FULL-TIME—PART-TIME

679 feet.

And

perhaps "improved" shoe design

is no

improvement and should be classed as an’" unnecessary operation" like some cireurncisions, appendioectomies, and tonsillectomies. Surely the logical conclusion to these " improvements " would be to support the foot in a specially designed shoe to " fit " each individual foot, complete with sponge rubber insole and crepe

sole; the result might be loss of all muscle tone and atrophy of the muscles. As for flat-feet, there is the story about the hundreds of Red Indians who walked 1000 miles to enlist in the American Independence Army : they were turned down because they had flat-feet, so they walked home again. STUDENT NURSE. outer

THE RECENT BURN

Sm,-I agree with Dr. Gardner (Jan. 16) that it is better to leave blisters intact when dealing with minor burns in industry. My method is to clean the blister and surrounding skin, and then with sterile needles make drainage channels from the blister. This is done by running the needles under the skin about 1/4 in. from the blister. Gentle pressure is applied until the blister is drained. A sterile dressing is then applied. This treatment may haye to be repeated. The patients continue working, because pain is immediately relieved ; and there is little or no risk of infection. I. YATES. FULL-TIME—PART-TIME

SiR,-The correspondence in the medical press about the delayed application of the betterment factor to consultants’ salaries has tended to suggest that the part-timer has an unfair financial advantage over the whole-timer. It would be deplorable if a wrangle were to develop between these two groups of consultants, but, while we have every sympathy with the claims of the whole-time workers, we should like to emphasise that many parttime consultants are often worse off than their whole-time

colleagues. as maximum part-time consultants in medical with appointments at hospitals both inside and outside Greater London. Visits once or twice a week to each hospital are no sinecure and may well continue late into the evenings. The furthest hospital is over 30 miles distant and our professional mileage is about 12,000 This also includes occasional visits to per annum. neighbouring hospitals and emergency hospital calls. The use of a car is for each of us a necessity and, although partly recompensed for routine professional motoring expenses, we are bound to find the means to purchase a new car about every four years. In this way we resemble the average general practitioner rather than the wholetime consultant whose work is confined to a singlehospital near his home. The introduction of consultant services to non-teaching hospitals in poor districts means that the part-time consultant who visits only this type of hospital, particularlv on the fringe of London, may through no fault of his own develop hardly any private practice. It may be little more than sufficient to pay the rent of a consulting-room and, unless he can afford to employ a private secretary, he will as likely as not have to type his own

We write

specialties

letters.

Income-tax allowances on private-practice expenses largely dependent upon the amount of independent income earned. It is quite clear, therefore, that the more modest the private earnings, the less likelihood is there of full expenses being allowed. While there is certainly a case for whole-time consultants to be paid for domiciliary visits, there seems to be an exaggerated conception of the number of domiciliary YMits carried out by part-time consultants. In some parts are

of the country and in some specialties the maximum number may be made, but this is most unusual in the areas in which we work. Our own experience, and that of other part-time colleagues whom we have questioned, is that it is unusual to attend more than 25 domiciliary consultations a year. It would be interesting to know the average figure. - We hold no financial grievance against our whole-time colleagues and we feel that part-time consultant work has many non-economic advantages. We believe, however, that it is time to modify the apparently widespread belief that all part-time consultants earn considerable private incomes, regularly make 200 domiciliary visits a year, and obtain large and unjustifiable income-tax allowances. Two JUNIOR PART-TIME CONSULTANTS. London, W.1.

SiR,-I feel that some of the points made in Dr. Gilchrist’s letter of March 13 cannot go unanswered. Dr. Gilchrist states that " unity amongst specialists is not fostered by insinuations about the work done by whole-time and part-time staff." With this I fully agree, but Dr. Gilchrist does not help such unity by his comments upon the constitution and work of the Joint Committee for Consultants and the staff side of the Whitley B Committee. He states both committees have always looked after the interests of part-timers even when it meant sacrificing those of whole-timers, as in the mileageallowance negotiations. This statement is completely out of accord with the facts. The Whitley B Committee has

only endeavoured repeatedly to impress upon the management side of the committee the just claims of whole-timers in relation to domiciliary consultations, mileage allowances, and legitimate expense allowances, but also arranged a special session of the Whitley B Committee to which three whole-timers, nominated by the Whole-time Specialists Association, were coopted, so that the whole-timers themselves could put their case to the management side of the committee. As a member of the committee I was present on that occasion, and the case for the whole-timer was put extremely forcefully and ably by these representatives, and was .fully supported by the whole of the staff side of the committee. Unfortunately no concession whatever was obtained from the management side, which remained as obdurate as before ; but in their reply the management side emphasised that they had heard all the arguments put forward by the whole-timers before. It is thus apparent from the management side’s own lips that Dr. Gilchrist’s statement that the Whitley B Committee has always looked after the interests of parttimers and sacrificed those of whole-timers is quite incorrect. I am surprised that Dr. Gilchrist is not aware not

of these facts.

Finally, Sir, Dr. Gilchrist is incorrect in saying that there are 15 part-time consultants and 1 whole-time consultant on the staff side of -Whitley B. There are in fact 14 part-time and 2 whole-time consultants, and unity would not be further fostered by having separate electorates for whole-timers and for part-timers. H. H. LANGSTON. SIR,-You have

one

type of reader who has studied

equanimity the recent correspondence conthe salaries of s.H.M.o.s and of consultants, whether they be full-time or part-time. I refer, of course, to the depressed class of registrars, many of whom are now approaching, or havepassed, their fortieth year. They, too, have been known to have children to educate and houses to buv. To them the salaries of S.H.M.o.s, consultants, and general practitioners appear princely. Surely, Sir, first things must come first in this struggle for money. Let registrars be given at least enough, if with

sour

cerning

680 necessary by annual increment or according to experience and qualifications, before more sops ate thrown to these other already more fortunate classes who are also more influential and more clamorous. EDWARD ELMHIRST. ’

A PHILOSOPHY OF HEALTH

SIR,—As one who has shown in his writings that he is not in harmony with many of the current practices of the art of medicine, I was expecting to be " damned with faint praise " for my philosophy of health. I was not expecting that you would completely falsify my main thesis as you have done in the review in your issue of March 13. You take the meaning of the conjunction " or" to be solely exclusive, as in guns or butter, ignoring the meaning of identity, as in scarlet fever or scarlatina. You say that I oppose happiness and health-" the author fairly gives the choice between living happily or healthily." This is quite untrue. It is shown in my book that the definitions of health and happiness are exactly the same and that there is no austerity in the system. The theme throughout is that true happiness and true health are synonymous terms. If you had said " the author fairly gives the choice between living happily in a brutish way or living healthily," you would have been absolutely justified. A. T. TODD. CONTROLLED HYPOTENSION WITH ARFONAD

SIR,—The two articles on this subject in your issue of Feb. 13 lead us to add our experiences in rather more than fiftv cases. We have been using the same technique as Dr. Scurr and Dr. Wyman-i.e., continuous intravenous infusion of a 1/1000 solution in saline. Wefeel that, with such a short-acting drug, this is a more logical and controllable method than intermittent dosage. Our results and conclusions are very similar. We find that the essential part of the technique is a slow and deliberate induction of hypotension, and that to ensure success no surgical interference should be permitted until the pressure is stabilised at the required level. Rapid induction results in complete loss of control of pressure, as happened in our first case. A maximum of 60 drops per min. at the beginning of induction should not be exceeded. In most cases, this is -

to reduce the pressure to the required level within five minutes. Healthy young people require greater doses. Hypertensives respond very readily to the drug. Prolongation of effect is, in our opinion, invariably due to overdosage. There appears to be a floor " below which the pressure will not fall in many cases; and if administration is continued at a constant rate when this is reached, a cumulative This is effect is produced, with resulting prolongation. reversible with small doses of methylamphetamine (’Methedrine ’) (5-15 mg.). Once we achieve the required level, we reduce dosage to the minimum, so that the pressure is tending to rise. There have been 3 failures, all of them involving operations on the head and neck (2 aural fenestrations and 1 block dissection). In all 3 cases the systolic pressure was 60 mm. Hg-, but continuous oozing occurred. This we attribute to the position of the head during operation and consequent obstruction of the great veins in the neck. In our series there have been no attributable deaths. The patients’ ages ranged from 30 to 73, the average being 50. Postoperative haemorrhage will occur unless the pressure is allowed to return to 100 mm. Hg+ before closure. The difficulty in controlling an extremely slow rate of infusion has been said to be a disadvantage. We are at the moment in the process of constructing an apparatus capable of delivering 1-60 drops per min.

enough

-

"

We feel that’‘ Arfonad ,’ because of its evanescent effect and consequent easy management, is a great advantage in hospitals where there is no " recovery unit," with

fully trained staff,

to

supervise

the

patients.

It is

a

great

solace to the ward sister and all concerned if the patient returns to the ward in approximately the same condition as he left. It is, however, not a technique that should be embarked upon lightheartedly by anyone who does not realise the dangers inherent in induced hypotension. We agree absolutely with Dr. Scurr and Dr. Wyman when they stress the contra-indications and the necessity for

perfect oxygenation throughout. S. G. DE CLIVE-LOWE J. NORTH. RECURRENCE OF SIMPLE PAPILLOMATA OF THE BLADDER SiR,,-In an article in your journal last year1reported three cases of recurrence of simple vesical papillomata after the lapse of 23, 24, and 28 years respectively. I would now like to call attention to another case in which the lapse is 16 years. The patient, a man, aged 59, was given a single cystoscopic

diathermy treatment by me for a simple papilloma of the bladder in 1938. I have made regular annual cystoscopic inspections of the bladder ever since and have always found it free of any signs of new growth, until yesterday, March 17,i, when the routine annual cystoscopy revealed the presence of seven small sessile papillomata which all appeared to be simple in character. There had been no hæmaturia or other symptom to suggest recurrence since 1938. This case is but another one which reminds us that with patients who are apparently cured the regular yearly cystoscopy must always be continued. I feel it is wise to put all such cases on record. H. P. WINSBURY-WHITE. THE EPILEPTIC AND HIS DRIVING LICENCE SIR,—Everyone is rightly agreed that a person suffering from epilepsy must not drive a car under any circum-

stances, because of the risk of

a fit causing an accident. It has been my practice up to the present, when consulted on this question, to advise my patients to hand in their driving licences. In due course many lose their fits completely, and my practice is to certify after a certain period of such freedom that they no longer suffer from epileptic fits. This period varies from three to five years according to the severity and frequency of the original attacks and according to the electro-encephalogram. It is commonly said that two of these years must be without even minimal doses of sedative, but this view may be open to question, particularly as many patients are unwilling to abandon all treatment, although they are quite content with a dose so small as to be little more than a placebo. Recently I gave evidence in court on behalf of a patient with infrequent nocturnal grand-mal attacks, who had voluntarily surrendered his driving licence in 1950 and had been free from attacks since then. He was appealing against the revoking of his new licence and, unfortunately, he had refused to abandon his halfgrain of phenobarbitone except for a week prior to an electro-encephalogram, which was normal. His appeal was dismissed because it was said in court on behalf of the county council that the Ministry of Transport require five years’ freedom, with at least two years

without treatment. This decision, however, raises two- points. Firstly. I know he could have obtained a driving licence in another

county after only two years’ freedom from attacks: and, secondly, it may be that I exceeded my duty to my patient by advising initially that he should surrender his licence, for he has been put to considerable trouble and legal expense in his attempt to recover it. Perhaps in the future I should advise such patients not to drive until I can certify to them that their epilepsy appears to be

fully controlled. 1.

Winsbury-White,

H. P.

Lancet, 1953, i, 757.