INTRATHECAL TETANUS SERUM
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1200 the abdominal wall, which normally requires only one dose, given by the doctor (where, rarely, subsequent doses are needed these could be given by the doctor with very little addition to his or her workload). Where the fact that prostaglandin abortions can still be done without nurses is not realised, late abortion will be restricted, which we wholly deplore. We also deplore the anti-abortion comments made by Lord Den- ning, beyond the legal ruling that it was in his jurisdiction to make, and would point out that his ruling seems to have been sufficiently confused for the Department of Health to withdraw its circular on abortion and await an interpretation before issuing another. Doctors for a Woman’s Choice on Abortion, 26 Leamington Road Villas, London W11 P. L. NEUSTATTER TEACHING COMMUNICABLE DISEASE EPIDEMIOLOGY SiR,-There is a renaissance in the study of communicable diseases, stimulated by changes in the pattern of communicable diseases, by the discovery of "new" pathogens, and by the possibility that some chronic diseases have an infective origin. The development of vaccines and antibiotics was not followed, as predicted, by the virtual disappearance of infectious disease. Infection is still a major cause of the illnesses managed by general practitioners and is a matter for concern in hospitals. Travel and other social changes, advances in medical care, and the recognition of new microbial diseases have increased the range of problems. The availability of effective methods of prevention and treatment make the diagnosis of infection especially rewarding. This expansion in knowledge has involved many specialties, with one unfortunate consequence: the teaching of communicable diseases and their epidemiology has become fragmented in the medical school curriculum. A survey, soon to be published by one of us (H. B. L. R.), has found that departments of general medicine, communicable and tropical diseases, paediatrics, microbiology, immunology, community medicine, and general practice are all involved; but unless the student can perceive the whole pattern of communicable disease epidemiology, much of its significance is lost. Because communicable disease epidemiology is a fundamental part of the whole of epidemiology, this loss is important. We believe that a person qualifying as a doctor should have a modicum of epidemiological knowledge and experience. This should include the use of epidemiological evidence in clinical diagnosis, the use of laboratory services, modes of transmission and control, a concept of surveillance, an appreciation of the relationship between host, parasite and environment, and an awareness of the administrative and legal aspects. We are concerned that many young doctors do not appear to have this knowledge. Possibly they have rejected the old image of "public health" during their training and have failed to see the applications of epidemiology to the infections that they encounter in the hospital and community. In any case, the importance of communicable diseases in the practice of modern medicine remains largely hidden until doctors begin to practise, when their medical education often seems not to have equipped them to meet the challenge of infection which awaits them, particularly in general practice. The importance of communicable disease epidemiology and control to everyone concerned with the diagnosis, treatment, and prevention of infections was clearly shown by the survey referred to. A way is needed to introduce the subject to medical undergraduates in a logical and interesting manner which will complement and support the teaching of all the departments involved. We have two recommendations to improve the teaching of communicable disease epidemiology. The first is that one person in each medical school should try to coordinate the teaching given in the specialties concerned and link it to the teaching of the epidemiology of other acute and chronic diseases. By this we do not wish to imply that the teaching should be concentrated in one department in one part of the curriculum. Epidemiological knowledge, like clinical skills, should grow as the student progresses through the different departments. We are encouraged to think that coordination is possible because, in a few schools, several departments have integrated their teaching on communicable diseases. Our second recommendation is that the teaching should be made interesting by stressing the modern aspects of infection, by small group tutonals, and by practical project work. Communicable disease epidemiology is a practical subject and, like clinical medicine, it cannot be learned by sitting in a large audience. Correspondence should be addressed to Dr R. T. Mayon-White, Pubhc Health Laboratory, John Radcliffe Hospital, Oxford OX3 9DU. R. T. MAYON-WHITE N. S. GALBRAITH R. J. C. HART J. S. ROBERTSON R. J. DONALDSON A. M. GEDDES D. L. MILLER D. A. ROBINSON F. ESKIN N. R. GRIST D. REID H. B. L. RUSSELL ONE PARENT FAMILIES SIR,-Your note (Nov. 15, p. 1095) on the 1980 report of the Na- tional Council for One Parent Families says that "the National Council aims to support the families suffering chronic economic hardship under a government which abdicates responsibility". You are probably citing the National Council verbatim, but this state- ment could easily be construed as reflecting an editorial view. I may sound old-fashioned and naive, but it seems to me that, in a large number of these families, it is the other parent who has ab- dicated responsibility. Secondly, the government which will do most for the poor, the sick, the old, and the disadvantaged of our society is not the government which rants most vehemently about "caring", but the government, of either party, which succeeds in restoring our economy to sufficient strength to allow the provision of adequate health and social services. The highly political wording used could easily have the opposite effect to that desired, and alienate sympathy from the sad plight of some of these families. Department of Geriatric Medicine, Chesterton Hospital, Cambridge CB4 1PT NICHOLAS CONI **Not in quotes, but more or less verbatim. Lord McGregor, the president of the National Council for One Parent Families, wrote: "... today, when the Government proclaims undiscriminating ab- dication of public responsibility for defenceless people as a goal of policy...".-ED. L. INTRATHECAL TETANUS SERUM SIR.-With reference to the article by Dr Gupta and colleagues and your editorial (Aug. 30), may I correct a possibly misleading in- ference regarding the use of steroids with intrathecal tetanus serum. Both the article and the editorial imply that to prevent possible reac- tion with the injection of intrathecal ATS horse serum, wel gave steroid. This is not strictly true since the use of steroid (betamethasone, not cortisone or predisilone which are contra- indicated) in clinical tetanus was already part of our standard treat- ment, the efficacy of this approach having been reported in 1963 bv T. N. Strong, M. L. Peacock and me in Trans R Soc Trop Med Hi’9 63; 746. Because we were already using the steroid, possible reac- tions to intrathecal horse serum seemed likely to be further diminished and hence we were encouraged to try intrathecal ATS as a way of short-circuiting lethal doses of tetanus toxin. It is likely that the New Delhi team’s encouraging results would have been better all round had betamethasone been given, as well as intravenous or intramuscular ATS (750 units) to those patients receiving m- trathecal ATS. Christian Medical Fellowship, 157 Waterloo Road, London SE1 8XN R. K. M. SANDERS 1. Sanders RKM, Joseph R, Martyn B, Peacock ML. Intrathecal antitetanus serum (horse) in the treatment of tetanus Lancet 1977; i: 974-77.
Transcript of INTRATHECAL TETANUS SERUM
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the abdominal wall, which normally requires only one dose, givenby the doctor (where, rarely, subsequent doses are needed thesecould be given by the doctor with very little addition to his or herworkload).Where the fact that prostaglandin abortions can still be done
without nurses is not realised, late abortion will be restricted, whichwe wholly deplore.We also deplore the anti-abortion comments made by Lord Den-
ning, beyond the legal ruling that it was in his jurisdiction to make,and would point out that his ruling seems to have been sufficientlyconfused for the Department of Health to withdraw its circular onabortion and await an interpretation before issuing another.
Doctors for a Woman’s Choice on Abortion,26 Leamington Road Villas,London W11 P. L. NEUSTATTER
TEACHING COMMUNICABLE DISEASEEPIDEMIOLOGY
SiR,-There is a renaissance in the study of communicablediseases, stimulated by changes in the pattern of communicablediseases, by the discovery of "new" pathogens, and by the
possibility that some chronic diseases have an infective origin. Thedevelopment of vaccines and antibiotics was not followed, as
predicted, by the virtual disappearance of infectious disease.Infection is still a major cause of the illnesses managed by generalpractitioners and is a matter for concern in hospitals. Travel andother social changes, advances in medical care, and the recognitionof new microbial diseases have increased the range of problems. Theavailability of effective methods of prevention and treatment makethe diagnosis of infection especially rewarding.This expansion in knowledge has involved many specialties, with
one unfortunate consequence: the teaching of communicablediseases and their epidemiology has become fragmented in themedical school curriculum. A survey, soon to be published by one ofus (H. B. L. R.), has found that departments of general medicine,communicable and tropical diseases, paediatrics, microbiology,immunology, community medicine, and general practice are allinvolved; but unless the student can perceive the whole pattern ofcommunicable disease epidemiology, much of its significance islost. Because communicable disease epidemiology is a fundamentalpart of the whole of epidemiology, this loss is important.We believe that a person qualifying as a doctor should have a
modicum of epidemiological knowledge and experience. Thisshould include the use of epidemiological evidence in clinicaldiagnosis, the use of laboratory services, modes of transmission andcontrol, a concept of surveillance, an appreciation of the
relationship between host, parasite and environment, and anawareness of the administrative and legal aspects. We are concernedthat many young doctors do not appear to have this knowledge.Possibly they have rejected the old image of "public health" duringtheir training and have failed to see the applications of epidemiologyto the infections that they encounter in the hospital and community.In any case, the importance of communicable diseases in thepractice of modern medicine remains largely hidden until doctorsbegin to practise, when their medical education often seems not tohave equipped them to meet the challenge of infection which awaitsthem, particularly in general practice.The importance of communicable disease epidemiology and
control to everyone concerned with the diagnosis, treatment, andprevention of infections was clearly shown by the survey referred to.A way is needed to introduce the subject to medical undergraduatesin a logical and interesting manner which will complement andsupport the teaching of all the departments involved. We have tworecommendations to improve the teaching of communicable diseaseepidemiology. The first is that one person in each medical schoolshould try to coordinate the teaching given in the specialtiesconcerned and link it to the teaching of the epidemiology of otheracute and chronic diseases. By this we do not wish to imply that theteaching should be concentrated in one department in one part ofthe curriculum. Epidemiological knowledge, like clinical skills,
should grow as the student progresses through the different
departments. We are encouraged to think that coordination is
possible because, in a few schools, several departments haveintegrated their teaching on communicable diseases. Our secondrecommendation is that the teaching should be made interesting bystressing the modern aspects of infection, by small group tutonals,and by practical project work. Communicable disease epidemiologyis a practical subject and, like clinical medicine, it cannot be learnedby sitting in a large audience.Correspondence should be addressed to Dr R. T. Mayon-White, Pubhc
Health Laboratory, John Radcliffe Hospital, Oxford OX3 9DU.
R. T. MAYON-WHITEN. S. GALBRAITH
R. J. C. HARTJ. S. ROBERTSON
R. J. DONALDSONA. M. GEDDESD. L. MILLERD. A. ROBINSON
F. ESKINN. R. GRISTD. REIDH. B. L. RUSSELL
ONE PARENT FAMILIES
SIR,-Your note (Nov. 15, p. 1095) on the 1980 report of the Na-tional Council for One Parent Families says that "the NationalCouncil aims to support the families suffering chronic economichardship under a government which abdicates responsibility". Youare probably citing the National Council verbatim, but this state-ment could easily be construed as reflecting an editorial view.
I may sound old-fashioned and naive, but it seems to me that, in alarge number of these families, it is the other parent who has ab-dicated responsibility. Secondly, the government which will domost for the poor, the sick, the old, and the disadvantaged of oursociety is not the government which rants most vehemently about"caring", but the government, of either party, which succeeds inrestoring our economy to sufficient strength to allow the provisionof adequate health and social services.The highly political wording used could easily have the opposite
effect to that desired, and alienate sympathy from the sad plight ofsome of these families.
Department of Geriatric Medicine,Chesterton Hospital,Cambridge CB4 1PT NICHOLAS CONI
**Not in quotes, but more or less verbatim. Lord McGregor, thepresident of the National Council for One Parent Families, wrote:"... today, when the Government proclaims undiscriminating ab-dication of public responsibility for defenceless people as a goal ofpolicy...".-ED. L.
INTRATHECAL TETANUS SERUM
SIR.-With reference to the article by Dr Gupta and colleaguesand your editorial (Aug. 30), may I correct a possibly misleading in-ference regarding the use of steroids with intrathecal tetanus serum.Both the article and the editorial imply that to prevent possible reac-tion with the injection of intrathecal ATS horse serum, wel gavesteroid. This is not strictly true since the use of steroid
(betamethasone, not cortisone or predisilone which are contra-indicated) in clinical tetanus was already part of our standard treat-ment, the efficacy of this approach having been reported in 1963 bvT. N. Strong, M. L. Peacock and me in Trans R Soc Trop Med Hi’963; 746. Because we were already using the steroid, possible reac-tions to intrathecal horse serum seemed likely to be furtherdiminished and hence we were encouraged to try intrathecal ATS asa way of short-circuiting lethal doses of tetanus toxin. It is likely thatthe New Delhi team’s encouraging results would have been betterall round had betamethasone been given, as well as intravenous orintramuscular ATS (750 units) to those patients receiving m-trathecal ATS.
Christian Medical Fellowship,157 Waterloo Road,London SE1 8XN R. K. M. SANDERS
1. Sanders RKM, Joseph R, Martyn B, Peacock ML. Intrathecal antitetanus serum(horse) in the treatment of tetanus Lancet 1977; i: 974-77.
