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BOARDS AND MANAGEMENT COMMITTEES
150
Letters
to
the Editor
BOARDS AND MANAGEMENT COMMITTEES
HIB,—Your leading article ot July 1G expresses uneasiabout the adequacy of the local administrative machinery for the new health service, and it makes some suggestions; but it does not touch on the division of function between the voting members of the different bodies and the officials and experts. Up to the present there has been little discussion of the theoretical aspect, and this is in harmony with the English tradition, with its love of compromise and its suspicion of anything that may be described as doctrinaire. But a little thought now may prevent a good deal of ness
muddle later. A managing committee (such as a regional hospitals board or a hospital management committee) might be a lay body without any claim to expert or special knowledge. It would represent the common undifferentiated man, the word " common " being used to imply the highest common factor of humanity. This principle of special ignorance is well established in English law, where the judge and jury approach each case without preconceived ideas and without any expert knowledge. They are assumed to be men of honesty, integrity, and honour who will reach conclusions on the evidence and information presented to them. In a similar way the voting members of a managing committee would make decisions after specialised technical information had been given to them by their paid servants or by expert
advisory committees. Alternatively the
committee might contain representatives of various interests, and this seems to have been the conception formed by the British Medical Association in its efforts to obtain medical representation on the various committees of the health service. Presumably the doctors so appointed would have been expected to look after the material interests of members of the
profession.
Both these conceptions of the committee have in fact been rejected by the Minister in favour of a third ; and the medical members of the new regional boards have been appointed because they are experts rather than because
they represent
the
profession. As experts,
however, they will occupy an anomalous position, and the same criticism would apply to the hard core of paid members suggested in your article. Most local-government officials have had experience of the expert as a voting member of a committee-the doctor who speaks with authority on medical matters and is treated with deference by the lay members because they have no pretention to knowledge of the subject and is immune to criticism from officials since they are his paid servants. Competent people will be very much needed in the service ; but the place for the technical experts would seem to be on advisory committees or on the paid staffs of the boards. HENRY H. MACWILLIAM.
every occasion from every threatened infection and quarantine is appallingly costly in terms of lessons, games, friendly meetings, and serenity of mind. It fails of its purpose but succeeds just enough to leave a sprinkling of unprotected adults ready to take these things from husband, wife, or child. Here are grounds which even " safety first " can comprehend for a saner and better-reasoned practice. Shall we not grasp
child
on
by isolation
our
chance ?? LINDSEY W. BATTEN.
PNEUMOTHORAX AFTER THYROIDECTOMY
SIR,-The communication by Mr. R. B. Billimoria (June 21) was of great interest to me ; on reading it
my immediate reaction was that the bilateral pneumothorax was not traumatic but was due to the mechanism suggested in the very important paper by H. J. Baxrie.1 I was extremely glad to read Mr. Edric Wilson’s letter
suggesting that interstitial emphysema entering the superior mediastinum was the probable mechanism and acknowledging my own (July 12),
also
due to air
interest in the matter. I have not come across a case personally since I became aware of the condition, but when I read Barrie’s article in 1940 it seemed to explain two deaths on the operatingtable which I had personally observed in the space of two weeks a short time previously. Both showed the same clinical picture of sudden respiratory embarrassment with cyanosis, and a clear airway guaranteed by the anaesthetist. I feel certain that this rare condition should be made known to all surgeons and anaesthetists who are concerned with thyroidectomy or other operations on the neck, and Barrie’s original paper should be carefully studied as the remedy can be so quickly applied. The modern tendency is to X ray the chest after abdominal and thoracic operations as a routine, in order to diagnose bronchial block with atelectasis ; and a similar procedure might be advocated after neck opera.tions to display a possible pneumothorax. I would again stress the point in my previous letter 2 : that in a fatal case the pathologist is likely to miss the pneumothorax at necropsy unless each pleura is opened under a water seal. A. P. M. PAGE. THE CURRICULUM March 29 you published a statement about SIR,-On changes that have been introduced in the anatomical The main curriculum at Birmingham University.3 innovations are : (1) To combine the anatomical and physiological approach in every course of lectures. (2) By divesting the subject of much unwieldy, and
probably anatomy
unnecessary, detail, to confine to three instead of five terms.
dissecting-room
(3) To devote the anatomical teaching of the fourth and fifth terms to surface and radiographic anatomy and to
neurology. (4) To divide the 2nd M.B. examination into a first part, dealing with topographical anatomy and histology, taken at the end of the third term, and a second part, dealing mainly with physiology and functional anatomy. One of your correspondents, Professor Green, of Newcastle, expressed the wish for information about the progress of the new scheme. We are now in a position to make a preliminary statement about the results of its first year of operation. The course was taken by 83 medical students, of whom 2 dropped out owing to illness and the rest sat the part I examination at the end of the third term. Of these, 58, or about 70 %, satisfied the examiners. The examination was conducted in the usual way, and comprised a written paper in anatomy and a fifteen-minute viva-voce ’
INFECTIONS AND THE DEVELOPING EMBRYO
SiR,-Forgive my harking back to your leading article of May 10. In it you were chiefly concerned with the now notorious effects of rubella in early pregnancy; and I read it with growing surprise because, to the last paragraph, I was expecting you to draw what I deemed the one immediately practicable conclusion-have rubella young. I suppose one must not quarrel with your suggestions for field research, though the notification of every febricula in pregnancy would multiply anxiety as well as work ; but when it comes to spreading the bad news, so that a sensitive schoolboy may accept and carry life-long blame for a congenital defect in his nephew or niece, the balance begins to tremble between loss and gain. Of course the pregnant woman should avoid contact if she can, and receive her gamma globulin on exposure if it works ; but a generation which had had rubella in the nursery would need neither isolation nor globulin ; nor would it fly in early pregnancy from a child with rubella as from a dog with rabies. The attempt, so commonly made at present, to protect every young
examination.
The paper
was
up to normal 2nd M.B.
standard, except that it was decided to omit any questions on
the central
nervous
system.
The oral examination
1. Lancet, 1940, i, 996. 2. Ibid, 1941, ii, 383. 3. Zuckerman, S. Revision of the Anatomical Curriculum at Birmingham University, Lancet, 1947, i, 395.
Letters
to
the Editor
BOARDS AND MANAGEMENT COMMITTEES
HIB,—Your leading article ot July 1G expresses uneasiabout the adequacy of the local administrative machinery for the new health service, and it makes some suggestions; but it does not touch on the division of function between the voting members of the different bodies and the officials and experts. Up to the present there has been little discussion of the theoretical aspect, and this is in harmony with the English tradition, with its love of compromise and its suspicion of anything that may be described as doctrinaire. But a little thought now may prevent a good deal of ness
muddle later. A managing committee (such as a regional hospitals board or a hospital management committee) might be a lay body without any claim to expert or special knowledge. It would represent the common undifferentiated man, the word " common " being used to imply the highest common factor of humanity. This principle of special ignorance is well established in English law, where the judge and jury approach each case without preconceived ideas and without any expert knowledge. They are assumed to be men of honesty, integrity, and honour who will reach conclusions on the evidence and information presented to them. In a similar way the voting members of a managing committee would make decisions after specialised technical information had been given to them by their paid servants or by expert
advisory committees. Alternatively the
committee might contain representatives of various interests, and this seems to have been the conception formed by the British Medical Association in its efforts to obtain medical representation on the various committees of the health service. Presumably the doctors so appointed would have been expected to look after the material interests of members of the
profession.
Both these conceptions of the committee have in fact been rejected by the Minister in favour of a third ; and the medical members of the new regional boards have been appointed because they are experts rather than because
they represent
the
profession. As experts,
however, they will occupy an anomalous position, and the same criticism would apply to the hard core of paid members suggested in your article. Most local-government officials have had experience of the expert as a voting member of a committee-the doctor who speaks with authority on medical matters and is treated with deference by the lay members because they have no pretention to knowledge of the subject and is immune to criticism from officials since they are his paid servants. Competent people will be very much needed in the service ; but the place for the technical experts would seem to be on advisory committees or on the paid staffs of the boards. HENRY H. MACWILLIAM.
every occasion from every threatened infection and quarantine is appallingly costly in terms of lessons, games, friendly meetings, and serenity of mind. It fails of its purpose but succeeds just enough to leave a sprinkling of unprotected adults ready to take these things from husband, wife, or child. Here are grounds which even " safety first " can comprehend for a saner and better-reasoned practice. Shall we not grasp
child
on
by isolation
our
chance ?? LINDSEY W. BATTEN.
PNEUMOTHORAX AFTER THYROIDECTOMY
SIR,-The communication by Mr. R. B. Billimoria (June 21) was of great interest to me ; on reading it
my immediate reaction was that the bilateral pneumothorax was not traumatic but was due to the mechanism suggested in the very important paper by H. J. Baxrie.1 I was extremely glad to read Mr. Edric Wilson’s letter
suggesting that interstitial emphysema entering the superior mediastinum was the probable mechanism and acknowledging my own (July 12),
also
due to air
interest in the matter. I have not come across a case personally since I became aware of the condition, but when I read Barrie’s article in 1940 it seemed to explain two deaths on the operatingtable which I had personally observed in the space of two weeks a short time previously. Both showed the same clinical picture of sudden respiratory embarrassment with cyanosis, and a clear airway guaranteed by the anaesthetist. I feel certain that this rare condition should be made known to all surgeons and anaesthetists who are concerned with thyroidectomy or other operations on the neck, and Barrie’s original paper should be carefully studied as the remedy can be so quickly applied. The modern tendency is to X ray the chest after abdominal and thoracic operations as a routine, in order to diagnose bronchial block with atelectasis ; and a similar procedure might be advocated after neck opera.tions to display a possible pneumothorax. I would again stress the point in my previous letter 2 : that in a fatal case the pathologist is likely to miss the pneumothorax at necropsy unless each pleura is opened under a water seal. A. P. M. PAGE. THE CURRICULUM March 29 you published a statement about SIR,-On changes that have been introduced in the anatomical The main curriculum at Birmingham University.3 innovations are : (1) To combine the anatomical and physiological approach in every course of lectures. (2) By divesting the subject of much unwieldy, and
probably anatomy
unnecessary, detail, to confine to three instead of five terms.
dissecting-room
(3) To devote the anatomical teaching of the fourth and fifth terms to surface and radiographic anatomy and to
neurology. (4) To divide the 2nd M.B. examination into a first part, dealing with topographical anatomy and histology, taken at the end of the third term, and a second part, dealing mainly with physiology and functional anatomy. One of your correspondents, Professor Green, of Newcastle, expressed the wish for information about the progress of the new scheme. We are now in a position to make a preliminary statement about the results of its first year of operation. The course was taken by 83 medical students, of whom 2 dropped out owing to illness and the rest sat the part I examination at the end of the third term. Of these, 58, or about 70 %, satisfied the examiners. The examination was conducted in the usual way, and comprised a written paper in anatomy and a fifteen-minute viva-voce ’
INFECTIONS AND THE DEVELOPING EMBRYO
SiR,-Forgive my harking back to your leading article of May 10. In it you were chiefly concerned with the now notorious effects of rubella in early pregnancy; and I read it with growing surprise because, to the last paragraph, I was expecting you to draw what I deemed the one immediately practicable conclusion-have rubella young. I suppose one must not quarrel with your suggestions for field research, though the notification of every febricula in pregnancy would multiply anxiety as well as work ; but when it comes to spreading the bad news, so that a sensitive schoolboy may accept and carry life-long blame for a congenital defect in his nephew or niece, the balance begins to tremble between loss and gain. Of course the pregnant woman should avoid contact if she can, and receive her gamma globulin on exposure if it works ; but a generation which had had rubella in the nursery would need neither isolation nor globulin ; nor would it fly in early pregnancy from a child with rubella as from a dog with rabies. The attempt, so commonly made at present, to protect every young
examination.
The paper
was
up to normal 2nd M.B.
standard, except that it was decided to omit any questions on
the central
nervous
system.
The oral examination
1. Lancet, 1940, i, 996. 2. Ibid, 1941, ii, 383. 3. Zuckerman, S. Revision of the Anatomical Curriculum at Birmingham University, Lancet, 1947, i, 395.