612

it we must refute the experience of many clinicianswho have seen descent at a later age, and we mustalso accept SOUTHAM and Coop-ER’s figures, compiledin 1927, as the last word on the subject. They arrivedat their estimate of incomplete descent of the testisin adults from recruiting-board figures in Scotland,the Austro-Hungarian Empire, and the United States,as well as from hospital-admission figures. Theymade no observations themselves, and even theirestimate-a mean of widely divergent figures-refers only to unilateral cryptorchidism. SCORER’S

arguments raise the question of how surely thetestis can be located in the newborn. SCORER

says that there has never been’ any difficulty in

deciding the position of the testis, providing itis outside the external abdominal ring ; and -bepoints out that the cremasteric reflex is not strongin the newborn. It could be, however, that his largeexperience enables him to do with ease what othersfind some difficulty in doing. The greatest problemin any discussion on undescended testicles is toexclude the retractile testis,4 for which no treatmentis required except categorical reassurance,, and whichin older boys has certainly fooled many doctorsand even experienced surgeons many times. Overhalf the patients sent to outpatients for treatment arein this category. If the retractile testis is " treated "the " results " are bound to be good, and it is vitalto exclude this type from the discussion.

’..

Hormones and surgery are both used in the treat-ment of undescended testicles, but there is little

agreement on the place or timing of either measure.Perhaps the only widely held view is that treatmentmust be started before puberty if it is to be effective.Even then some will say that any improvement that fol-lows might have taken place later anyway. If we could

say that no testicular descent takes place after acertain age, that would be a firmer basis for treatment ;and for this reason inquiries such as SCORER’S areespecially welcome. Many surgeons- use hormones,particularly, as MACNAB 5 points out, as a diagnostictest. Those who do so feel that they encouragedescent of the normal testis, while they can have noaction on the mechanically tethered gland. Butthere may be more support for Louw’s ’View 6 thathormones should probably be reserved for patientsof the Frohlich type with bilateral undescendedtesticles and genital hypoplasia.

It is fortunate that unilateral cryptorchidism isfar the commoner problem. Orchidopexy for uni-lateral incomplete descent or unilateral ectopictestis is undertaken as much for cosmetic or

psychological reasons as to put the tethered organout of harm’s way. HANSEN has shown by his carefulstudies that, in unilateral maldescent, orchidopexyhas no effect on the quality or quantity of the sperm-counts. Most surgeons like to operate when thesepatients are 9 or 10 years old, but there is a move,supported by the histological findings, towardsearlier surgery. HINMAN summarises recent histo-

logical investigations by saying that up to the age of6 years microscopic changes in the undescendedtestis are few, but from then on the differences between

4. Browne, D. Brit. med. J. 1938, ii, 168.5. Macnab, G. H. J. R. Coll. Surg. Edinb. 1955, 1, 126.6. Louw, J. H. S. Afr. med. J. 1954, ii, 807.7. Hansen, T. S. Proc. R. Soc. Med. 1949, 42, 645.8. Hinman, F. Fertil. Steril. 1955, 20, 214.

normal and undescended testicles are progressivOn the other hand, the larger the patient the lelikelihood there is of damaging the blood-suppthrough the testicular artery, which is the

limiting factor in the operation. As for undescended testicles, the best published judged from the important viewpoint of seem to be those of GROSS and JEWETT.9 Of 38 who had had the bilateral operation between the d:of 9 and 11 years, 79% proved fertile. Until theresults are bettered, this will probably remain tht 0of choice.

There is no doubt that some testes will nev

function, regardless of hormonal or operative trea

ment. The shape, size, and consistence of the are more important than its position. If it is soft a

flabby at operation or hard afterwards, it is unlikto be functioning normally. But further critiinquiries into the natural history of the condition needed, before we can be sure what effect treatmeis really having.

9. Gross, R. E., Jewett, T. L. J. Amer. med. Ass. 1956, 160, 63

The Edinburgh VentureIT has been said that, as a nation, we are bet

at planning than putting into action the plan&mwe make ; ; and that we tend to underestimate own academic achievements. It is perhaps fitttherefore, that an account of the Edinburgh Universigeneral-practice teaching unit, written by the undirector, Dr. RICHARD SCOTT, should appear the American Journal of Medical Educatiou t

month. The teaching of general practice to studenin Edinburgh University is, in fact, as old as United States itself, for the Royal Dispensarv wfounded in 1776, the year of the Declaration

Independence, and until 1948 this dispensary providmedical care for the " sick poor

" of the city. Genertions of medical students have received their intduction to general practice in the Edinburgh d

pensaries, where they have been taught.by manythe most distinguished teachers of their day. Whthe National Health Service was planned, there wno place for the particular blend of care and teachwhich the dispensaries had perfected, for complemedical cover was provided by the general-practtioner side of the N.H.S. The obsolescence of

dispensaries was at once an opportunity and

challenge, and we know with what inspiration tchallenge was met. Two dispensaries, each withgroup of people who looked to it for medical c

were taken over as general medical practices, equipped and staffed by the university. The patiecould get the same range of care as they could registering with a general practitioner in the ordinway. Thus, the tradition of service to man anmedicine continued unbroken.The teaching responsibilities of the general

teaching unit have increased its need for staff

accommodation, and generous help from the Rocfeller Foundation made expansion possible. Epractice is now staffed by two doctors, a nur

medico social worker, and a secretary ; and a dispenattends at one of the centres. The population servedeach team is no more than 2500, so that the practiare strongly staffed ; ’; but that enables 60 stude

613

in each academic year to be given an insight into theproblems of general practice in a way which mustpurely be unique. Certainly the students have nodoubts about the merits of the three-month course,and applications exceed vacancies. Those selected areintroduced to patients at first in consulting sessionsand later on home visits with one of the doctors iniie team. Each student is given progressively increas-ing responsibility for the care of one or two patients,under the supervision of the doctor, and at case-

conferences and tutorials he is given opportunity todisplay his grasp of the things that cause or aggravatethe illness of the patient in his charge. This is a new

approach to a clinical situation for many students,who have not previously considered the relative

importance of social as well as clinical factors in aniilness or family situation. Some of the methods used—case-work, seminars, and group conferences-are modified from American patterns, and achievetheir purpose well as a Scottish interpretation.Though the population served by the two practices

does not accurately reflect the social distributionof the population as a whole, the two communitiesare nevertheless being used for observational research,particularly in that province somewhere betweenthose of the strictly medical and the strictly social

1. Ministry of Health, Central Health Services Council, Report

of the subcommittee on the Medical Care of Epileptics. H.M.Stationery Office, 1956. 1s. 6d.

workers-a field which may prove very fruitful in

helping to understand the environmental causes ofdisease. In the unit the student can see field researchin general practice, the recording of morbidity inthe family context, and the interpretation of findingsin preventive terms. The old dispensary, once limitingits service to advice and medicines, is now a growing-point of public health as well.

In other university cities where there used to be

dispensaries, opportunities for medical teaching mayhave been lost, for the potential practices surroundingthe dispensaries have by now dispersed. There isstill a chance, however, to develop the further teachingof general practice by absorbing active practicesinto the university or medical school, and increasingtheir staff, as Edinburgh has done, to allow them tocarry a full teaching load. A teaching practice neednot necessarily be based upon a dispensary ; andthe social background to general practice would bemore accurately presented by a practice in whichall social groups were represented. The next evolu-

tionary stage may be the university department ofgeneral practice, which would coordinate the teachingand research work in a number of practices, demonstrateing not only urban and suburban conditions butthose of country practice too.

Annotations

CARING FOR EPILEPTICS

As Hippocrates said, epilepsy is a disease unlike anyother disease, and epileptics are equally, by ancienttradition, people set apart. This unhappy apartheidwas curiously perpetuated in the framing of the NationalIlealth Service ; and a subcommittee of the CentralHealth Services Council, under the chairmanship ofLord Cohen of Birkenhead,l has lately pointed out

many defects in the care given to epileptics and hassuggested ways in which the defects might be remedied.At present the care of epileptics is haphazard : someno treatment and others get too much. Some are

treated by their family doctors only ; others wanderbetween the general physician, the paediatrician, the

neurologist, the neurosurgeon, and the psychiatrist.The report of the Cohen committee makes plain that this: matter in which the coordination of many specialties essential and in which, in fact, a coordinated service.’ at present lacking. The committee recommend thatspecial clinics and centres be set up

’

at which epilepticshave the necessary investigations and from which-

their medical care and social rehabilitation may b0supervised. Apart from closing a disturbing gap in theprovisions of the National Health Service, such centreswould be an economic asset, for many adult epilepticshave drifted down the social ladder for lack of adequatesipport and wasted their abilities in dead-end jobs ;’L’l many affected children have been excluded from ordinary schools and given residential

that they did not really need. The British EpilepsyAssociation has already done magnificent work inpreventing such tragedies and in breaking the taboos

epileptics from normal life. There is no doubt the association will be glad of the opportunity

its work in partnership with the new centres.The committee criticise the arrangement whereby

colonies were excluded from those institutions’ were taken over by the National Health Service

under the 1946 Act : rightly so, for the whole idea of acolony of permanent inmates is now seen to be wrong.The colonies should be, and no doubt wish to be, centresfor active treatment and rehabilitation : as such, theyshould be integrated with - other hospital services.Whether this will now be possible is uncertain. Fresh

legislation would be needed and this might raise politicaldifficulties. Yet it is hard to see why there should be apermanent bar to the inclusion- of the colonies in theNational Health Service ; but if there is the committeesuggest that friendly arrangements between each colonyand its local regional hospital board might meet thecase.

’

The committee’s terms of reference did not allowthem to discuss the linked questions of prophylaxisand of research : yet these are matters which mustconcern the new service. Most of the recent research intoepilepsy has dealt with the minutiae of electrophysiologyand neurosurgery ; and background research into thenatural history of the convulsive disorders has beenmuch neglected in this country. For example, we haveno firm definition of the word " epilepsy " : different

people mean different things. There is no agreed classifica-tion of the many varieties of epileptic experience, norare their prevalences known. We do not know exactlywhat the problem is we are trying to tackle or how bigit is. Questions of aetiology,’ and in particular theinfluence of hereditary factors, are raised by patientsand their relatives in every clinic; but no reliableanswers can be given. And prognosis is equally vague.The plan proposed by Lord Cohen’s committee will

offer very rewarding tasks to those who put it into

action, and it will give new encouragement to epileptics.

TINEA CAPITIS

DURING the early years of this century tinea capitiswas a considerable problem to local health authorities.The infection was commonly due - to .Jficrosporon,audouini, which affects only children and disappearsspontaneously at the age of puberty. Its diagnosis isrelatively easy since one or more scaly patches appearon the scalp, and hairs are regularly broken off 1/8 in.above the surface. The infected hair stumps fluoresceunder Wood’s light and the mycelial threads are easily