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SENIORS AND JUNIORS
324 ’ It may be argued that my figures are comparable with those of Dr. Bene because
not strictly my patients
had been at rest for several hours and his for only five minutes. There is justice in this argument, but it weights the scales against Dr. Bene. As I have pointed out, his figures cannot be equally accurate because his data are not equally basal (and it is the basal metabolism he seeks to estimate). But supposing they were equally accurate, one would expect them to give figures higher than mine because his conditions are less basal. The fact that the R.P. index is in 60 % of my cases lower than the B.M.R. provides a final proof of my assertions that the two are completely unrelated to one another. RAYMOND GREENE. Thyroid Clinic, New End Hospital, London, N.W.3.
SIR,—There are four standard methods for estimating the basal metabolism, and these depend upon measuring: 1. 2. 3. 4.
The heat output. The oxygen consumption. The carbon-dioxide output. Both the oxygen consumption and the carbon-dioxide output. -
For many years now, formulae have been proposed for
translating simple bedside records into an approximate figure for the basal metabolism.’- These formulae, like Dr. Bene’s, are based on the fact that in thyrotoxicosis there may be tachycardia, an increased respiration-rate, and a rise in pulse pressure, whereas in hypothyroidism there may be the converse, and in normal people there The normal range of pulse-rate, may be more of these. respiration-rate, and pulse pressure is very wide, and, as they are not always greatly altered in thyrotoxicosis and in hypothyroidism, it is doubtful whether any of
the formulae can serve as a substitute for direct measurement of the basal metabolism. They may nevertheless have a certain clinical value : for example, the product of the pulse and respiration rates may well fall when thyrotoxicosis is reduced and rise when hypothyroidism is relieved. For basal metabolism, the range accepted as normal is wide. Indeed, the range accepted by Miss Lovell and Dr. Martin is different from my own, based on a study of some 2300 people of both sexes from the ages of three to eighty. This makes the interpretation of the basal rate at times not easy, and on occasions erroneous. Severe thyrotoxicosis or hypothyroidism may be easy to diagnose clinically, and in these cases the basal metabolism is usually well outside the normal range ; on the other hand, in the very mild cases, where assistance in the diagnosis may be most required, an isolated reading of the basal metabolism is of limited value.2 Observations on the variations in the basal metabolism can be made a most sensitive index of thyroid dysfunction if: 1. In the diagnosis of thyrotoxicosis, the basal rate is measured before and after twelve days of iodine medication. Only in thyrotoxicosis does iodine cause a significant alteration in the basal metabolism. 2. In the diagnosis of hypothyroidism the basal metabolism is measured before and after two to four weeks of thyroid -2 grains daily. Only in hypothyroidism does thyroid medication in such doses and over such a period cause a significant rise in the basal rate. Returning to Lovell and Martin’s criticism of Bene’s R.P. index, it appears possible that they may not have repeated quite accurately Bene’s observations. Bene counted the pulse and respirations after a rest of only five minutes, whereas basal conditions require a rest period of at least thirty minutes. As Lovell and Martin referred to 50 unselected cases from their records, no doubt the respirations and pulses were recorded under basal conditions. It is no criticism of Bene’s work that he chose arbitrarily a period of five, and not ten, twenty, or thirty minutes, for in seeking to make an intelligent guess at the basal metabolism, by a formula in no way related to heat output, it is not essential to comply with standard heat-output conditions. If he could devise the perfect formula by making certain observations while patients were standing on their heads, then all the more credit to Dr. Bene. ’
1. E.g., Read, J. M. J. Amer. med. Ass. 1922, 78, 1887. Gale, A.M., Gale, C. H. Lancet, 1931, i, 1287. Jenkins, R. L. Arch. intern. Med. 1932, 49, 188. 2. Robertson, J. D. Lancet, 1934, ii, 1076; Ann. Surg. 1949, 4, 3.
In summary -’Ithink it can be .said that the pulserespiration product after a five-minuter rest period may
well have
a certain clinical value, provided a correlation with the basal metabolism is not attempted. J. DOUGLAS ROBERTSON. Department of Clinical Investigation,
The London Clinic, W.1.
SENIORS AND JUNIORS have read with astonishment "Physician’s " SIR,—I letter in your last issue. He states that the assessing committees appointed to advise the regional hospital boards on the status of consultant staffs are instructed to relegate junior consultants to a new category of " senior hospital officer." Last June the Minister of Health announced that the Government accepted in principle the recommendations of the Spens Committee. There is no doubt that the creation of a new barrier between the training of a specialist and the realisation of specialist status is a complete denial of the principles enunciated by the Spens Committee on this matter. It is dreadful to think that a decision of such importance to so many specialists can be taken in camera, especially when that decision is a categorical contradiction of an ’
accepted principle. Perhaps " Physician " is misinformed ; but if he is not, then I hope this violation of principle will be actively resisted by such bodies as represent us. SECOND PHYSICIAN.
MEDICAL TECHNOLOGY IN BRITAIN AND AMERICA SIR,—Dr. Whitehead’s article in your issue of Jan. 15 has been read with great interest by medical- and scientific laboratory technicians throughout this country. Dr. Whitehead is to be congratulated upon his comprehensive survey of the position, particularly with reference to the training of those technicians who are eligible for membership of the Institute of Medical Laboratory ’
Technology. In discussing the work of technicians in anatomy and physiology and of those who are associated with science
suggests that the formation of independent association of these technicians might The majority of prove a satisfactory arrangement.
rather than medicine, he an
those concerned are of the same opinion, and I am sure that Dr. Whitehead will be glad to learn that such an organisation is in existence. It has for its object the preparation of the ground for the establishment of a professional institute for the education and registration of laboratory technicians not’ at present within the jurisdiction of the Institute of Medical Laboratory Technology, with which it will be in many ways comparable. During the interim period which must elapse before the institute can be fully established, an association, called for the time being the Science Technologists’ Association, has been set up and has the temporary use of an office at 151, Victoria - Street. London, S.W.I. These two organisations-the I.M.L.T. and the S.T.A. -are independent of each other, although there is an abundance of common interest ; and we are grateful to the I.M.L.T. for advice and practical assistance which have been freely given. Membership of the new institute will be restricted to the holders of certain certificates and/or diplomas, the exact details of which have not yet been finally settled, although the general scheme has been agreed upon and pilot and preliminary courses of study are in operation at Paddington Technical College, London, W.9, and The similar courses are contemplated elsewhere. educational requirements are as follows : Preliminary education should be at or approaching present school certificate or senior College of Preceptors certificate ’
’
standard in selected subjects, such as elementary mathematics, English, and general science. In special cases, other evidence of general education would be considered. The following technological courses are to be taken concurrently with general laboratory work in which the technician is normally engaged : (1) a 3-year course prior to a certificate examination ; and (2) a course lasting a further 2 years prior to a diploma examination. Candidates who have satisfactorily completed the courses and passed the.
not strictly my patients
had been at rest for several hours and his for only five minutes. There is justice in this argument, but it weights the scales against Dr. Bene. As I have pointed out, his figures cannot be equally accurate because his data are not equally basal (and it is the basal metabolism he seeks to estimate). But supposing they were equally accurate, one would expect them to give figures higher than mine because his conditions are less basal. The fact that the R.P. index is in 60 % of my cases lower than the B.M.R. provides a final proof of my assertions that the two are completely unrelated to one another. RAYMOND GREENE. Thyroid Clinic, New End Hospital, London, N.W.3.
SIR,—There are four standard methods for estimating the basal metabolism, and these depend upon measuring: 1. 2. 3. 4.
The heat output. The oxygen consumption. The carbon-dioxide output. Both the oxygen consumption and the carbon-dioxide output. -
For many years now, formulae have been proposed for
translating simple bedside records into an approximate figure for the basal metabolism.’- These formulae, like Dr. Bene’s, are based on the fact that in thyrotoxicosis there may be tachycardia, an increased respiration-rate, and a rise in pulse pressure, whereas in hypothyroidism there may be the converse, and in normal people there The normal range of pulse-rate, may be more of these. respiration-rate, and pulse pressure is very wide, and, as they are not always greatly altered in thyrotoxicosis and in hypothyroidism, it is doubtful whether any of
the formulae can serve as a substitute for direct measurement of the basal metabolism. They may nevertheless have a certain clinical value : for example, the product of the pulse and respiration rates may well fall when thyrotoxicosis is reduced and rise when hypothyroidism is relieved. For basal metabolism, the range accepted as normal is wide. Indeed, the range accepted by Miss Lovell and Dr. Martin is different from my own, based on a study of some 2300 people of both sexes from the ages of three to eighty. This makes the interpretation of the basal rate at times not easy, and on occasions erroneous. Severe thyrotoxicosis or hypothyroidism may be easy to diagnose clinically, and in these cases the basal metabolism is usually well outside the normal range ; on the other hand, in the very mild cases, where assistance in the diagnosis may be most required, an isolated reading of the basal metabolism is of limited value.2 Observations on the variations in the basal metabolism can be made a most sensitive index of thyroid dysfunction if: 1. In the diagnosis of thyrotoxicosis, the basal rate is measured before and after twelve days of iodine medication. Only in thyrotoxicosis does iodine cause a significant alteration in the basal metabolism. 2. In the diagnosis of hypothyroidism the basal metabolism is measured before and after two to four weeks of thyroid -2 grains daily. Only in hypothyroidism does thyroid medication in such doses and over such a period cause a significant rise in the basal rate. Returning to Lovell and Martin’s criticism of Bene’s R.P. index, it appears possible that they may not have repeated quite accurately Bene’s observations. Bene counted the pulse and respirations after a rest of only five minutes, whereas basal conditions require a rest period of at least thirty minutes. As Lovell and Martin referred to 50 unselected cases from their records, no doubt the respirations and pulses were recorded under basal conditions. It is no criticism of Bene’s work that he chose arbitrarily a period of five, and not ten, twenty, or thirty minutes, for in seeking to make an intelligent guess at the basal metabolism, by a formula in no way related to heat output, it is not essential to comply with standard heat-output conditions. If he could devise the perfect formula by making certain observations while patients were standing on their heads, then all the more credit to Dr. Bene. ’
1. E.g., Read, J. M. J. Amer. med. Ass. 1922, 78, 1887. Gale, A.M., Gale, C. H. Lancet, 1931, i, 1287. Jenkins, R. L. Arch. intern. Med. 1932, 49, 188. 2. Robertson, J. D. Lancet, 1934, ii, 1076; Ann. Surg. 1949, 4, 3.
In summary -’Ithink it can be .said that the pulserespiration product after a five-minuter rest period may
well have
a certain clinical value, provided a correlation with the basal metabolism is not attempted. J. DOUGLAS ROBERTSON. Department of Clinical Investigation,
The London Clinic, W.1.
SENIORS AND JUNIORS have read with astonishment "Physician’s " SIR,—I letter in your last issue. He states that the assessing committees appointed to advise the regional hospital boards on the status of consultant staffs are instructed to relegate junior consultants to a new category of " senior hospital officer." Last June the Minister of Health announced that the Government accepted in principle the recommendations of the Spens Committee. There is no doubt that the creation of a new barrier between the training of a specialist and the realisation of specialist status is a complete denial of the principles enunciated by the Spens Committee on this matter. It is dreadful to think that a decision of such importance to so many specialists can be taken in camera, especially when that decision is a categorical contradiction of an ’
accepted principle. Perhaps " Physician " is misinformed ; but if he is not, then I hope this violation of principle will be actively resisted by such bodies as represent us. SECOND PHYSICIAN.
MEDICAL TECHNOLOGY IN BRITAIN AND AMERICA SIR,—Dr. Whitehead’s article in your issue of Jan. 15 has been read with great interest by medical- and scientific laboratory technicians throughout this country. Dr. Whitehead is to be congratulated upon his comprehensive survey of the position, particularly with reference to the training of those technicians who are eligible for membership of the Institute of Medical Laboratory ’
Technology. In discussing the work of technicians in anatomy and physiology and of those who are associated with science
suggests that the formation of independent association of these technicians might The majority of prove a satisfactory arrangement.
rather than medicine, he an
those concerned are of the same opinion, and I am sure that Dr. Whitehead will be glad to learn that such an organisation is in existence. It has for its object the preparation of the ground for the establishment of a professional institute for the education and registration of laboratory technicians not’ at present within the jurisdiction of the Institute of Medical Laboratory Technology, with which it will be in many ways comparable. During the interim period which must elapse before the institute can be fully established, an association, called for the time being the Science Technologists’ Association, has been set up and has the temporary use of an office at 151, Victoria - Street. London, S.W.I. These two organisations-the I.M.L.T. and the S.T.A. -are independent of each other, although there is an abundance of common interest ; and we are grateful to the I.M.L.T. for advice and practical assistance which have been freely given. Membership of the new institute will be restricted to the holders of certain certificates and/or diplomas, the exact details of which have not yet been finally settled, although the general scheme has been agreed upon and pilot and preliminary courses of study are in operation at Paddington Technical College, London, W.9, and The similar courses are contemplated elsewhere. educational requirements are as follows : Preliminary education should be at or approaching present school certificate or senior College of Preceptors certificate ’
’
standard in selected subjects, such as elementary mathematics, English, and general science. In special cases, other evidence of general education would be considered. The following technological courses are to be taken concurrently with general laboratory work in which the technician is normally engaged : (1) a 3-year course prior to a certificate examination ; and (2) a course lasting a further 2 years prior to a diploma examination. Candidates who have satisfactorily completed the courses and passed the.