- Email: [email protected]
RECRUITMENT TO MENTAL HANDICAP
174 N.A.D. content
of
mouse
pancreatic islets.
It
was
then
found that N.M.U., like streptozotocin, drastically lowered the N.A.D. levels and caused degeneration and destruction of the beta cells as revealed by light-microscopic examination. The diabetogenic action of N.M.U. was found also in Chinese hamsters. The doses used by us are of the same order of magnitude as those used in experimental studies of the carcinogenic or mutagenic properties of N.M.U., which belongs to that class of nitrosamines that can be formed from nitrite and its methylurea precursor in the stomach of rats.33 Without taking up a standpoint as to whether nitrosamines formed endogenously from precursors present in very low levels in the food are able to exert their noxious action on man, we would like to propose that, when the actions of environmental nitrosamines on a human population are studied, not only their carcinogenic and mutagenic but also their diabetogenic effects should be subjected to thorough scrutinv. C. BERNE Departments of Histology and
R. GUNNARSSON C. HELLERSTRÖM E. WILANDER.
Pathology, University of Uppsala, Sweden.
Rakieten, N., Rakieten, M. L., Nadkarni, M. V. Cancer Chemother. Rep. 1963, 29, 91. 2. Murray-Lyon, I. M., Eddleston, A. L. W. F., Williams, R., Brown, M., Hogbin, B. M., Bennett, A., Edwards, J. C., Taylor, K. W. Lancet, 1968, ii, 895. 3. Sander, J. Arzneimittel-Forsch. 1971, 21, 1707.
timers " as a lifetime’s occupation; but it should be possible make any specialty suitable for women, temporarily working part-time, in the training grades. I am convinced that one reason for the lack of enthusiasm shown by many women doctors in the past for remaining in or resuming active practice is that most of the more demanding-and therefore more interesting-specialties have been for practical purposes closed to them. As you indicate, women have to be both able and highly motivated in order to enter the profession in the first place; steer such people into a " comfortable " professional backwater not of their choosing and of course they will become frustrated and disillusioned and may then be lost to the profession. Secondly, the women specialists of the future must surely resist most strongly any reintroduction of permanent subconsultant posts other than in exceptional, individual cases, unless they wish to be for ever labelled second-class specialists-for it seems likely that the " establishment" will continue to channel women, however well trained, into such posts as long as the posts exist. University Department of Surgery,
to
Elizabeth Street, Liverpool L69 3BX.
JEAN TURNER.
1.
THE DEAN’S DILEMMA
SIR,-While I agree wholeheartedly with the two basic solutions which you propose (Jan. 5, p. 21), and which, if effected, could abolish that economic wastage which is the concern of earlier writers to whom you refer, I should like if I may to enlarge on them. The provision of better opportunities for employment must be directed initially at the years of postgraduate training (which are also the childbearing years of most of these women), and this means part-time training of sufficient quality to ensure that, after a proportionately increased duration of training, the woman could be recognised and accredited in the same way as her full-time counterpart. Her post should probably be not less than half-time to ensure adequate intensity, and should include emergency commitment pro rata-a situation which would lend itself to the sharing of one full-time post between two, as you envisage for consultants. The financial help which you suggest would also be important; such a trainee, before she even begins to think of home-helps, must find the same money for registration, defence, examinations, and college fees as do her full-time,
fully paid colleagues. Such a scheme of training should allow the emphasis to be placed on continuing training during the childbearing years, rather than on a return to work after them, which is, as you infer, a daunting prospect. If women could thus be kept in active practice they would, even if postgraduate training took ten or fifteen years, have twenty to thirty years of useful, highly trained service to the profession remaining to them, much of it presumably being full-time as their children matured. Ideally, if the scheme were applied nationally and maximally, we might at last achieve the desirable state in which women no longer need special consideration or career guidance because of their womanhood, but can be employed as surgeons, general practitioners, obstetricians, and so on in a career structure in which they need not approximate themselves as closely as possible to men to approach the norm. On two points I take issue with you. The specialties which you mention may be eminently suitable for part"
CHOLERA
SIR,-Dr MacKay (Dec. 22, p. 1239) wondered whether controlled trials of mass chemoprophylaxis by tetracycline have been done with the hope of controlling an epidemic of cholera in an endemic area. To our knowledge no controlled trial of mass chemoprophylaxis of cholera has been carried out. Mass chemoprophylaxis, without appropriate control studies, using chloramphenicol 500 mg. every six hours for 3 days were carried out in Japan and Iran. However, in smaller controlled studies of Gangarosa et al.,1Fanasil’, chloramphenicol, penicillin, and streptomycin were not effective prophylactic agents. Tetracyline, the drug of choice in cholera, was not included in the studies. Chemoprophylaxis by tetracycline has been carried out in family contacts in an endemic area of Bangladesh by McCormack et awl. and was found to prevent cholera in the families of cholera patients when given in single doses of 1-0 g. daily for 5 days. The cost alone of administering tetracycline to as many as a million or more people in a mass campaign would be prohibitive. Cholera Research Laboratory (Institute of Public Health), G.P.O. Box 128, Dacca-2,
Bangladesh. 1. 2.
K. M. S. AZIZ GEORGE CURLIN.
Gangarosa, E. J., Saghari, H., Emile, J., Sanati, A., Siadat, A., Watanabe, Y. Bull. Wld Hlth Org. 1966, 35, 669. McCormack, W. M., Chowdhury, A. M., Jahangir, N., Ahmed, A. B. F., Mosley, W. H. ibid. 1968, 38, 787.
RECRUITMENT TO MENTAL HANDICAP
SIR,-A consultant post in mental handicap at this hospital, vacant for over 12 months, has been twice advertised without an appointment being made, no candidate with enough experience being forthcoming. Perusal of the advertisement columns in the journals suggests that this is happening in other areas of the country. Posts offering a salary of up to E7599 plus expenses and lecture fees are unfilled because there are evidently too few doctors with the necessary inclination, experience, and personality. Unlike many consultant jobs the appointees to these posts will not be expected to work during the night. They will have scope for teaching various groups of students, for research, for developing multidisciplinary assessment and care of their patients, and for forging links as they wish
175
local-authority social-services departments, special schools, training centres, and voluntary bodies. Indeed
with
there can be few posts with such open prospects of practising family and community medicine and for combining clinical work, teaching, and research with participation in hospital
The more such specialists there are in a the more effective and satisfying their contribution will be. Their work deals with the mentally handicapped and their families, people who desperately need positive medical in addition to social and education help. Is service to these
management. centre
patients regarded as unattractive, infra dig., or professionally or financially unrewarding ? Such questions are relevant to present and future provision for the mentally handicapped, and the medical profession must answer them. Meanwood Park Hospital,
Tongue Lane, Leeds LS6 4QB.
D. A. SPENCER.
more sophisticated and the formulation of explanatory hypotheses more cautious and scientifically rigorous. The days of high-level generalisations based on a study of a handful of cases are over. Preoccupation with alleged psychogenesis of the so-called psychosomatic disorders is largely a matter of history now. Research aimed at elucidation of the intervening neurophysiological, neuroendocrine, and immune mechanisms which enable personally meaningful information inputs to bring about changes in the functioning of organs and tissue systems in the direction of health or pathology occupy the centre of the field. It is your correspondent’s privilege to refer to this work "
ill-defined humanism ", but he owes it to his readers conclusion by an informed presentation of the current state of the field.
as
to
justify this
Department of Psychiatry, Dartmouth Medical School, Hanover, New Hampshire 03755, U.S.A.
PSYCHOSOMATIC MEDICINE
SIR,-Your correspondent’s remarks about psycho(Dec. 15, p. 1380) are too biased and
Z. J. LIPOWSKI.
1. Brain. Lancet, 1964, ii, 325. 2. Crisp, A. H. Br. J. med. Psychol. 1968, 41, 323. 3. Lipowski, Z. J. Canad. Psychiat. Ass. J. 1970, 15, 515. 4. Lipowski, Z. J. Comprehensive Psychiatry, 1973, 14, 203.
somatic medicine misleading to go
unchallenged. To generalise about an inquiry from a casual encounter with one, and not necessarily a representative, group of investigators is hardly consonant with fair reporting. To say that psychosomatic medicine is a field " where the only common thread often appears to be a well-meaning but ill-defined humanism" betrays woeful ignorance which provides a precarious basis for generalisations. It would be fair to your readers to put the record straight. Ten years ago you published a fine article by the late Lord Brain1 in which some of the key concerns of psychosomatic medicine are stated. One of them is the study of the reciprocal relationships between cerebral processes described in the language of the neurosciences and the mental processes described in psychological terms and studied by the methods of psychology, respectively. A related scientific concern of psychosomatic medicine is the study-experimental, clinical, and epidemiological-of the psychophysiological responses to a variety of social stimuli, and of the influence of these responses on the predisposition to, and precipitation and timing of the onset of, as well as the course and outcome of, human diseases .2-4 Psychosomatic medicine as a scientific discipline concerned with investigation of the role of psychosocial variables in human morbidity and of the physiological and biochemical influences on behaviour and subjective experience is about
area
of scientific
50 years old. It has had its ups and downs related to premature and uncritical dissemination of some of its early hypotheses about the postulated role of unconscious psychological factors in the aaiology of a few chronic disorders, such as duodenal ulcer or bronchial asthma, misnamed " psychosomatic ". It has been criticised for being excessively speculative and insufficiently scientific. It has had a share of problems related to issues of semantics and to its ill-defined scope. Such problems are not surprising in a highly complex area whose avowed purpose has been the study of the interface between behavioural sciences and human biology, an inquiry which calls for crossing of interdisciplinary boundaries and the simultaneous, or sequential, observation of processes and events belonging to different levels of abstraction with their distinct research methodologies and languages. Anyone interested in the development and current trends in this rich and lively field of inquiry needs to acquaint himself with the contents of journals like Psychosomatic Medicine Journal of Psychosomatic Research, Psychophysiology, &c. This field has undergone sweeping changes in the past two decades. Research methodology has become increasingly
BRAN AND BLOOD-LIPIDS
SIR,—It is just possibly meaningful to study the effect of dietary bran on the blood-lipids of only 3 men and 11 women; but when 2 have gallstones and 6 have had cholecystectomies, their ages range from 36 to 63, their bran intakes vary from 18 to 100 g. a day, and the periods of supplement from 4 to 9 weeks, it is surely time to call in the referee. Dr Heaton and Dr Pomare (Jan. 12, p. 49) had a good idea on an important subject, but paired t tests and regression analysis cannot make a silk purse out of a sow’s ear. Glyncorrwg Health Centre, near
Port Talbot, 3BL.
Glamorgan SA13
JULIAN TUDOR HART IAN SCOTT.
ORGANISATION IN THE SURGICAL UNIT
MR,—1 agree that the surgical
admission
system operated
Mr Mynors (Dec. 22, p. 1438) is ideal if work potential matches the available facilities consistently. It is, however, not possible to implement this system when there is a lengthy and lengthening waiting-list, urgent and semiurgent patients apart. Here the problem is to integrate as accurately as possible the admissions with the bed-space and operating-time available. To do this the patient must share the responsibility of achieving this end. In this hospital an admissions procedure is in operation which has shown considerable advantages. The consultant himself, and no other, selects the patients for admission from the waiting-list, giving priority to the urgent and for-early-admission patients, and they are notified two weeks in advance. It is felt that two weeks is the maximum notice a hospital can give, and this is sufficient for most patients to make suitable personal arrangements. The patient’s admission notice is accompanied by a returnable form and a stamped addressed envelope addressed to the admissions officer of the hospital. The purpose of this form is to enable the patient to inform the hospital of his or her intentions; there is an enjoinder to return the form promptly otherwise the bed may be switched to the next person on the waiting-list. This is carried out if a reply is not received within a week, while there is sufficient time to notify another patient. Replies to the effect that the patient wishes admission postponed owing to domestic reasons, changes of mind regarding treatment, or other contingency enables the admissions officer to make appro-
by
of
mouse
pancreatic islets.
It
was
then
found that N.M.U., like streptozotocin, drastically lowered the N.A.D. levels and caused degeneration and destruction of the beta cells as revealed by light-microscopic examination. The diabetogenic action of N.M.U. was found also in Chinese hamsters. The doses used by us are of the same order of magnitude as those used in experimental studies of the carcinogenic or mutagenic properties of N.M.U., which belongs to that class of nitrosamines that can be formed from nitrite and its methylurea precursor in the stomach of rats.33 Without taking up a standpoint as to whether nitrosamines formed endogenously from precursors present in very low levels in the food are able to exert their noxious action on man, we would like to propose that, when the actions of environmental nitrosamines on a human population are studied, not only their carcinogenic and mutagenic but also their diabetogenic effects should be subjected to thorough scrutinv. C. BERNE Departments of Histology and
R. GUNNARSSON C. HELLERSTRÖM E. WILANDER.
Pathology, University of Uppsala, Sweden.
Rakieten, N., Rakieten, M. L., Nadkarni, M. V. Cancer Chemother. Rep. 1963, 29, 91. 2. Murray-Lyon, I. M., Eddleston, A. L. W. F., Williams, R., Brown, M., Hogbin, B. M., Bennett, A., Edwards, J. C., Taylor, K. W. Lancet, 1968, ii, 895. 3. Sander, J. Arzneimittel-Forsch. 1971, 21, 1707.
timers " as a lifetime’s occupation; but it should be possible make any specialty suitable for women, temporarily working part-time, in the training grades. I am convinced that one reason for the lack of enthusiasm shown by many women doctors in the past for remaining in or resuming active practice is that most of the more demanding-and therefore more interesting-specialties have been for practical purposes closed to them. As you indicate, women have to be both able and highly motivated in order to enter the profession in the first place; steer such people into a " comfortable " professional backwater not of their choosing and of course they will become frustrated and disillusioned and may then be lost to the profession. Secondly, the women specialists of the future must surely resist most strongly any reintroduction of permanent subconsultant posts other than in exceptional, individual cases, unless they wish to be for ever labelled second-class specialists-for it seems likely that the " establishment" will continue to channel women, however well trained, into such posts as long as the posts exist. University Department of Surgery,
to
Elizabeth Street, Liverpool L69 3BX.
JEAN TURNER.
1.
THE DEAN’S DILEMMA
SIR,-While I agree wholeheartedly with the two basic solutions which you propose (Jan. 5, p. 21), and which, if effected, could abolish that economic wastage which is the concern of earlier writers to whom you refer, I should like if I may to enlarge on them. The provision of better opportunities for employment must be directed initially at the years of postgraduate training (which are also the childbearing years of most of these women), and this means part-time training of sufficient quality to ensure that, after a proportionately increased duration of training, the woman could be recognised and accredited in the same way as her full-time counterpart. Her post should probably be not less than half-time to ensure adequate intensity, and should include emergency commitment pro rata-a situation which would lend itself to the sharing of one full-time post between two, as you envisage for consultants. The financial help which you suggest would also be important; such a trainee, before she even begins to think of home-helps, must find the same money for registration, defence, examinations, and college fees as do her full-time,
fully paid colleagues. Such a scheme of training should allow the emphasis to be placed on continuing training during the childbearing years, rather than on a return to work after them, which is, as you infer, a daunting prospect. If women could thus be kept in active practice they would, even if postgraduate training took ten or fifteen years, have twenty to thirty years of useful, highly trained service to the profession remaining to them, much of it presumably being full-time as their children matured. Ideally, if the scheme were applied nationally and maximally, we might at last achieve the desirable state in which women no longer need special consideration or career guidance because of their womanhood, but can be employed as surgeons, general practitioners, obstetricians, and so on in a career structure in which they need not approximate themselves as closely as possible to men to approach the norm. On two points I take issue with you. The specialties which you mention may be eminently suitable for part"
CHOLERA
SIR,-Dr MacKay (Dec. 22, p. 1239) wondered whether controlled trials of mass chemoprophylaxis by tetracycline have been done with the hope of controlling an epidemic of cholera in an endemic area. To our knowledge no controlled trial of mass chemoprophylaxis of cholera has been carried out. Mass chemoprophylaxis, without appropriate control studies, using chloramphenicol 500 mg. every six hours for 3 days were carried out in Japan and Iran. However, in smaller controlled studies of Gangarosa et al.,1Fanasil’, chloramphenicol, penicillin, and streptomycin were not effective prophylactic agents. Tetracyline, the drug of choice in cholera, was not included in the studies. Chemoprophylaxis by tetracycline has been carried out in family contacts in an endemic area of Bangladesh by McCormack et awl. and was found to prevent cholera in the families of cholera patients when given in single doses of 1-0 g. daily for 5 days. The cost alone of administering tetracycline to as many as a million or more people in a mass campaign would be prohibitive. Cholera Research Laboratory (Institute of Public Health), G.P.O. Box 128, Dacca-2,
Bangladesh. 1. 2.
K. M. S. AZIZ GEORGE CURLIN.
Gangarosa, E. J., Saghari, H., Emile, J., Sanati, A., Siadat, A., Watanabe, Y. Bull. Wld Hlth Org. 1966, 35, 669. McCormack, W. M., Chowdhury, A. M., Jahangir, N., Ahmed, A. B. F., Mosley, W. H. ibid. 1968, 38, 787.
RECRUITMENT TO MENTAL HANDICAP
SIR,-A consultant post in mental handicap at this hospital, vacant for over 12 months, has been twice advertised without an appointment being made, no candidate with enough experience being forthcoming. Perusal of the advertisement columns in the journals suggests that this is happening in other areas of the country. Posts offering a salary of up to E7599 plus expenses and lecture fees are unfilled because there are evidently too few doctors with the necessary inclination, experience, and personality. Unlike many consultant jobs the appointees to these posts will not be expected to work during the night. They will have scope for teaching various groups of students, for research, for developing multidisciplinary assessment and care of their patients, and for forging links as they wish
175
local-authority social-services departments, special schools, training centres, and voluntary bodies. Indeed
with
there can be few posts with such open prospects of practising family and community medicine and for combining clinical work, teaching, and research with participation in hospital
The more such specialists there are in a the more effective and satisfying their contribution will be. Their work deals with the mentally handicapped and their families, people who desperately need positive medical in addition to social and education help. Is service to these
management. centre
patients regarded as unattractive, infra dig., or professionally or financially unrewarding ? Such questions are relevant to present and future provision for the mentally handicapped, and the medical profession must answer them. Meanwood Park Hospital,
Tongue Lane, Leeds LS6 4QB.
D. A. SPENCER.
more sophisticated and the formulation of explanatory hypotheses more cautious and scientifically rigorous. The days of high-level generalisations based on a study of a handful of cases are over. Preoccupation with alleged psychogenesis of the so-called psychosomatic disorders is largely a matter of history now. Research aimed at elucidation of the intervening neurophysiological, neuroendocrine, and immune mechanisms which enable personally meaningful information inputs to bring about changes in the functioning of organs and tissue systems in the direction of health or pathology occupy the centre of the field. It is your correspondent’s privilege to refer to this work "
ill-defined humanism ", but he owes it to his readers conclusion by an informed presentation of the current state of the field.
as
to
justify this
Department of Psychiatry, Dartmouth Medical School, Hanover, New Hampshire 03755, U.S.A.
PSYCHOSOMATIC MEDICINE
SIR,-Your correspondent’s remarks about psycho(Dec. 15, p. 1380) are too biased and
Z. J. LIPOWSKI.
1. Brain. Lancet, 1964, ii, 325. 2. Crisp, A. H. Br. J. med. Psychol. 1968, 41, 323. 3. Lipowski, Z. J. Canad. Psychiat. Ass. J. 1970, 15, 515. 4. Lipowski, Z. J. Comprehensive Psychiatry, 1973, 14, 203.
somatic medicine misleading to go
unchallenged. To generalise about an inquiry from a casual encounter with one, and not necessarily a representative, group of investigators is hardly consonant with fair reporting. To say that psychosomatic medicine is a field " where the only common thread often appears to be a well-meaning but ill-defined humanism" betrays woeful ignorance which provides a precarious basis for generalisations. It would be fair to your readers to put the record straight. Ten years ago you published a fine article by the late Lord Brain1 in which some of the key concerns of psychosomatic medicine are stated. One of them is the study of the reciprocal relationships between cerebral processes described in the language of the neurosciences and the mental processes described in psychological terms and studied by the methods of psychology, respectively. A related scientific concern of psychosomatic medicine is the study-experimental, clinical, and epidemiological-of the psychophysiological responses to a variety of social stimuli, and of the influence of these responses on the predisposition to, and precipitation and timing of the onset of, as well as the course and outcome of, human diseases .2-4 Psychosomatic medicine as a scientific discipline concerned with investigation of the role of psychosocial variables in human morbidity and of the physiological and biochemical influences on behaviour and subjective experience is about
area
of scientific
50 years old. It has had its ups and downs related to premature and uncritical dissemination of some of its early hypotheses about the postulated role of unconscious psychological factors in the aaiology of a few chronic disorders, such as duodenal ulcer or bronchial asthma, misnamed " psychosomatic ". It has been criticised for being excessively speculative and insufficiently scientific. It has had a share of problems related to issues of semantics and to its ill-defined scope. Such problems are not surprising in a highly complex area whose avowed purpose has been the study of the interface between behavioural sciences and human biology, an inquiry which calls for crossing of interdisciplinary boundaries and the simultaneous, or sequential, observation of processes and events belonging to different levels of abstraction with their distinct research methodologies and languages. Anyone interested in the development and current trends in this rich and lively field of inquiry needs to acquaint himself with the contents of journals like Psychosomatic Medicine Journal of Psychosomatic Research, Psychophysiology, &c. This field has undergone sweeping changes in the past two decades. Research methodology has become increasingly
BRAN AND BLOOD-LIPIDS
SIR,—It is just possibly meaningful to study the effect of dietary bran on the blood-lipids of only 3 men and 11 women; but when 2 have gallstones and 6 have had cholecystectomies, their ages range from 36 to 63, their bran intakes vary from 18 to 100 g. a day, and the periods of supplement from 4 to 9 weeks, it is surely time to call in the referee. Dr Heaton and Dr Pomare (Jan. 12, p. 49) had a good idea on an important subject, but paired t tests and regression analysis cannot make a silk purse out of a sow’s ear. Glyncorrwg Health Centre, near
Port Talbot, 3BL.
Glamorgan SA13
JULIAN TUDOR HART IAN SCOTT.
ORGANISATION IN THE SURGICAL UNIT
MR,—1 agree that the surgical
admission
system operated
Mr Mynors (Dec. 22, p. 1438) is ideal if work potential matches the available facilities consistently. It is, however, not possible to implement this system when there is a lengthy and lengthening waiting-list, urgent and semiurgent patients apart. Here the problem is to integrate as accurately as possible the admissions with the bed-space and operating-time available. To do this the patient must share the responsibility of achieving this end. In this hospital an admissions procedure is in operation which has shown considerable advantages. The consultant himself, and no other, selects the patients for admission from the waiting-list, giving priority to the urgent and for-early-admission patients, and they are notified two weeks in advance. It is felt that two weeks is the maximum notice a hospital can give, and this is sufficient for most patients to make suitable personal arrangements. The patient’s admission notice is accompanied by a returnable form and a stamped addressed envelope addressed to the admissions officer of the hospital. The purpose of this form is to enable the patient to inform the hospital of his or her intentions; there is an enjoinder to return the form promptly otherwise the bed may be switched to the next person on the waiting-list. This is carried out if a reply is not received within a week, while there is sufficient time to notify another patient. Replies to the effect that the patient wishes admission postponed owing to domestic reasons, changes of mind regarding treatment, or other contingency enables the admissions officer to make appro-
by