HOSPITAL REPORTS FOR INDUSTRIAL MEDICAL OFFICERS

677 lysis ;

the reduction of available histaminase at birth the onset immediately afterwards of icterus

explain gravis. may

In the light of this working hypothesis I administer anti-histamine substances in tox2emia of pregnancy and Rh incompatibility. R. SCHUURMANS. Amsterdam. INACCURACY IN THE LABORATORY

SIR,-It is gratifying to note, from your annotation last week, that freeze-dried samples of blood-serum will soon be available for use as standards in hospital laboratories. But one wonders to what extent this will be effective in localising the sources of error in clinical biochemistry, and in remedying them. The international survey to which you referredwas conducted with similar material, and this was available Yet only a few to all laboratories in this country. detailed Besides, analysis of the problem 2, participated. has shown the matter to be complicated by a number of factors, not the least being the degree of skill and Further the psychological condition of the analyst. work3 has shown that the standardisation of proprietary brands of laboratory reagents may leave much to be desired; while some of the techniques employed do not stand up to critical scientific appraisal. What does seem desirable is a thorough overhaul, possibly at the national level, to involve analytical methods, standardisation of reagents, laboratory equipment, and personnel. Would the clinical value of the laboratory results warrant such an effort ? IN-hat is the position with regard to the other branches of clinical pathology? Area Pathology Laboratory, Westwood Hospital, Beverley, Yorks.

The finding of an "abnormal" electro-encephalogram in patients with vomiting surely does not prove that the vomiting is due to epilepsy. After all, epilepsy is common. So are cyclical vomiting, headaches, three-month colic, abdominal pain, and personality disorders ; and it would be surprising if some epileptics did not have some of these conditions.

It would be a tragedy if all children with cyclical vomiting and the other conditions mentioned were deemed to be epileptics. If general practitioners accepted Dr. Wallis’s thesis, the hospitals would be inundated with requests to investigate these cases for epilepsy. Department of Child Health, University of Sheffield.

Dr. Wallis’s article and his to Dr. Millichap’s letter (Feb. 19), I want to add that we saw in our clinic about four months ago a patient with cyclical vomiting and a patient

SiR,-Having reply (Feb. 26)

O. BASSIR.

MASKED EPILEPSY

SiR,łI am glad that Dr. Kempton (Jan. 22) commented on Dr. Wallis’s paper on masked epilepsy (Jan. 8). It is, of course, well known that there are various unusual manifestations of epilepsy, such as sudden attacks of abdominal pain, sudden vomiting, and psychomotor equivalents. I agree with Dr. Kempton, however, that it is going altogether too far to suggest that epilepsy is an important cause of cyclical vomiting, headaches,

night terrors, unexplained fever, personality disorders, pains in various parts of the body, and even the so-called three-month colic. I can see not the slightest connection resemblance between, for instance, three-month colic and epilepsy.

or

I found Dr. Wallis’s case-records unconvincing. The two of so-called cyclical vomiting were certainly not typical of that condition ; and the association with unconsciousness suggests that the diagnosis was something else, perhaps epilepsy. Dr. Wallis does not mention the mode of onset in his case-histories. For instance, headache of gradual onset would not make one suspect epilepsy ; headache or other pain of very sudden onset might. It is well known that acute infection with fever may precipitate fits in an epileptic (apart from the so-called febrile convulsions), and that elevation of temperature may result from a severe major convulsion. That is another thing, however, from saying that attacks of fever may be manifestations of epilepsy. I am similarly unconvinced by the finding of an abnormal" electro-encephalogram. In the first place, very few of us clinicians are competent to interpret electro-encephalograms. We have to rely on someone who knows how to interpret them. " Abnormal electro-encephalograms can be found in otherwise normal persons, such as relatives of epileptics, and in children with fever as a result of an acute infectious disease.

cases

"

"

1. Proceedings of the 1st European Congress on Clinical Chemistry, Amsterdam, 1954. 2. Bassir, O. Ass. clin. Biochem. Newsletter, 1954, 2, 10. 3. Bassir, O. Unpublished.

R. S. ILLINGWORTH.

read

with periodic symptoms who had received several forms of treatment without benefit. We concluded that these might be instances of masked epilepsy ; and we began treatment with phenobarbitone, which has proved successful. We hope soon to publish these cases along with the electro-encephalographic findings. Gureba Hospital,

Istanbul, Turkey.

O. N. ULUTIN.

TREATMENT OF CHRONIC AMŒBIC DYSENTERY on the Treatment of Chronic his article SIR,-In Amoebic Dysentery with Antibiotics in Combination with other Drugs (March 12), Lieut.-Colonel Inder Singh says : Usually gr. 4 of emetine will quickly control an acute attack of amcebic dysentery but the amoebic cysts are not affected." Again, later in the article, he States : " Since then aureomycin and oxytetracycline have been found to combat the secondary infection and to destroy both the trophozoites and the cysts." One gets the impression that the destruction of cysts is an important aim in treatment. This misapprehension is prevalent even among physicians with a wide experience of tropical diseases. In reality it is pointless to consider treatment to destroy harmless cysts whose presence in the fseces is merely indicative of the existence of an infection of the bowel wall with amcebae. Destroy the amoebae and cyst production ceases. Despite assertions to the contrary it is by no means certain that any drug given by mouth destroys cysts within the lumen of the bowel; it is much more probable that such a drug would destroy trophozoites, thus preventing further formation of cysts with consequent disappearance of the latter from the fseces. C. B. ANDRADE. Calcutta. "

HOSPITAL REPORTS FOR INDUSTRIAL MEDICAL OFFICERS

SiR,-In common with many other industrial medical services it is the practice in this department to examine all employees who have had accidents or serious illnesses or operations, before they resume duty. Most of them have attended hospital either as an outpatient or

inpatient. Obviously clear history

it is vitally important for us to have a of what has happened, what diagnosis has been made, and what treatment given before we can assist in the patient’s full rehabilitation by giving him a suitable job. The patient is seldom able to supply this information, and never with accuracy. Therefore we obtain his consent and write for details to his general practitioner, who almost without exception is extremely courteous and cooperative. Although this help is willingly given, it must be an infernal nuisance for the doctor (possibly at the end of a long day) to dig out. hospital reports, and often write further details and send them to us.

678 I suggest therefore that hospital consultants and their assistants could help considerably by asking their patients : What is’your occupation ? Has your firm an industrial medical serviceWill you agree to a report on your condition being given to your company’s doctor ? If this is done a copy of the report issued to the general practitioner could be sent to the industrial medical officer, and it would save a great deal of work and speed up full rehabilitation. It should of course be indicated on the general practitioner’s report that a copy has been sent. So many of our good friends now automatically send us a copy of reports when they sign their patients off, and one wants to save them unnecessary work. Medical Department, British Railways, Southern Region, London, S.E.1.

L. J. HAYDON.

HOSPITAL STAFFS

SIR,-For several years your correspondence columns have carried cris de cœur from senior registrars about the shortage of consultant posts. Many suggestions have been made, including increasing the number of such posts and decreasing the number of senior registrarships. Although both these measures would go some way towards improving the position, the remedy would at best be only temporary and at worst might increase the present difficulties within a few years, as well as being extravagant in public money. There is a different aspect of this question which is not often enough considered. When the generation of consultants now retiring made their choice of specialisation as against general practice, most of them knew that their career would be lengthy and at first economically crippling. They needed either considerable faith or large private means. Many of them sacrificed in the first ten years after qualifying the opportunity for marriage and having a family. If they failed to make the grade their outlook was much as it is today. But their numbers were restricted without the necessity for artificial control, since only determined and confident men were prepared to face the risk. Since the war, and particularly since the start of the National Health Service, the whole emphasis of medicine has shifted to the hospitals. The first ten years of a specialist’s career have been made feather-bedded and easily accessible to many who would formerly have been put off by the financial hardships. Every increase in the salary of junior hospital staff exaggerates this tendency, and will ultimately increase the number of senior registrars competing for consultant

For obvious reasons it is not likely to be a popular one. None the less I feel that it needs stating. It sounds priggish from the mouth of a registrar and complacent from the mouth of a consultant, and equally unconvincing from either. I write therefore as one who has benefited from and appreciated junior-hospital-staff pay, who is not at present contemplating entry to general practice, who is in a good position for unprejudiced thinking-

and who dislikes

unsigned

letters. C. J. DICKINSON.

London, S.W.I.

SIR,-I am amazed by the solution to the senior. registrar problem suggested by Mr. McCarthy last week. The " really worthy senior registrarwould have an additional letter (E) to his title, and an extra Y200 a year. He would, of course, continue indefinitely to do work virtually equivalent to a consultant’s, as at present, with never any hope of assuming full clinical responsibility. In Mr. McCarthy’s scheme the newly graded men are to be at the disposal of the hospital boards for " duties throughout the region." I take this to mean that they will be directed from peripheral hospital to peripheral hospital in the region concerned, as and when difficulties of staffing in the junior grades arise. They might even occasionally be working near their home and have a chance to see their family; for, as Mr. McCarthy himself points out, these men do have families. Should some such solution be accepted, the problem would be considered solved once and for all.

The

about " the plight of senior registrars," presumably from the increasing difficulty of junior-grade staffing of peripheral hospitals. I submit that the real cause of this difficulty is the awareness among the younger men of the hopeless struggle of non-teaching-hospital senior registrars in recent years to obtain a permanent post in their own.

present

acute

concern

arises

specialty. for the shortage of consultant posts is, sometimes given to understand, a financial one, then I would offer the following simple suggestions: If the

reason

as we are

the senior registrars who have completed their who receive adequate recommendation from their and training, chiefs, a small number of consultant sessions in a hospital group. Even three or four sessions would do provided (2) below is also granted. (2) Allow them to make up for the other sessions with whatever private practice they can obtain in competition with other consultants.

(1) Give

SENIOR REGISTRAR.

posts. This is not to say that the tendency I am criticising has been entirely bad. Junior hospital staff can lead fuller, easier, and perhaps eugenically better lives. The discrimination in favour of those with private means has been eliminated. Unfortunately the sacrifices and struggles of the early years have not been eliminated also : they have been deferred until later on in life. This cannot be a healthy tendency. A man approaching middle age should be able to look forward to reasonable financial security. The right time for struggling is when you are young.

I feel very strongly that when the next pay increases made (politicians nowadays refer to " change in the rate of rise of the cost of living " as if it were an inevitable process) they should be made in such a way as to help the young entrant into general practice. The lure of the hospital and consultant ladder is quite great enough already. It is at present often more profitable for the man qualified, say, for three years to go into hospital rather than into general practice. The work is easier, and the hours and conditions better. It is silly to say that one job is more worth while than another. Both are necessary-though the country could spare registrars The decline more easily than general practitioners. in the status of general practice is an artificial one, capable of correction. The view that junior hospital staffs are perhaps overpaid is not one that is often expressed in your columns. are

DIAGNOSIS OF ACTIVE CARDITIS

SIR,-In the carditis, one of gram (E.C.G.) of

course us

of

investigations

on

rheumatic

(G. C.) noted that the electrocardio-

patient with rheumatic fever showed a peculiar change following the administration of digitalis: after no more than an average therapeutic dose, the P-R interval increased to an extent normally observed only after toxic doses, and even then but rarely. This observation suggested to us that the peculiar sensitivity to digitalis of patients suffering from carditis (already alluded to by some authors) might prove of diagnostic a

value. We therefore gave 0-8 mg. ’Cedilanid’ (lanatoside C) to 34 patients with rheumatic carditis, and to a control group of 82 people with neurocirculatory asthenia. The results supported our hypothesis : a significant delay in the P-R interval was observed in 10 out of the 34 patients with rheumatic carditis. The E.C.G.s began to show changes 3-/,-lhour after the injection. These reached a maximum often as late as 24 hours after the injections and the changes lasted for 1-2 days. The delay in conduction was 0-16 sec. in 2 cases, and 0-10 sec. in 2 other cases, and it exceeded 0-03 sec. in every case. On the other hand, this effect was observed in none of the 82 people in the control group. This alteration in the E.C.G. may therefore be a sign of active carditis ; and this is supported by the fact that the changes were observed only during the active

intravenously