- Email: [email protected]
PNEUMONIC PLAGUE
728
Ministry of Labour (see 2 above).. The decision as to suitability for admission to Papworth and to the scheme will rest entirely with the medical staff at Papworth who
will require full clinical details and X-ray films in each
case from the tuberculosis officer. Both the committee of management of Papworth Village Settlement and the Ministry of Labour feel that this is a considerable step forward in the rehabilitation 01 ;the tuberculous and anticipate its extension in the future. To this end the Ministry has undertaken to provide half the cost of two hostels of 50 beds each for men and women at Papworth. RICHARD R. TRAIL Papworth Village Settlement, Medical Director. Papworth Hall, Cambridge. BACK STREET SURGERY trickle of inquiries and a few new members SiR,—A have resulted from your kindly review of the Abortion Law Reform Association’s latest publication Back Street Sùrgery. I feel sure that we should gain increased medical support if your readers could examine the association’s collection of press reports of abortion cases heard in the criminal courts during the past 12 years. These tragic stories get little publicity in our leading daily newspapers. If each were to be as widely reported as are other tragedies, cumulative horror might arouse the public conscience to the’ necessity of clarifying our
of the normal capacity to convert fat and protein into sugar -a normal capacity seen in its extreme in the hibernating marmot with a respiratory quotient of 0-3 ? If this is so then it is reasonable to postulate further that this exaggerated demand to form sugar will carry with it the physiologically related demand for excretion of sugar reserves into the blood : therefore the fatty diabetic liver is full of fat which it turns to sugar, and empty of this sugar because it hands it on to the blood. To go back a stage further, has the diabetic got a blood. sugar " set " at a very high level which he attempts to achieve by normal physiological processes ? 5. Is the ketosis of diabetes due to such an overriding priority being given to sugar formation that the breakdown of fat is interrupted at the aceto-acetic acid stage-that is, at the stage to which fat must be broken down before it can be built up again into sugar ? 6. Was Allen’s pre-insulin starvation treatment for diabetics effective-when it was effective-because this stimulated the body to reverse its exaggerated conversion of fat into sugar in favour of a conversion of sugar into fat, as may occur in
’
abortion law. Usually abortion- fatalities are the result of interference by an unskilled- " helper " ; but many fallow on Recently a single attempted self-induced abortion. batch of press cuttings contained reports of inquests on two married women each of whom had been found dead by her husband. One, a mother, had expired alone and unattended whilst seated in a few inches of bath water ; the other, also a mother and also alone and unattended, had collapsed and died on the bedroom floor whilst douching herself. The verdicts were identicaldeath from attempted self-induced miscarriage. Recent police-court history has shown us what can happen under present law when medical practitioners take the risk of giving skilled help in cases which to them seem in need of it. When enough’ people within the medical profession join in the demand for reform, it can be clearly established that it will henceforth not be criminal for a qualified medical practitioner’to terminate the pregnancy of a woman with her consent, when this appears to be medically justified. ALICE JENKINS Hon. Secretary, The Abortion 53, Gloucester Terrace, Law Reform Association. London, W.2. ’
,
BLOOD-SUGAR LEVELS IN SLOW STARVATION SIR,-The valuable paper by Dr. Chakrabarty in your issue of April 17 should be read in conjunction with Simonart’s La Dénutrition de Guerre (Brussels, 1947). These two studies suggest several important questions : 1. Is the low blood-sugar often found in prolonged starvation due not to lack of food from which glucose can be obtained, but instead to an exaggeration of the body’s normal capacity to turn sugar into fat-a pathological exaggeration so great that it may persist in spite of a fatal hypoglycsemia ? This would appear to be the only explanation of the low bloodsugars and high respiratory quotients found by Simonart : the quotient was often above unity, one being as high as 1-95-a figure higher than that recorded for the carbohydrate-
hog (1-58). goose (1-33) 2. Is this lust of the slowly starved body for making fat a sign that there comes a stage in starvation when the fat of the tissues has to be replenished whatever the cost ? 3. Are the attacks of sudden acute fatigue, clinically resembling hypoglycaemia, which occur most commonly in thin people and which are promptly relieved by sugar, due not to lack of glycogen reserves but to a sudden demand by the thin body for fat formation from sugar, even at the expense of reducing the blood-sugar below the minimum necessary ? 4. Is the diabetic with his low respiratory quotient the reverse of the starving man with a high respiratory quotient ? Are the biochemical changes in starvation and in diabetes merely examples of upsetting-but in opposite directionsthe normal balance between fat and sugar formation ? Is the diabetic not primarily incapable of metabolising sugar, but is he merely suffering from a pathological exaggeration
fattening
or
’
starvation ? London, W.l.
FRANKLIN BICKNELL. JOHN HILTON
SIR,-We are preparing an entirely new edition- of John Hilton’s surgical classic Rest and Pain to be published by Messrs. G. Bell & Sons Ltd. the publishers of the original lectures. We should be most grateful to any of your readers who can give us any information that might help us in this work. As we propose to include a short biographical note on Hilton we would welcome details of his life-especially his early life-and the loan of any portrait suitable for reproduction. ELLIOT E. PHILIPP Middlesex Hospital Medical School; E. W. WALLS. London, W.1. PNEUMONIC PLAGUE SIR,-The article by Dr. Wynne-Griffith in your issue of April 24 points out clearly that pneumonic plague is not as infectious as it is generally thought to be. I should like to refer to an outbreak of pneumonic plague that occurred at Nyaunglebin, which is 100 miles north of Rangoon. The cases presented themselves in much the same way as those seen in Rangoon by Wynne-Griffith. Pneumonic plague was not suspected at all till a public-health inspector casually remarked that there had been an epidemic of pneumonic plague in the same locality a few years before. In Nyaunglebin also there were quite a number of people who, although they had come in close contact with cases of pneumonic plague (some of them had not even been inoculated against plague), did not themselves develop the disease. A surprising fact which emerged from the Nyaunglebin outbreak was that pneumonic plague need not be fatal. An excellent report on one of the cases which did not prove fatal was published by my colleague Dr. Than Aurig 1 ; plague bacillus was found in the sputum of this Another case long after the acute phase was over. instance of recovery has been recorded by Clark and -
’
Goldberg.2
Than Aung’s
I ,
case
raises certain
important questions:
(1) is it possible for pneumonic plague to be transmitted convalescent carriers ? (2) can a contact be a passive carrier without contracting the disease himself ? The view held at present is that the disease is contracted by the inhalation of dust laden with bacilli, the bacilli
by
being passed in the faeces of infected rodents. Another possibility is that of a small proportion of bubonic_cases developing into secondary pneumonic ones. The possibility of carriers transmitting the disease is never considered, because it is assumed that pneumonic plague is always fatal.. The cases recorded by Clark and Goldberg. of which one had an incubation period of as long as 12 days and another did not provefatal ; the finding of plague bacillus in the sputum of a convalescent case by Than Aung ; and the observation by Wynne-Griffith and others that people in intimate contact with prieu1. Indian med. Gaz. 1947, 82, 275. 2. Clark, B. M., Goldberg, S. S. Afr. med. J.
1943, 17, 57.
729 monic plague cases sometimes did not develop the disease suggest another possibility in the epidemiology of the disease. This is as follows.
Benign pneumonic plague
may
appear
during
an
interepidemic period and be diagnosed as bronchopneumonia or bronchitis. Increase in the virulence of the bacilli may subsequently result in an epidemic and After the of the illness’s true nature. few of the undetected cases or contacts may become carriers ; the only way to confirm this is by thorough bacteriological examination of the sputum’ of every contact. Dr. Than Aung showed me a smear of tlíe sputum of a patient well on her way to recovery ; and I was struck by the numerous bacilli swarming in it. This case was undoubtedly a potential danger to others. M. V. CHARI. London, S.W.1.
recognition epidemic a
HOSPITALITY FOR GERMAN DOCTORS SrR,-The Foreign Office (German section) is arranging to bring over from the British zone of Germany a number of doctors of influence in the profession, on visits to this country. The object of these visits is to renew contact between the profession in Germany and in the British Isles and to allow the visitors to see some of the developments in medicine which have taken place during the past years when they have been cut off from outside contactsThe Medical Supplies Committee for Germany and Austria, of which 1 am chairman, has been asked to assist this scheme by arranging hospitality, mainly in London but possibly also in the larger provincial cities, so that expenses will be reduced and more doctors can Will any readers willing to offer come on such- visits. hospitality for a week or a fortnight write to Mrs. Duff, 20, Parliament Hill Mansions, London, N.W.5, who will be responsible for these arrangements ?2 We expect that all these visitors will have some knowledge of English so it is not necessary that the host should speak German. Doctors in Germany have been faced during the past few years with tremendous difficulties due to shortage of supplies, influx of refugees, and the standard of living conditions, and we hope these visits will be an encouragement to them in their work. We shall be grateful to anv doctors or friends who can help by onerinsr SOMERVILLE HASTINGS hospitality. Chairman, Medical Supplies Committee for Germany and Austria.
House of Commons.
ATTACK ON RHEUMATISM 8lB.—The discussion arising from your leading article of Nlarch 27has opened up some important questions The most that must be settled in the near future. important of these is the relations that should exist between rheumatology and physical medicine. Guidance towards the solution can be. found in the history of these
in general surgery preoperative and postoperative rehabilitation can materially shorten convalescence. Apparatus and techniques are continually multiplying and becoming more accurate, as is exemplified in electromyography. Here, then, is a growing field of medicine whose future importance has been enhanced by recent atomic research; it should be closely allied to biochemistry, and the future specialist in physical medicine should also be the honoured biophysicist. The study of the rheumatic diseases has also made great strides, especially in the past 15-20 years, aided chiefly by progress in general medicine. No longer does the rheumatologist turn primarily to physical methods for treatment. His first care is a basic diagnosis. In his subsequent attack drugs-whether penicillin, T.A.B., ’
,
vitamins, gold,
place.
century—i.e., shortly after the rays-radiologists, who had mostly been practising electrotherapists, rapidly widened the scope and techniques of radiology to such an extent that separation was inevitable, and radiology became confined to diagnosis while electrotherapy dealt only with treatdent. This divergence led to the formation of a separate section of radiology by the Royal Society of Medicine. The electrotherapists, who had also been widening their field by adopting new methods not covered by electrotherapy," found in the spa practice (balneology) section "
a
group of
men
who
were
skilled and constant
users
of
Physical methods, many of which were, again, no longer covered by " balneology." Thus was formed the section
of physical medicine. Tracing the further history of radiology, we find X-ray diagnosis and radium and X-ray therapy diverging into two entirely different subjects as a result of the stupendous advances of the last 15 years. There have also been startling advances in the methods of physical ’Medicine and rehabilitation, which in many branches of dedicine and surgery now play a critical part in aiding or accelerating recovery. Thus proper physical methods must be applied to prevent severe deformity after
lubectomy and, of
or
pneumonectomy, peripheral-nerve injuries, orthopaedic conditions ; while
course, in various
or
endocrine products-find a leading he constantly encounters other
diagnosis
serious diseases masked by a more obviously crippling arthritis ; over 30 incidents of this kind were recorded during the treatment of the first 250 cases at the British Legion Unit. The rheumatologist of the future must therefore be primarily a sound and knowledgeable physician, but sympathetic to and informed on the I and scope of physical methods. During the period of divergence there will be physicians who have some experience of both rheumatology and physical medicine. But it has become impossible to be first-class in both these subjects. Let the practitioner who wishes to specialise in this field decide whether his tastes lie along the lines of a physical approach, with its new and intriguing possibilities, or whether medicine shall be the background for his approach to the special diagnostic and therapeutic problems presented by the rheumatic diseases. The results achieved by the British Legion Unit, both earlier and after it moved to London and opened its doors to both sexes and all classes of the community, have already been favourably commented on in your journal. They justify recognition of rheumatology as a distinct entity, the rheumatologist working in close association with the general physician, and with the orthopaedic surgeon and the physical-medicine specialist as constant and valued advisers. The first practical steps to this end would be the formation of a section of rheumatology by the Royal Society of Medicine (ample membership would be found among the members of the keen and alive Heberden Society), and the institution by the University of London of a chair in rheumatology ; the Senate are doubtless aware of the progress being made in Manchester University as a result of the Nuffield Foundation bequest. In this way the advances already made would be consolidated, the inroads of this major industrial disability checked, and the means for- development and good recruitment provided. C. B. HEALD. London, ZV.1.
value .
two subjects.
At the end of last discovery of X
In
SHORTAGE OF SPECIALISTS?
SIR,—Surely
it is time
people stopped talking
about
One has only to consult the superintendents or secretaries of hospitals to discover that they are snowed under with applications for ’any post advertised ; and the teachers at the medical schools must be tired to death of writing testimonials and a
shortage of specialists.
answering inquiries. Now that the health service is to begin, may we, the practical steps will be taken an adequate hospital service ? Could not the senior administrative medical officers of the regions compile a register, on voluntary ’lines, of unemployed specialists in their regions and try to. fit them-with the consent, naturally, of the hospitals concerned-into the vacancies which presumably exist or will exist ? After the hospital surveys they must surely have by now some idea of what staff will be needed. Incidentally, when posts are advertised it would save much paper and wasted effort if they were to be starred. One star would mean that the advertisement is a formality, since the job is " fixed " ; two stars that there is’a local candidate but that he is not up to much ; and three stars that the job is really open.
unemployed, hope that immediately to organise
’
DEMOBILISED
F.R.C.S.
-
Ministry of Labour (see 2 above).. The decision as to suitability for admission to Papworth and to the scheme will rest entirely with the medical staff at Papworth who
will require full clinical details and X-ray films in each
case from the tuberculosis officer. Both the committee of management of Papworth Village Settlement and the Ministry of Labour feel that this is a considerable step forward in the rehabilitation 01 ;the tuberculous and anticipate its extension in the future. To this end the Ministry has undertaken to provide half the cost of two hostels of 50 beds each for men and women at Papworth. RICHARD R. TRAIL Papworth Village Settlement, Medical Director. Papworth Hall, Cambridge. BACK STREET SURGERY trickle of inquiries and a few new members SiR,—A have resulted from your kindly review of the Abortion Law Reform Association’s latest publication Back Street Sùrgery. I feel sure that we should gain increased medical support if your readers could examine the association’s collection of press reports of abortion cases heard in the criminal courts during the past 12 years. These tragic stories get little publicity in our leading daily newspapers. If each were to be as widely reported as are other tragedies, cumulative horror might arouse the public conscience to the’ necessity of clarifying our
of the normal capacity to convert fat and protein into sugar -a normal capacity seen in its extreme in the hibernating marmot with a respiratory quotient of 0-3 ? If this is so then it is reasonable to postulate further that this exaggerated demand to form sugar will carry with it the physiologically related demand for excretion of sugar reserves into the blood : therefore the fatty diabetic liver is full of fat which it turns to sugar, and empty of this sugar because it hands it on to the blood. To go back a stage further, has the diabetic got a blood. sugar " set " at a very high level which he attempts to achieve by normal physiological processes ? 5. Is the ketosis of diabetes due to such an overriding priority being given to sugar formation that the breakdown of fat is interrupted at the aceto-acetic acid stage-that is, at the stage to which fat must be broken down before it can be built up again into sugar ? 6. Was Allen’s pre-insulin starvation treatment for diabetics effective-when it was effective-because this stimulated the body to reverse its exaggerated conversion of fat into sugar in favour of a conversion of sugar into fat, as may occur in
’
abortion law. Usually abortion- fatalities are the result of interference by an unskilled- " helper " ; but many fallow on Recently a single attempted self-induced abortion. batch of press cuttings contained reports of inquests on two married women each of whom had been found dead by her husband. One, a mother, had expired alone and unattended whilst seated in a few inches of bath water ; the other, also a mother and also alone and unattended, had collapsed and died on the bedroom floor whilst douching herself. The verdicts were identicaldeath from attempted self-induced miscarriage. Recent police-court history has shown us what can happen under present law when medical practitioners take the risk of giving skilled help in cases which to them seem in need of it. When enough’ people within the medical profession join in the demand for reform, it can be clearly established that it will henceforth not be criminal for a qualified medical practitioner’to terminate the pregnancy of a woman with her consent, when this appears to be medically justified. ALICE JENKINS Hon. Secretary, The Abortion 53, Gloucester Terrace, Law Reform Association. London, W.2. ’
,
BLOOD-SUGAR LEVELS IN SLOW STARVATION SIR,-The valuable paper by Dr. Chakrabarty in your issue of April 17 should be read in conjunction with Simonart’s La Dénutrition de Guerre (Brussels, 1947). These two studies suggest several important questions : 1. Is the low blood-sugar often found in prolonged starvation due not to lack of food from which glucose can be obtained, but instead to an exaggeration of the body’s normal capacity to turn sugar into fat-a pathological exaggeration so great that it may persist in spite of a fatal hypoglycsemia ? This would appear to be the only explanation of the low bloodsugars and high respiratory quotients found by Simonart : the quotient was often above unity, one being as high as 1-95-a figure higher than that recorded for the carbohydrate-
hog (1-58). goose (1-33) 2. Is this lust of the slowly starved body for making fat a sign that there comes a stage in starvation when the fat of the tissues has to be replenished whatever the cost ? 3. Are the attacks of sudden acute fatigue, clinically resembling hypoglycaemia, which occur most commonly in thin people and which are promptly relieved by sugar, due not to lack of glycogen reserves but to a sudden demand by the thin body for fat formation from sugar, even at the expense of reducing the blood-sugar below the minimum necessary ? 4. Is the diabetic with his low respiratory quotient the reverse of the starving man with a high respiratory quotient ? Are the biochemical changes in starvation and in diabetes merely examples of upsetting-but in opposite directionsthe normal balance between fat and sugar formation ? Is the diabetic not primarily incapable of metabolising sugar, but is he merely suffering from a pathological exaggeration
fattening
or
’
starvation ? London, W.l.
FRANKLIN BICKNELL. JOHN HILTON
SIR,-We are preparing an entirely new edition- of John Hilton’s surgical classic Rest and Pain to be published by Messrs. G. Bell & Sons Ltd. the publishers of the original lectures. We should be most grateful to any of your readers who can give us any information that might help us in this work. As we propose to include a short biographical note on Hilton we would welcome details of his life-especially his early life-and the loan of any portrait suitable for reproduction. ELLIOT E. PHILIPP Middlesex Hospital Medical School; E. W. WALLS. London, W.1. PNEUMONIC PLAGUE SIR,-The article by Dr. Wynne-Griffith in your issue of April 24 points out clearly that pneumonic plague is not as infectious as it is generally thought to be. I should like to refer to an outbreak of pneumonic plague that occurred at Nyaunglebin, which is 100 miles north of Rangoon. The cases presented themselves in much the same way as those seen in Rangoon by Wynne-Griffith. Pneumonic plague was not suspected at all till a public-health inspector casually remarked that there had been an epidemic of pneumonic plague in the same locality a few years before. In Nyaunglebin also there were quite a number of people who, although they had come in close contact with cases of pneumonic plague (some of them had not even been inoculated against plague), did not themselves develop the disease. A surprising fact which emerged from the Nyaunglebin outbreak was that pneumonic plague need not be fatal. An excellent report on one of the cases which did not prove fatal was published by my colleague Dr. Than Aurig 1 ; plague bacillus was found in the sputum of this Another case long after the acute phase was over. instance of recovery has been recorded by Clark and -
’
Goldberg.2
Than Aung’s
I ,
case
raises certain
important questions:
(1) is it possible for pneumonic plague to be transmitted convalescent carriers ? (2) can a contact be a passive carrier without contracting the disease himself ? The view held at present is that the disease is contracted by the inhalation of dust laden with bacilli, the bacilli
by
being passed in the faeces of infected rodents. Another possibility is that of a small proportion of bubonic_cases developing into secondary pneumonic ones. The possibility of carriers transmitting the disease is never considered, because it is assumed that pneumonic plague is always fatal.. The cases recorded by Clark and Goldberg. of which one had an incubation period of as long as 12 days and another did not provefatal ; the finding of plague bacillus in the sputum of a convalescent case by Than Aung ; and the observation by Wynne-Griffith and others that people in intimate contact with prieu1. Indian med. Gaz. 1947, 82, 275. 2. Clark, B. M., Goldberg, S. S. Afr. med. J.
1943, 17, 57.
729 monic plague cases sometimes did not develop the disease suggest another possibility in the epidemiology of the disease. This is as follows.
Benign pneumonic plague
may
appear
during
an
interepidemic period and be diagnosed as bronchopneumonia or bronchitis. Increase in the virulence of the bacilli may subsequently result in an epidemic and After the of the illness’s true nature. few of the undetected cases or contacts may become carriers ; the only way to confirm this is by thorough bacteriological examination of the sputum’ of every contact. Dr. Than Aung showed me a smear of tlíe sputum of a patient well on her way to recovery ; and I was struck by the numerous bacilli swarming in it. This case was undoubtedly a potential danger to others. M. V. CHARI. London, S.W.1.
recognition epidemic a
HOSPITALITY FOR GERMAN DOCTORS SrR,-The Foreign Office (German section) is arranging to bring over from the British zone of Germany a number of doctors of influence in the profession, on visits to this country. The object of these visits is to renew contact between the profession in Germany and in the British Isles and to allow the visitors to see some of the developments in medicine which have taken place during the past years when they have been cut off from outside contactsThe Medical Supplies Committee for Germany and Austria, of which 1 am chairman, has been asked to assist this scheme by arranging hospitality, mainly in London but possibly also in the larger provincial cities, so that expenses will be reduced and more doctors can Will any readers willing to offer come on such- visits. hospitality for a week or a fortnight write to Mrs. Duff, 20, Parliament Hill Mansions, London, N.W.5, who will be responsible for these arrangements ?2 We expect that all these visitors will have some knowledge of English so it is not necessary that the host should speak German. Doctors in Germany have been faced during the past few years with tremendous difficulties due to shortage of supplies, influx of refugees, and the standard of living conditions, and we hope these visits will be an encouragement to them in their work. We shall be grateful to anv doctors or friends who can help by onerinsr SOMERVILLE HASTINGS hospitality. Chairman, Medical Supplies Committee for Germany and Austria.
House of Commons.
ATTACK ON RHEUMATISM 8lB.—The discussion arising from your leading article of Nlarch 27has opened up some important questions The most that must be settled in the near future. important of these is the relations that should exist between rheumatology and physical medicine. Guidance towards the solution can be. found in the history of these
in general surgery preoperative and postoperative rehabilitation can materially shorten convalescence. Apparatus and techniques are continually multiplying and becoming more accurate, as is exemplified in electromyography. Here, then, is a growing field of medicine whose future importance has been enhanced by recent atomic research; it should be closely allied to biochemistry, and the future specialist in physical medicine should also be the honoured biophysicist. The study of the rheumatic diseases has also made great strides, especially in the past 15-20 years, aided chiefly by progress in general medicine. No longer does the rheumatologist turn primarily to physical methods for treatment. His first care is a basic diagnosis. In his subsequent attack drugs-whether penicillin, T.A.B., ’
,
vitamins, gold,
place.
century—i.e., shortly after the rays-radiologists, who had mostly been practising electrotherapists, rapidly widened the scope and techniques of radiology to such an extent that separation was inevitable, and radiology became confined to diagnosis while electrotherapy dealt only with treatdent. This divergence led to the formation of a separate section of radiology by the Royal Society of Medicine. The electrotherapists, who had also been widening their field by adopting new methods not covered by electrotherapy," found in the spa practice (balneology) section "
a
group of
men
who
were
skilled and constant
users
of
Physical methods, many of which were, again, no longer covered by " balneology." Thus was formed the section
of physical medicine. Tracing the further history of radiology, we find X-ray diagnosis and radium and X-ray therapy diverging into two entirely different subjects as a result of the stupendous advances of the last 15 years. There have also been startling advances in the methods of physical ’Medicine and rehabilitation, which in many branches of dedicine and surgery now play a critical part in aiding or accelerating recovery. Thus proper physical methods must be applied to prevent severe deformity after
lubectomy and, of
or
pneumonectomy, peripheral-nerve injuries, orthopaedic conditions ; while
course, in various
or
endocrine products-find a leading he constantly encounters other
diagnosis
serious diseases masked by a more obviously crippling arthritis ; over 30 incidents of this kind were recorded during the treatment of the first 250 cases at the British Legion Unit. The rheumatologist of the future must therefore be primarily a sound and knowledgeable physician, but sympathetic to and informed on the I and scope of physical methods. During the period of divergence there will be physicians who have some experience of both rheumatology and physical medicine. But it has become impossible to be first-class in both these subjects. Let the practitioner who wishes to specialise in this field decide whether his tastes lie along the lines of a physical approach, with its new and intriguing possibilities, or whether medicine shall be the background for his approach to the special diagnostic and therapeutic problems presented by the rheumatic diseases. The results achieved by the British Legion Unit, both earlier and after it moved to London and opened its doors to both sexes and all classes of the community, have already been favourably commented on in your journal. They justify recognition of rheumatology as a distinct entity, the rheumatologist working in close association with the general physician, and with the orthopaedic surgeon and the physical-medicine specialist as constant and valued advisers. The first practical steps to this end would be the formation of a section of rheumatology by the Royal Society of Medicine (ample membership would be found among the members of the keen and alive Heberden Society), and the institution by the University of London of a chair in rheumatology ; the Senate are doubtless aware of the progress being made in Manchester University as a result of the Nuffield Foundation bequest. In this way the advances already made would be consolidated, the inroads of this major industrial disability checked, and the means for- development and good recruitment provided. C. B. HEALD. London, ZV.1.
value .
two subjects.
At the end of last discovery of X
In
SHORTAGE OF SPECIALISTS?
SIR,—Surely
it is time
people stopped talking
about
One has only to consult the superintendents or secretaries of hospitals to discover that they are snowed under with applications for ’any post advertised ; and the teachers at the medical schools must be tired to death of writing testimonials and a
shortage of specialists.
answering inquiries. Now that the health service is to begin, may we, the practical steps will be taken an adequate hospital service ? Could not the senior administrative medical officers of the regions compile a register, on voluntary ’lines, of unemployed specialists in their regions and try to. fit them-with the consent, naturally, of the hospitals concerned-into the vacancies which presumably exist or will exist ? After the hospital surveys they must surely have by now some idea of what staff will be needed. Incidentally, when posts are advertised it would save much paper and wasted effort if they were to be starred. One star would mean that the advertisement is a formality, since the job is " fixed " ; two stars that there is’a local candidate but that he is not up to much ; and three stars that the job is really open.
unemployed, hope that immediately to organise
’
DEMOBILISED
F.R.C.S.
-