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MERIT AWARDS
1296 This method does not absolve the anaesthetist from ensuring as far as possible that the stomach has been emptied through a suitably wide tube, but even with the utmost care some material may remain in the stomach. One important point must be borne in mind when using the method : it is more important than ever that the anaesthetist should be fully aware of the danger of inducing hypotension in the shocked or oligaemic patient by giving too large a dose of thiopentone. Newcastle General Hospital, Newcastle upon Tyne.
P. HEX VENN.
MERIT AWARDS
SiR,ŁThe council of the Regional Hospitals’ Consultants
and Specialists Association is aware that throughout the country there is considerable disquiet at the manner in which merit awards are distributed. This disquiet is no doubt due in the main to the overt secrecy which enshrouds the subject. Since the early days of the National Health Service there have in many regions been no local consultations and little or nothing is known of how recommendations are made or considered. In many areas local advisory committees have not been further consulted and, indeed, in some cases have been summarily dissolved. At its meeting on June 3 the council of this association accepted the following resolution put forward by one of its constituent bodies : The Council of the Regional Hospitals’ Consultants and "
Specialists Association is of opinion that in the granting of Distinction Awards the Awards Committee should consult local medical opinion, and that this could best be done through small Regional Advisory Panels of Consultants elected by the Consultants in each Region." JOHN SIMONS President.
HYPERTHYROIDISM AND MYASTHENIA GRAVIS
SIR,-In their interesting article (May 8) Dr. Maclean and Dr. Wilson refer to the antagonism between these two disorders where they co-exist. They note that appropriate treatment for the thyrotoxicosis aggravates the myasthenia gravis, whereas in patients with myasthenic symptoms produced by thyrotoxicosis these symptoms are relieved by such treatment. They suggest that thyrotoxic myasthenia may be due to the rapid- destruction or defective production of cholinesterase at the neuromuscular junction, possibly Elseas the result of a high blood-thyroxine content. where they make the apparently contradictory suggestion that a high blood-thyroxine level may cause deficient production or too rapid destruction of acetylcholine. Does the first of these suggestions provide a clue to the phenomena observed ? If in thyrotoxicosis acetylcholine is present in excess owing to the absence of adequate amounts of cholinesterase, might not the myasthenia that may supervene in such a case be due to -the persistent effects of unhydrolysed acetylcholine producing neuromuscular blocking ? Feldbergfound that an excess of acetylcholine produced a spread of the depolarisation current from the motor end-plate to adjacent parts of the muscle-fibre. Might the tendency to persistence of acetylcholine, though in less amounts than would produce neuromuscular blocking, account for the fine tremors of the voluntary musculature in
thyrotoxicosis ? On this hypothesis the alleviation of symptoms of myasthenia gravis in thyrotoxicosis would be explained by the relatively small amounts of cholinesterase at the nerve-endings sparing the acetylcholine to some extent. Royal Mental Hospital, Aberdeen. 1. Feldberg, W.
H. C. S. MACLEAN. Brit. med. J. 1951, i, 967.
PERIPATETIC PRACTITIONERS
SiR,ŁMay
I
strongly
endorse Dr. Forbes’s advice
(June 5) about the importance of doctors keeping their defence societies and the General Medical Council informed of a change of permanent address ?’? There is another disadvantage in failing to do so which he does not mention. The Medical Protection Society sometimes hears of impending litigation which may involve a member whose present whereabouts are unknown to us, and delay in establishing contact with him at an early stage may later seriously prejudice his legal position or that of his colleagues as the action matures.
The difficulty in tracing a woman practitioner may be further increased when she does not inform her defence society or the Registrar of the that she has changed her surname as well as her permanent address ! Medical Protection Society, Victory House. Leicester Square, London, W.C.2.
ALISTAIR FRENCH Secretary.
MENTAL CARE
SiR,-The articles by Dr. Bickford (May 1) and Dr. Ling (May 29) and your leader (May 29) raise many issues for the planning of the mental health While with enthusiasm and well-directed effort much can be done to improve the situation, neither the well-known and already widely practised methods of rehabilitation so eloquently presented by Dr. Bickford nor the highly suceesful approach devised by Professor Querido will entirely solvethe problems which mental illness presents. One does not want to be pessimistic at this stage, but it is important to realise the limitations imposed by the clinical, social, and cultural complexities inherent in the problems of mental illness. The mental hospitals’ deficiencies do not always account for not achieving the desired complete remission of all symptoms. One must agree with Dr. Bickford, however, that most patients with psychiatric disorder show a very high capacity for social rehabilitation and an ability to live with their symptoms. more research is required into the causes of our successes and failures before we can say what results can be expected from this new approach. Faced with the serious overcrowding, which burdens and often almost paralyses the proper futtotioning of the mental hospitals, my colleague, Dr. D. 11. Bennett, and I paid a visit to Professor Querido and his colleagues in Amsterdam a little while back. We have spent some time and thought on the problems that could arise, for our own mental hospital and the community it serves, with the introduction of such a scheme as that outlined in Dr. Ling’s article and your leader. The Amsterdam scheme was developed and is operated by the local health authority, of which Professor Querido, a psychiatrist, is also the chief medical officer of health. The mental hospital under these circumstances remains without its own outpatients and other aftercare services, and we came to the conclusion that this conception was not entirely satisfactory. We therefore suggest that the scheme will require modifications in this respect. For our population area of 600,000 we should require for such a twenty -four-hour psychiatric service, apart from transport, about six additional psychiatrists and six psychiatric social workers. Even with this increased number of staff, if these were available, the saving not only in the adult mental health field but also in the departments of child care and education would be very considerable. All this might sound unduly cautious. It is, however, certain that many of the new principles at present under discussion, adapted to this country’s needs, will yield promising results. We do not mean to leave your readers
important services.
P. HEX VENN.
MERIT AWARDS
SiR,ŁThe council of the Regional Hospitals’ Consultants
and Specialists Association is aware that throughout the country there is considerable disquiet at the manner in which merit awards are distributed. This disquiet is no doubt due in the main to the overt secrecy which enshrouds the subject. Since the early days of the National Health Service there have in many regions been no local consultations and little or nothing is known of how recommendations are made or considered. In many areas local advisory committees have not been further consulted and, indeed, in some cases have been summarily dissolved. At its meeting on June 3 the council of this association accepted the following resolution put forward by one of its constituent bodies : The Council of the Regional Hospitals’ Consultants and "
Specialists Association is of opinion that in the granting of Distinction Awards the Awards Committee should consult local medical opinion, and that this could best be done through small Regional Advisory Panels of Consultants elected by the Consultants in each Region." JOHN SIMONS President.
HYPERTHYROIDISM AND MYASTHENIA GRAVIS
SIR,-In their interesting article (May 8) Dr. Maclean and Dr. Wilson refer to the antagonism between these two disorders where they co-exist. They note that appropriate treatment for the thyrotoxicosis aggravates the myasthenia gravis, whereas in patients with myasthenic symptoms produced by thyrotoxicosis these symptoms are relieved by such treatment. They suggest that thyrotoxic myasthenia may be due to the rapid- destruction or defective production of cholinesterase at the neuromuscular junction, possibly Elseas the result of a high blood-thyroxine content. where they make the apparently contradictory suggestion that a high blood-thyroxine level may cause deficient production or too rapid destruction of acetylcholine. Does the first of these suggestions provide a clue to the phenomena observed ? If in thyrotoxicosis acetylcholine is present in excess owing to the absence of adequate amounts of cholinesterase, might not the myasthenia that may supervene in such a case be due to -the persistent effects of unhydrolysed acetylcholine producing neuromuscular blocking ? Feldbergfound that an excess of acetylcholine produced a spread of the depolarisation current from the motor end-plate to adjacent parts of the muscle-fibre. Might the tendency to persistence of acetylcholine, though in less amounts than would produce neuromuscular blocking, account for the fine tremors of the voluntary musculature in
thyrotoxicosis ? On this hypothesis the alleviation of symptoms of myasthenia gravis in thyrotoxicosis would be explained by the relatively small amounts of cholinesterase at the nerve-endings sparing the acetylcholine to some extent. Royal Mental Hospital, Aberdeen. 1. Feldberg, W.
H. C. S. MACLEAN. Brit. med. J. 1951, i, 967.
PERIPATETIC PRACTITIONERS
SiR,ŁMay
I
strongly
endorse Dr. Forbes’s advice
(June 5) about the importance of doctors keeping their defence societies and the General Medical Council informed of a change of permanent address ?’? There is another disadvantage in failing to do so which he does not mention. The Medical Protection Society sometimes hears of impending litigation which may involve a member whose present whereabouts are unknown to us, and delay in establishing contact with him at an early stage may later seriously prejudice his legal position or that of his colleagues as the action matures.
The difficulty in tracing a woman practitioner may be further increased when she does not inform her defence society or the Registrar of the that she has changed her surname as well as her permanent address ! Medical Protection Society, Victory House. Leicester Square, London, W.C.2.
ALISTAIR FRENCH Secretary.
MENTAL CARE
SiR,-The articles by Dr. Bickford (May 1) and Dr. Ling (May 29) and your leader (May 29) raise many issues for the planning of the mental health While with enthusiasm and well-directed effort much can be done to improve the situation, neither the well-known and already widely practised methods of rehabilitation so eloquently presented by Dr. Bickford nor the highly suceesful approach devised by Professor Querido will entirely solvethe problems which mental illness presents. One does not want to be pessimistic at this stage, but it is important to realise the limitations imposed by the clinical, social, and cultural complexities inherent in the problems of mental illness. The mental hospitals’ deficiencies do not always account for not achieving the desired complete remission of all symptoms. One must agree with Dr. Bickford, however, that most patients with psychiatric disorder show a very high capacity for social rehabilitation and an ability to live with their symptoms. more research is required into the causes of our successes and failures before we can say what results can be expected from this new approach. Faced with the serious overcrowding, which burdens and often almost paralyses the proper futtotioning of the mental hospitals, my colleague, Dr. D. 11. Bennett, and I paid a visit to Professor Querido and his colleagues in Amsterdam a little while back. We have spent some time and thought on the problems that could arise, for our own mental hospital and the community it serves, with the introduction of such a scheme as that outlined in Dr. Ling’s article and your leader. The Amsterdam scheme was developed and is operated by the local health authority, of which Professor Querido, a psychiatrist, is also the chief medical officer of health. The mental hospital under these circumstances remains without its own outpatients and other aftercare services, and we came to the conclusion that this conception was not entirely satisfactory. We therefore suggest that the scheme will require modifications in this respect. For our population area of 600,000 we should require for such a twenty -four-hour psychiatric service, apart from transport, about six additional psychiatrists and six psychiatric social workers. Even with this increased number of staff, if these were available, the saving not only in the adult mental health field but also in the departments of child care and education would be very considerable. All this might sound unduly cautious. It is, however, certain that many of the new principles at present under discussion, adapted to this country’s needs, will yield promising results. We do not mean to leave your readers
important services.