- Email: [email protected]
THE NON-COMMUNICATING CHILD
940
Our experience with ospolot over a period of eighteen months has been very encouraging, and we believe that it has a place in the treatment of epilepsy in the mentally subnormal, in conjunction with other drugs. Patients without fits before and after ospolot were included because some new anti-epileptic drugs have been found to precipitate fits in some patients, previously adequately con tro 11 ed Llanfrechfa Grange Hospital, Cwmbran, Mon.
T. S. DAVIES M. W. LEYSHON.
PATHOGENESIS OF DIABETES SIR,-We read with great interest the papers of Randle et al. and Hales and Randle 2 which put forward a new idea about the pathogenesis of diabetes. Their
that a primary fault in diabetes disturbance of fat metabolism, the changes in carbohydrate metabolism being a secondary result. Our findings are in agreement with their theory. We have found that a diminished glucose tolerance and signs of prediabetes are often present in patients with hyperlipaemia. The serum level of total lipids, triglycerides, and cholesterol was determined, and oral glucose tolerance performed in 40 female patients aged 27-79, none of whom had a previous history of diabetes. The serum-lipid level was found to be raised in 27 of them, and of these 23 had diminished glucose tolerance as well (see figure). The clinical diagnoses of these 23 patients were: 6 with
investigations suggest can
be
a
hvoertension. 5 ischasmic heart-disease dncludins 3 who had coronary occlusion), 1 retinal
hxmorrhage, 3 general arteriosclerosis, 1 lesion of acoustic nerve,1 peripheral facial palsy, 1 Cushing’s syndrome complicated by coronary occlusion, 1 idiopathic oedema, 1 cholelithiasis, and 3 Morgagni syndrome. After the ingestion of 60 g. of glucose, in all of them the blood-sugar than 200 mg. per 100 ml. and was still above 140 mg. at the end of two hours. Serum total lipids ranged from 900 to 4100 mg. per 100 ml. and triglycerides 550 to 1200 mg. Serumcholesterol was more than 250 mg. per 100 ml. in only 11 patients of this group. rose to more
Glucose-tolerance
curves.
Continuous line: hyperlipasmic cases (mean of 23 cases). Dotted line: normoHpsmic cases (mean of 18 cases).
All these patients were nrohahlv latent diabetics. It
is interesting to note that 7 had diabetic relatives and that of 20 women who had children, 11 had had offspring weighing more than 4-5 kg. at birth, 5 had had stillbirths or spontaneous abortions, 16 had become obese during pregnancy, and 5 had had hyperlactation. Thus signs of what has been termed Young’s syndrome were present at some stage in the history of these patients. Serum-lipid level was determined in another group of 6 patients who showed characteristic features of prediabetes but whose glucose tolerance became abnormal only after prednisolone administration.33 Serum-lipid level was significantly raised in 3 patients in this group. On followup they were observed to pass from prediabetes to latent diabetes and eventually to frank diabetes. 1. Randle, P. J., Garland, P. B., Hales, C. N., Newsholme, E. A. 1963, i, 785. 2. Hales, C. N., Randle, P. J. ibid. p. 790. 3. Fajans, S. S., Conn, J. W. Diabetes, 1961, 10, 63.
Lancet,
It is known that elderly people with arteriosclerosis and coronary-artery disease often have diminished glucose tolerance. 4-7 Waddel et al.5 and Wahlbergfound no correlation between the cholesterol level of the blood and the glucose tolerance. Likewise we have found hypercholesterolasmia in only half of our patients with hyperlipeemia. It is therefore essential to estimate the total lipid in the blood of these patients. It is surprising that the serum-lipid content should be high in patients with mild diabetes who do not require insulin therapy, and even in the earlier stages of prediabetes and latent diabetes, though it is often normal in severe diabetes treated with insulin. This paradox can be explained, however, if one considers diabetes to be primarily a disturbance of fat metabolism. Randle et aU suggest that endogenous insulin cannot control lipid metabolism effectively in these patients because an unknown agent counteracts its effect by increasing fat mobilisation. This agent could be growth hormone, as suggested by Young. That this hormone may play a part in the development of diabetes is suggested by the large babies and hyperlactation of prediabetic mothers, and its ability to stimulate fat mobilisation and insulin secretion in laboratory animals. Ehrlich and Randle9 found an increased level of growth hormone in the blood of certain types of diabetes. J ulesz 10 also regards the initial phase of juvenile diabetes as pituitary in origin. Chalmers et al.11 observed a fat-mobilising material, possibly of pituitary origin, in the urine of diabetic patients in ketosis, though this fat-mobilising factor has not been identified. It is clinically important that latent diabetes is latent only as regards carbohydrate metabolism. A. GOTH G. BLUMENFELD Janos Hospital and Outpatient Clinic Madách tér, MARGARET GOTH. Budapest. THE NON-COMMUNICATING CHILD
SIR,-Dr. Minski (Aug. 31) rightly draws attention to the need for increased diagnostic and therapeutic facilities for children with delayed development of speech. In discussing the causes of a lack of this type of communication he does not list the group of children with a specific defect of language development. These are often of average intelligence and capable of responding to appropriate treatment. Their behaviour may be abnormal and they may even show psychotic features, but often these symptoms seem to be secondary and not the primary cause of lack of speech. Dr. Minski mentions that the electroencephalograms of these children may be abnormal and suggestive of damage to the brain, although abnormal neurological findings are uncommon. This may be evidence of the relative importance of organic factors in causing these patients’ disability without being proof of the presence of an acquired cerebral lesion. Many of these children may have a developmental type of disorder, in which integration fails to take place at a normal rate, but this does not necessarily imply a structural lesion. Such a disturbance of function might result in the type of electroencephalographic abnormalities seen among these patients, which are rarely of a focal nature. The best means of educating these children is a matter for further study; but in deciding on the approach to be made, it does seem important to stress that many of these 4. 5. 6. 7. 8. 9. 10.
11.
Magyar, I., Márton, I. Orv. Hetil, 1962, 113, 1123. Waddel, R. W., Geyer, R. R., Hurley, N., Stare, F. J. Metabolism, 1957, 7, 707. Waddel, R. W., Field, R. A. ibid. 1960, 9, 800. Wahlberg, F. Acta med. scand. 1962, 171, 1. Young, F. G. Brit. med. J. 1961, ii, 1449. Ehrlich, R. M., Randle, P. J. Lancet, 1961, ii, 233. Julesz, M. A neuroendokrin betegségek kórtana és diagnosztikája. Budapest, 1957. Chalmers, T. M., Pawan, G. L. S., Kekwick, A. Lancet, 1960, ii, 6.
941
children have a primary disorder of language function and that the principal effort must be made to overcome this. Booth Hall Children’s Hospital, Manchester, 9.
NEIL GORDON.
A COLLEGE OF PSYCHIATRY
SIR,-Is it really necessary to introduce yet another examination in order to establish a College of Psychiatry ? As Dr. Barker (Oct. 19) has pointed out, there are already three available-M.D., M.R.C.P. Edin., and D.P.M.-and the standards of these could be raised still higher if desirable. Are we not becoming obsessed with a habit of sticking more and more letters after our names ? Continental doctors are quite bewildered to note letters attached to the names of specialists in this country, such as F.R.C.S., M.R.C.P., D.P.M., D.T.M., D.C.H., D.P.H., D.OBST., D.O.M.S., D.M.R., D.A., D.BACT., M.S., D.L.O., D.PHYS.MED., &c., &c. Abroad they seem to manage quite satisfactorily
with
a
simple
Park Prewett
M.D.
Why
cannot we manage
Hospital,
Basingstoke, Hampshire.
SIR,-In
likewise ? I. ATKIN.
NEONATAL HYPOGLYCÆMIA my earlier work 1-3 on neonatal blood-sugar
levels I employed a method which, while providing results that were more reproducible than with some other copper methods, nevertheless determined " total reducing substance ". The method seemed to show quite clearly that normal infants as well as those born to diabetic women may have low but asymptomatic blood-sugar levels, and that symptoms once commonly attributed to hypoglycsemia are often associated with normal levels. This view was accepted for some years, but observations by Cornblath4 and others56have established beyond doubt that hypoglycaemia can produce severe disturbance which can be corrected by the prompt restoration of normoglycEemia. We have been re-examining this subject in the past three years. The blood-glucose has been determined by the enzyme method at very short intervals after birth in groups of asymptomatic mature, premature, and post-mature infants and in The others with neurological disturbance, hypothermia, &c. each for was also determined the first blood-glucose morning four days of life in a large group of asymptomatic babies. The results will be published when the investigation is complete, but the conclusion remains that infants with blood-glucose levels below 20 mg. per 100 ml. are often entirely asymptomatic, and some such babies are known to progress normally. Hypoglycaemia is not necessarily accompanied by what some call neuroglycopenia and its duration may well be as important as its extent; for in asymptomatic babies it is quite brief, whereas in the cases which have received recent attention it has been long-continued or, rather, late, and has been resistant to all but intensive treatment. Dr. Neligan’s experience of the slow absorption of oral glucose in treatment is in keeping with our own, and with that of others who have studied glucose tolerance in recent years. Even at 2 cases per 1000 hospital births 6 symptomatic neonatal hypoglycaemia is surprisingly uncommon, in view of the frequency of asymptomatic hypoglycxmia of prematurity and of dysmaturity in a group of that size. The relationships
dysmaturity or placenta-insufficiency syndrome 6 must be significant; and yet hypoglycxmia is not a consistent finding, even in cases whose intravenous glucose tolerance may not to
the
differ from the neonatal normal.
Perhaps it is commoner in some hospitals than in others. At the Elsie Inglis Maternity Hospital where I have charge of almost 2000 infants each year, where neonatal supervision is 1. 2. 3. 4. 5. 6.
Farquhar, J. W. Arch. Dis. Childh. 1954, 29, 519. Farquhar, J. W. ibid. 1956, 31, 203. Farquhar, J. W. ibid. 1958, 34, 76. Cornblath, M., Odell, G. B., Levin, E. Y. J. Pediat. 1959, 55, 545. Brown, R. J. K., Wallis, P. Lancet, 1963, i, 1278. Neligan, G. A., Robson, E., Watson, J. ibid. p. 1282.
close and where active study of blood-glucose levels has been pursued for about three years, only 1 infant has been found to have signs of profound hypoglycaemia, although colleagues have shown me a few such cases elsewhere in the city. Differences such as these between hospitals are not uncommon and may depend not only on the alertness of the staff but on the socio-economic status of the population served, the proportion of unbooked and complicated deliveries, and the possible use of The drugs influencing foetal carbohydrate metabolism. finding 6 that neonatal hypoglycasmia may recur in later infancy and childhood is inconsistent with iatrogenic disease, with the temporary effects of maternal toxaemia, and with But recurrent spontaneous hypoglycogen inadequacy. glycsemia of children is a relatively uncommon and muchsought diagnosis in Edinburgh where, on the basis of the Newcastle figures, the pxdiatricians might expect about 14 fresh cases of neonatal hypoglycsemia annually and continuous trouble with a proportion of the survivors for some years.
The London and Newcastle studies have confirmed and supplemented Cornblath’s and have alerted us to the need for blood-glucose determinations in symptomatic babies; but pxdiatricians must take care that they do not return to the uncritical assumptions so prevalent 10 years ago that a low blood-glucose level, rather than anoxia, intracranial
bleeding, pulmonary hyaline membrane, congenital malformation, or sepsis, is the cause of distress or of episodes of cyanosis. Determination of the blood-glucose can be only one of a number of diagnostic measures and a clear, sustained response to treatment is essential confirmation. W.H.O. Edinburgh University Team, Baroda
Medical College, Baroda, Gujarat State, India.
JAMES W. FARQUHAR.
A DESIGN FOR GENERAL PRACTICE
SIR,-The temperate and sensible article by Dr. Eimerl and Dr. Pinsent (Oct. 12) must have impressed many of your readers. The two family doctors know exactly what is needed as Reinforcement for the Family Doctor, and we hope that it will be taken as a model presentation of a statement of needs. I merely write to thank the writers for kindly and wisely omitting to mention that objectionable word the " surgery ". They speak precisely, correctly, and affirmatively of help in the consulting-room. Of this, I have written elsewhere.1 The family doctor in general practice has unique opportunity to be consulted by his families and therefore he must have his or her consulting-room. This would also give, particularly for the younger doctors, a better feeling of being consulted and giving advice and guidance and of taking an increasing interest in health-mindedness, instead of so often generating a degree of boredom arising out of trying to do only patchwork treatment of episodic illness. The dignity of the consulting-room could set new patterns of general practice in its allied functions with preventive and social medicine, mental health, family practice, and total personal care-much, if not most, through advice and guidance by consultation in good, clean, well-lighted, and attractive circumstances. It would also provide a better place and opportunity for discussion and cooperation between the family doctor and his allied paramedical workers: the family doctor is, or should be, the first and last " adviser in the guidance " of all those who work on his own patients. The benefits, psychological and other, would be great, both to the doctor and to those who consult him. The abolition of the " surgery " in favour of the consulting-room could alter and improve 1.
J. Coll.
gen. Practit.
1963, 6, 480.
Our experience with ospolot over a period of eighteen months has been very encouraging, and we believe that it has a place in the treatment of epilepsy in the mentally subnormal, in conjunction with other drugs. Patients without fits before and after ospolot were included because some new anti-epileptic drugs have been found to precipitate fits in some patients, previously adequately con tro 11 ed Llanfrechfa Grange Hospital, Cwmbran, Mon.
T. S. DAVIES M. W. LEYSHON.
PATHOGENESIS OF DIABETES SIR,-We read with great interest the papers of Randle et al. and Hales and Randle 2 which put forward a new idea about the pathogenesis of diabetes. Their
that a primary fault in diabetes disturbance of fat metabolism, the changes in carbohydrate metabolism being a secondary result. Our findings are in agreement with their theory. We have found that a diminished glucose tolerance and signs of prediabetes are often present in patients with hyperlipaemia. The serum level of total lipids, triglycerides, and cholesterol was determined, and oral glucose tolerance performed in 40 female patients aged 27-79, none of whom had a previous history of diabetes. The serum-lipid level was found to be raised in 27 of them, and of these 23 had diminished glucose tolerance as well (see figure). The clinical diagnoses of these 23 patients were: 6 with
investigations suggest can
be
a
hvoertension. 5 ischasmic heart-disease dncludins 3 who had coronary occlusion), 1 retinal
hxmorrhage, 3 general arteriosclerosis, 1 lesion of acoustic nerve,1 peripheral facial palsy, 1 Cushing’s syndrome complicated by coronary occlusion, 1 idiopathic oedema, 1 cholelithiasis, and 3 Morgagni syndrome. After the ingestion of 60 g. of glucose, in all of them the blood-sugar than 200 mg. per 100 ml. and was still above 140 mg. at the end of two hours. Serum total lipids ranged from 900 to 4100 mg. per 100 ml. and triglycerides 550 to 1200 mg. Serumcholesterol was more than 250 mg. per 100 ml. in only 11 patients of this group. rose to more
Glucose-tolerance
curves.
Continuous line: hyperlipasmic cases (mean of 23 cases). Dotted line: normoHpsmic cases (mean of 18 cases).
All these patients were nrohahlv latent diabetics. It
is interesting to note that 7 had diabetic relatives and that of 20 women who had children, 11 had had offspring weighing more than 4-5 kg. at birth, 5 had had stillbirths or spontaneous abortions, 16 had become obese during pregnancy, and 5 had had hyperlactation. Thus signs of what has been termed Young’s syndrome were present at some stage in the history of these patients. Serum-lipid level was determined in another group of 6 patients who showed characteristic features of prediabetes but whose glucose tolerance became abnormal only after prednisolone administration.33 Serum-lipid level was significantly raised in 3 patients in this group. On followup they were observed to pass from prediabetes to latent diabetes and eventually to frank diabetes. 1. Randle, P. J., Garland, P. B., Hales, C. N., Newsholme, E. A. 1963, i, 785. 2. Hales, C. N., Randle, P. J. ibid. p. 790. 3. Fajans, S. S., Conn, J. W. Diabetes, 1961, 10, 63.
Lancet,
It is known that elderly people with arteriosclerosis and coronary-artery disease often have diminished glucose tolerance. 4-7 Waddel et al.5 and Wahlbergfound no correlation between the cholesterol level of the blood and the glucose tolerance. Likewise we have found hypercholesterolasmia in only half of our patients with hyperlipeemia. It is therefore essential to estimate the total lipid in the blood of these patients. It is surprising that the serum-lipid content should be high in patients with mild diabetes who do not require insulin therapy, and even in the earlier stages of prediabetes and latent diabetes, though it is often normal in severe diabetes treated with insulin. This paradox can be explained, however, if one considers diabetes to be primarily a disturbance of fat metabolism. Randle et aU suggest that endogenous insulin cannot control lipid metabolism effectively in these patients because an unknown agent counteracts its effect by increasing fat mobilisation. This agent could be growth hormone, as suggested by Young. That this hormone may play a part in the development of diabetes is suggested by the large babies and hyperlactation of prediabetic mothers, and its ability to stimulate fat mobilisation and insulin secretion in laboratory animals. Ehrlich and Randle9 found an increased level of growth hormone in the blood of certain types of diabetes. J ulesz 10 also regards the initial phase of juvenile diabetes as pituitary in origin. Chalmers et al.11 observed a fat-mobilising material, possibly of pituitary origin, in the urine of diabetic patients in ketosis, though this fat-mobilising factor has not been identified. It is clinically important that latent diabetes is latent only as regards carbohydrate metabolism. A. GOTH G. BLUMENFELD Janos Hospital and Outpatient Clinic Madách tér, MARGARET GOTH. Budapest. THE NON-COMMUNICATING CHILD
SIR,-Dr. Minski (Aug. 31) rightly draws attention to the need for increased diagnostic and therapeutic facilities for children with delayed development of speech. In discussing the causes of a lack of this type of communication he does not list the group of children with a specific defect of language development. These are often of average intelligence and capable of responding to appropriate treatment. Their behaviour may be abnormal and they may even show psychotic features, but often these symptoms seem to be secondary and not the primary cause of lack of speech. Dr. Minski mentions that the electroencephalograms of these children may be abnormal and suggestive of damage to the brain, although abnormal neurological findings are uncommon. This may be evidence of the relative importance of organic factors in causing these patients’ disability without being proof of the presence of an acquired cerebral lesion. Many of these children may have a developmental type of disorder, in which integration fails to take place at a normal rate, but this does not necessarily imply a structural lesion. Such a disturbance of function might result in the type of electroencephalographic abnormalities seen among these patients, which are rarely of a focal nature. The best means of educating these children is a matter for further study; but in deciding on the approach to be made, it does seem important to stress that many of these 4. 5. 6. 7. 8. 9. 10.
11.
Magyar, I., Márton, I. Orv. Hetil, 1962, 113, 1123. Waddel, R. W., Geyer, R. R., Hurley, N., Stare, F. J. Metabolism, 1957, 7, 707. Waddel, R. W., Field, R. A. ibid. 1960, 9, 800. Wahlberg, F. Acta med. scand. 1962, 171, 1. Young, F. G. Brit. med. J. 1961, ii, 1449. Ehrlich, R. M., Randle, P. J. Lancet, 1961, ii, 233. Julesz, M. A neuroendokrin betegségek kórtana és diagnosztikája. Budapest, 1957. Chalmers, T. M., Pawan, G. L. S., Kekwick, A. Lancet, 1960, ii, 6.
941
children have a primary disorder of language function and that the principal effort must be made to overcome this. Booth Hall Children’s Hospital, Manchester, 9.
NEIL GORDON.
A COLLEGE OF PSYCHIATRY
SIR,-Is it really necessary to introduce yet another examination in order to establish a College of Psychiatry ? As Dr. Barker (Oct. 19) has pointed out, there are already three available-M.D., M.R.C.P. Edin., and D.P.M.-and the standards of these could be raised still higher if desirable. Are we not becoming obsessed with a habit of sticking more and more letters after our names ? Continental doctors are quite bewildered to note letters attached to the names of specialists in this country, such as F.R.C.S., M.R.C.P., D.P.M., D.T.M., D.C.H., D.P.H., D.OBST., D.O.M.S., D.M.R., D.A., D.BACT., M.S., D.L.O., D.PHYS.MED., &c., &c. Abroad they seem to manage quite satisfactorily
with
a
simple
Park Prewett
M.D.
Why
cannot we manage
Hospital,
Basingstoke, Hampshire.
SIR,-In
likewise ? I. ATKIN.
NEONATAL HYPOGLYCÆMIA my earlier work 1-3 on neonatal blood-sugar
levels I employed a method which, while providing results that were more reproducible than with some other copper methods, nevertheless determined " total reducing substance ". The method seemed to show quite clearly that normal infants as well as those born to diabetic women may have low but asymptomatic blood-sugar levels, and that symptoms once commonly attributed to hypoglycsemia are often associated with normal levels. This view was accepted for some years, but observations by Cornblath4 and others56have established beyond doubt that hypoglycaemia can produce severe disturbance which can be corrected by the prompt restoration of normoglycEemia. We have been re-examining this subject in the past three years. The blood-glucose has been determined by the enzyme method at very short intervals after birth in groups of asymptomatic mature, premature, and post-mature infants and in The others with neurological disturbance, hypothermia, &c. each for was also determined the first blood-glucose morning four days of life in a large group of asymptomatic babies. The results will be published when the investigation is complete, but the conclusion remains that infants with blood-glucose levels below 20 mg. per 100 ml. are often entirely asymptomatic, and some such babies are known to progress normally. Hypoglycaemia is not necessarily accompanied by what some call neuroglycopenia and its duration may well be as important as its extent; for in asymptomatic babies it is quite brief, whereas in the cases which have received recent attention it has been long-continued or, rather, late, and has been resistant to all but intensive treatment. Dr. Neligan’s experience of the slow absorption of oral glucose in treatment is in keeping with our own, and with that of others who have studied glucose tolerance in recent years. Even at 2 cases per 1000 hospital births 6 symptomatic neonatal hypoglycaemia is surprisingly uncommon, in view of the frequency of asymptomatic hypoglycxmia of prematurity and of dysmaturity in a group of that size. The relationships
dysmaturity or placenta-insufficiency syndrome 6 must be significant; and yet hypoglycxmia is not a consistent finding, even in cases whose intravenous glucose tolerance may not to
the
differ from the neonatal normal.
Perhaps it is commoner in some hospitals than in others. At the Elsie Inglis Maternity Hospital where I have charge of almost 2000 infants each year, where neonatal supervision is 1. 2. 3. 4. 5. 6.
Farquhar, J. W. Arch. Dis. Childh. 1954, 29, 519. Farquhar, J. W. ibid. 1956, 31, 203. Farquhar, J. W. ibid. 1958, 34, 76. Cornblath, M., Odell, G. B., Levin, E. Y. J. Pediat. 1959, 55, 545. Brown, R. J. K., Wallis, P. Lancet, 1963, i, 1278. Neligan, G. A., Robson, E., Watson, J. ibid. p. 1282.
close and where active study of blood-glucose levels has been pursued for about three years, only 1 infant has been found to have signs of profound hypoglycaemia, although colleagues have shown me a few such cases elsewhere in the city. Differences such as these between hospitals are not uncommon and may depend not only on the alertness of the staff but on the socio-economic status of the population served, the proportion of unbooked and complicated deliveries, and the possible use of The drugs influencing foetal carbohydrate metabolism. finding 6 that neonatal hypoglycasmia may recur in later infancy and childhood is inconsistent with iatrogenic disease, with the temporary effects of maternal toxaemia, and with But recurrent spontaneous hypoglycogen inadequacy. glycsemia of children is a relatively uncommon and muchsought diagnosis in Edinburgh where, on the basis of the Newcastle figures, the pxdiatricians might expect about 14 fresh cases of neonatal hypoglycsemia annually and continuous trouble with a proportion of the survivors for some years.
The London and Newcastle studies have confirmed and supplemented Cornblath’s and have alerted us to the need for blood-glucose determinations in symptomatic babies; but pxdiatricians must take care that they do not return to the uncritical assumptions so prevalent 10 years ago that a low blood-glucose level, rather than anoxia, intracranial
bleeding, pulmonary hyaline membrane, congenital malformation, or sepsis, is the cause of distress or of episodes of cyanosis. Determination of the blood-glucose can be only one of a number of diagnostic measures and a clear, sustained response to treatment is essential confirmation. W.H.O. Edinburgh University Team, Baroda
Medical College, Baroda, Gujarat State, India.
JAMES W. FARQUHAR.
A DESIGN FOR GENERAL PRACTICE
SIR,-The temperate and sensible article by Dr. Eimerl and Dr. Pinsent (Oct. 12) must have impressed many of your readers. The two family doctors know exactly what is needed as Reinforcement for the Family Doctor, and we hope that it will be taken as a model presentation of a statement of needs. I merely write to thank the writers for kindly and wisely omitting to mention that objectionable word the " surgery ". They speak precisely, correctly, and affirmatively of help in the consulting-room. Of this, I have written elsewhere.1 The family doctor in general practice has unique opportunity to be consulted by his families and therefore he must have his or her consulting-room. This would also give, particularly for the younger doctors, a better feeling of being consulted and giving advice and guidance and of taking an increasing interest in health-mindedness, instead of so often generating a degree of boredom arising out of trying to do only patchwork treatment of episodic illness. The dignity of the consulting-room could set new patterns of general practice in its allied functions with preventive and social medicine, mental health, family practice, and total personal care-much, if not most, through advice and guidance by consultation in good, clean, well-lighted, and attractive circumstances. It would also provide a better place and opportunity for discussion and cooperation between the family doctor and his allied paramedical workers: the family doctor is, or should be, the first and last " adviser in the guidance " of all those who work on his own patients. The benefits, psychological and other, would be great, both to the doctor and to those who consult him. The abolition of the " surgery " in favour of the consulting-room could alter and improve 1.
J. Coll.
gen. Practit.
1963, 6, 480.