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Perhaps for the same reason, criteria of improvementwith physical methods are difficult to establish. .

Haphazard investigation into the aetiology of locomotordisorders wastes time and energy ; some recent paperson the treatment of rheumatoid arthritis add point tothis view. Before any extensive piece of research is

begun, a pilot experiment should be conducted to discoverthe likely pitfalls, and the highest authorities should beconsulted to determine the best way to approach theproblem in hand.With regard to teaching : undergraduates should not

be overwhelmed with a mass of technical specialist detail,which unbalances the curriculum and does not makethem think for themselves. If the br6ad outline of thelocomotor system is described with special reference todisease, students will be able to deduce their own details.Postgraduate instruction differs entirely from this andis especially aimed at showing the possible lines ofadvance ; it follows that a great deal of detail must beincluded.Rheumatic units are on trial, and it is essential that

they should reach the same high standard as do the otherdepartments of teaching hospitals. The study of themedical locomotor disorders seems to me a satisfyingbranch of general medicine, and it is encouraging thatyoung men with distinguished records are now comingforward to make it their career.London. W.1. ERNEST FLETCHER.

SIR,-Correspondents have stressed the necessity ofbeing a general physician before concentrating on thediagnosis and treatment of the rheumatic diseases.However, if the attack on rheumatism is to be more thana mere harassing operation by scattered physicians,it must be planned on military lines. In 1939 thereexisted two conceptions of the rôle of the tank in war-fare. One school argued that these special weaponsshould be evenly distributed up and down the frontamong the various infantry divisions, the other (thatof de Gaulle) that they should be grouped into specialunits which would thus carry a heavy punch. Weknow now which conception was the correct one. Theestablishment of special rheumatic units by the Swedeshas shown that in the realm of medicine, as in that ofmilitary tactics, it is the weight of the attack (by theconcentration of specialists with a common purpose)which really matters.London, W.I. DAVID PREISKEL.

A POSTMAN’S OPINION

SiR,-It may interest you to know that our localpostman, who delivers THE LANCET when it eventuallygets here and whose daughter with a huge extrinsiccarcinoma of larynx is spending her last days in ourhospital with tracheotomy and gastrostomy tubes inpJace, has thrice (out of his very meagre governmentpay) made subscriptions to a rebuilding fund for thehospital on the score that the British people are still willingto send their books and medical periodicals to help themedical work in China. -

Methodist Hospital, Fatshan via Canton,South China.

J. R. ROSE.

THE DOCTOR’S WIFE

SiR,-I should like to support, from my limited buthappy experience of panel practice, the views expressedby " Practitioner " in your issue of April 17. To be

able to institute treatment and to visit the patient’shome without thinking about money, is of the veryessence of professional freedom. As to certification,surely that is not too heavy a burden to bear ? It{loes not require much physical or mental effort to fill]11 one, two, or even three certificates. I think themoaners and groaners are overdoing their pose ofmartyrdom here. After all, the average doctor does notobject to entering a note on the patient’s condition inhis records, nor to writing out a prescription.

I have never felt that my resources and time are

unduly exploited by panel patients. The average manwill give a square deal, if he himself gets one. Moreover,what is trivial to the observer may be important to thesufferer, and we cannot ignore his mental state. As’’Practitioner " points out, only re-education can restore

the patient’s faith in himself and make him independentof the " bottle."

In conclusion, Sir, I should like to express my thanksto " Practitioner " for his humane and sensitive letter.It is satisfactory to feel that there are among us somewho have a positive attitude to life and work, and faithin their fellow men.

ENCOURAGED.

PENICILLIN AND SULPHONAMIDE IN TYPHOIDFEVER

SiR,-In 1946 I described in your columns the resultsobtained in the treatment of 5 cases of typhoid feverwith large doses of penicillin and sulphathiazole.11, stated that two courses, each of 10 inega units ofpenicillin with 34 g. sulphathiazole given during 4

days, with an interval of 2-3 days between the courses.had caused speedy subsidence of toxaemia and pyrexiaand disappearance of organisms from blood, fseces, andurine. I added that the system of dosage was arbitraryand might require modification with further experience.

In your issues of April 3 and 10 appear two articles-which purport to give the results of clinical trials ofthis new approach to typhoid therapy. The first is acommentary by Brigadier Parsons on the opinionsconveyed to him by about a dozen military specialistsfrom Egypt, Palestine, and Iraq concerning small groupsof cases treated by them. Parsons makes it clear thatthe methods of administration suggested by me were" closely followed only on rare occasions." In thereports of his colleagues I cannot find one single recordof a patient who received two courses of 10 mega unitsof penicillin and 34 g. sulphathiazole separated by aninterval of 2-3 days ; this interval is necessary to permit" persisters " to grow out after the first course. Somecases got an extended course (8 days) without inter-mission, and others got fantastic doses of penicillin forbrief periods-e.g., 24 mega units in 24 hours. Themajority of the Egyptian cases were given a dose ofpenicillin less than one-third of that necessary to producethe concentration of penicillin in the blood suggestedby the work of Bigger 2 as requisite to destroy Salmonellatyphi; and this inadequate dosage was given in a singlecourse. In fairness to Parsons it must be said that hedid not see the cases himself, and that he does notconsider it feasible to analyse statistically these MiddleEast reports. He is quite right in assuming that typhoidfever does not react to chemotherapy in the dramaticway pneumonia and meningococcal meningitis do. Theadjective " synergistic " is a more apt word than"

specific " to apply to the combined action of penicillinand sulphathiazole on S. typhi; and the best that canbe expected is a steady downward trend in the tempera-ture and relief of toxaemia spread over a week or 10

davs. Rarely, a case may react more rapidly. ’

Very different to the non-committal and guardedsumming-up of Parsons are the conclusions of theWelsh investigators published in your issue of April 10.An outbreak of typhoid occurred in Aberystwyth inJuly, 1946, involving some 200 cases ; this offered agood opportunity of evaluating the results of the newsynergistic therapy just then published. No less than97 cases were reported from Aberystwyth, 30 fromadjoining rural districts, and 75 from various otherparts of the county. " It was decided to follow as closelyas possible the procedure McSweeney had adopted."Let us see how this intention was carried out.At the Fever Hospital, Aberystwyth, where 57 cases were

treated, we get particulars of 25. Of these, 10 patientsreceived one course only of penicillin and sulphathiazole.4 receiving less than 10 mega units and 1-said to be veryseverely ill-little more than 2 mega units ; none died.Another 11 cases received two courses, but in 7 of these thefirst course was less than 7 mega units and in 7 the intervalbetween the two courses (which should have been 2--3 days)varied from 6 to 40 days. Yet 8 of them are said to have

improved after one or other course (table i). These 11 caseswere graded : very severe (5), severe (2), and moderatelysevere (4). None died. It would appear that 2 were notgiven their second course until a relapse had actually occurred.

1. Lancet, 1946, ii, 114.2. Bigger, J. W. Ibid, 1946, i, 81.