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THE DOCTOR’S DAY

Come, tell me how you live," I cried," And what it is you do I

"

V.-BIOCHEMIST AND TEACHERMY day begins with a fairly long journey from the

suburbs. All biochemists live in the suburbs, forreasons so obvious that they need not be given here.

THE POST BAG

A little before 9 A.M., on the desk in my privateroom, I find the morning post, and with precisionI sort out the departmental bills from the othercorrespondence. There will first of all be lettersfrom patients explaining why they cannot keepappointments for examinations such as test-meals.One patient is under the impression that as soon asshe has been persuaded to lie down for a basal-metabolism determination some major operation willbe performed on her. There will be requests forreprints from other institutions, and a line or twofrom personal friends abroad. A letter from Berlindescribes a meeting at the Harnackhaus in Dahlem,wnen an important announcement was made by aleading German biochemist: maybe the isolation ofthe œstrus-producing hormone in crystalline form,or the discovery of a link in the constitution ofvitamin D. Another letter contains a warning tolook out for so and so’s paper in this or that prominent journal as it is all rubbish. From America comes the description of a new and ingenious piece of apparatus 1

for the determination of the B.M.R. Of a heavier ]type is an inquiry from the University whether a certain person can be registered as a Ph.D. ; he has a chequered past of qualifications taken and courses <

done in various parts of the Empire. To sort these out is one of the most difficult tasks of a University i

teacher ; a struggle with research problems comes as a ir

welcome relief from the knotty problems of boards of (

studies. The post brings notices of University r

meetings and agendas of learned societies ; were I to r

attend all of these I should not get home for dinner tonce a week. tThe post brings also letters from practitioners a

describing wonderful cases in which they have per- c

formed biochemical investigations-and will the s

biochemist please arrange for publication in a suitable tjournal. In the routine testing of a patient’s urine u

for pus the doctor noticed that on adding a drop or ttwo of alkali the urine turned a delicate pink. On hisbookshelf the only reference he could find was to bcongenital h&aelig;matoporphyria ; so he borrowed a ii

pocket spectroscope from the secretary of the local t]scientific society, but failed to find the characteristic spectrum. Ergo here was an entirely new inborn Aerror attended with the excretion of a substance pturning pink in alkaline solution. The patient was nobstinately constipated. I suggested the collection hof a 24-hour specimen of urine to be sent to the ir

laboratory. It contained phenolphthalein. Inquiry ojelicited that the patient had taken large quantities tlof this valuable aperient for a number of years. Many similar problems have been solved. A young practi- ai

tioner observed a serious outbreak of leucinuria in the SL

babies under his charge. Microscopic examination of the urine revealed the presence of peculiar laminated bodies, corresponding exactly with the picture of cc

leucin crystals in the practitioner’s text-book. is" Epidemic of Excretion of Leucin in Urine " was su

to be the title of the clinical note. Careful examina- thtion in my laboratory convinced the doctor that the thleucin crystals were granules of the starch dusting inpowder which he always recommended mothers to thuse. Finally, there will be the letter from the maker diexplaining that it was really quite correct for the forefrigerator to run up to 37&deg; C. over the week-end, .and why should anyone be unpleasant about it P in-By 9.45 my letters are answered and the next of

duty is to scan the titles of papers in current clinical, ev

chemical, physiological, and pharmacological journals

of England, America, Germany, and France, andpick out those which the biochemist must study.Here is a new method for the determination of blood-urea ; this must be investigated. Here is a modifica-tion of the dietary regime for diabetics ; this will betried in a refractory case. Here is the account of anew and accurate method for the serum diagnosisof cancer ; but my German friends have put me onmy guard. A reference to the difficulties in theanalysis of proteins suggests a method of overcomingthem ; to be passed on to a research worker in thedepartment who has found these very difficulties.

A STAFF ROUND

Then comes the daily round of the department.I begin with my own personal assistant, checking upthe work done yesterday and making suggestionsfor to-day. And so in turn to all the research workersand assistants, whose problems may keep me occupieduntil noon. This is the best part of the biochemist’sday, because it enables him to keep in touch withwork which varies from pure clinical to elaboratephysico-chemical. Incidentally this means that thechief must read current literature so widely that hecan discuss every recent advance with his staff.

To-day, however, no prolonged discussions ariseand about 11 comes the hospital visit. I go to anumber of medical, surgical, and gynaecological wardsand ask the house physician or house surgeon whetherthey have any of the type of case in which I amparticularly interested at the moment-it may bediabetes, Graves’s disease, oedematous nephritis, orwhat not. If there is I suggest, with what tact Ian muster, a thorough investigation, and am generallysuccessful in getting permission. This is the more’emarkable when the biochemist does not possess anedical qualification. To-day a complicated problem)f renal function arises. The patient has a hydro-lephrosis on one side, and the surgeon wishes to’emove that kidney ; clinical examination suggestshat the function of the other kidney is insufficiento carry on. I am faced with the alternative of

,ssuming responsibility for the removal of the kidneyr admitting that I cannot help the surgeon. I

uggest the performance of a Van Slyke urea-clearanceest, to be followed by analysis of specimens fromreteric catheters ; on the results of these I shalllase my opinion.In the treatment of Graves’s disease the biochemist

ecomes more and more important ; few surgeons1 my hospital will take the responsibility of removinghe thyroid without a series of B.M.R. determinationsfind out whether iodine treatment reduces the rate.

,gain, I am frequently consulted about unconsciousatients, particularly diabetics. Only a quick deter-iination of the blood-sugar can distinguish betweenypoglyc&aelig;mic and diabetic coma in a patient broughtl unconscious from the street. Even the findingf sugar in a catheter specimen of urine will not makeie diagnosis of diabetic coma certain, since a largese of insulin may have been taken on a full bladder,Id hypoglyc&aelig;mia may have developed before thegar-containing urine was voided. Sometimes I amked by the house-man about a patient who excretesgar irregularly, or another who has surprisingtncentration of urea in the blood. The biochemistoften invited to meet the honorary physician or

lrgeon during his afternoon round, and a visit toe wards may mean a lot of work coming over toe laboratory. From such investigations all kinds ofteresting possibilities may arise, and fascinatingeories for the aetiology of diabetic coma, Graves’ssease, oedema production or proteinuria are putrward, which rarely-or never&mdash;emerge from theboratory circle. It is, however, from such constantvestigation of clinical cases, and the considerationbiochemical and clinical data alongside, that

entually lasting theories are evolved. For thisson in some hospitals the biochemist is put in

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almost sole charge of the treatment of disorders ofmetabolism.

THE TEACHER’S TROUBLES

At noon intruders leave the wards and the bio-chemist returns to the laboratory to deal withproblems which have arisen during his absence.After lunch he has to give a lecture, possibly tosecond-year medical students, possibly to third- orfourth-year men, on chemical pathological subjects ;or it may be to some post-graduate class working fora higher medical or surgical examination. Teachingis perhaps the greatest of the biochemist’s worries.He knows that his audience cannot follow the advancesin his subject because they have no sound basis ofchemistry, mathematics, or physical chemistry. Thetype of lecture therefore depends upon the attitudeof the teacher. Some will give advanced lectures andfeel they have done well, even though they areconvinced that their audience has not understood aquarter of what they have said. Others will giveelementary lectures outlining only in the briefestway the processes of digestion, absorption, andmetabolism, fixing the student’s attention on thepractical outcome and only teaching him methodswhich the learner can both do himself accurately andunderstand. The latter type of biochemist is, I amafraid, in the minority. Most teachers give an elaborateseries of lectures with complicated practical courses,finishing up with the remark that the actual resultobtained by the student does not matter so long ashe has understood the principle. But in either casethe teacher will leave the lecture room unhappyabout what he should do for the next course he gives,probably intending to bring the matter up at theboard of studies. The students leave the lectureand proceed to the practical course, conducted byone of the assistants in the department. The chiefwill wander round talking to the students and comeaway still more unhappy as he sees them rushingthrough their practical work without exercising any

Bthought and feeling that, provided they are signed (up, all is well. I can myself see no solution to the

problem of teaching biochemistry to students whosetime is already crowded with other subjects.

After this I can go back to my own research labora-

tory. But the head of a large department where anumber of researches are being carried on simul-taneously must resort to the regular use of a

personal research assistant in order to make hisdiscontinuous activities continuous. I may perhapswork with my own hands until 5.30 or 6, when myday’s work at the laboratory is ended and I canattend one or other of the meetings to which I havebeen invited. One of the major difficulties is toselect which particular activity to pursue each day.The head of the laboratories must envy the life ofone of his assistants who can do the work in whichhe is interested without perpetual interruption.

It may seem to the casual reader that the picture Ihave drawn is not one of a happy day. This howeveris not a fair conclusion. Writing under the cloakof anonymity one is tempted by the opportunity toventilate grievances. But the biochemist has thesatisfaction of knowing that his clinical observationsare appreciated by the majority of his colleagues,who realise that such tests as the fractional method ofgastric analysis, the urea-clearance test, the glucose-tolerance test, give them information surpassing inaccuracy that which can be obtained by other means.Physicians and surgeons employ him as a means ofconfirming or refuting their clinical diagnoses-notin any sense as a surrender to the laboratory. AndI have lived to see conviction come to members of theclinical staff who not so long ago scorned laboratoryinvestigations. Presently the rivalry in the diagnosticfield between the clinical observer and the laboratoryinvestigator will disappear completely. The purelyacademic investigations are also of the greatestinterest ; take, for example, recent work on thethyreotropic fraction of the hormones of the anteriorlobe of the pituitary on experimental animals, andthe possible application of this work to Graves’s disease.The elaboration of new methods and the investigationof new metabolic processes is fascinating work.

PUBLIC HEALTH SERVICES

The Annual Returns

AT this time of year the Minister of Health remindsthe local sanitary authorities of their obligationto send in certain returns of the services dealing withmaternity and child welfare, tuberculosis, venerealdiseases, and hospital treatment. The formidable

array of questions accompanying the reminder maygive rise to a query as to the purpose of this collectionof information. The answer can be found in theannual report of the chief medical officer to the

Ministry. One of the requirements of the LocalGovernment Act of 1929 imposes on the Minister ofHealth the duty of assuring himself that the publichealth service provided by the authorities is satis-

factory both in respect of efficiency and progress.The Minister secures his evidence by means of specificsurveys of areas by medical officers and by means ofthe information set out in these returns. The intentis that this information should serve a double purpose ;it should indicate the provision that each authoritymakes both for preventive and curative medicine,and it should indicate in various ways the success

attending this provision.For instance, summarising the returns from venereal

disease treatment centres (Form V.D. (R.)), Sir GeorgeNewman shows in his most recent report (1932) that therehas been, generally, since 1923 a steady improvement inthe ratio of attendances to total number of cases. Thesame returns showed, starting from 1931, the numberof cases of congenital syphilis dealt with at the centresfor the first time. The resulting figures give the importantresult that less than one-quarter of the cases came to light

under the age of 5 years, so that the great majority of allcases are suffering from interstitial keratitis which oughtto be prevented by treatment in the earlier years of life-clear evidence of a further need for action. Turning to thearrangements made for maternity and child welfare (FormM.C.W. 96), it will be remembered that the Committee onMaternal Mortality laid particular stress on the lack ofantenatal care evident in 33 per cent. of the estimatedpreventable cases of death. The returns under this headingshould in time provide some evidence of the progress madein attracting the expectant mother to the clinic, and inpersuading her to bring her infant and her children of pre-school age for treatment and advice.

I It is, in Sir George Newman’s words, a nationalstocktaking that is involved ; are the health services.really delivering the goods, at what cost is it workingout, and are the health and capacity of the communitythe better for it all ? The justification of thesereturns lies in their contribution to this audit. It is.important, therefore, that they should be compiledwith precision ; it is equally important not onlythat the questions should be so framed that theirinterpretation is uniform and subjective influences.are at a minimum but that unproductive questionsshould be eliminated.

Venereal Disease Schemes in ScotlandThe Edinburgh scheme for venereal disease deal&

with a population of about a million in south-easternScotland. Dr. David Lees reports that 4148 patients.had not completed their treatment at the end of1930. Of 5266 new patients in 1931, 1266 sufferedfrom syphilis, 1604 from gonorrhoea, 77 from soft sore,and 92 from a dual infection ; whilst in 2227 patients.