CERTIFICATES

312 vessels and the atmospheric pressure, and on the radius of vessels cut. Blood-flow through the tissue does not depend on atmospheric pressure, but on the pressuredifference between arteries and veins, or, to be more precise, between arterial and venous ends of the capillaries. Elevation of a limb has, I believe, as great an effect on the pressure in the veins as in the arteries and the pressure-difference is not necessarily altered. Consequently the blood-flow may be maintained though bleeding is slight. These principles can be demonstrated by arranging a rubber tube to act as a siphon and by cutting across it at its highest point when there is a steady flow through it. These considerations apply particularly to the brain if the skull is intact, but do not necessarily apply if the brain isexposed. The skin and the more superficial tissues are exposed to atmospheric pressure from without, and the dependent limb becomes engorged because the absolute pressure in the small vessels is greater than atmospheric. The raised limb is not engorged because the pressure in the small vessels may be little above atmospheric. Momentarily the small vessels collapse completely on raising the limb and this effectively stops the blood-flow. The principles of hydrostatics now apply and flow will only start again if the blood-pressure at heart level is sufficient to raise the blood to the level of the raised limb. The same argument applies to the exposed brain, and I would imagine that after injection of hexamethonium the reversed Trendelenburg position is more dangerous during operations inside the skull than during operations on the face or scalp. The converse argument applies to " other vital organs." The blood-flow is not necessarily higher because the local arterial pressure is higher. Nuffield Department of Industrial Health, Medical School, G. L. LEATHART. Newcastle upon Tyne.

lated areas, the scheme would be unworkable. I think this is an important point to make, because otherwise people might feel this is the ideal kind of establishment to set up everywhere. The other feature about this scheme is that it is obviously designed for the less severely handicapped children and for relatively short-term treatment. Other. wise the turnover could not be anything like as quick as is described in this experiment ; and that, I think, is further evidenced by the fact that the L.C.C. does send its severer cases out of its own area and to schools which offer longer-term treatment. Clearly they feel themselves that this particular arrangement is not designed for the severer types of personality disorders. Department of Psychiatry, University of Leeds.

W. MARY BURBURY.

COLLEGE OF GENERAL PRACTITIONERS

SiR,-At the Old Bailey recently

an employee of the College of General Practitioners was convicted of obtaining money from the bank by forgery. We would like it known that the college’s bankers have now re-credited the college’s account with the whole of the sum involved.

THE MALADJUSTED SCHOOL

SIR,—Iwas much interested and pleased to see I think it is extremely Dr. Model’s letter (Jan. 23). valuable that people should point out the limitations and alternatives to the outline scheme which I suggested, and I would entirely agree with Dr. Model that, in theory at any rate, there is a place for the kind of school he describes, and that such a school, properly run, is an extremely valuable contribution to this problem. My remarks about the coeducational school are really based on the very difficult problems these schools tend to arouse-difficult in themselves, but even more so, I think, because of the attitude of public opinion to them. So, while I feel, with Dr. Model, that this is an important aspect of treatment in children, I feel both that we need to be very careful in our selection of schools, and that, having accepted them, we should be prepared to support them against public opinion if difficulties arise. I would like, at this point, also to comment on the very interesting scheme run by the London County Council that was described in your issue of Dec. 12, in which my own article appeared. Again, one feels this is a very useful contribution, but there are two points about it that I think need to be made. The first is that such a scheme is almost limited to an authority of the size of the L.C.C. ; no other single authority is big enough to be able to fill the school, maintain contact with the parents by their regular visiting, and allow the children the gradually increasing freedom of going home for more and more time. One can imagine that a combined scheme between other big authorities, such as Liverpool and Manchester together with the Lancashire County Council, or Sheffield, Leeds, and Bradford together with the West Riding of Yorkshire, might also run such a school, but they would need to be combined, and they would find much more difficulty in the type of contact described by the L.C.C. experiment. Aside from these thickly popu-

G. F. ABERCROMBIE Chairman of council

H. L. GLYN HUGHES Hon. treasurer

14, Black Friars Lane,

J. Hon.

London. E.C.4.

H. HUNT secretary.

CERTIFICATES

SIR,—Mr. Van den Bergh (Jan. 16) voices a justifiable grievance. Dr. Tripp in his reply (Jan. 23) makes suggestions which are identical in principle with those which I have myself made without success to one large industrial concern during the last few years. Mr. Van den Bergh’s difficulty is only one part of a wider problem which has many facets, some of which I will enumerate. With the creation of the Welfare State we have, as a nation, provided a very wide range of benefits which become available to all under certain conditions. The -evidence required to establish the fact thata particular contingency has arisen is, in most cases, medical. The practice of many enlightened employers of continuing to pay their employees during a period of illness is a comparatively modern development harmonising with the social advances which, integrated, make up the Welfare State. It is unfortunate that the coming into being of these widespread social advances has coincided with a period of testing when the general moral fibre and integrity of the mass of the people is at a lower level than has been known for many years. It is not my intention to discuss the many reasons for and examples of this state, which were beautifully enunciated by Lord Samuel in a recent address. It is widely acknowledged that there has been, in recent years, a decline in the respect of the community in general for the medical practitioner. In my view this decline is associated not only with the appointment of the doctor as the arbiter in the issue of many of the benefits conferred by the State but with a degree of laxity in certification resulting in lack of respect fora medical certificate. I believe that the majority of doctors wish to do everything they can to restore the lost confidence. Nevertheless it is true to say that there are many who have ceased to set themselves a very high standard in the matter of certification. The lowered standard of behaviour in this respect is, as Dr. Tripp suggests, often due to compassion for a worker about to lose pay or some State benefit and is seen in many doctors whose absolute integrity in other respects is beyond reproach. In a small proportion of doctors, however, I am convinced that the lowered standard of certification has

313

part of a deliberate effort to and thereby increase income. Small patients doctors may be, it is sufficient of such number the though to influence the standard of certification of the remainder of the profession by economic pressure, for all are concerned to survive and succeed in practice. Any departure from the highest standards of certification must: no

such motive but is

attract

(a) Increase the drain on the Exchequer and on the moneys of the National Insurance scheme, which is already threatened with an increase in the weekly contribution ; (b) cause a fall in the productivity of industry-it has been estimated that the elimination of unnecessary absenteeism could increase production by 10 %· A solution to this social problem must involve the of the entire community. There must be, in the fullest sense of the words, a reawakening by the mass of the people to their responsibilities as well as to their rights. Whatever may be done by any group within the community to improve the present state of affairs, the problem cannot be solved without a return to some of the moral standards of behaviour of the past. I would direct attention again to the moving words of Lord Samuel. My suggestions are :

cooperation

(1) In order to ease the burden on both doctor and employee, employers should trust their workers by allowing a limited period of absence from work without loss of pay and without medical certificate ; the privilege to be withdrawn in any case in which the employer feels that it is being abused. Alternatively, employers may prefer to grant the privilege initially only to employees in whom they feel able by reason or her record to place trust. Details of such a scheme should be discussed between representatives of the employers and representatives of the medical profession, and some uniformity of certification requirements agreed upon and then made known throughout the country in every place of employment. (3) Any employee who is not given the trust ot his employer should be notified by the employer that a medical certificate, which covers the entire period of his absence, must be produced at the time of his return to work and such certificate must state clearly the date on which the patient was examined by the doctor and express an opinion on the fitness of the employee for work. It is not, in my view, essential that the nature of the patient’s illness should be disclosed. (4) In accord with the decision of the representative body of the B.M.A. at Cardiff last year, no medical certificate should ever be issued concerning a period when the doctor was not-in attendance. (5) Employers must, in contrast to the present habit of many, accept the responsibility for recognition of the honest employee. This would include the acceptance of the statement of an employee about occasional absence from work for such reasons as family bereavements or serious illness of a relative. I have the impression that some employers seek to shelter behind the doctor by encouraging their workers to obtain medical certificates which the employer knows to be inaccurate rather than accept the responsibility of taking disciplinary action against an employee who has erred. (6) The professional organisations must do everything within their power to raise the standard of medical certification by : (a) recommending the exclusive use of a simple form of certificate on the lines I have already suggested (the old Ministry of Labour certificate is useless in this connection and merely encourages doctors to compromise with their conscience) ; and (b) withdrawing the privilege of membership from doctors who can be proved to have certified

of his

(2)

I

dishonestly. (7) Both employers

and the Government departments concerned must accept the responsibility of referring to the General Medical Council any case in which they hav3 overwhelming evidence of dishonest certification.

that these

hope proposals will at any rate provide a basis for discussion of an urgent social problem, the solution of which would not only go a long way in raising the esteem in which the profession is held but would contribute in no small degree to our national I

recoverv.

IVOR M. JONES.

BRITISH PSYCHIATRY

SiR,-Professor Lewis, in the article1 to which you refer in your annotation (Jan. 9), mentions the temporary

troubles of British psychiatry incident to human affairs in 1953. Amongst these are included the shortage of human resources and the grim old buildings. Such shortcomings as these musi1 inevitably be to some extent interrelated. As far as the psychiatric units of London teaching hospitals are concerned, some feel that the separation of these units (in varying degree) from their parent hospital buildings likewise hinders solution of the staff problem. ’ The separation of psychiatric units from their parent teaching hospitals is no doubt due to the difficulty of providing the necessary space and grounds in a large and long-established city ; but there can be advantage as well as disadvantage in the arrangement, for since psychiatry has found a greater need of social concepts than has, for example, general medicine, the separation can be used to emphasise an orientation toward the normal society to which patients return, rather than an undue preoccupation with pathology to the exclusion of treatment. J. P. CRAWFORD. SALARIES OF WHOLE-TIME SPECIALISTS SiR,ŃWith the arguments of Dr. Gilchrist’s letter

(Jan. 23) no whole-time consultant will disagree, but I would like to correct and emphasise his point about the amount of work done in the National Health Service bv whole-time specialists. He suggests that " one-third of the consultant work is done by whole-time specialists " and the whole tenor of his letter indicates that he includes s.H.M.o.s as specialists. With this point I agree, but on this basis it would be more correct to say that two-thirds of the consultant work of the country is now being done by whole-timers. It is difficult to get figures for the country as a whole, but on the last occasion when a check was made in the South West Metropolitan Region, it appeared that, counting by sessions, a full two-thirds of all consultant and specialist cover was given by wholetime men. When allowance is made for travelling-time and other factors, it is probably true for this region that 70% of the cover is given by whole-timers ; and for the country as a whole I am quite certain that a corresponding figure could be worked out. D. STARK MURRAY. CORTISONE DESENSITISATION

SiR,ŃIn his article of Jan. 30 Dr. Long has pushed his explanation of the mode of desensitisation in the guineapig a step forward. His hypothesis depends on the assumption that cortisone facilitates the’ oxidation of ascorbic acid to its first oxidation product, dehydroascorbic acid. Dr. Long and his colleagues have produced in the past a considerable weight of circumstantial evidence for this assumption. Would it not now be wise for this assumption to be put to a more direct test, especially as the evidence in the human points to the exact opposite-that is, cortisone seems to facilitate the reduction of dehydro-ascorbic acid to ascorbic acid’! Stewart et al.2 have shown that cortisone alters the

proportion of ascorbic acid to dehydro-ascorbic acid in the plasma in favour of the reduced form. Their work has lately been confirmed by Harkness and Donovan.3 We have shown4 that cortisone causes a fall in the electrode potential of the subcutaneous tissues, which again lends support to the view that cortisone facilitates the reduction of dehydro-ascorbic acid to ascorbic acid-the opposite change to that suggested by the Long hypothesis. 1. 2. 3. 4.

Lewis, A. J. Amer. J. Psychiat. 1953, 110, 401. Stewart, C. P., Horn. D., Robson, J. S. Biochem. J. 1953, 53, 254. Harkness, J., Donovan, C. J. clin. Path. 1953, 6, 330. Loxton, G. E., Le Vay, D. Nature, Lond. 1953, 171, 524.