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THE LONDON MEMBERSHIP AND PSYCHIATRISTS
1217 number of cases where " 5 Perhaps some or all of these points will receive careful micron filters " have been installed the dust in the theatre has consideration in future, and in this respect it is encouraging been so clearly apparent that it has been considered essential to note that the new regulations do not appear to be final to modify the system by installing high-efficiency filters and may be reviewed and possibly modified by the " (referred to in the article as 0-5" micron filters ") as terminal Comitia in 4 years’ time (May 16, p. 1100). 5 micron filters to act as filters in the suite, leaving the Shelton Hospital, pre-filters. Where this has been done, satisfactory conditions Shrewsbury, J. C. BARKER. Shropshire. have resulted. The usual reason given in support of using less than the best quality of filters available is that of cost. If high-efficiency THE LONDON MEMBERSHIP AND PSYCHIATRISTS filters are properly installed, with efficient renewable or SiR,ŃThe title of your editorial of May 16 suggests cleanable pre-filters to protect them from being prematurely that one of the main reasons for changing the London clogged, the main filters should last for at least five years. On M.R.C.P. was the appeasement of a minority of psychiathis basis the replacement cost for an average operating-theatre and so, possibly, " reduce the demand for " the would work out at the rate of only E30 per annum. In the case trists, foundation of a College of Psychiatrists. Time will show " quoted in your article where the annual cost of 0-5 micron filter replacement was 8% of the installation cost of the whole whether the changes will be considered satisfactory by plant, it would appear that the normal practice of using pre- the general physicians themselves; as you point out, the examination will be taken at an inconvenient time, part filters could not have been followed. The established experience of many other users is that the annual replacement cost of way in the training of the physician. Furthermore, it properly installed high-efficiency filters is no more than a fifth will lead to two classes of members-those who qualify of the cost of the actual filters themselves. at stage 11 and those who qualify at stage III. Be that as
by the ventilation system. In
a
"
"
Salisbury, Wilts.
J. E. FIRMAN.
THE LONDON MEMBERSHIP to comment on some of the in the revised anomalies apparent regulations for the London membership ?
SIR,-May I be permitted
(1) The introduction of a part i is long overdue and is likely to be universally welcomed. It is, however, questionable whether a multiple-choice written examination is preferable to an ordinary type of intelligence test, such as the Wechsler, of excluding unsuitable candidates. If the latter instituted it might be interesting to see if there was any correlation between performance on part I with success in the M.R.C.P. at the part 11 or part III levels. (2) In my opinion the decision to partition the M.R.c.P. into part 11 and part ill unnecessarily complicates the examination and is open to serious objections. The streaming of candidates resulting therefrom is reminiscent of the eleven-plus and may be similarly criticised. In contradistinction to the eleven-plus, however, candidates are presumably still free to attempt the M.R.C.P. on an unlimited number of occasions, perhaps until successful, and some restrictions in this connection would now seem to me to be appropriate. (3) When the revised regulations have become fully operative some future appointments committees for consultant posts may require the applicant to declare whether he obtained a part n (" first class ") or part ill (" second class ") M.R.C.P. Other considerations being equal, the applicant who obtained his M.R.C.P. at the part-ll level would have a distinct advantage over any of his part-in opponents. There are at present no provisions in the new regulations to convert a part-in into a part-n membership at a later stage in order to surmount this invidious situation, should this prove desirable. (4) Under the new system candidates may prefer to write the M.R.C.P. examination of one of the other colleges (such as the M.R.C.P. Edinburgh) where the examination is not partitioned in the same way and no " class distinctions are drawn. For some this course might be preferable to running the risk of obtaining a part III M.R.C.P. (Lond.). It would indeed be interesting to speculate whether the revised regulations for the M.R.C.P. (Lond.) will increase the number
as a means were
it may, it is obvious, as you concede, that the London Membership is not a higher qualification in psychiatry. It will call for continual practice in general medicine and so interfere with training in psychiatry. The examination can be passed without any special training in psychiatry. Indeed, an aspiring psychiatrist who is successful at stage 11 will deny himself any training in psychiatry and be a psychiatrist by inspiration only. A less able psychiatrist qualifying at stage III will at least have the dubious advantage of an inadequate training. A desire for parity with other major specialties is the main reason for psychiatrists wishing to found a College. It is unfortunate that the President of the Royal MedicoPsychological Association should deem it proper to imply with his intervention (May 16) that the main reason is the need for a higher examination in psychiatry and that this is, possibly, achieved by " an event of such importance " as changes in the London M.R.C.P. Very wisely, as the President says, the Council of the R.M.P.A. " do not feel that it would be right for them to publicise or circulate the decision of another body ". But this has not prevented the President of the R.M.P.A. himself using his authority at a critical moment to publicise the decision of another body. A majority in favour of a College of Psychiatrists in the results of the recent ballot would again show the divergence between the views of some of the officers of the R.M.P.A. and of most of its members. Should these officers lose the confidence of the members, changes must take place and allow the general secretary to be assisted by a democratic and representative sovernment in the tasks still before him. Ipswich and
East Suffolk Hospital,
Ipswich.
JOHN G. HOWELLS.
"
** The title of one of our leaders seems a slender basis for speculation on the intentions of the Royal College of Physicians. The title simply showed what the article was about.-ED. L.
of applicants
seeking membership of the other colleges offering less complex type of examination procedure, and trends in this direction may shortly become apparent. (5) The decision not to grant exemption from the M.R.C.P. (Lond.) examination by published work of suitable merit is not calculated to be favourably received by those senior members of the profession who, perhaps after many years, are not prepared to compete in further examinations and yet desire and deserve the status which the M.R.C.P. (Lond.) at present affords. It is to be hoped, however, that they will not be precluded from obtaining the F.R.C.P. (Lond.) by this means. a
SIR,-May I remind you of St. Luke, chap. 5, verse 37: " And no one puts new wine into old wine skins. If he does the new wine will burst the skin and it will be spilled and the skins will be destroyed but new wine must be put into fresh wine skins." Whether a new wine of psychiatry would in fact burst the creaking and cracked leather of the Royal College of Physicians is probably doubtful, but it would seem to me a case for a Royal College of Psychiatry is still clear.
1218 Whilst one welcomes the new provisions for the membership examination, nevertheless this examination is still not a higher qualification in psychiatry. This is still needed and only a Royal College could provide it. It is still false to say that by forming a Royal College of Psychiatry we shall be formally dissociating psychiatrists from other kinds of physician. By forming a Royal College we shall raise our standards and increase our influence. As you rightly say, the Physicians’ College could not and should not be expected to speak for psychiatry alone. It is because psychiatry is concerned with the whole man and not just a narrow specialty such as neurology or pathology that it must be able to speak powerfully for itself. A psychiatrist is concerned not only with the treatment of mental illness but also with the promotion of mental health and is therefore concerned with the broader issues of hospital organisation, nursepatient relationships, communication, and so on, all of which are of vital importance to both family doctoring and hospital medicine. It is also this aspect of our work which needs a voice.
that the new membership regulations flexible for the aspiring psychiatrist to be sufficiently able to take the membership in a way that was not possible before. He could take this before taking his higher qualification in psychiatry. It would therefore seem feasible for far more psychiatrists than at present to be members of the Royal College of Physicians and members of any new College of Psychiatry. If this comes about, certainly the M.R.C.P. should not be considered a sine-quanon of consultant eligibility, but, because (I believe) many more psychiatrists would take this examination, psychiatry in the long run will have a powerful voice through its own Royal College and be sufficiently linked with other kinds of physicians through an increased membership in the Roval College of Phvsicians. H. B. KIDD Towers Hospital, It
seems to me
are
Humberstone, Leicester.
Medical Superintendent.
LOW-MOLECULAR-WEIGHT DEXTRAN SIR,-May I comment on the case-report of Dr. Farrant and Dr. Sagar (May 16). Langsjoen et aU successfully administered low-molecularweight dextran (’Rheomacrodex’ 10%) continuously for periods of 76 hours at a dose of 1-5-3-0 g. per kg. in 24 hours (equivalent to 15-30 ml. per kg. in 24 hours) to patients with known cardiac infarcts. They stated that " there was no evidence of major complications in these 34 patients as a result of treatment with low-molecular-weight dextran ". Seemingly, infusions of rheomacrodex of the order of 15-30 ml. per kg. in 24 hours are well tolerated, even by patients with cardiac disease. The patient treated by Dr. Farrant and Dr. Sagar received a greater amount of rheomacrodex. That infusions limited to 500 ml. (rheomacrodex 10%) daily benefit patients with peripheral ischaemia has been shown by Powley,2 and Bienenstock and Hardingusing doses somewhat greater than this for initial treatment but continuing with intermittent doses of 500 ml. per day. At this dose level, which is well within that described above, the circulation is not overloaded. Farrant and Sagar, however, are the first investigators to confirm by skin-temperature measurement the increase in temperature of ischxmic limbs soon after infusion of rheomacrodex, and this is a most valuable observation. With regard to the authors’ note of caution, I think it would be fair to state that the reports which I have quoted and the many other references to rheomacrodex show that, at the dosage levels described above, overtransfusion is not reported and that definite therapeutic advantages ensue. D. R. CHAMBERS Pharmacia (Great Britain), Ltd., 1.
Medical Adviser. Ealing, London, W.13. H. S. S., Sanchez, A., Lynch, D. J. Angiology, Langsjoen, H., Falconer,
2. 3.
1963, 14, 465. Powley, P. H. Lancet, 1963, i, 1189. Bienenstock, J., Harding, E. L. T. ibid. 1964, i, 524.
West
MEGALOBLASTIC ANÆMIA DUE TO DIETARY DEFICIENCY SIR,-The relatively high incidence of nutritional megaloblastic anaemia described by my colleagues and
myself (May 9) is supported by the impressive results obtained by Dr. Varadi and Mr. Elwis (May 23). Howdifference between the incidence of megaloblastic change during pregnancy in their series and in ours-namely 48% and 4% respectively-requires a brief comment. Since 1958, when I found that the incidence of megaloblastic anxmia was 1 case in every 67 hospital confinements1 we have observed a notable decrease in the incidence of this complication of pregnancy, and this must be due to the fact that folic acid is given to a high proportion of pregnant women in this area. I am surprised, therefore, that in some districts there must still be hesitation in giving folic acid as a prophylactic measure. ever, the clear
Sefton General
Hospital, Liverpool, 15.
J. FORSHAW.
EFFECT OF ALDOSTERONE ON ANGIOTENSIN SKIN-TEST
SIR,-Recent observations have pointed to a connection between angiotensin and aldosterone. Angiotensin II has been said to increase the rate of secretion of aldosterone. Moreover, it is considered to be the physiological regulator of aldosterone secretion. Although this view has not as yet received sufficient support, it seems likely that angiotensin is responsible in some disorders for increased secretion of aldosterone. a dual angiotensin/aldosterone system has triple angiotensinase/angiotensin/aldosterone system, by the demonstration of an angiotensin-inhibiting substance in the blood-angiotensinase. Hickler et a1. showed that in pregnant women and patients with secondary hyperaldosteronism angiotensinase activity in the blood decreased.
The notion of
given
way to
a
According to some research IZrOUDs.2-.11 ansiotensinase activitv in the blood is diminished also in patients with essential or renal hypertension. Considering that in many patients
with essential hypertension, and in most renal hypertensives, aldosterone excretion attains or considerably exceeds normal values, some direct or indirect connection between angiotensinase and aldosterone may be assumed. We tried to find outwhether aldosterone influenced
angiotensinase activity. Angiotensinase activity was measured by means of the angiotensin skin-test described by Jablons.4 Essentially, the test is based on the observation that, after the intracutaneous injection of 0-1 pg. of angiotensin 11, a circumscrihed
area
of nallnr
Results of angiotensin skin-test in controls and hyperaldosteronæmia.
the skin, the duration of which is supposed to be appears inversely related to angiotensinase activity. Our examinations were carried out on 18 young, healthy subjects. In the control series the Jablons test was carried out with synthetic angioon
1. 2. 3. 4. 5. 6.
Postgrad. med. J. 1958, 34, 222. Hickler, R. B., Lauler, D. P., Thorn, G. W. J. clin. Invest. 1963, 42, 635. Gömöri, P., Egedy, S., Kerekes, G. Orv. Hetil. 1963, 104, 2067. Jablons, B. Circulation, 1962, 25, 259. Mendlowitz, M., Wolf, R. L., Gitlow, S. E., Naftchi, N. E. ibid. p. 231. Wood, J. E. ibid. p. 225.
by the ventilation system. In
a
"
"
Salisbury, Wilts.
J. E. FIRMAN.
THE LONDON MEMBERSHIP to comment on some of the in the revised anomalies apparent regulations for the London membership ?
SIR,-May I be permitted
(1) The introduction of a part i is long overdue and is likely to be universally welcomed. It is, however, questionable whether a multiple-choice written examination is preferable to an ordinary type of intelligence test, such as the Wechsler, of excluding unsuitable candidates. If the latter instituted it might be interesting to see if there was any correlation between performance on part I with success in the M.R.C.P. at the part 11 or part III levels. (2) In my opinion the decision to partition the M.R.c.P. into part 11 and part ill unnecessarily complicates the examination and is open to serious objections. The streaming of candidates resulting therefrom is reminiscent of the eleven-plus and may be similarly criticised. In contradistinction to the eleven-plus, however, candidates are presumably still free to attempt the M.R.C.P. on an unlimited number of occasions, perhaps until successful, and some restrictions in this connection would now seem to me to be appropriate. (3) When the revised regulations have become fully operative some future appointments committees for consultant posts may require the applicant to declare whether he obtained a part n (" first class ") or part ill (" second class ") M.R.C.P. Other considerations being equal, the applicant who obtained his M.R.C.P. at the part-ll level would have a distinct advantage over any of his part-in opponents. There are at present no provisions in the new regulations to convert a part-in into a part-n membership at a later stage in order to surmount this invidious situation, should this prove desirable. (4) Under the new system candidates may prefer to write the M.R.C.P. examination of one of the other colleges (such as the M.R.C.P. Edinburgh) where the examination is not partitioned in the same way and no " class distinctions are drawn. For some this course might be preferable to running the risk of obtaining a part III M.R.C.P. (Lond.). It would indeed be interesting to speculate whether the revised regulations for the M.R.C.P. (Lond.) will increase the number
as a means were
it may, it is obvious, as you concede, that the London Membership is not a higher qualification in psychiatry. It will call for continual practice in general medicine and so interfere with training in psychiatry. The examination can be passed without any special training in psychiatry. Indeed, an aspiring psychiatrist who is successful at stage 11 will deny himself any training in psychiatry and be a psychiatrist by inspiration only. A less able psychiatrist qualifying at stage III will at least have the dubious advantage of an inadequate training. A desire for parity with other major specialties is the main reason for psychiatrists wishing to found a College. It is unfortunate that the President of the Royal MedicoPsychological Association should deem it proper to imply with his intervention (May 16) that the main reason is the need for a higher examination in psychiatry and that this is, possibly, achieved by " an event of such importance " as changes in the London M.R.C.P. Very wisely, as the President says, the Council of the R.M.P.A. " do not feel that it would be right for them to publicise or circulate the decision of another body ". But this has not prevented the President of the R.M.P.A. himself using his authority at a critical moment to publicise the decision of another body. A majority in favour of a College of Psychiatrists in the results of the recent ballot would again show the divergence between the views of some of the officers of the R.M.P.A. and of most of its members. Should these officers lose the confidence of the members, changes must take place and allow the general secretary to be assisted by a democratic and representative sovernment in the tasks still before him. Ipswich and
East Suffolk Hospital,
Ipswich.
JOHN G. HOWELLS.
"
** The title of one of our leaders seems a slender basis for speculation on the intentions of the Royal College of Physicians. The title simply showed what the article was about.-ED. L.
of applicants
seeking membership of the other colleges offering less complex type of examination procedure, and trends in this direction may shortly become apparent. (5) The decision not to grant exemption from the M.R.C.P. (Lond.) examination by published work of suitable merit is not calculated to be favourably received by those senior members of the profession who, perhaps after many years, are not prepared to compete in further examinations and yet desire and deserve the status which the M.R.C.P. (Lond.) at present affords. It is to be hoped, however, that they will not be precluded from obtaining the F.R.C.P. (Lond.) by this means. a
SIR,-May I remind you of St. Luke, chap. 5, verse 37: " And no one puts new wine into old wine skins. If he does the new wine will burst the skin and it will be spilled and the skins will be destroyed but new wine must be put into fresh wine skins." Whether a new wine of psychiatry would in fact burst the creaking and cracked leather of the Royal College of Physicians is probably doubtful, but it would seem to me a case for a Royal College of Psychiatry is still clear.
1218 Whilst one welcomes the new provisions for the membership examination, nevertheless this examination is still not a higher qualification in psychiatry. This is still needed and only a Royal College could provide it. It is still false to say that by forming a Royal College of Psychiatry we shall be formally dissociating psychiatrists from other kinds of physician. By forming a Royal College we shall raise our standards and increase our influence. As you rightly say, the Physicians’ College could not and should not be expected to speak for psychiatry alone. It is because psychiatry is concerned with the whole man and not just a narrow specialty such as neurology or pathology that it must be able to speak powerfully for itself. A psychiatrist is concerned not only with the treatment of mental illness but also with the promotion of mental health and is therefore concerned with the broader issues of hospital organisation, nursepatient relationships, communication, and so on, all of which are of vital importance to both family doctoring and hospital medicine. It is also this aspect of our work which needs a voice.
that the new membership regulations flexible for the aspiring psychiatrist to be sufficiently able to take the membership in a way that was not possible before. He could take this before taking his higher qualification in psychiatry. It would therefore seem feasible for far more psychiatrists than at present to be members of the Royal College of Physicians and members of any new College of Psychiatry. If this comes about, certainly the M.R.C.P. should not be considered a sine-quanon of consultant eligibility, but, because (I believe) many more psychiatrists would take this examination, psychiatry in the long run will have a powerful voice through its own Royal College and be sufficiently linked with other kinds of physicians through an increased membership in the Roval College of Phvsicians. H. B. KIDD Towers Hospital, It
seems to me
are
Humberstone, Leicester.
Medical Superintendent.
LOW-MOLECULAR-WEIGHT DEXTRAN SIR,-May I comment on the case-report of Dr. Farrant and Dr. Sagar (May 16). Langsjoen et aU successfully administered low-molecularweight dextran (’Rheomacrodex’ 10%) continuously for periods of 76 hours at a dose of 1-5-3-0 g. per kg. in 24 hours (equivalent to 15-30 ml. per kg. in 24 hours) to patients with known cardiac infarcts. They stated that " there was no evidence of major complications in these 34 patients as a result of treatment with low-molecular-weight dextran ". Seemingly, infusions of rheomacrodex of the order of 15-30 ml. per kg. in 24 hours are well tolerated, even by patients with cardiac disease. The patient treated by Dr. Farrant and Dr. Sagar received a greater amount of rheomacrodex. That infusions limited to 500 ml. (rheomacrodex 10%) daily benefit patients with peripheral ischaemia has been shown by Powley,2 and Bienenstock and Hardingusing doses somewhat greater than this for initial treatment but continuing with intermittent doses of 500 ml. per day. At this dose level, which is well within that described above, the circulation is not overloaded. Farrant and Sagar, however, are the first investigators to confirm by skin-temperature measurement the increase in temperature of ischxmic limbs soon after infusion of rheomacrodex, and this is a most valuable observation. With regard to the authors’ note of caution, I think it would be fair to state that the reports which I have quoted and the many other references to rheomacrodex show that, at the dosage levels described above, overtransfusion is not reported and that definite therapeutic advantages ensue. D. R. CHAMBERS Pharmacia (Great Britain), Ltd., 1.
Medical Adviser. Ealing, London, W.13. H. S. S., Sanchez, A., Lynch, D. J. Angiology, Langsjoen, H., Falconer,
2. 3.
1963, 14, 465. Powley, P. H. Lancet, 1963, i, 1189. Bienenstock, J., Harding, E. L. T. ibid. 1964, i, 524.
West
MEGALOBLASTIC ANÆMIA DUE TO DIETARY DEFICIENCY SIR,-The relatively high incidence of nutritional megaloblastic anaemia described by my colleagues and
myself (May 9) is supported by the impressive results obtained by Dr. Varadi and Mr. Elwis (May 23). Howdifference between the incidence of megaloblastic change during pregnancy in their series and in ours-namely 48% and 4% respectively-requires a brief comment. Since 1958, when I found that the incidence of megaloblastic anxmia was 1 case in every 67 hospital confinements1 we have observed a notable decrease in the incidence of this complication of pregnancy, and this must be due to the fact that folic acid is given to a high proportion of pregnant women in this area. I am surprised, therefore, that in some districts there must still be hesitation in giving folic acid as a prophylactic measure. ever, the clear
Sefton General
Hospital, Liverpool, 15.
J. FORSHAW.
EFFECT OF ALDOSTERONE ON ANGIOTENSIN SKIN-TEST
SIR,-Recent observations have pointed to a connection between angiotensin and aldosterone. Angiotensin II has been said to increase the rate of secretion of aldosterone. Moreover, it is considered to be the physiological regulator of aldosterone secretion. Although this view has not as yet received sufficient support, it seems likely that angiotensin is responsible in some disorders for increased secretion of aldosterone. a dual angiotensin/aldosterone system has triple angiotensinase/angiotensin/aldosterone system, by the demonstration of an angiotensin-inhibiting substance in the blood-angiotensinase. Hickler et a1. showed that in pregnant women and patients with secondary hyperaldosteronism angiotensinase activity in the blood decreased.
The notion of
given
way to
a
According to some research IZrOUDs.2-.11 ansiotensinase activitv in the blood is diminished also in patients with essential or renal hypertension. Considering that in many patients
with essential hypertension, and in most renal hypertensives, aldosterone excretion attains or considerably exceeds normal values, some direct or indirect connection between angiotensinase and aldosterone may be assumed. We tried to find outwhether aldosterone influenced
angiotensinase activity. Angiotensinase activity was measured by means of the angiotensin skin-test described by Jablons.4 Essentially, the test is based on the observation that, after the intracutaneous injection of 0-1 pg. of angiotensin 11, a circumscrihed
area
of nallnr
Results of angiotensin skin-test in controls and hyperaldosteronæmia.
the skin, the duration of which is supposed to be appears inversely related to angiotensinase activity. Our examinations were carried out on 18 young, healthy subjects. In the control series the Jablons test was carried out with synthetic angioon
1. 2. 3. 4. 5. 6.
Postgrad. med. J. 1958, 34, 222. Hickler, R. B., Lauler, D. P., Thorn, G. W. J. clin. Invest. 1963, 42, 635. Gömöri, P., Egedy, S., Kerekes, G. Orv. Hetil. 1963, 104, 2067. Jablons, B. Circulation, 1962, 25, 259. Mendlowitz, M., Wolf, R. L., Gitlow, S. E., Naftchi, N. E. ibid. p. 231. Wood, J. E. ibid. p. 225.