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itis. The average interval between operation and in-vestigation was 5 years and 4 months, the range being1 to 15 years.Ward and Collis’s evidence vindicates the use of
the stomach for oesophageal replacement, and shouldencourage surgeons to make an oesophagogastricanastomosis in many cases where they would pre-viously have felt bound to embark on the more compli-cated and dangerous technique of colonic replacement.
THE PROSPECT FOR GENERAL PRACTICE" OPPORTUNITIES to secure major advances in
medical care come infrequently, erratically, and oftenwith little warning. If advantage is to be taken ofopportunity, there should always be available an
up-to-date store of ascertained facts and, based uponthese, an informed opinion upon the objectives to
be sought." This advice was given by Dr. A.Talbot Rogers in his Wander lecture this week tothe Royal Society of Medicine’s General PracticeSection. Having been in the thick of the comings andgoings that heralded the National Health Service in1948, Dr. Rogers had an example ready to hand.The example was the British Medical Association,among whose leaders he almost alone called for con-structive negotiations. Unhappily his contemporarieswere obsessed with what they would not accept;and accordingly the opportunity to design the serviceslipped by default into other hands. Dr. Rogersrecounted these events without rancour. Today alldoctors in the United Kingdom, bar a few eccentrics,accept the N.H.S. as desirable. This is not the onlyinstance of an idea first spurned and then, after thepassage of years, warmly embraced. There was, for
example, the Dawson report of 1920 whose proposalsfor group practice were more or less firmly cold-shouldered for over thirty years before winningacceptance. Amid these and other developments Dr.Rogers has himself always spoken ahead of his time:for instance, he was calling for university chairs ofgeneral practice in 1949, fourteen years before Edin-burgh blazed the trail with the first such professorship.Accordingly his vision of the future should be heeded.He described it thus:
" Here is my list: to find ways of ensuring that voca-tional training for general practice is universally availableand universally acceptable; to experiment in new practicetechniques, including the proper deployment of socialworkers, nurses, and the professions supplementary to
medicine; to explore the role of practice managers; to
assess the value of better provision of transport to bringthe patient, or certain types of patients, to the doctor;to close the still existing gaps between general practice,hospital practice, and preventive medicine; to take cog-nisance of the fact that our theoretical ability to providean awesome variety of therapy has now outstripped ouravailable resources, both of money and of manpower,and to decide how we can best and most justly determinepriorities, and, in connection with this, how we can bringthe public-that is to say our patients-to a better under-standing both of the potentialities and the limitations ofmedical practice today."
If the perceptiveness of Dr. Rogers’ earlier fore-casts is any guide, these questions will be to the forein the next decade or two.
" Science gnaws irregularly at the lump of the
unknown, and the undigested portions are temporarilybridged over by theories. Moreover the face of natureand of civilization is steadily changing and therebychanging the host-parasite relations. That is to say,we must go on so as not to go backwards." Thesewords appear in the introduction to Theobald Smith’sParasitism and Disease,l published in 1934, and theyare highly relevant to the newly uncovered problem ofMarburg disease. 2 So far as can be made out, the
Marburg outbreak arose because wild-caughtvervet monkeys from Uganda were dissected inlaboratories in Germany and elsewhere, the previouslysilent or unrecognised host/parasite relationship be-tween vervet monkeys and the parasite changing into ahighly unstable relationship between the parasite andman, resulting in 7 deaths among 24 primary humaninfections. The nature of the Marburg disease agentis still not known with certainty; it is probably avirus, and it may be a rhabdovirus, a family whichincludes rabies virus, vesicular stomatitis virus, andsome plant viruses. There is no reason to say that it is a" new " virus, but it is certainly a newly recognisedvirus.Many thousands of monkeys have been dissected in
laboratories throughout the world since the use ofmonkey-kidney cells for the preparation of poliovirusvaccines was introduced, but this is the first time thatthings have gone wrong on this scale. We will prob-ably never know precisely what started off the chainof events that led to the Marburg incident, but wecan examine the known facts and try to learn from them.This is the approach taken by Gordon Smith,3 whoemphasises the lessons to be drawn from a study ofthe epidemiology of the Marburg agent and thedisease itself. Clearly, wild species may harbourstill unknown infections which may be highly lethal toman; and the greatest practicable care must be takenin handling monkeys at all stages from capture toarrival in the laboratory. Thereafter, all wild-caughtanimals should be adequately quarantined before
laboratory use (and indeed before sale as pets); andall laboratory experiments should be carried out withthorough precautions. Gordon Smith also concludesthat each major country should have at least one
laboratory especially staffed and equipped to investigatesafely new and serious infectious-disease problems;and the ever-present risk of imported disease can becountered only by maintaining an adequate cadre ofexperienced doctors and nurses and facilities for thesafe and efficient handling of cases.Some conservationists of today would impose a total
ban on the importation of exotic animals and use theMarburg incident as evidence in support of their case.Gordon Smith does not share this view, nor wouldTheobald Smith, but both would agree that when manventures to disturb a balanced host/parasite relation-ship he must take care to guard against the possibilityof so favouring the parasite that man is the victim.
1. Smith, T. Parasitism and Disease. Princeton, New Jersey, 1934.2. See Lancet, 1968, i, 901.3. Gordon Smith, C. E. in The Scientific Basis of Medicine Annual
Reviews 1971 (edited by I. Gilliland, F.R.C.P., and Jill Francis);p. 58. London: Athlone Press. Pp. 327. £3.50.