- Email: [email protected]
SALARIES IN THE PUBLIC-HEALTH SERVICE
142 from as many sources as possible. So only can we hope to eliminate prejudice and to attain to some degree of accurate appraisement. And here let me express the gratitude of the Awards Committee to the very large number of specialists who by their detachment and good sense have made the successful working of this method of remuneration possible. I have spoken of the successful working of the awards system. Am I entitled to make any such claim? The letter in your issue of June 19, signed by Mr. ’John Simons on behalf of the Association which he represents (which is not to be confused with the Central Consultants and Specialists Committee of the British Medical Association), has not been followed up ; so it is perhaps necessary to remind your readers that he would flatly deny my claim. What then is the truth ? There are more than Of these a 6000 specialists in England and Wales.-. majority have not been given a merit award, and it is perhaps inevitable that there are some who are not It would satisfied with the committee’s selection. probably be possible, with a little organisation, to whip up a number of letters in support of Mr. Simons’s That there is" considerable disquiet " is, assertion. however, diametrically opposed to our experience. On our recent tour of the country the meetings were very large ; the attendance was often twice what it had been in previous years, and there appeared to be a very generous appreciation of the time and trouble that the committee gave to the task in hand and of the success that had attended its attempt to overcome the more obvious difficulties inherent in such a system. There are a number of bodies representing specialists, and if the Awards Committee have not made full use of this particular association, it is never too late to amend our ways. In England, when we do anything remarkable it is our custom to hasten to deny that it is anything out of the way. The body of specialists in England and Wales have taken this system of merit awards and by their individual help and advice have made it work. It is indeed a remarkable achievement, which has its roots in the good sense of our people, an achievement, I think, beyond the reach of more selfish countries. MOBAN. MORAN. London, -BV.1. -
Although it is still too early to be certain, it seems that bifacton by mouth is just as effective in controlling an established case of pernicious ansemia as any of the various injections. It would be very interesting to see how a newly diagnosed case would respond, and I have been on the look-out for one in my practice-so far, without success. One must also consider the questions of cost and convenience ; bifacton is more expensive than any of the injections and many patients might prefer a weekly or fortnightly injection to a daily tablet. The blood examinations were performed by Dr. A. L. and his assistants in the laboratory of the Bristol General Hospital, and to them my thanks are due.
Taylor
SERUM HEPATITIS
SIR,—The last paragraph of your leading article of June 26 states that " one can feel relatively safe in Great Britain when administering fresh whole blood, or plasma prepared from pools of 8-10 donations." To avoid any possible misconceptions regarding the icterogenicity of fresh as compared with stored blood, I would like to point out that the blood used in the trials, on the results of which the above statement is based, was from a few days to 3 weeks old when transfused.
ORAL TREATMENT OF PERNICIOUS ANÆMIA SIR,—I was much interested in the article by Dr. Lowther and his colleagues in your issue of March 6, for I had then been treating 4 established cases with ,
Bifacton ’ for over three months. Now after more than months on the tablets alone, my experience is the same as theirs.
seven
Some details of my cases are given in the accompanying table. It is noted that 3 patients have had neurological symptoms, and these recurred from time to time in the older men Case
A--e
1
57 57 ( 70 74
2 3 4
despite
’
Previous treatment
Diagnosed
Sept. 22, 1949 April 7, 1949 Sept. 4, 1942 June 5, 1944
,
Anahæmin ’
I ! ’ i.
are
free except
case
Neurological symptoms
i j ’
Neohepatex ’ Cytamen 100 ’! ,
Anahæmin ’
treatment controlled with
Now all
I
periodic
)
Absent
Slight Present Present
blood examinations.
3, whose symptoms returned for
short time when dosage was reduced to one tablet a day, but have since disappeared on two tablets daily. All 4 have kept in excellent health on bifacton only, except case 2, who had a month on ’ Fersolate ’ tablets as well. Blood pictures show normal films and the Hb is 100% or above. Dosage was begun at two tablets daily, reduced to one after three months, except case 3 as I have mentioned. The 2 younger patients are at work and say they feel better than they did on injections, while the older 2 say they are as well as before ; and all prefer the tablets. a
JOSEPH SLUGLETT.
Bristol, 4.
Lister Institute of Preventive Medicine, Elstree, Herts.
W. D’A. MAYCOCK. Herts.
SALARIES IN THE PUBLIC-HEALTH SERVICE
of the forgotten men (and some women) draw your attention to the salary position of medical officers of health. I hardly need to remind you that we unfortunates are the only doctors who must hold two statutory qualifications. This we do not quarrel with, but it should surely be reflected in the salaries paid. These may be adequate for county medical officers and the medical officers of health of the big county boroughs, but for those of the smaller county boroughs, and in particular for those medical officers of health holding what are termed mixed appointments, the salaries paid are in no way commensurate with the responsibility. In my own case, after seventeen years as an M.o.H., my salary (the maximum on the present complicated formula) is less than £1700—i.e., only £400 more than an assistant medical officer’s and only E300 more than that of an assistant dental surgeon under the recent award. This example can be multiplied many times as many of my colleagues are in the same boat. Unless there is a very substantial revision upward I should strongly advise any potential recruits to medicine to choose some other branch. You, Sir, have not been particularly vocal in championing the case for adequate salaries in the public-health service, but I am sure we can ask for fair play. K. DUNSCOMBE W. K. W.
SIR,—As
I
am
one
writing to
Penzance.
Medical officer of health.
SIR,—I think most doctors would agree that the maximum
salary for the assistant medical officer in the public-health service compares unfavourably with that of his colleagues in any other branch of medicine. Most of us are now fairly senior ; we entered the service with the D.p.H. qualification and all-round postgraduate hospital experience ; and we do work similar to that of an s.H.M.o., yet we do not get the same pay as the There are higher-paid appointments as M.O.H., S.H.M.O. senior medical officer, and divisional M.O.H., deputy medical officer ; but these appointments are, in the main, administrative, and there are not enough vacancies for all. Meanwhile, the maximum salary for an assistant medical officer remains £1300. Until this is remedied I cannot see how the public-health service can attract I am convinced that if the maximum many recruits.
143
salary is not raised to the same level as that in the hospital service we shall see the decline of public-health work. I regard the salary scale as quite inadequate. D.P.H. DOES IRON
SMELL?
am extremely interested in the development ferrotherapy, I readwith particular interest the illuminating article by Dr. Wilmers and Mr. Heriot in your issue of July 10. But I am much intrigued by the report, in case 2, that the stomach contents " smelled strongly of ferrous sulphate," and also by the comment, passed a soft black stool which smelled of iron." Surely this is not strictly in accordance with the facts. I have before me a wide range of iron-containing preparations, including’Analar ’ ferrous sulphate. This material I submitted to personal olfactory tests, and I also asked 6 assorted observers, who happened to be immediately available, to report on the smell of a container containing ferrous sulphate. All were agreed that no smell was
SIR,—As I
of
observable. I experimented, with the same observers, with a range of ferrous salts, including ferrous carbonate (impure admittedly),’ ferrous succinate (pure), ferrous chloride (impure), ferric chloride solution, ferric nitrate, and also with pure iron powder. In our opinion, none of these exhibited any smell whatever. It must be admitted that solutions of iron salts possess a characteristic inky or metallic taste, but, in the interests of accuracy, I feel I must protest against a scientific report which includes a statement that ferrous sulphate has a distinctive smell. DAVID HALER. London, W.l. ’
-
-
SHADOW OVER THE BARBITURATES
SIR,-Your leading article last week and the paper by Dr. Hunter and Dr. Greenberg draw attention to the problem of addiction to barbiturates. Among the possible methods of dealing with this, a restraint in prescribing hypnotics in general certainly appears to be preferable to the alternative method of older or newer hypnotics. replacing the barbiturates" While there may still be a large place for chloral and is present paraldehyde as sedatives," the risk of addiction " the safest of even with paraldehyde, considered to be hypnotics,"1 though the risk is much less than with barbiturates. You point out that " addiction [to barbiturates] is liable to develop only in psychologically abnormal people ; " but if unstable people were introduced to paraldehyde they might also become victims of this much rarer type of addiction,in spite of its unpleasant taste. This appears to be definitely the case with psychopaths and alcoholics. During the last year we have seen several such cases among our patients ; they had either got their paraldehyde without a preor had paid exorbitant prices at scription at a chemist’s, " unoincial sources. Alcoholics put on paraldeprivate hyde after withdrawal of alcohol frequently develop a liking for paraldehyde very rapidly, stressing the fact that it seems to do for them exactly what alcohol had done for them previously. Fleming2 refers to a paper describing 40 cases of paraldehyde addiction among alcoholics. In the case of a new hypnotic, it takes time to find out whether it is habit-forming or addiction-producing. As far as methylpentynol is concerned, May and Ebaugh 3 state that " if it is used as a hypnotic only, addiction will not occur ; if used as a sedative there is a definite possibility that patients may develop addiction, although this may be less likely than with other sedative-hypnotic
by
...
"
drugs."
Among approximately
100
patients (chiefly
Morgan, T. N. Practitioner, 1953, 171, 196. 2. Fleming, R. In Alcohol, Science and Society. New Haven, 1945 ; p. 392. 3. May, P. R., Ebaugh, F. G. Amer. J. Psychiat. 1953, 109, 881. 1.
a smaller number of neurotics), we have far found no evidence that methylpentynol leads to craving, increase in tolerance, or psychological or physical dependence. It is interesting to note that 5 chronic alcoholics, who had also taken large doses of barbiturates and paraldehyde before admission, stated that with methylpentynol they missed the " kick " or "lift" which they obtained from those two other drugs, and that they could not visualise becoming addicted to it. But one has to keep an open mind regarding this question. In view of the fact that this drug has recently received some publicity in the daily press and can be bought without prescription, it may be useful to remember that although methylpentynol has generally been found to be non-toxic, a case of fatal poisoning due to a suicidal overdose of from 18 to 24 capsules has lately been reported from America.4 Cases of multiple drug-addiction similar to the one mentioned by Dr. Hunter and Dr. Greenberg were frequent among our alcoholic patients. Over 25% of 100 alcoholics admitted taking excessive doses of other drugs, chiefly barbiturates, often combined with the use of amphetamines in the morning. The World Health Organisation’s expert committee on drugs liable to produce addiction, which already, in 1952,5 considered the barbiturates " drugs liable -to produce addiction," now recommends that amphetamines should be submitted to the same restrictions as barbiturates.6 Your recommendation of restraint in the prescription of barbiturates and your warning of the " risks in repeatedly handing out barbiturates to a neurotic patient " appear to be almost equally justified in the case of these other drugs mentioned, which are sometimes taken by unstable personalities for similar purposes as the barbiturates, though the problem may be less urgent both as far as the numbers of people affected and the risk of consequences is concerned. M. M. M. GLATT. Warlingham, Surrey.
alcoholics, with so
_
SiR,,-Your leading article in last week’s issue is very For years I have been warning against their In The Medical Review, which I edit, I have dangers. time and again written against their continued prescription by doctors. In a textbook intended for students, they are actually stated not to cause addiction. That they do is, of course, undeniable. I know of 3 or 4 persons who take barbiturates regularly every night and cannot give up this pernicious and withal dangerous habit. They must, of course, be obtaining regular prescriptions for phenobarbitone from their medical attendants. They have, unwittingly, become " phenobarbitonists," just like the morphinist of old. Insomnia, like all abnormal conditions, must always have a cause, but many doctors today have no time to discover it, so the easiest way out is to prescribe phenobarbitone-which is not a cure. I have seen some very severe attacks of dermatitis which were produced by phenobarbitone and which took weeks to cure. Apart from fatal cases, the result of suicide or the taking of an overdose, it is not at all unlikely that phenobarbitone produces other far-reaching effects on those who habitually resort to its use for insomnia. But why prescribe it at all when there are infinitely safer, if older, remedies, such as methylsulphonal, paraldehyde, and so on ? Of course, phenobarbitone is not the only drug that is being indiscriminately prescribed by the modern doctor : there are others, such as cortisone, aspirin, and penicillin, to name but a few examples. When will doctors cease to be the slaves of the experimental laboratory and when welcome.
4. Cares, R. M. Amer. J. clin. Path. 1953, 23, 129. 5. Third Report of W.H.O. Expert Committee on drugs liable to produce addiction. Geneva, 1952. 6. Fourth Report of W.H.O. Expert Committee on drugs liable to produce addiction. Geneva, 1954.
Although it is still too early to be certain, it seems that bifacton by mouth is just as effective in controlling an established case of pernicious ansemia as any of the various injections. It would be very interesting to see how a newly diagnosed case would respond, and I have been on the look-out for one in my practice-so far, without success. One must also consider the questions of cost and convenience ; bifacton is more expensive than any of the injections and many patients might prefer a weekly or fortnightly injection to a daily tablet. The blood examinations were performed by Dr. A. L. and his assistants in the laboratory of the Bristol General Hospital, and to them my thanks are due.
Taylor
SERUM HEPATITIS
SIR,—The last paragraph of your leading article of June 26 states that " one can feel relatively safe in Great Britain when administering fresh whole blood, or plasma prepared from pools of 8-10 donations." To avoid any possible misconceptions regarding the icterogenicity of fresh as compared with stored blood, I would like to point out that the blood used in the trials, on the results of which the above statement is based, was from a few days to 3 weeks old when transfused.
ORAL TREATMENT OF PERNICIOUS ANÆMIA SIR,—I was much interested in the article by Dr. Lowther and his colleagues in your issue of March 6, for I had then been treating 4 established cases with ,
Bifacton ’ for over three months. Now after more than months on the tablets alone, my experience is the same as theirs.
seven
Some details of my cases are given in the accompanying table. It is noted that 3 patients have had neurological symptoms, and these recurred from time to time in the older men Case
A--e
1
57 57 ( 70 74
2 3 4
despite
’
Previous treatment
Diagnosed
Sept. 22, 1949 April 7, 1949 Sept. 4, 1942 June 5, 1944
,
Anahæmin ’
I ! ’ i.
are
free except
case
Neurological symptoms
i j ’
Neohepatex ’ Cytamen 100 ’! ,
Anahæmin ’
treatment controlled with
Now all
I
periodic
)
Absent
Slight Present Present
blood examinations.
3, whose symptoms returned for
short time when dosage was reduced to one tablet a day, but have since disappeared on two tablets daily. All 4 have kept in excellent health on bifacton only, except case 2, who had a month on ’ Fersolate ’ tablets as well. Blood pictures show normal films and the Hb is 100% or above. Dosage was begun at two tablets daily, reduced to one after three months, except case 3 as I have mentioned. The 2 younger patients are at work and say they feel better than they did on injections, while the older 2 say they are as well as before ; and all prefer the tablets. a
JOSEPH SLUGLETT.
Bristol, 4.
Lister Institute of Preventive Medicine, Elstree, Herts.
W. D’A. MAYCOCK. Herts.
SALARIES IN THE PUBLIC-HEALTH SERVICE
of the forgotten men (and some women) draw your attention to the salary position of medical officers of health. I hardly need to remind you that we unfortunates are the only doctors who must hold two statutory qualifications. This we do not quarrel with, but it should surely be reflected in the salaries paid. These may be adequate for county medical officers and the medical officers of health of the big county boroughs, but for those of the smaller county boroughs, and in particular for those medical officers of health holding what are termed mixed appointments, the salaries paid are in no way commensurate with the responsibility. In my own case, after seventeen years as an M.o.H., my salary (the maximum on the present complicated formula) is less than £1700—i.e., only £400 more than an assistant medical officer’s and only E300 more than that of an assistant dental surgeon under the recent award. This example can be multiplied many times as many of my colleagues are in the same boat. Unless there is a very substantial revision upward I should strongly advise any potential recruits to medicine to choose some other branch. You, Sir, have not been particularly vocal in championing the case for adequate salaries in the public-health service, but I am sure we can ask for fair play. K. DUNSCOMBE W. K. W.
SIR,—As
I
am
one
writing to
Penzance.
Medical officer of health.
SIR,—I think most doctors would agree that the maximum
salary for the assistant medical officer in the public-health service compares unfavourably with that of his colleagues in any other branch of medicine. Most of us are now fairly senior ; we entered the service with the D.p.H. qualification and all-round postgraduate hospital experience ; and we do work similar to that of an s.H.M.o., yet we do not get the same pay as the There are higher-paid appointments as M.O.H., S.H.M.O. senior medical officer, and divisional M.O.H., deputy medical officer ; but these appointments are, in the main, administrative, and there are not enough vacancies for all. Meanwhile, the maximum salary for an assistant medical officer remains £1300. Until this is remedied I cannot see how the public-health service can attract I am convinced that if the maximum many recruits.
143
salary is not raised to the same level as that in the hospital service we shall see the decline of public-health work. I regard the salary scale as quite inadequate. D.P.H. DOES IRON
SMELL?
am extremely interested in the development ferrotherapy, I readwith particular interest the illuminating article by Dr. Wilmers and Mr. Heriot in your issue of July 10. But I am much intrigued by the report, in case 2, that the stomach contents " smelled strongly of ferrous sulphate," and also by the comment, passed a soft black stool which smelled of iron." Surely this is not strictly in accordance with the facts. I have before me a wide range of iron-containing preparations, including’Analar ’ ferrous sulphate. This material I submitted to personal olfactory tests, and I also asked 6 assorted observers, who happened to be immediately available, to report on the smell of a container containing ferrous sulphate. All were agreed that no smell was
SIR,—As I
of
observable. I experimented, with the same observers, with a range of ferrous salts, including ferrous carbonate (impure admittedly),’ ferrous succinate (pure), ferrous chloride (impure), ferric chloride solution, ferric nitrate, and also with pure iron powder. In our opinion, none of these exhibited any smell whatever. It must be admitted that solutions of iron salts possess a characteristic inky or metallic taste, but, in the interests of accuracy, I feel I must protest against a scientific report which includes a statement that ferrous sulphate has a distinctive smell. DAVID HALER. London, W.l. ’
-
-
SHADOW OVER THE BARBITURATES
SIR,-Your leading article last week and the paper by Dr. Hunter and Dr. Greenberg draw attention to the problem of addiction to barbiturates. Among the possible methods of dealing with this, a restraint in prescribing hypnotics in general certainly appears to be preferable to the alternative method of older or newer hypnotics. replacing the barbiturates" While there may still be a large place for chloral and is present paraldehyde as sedatives," the risk of addiction " the safest of even with paraldehyde, considered to be hypnotics,"1 though the risk is much less than with barbiturates. You point out that " addiction [to barbiturates] is liable to develop only in psychologically abnormal people ; " but if unstable people were introduced to paraldehyde they might also become victims of this much rarer type of addiction,in spite of its unpleasant taste. This appears to be definitely the case with psychopaths and alcoholics. During the last year we have seen several such cases among our patients ; they had either got their paraldehyde without a preor had paid exorbitant prices at scription at a chemist’s, " unoincial sources. Alcoholics put on paraldeprivate hyde after withdrawal of alcohol frequently develop a liking for paraldehyde very rapidly, stressing the fact that it seems to do for them exactly what alcohol had done for them previously. Fleming2 refers to a paper describing 40 cases of paraldehyde addiction among alcoholics. In the case of a new hypnotic, it takes time to find out whether it is habit-forming or addiction-producing. As far as methylpentynol is concerned, May and Ebaugh 3 state that " if it is used as a hypnotic only, addiction will not occur ; if used as a sedative there is a definite possibility that patients may develop addiction, although this may be less likely than with other sedative-hypnotic
by
...
"
drugs."
Among approximately
100
patients (chiefly
Morgan, T. N. Practitioner, 1953, 171, 196. 2. Fleming, R. In Alcohol, Science and Society. New Haven, 1945 ; p. 392. 3. May, P. R., Ebaugh, F. G. Amer. J. Psychiat. 1953, 109, 881. 1.
a smaller number of neurotics), we have far found no evidence that methylpentynol leads to craving, increase in tolerance, or psychological or physical dependence. It is interesting to note that 5 chronic alcoholics, who had also taken large doses of barbiturates and paraldehyde before admission, stated that with methylpentynol they missed the " kick " or "lift" which they obtained from those two other drugs, and that they could not visualise becoming addicted to it. But one has to keep an open mind regarding this question. In view of the fact that this drug has recently received some publicity in the daily press and can be bought without prescription, it may be useful to remember that although methylpentynol has generally been found to be non-toxic, a case of fatal poisoning due to a suicidal overdose of from 18 to 24 capsules has lately been reported from America.4 Cases of multiple drug-addiction similar to the one mentioned by Dr. Hunter and Dr. Greenberg were frequent among our alcoholic patients. Over 25% of 100 alcoholics admitted taking excessive doses of other drugs, chiefly barbiturates, often combined with the use of amphetamines in the morning. The World Health Organisation’s expert committee on drugs liable to produce addiction, which already, in 1952,5 considered the barbiturates " drugs liable -to produce addiction," now recommends that amphetamines should be submitted to the same restrictions as barbiturates.6 Your recommendation of restraint in the prescription of barbiturates and your warning of the " risks in repeatedly handing out barbiturates to a neurotic patient " appear to be almost equally justified in the case of these other drugs mentioned, which are sometimes taken by unstable personalities for similar purposes as the barbiturates, though the problem may be less urgent both as far as the numbers of people affected and the risk of consequences is concerned. M. M. M. GLATT. Warlingham, Surrey.
alcoholics, with so
_
SiR,,-Your leading article in last week’s issue is very For years I have been warning against their In The Medical Review, which I edit, I have dangers. time and again written against their continued prescription by doctors. In a textbook intended for students, they are actually stated not to cause addiction. That they do is, of course, undeniable. I know of 3 or 4 persons who take barbiturates regularly every night and cannot give up this pernicious and withal dangerous habit. They must, of course, be obtaining regular prescriptions for phenobarbitone from their medical attendants. They have, unwittingly, become " phenobarbitonists," just like the morphinist of old. Insomnia, like all abnormal conditions, must always have a cause, but many doctors today have no time to discover it, so the easiest way out is to prescribe phenobarbitone-which is not a cure. I have seen some very severe attacks of dermatitis which were produced by phenobarbitone and which took weeks to cure. Apart from fatal cases, the result of suicide or the taking of an overdose, it is not at all unlikely that phenobarbitone produces other far-reaching effects on those who habitually resort to its use for insomnia. But why prescribe it at all when there are infinitely safer, if older, remedies, such as methylsulphonal, paraldehyde, and so on ? Of course, phenobarbitone is not the only drug that is being indiscriminately prescribed by the modern doctor : there are others, such as cortisone, aspirin, and penicillin, to name but a few examples. When will doctors cease to be the slaves of the experimental laboratory and when welcome.
4. Cares, R. M. Amer. J. clin. Path. 1953, 23, 129. 5. Third Report of W.H.O. Expert Committee on drugs liable to produce addiction. Geneva, 1952. 6. Fourth Report of W.H.O. Expert Committee on drugs liable to produce addiction. Geneva, 1954.