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943 NOT FOR SALE SIR,-After a special meeting of the Consultants and Specialists Committee (no. 13 region) on Monday, April 17, at Preston Royal Infirmary, the following statement was issued to the Press. " The Manchester Regional Consultants’ and Specialists’ Committee has considered allegations of improper professional conduct made by Dr. A. A. Dunlevy in a recent letter to The Lancet and in subsequent television and radio broadcasts. If any such allegation be true, this Committee condemns such conduct as repugnant to the ethics of the medical profession, and is satisfied that this condemnation would be supported by our fellow consultants and specialists throughout the United Kingdom. " The Committee invited Dr. Dunlevy to attend this evening’s meeting, to give him full opportunity for substantiating his accusations, but he declined to come. He has also failed to send us any specific complaints which we could investigate. This Committee is, of course, unable to compel the attendance of any doctor at its meetings, and must therefore content itself with the clear expression of its views on professional conduct given above ".
H. MILNES WALKER Chairman, Specialists Committee.
Manchester Consultants &
SIR,-Iread with interest the result of the Preston meeting of the Manchester Regional Consultants and Specialists Committee. The fact that they are now prepared to deal with the matter as a serious one is a wonderful step forward since 1960 when the spokesman for the local B.M.A. refused to discuss it. Obviously the fact that I did not accept the invitation to attend this meeting is open to misinterpretation. However, my reasons were fully stated in my reply to Mr. Milnes Walker. Briefly they are:
(a) The Consultants and Specialists Committee of the B.M.A. is part of a voluntary organisation. It is not a statutory body and has no legal standing. A member of the B.M.A. could give evidence in front of it and this would be an occasion of qualified privilege. I am not a member of the B.M.A.therefore my evidence would not be an occasion of qualified privilege. (b) I feel this
matter is of such importance that my evidence sufficient. To be really effective, we must be in a position to bring patients forward to give their evidence, and we must also be in such a position that these patients are
alone is
not
protected.
Finally let me state that I am anxious to put all the evidence I have before any committee set up by the Minister of Health. This inquiry should have an independent, impartial, and legally qualified chairman and should have power
to
subpoena witnesses.
Withington Hospital, West Didsbury, Manchester.
A. DUNLEVY.
THYROID FUNCTION IN THE PRESENCE OF BREAST CANCER
SIR,-We observed1 that in patients with carcinoma of the breast those with local disease only (stages i, 11, and m) had, on the average, normal thyroid function, while those with blood-borne metastases (stage iv) appeared to have significantly lower function. Mr. Reeve and his colleagues (March 25) have been unable to confirm these findings. However, they do not draw attention to the fact that their data reveal lower function in patients in stages 11, III, and iv (combined mean in their units=0-316) than in those in stage i (0-444); t-test for significance gives 1.
Edelstyn, G. A., Lyons, A. R., Welboum, R. B. Lancet, 1958, i, 670.
p<0’05.
(We
are
grateful
to
Mr.
J. D. Merrett for this
analysis.) They attribute to us the suggestion that " metastases in the pituitary or in the thyroid or in both may destroy functioning tissue ". We certainly used these words but concluded that this was an unlikely cause of depressed thyroid function. G. A. EDELSTYN A. R. LYONS R. B. WELBOURN.
Department of Surgery,
Institute of Clinical Science, Belfast.
CARE OF THE INJURED SIR,-There is so much wisdom in Mr. Devenish’s letter of April 8 that one wonders what can be in dispute. Any conclusion, however, that all is well is belied by
experience of the inadequacy of treatment of injuries. Shortage of staff is clearly an important limiting factor-we would suggest that a deliberate policy could current
make the best use of what is available. It may well be that London is a special case; the development of its hospital services has been different, and its solution of the problems of accidents may also be different. In the rest of the country, large cities, towns of various sizes, and rural areas, the background is not the same; and though services are good in some areas, there are many gaps. The problem is how best to fill these gaps. The special needs of the seriously injured patient derive from the following: (a) Injuries occur at all times, with an important peak late at night. A few take place in the small hours, and these are often the most severe.
(b) The successful management of most of these cases requires urgent first-class diagnosis and surgery. (c) Many of the injuries are multiple. They have features in but they do not fall naturally into common in respect of shock, &c.; any one of the present specialties. Their treatment often requires special experience and judgment rather than special technical skill. For these needs to be met there should be a fully equipped accident service within reasonable distance of any accident. The service must be staffed by fully qualified surgeons; and they should be genuinely, and not only nominally, available throughout the twenty-four hours. There is a size below which an accident service becomes inefficient and uneconomical; this is the rationale behind the need for " centres ". Other hospitals may be able to give adequate service during the day, but need to redirect patients to the " centres " at night; in this sense some coordination would be beneficial. This incidentally implies more, not less, efficient use of ambulance services. The staff requirements for such a service include nurses, X-ray and laboratory staff, and surgeons. At present valuable help comes from surgeons from the Commonwealth and elsewhere who visit us to complete their training. All these are more likely to be attracted if there is a clear policy and enthusiasm for first-rate accident work. This same environment is ideal for research into both the clinical aspects and the causes and prevention of injuries. There should be a career structure as Devenish suggests, and this could be eased by providing teachand research at the " centre " with exchange of staff between ing " centre " and periphery-in this sense also " coordination is valuable. The present improvements in some areas are largely the result of recent increased interest in this problem, coupled with the enthusiasm of surgeons such as Mr. Devenish. An organisational structure however is required which will maintain and develop such services when the present interest wanes, and will prevent the reversion of accident treatment to its previous state of dependence on junior staff. Disagreement and confusion have arisen in an attempt to allocate accidents to one or other of the established specialties. Since multiple injuries affect so many parts of the body it seems that a general surgeon with special interest in injuries is required. A variety of "
"
H. MILNES WALKER Chairman, Specialists Committee.
Manchester Consultants &
SIR,-Iread with interest the result of the Preston meeting of the Manchester Regional Consultants and Specialists Committee. The fact that they are now prepared to deal with the matter as a serious one is a wonderful step forward since 1960 when the spokesman for the local B.M.A. refused to discuss it. Obviously the fact that I did not accept the invitation to attend this meeting is open to misinterpretation. However, my reasons were fully stated in my reply to Mr. Milnes Walker. Briefly they are:
(a) The Consultants and Specialists Committee of the B.M.A. is part of a voluntary organisation. It is not a statutory body and has no legal standing. A member of the B.M.A. could give evidence in front of it and this would be an occasion of qualified privilege. I am not a member of the B.M.A.therefore my evidence would not be an occasion of qualified privilege. (b) I feel this
matter is of such importance that my evidence sufficient. To be really effective, we must be in a position to bring patients forward to give their evidence, and we must also be in such a position that these patients are
alone is
not
protected.
Finally let me state that I am anxious to put all the evidence I have before any committee set up by the Minister of Health. This inquiry should have an independent, impartial, and legally qualified chairman and should have power
to
subpoena witnesses.
Withington Hospital, West Didsbury, Manchester.
A. DUNLEVY.
THYROID FUNCTION IN THE PRESENCE OF BREAST CANCER
SIR,-We observed1 that in patients with carcinoma of the breast those with local disease only (stages i, 11, and m) had, on the average, normal thyroid function, while those with blood-borne metastases (stage iv) appeared to have significantly lower function. Mr. Reeve and his colleagues (March 25) have been unable to confirm these findings. However, they do not draw attention to the fact that their data reveal lower function in patients in stages 11, III, and iv (combined mean in their units=0-316) than in those in stage i (0-444); t-test for significance gives 1.
Edelstyn, G. A., Lyons, A. R., Welboum, R. B. Lancet, 1958, i, 670.
p<0’05.
(We
are
grateful
to
Mr.
J. D. Merrett for this
analysis.) They attribute to us the suggestion that " metastases in the pituitary or in the thyroid or in both may destroy functioning tissue ". We certainly used these words but concluded that this was an unlikely cause of depressed thyroid function. G. A. EDELSTYN A. R. LYONS R. B. WELBOURN.
Department of Surgery,
Institute of Clinical Science, Belfast.
CARE OF THE INJURED SIR,-There is so much wisdom in Mr. Devenish’s letter of April 8 that one wonders what can be in dispute. Any conclusion, however, that all is well is belied by
experience of the inadequacy of treatment of injuries. Shortage of staff is clearly an important limiting factor-we would suggest that a deliberate policy could current
make the best use of what is available. It may well be that London is a special case; the development of its hospital services has been different, and its solution of the problems of accidents may also be different. In the rest of the country, large cities, towns of various sizes, and rural areas, the background is not the same; and though services are good in some areas, there are many gaps. The problem is how best to fill these gaps. The special needs of the seriously injured patient derive from the following: (a) Injuries occur at all times, with an important peak late at night. A few take place in the small hours, and these are often the most severe.
(b) The successful management of most of these cases requires urgent first-class diagnosis and surgery. (c) Many of the injuries are multiple. They have features in but they do not fall naturally into common in respect of shock, &c.; any one of the present specialties. Their treatment often requires special experience and judgment rather than special technical skill. For these needs to be met there should be a fully equipped accident service within reasonable distance of any accident. The service must be staffed by fully qualified surgeons; and they should be genuinely, and not only nominally, available throughout the twenty-four hours. There is a size below which an accident service becomes inefficient and uneconomical; this is the rationale behind the need for " centres ". Other hospitals may be able to give adequate service during the day, but need to redirect patients to the " centres " at night; in this sense some coordination would be beneficial. This incidentally implies more, not less, efficient use of ambulance services. The staff requirements for such a service include nurses, X-ray and laboratory staff, and surgeons. At present valuable help comes from surgeons from the Commonwealth and elsewhere who visit us to complete their training. All these are more likely to be attracted if there is a clear policy and enthusiasm for first-rate accident work. This same environment is ideal for research into both the clinical aspects and the causes and prevention of injuries. There should be a career structure as Devenish suggests, and this could be eased by providing teachand research at the " centre " with exchange of staff between ing " centre " and periphery-in this sense also " coordination is valuable. The present improvements in some areas are largely the result of recent increased interest in this problem, coupled with the enthusiasm of surgeons such as Mr. Devenish. An organisational structure however is required which will maintain and develop such services when the present interest wanes, and will prevent the reversion of accident treatment to its previous state of dependence on junior staff. Disagreement and confusion have arisen in an attempt to allocate accidents to one or other of the established specialties. Since multiple injuries affect so many parts of the body it seems that a general surgeon with special interest in injuries is required. A variety of "
"