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TEXTBOOK ILLUSTRATIONS
1031 same
time
as
explicitly,
if
silently,
in
opposition
ably
like to
see a
clear-cut
rejection
of
Christianity by
dominant opinion and a firm espousal of secular humanism as a means
to mental health. I recommend the
opposite
course.
JOSEPH V. WALKER
Darlington.
Medical Officer of Health.
APPOINTMENT OF REGISTRARS
SIR,—In
your issue of
May 1, six senior registrar posts are advertised by Guy’s Hospital
in various specialties and the South East Metropolitan Regional Hopsital Board. It is stated that preference will be given to applicants who have held a registrar post in the appropriate specialty in a teaching hospital. In your journal, not very many issues ago, the question of junior staffing in peripheral hospitals was discussed and it was agreed that one of the causes of the dearth of applicants for such junior posts was just this tendency to select for the more senior teaching-hospital posts those doctors who were already working in teaching hospitals. Are we now to assume that the South East Metropolitan Regional Hospital Board desire to stimulate this drift from the " country " One wonders how soon it will be before the other regions follow suit, if they have not already done so. It is also demoralising to speculate on the power of the " old school tie " philosophy in the regional boards, which blossoms forth in this type of
prejudice against the non-teaching hospitals. What makes the position more depressing is the present policy of making all senior registrar posts on an exchange basis between the parent teaching hospital and a group of peripheral hospitals. This gives the teaching-hospital boards
greater
power than ever before to influence the of all the senior-registrar posts in their
appointments region. I suggest, Sir, that there is something dubious in this senior-registrar exchange scheme, and that it is made apparent by the prejudice expressed in these advertisements.
REGISTRAR. TEXTBOOK ILLUSTRATIONS SIR,—In his letter of May 8 Mr. Engel really raises two " issues-namely, the supply of opaque " photographs, which lend themselves immediately to textbook illustration ; and sources of transparencies for teaching purposes. In relation to his suggested central library the two problems are slightly different in that the writing of textbooks generally represents individual effort, whereas
these have a common framework : factors must influence the selection of material. Even at the present time it is not difficult to view a reasonable supply of photographic prints of a given subject by contacting a number of photographic depart-
teaching should
copies are generally available. frequently done between departments informally, much to the surprise of medical staff who are unaware of this facility. Arrangements for specialised illustrative techniques may often be arranged on a similar basis. As has been suggested by your correspondent, collections of miniature transparencies would be simple to establish and maintain. This has already been done in America by a commercial firm ; slides being purchased from various departments after which they are duplicated and resold singly or in sets. The resulting turnover is reported to be in the region of 100,000 per yearobviously there is some demand for this service ! ments from which file
This is
Westminster Hospital Medical School. London, S.W.1.
PROLONGED ANURIA
as
when Tertullian contemptuously asked what Athens could expect to find in common with Jerusalem. ’Dr. Comfort, if he remains true to the sentiments expressed in his broadcast talks in 1949, would presum-
PETER HANSELL.
SIR,—We
were
interested in the discussion
on
the
management of prolonged anuria by Prof. Scott Russell and his colleagues in your issue of May 1. We have recently treated 3 similar cases on the same lines and by the infusion of hypertonic dextrose solution into the inferior vena cava via the saphenous vein at the groin. One of us has used this method of intravenous years in all cases where difficulty in has been anticipated—for the infusion maintaining example, while operating with a steep Trendelenburg
infusion for
some
position. In addition to the merits of this method of infusion mentioned in the article, we prefer it because it seems to us technically easier than infusion into the superior vena cava and also because it is appreciably more comfortable for the patient when infusion must be continued for some days. As regards technique, we do not consider it necessary to ligate the main tributaries at the upper end of the saphenous vein; we merely ligate the distal end. Similarly, we find that a gauze pad and ’ Elastoplast ’ gives quite adequate pressure both during infusion and when the catheter is removed. GAVIN SHAW Southern General Hospital, JAMES MAIR. Glasgow. CLINICAL TESTS FOR KETONURIA SIR,—We regret that Dr. Archer and Dr. Lehmann (May 1) were misled into thinking that we wished to decry the method of discovering ketonuria used hitherto. Our comments were directed towards the quantitative interpretation of essentially qualitative clinical tests. Our paper was not intended as a contribution to chemical pathology but rather to the use of these tests in clinical
practice. Dr. Archer and Dr. Lehmann do service to the historical
aspect of the subject in drawing attention to the important papers by Kennaway and Hurtley. One of- the latter’s most important contributions to the Rothera test was his demonstration of the sensitivity of the test to acetoacetic acid, which was unknown to Rothera. Hurtley’s own test, however, is not used in clinical practice. Although the concentrations of aceto-acetic acid and acetone in urine have been well known for many years, the numerous variations in technique in performing the clinical tests have, we believe, prevented a uniform interpretation in clinical practice and have made a standardised procedure desirable. We set out to compare the two classical tests with the tablet test, we made it clear that our sensitivity tests corresponded to those of previous workers, and we referred readers to the review by Friedemann. It is true that Kennaway’s " slow-weak " reaction and similar reactions have been regarded as of no clinical imporWe considered this point and tance by some clinicians. concluded that the significance of such results is still not clear. It is a dangerous assumption to regard them as of no clinical importance until more is known about the problem. A positive test for ketonuria should always be assessed in relation to the clinical state of the patient. Our references to various textbooks were intended not so much as a criticism of the methods described as an illustration of the various descriptions which are current. We agree that when Gerhardt’s test is performed, as described by Harrison, it is usually adequate. We believe, however, that many nurses and clinicians throughout the do not practise thorough boiling in a boiling-tube or open vessel. Indeed, we are certain that many of them possess neither a boiling-tube nor a beaker.
country
’
,
Dr. Archer and Dr. Lehmann conclude that because the tablet test is a " dehydrated," less sensitive Rothera test it has no advantages in the laboratory. We think that they should have more adequate reasons for what seems to us a hasty and illogical condemnation. We
time
as
explicitly,
if
silently,
in
opposition
ably
like to
see a
clear-cut
rejection
of
Christianity by
dominant opinion and a firm espousal of secular humanism as a means
to mental health. I recommend the
opposite
course.
JOSEPH V. WALKER
Darlington.
Medical Officer of Health.
APPOINTMENT OF REGISTRARS
SIR,—In
your issue of
May 1, six senior registrar posts are advertised by Guy’s Hospital
in various specialties and the South East Metropolitan Regional Hopsital Board. It is stated that preference will be given to applicants who have held a registrar post in the appropriate specialty in a teaching hospital. In your journal, not very many issues ago, the question of junior staffing in peripheral hospitals was discussed and it was agreed that one of the causes of the dearth of applicants for such junior posts was just this tendency to select for the more senior teaching-hospital posts those doctors who were already working in teaching hospitals. Are we now to assume that the South East Metropolitan Regional Hospital Board desire to stimulate this drift from the " country " One wonders how soon it will be before the other regions follow suit, if they have not already done so. It is also demoralising to speculate on the power of the " old school tie " philosophy in the regional boards, which blossoms forth in this type of
prejudice against the non-teaching hospitals. What makes the position more depressing is the present policy of making all senior registrar posts on an exchange basis between the parent teaching hospital and a group of peripheral hospitals. This gives the teaching-hospital boards
greater
power than ever before to influence the of all the senior-registrar posts in their
appointments region. I suggest, Sir, that there is something dubious in this senior-registrar exchange scheme, and that it is made apparent by the prejudice expressed in these advertisements.
REGISTRAR. TEXTBOOK ILLUSTRATIONS SIR,—In his letter of May 8 Mr. Engel really raises two " issues-namely, the supply of opaque " photographs, which lend themselves immediately to textbook illustration ; and sources of transparencies for teaching purposes. In relation to his suggested central library the two problems are slightly different in that the writing of textbooks generally represents individual effort, whereas
these have a common framework : factors must influence the selection of material. Even at the present time it is not difficult to view a reasonable supply of photographic prints of a given subject by contacting a number of photographic depart-
teaching should
copies are generally available. frequently done between departments informally, much to the surprise of medical staff who are unaware of this facility. Arrangements for specialised illustrative techniques may often be arranged on a similar basis. As has been suggested by your correspondent, collections of miniature transparencies would be simple to establish and maintain. This has already been done in America by a commercial firm ; slides being purchased from various departments after which they are duplicated and resold singly or in sets. The resulting turnover is reported to be in the region of 100,000 per yearobviously there is some demand for this service ! ments from which file
This is
Westminster Hospital Medical School. London, S.W.1.
PROLONGED ANURIA
as
when Tertullian contemptuously asked what Athens could expect to find in common with Jerusalem. ’Dr. Comfort, if he remains true to the sentiments expressed in his broadcast talks in 1949, would presum-
PETER HANSELL.
SIR,—We
were
interested in the discussion
on
the
management of prolonged anuria by Prof. Scott Russell and his colleagues in your issue of May 1. We have recently treated 3 similar cases on the same lines and by the infusion of hypertonic dextrose solution into the inferior vena cava via the saphenous vein at the groin. One of us has used this method of intravenous years in all cases where difficulty in has been anticipated—for the infusion maintaining example, while operating with a steep Trendelenburg
infusion for
some
position. In addition to the merits of this method of infusion mentioned in the article, we prefer it because it seems to us technically easier than infusion into the superior vena cava and also because it is appreciably more comfortable for the patient when infusion must be continued for some days. As regards technique, we do not consider it necessary to ligate the main tributaries at the upper end of the saphenous vein; we merely ligate the distal end. Similarly, we find that a gauze pad and ’ Elastoplast ’ gives quite adequate pressure both during infusion and when the catheter is removed. GAVIN SHAW Southern General Hospital, JAMES MAIR. Glasgow. CLINICAL TESTS FOR KETONURIA SIR,—We regret that Dr. Archer and Dr. Lehmann (May 1) were misled into thinking that we wished to decry the method of discovering ketonuria used hitherto. Our comments were directed towards the quantitative interpretation of essentially qualitative clinical tests. Our paper was not intended as a contribution to chemical pathology but rather to the use of these tests in clinical
practice. Dr. Archer and Dr. Lehmann do service to the historical
aspect of the subject in drawing attention to the important papers by Kennaway and Hurtley. One of- the latter’s most important contributions to the Rothera test was his demonstration of the sensitivity of the test to acetoacetic acid, which was unknown to Rothera. Hurtley’s own test, however, is not used in clinical practice. Although the concentrations of aceto-acetic acid and acetone in urine have been well known for many years, the numerous variations in technique in performing the clinical tests have, we believe, prevented a uniform interpretation in clinical practice and have made a standardised procedure desirable. We set out to compare the two classical tests with the tablet test, we made it clear that our sensitivity tests corresponded to those of previous workers, and we referred readers to the review by Friedemann. It is true that Kennaway’s " slow-weak " reaction and similar reactions have been regarded as of no clinical imporWe considered this point and tance by some clinicians. concluded that the significance of such results is still not clear. It is a dangerous assumption to regard them as of no clinical importance until more is known about the problem. A positive test for ketonuria should always be assessed in relation to the clinical state of the patient. Our references to various textbooks were intended not so much as a criticism of the methods described as an illustration of the various descriptions which are current. We agree that when Gerhardt’s test is performed, as described by Harrison, it is usually adequate. We believe, however, that many nurses and clinicians throughout the do not practise thorough boiling in a boiling-tube or open vessel. Indeed, we are certain that many of them possess neither a boiling-tube nor a beaker.
country
’
,
Dr. Archer and Dr. Lehmann conclude that because the tablet test is a " dehydrated," less sensitive Rothera test it has no advantages in the laboratory. We think that they should have more adequate reasons for what seems to us a hasty and illogical condemnation. We