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pathy (e.g., hypertrophic obstructive or congestive types); coronary-artery disease, with resulting abnormal ventricular contraction or papillary-muscle dysfunction (30 out of 95 patients with coronaryartery disease had mitral-valve prolapse 8); collagen disorders, such as polyarteritis nodosa; and trauma.9 The prognosis depends on the aetiology," but a high incidence of supraventricular and ventricular arrhythmias has been reported, with occasional instances of sudden death. 10 These arrhythmias may be induced or aggravated by exercise.11,12 An exercise test may therefore help to single out patients with electrical instability, who can then be given preventive treatment. A possible complication is infective endocarditis, so the usual prophylactic measures are indicated. Nevertheless, the syndrome is compatible with longevity.
INCISION DECISION SCARS are usually the only visible results of intraabdominal surgery, and it is understandable that a patient may judge the skill of his surgeon largely on the evidence before his eyes. On the whole, the best cosmetic results follow transverse incisions parallel to the skin-creases in the abdomen, but there are many indications for vertical incisions which can be made more rapidly and extended with ease from xiphoid to pubis if necessary. It is perhaps less generally known that the decision to cut the upper abdomen up-anddown or side-to-side can be crucial (in more than one sense), for in certain circumstances a vertical incision can prejudice the safety of the patient in the immediate postoperative period far more than a transverse incision. Respiratory movements will tend to pull apart a vertical wound in the upper abdomen, the consequent pain will inhibit respiration, and the patient will be particularly reluctant to breathe deeply. Transverse upper abdominal wounds are generally less painful because flaring of the costal margin on deep inspiration tends to oppose the edges of the incision down to a slit. Prolonged shallow respiration postoperatively will cause progressive patchy pulmonary atelectasis, and inability to cough adequately will allow secretions to accumulate in the bronchial tree. Obese patients are particularly at risk, and Vaughan and Wise 13 have reported a study which suggests that the type of abdominal incision can have a considerable effect on arterial oxygen tension in the first few days after operation in such cases. They investigated patients who were undergoing jejuno-ileal bypass for gross obesity. Their patients were divided into two groups according to whether they had vertical or
supraumbilical incisions. They found that, whereas both groups had similar substantial reductions in arterial oxygen tension during the first three postoperative days, over the next two days patients who had had a transverse incision showed significantly higher arterial oxygen tensions than those who had transverse
8. Aranda, J., et al. Circulation, 1975, 52, 245. 9. Epstein, E. J., Coulshed, N. Br. Heart J. 1973, 35, 260. 10. Hancock, E. W., Cohn, K. Am. J. Med. 1966, 41, 183. 11. Pocock, W. A., Barlow, J. B. Am. Heart J. 1970, 80, 740. 12. Sloman, G., Wong, M., Walker, J. ibid. 1972, 83, 312. 13. Vaughan, R. W., Wise, L. Ann. Surg. 1975, 181, 829.
had vertical incisions. Because of the more prolonged hypoxaemia in obese patients with vertical incisions, Vaughan and Wise conclude that it is preferable whenever possible in these cases to use transverse abdominal incisions. The further complications of old age, cigarette smoking, chronic bronchitis, and cardiovascular defects can make the decision to use a transverse incision even more compelling.
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THE Review Body’s pricing of the controversial new for junior hospital doctors was published last 1 week. Once the Government had made it clear that there would be no more money than now for out-ofhours payments the only question was whether Sir Ernest Woodroofe and his colleagues would bow to the inevitable. In the event they have, after a small show of reluctance (para. 16), and all their report means is a redistribution of the S12 million now paid for out-of-hours work: one doctor in six will stay as he is, and the improved earnings of three will be paid for by sacrifices from the remaining two. This reallocation will be achieved by cutting dramatically the rate of pay for overtime and lowering the threshold at which it comes into play from eighty to forty-four hours a week. No-one can be certain that these adjustments will not change the global sum, and individual doctors cannot be confident about how their own earnings will be affected. Doctors would have individual contracts in which availability for duty, including time on call, over forty hours a week would be laid down. For standing by or working at the hospital (class A) the rate would be 30% of basic-salary rate (60p an hour for a first-year registrar) and for being available on call (class B) the supplement would contract
be only 10%. The Review Body wants area health authorities to have an incentive to avoid the really very long hours worked by some doctors. In fact very long hours will now be economical from a management point of view. However, there may be an indirect incentive because doctors are likely to be reluctant to contract themselves to more than forty-eight hours of extra duty (the point when they would seem to be worse off). The only striking advantage of the new system would be that some specialties-notably service ones where long hours are unusual and where manpower shortages are common-will be eligible for overtime. Negotiations over the new contract have dragged on into a period of voluntary incomes restraint which is in effect compulsory when Government is the employer. A contract which was easy to sell when huge increments were being talked about looks less attractive now that it has been pricedand increasing numbers of doctors will want a say in whether or not the scheme should go ahead at this time. If they get their referendum it is to be hoped that they participate more conscientiously than they did in the Review Body survey of out-of-hours work, where only 15% of doctors returned properly completed forms. 1. Review
Body on Doctors’ and Dentists’ Remuneration. Supplement Fifth Report 1975. Cmnd. 6243. H.M. Stationery Office. 56p. 2. Lancet, Sept. 13, 1975, p. 489. to
pathy (e.g., hypertrophic obstructive or congestive types); coronary-artery disease, with resulting abnormal ventricular contraction or papillary-muscle dysfunction (30 out of 95 patients with coronaryartery disease had mitral-valve prolapse 8); collagen disorders, such as polyarteritis nodosa; and trauma.9 The prognosis depends on the aetiology," but a high incidence of supraventricular and ventricular arrhythmias has been reported, with occasional instances of sudden death. 10 These arrhythmias may be induced or aggravated by exercise.11,12 An exercise test may therefore help to single out patients with electrical instability, who can then be given preventive treatment. A possible complication is infective endocarditis, so the usual prophylactic measures are indicated. Nevertheless, the syndrome is compatible with longevity.
INCISION DECISION SCARS are usually the only visible results of intraabdominal surgery, and it is understandable that a patient may judge the skill of his surgeon largely on the evidence before his eyes. On the whole, the best cosmetic results follow transverse incisions parallel to the skin-creases in the abdomen, but there are many indications for vertical incisions which can be made more rapidly and extended with ease from xiphoid to pubis if necessary. It is perhaps less generally known that the decision to cut the upper abdomen up-anddown or side-to-side can be crucial (in more than one sense), for in certain circumstances a vertical incision can prejudice the safety of the patient in the immediate postoperative period far more than a transverse incision. Respiratory movements will tend to pull apart a vertical wound in the upper abdomen, the consequent pain will inhibit respiration, and the patient will be particularly reluctant to breathe deeply. Transverse upper abdominal wounds are generally less painful because flaring of the costal margin on deep inspiration tends to oppose the edges of the incision down to a slit. Prolonged shallow respiration postoperatively will cause progressive patchy pulmonary atelectasis, and inability to cough adequately will allow secretions to accumulate in the bronchial tree. Obese patients are particularly at risk, and Vaughan and Wise 13 have reported a study which suggests that the type of abdominal incision can have a considerable effect on arterial oxygen tension in the first few days after operation in such cases. They investigated patients who were undergoing jejuno-ileal bypass for gross obesity. Their patients were divided into two groups according to whether they had vertical or
supraumbilical incisions. They found that, whereas both groups had similar substantial reductions in arterial oxygen tension during the first three postoperative days, over the next two days patients who had had a transverse incision showed significantly higher arterial oxygen tensions than those who had transverse
8. Aranda, J., et al. Circulation, 1975, 52, 245. 9. Epstein, E. J., Coulshed, N. Br. Heart J. 1973, 35, 260. 10. Hancock, E. W., Cohn, K. Am. J. Med. 1966, 41, 183. 11. Pocock, W. A., Barlow, J. B. Am. Heart J. 1970, 80, 740. 12. Sloman, G., Wong, M., Walker, J. ibid. 1972, 83, 312. 13. Vaughan, R. W., Wise, L. Ann. Surg. 1975, 181, 829.
had vertical incisions. Because of the more prolonged hypoxaemia in obese patients with vertical incisions, Vaughan and Wise conclude that it is preferable whenever possible in these cases to use transverse abdominal incisions. The further complications of old age, cigarette smoking, chronic bronchitis, and cardiovascular defects can make the decision to use a transverse incision even more compelling.
MORE OR LESS
THE Review Body’s pricing of the controversial new for junior hospital doctors was published last 1 week. Once the Government had made it clear that there would be no more money than now for out-ofhours payments the only question was whether Sir Ernest Woodroofe and his colleagues would bow to the inevitable. In the event they have, after a small show of reluctance (para. 16), and all their report means is a redistribution of the S12 million now paid for out-of-hours work: one doctor in six will stay as he is, and the improved earnings of three will be paid for by sacrifices from the remaining two. This reallocation will be achieved by cutting dramatically the rate of pay for overtime and lowering the threshold at which it comes into play from eighty to forty-four hours a week. No-one can be certain that these adjustments will not change the global sum, and individual doctors cannot be confident about how their own earnings will be affected. Doctors would have individual contracts in which availability for duty, including time on call, over forty hours a week would be laid down. For standing by or working at the hospital (class A) the rate would be 30% of basic-salary rate (60p an hour for a first-year registrar) and for being available on call (class B) the supplement would contract
be only 10%. The Review Body wants area health authorities to have an incentive to avoid the really very long hours worked by some doctors. In fact very long hours will now be economical from a management point of view. However, there may be an indirect incentive because doctors are likely to be reluctant to contract themselves to more than forty-eight hours of extra duty (the point when they would seem to be worse off). The only striking advantage of the new system would be that some specialties-notably service ones where long hours are unusual and where manpower shortages are common-will be eligible for overtime. Negotiations over the new contract have dragged on into a period of voluntary incomes restraint which is in effect compulsory when Government is the employer. A contract which was easy to sell when huge increments were being talked about looks less attractive now that it has been pricedand increasing numbers of doctors will want a say in whether or not the scheme should go ahead at this time. If they get their referendum it is to be hoped that they participate more conscientiously than they did in the Review Body survey of out-of-hours work, where only 15% of doctors returned properly completed forms. 1. Review
Body on Doctors’ and Dentists’ Remuneration. Supplement Fifth Report 1975. Cmnd. 6243. H.M. Stationery Office. 56p. 2. Lancet, Sept. 13, 1975, p. 489. to