be

lost from pulmonary cedema due to using too muchfluid intravenously or to errors in the make-up of theformula or failure to alter it as the circumstances inthe individual case require. Some patients will bewaterlogged as a result of useless efforts at forcingdiuresis before the start of peritoneal irrigation. Thedepth of acidosis and its variations retire alterationsof the formula. Much work remains to be done before themethod becomes sufficiently standardised to permit itsgeneral use.

Kolff’s " artificial kidney " method deserves to beexplored at the same time, for it avoids the complication1. Bett, W. R. Post-grad. med. J. 1946, 22, 205.

1. Fine, J., Frank, H. A., Seligman, A. M. Ann. Surg. 1946,124, 857.

of peritonitis and presumbly is as capable of establishingfluid balance as our method. It has the obvious dis-advantages of complicated apparatus, the need of totalheparinisation, the establishment of an arteriovenousanastomosis, and the possibility of leakage from injuryto the ’ Cellophane’ coil.

-

JACOB FINE.Department of Surgery, HarvardUniversity, Boston, Mass.

HEALTH CENTRES OF TOMORROW

SiR,-Your new series of articles should be of consider-able value, for the subject can do with a great deal ofpublic discussion. I thought I had made my own viewsfairly clear, but a note on p. 46 of your issue of Jan. 4suggests that I advocate an " enormous, elaborate,all-purpose centre." I certainly advocate an all-purposecentre so far as general practice is concerned, and agreewith your own definition of a

" centre in which generalpractitioners undertake all work ordinarily coming withintheir scope, and where they assist each other, with ampleaid from technicians." I include among those tech-nicians the specialists of the medical profession.

It is, however (among other reasons), because I donot advocate elaborate health centres that I disagreewith your suggestions about laboratory provision inthe centres. I do not believe that the finest service forpatients and for general practitioners, which is what weare aiming at, can be given by multiplying the numberof small laboratory units and placing them in charge oftechnicians however well trained. There is, as yousay, " undoubtedly a very wide undisclosed demand "for laboratory help ; but can you produce figures tojustify the multiplication of laboratories and the employ-ment of full-time technicians at every one of them ? 2I have already tried to give such figures.lMy experience in a laboratory which has made a special

point of providing every possible facility for every generalpractitioner in its area indicates that, even when satura-tion-point is reached, a health centre for ten generalpractitioners or less will still not have enough work-that can be done unaided on the spot by one technician-to justify the inclusion of a laboratory. General practi-tioners with experience of a service in which a centrallaboratory handles the whole of the clinical pathologyof an area cheaply, rapidly, and willingly, will not easilybe convinced that any other method is preferable.From those who believe that each centre should have itslaboratory it would be helpful to have estimates of thevolume of work likely to be done there.Richmond, Surrey. D. STARK MURRAY.

SiR,-It seems pretty obvious that in the new healthcentres for some time to come we shall have neitherenough X-ray plants nor the trained staff to work them.It may take several years until " the ideal arrangementfor the future," as visualised by the more progressiveadvocates of well-equipped health centres, will become areality. Surely something could and should be done inthe meantime to provide a sort of " basic X-ray service

"

for the patients attending their doctors at these centres.So far 19 local authorities in England and Wales have

been equipped with mass-radiography units ; and itcan, I believe, be assumed that all major local authoritiesin the country will have a mobile mass-radiographyunit, adequately staffed, at their disposal in the nearfuture. It has already been demonstrated that voluntarymass radiography of the supposedly healthy, working-fitpopulation in single surveys gives a relatively poorreturn. The time has now come to shift these mobileunits from the fit to the sick people. The experimentalstage of mass surveys of cross-sections of the workingpopulation could now be followed by the more promisingenterprise of employing mass radiography as a routineexamination of contacts and as an unrivalled aid to theearly diagnosis of clinical chest diseases.Our clinical experience in chest clinics as well as in

sanatoria shows every day the disturbing fact that toomany cases of tuberculosis, as well as of bronchialcarcinoma, severe bronchiectasis, and other clinical chestdiseases, are being missed because of inadequate exami-nation. Present-day knowledge, however, tells us thatno chest examination can be considered " adequate "

1. Clinical Pathology in the National Health Service. Med. Pr.1944, 211, 166.

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without " early "-and, if inconclusive, repeated-X-rayexamination. Apart from periodical (and compulsory)mass surveys in hazardous industries it is the HealthCentres of Tomorrow which ought to be the Target forTomorrow of mass routine radiography.

E. G. W. HOFFSTAEDT.Holywood Hall Sanatorium, Wolsingham.

PREVENTION OF EPIDEMIC NEONATALDIARRHŒA

.SiR,—Mr. Stern (Jan. 11), in indicating the film whichforms inside feeding-bottles, may well have found oneof the causal factors of otherwise baffling epidemics ofneonatal diarrhoea. Removal of this very adherentfilm is difficult but desirable even though the bottlesare sterilised after use. Mr. Stern does not recommenda method by which the bottles may be " thoroughlycleansed of film." I have found the best cleansing agentto be one of the sulphonated alcohols or soapless deter-gents called Teepol ’ (Technical Products Ltd.). Asmall quantity of this in the washing-up water and theuse of a bottle brush will quickly remove film.London, N.14. C. ALLAN BIRCH.

PSYCHOTHERAPY OF ULCERATIVE COLITIS

SIR,-Dr. West (Dec. 21) remarks on the disregard inthe 1920’s of the emotional element in the causation ofcolitis.

It may be of historical interest to record that in thesummer of 1921, after a preliminary psychologicalinvestigation to prove the need, I referred a patient toDr. Millais Culpin for psychotherapy. She was a musicallytalented woman with aspirations to become a profes-sional, who for 23 years, from the age of 15, had beenvirtually a prisoner confined to the vicinity of a w.c.The treatment was completely successful. Before longI was successfully treating colonic spasm in the sameway.Those were the days when the appendix was stitched

to the abdominal wall and used as a channel throughwhich to wash out the colon in an attempt to rid it of anirritant existing, as Groddeck had shown long before,only in the mind. Neither Culpin nor I had heard ofGrnrfe <-(iMi

Portsmouth. W. S. INMAN.

A MORAL PROBLEM

SIR,-Leaving out of consideration the sense of degra-dation which most of your readers would feel on readingdetails of experiments on innocent outraged humanvictims, the argument against the German medicalatrocities is that any small step forward in medicalknowledge is at the expense of an immense step back-ward in civilisation. I realised from the beginning thatsomeone would put the entirely hypothetical questionwhether such atrocities would be justified if they produceda major medical advance such as a cure for tuberculosis,and my answer would still be No ; for even the hurryingby some years of such great relief of human sufferingwould be too dearly purchased by the immeasurablygreater harm done to the respect for the human person-ality on which civilised human life depends. It is betterto be a Keats or a Stevenson with tuberculosis than aHimmler or a Goebbels without it.The publication of medical knowledge obtained by

the treatment of war wounds or Belsen starvation is notat all analogous, because that was obtained in the propermedical function of rendering aid to the sick and wounded,and not in its perversion in experimental atrocity. Thereis all the difference.The point to consider therefore, apart from the sense

of degradation and shame which editors, secretaries,printers, and readers would feel in dealing with suchstuff (which some would discount as mere sentiment),is whether the consummation of such " research " byits publication and use would make us accessories afterthe crime. I personally feel that they would, and thatthey would make it considerably easier for some futurewould-be human vivisectionists to give way to theirinhuman instincts.The records should be destroyed-the sooner the better.

They should never be published.London, S.W.15. A. NELSON-JONES.

ObituaryWILLIAM HAROLD WHITE

M.R.C.S.

FOR the past 25 years Dr. W. H. White put intopractice in his maternity home at Blackheath his theorieson the advantages of a vegetarian diet and suitableexercises for expectant mothers. Born in 1882, theson of the Rev. Samuel White, vicar of Marley Hill, nearDurham, he was educated at the Clergy OrphanageSchool at Canterbury, and at first worked in an insuranceoffice. But the conditions of midwifery at the time of thebirth of his first child so shocked him that he determinedto become a doctor. In 1917 he took the Conjointqualification at St. Thomas’s Hospital, later servingwith the R.A.M.C. in India. But he had not forgottenwhy he had joined his new profession, and on demobilisa-tion, after holding a house-appointment at the GeneralLying-in Hospital in York Road, he opened StonefieldMaternity Home with Dr. Cyril Pink in 1920. " Perhapsthe most valuable contribution Dr. White made toobstetrics," writes a colleague, " was his encouragementof the use of exercise during pregnancy and the puer-perium, and through his enthusiasm many patientsreceived great benefits. He tried to plan antenatal careso as to secure a small child, and so was an experimentalobserver in one of the most complex biochemical fields."

Dr. White died at Hindhead on Dec. 29. His wife,Miss Ethel Hutchings, whom he married in 1907, surviveshim with three sons and two daughters.

CHARLES GRANT PUGH

M.D., B.SC. LOND., D.P.H.

Dr. C. Grant Pugh, for 32 years medical officer ofhealth for Southend-on-Sea, died on Dec. 19. OfScottish and Welsh descent, he came of a family with amedical bent, for his elder brother, the late W. T. GordonPugh, was for many years medical superintendent ofQueen Mary’s Hospital for Children, Carshalton, hissister was formerly a senior member of the LondonCounty Council nursing staff, and his surviving brotheris a dental surgeon in practice in Streatham.He was educated at Aberystwyth and at the Middlesex

Hospital, which characteristically he chose as his medicalschool because the house-appointments were made onthe examination results. He had already graduatedB.SC. Lond. in 1894, and in 1899, after winning thesenior Broderip and Murray scholarships, he took hisM.B. Lond. with honours in medicine. The followingyear he was awarded the gold medal for his M.D. Atthat period it seemed unlikely that he could expectpromotion to the honorary staff of the Middlesex for aconsiderable time, and Pugh accordingly relinquishedthe project of setting up in consultant practice. In1902 he took the D.P.H. at Cambridge, and after somefruitful years with the Metropolitan Asylums Boardand experience as deputy medical superintendent atBethnal Green Infirmary he became one of J. C. Thresh’sassistants in Essex, and Thresh was for him a formativeinfluence of the first importance.

In 1908 Pugh was appointed M.o.H. for Southend, andthere he found ample scope both as physician andadministrator, for, in those days when the area was lesswell served by consultants, his opinion was often soughtby his colleagues in difficult medical cases. The healthservices of this rapidly growing population were developedby him on sound lines till the outbreak of the first worldwar temporarily arrested progress. After serving in theBalkans with the rank of captain, R.A.M.C., he returnedto Southend where he was foremost in calling attentionto the urgent needs for better hospital provision, andwithin a few years the generosity of Lord Iveagh and aspirited local initiative had created the new SouthendGeneral Hospital.The Local Government Act of 1929 offered a great

opportunity of which, on Pugh’s advice, the corporationtook full advantage. The sick wards of the poor-lawinstitution at Rochford were transferred from the boardof guardians and appropriated for hospital purposes, and,when the extensions begun by the guardians were com-pleted, Pugh set himself the task of .modernising thehospital. In 1940, a few weeks before his retirement,