JOINT CONSULTANTS COMMITTEE

388

SPECIAL ARTICLES

Within the treatment wards or units the problems are different. The careful selection of staff is, of course, a prerequisite for good treatment, but it is not enough. Staff meetings and tutorials are necessary for the discussion of emotional involvements of staff in the work as well as for the communication of information relevant to treatment. The reluctance of many doctors to give up their prerogatives of unquestionable authority has hampered these collaborative procedures. The sharing of perplexities, anxieties, and so on with the lower echelons of the staff has many mutual benefits. It frees the flow of useful communications to the psychiatrists, and increases the clinical teams’ effectiveness. The Lancet, referring to the difficulty of recruiting and retaining mental nurses in even our most famous teaching hospitals, recently quoted the report of the Maudsley and Bethlem Royal Hospitals on the function and training of mental nurses which suggests that every student nurse might with advantage be attached to a psychiatric firm. This would, it is hoped, allow her a greater share in treatment and improve communications between nurses and doctors. Experience suggests that good rather than harm results from this collective approach which lessens the gulf between doctors and nurses in most of our psychiatric hospitals. The nurse, whether experienced or not, is helped to find a treatment role and feels that she has a special contribution to make through her greater contact with the patient. This is why she came to nursing and it is difficult to see why she should not play a useful part from the day she arrives on the ward, if interest and guidance is available through frequent staff seminars. For many of the problems of nursing recruitment we have only ourselves to blame. The changes needed to reform the mental hospital system can succeed only with the support and good will of senior administrative personnel. Physician-superintendents, matrons, and others cannot give up their privileged defences unless they feel secure enough to expose themselves to the disruptive consequences of a permissive system. The delegation of authority to semi-autonomous treatment units will raise new problems of intra-hospital administration, and these, like the others, can only be worked through by critical self-appraisal, and freedom of communications from those most concerned-the patients and treatment staff. We are indebted to Dr. Louis Minski, physician-superintendent at Belmont Hospital, and to Miss P. Arnold, Matron, for their cooperation in the development of social psychiatric practice and research at the social rehabilitation unit. BIBLIOGRAPHY

Caudill, W., Redlich, F. C., Gilmore, H. R., Brody, E. B. (1952) Amer. J. Orthopsychiat. 22, 314. 2. (1953) In Kroeber’s Anthropology Today. New York. 3. Goldhamer, H., Marshall, A. (1953) Psychosis and Civilisation. Glencoe, Ill. 4. Hollingshead. A. B., Redlich, F. C. (1953) Amer. Sociol. Rev. 18, 1.

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169.

Hyde, R. W., Solomon, H. C. (1950) Dig. Neurol. Psychiat. 18, 201. 6. Jones, M., Rapoport, R. N. (1955) Psychiatric Rehabilitation. 5.

Yearbook of Education. London. 7. (1953) Social Psychiatry. London. 8. (1954) Lancet, ii, 1277. 9. Lancet (1955) i, 753. 10. Milbank Memorial Fund (1953) Interrelations between the Social Environment and Psychiatric Disorders. New York. 11. Rose, A. (1955) Mental Health and Mental Disorder. New York. 12. Ruesch, J., Bateson, G. (1951) Communication : the Social Matrix of Psychiatry. New York. 13. Simmons, L., Wolff, H. (1954) Social Science in Medicine. New York. 14. Stanton, A., Schwartz, M. (1955) The Mental Hospital. London. 15. Weinberg, S. K. (1952) Society and Personality Disorders. New York. 16. World Health Organisation (1953) Technical Report Series, no. 73. Geneva. —

—

JOINT CONSULTANTS COMMITTEE MEETING of the Joint Consultants Committee was held in London on July 27 under the chairmanship of Sir Russell Brain. The committee received from a subcommittee a report on exploratory discussions which had taken place with the Ministry of Health a few days earlier on the subject of hospital medical staffing. At the beginning of these discussions the Ministry had made the reservation that plans for reorganising the medical staffing structure should not be used as a means of securing salary increases, which were a matter for Whitley negotiations. The members of the subcommittee had replied that, as adequate recruitment of hospital medical staff was one of the fundamental problems, the question of salary ranges was entirely relevant and could not be Apart from this disappointing beginning, the discussions had been useful and constructive. One of the major points made by the subcommittee had been that the rigid training ladder should be abolished, and appointments made according to the needs of the hospital. To secure adequate training through experience in suitable appointments would be the responsibility of the aspirant to consultant status. There would be no limitation of the number or variety of posts he might hold, and he would not lose his prospect of promotion solely by the operation of a time factor. Appointments would be renewable in competition, or in some cases (in the higher posts) of indefinite tenure ; and posts comparable with the present senior-registrar posts might be temporarily upgraded as necessary to retain the services of promising men, pending opportunities of appointment to consultant vacancies. The Ministry had been critical of the suggestion that there should be a comprehensive central review of establishments. The previous reviews had not proved entirely satisfactory, and the Ministry thought that the changing needs should be kept under continuous review locally and only special problems referred for decision centrally. The subcommittee had agreed that the initiative should be taken at the hospital level, but thought that past experience pointed to the need for

A

ignored.

over-all

planning. Among other matters which had been discussed with the Ministry were the machinery for making appointments and the means of attracting practitioners back into hospital appointments after completion of National Service. The Ministry had undertaken to put its own views on hospital medical staffing into writing as a basis for further discussions. The committee also received a report of a meeting with the chairmen of the Regional Hospital Boards in England and Wales, at which the main subject discussed had been the development of suitable medical advisory machinery at the regional-board level. The views expressed on behalf of the Joint Committee at this meeting were published in these columns on Aug. 6. It was reported that, after discussions between representatives of the Joint Committee and the Ministry on the retiring age and superannuation benefits of mentalhealth officers, the Staff and Management Sides of Committee B of the Medical Whitley Council had agreed to delete from the terms and conditions of service the provision requiring hospital medical staff classified as mental-health officers to retire at the age of 60. The effect of this is that mental-health officers will retain their special superannuation benefits but may continue in the hospital service until 65 if they so desire. A request was considered for the views of the committee on the practice adopted by a number of nonteaching hospitals of offering facilities for senior medical students to obtain additional experience during their holiday periods. While reaffirming the opinion previously expressed to the Ministry that the employment of students

389

CONFERENCES AND CONGRESSES

house-officers should in no circumstances be allowed, the committee considered that the granting of facilities to students to gain additional experience as students Some hospital should be encouraged in every way. authorities were tending to discourage this practice because of the fear of litigation, but legal advice which the committee had obtained made it clear that the liability of a non-teaching hospital in respect of such students differed in no way from that of a teaching hospital. Resolutions were received from the dermatologists’ and venereologists’ groups of the British Medical Association which urged that combined appointments in the two specialties should be opposed. These resolutions had been endorsed by the Central Consultants and Specialists Committee, and the Joint Committee agreed that, although in some areas there might be difficulty in making satisfactory arrangements for the staffing of venereal diseases departments, the solution of the problem did not lie in the combination of venereology with dermatology. It was decided that the matter should be discussed with the Ministry. Other matters discussed included the proposals for statutory registration of medical auxiliaries, the operation of the " moral obligation " clause in paragraph 16 of the terms of service, and the expansion of the senior-registrar establishment in anaesthetics and certain other specialties. as

.

showed no depression of 1311 uptake after thyroid hormone. While definite depression of the uptake curve indicates euthyroidism in nodular goitre, an unvarying uptake does not indicate hyperthyroidism.

Deiodination of Thyroxine to Triiodothyronine by Kidney Slices of Rats with 17 arying Thyroid lJ’unction F. C. LARSON, K. TOMITA, and E. C. ALBRIGHT (Madison) concluded, from their researches with kidney slices in rats, that there is a deiodinating system in the tissues which converts thyroxine to triiodothyronine ; and they postulated that this enzyme system is adaptive, since deiodination is enhanced by increasing the amount of thyroxine present in the tissue.

Metabolism of Triiodothyronine and Thyroxine in Plasma, and Oentral Nervous System of the Rabbit J. GROSS, D. H. FORD, and M. POSNER (New York) had

Pituitary,

shown, by injecting rabbits with 13’I-labelled triiodothyronine

killing them at various intervals after injection, that the plasma activity fell rapidly and at four hours was predominantly in the form of iodide. There was, on the other hand, a rapid entry of radioactivity into the pituitary and the diencephalon. The concentration of 1311 was highest in the posterior pituitary and lower in the anterior lobe, which respectively attained over 20 and 7 times the plasma-1311 concentration at and

four hours. Most of the concentrated radio-iodine was identifiable as triiodothyronine. Dr. Gross emphasised that these results did not necessarily apply to other animals in the same degree. When labelled thyroxine was similarly injected, the concentration of radio-iodine was demonstrable only in the

posterior pituitary.

Conferences and

A

Congresses

CLINICAL ENDOCRINOLOGY IN U.S.A. THE 37th annual meeting of the Endocrine Society of the United States was held at Atlantic City on June 2-4, under the presidency of Dr. ALLAN T. KENYON. The papers were strictly limited to ten minutes each, and this demanded not only rapid reading but also high receptivity in the audience, 24 papers being read on the first day alone. The mental receiving-sets in the audience avoided fatigue by practising selectivity, and there was much coming and going in the large auditorium. The following is an abstract of some of the papers of most clinical importance. The

The

Thyroid

Creti-t-asm and Hypothyroidism A. M. DIGEORGE, S. A. D’ANGELO, and K. E. PASCHKIS (Philadelphia) had demonstrated, by tadpole bio-assay, that,

Thyropituitary Relations in

thyroid-stimulating-hormone (T.S.H.) levels frequently raised in hypothyroidism, in some cases they while the

were were

low or even absent. Therefore a reduced or negative T.S.H. level cannot be taken to indicate a pituitary origin for the hypothyroidism. In some cases T.s.H. returned after thyroid therapy had been started, which suggested that the synthesis or release of T.S.H. may sometimes require the presence of thyroid hormone. In the discussion Dr. Paschkis observed that all functions of the pituitary may not be equally affected, since a high output of F.S.H.may occur in hypothyroidism.

Therapeutic Implications of the Avidity of Solitary Thyroid Nodules for 131I .

M. PERLMUTTER and S. L. SLATER (New York) had compared the uptake of 1311 in non-toxic nodules with the uptake in a non-nodular area of thyroid tissue in the same patient. The nodule was described as " hot " if the uptake was higher than that of the surrounding tissue, and " cold " if the uptake was identical with the thyroid uptake. The 22 malignant nodules thus assessed were " cold." Of the 97 non-toxic nodules 65 were " cold " and 32 " hot." In the discussion Dr. E. B. ASTWOOD observed that it was the ’’ cold"" nodules-those not avid for iodine-which responded best to thyroid therapy. The ingestion of thyroid hormone significantly decreases the thyroid uptake of 131I in 95% of euthyroid subjects and in only 3% of thyrotoxic patients.Dr. Perlmutter and Dr. Slater had therefore applied this test to thyroid nodules. All the toxic " hot " nodules and half the " hot " non-toxic nodules 1. This is the basis of S. C. Werner’s test for thyrotoxicosis. N.Y. Acad. Med. 1955, 31, 137.)

Study of Endemic Goitre

M. ROCHE, F. DE VENANZI, J. VERA, E. COLL, and M. S. BERTI (Merida) reported a survey in a goitrous region in the Venezuelan Andes. Palpable thyroids were found in 84-5% of 718 adults examined and in 83-0% of 641 school-children. In 44-2% of the adults and 31-4% of the children the goitres were visible as well as palpable. Radio-iodine tests showed that the glands were avid for iodine : the forty-eight-hour radio-iodine uptake in 100 adults averaged 74% and in 28 children 79%. No statistical difference in the iodine-uptake curves could be demonstrated between those adults with a goitre and those without. Potassium perchlorate in doses of 300 mg. two hours after administration of 131l decreased the radioactivity in the thyroid of 11 out of 13 goitrous subjects tested-a result which suggested that part of the thyroid iodine in endemic goitre is in the unbound state.’

(Bull.

Analysis of

the

Polyuria

Pituitary

,

Produced

by Hypophysectomy

in man M. B. LIPSETT, J. P. MACLEAN, M. C. Li, C. D. WEST, B. S. RAY, and 0. H. PEARSON (New York) reported that polyuria occurred in 67% of cases in which a complete hypophysectomy had been performed, but it was not seen when the pituitary stalk remained intact. They did not report the succeeding oliguric interphase described by Ikkos, Luft, and Olivecrona 3 ; nor did they observe that the subsequent polyuria depended on the presence of cortisone.

Effect of Partial Hypophysectomy Thyroid, and Gonadal Fnctio-rz in

on

the

Adrenocortical, Dog

W. F. GANONG and D. M. HUME (Boston) confirmed the clinical observation that, in lesions destructive of the pituitary, gonadal function was depressed first, then thyroidal, and finally adrenocortical. They removed varying amounts of pituitary tissue in 31 dogs. More than four-fifths of the pituitary was removed before any abnormality could be demonstrated in the target glands. For complete suppression of adrenocortical activity it was necessary to remove the whole pituitary, and minute fragments remaining were capable of supporting significant compensatory hypertrophy in the adrenal cortex.

Reproduction

and Sex Hormones

Congenital Dysgenesis, Ovarian Agenesis, Male Pseudohermaphroditism : the Relationship to Theories of Human Sex Differentiation Gonadal

M. M. GRUMBACH, J. J. VAN WYK, and L. WiLKiNS

more)

had

investigated

17

patients

with ovarian

(Balti-

agenesis by

2. These results are similar to those reported by J. S. Stanbury (J. clin. Endocrin. 1953, 13, 1270) in a goitre survey in western

Argentina. 3. J. clin. Endocrin.

1955, 15, 553.