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It should be added that other grades of Africanworkers have long been trained for service among thevillagers. Thus at Fort Hare " medical aids " take acourse lasting 4 years, mainly in preventive measures andpractical sanitation, and finally sit for a degree in hygiene.They are appointed to the health centres now being setup in native areas, holding posts under either the

government or the local authorities. African nurses aretrained in large numbers at the mission and provincial

. hospitals, their courses being subsidised by the State.They take the same nursing and midwifery qualificationsas British nurses. In the Transkei women social workersare trained in hygiene and mothercraft, and are taughtsomething about the soil from the agricultural andnutritional points of view. People of a simpler type aretrained as health assistants ; they undertake practicalpreventive work-for example, spraying to destroymalarial mosquitoes.

Medical services to Africans have hitherto been givenlargely by missionary hospitals assisted by public grants.The present government programme is largely the out-come of the Health Commission’s report of 1944 ; it iswider than any previous one, and likely to grow.

CLARIFYING CORONARY DISEASE

THE rising incidence of circulatory diseases and theincreasing proportion of old people in the populationdemand a clarification of our ideas concerning thediagnosis, treatment, and prognosis of disease of thecoronary system. Our knowledge of the subject hasadvanced a long way since Herrick first showed thatcoronary thrombosis can be diagnosed at the bedside,but it has proved difficult to correlate satisfactorily theclinical, pathological, and electrocardiographic findings.The necropsy study by Blumgart and his colleagues of125 consecutive cases in which the coronary arteries were

injected post mortem threw much fresh light on theproblem. In normal hearts anastomotic communicationsless than 40 micra in diameter exist between the coronaryarteries, but these are probably of little value in over-coming the untoward effects of sudden coronary occlu-sion. Intercoronary anastomoses greater than 40 micrado not exist in normal hearts ; they are found in thepresence of coronary sclerosis, but only when and whererequired. No evidence was found that such anasto-moses increase with age in the absence of arterial narrow-ing. This anastomotic development explains many ofthe apparent anomalies. Thus, if coronary occlusion

develops slowly, it may result in the complete occlusion,of at least one of the major coronary arteries withoutthere being more than a moderate degree of myocardialfibrosis ; in such cases the collateral circulation developspari pa’ssu with the occlusion, so that the blood-supply tothe myocardium in the affected area is adequate for itslocal requirements, though if the demands on it increasethe patient will show the typical clinical picture of anginapectoris. On the other hand, if the occlusion developsmore rapidly than the anastomosis the myocardium willshow varying degrees of fibrosis.

In other words, coronary thrombosis (or occlusion)does not produce any characteristic clinical manifesta-tion. The condition commonly referred to under thislabel by clinicians, and characterised by severe substernalpain, shock, hypotension, tachycardia, pyrexia, leuco-cytosis, and typical electrocardiographic changes, isdue to myocardial infarction, and only incidentally tocoronary thrombosis. For this reason it would be wellto use the term myocardial infarction instead of coronarythrombosis. This was the practice among clinicianstwenty years ago, and it is not clear why the name wasever given up. If it is reinstated we shall be able to referto coronary occlusion which is either chronic, resulting inangina pectoris, or acute, resulting in myocardial infarc-1. Blumgart, H. L., Schlesinger, M. J., Davis, D. Amer. Heart J.

1940, 19, 1.

tion. As Blumgart and his colleagues pointed out, thedevelopment of a myocardial infarct depends largely onthe duration of the period of anoxia. If this period canbe reduced, or if, while the blood-supply to the affectedarea is reduced, the demands on the myocardium can berapidly lowered by rest in bed, sedatives, or control of therapid ventricular rate, then infarction may not occur.Clinically such episodes may simulate myocardial infarc-tion, but the typical electrocardiographic changes are notobtained and there is no pyrexia, leucocytosis, or raisedsedimentation-rate.

THE PRACTITIONER AS TEACHER

SPEAKING as a medical-officer of health, Dr. H. R.Tighe 1 argues that the general practitioner should nottry to practise preventive medicine but should confinehimself to the diagnosis and treatment of disease. Oncethe stage of pioneering is past, routine preventive work,he says, is generally handed over to the lay specialist orto the lay public. Today " the sanitary inspector, thehealth visitor, the school nurse, the school teacher, theengineer, the architect, the policeman, the social welfareofficer, the newspaper reporter, and recently the officialsof the Ministry of Food, are among the host of lay workersin preventive medicine," and " if the general medicalpractitioner thinks he is going tQ gain honour or glony,much less riches, by competing with these experts, he isgreatly mistaken." Against those who say that thedoctor must be a teacher, perpetually preaching thegospel of’ health, Dr. Tighe declares that mere talk,without coercion, will do nothing to persuade " themental defective to remain under control, the dull not tomultiply, the physically fit to have children, or the

physically unfit not to have children," and it will doequally little to combat the activities of the avariciousindustrialist, the owner of slums, or the adulterator offood. And even assuming that talk is sometimeseffective, is the individual doctor the right person toundertake this form of propaganda ?

.

" I cannot imagine he is or that he really desires the office.I cannot imagine that the general medical practitionerdesires to turn himself into a living gramophone record tokeep repeating what to him must be the same platitudes adnauseam. If there be any who consider this to be suitablework for the product of the most lengthy and expensiveprofessional training known, I cannot share their view. Ishould regard the school teacher, the health visitor, thepublic lecturer, the newspaper, the cinema, the billposter,and the wireless as the proper media. I do not deny thatthe doctor should play an important part in all such healtheducation, but his work should be collective, not individual."

Dr. Tighe’s thesis is, in fact, that two main divisions ofmedicine should be recognised, and maintained. Firstthere is clinical medicine, concerned in the widest sensewith diagnosis and treatment ; and secondly there is

preventive medicine, concerned with the prevention ofdisease or injury, the maintenance and improvement ofhealth, and the improvement of the race both mentallyand physically. The practitioner of clinical medicineshould know how and when to link up with the organisa-tion of preventive medicine, but " his essential job shouldbe to discover disease and to treat it, not to keep peoplewell or to prevent disease." The practitioner of preven-tive medicine, on the other hand, should concentrate histhoughts " not only on prevention as distinct from cure,but on the human herd as distinct from the individual,for to him the individual is of small account."

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Obviously this argument runs counter to a great dealthat is nowadays being said and thought about thegeneral practitioner’s functions ; and it may appeal tomany practitioners who cannot quite see themselves inthe role cast for them by some of the exponents of"positive health." But even those who agree thatclinicians must always be mainly interested in diagnosis

1. Publ. Hlth, January, 1945, p. 43.

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and treatment may hesitate to go so far as Dr. Tighein excluding them from preventive work. Surely heover-simplifies when he accepts the definition that" preventive medicine is that which starts off with healthand sees to its maintenance, and clinical or curativemedicine is that which starts off with disease and endea-vours to effect its cure or amelioration " I Health anddisease cannot be such definite entities as this implies : ethey are better conceived as different ends of a scalewhich records the degree of success in reacting to environ-ment. Perhaps therefore the clinician need not troubleto pursue, with Dr. Tighe, such academic questions aswhether prevention does or does not embrace treatmentof the small beginnings of disease, or the avoidance ofsequelse. His task is simply to give the help and advicemost likely to be useful to his patient, regardless ofwhether this advice can be labelled curative or pre-ventive.

Any new boundary between the territories of themedical officer of health and the’ practitioner can hardlygive the whole field of preventive medicine to the former.In so far as they must be separated, the natural divisionappears to lie between communal medicine on the onehand and personal medicine on the other. The clinicianis concerned primarily with the individual, while theMOH is concerned primarily with the community. But

preventive medicine can properly be practised by both.

A SERVICE FOR DOCTORS AND PATIENTS

THE problem of disposing of patients in need ofimmediate hospital treatment has exercised both townand country doctors for many years. In 1938 KingEdward’s Hospital Fund for London determined to makean attempt to solve the problem for the London area byinitiating, after discussions with the Voluntary HospitalsCommittee, the Voluntary Hospitals Emergency BedService. This service opened in June, 1938, and in itsfirst year dealt with 7859 cases. The rapid increase inthe number of calls in the first half of 1939, when 5131cases were dealt with, showed that the service wasvalued. At the outbreak of war the work was interruptedfor three weeks, when the whole staff was lent to theMinistry of Health to help in the organisation of theEmergency Medical Service. It was then opened againand records of the period between 1940 and the end ofthe flying-bomb attacks show that calls on it increasedrapidly whenever conditions in London became relativelynormal. Cases dealt with in the first half of 1945 havebeen more numerous than in any other half-year sinceJuly, 1940. It seems that as soon as the London

population becomes stable and hospitals extend theiractivities to pre-war limits, the scope of the service isbound to increase.

It operates on a system now backed by seven years’experience, and has reached a high pitch of efficiency.Doctors who in the past have waited, weary and exasper-ated, by a telephone at their own or at a patient’s house,will be surprised to know that the average number oftelephone calls to hospitals for each admission throughthe Emergency Bed Service has never exceeded 1’7 in anyone year, and has at times been as low as 1-5. The

flexibility of the arrangements is well illustrated by anincident of the flying-bomb period when the buildingwhich housed the EBS was damaged by a flying bombtwo minutes after a call came through. The staff on

duty, despite minor injuries, moved down to the emer-gency telephone in the basement, booked a bed at ahospital, arranged for the ambulance to collect the

patient, and rang the doctor back to say that all arrange-ments had been made, within 20 ininutes of receiving thecall. Happily the service may now look forward toemergencies of a. more peaceable nature, of which it

already has some experience. Its records show that onone occasion it succeeded within 10 minutes in tracing adoctor’s aunt who lived alone in London, and had

disappeared without tace, after being taken acutelyill.Owing to the nature of its work the EBS has a compre-

hensive view of the .hospital needs of the metropolitanarea. It has constant evidence of the acute shortageof accommodation for chronically sick and aged people,who though not presenting acute emergencies need eitherhospital treatment or institutional care. Waiting-listsoffer complex problems : the patient must be allowed tochoose the neighbourhood in which he wants to be treated,and the doctor under whom he is to be admitted; andthe hospital which has advised treatment through itsexpert medical staff must be responsible for carryingthat treatment through to a conclusion. The problemsare greater in magnitude than those already solved,but not different in kind; and having gained theconfidence of doctors and hospital authorities the EBSmay well help to overcome another of their jointdifficulties.

It is important that London doctors should knowwhat the service has to offer at the present time ; besidesbeing able to arrange for the admission of patients tohospital with the least possible delay, it provides anambulance when necessary, and informs the doctor bytelephone when arrangements are complete. The doctoris always asked if he prefers any particular hospital, buthe often leaves the choice open. Before the war, theservice used to work all night : it now operates from 9 AMto 10 PM daily, and hopes to resume all-night servicewhen the labour position becomes easier. In the tele.phone book, it is given under the heading of EmergencyBed Service, the numbers being City 2162 and Clerken-well 6571.

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EWART’S SIGN

WHEN William Ewart,l then physician to St. George’sHospital, published his classical paper on pericardialeffusion nearly fifty years ago he described ten diagnosticsigns, the eighth (the posterior pericardial patch of

dullness) and the tenth (the posterior pericardial patchof tubular breathing and segophony) of which togethercame to be known as Ewart’s sign. These findings werefor long accepted as among the classical signs of

pericardial effusion, being ascribed to pulmonary col-lapse as a result of -pressure on the bronchi by thedistended pericardium, although it has also been sug-gested that Ewart’s sign only occurs in rheumatic caseswhere it is due to rheumatic pneumonia. Incidentally,Ewart’s sign is not mentioned in Morton’s revised editionof Garrison’s Medical Bibliography, while one well-known English textbook refers to it as Bamberger’ssign. The specificity of the sign has gradually comeunder suspicion, similar findings having been describedin patients with a large left auricle in whom there was noevidence of a pericardial effusion. American workers 2:

have now suggested that all types of cardiac enlargementmay produce one or more’of the following signs over thelower lobe of the left lung : an areaof dullness just belowthe angle of the left scapula, sometimes only elicited onheavy percussion ; a prolongation of the expiratorybreath-sound varying from that in bronchovesicular

breathing to that obtained in bronchial breathing;diminished breath-sounds ; crepitations ; and an in-creased, almost nasal, vocal resonance. In none of the

patients on whom the American study was based, wasthere any evidence of other conditions, such as pul-monary infarction, congestion, an elevated diaphragmor pericardial effusion, that might account for these

signs. The findings are said to be most common withan enlarged left auricle, as in mitral stenosis, and itshould be remembered that in hypertension the leftauricle is often considerably enlarged and may be

displaced backwards by the hypertrophied left ventricle 31. Ewart, W. Brit. med. J. 1896, i, 717.2. Chapman, E. M., Sanderson, R. G. Ann. intern. Med. 1945, 23, 35.3. Babey, A. Amer. Heart J. 1937, 13, 228.