- Email: [email protected]
GRADUATE WIVES
1081 The eldest girl is in her last term at school. There are 42 others in her class-an impossible task for any schoolteacher. Judging by the late hours the girl keeps and her complete lack of discipline, her future vocation will surprise no-one.
But what is at fault with " Our Bills " and " Our Ritas "7 A diagnosis of " high-grade mental deficiency " helps administrators more than the patient. It takes little or no account of his emotional state, his thought processes, or his physical condition. Nor does it describe the interaction between the patient and society. Moreover, there are innumerable high-grade defectives capable of profiting by instruction and wise discipline. Hence the need for more schools, and, of course, many more teachers-not forgetting playing-fields. Otherwise more borstal institutions and prisons. In the long run the Ministry of Education will pay greater dividends than the Home Office. I. H. M. SURGICAL TREATMENT OF ACUTE OSTEITIS IN CHILDHOOD
SIR,—May we congratulate Mr. Bremner, Dr. Neligan, and Dr. Warrick on a paper (May 8) which continues worthily the valuable contributions made to paediatric surgery by the Newcastle school. We are pleased to see that it confirms the claims which we (with Mr. Twistington Higgins) put forward in 1947 as to the excellent results which can be obtained by aspiration alone in the osteomyelitis of childhood.l This is the more gratifying as our report was attacked with almost theological vehemence by Trueta and Agerholm ; and, although our criticism of their criticism put an end to the argument, this must have prevented the method being taken up as widely as it might otherwise have been. The criticisms made by Bremner, Neligan, and Warrick that our cases must have been slight because the doses of penicillin were low seems to carry the corollary that if the doses had been higher the cases would have been more severe. Actually the smallness of the doses and their surprising success were both due to temporary conditions-namely, the scarcity of penicillin and the absence of resistant strains of infection. We have not ourselves tried a similar series of contrasted cases, because of our conviction that it was hardly fair to the patients to use on them a method we were convinced was not the best available. The criteria on which we came to this conclusion were different from those of Bremner et al. They
were :
1.The avoidance of chronicity.—This we regard as far the most important of all considerations. All our experience and the published papers we have studied appear to show that chronicity is less common with aspiration than with open operation. 2. Scarring we rate higher as a disadvantage than do many surgeons, though probably not as highly as do the general public in these days of bodily exposure. 3. Duration of treatment.—The sole criterion mentioned by Bremner et al. we consider of hardly any importance in a child, unless the difference were extremely large. It is interesting to note that it hardly exists.
Your annotation suggests that, although first-class surgeons may use aspiration, others should employ open operation. It seems to us that it is just when experience and perfect asepsis is lacking that chronic osteomyelitis is likely to be produced, and a good many cases entering our hospital bear this out. However, it is certain that very few surgeons throughout the country have any notion of the excellence of the results to be obtained by aspiration : let us hope that the suggestion that open operation is for the less expert may stimulate the alternative method. As to technique, one of us (D. B.) has for some years been using what may be called lavage rather than 1. Brit. med. J.
1947, i, 757.
aspiration. It needs an anaesthetic and two surgeons, sitting on either side-of the abscess. They each insert needles, and when the first gush of pus has subsided oneslowly injects normal saline, while the other keeps the lumen of the exit needle on his side clear with a stylet. When the effluent is completely clear a final washout with penicillin is given, and firm pressure with a thick pad of cotton-wool is used to obliterate the abscess cavity as much as possible. The improvement in results when the abscess cavity involves a joint is particularly marked ; and such
cases are
far from
The Hospital for Sick Children, Great Ormond Street, London, W.C.1.
in children. DENIS BROWNE MARTIN BODIAN.
uncommon
THE PLIGHT OF SENIOR REGISTRARS
SIR,—The unfortunate position of many senior. regisfamilies, so well outlined by a senior
trars and their
wife in your issue of May 8, must make us all think hard about this problem, especially those of us. who are hoping. for a post in this grade. Now that the National Health Service has been in existence for over five years we should be in a position to see what kind of medical staffing hospitals require, and to boldly reorganise the various grades. One of the major difficulties has been due to the employment of "trainees" to do the basic work of hospitals in almost all grades short of consultant. It is doubtful whether they are being " trained " any more than anyone else in medicine who is constantly learning in his job. Yet we see an experienced senior registrar essential work being sacked simply because his doing " period of training is up and no consultant has died or retired to make a vacancy for him. Another man is then put in his place for " training." Surely we should now be able to offer a man of the status of senior registrar a relatively permanent appointment to do a job of work, until he finds a more senior post. The reorganisation of junior hospital staffing must not be allowed to wait much longer before the present senior registrars are lost to the hospital service.
registrar’s
"
Royal Southern Hospital, Liverpool, 8.
J. E. FORSTER.
GRADUATE WIVES
SIR,—Dr. Mary Lennox in her letter of May 8 draws attention to the difficulties that women doctors are experiencing who seek part-time sessional work during the years when they are rearing their children. This is a problem of growing urgency to an increasing number of women medical graduates. There are many statements in Dr. Lennox’s letter which are matters of personal opinion and on which I could well comment at length. I would like, however, to deal with the last paragraph in which she suggests that part-time public-health work is ceasing to exist because " the large fee " per session encourages local health authorities to economise by using full-time staff for their clinics. Here she seems to be misinformed, for there is little difference between the scale for full-time assistant medical officers (.E950-1300 per annum) and eleven weekly sessions at £2 5s. per session (£1287 per annum). Moreover, under a recent Whitley agreement (M.D.C. circular no. 19) part-time medical officers, previously paid a "flat rate" annual salary, are now remunerated at the appropriate salary scale-i.e., they become entitled to annual increments in the same way as their whole-time colleagues. Dr. Lennox’s proposal that many married women doctors might feel prepared to undertake part-time work at a reduced rate of remuneration is dangerous in the extreme. The British Medical Association has for many years worked most vigorously, in collaboration with the Medical Women’s Federation, to eradicate undercutting
1082
by members of the profession, men or women. Much of the good feeling within the profession is founded upon long-standing coöperation on this very point. It cannot be stated too clearly that, when the rate for the job has been agreed by proper negotiation, that agreement must be honoured whatever the personal circumstances of any individual doctor. Too often this aspect of the matter escapes the attention of the young woman
doctor who concentrates only on the short view when she marries. It is, of course, true that the present high cost of domestic help, and the system of taxation of income of husband and wife as one (which falls particularly hard in cases where the joint income exceeds £2000) may make the net value of part-time work comparatively small, but this must not be allowed to confuse the main issue. The Medical Women’s Federation is giving particular attention to the problems of the married woman doctor. The predicament of the many medical graduate wives whose experience with their own families enriches their professional training, but who can find no opportunity to make use of it, is a serious one ; but the fact remains that it is essential that the married woman doctor, like her unmarried sister, must equip herself fully by undertaking adequate postgraduate work, and, where at all possible, obtain the recognised specialist diploma. She must offer her services based on more than the personal family experience, valuable though this may be, and in any medical work, whole-time or parttime, she must clearly recognise her responsibilities to the job and (more important) to her patients. A suggestion such as the one put forward by Dr. Lennox is only too readily made, but- it is short-sighted and to all concerned. I hope, however, that it will help to draw the attention of the profession to the loss to the community which may result if this group of medical women is unable to obtain the work for which it should be so eminently suited.
be the fault of the ill-considered and dogmatic evidence offered by the medical witness. You refer to a recent murder trial in which the accused was convicted, although the only’ medical witness declared him to be suffering from a serious mental disease ; but a much more disturbing case occurred a few years ago when the accused was convicted and the sentence of death later carried out, although at the trial all three medical witnesses, two for the prosecution and one for the defence, agreed that the prisoner, at the time of committing the crime, was insane. I do not think that sufficient attention has been paid to this -case, which, in my opinion, marks the lowest point to which psychiatric evidence has sunk in the estimation of a judge and jury. It is, to say the least, a disturbing state of affairs when a jury can return a verdict which completely ignores the opinion of three medical men on the state of mind of a man accused of murder. St. Andrew’s Hospital, W. J. MCCULLEY.
largely
Thorpe, Norwich.
ISOLATION OF CASTLE’S INTRINSIC FACTOR
SiR,-The preliminary communication (March 6) by Dr. Latner and his colleagues does not, I think, satisfy the customary requirements -for a report on the first isolation of a substance. I should say that these
requirements
Medical Women’s Federation, Tavistoek House North, Tavistock Tavistock Square, London, W.C.1.
ANNIS GILLIE President.
SIR,—Dr. Lennox’s letter contains an error of reasoning and proposes a course of action which I think would be to the detriment of this profession. The idea that a woman doctor who has brought up a family is, ipso facto, well suited for infant welfare is as sensible as saying that a doctor who has looked after one brother a schizophrenic and the other a manicdepressive is well suited to treat psychotic patients :-. the latter in fact has a certain advantage over the former. In her last paragraph, what Dr. Lennox is in fact suggesting is that married women should undercut their colleagues : this is acceptable in Petticoat Lane but hardly in a supposedly learned profession. London, N.10. A. W. BEARD.
,
(1) A short reference to the present position of the problem. (2) A description of the isolation procedure. (3) Analytical data about the newly isolated substance. (4) Proof of its chemical purity. (5) Evidence of its differentiation from similar materials
undertaking
dangerous
are :
isolated
previously. on its physiological activity (if physiologically active). (6)
My
Data
reasons
for this criticism
it is known to be
are :
(1) No reference to the question of the mucoprotein nature of intrinsic factor, prior to Latner’s work, is made in this or in any of the other papers to which he has contributed. 12 (2) All that is said about the isolation procedure is : " The major part of the intrinsic factor activity can in the first place be extracted by a suitable buffer solution at pH 6-35. The active fraction finally obtained has proved easily soluble at pH 2 ..." This leaves us with the expectation that " full details of this isolation procedure will shortly be published." (3) The analytical data merely confirm the mucoprotein nature of the intrinsic factor, about which evidence was presented three years ago by our group, 3 but they do not include the elementary analysis of the newly isolated intrinsic factor. Even the data on the carbohydrate composition are. rather fragmentary and conflicting. Thus, in September, 1953, the nitrogen content of Dr. Latner’s intrinsic factor preparation obtained by electrophoresis was given as 10 % and the hexosamine content as 6 %,l2 but in this latest paper the electrophoretic fraction contains 9-0-9-7% nitrogen and as much as 11-12 % hexosamine. of chemical purity is based on data from (4) The paper-strip electrophoresis and the ultracentrifuge, and it appears convincing, although the electrophoretic findings would have more value if data were included indicating the homogeneity of this fraction at various pHs and ionic strengths. (5) In order to satisfy the fifth requirement, Dr. Latner has sought to show that his mucoprotein is different from the " glandular mucoprotein " the intrinsic factor activity of which we demonstrated a few years ago and on which we have since accumulated further data. For this purpose he tries to dissociate himself from any work done previously, and he mentions three points as evidence
proof
PSYCHIATRIC
EVIDENCE
AT
MURDER
TRIALS
SIR,-I read your leading article of May 8 with great interest and I would strongly support your four recommendations—especially the period of observation by at least two psychiatrists before a report is made. I feel, however, that some of your statements may be misleading. I believe it is the practice for a prisoner accused of murder and remanded to an ordinary prison to be transferred to a prison where there is a full-time medical officer with psychiatric experience, usually indeed to Brixton Prison, and in my own experience I have had the fullest possible cooperation from the principal medical officer of Brixton Prison, as well as the local prison medical officer. I must also say that I, myself, have not experienced any hostile cross-examination in court, and I feel that when it does occur it may
Latner, A. L., Ungley, C. C., Cox, E. V., MeEvoy-Bowe, E., Raine, L. Brit. med. J. 1953, i, 467. 2. Latner, A. L., McEvoy-Bowe, E. Biochem. J. 1953, 55, xxiii. 3. Glass, G. B. J., Boyd, L. J., Rubinstein, M. A., Svigals, C. S., Chevalley, J. E. Fed. Proc. 1951, 10, 50. 4. Glass, G. B. J., Boyd, L. J., Rubinstein, M. A., Svigals, C. S. Science, 1952, 115, 101. 1.
.
,
But what is at fault with " Our Bills " and " Our Ritas "7 A diagnosis of " high-grade mental deficiency " helps administrators more than the patient. It takes little or no account of his emotional state, his thought processes, or his physical condition. Nor does it describe the interaction between the patient and society. Moreover, there are innumerable high-grade defectives capable of profiting by instruction and wise discipline. Hence the need for more schools, and, of course, many more teachers-not forgetting playing-fields. Otherwise more borstal institutions and prisons. In the long run the Ministry of Education will pay greater dividends than the Home Office. I. H. M. SURGICAL TREATMENT OF ACUTE OSTEITIS IN CHILDHOOD
SIR,—May we congratulate Mr. Bremner, Dr. Neligan, and Dr. Warrick on a paper (May 8) which continues worthily the valuable contributions made to paediatric surgery by the Newcastle school. We are pleased to see that it confirms the claims which we (with Mr. Twistington Higgins) put forward in 1947 as to the excellent results which can be obtained by aspiration alone in the osteomyelitis of childhood.l This is the more gratifying as our report was attacked with almost theological vehemence by Trueta and Agerholm ; and, although our criticism of their criticism put an end to the argument, this must have prevented the method being taken up as widely as it might otherwise have been. The criticisms made by Bremner, Neligan, and Warrick that our cases must have been slight because the doses of penicillin were low seems to carry the corollary that if the doses had been higher the cases would have been more severe. Actually the smallness of the doses and their surprising success were both due to temporary conditions-namely, the scarcity of penicillin and the absence of resistant strains of infection. We have not ourselves tried a similar series of contrasted cases, because of our conviction that it was hardly fair to the patients to use on them a method we were convinced was not the best available. The criteria on which we came to this conclusion were different from those of Bremner et al. They
were :
1.The avoidance of chronicity.—This we regard as far the most important of all considerations. All our experience and the published papers we have studied appear to show that chronicity is less common with aspiration than with open operation. 2. Scarring we rate higher as a disadvantage than do many surgeons, though probably not as highly as do the general public in these days of bodily exposure. 3. Duration of treatment.—The sole criterion mentioned by Bremner et al. we consider of hardly any importance in a child, unless the difference were extremely large. It is interesting to note that it hardly exists.
Your annotation suggests that, although first-class surgeons may use aspiration, others should employ open operation. It seems to us that it is just when experience and perfect asepsis is lacking that chronic osteomyelitis is likely to be produced, and a good many cases entering our hospital bear this out. However, it is certain that very few surgeons throughout the country have any notion of the excellence of the results to be obtained by aspiration : let us hope that the suggestion that open operation is for the less expert may stimulate the alternative method. As to technique, one of us (D. B.) has for some years been using what may be called lavage rather than 1. Brit. med. J.
1947, i, 757.
aspiration. It needs an anaesthetic and two surgeons, sitting on either side-of the abscess. They each insert needles, and when the first gush of pus has subsided oneslowly injects normal saline, while the other keeps the lumen of the exit needle on his side clear with a stylet. When the effluent is completely clear a final washout with penicillin is given, and firm pressure with a thick pad of cotton-wool is used to obliterate the abscess cavity as much as possible. The improvement in results when the abscess cavity involves a joint is particularly marked ; and such
cases are
far from
The Hospital for Sick Children, Great Ormond Street, London, W.C.1.
in children. DENIS BROWNE MARTIN BODIAN.
uncommon
THE PLIGHT OF SENIOR REGISTRARS
SIR,—The unfortunate position of many senior. regisfamilies, so well outlined by a senior
trars and their
wife in your issue of May 8, must make us all think hard about this problem, especially those of us. who are hoping. for a post in this grade. Now that the National Health Service has been in existence for over five years we should be in a position to see what kind of medical staffing hospitals require, and to boldly reorganise the various grades. One of the major difficulties has been due to the employment of "trainees" to do the basic work of hospitals in almost all grades short of consultant. It is doubtful whether they are being " trained " any more than anyone else in medicine who is constantly learning in his job. Yet we see an experienced senior registrar essential work being sacked simply because his doing " period of training is up and no consultant has died or retired to make a vacancy for him. Another man is then put in his place for " training." Surely we should now be able to offer a man of the status of senior registrar a relatively permanent appointment to do a job of work, until he finds a more senior post. The reorganisation of junior hospital staffing must not be allowed to wait much longer before the present senior registrars are lost to the hospital service.
registrar’s
"
Royal Southern Hospital, Liverpool, 8.
J. E. FORSTER.
GRADUATE WIVES
SIR,—Dr. Mary Lennox in her letter of May 8 draws attention to the difficulties that women doctors are experiencing who seek part-time sessional work during the years when they are rearing their children. This is a problem of growing urgency to an increasing number of women medical graduates. There are many statements in Dr. Lennox’s letter which are matters of personal opinion and on which I could well comment at length. I would like, however, to deal with the last paragraph in which she suggests that part-time public-health work is ceasing to exist because " the large fee " per session encourages local health authorities to economise by using full-time staff for their clinics. Here she seems to be misinformed, for there is little difference between the scale for full-time assistant medical officers (.E950-1300 per annum) and eleven weekly sessions at £2 5s. per session (£1287 per annum). Moreover, under a recent Whitley agreement (M.D.C. circular no. 19) part-time medical officers, previously paid a "flat rate" annual salary, are now remunerated at the appropriate salary scale-i.e., they become entitled to annual increments in the same way as their whole-time colleagues. Dr. Lennox’s proposal that many married women doctors might feel prepared to undertake part-time work at a reduced rate of remuneration is dangerous in the extreme. The British Medical Association has for many years worked most vigorously, in collaboration with the Medical Women’s Federation, to eradicate undercutting
1082
by members of the profession, men or women. Much of the good feeling within the profession is founded upon long-standing coöperation on this very point. It cannot be stated too clearly that, when the rate for the job has been agreed by proper negotiation, that agreement must be honoured whatever the personal circumstances of any individual doctor. Too often this aspect of the matter escapes the attention of the young woman
doctor who concentrates only on the short view when she marries. It is, of course, true that the present high cost of domestic help, and the system of taxation of income of husband and wife as one (which falls particularly hard in cases where the joint income exceeds £2000) may make the net value of part-time work comparatively small, but this must not be allowed to confuse the main issue. The Medical Women’s Federation is giving particular attention to the problems of the married woman doctor. The predicament of the many medical graduate wives whose experience with their own families enriches their professional training, but who can find no opportunity to make use of it, is a serious one ; but the fact remains that it is essential that the married woman doctor, like her unmarried sister, must equip herself fully by undertaking adequate postgraduate work, and, where at all possible, obtain the recognised specialist diploma. She must offer her services based on more than the personal family experience, valuable though this may be, and in any medical work, whole-time or parttime, she must clearly recognise her responsibilities to the job and (more important) to her patients. A suggestion such as the one put forward by Dr. Lennox is only too readily made, but- it is short-sighted and to all concerned. I hope, however, that it will help to draw the attention of the profession to the loss to the community which may result if this group of medical women is unable to obtain the work for which it should be so eminently suited.
be the fault of the ill-considered and dogmatic evidence offered by the medical witness. You refer to a recent murder trial in which the accused was convicted, although the only’ medical witness declared him to be suffering from a serious mental disease ; but a much more disturbing case occurred a few years ago when the accused was convicted and the sentence of death later carried out, although at the trial all three medical witnesses, two for the prosecution and one for the defence, agreed that the prisoner, at the time of committing the crime, was insane. I do not think that sufficient attention has been paid to this -case, which, in my opinion, marks the lowest point to which psychiatric evidence has sunk in the estimation of a judge and jury. It is, to say the least, a disturbing state of affairs when a jury can return a verdict which completely ignores the opinion of three medical men on the state of mind of a man accused of murder. St. Andrew’s Hospital, W. J. MCCULLEY.
largely
Thorpe, Norwich.
ISOLATION OF CASTLE’S INTRINSIC FACTOR
SiR,-The preliminary communication (March 6) by Dr. Latner and his colleagues does not, I think, satisfy the customary requirements -for a report on the first isolation of a substance. I should say that these
requirements
Medical Women’s Federation, Tavistoek House North, Tavistock Tavistock Square, London, W.C.1.
ANNIS GILLIE President.
SIR,—Dr. Lennox’s letter contains an error of reasoning and proposes a course of action which I think would be to the detriment of this profession. The idea that a woman doctor who has brought up a family is, ipso facto, well suited for infant welfare is as sensible as saying that a doctor who has looked after one brother a schizophrenic and the other a manicdepressive is well suited to treat psychotic patients :-. the latter in fact has a certain advantage over the former. In her last paragraph, what Dr. Lennox is in fact suggesting is that married women should undercut their colleagues : this is acceptable in Petticoat Lane but hardly in a supposedly learned profession. London, N.10. A. W. BEARD.
,
(1) A short reference to the present position of the problem. (2) A description of the isolation procedure. (3) Analytical data about the newly isolated substance. (4) Proof of its chemical purity. (5) Evidence of its differentiation from similar materials
undertaking
dangerous
are :
isolated
previously. on its physiological activity (if physiologically active). (6)
My
Data
reasons
for this criticism
it is known to be
are :
(1) No reference to the question of the mucoprotein nature of intrinsic factor, prior to Latner’s work, is made in this or in any of the other papers to which he has contributed. 12 (2) All that is said about the isolation procedure is : " The major part of the intrinsic factor activity can in the first place be extracted by a suitable buffer solution at pH 6-35. The active fraction finally obtained has proved easily soluble at pH 2 ..." This leaves us with the expectation that " full details of this isolation procedure will shortly be published." (3) The analytical data merely confirm the mucoprotein nature of the intrinsic factor, about which evidence was presented three years ago by our group, 3 but they do not include the elementary analysis of the newly isolated intrinsic factor. Even the data on the carbohydrate composition are. rather fragmentary and conflicting. Thus, in September, 1953, the nitrogen content of Dr. Latner’s intrinsic factor preparation obtained by electrophoresis was given as 10 % and the hexosamine content as 6 %,l2 but in this latest paper the electrophoretic fraction contains 9-0-9-7% nitrogen and as much as 11-12 % hexosamine. of chemical purity is based on data from (4) The paper-strip electrophoresis and the ultracentrifuge, and it appears convincing, although the electrophoretic findings would have more value if data were included indicating the homogeneity of this fraction at various pHs and ionic strengths. (5) In order to satisfy the fifth requirement, Dr. Latner has sought to show that his mucoprotein is different from the " glandular mucoprotein " the intrinsic factor activity of which we demonstrated a few years ago and on which we have since accumulated further data. For this purpose he tries to dissociate himself from any work done previously, and he mentions three points as evidence
proof
PSYCHIATRIC
EVIDENCE
AT
MURDER
TRIALS
SIR,-I read your leading article of May 8 with great interest and I would strongly support your four recommendations—especially the period of observation by at least two psychiatrists before a report is made. I feel, however, that some of your statements may be misleading. I believe it is the practice for a prisoner accused of murder and remanded to an ordinary prison to be transferred to a prison where there is a full-time medical officer with psychiatric experience, usually indeed to Brixton Prison, and in my own experience I have had the fullest possible cooperation from the principal medical officer of Brixton Prison, as well as the local prison medical officer. I must also say that I, myself, have not experienced any hostile cross-examination in court, and I feel that when it does occur it may
Latner, A. L., Ungley, C. C., Cox, E. V., MeEvoy-Bowe, E., Raine, L. Brit. med. J. 1953, i, 467. 2. Latner, A. L., McEvoy-Bowe, E. Biochem. J. 1953, 55, xxiii. 3. Glass, G. B. J., Boyd, L. J., Rubinstein, M. A., Svigals, C. S., Chevalley, J. E. Fed. Proc. 1951, 10, 50. 4. Glass, G. B. J., Boyd, L. J., Rubinstein, M. A., Svigals, C. S. Science, 1952, 115, 101. 1.
.
,