- Email: [email protected]
THE REGISTRAR'S FUTURE
930 He was given aneurine 3 mg. t.i.d. for four months, and then 3 mg. daily from Dec. 29, 1948. On March 21, 1949, he had right lower lobar pneumonia with dry pleurisy. On April 6, 1949, he was well and ambulant, with no cardiac damage. On Jan. 6, 1950, he was still well, with blood-pressure 140/70.
Aneurine thus seems to restore the cardiac cells to and may have a beneficial effect on conduction in the bundle of His. A. HENRY GREGSON. Cromer.
normality,
But there is
one
aspect
of
pharmacologic knowledge
which is lacking at present as regards drug action. Why should a vasodilator, for example, act maximally on the pathologically constricted blood-vessels and not on all the blood-vessels? It would almost seem that drug action may operate in direct proportion to the intensity of the nervous impulses in activity. A. T. TODD. Bristol. THE REGISTRAR’S FUTURE
VITAMIN B12 IN MEGALOBLASTIC ANÆMIAS
SIR,—In reterring to the eilect ot vitamin lS12 ill megaloblastic anaemias without gastric atrophy, Dr. Tuck and Dr. Whittaker (April 22, p. 757) incorrectly abbreviate a report 1 of my remarks at the British Association meeting last year which was already too condensed to be accurate. These anaemias are a " mixed bag " and the response to vitamin B12 varies widely. It is true that megaloblastic anaemias of pregnancy and the puerperium in temperate climates did not respondbut Patel and Kocher3 report good results in a tropical variety of the syndrome. Megaloblastic anaemias associated with intestinal disorders-even those encountered in this country-ha,ve not always failed to respond to vitamin B12.45 On the other hand, a state refractory to vitamin B12 may exist temporarily even in a patient presumed to have gastric atrophy. Such cases are rare. In one instance the ansemia became responsive to vitamin B12 only after small amounts of folic acid had been supplied.4 This recalls the pigs of Heinle, Welch, and Pritchard,6 which were so depleted of hæmopoietic factors that folic acid had to be given before liver extract would work, and vice versa. The Royal Victoria Infirmary, C. C. UNGLEY. Newcastle upon Tyne.
RELIEF OF PAIN IN RHEUMATOID ARTHRITIS WITH TETRAETHYLAMMONIUM BROMIDE
SIR,—In your issue of April 1, Dr. F. Heyman and his describe their experiences with tetraethylammonium bromide. That relief of pain, and therefrom increased motility, should be given by this remedy is in complete harmony with the theory of pain production which I give in the second edition of my Treatment of Some Chronic and Incurable Diseases (1947). This is an extension of Mackenzie’s theory to embrace the autonomous system, especially its vasomotor system. The whole is too long to embody in a letter, but an important paragraph is :
colleagues
" Now it
was pointed out above that pain stimuli pass also the autonomous nerves which are present in all tissues ; it is the stimuli which are conducted by them which I think important as pain producing, for they induce vaso-constriction in the myotome concerned and so tend to produce this local ischaemia of the nerve endings which, as a result, register
by
pain " (p. 260). My thesis is,
in
brief, that local
trauma induces
an
adrenergic overplay causing ischaemia in the affected myotome ; thus also giving a reason for so-called referred pain. In addition the theory gives help in the understanding of relief of arthritic pain from ascorbic acid with deoxycortone, both of which would tend to correct overplay of the adrenal medulla by assisting the cortex-i.e., Hallion’s
"
law " : the administration of a extract causes increased action of that gland. In two cases of Addison’s disease I found that massive ascorbic acid resulted in considerable lightening of pigmented skin and mucosa.
gland
1. 2. 3. 4. 5.
Brit. med. J. 1949, ii, 646. Ungley, C. C., Thompson, R. B. Ibid, April 22, p. 919. Patel, J. C., Kocher, B. R. Ibid, p. 924. Ungley, C. C. Proc. R. Soc. Med. (in the press). Cooke, W. T., Peeney, A. L. P., Hawkins, C. F.
6.
April 29, p. 834. Heinle, R. W., Welch, 1948, 33, 1647.
A.
D., Pritchard,
J. A.
Lancet,
J. Lab. clin. Med.
particularly interested in Mr. Mitchiner’s letter last week because the association of which I have the honour to be president is most concerned with this problem at the moment. SIR,—I
was
Registrars at non-teaching hospitals, though they gain large experience, find that when they apply for promotion to a consultant post, even in a non-teaching hospital, they are severely handicapped as the appointment committee is very largely composed of teachers, and if a registrar from a non-teaching hospital is competing against a registrar from a teaching hospital the latter, though possibly junior and with less practical experience, will probably get the job. Young men tend, therefore, to hang about the teaching hospitals fearful to venture into the periphery lest they quit irrevocably the ladder of promotion. If this state continues the tion-teaching hospitals, in spite of the practical experience they afford, will be unable to get satisfactory applicants for registrar posts, and a general decline in efficiency will result. Furthermore, the disadvantages of inbreeding within the teaching hospitals will be accentuated. I am sure it would be a great advantage to both teaching and non-teaching hospitals if consultants on both had the widest experience, and I feel that registrars should be encouraged to widen their experience by a term of service in a regional hospital, not because of pious exhortations to clear the congestion at the centre and by so doing diminish the field of applicants for promotion, but because such experience would be regarded as an asset, if not an essential qualification, when appointments of consultant rank were made in either teaching or non-teaching hospitals. a
very
H. J. MCCURRICH 45, Lincoln’s Inn Fields, W.C.2.
President, Regional Hospitals’ Consultants and Specialists Association (Non-Undergraduate Teaching Hospitals).
SIR,—Mr. Mitchiner’s letter last week is of importance
only to registrars but also to all those who are concerned with the staffing of medical posts abroad. In the past such posts have very largely been filled by men who chose to spend twenty or thirty years of their lives in Africa, India, or the East. Similar posts are available now. Most posts advertised for short terms of service are unattactive owing to the uncertainty as to what will happen when the contract ends. But there are, I believe, some posts-and the number of these may increase-to which those who have special experience and higher qualifications would be welcomed for periods of from four to six years. I am thinking particularly of general physicians, general surgeons, orthopaedic and ophthalmic surgeons, gynæcologists, anaesthetists, psychiatrists, and those who practise physical medicine. Here again the main problem is that of reabsorption in this country when their period of foreign service is over. I can only suggest that some or all of the regional boards, with the concurrence of the Ministry of Health, might be willing in the interests of British medicine to increase their specialist or consultant establishments to include some supernumerary posts, so as to allow of secondment of a limited number at a time for work abroad. This would involve financial arrangenot
being worked out between the two employers. But it is no new thing to second men in established posts in Government service in this country to Government ments
931
posts abroad for limited periods without loss of status on return. It might even be and pension rights, &c., possible for one particular regional board in this country to develop a special liaison with one Dominion, Colonial, Protectorate government on these lines. The matter is urgent and demands very early consideration, though some delay seems inevitable until the various regional boards have at last been able to declare their consultant establishments. H. C. SQUIRES or
Consulting Physician to the Sudan Government.
London, «’.1.
Public Health Epidemics
in Schools
IN 1929 the Medical Research Council appointed a committee to investigate epidemic and other illness in schools. An interim report, based on detailed morbidity statistics from a number of boys’ and girls’ public schools and some Naval schools, was published in 1938.1 An analysis of the data collected during the years 1935-39 now appears as a sequel.2 Taken together, the two reports present a detailed picture of the illnesses that affected a sample school-age population during ten years. Some of the most interesting findings relate to the large, ill-defined, and ubiquitous group of nasopharyngeal infections. Influenza is shown to have been an epidemic disease essentially belonging to the spring term, with a universally high attack-rate in 1937 : this presumably reflected a generalised epidemic since Influenza Deaths in Great Towns showed a corresponding peak. There was no evidence that infection in this year conferred any immunity towards a second epidemic two years later. Other nasopharyngeal infections (sore throat, colds, chills, coughs) were the commonest causes of sickness, and these also showed highest attack-rates during the spring term. An interesting finding here was an attackrate on girls’ schools 150-300% higher than on boys’ schools ; the difference was especially evident in the A high case of colds and did not apply to sore throat. correlation was shown between the attack-rates of otitis media and sore throat in both boys’ and girls’ schools, and between otitis media and all nasopharyngeal infections in boys’ schools. In girls’ schools, however, there was a negative correlation between otitis media and all nasopharyngeal infections. The incidence of sinusitis showed a precisely similar behaviour. The report suggests that these apparently anomalous findings were connected with the much higher attack-rate, already mentioned, in girls’ schools of nasopharyngeal infections ; the coughs and colds were perhaps treated more seriously and in consequence the complications were fewer. Nonmuscular rheumatism, though often associated in the individual case with a history of sore throat, did not show a correlation with attack-rates of sore throat ; but scarlet fever and non-muscular rheumatism showed a high correlation. In this connection it seems a great pity that no test for correlation between sore throat and scarlet fever was made, since the occurrence of cases of scarlet fever a,s incidents in a wider epidemic of infectious sore throat must be a common experience. Turning to the exanthemata and mumps and whoopingcough, it is shown that these occurred more often in the spring and summer terms than in the winter term, with the exception of chickenpox. The sex-incidences did not differ significantly, except in the case of whoopingcough which occurred more often in girls. Measles showed a significantly larger number of single-case outbreaks in girls’ than in boys’ schools ; the report 1. Spec. Rep. Ser. med. Res. Coun., Lond. no. 227. 1938. 2. Epidemics in Schools. Spec. Rep. Ser. med. Res. Coun., Lond. 1950. Pp. 96, 3s. no. 271. H.M. Stationery Office.
that this again is connected with the higher incidence of nasopharyngeal infection, already noted, in girls’ schools : if the minor catarrhs are put to bed earlier, cases of measles will be more often isolated in the early infectious stages. The association between herpes zoster and chickenpox was again observed. Another finding worth mentioning was the much lower incidence of tinea cruris in those schools that practised isolation of this complaint. The sceptical, however, may ask whether the latter finding is not due to a high rate of concealment, since isolation for what is usually a trivial complaint will not appeal to the
suggests
schoolboy. On the whole it must be admitted that this report does not throw much new light on the general problems of epidemiology. Perhaps one reason for this is that the residential school is a semi-isolated community " only in a very limited sense, since its inmates form part of the general community for a third of the year ; and no epidemic runs a natural course, because of the disruption of the community at the end of term. On the other hand the report (with its predecessor) fulfils two important purposes. In the first place it provides statistical proof of a number of phenomena which, though well recognised by many workers in school medicine, have existed only as general impressions unchecked by figures. In the second place it provides a work of reference of great value for all future workers in this field. "
Smallpox Certain cases of smallpox or suspected smallpox have come to light: 1. A girl who arrived in this country by air from Switzerland on April 28 attended the outpatient department of a London
teaching hospital with a generalised rash which raised a suspicion of smallpox. All precautions were taken accordingly, pending laboratory investigations. These ultimately proved the case to be one of generalised vaccinia. 2. On May 5 a man was taken off an aeroplane due to depart from Northolt for Renfrew, with signs and symptoms of an acute illness accompanied by a rash. The airport medical officer considered there was the possibility of the case being one of smallpox, and the man, after being seen by a smallpox This man had earlier was removed to isolation. the same day landed at London Airport from Calcutta, which he had left on May 3. All the necessary administrative action was taken, including notification of the circumstances of the case to countries to which contacts were proceeding. Laboratory examinations do not confirm the original suspicion, and the case is not now regarded as one of smallpox. 3. On May 4 and 5 two patients from Halifax and one from Sowerby Bridge, adjacent to Halifax, were taken into isolation as cases of smallpox. The normal preventive measures were at once put in hand by the local authorities concerned.
consultant,
Infectious Diseases in
England
and Wales
Aneurine thus seems to restore the cardiac cells to and may have a beneficial effect on conduction in the bundle of His. A. HENRY GREGSON. Cromer.
normality,
But there is
one
aspect
of
pharmacologic knowledge
which is lacking at present as regards drug action. Why should a vasodilator, for example, act maximally on the pathologically constricted blood-vessels and not on all the blood-vessels? It would almost seem that drug action may operate in direct proportion to the intensity of the nervous impulses in activity. A. T. TODD. Bristol. THE REGISTRAR’S FUTURE
VITAMIN B12 IN MEGALOBLASTIC ANÆMIAS
SIR,—In reterring to the eilect ot vitamin lS12 ill megaloblastic anaemias without gastric atrophy, Dr. Tuck and Dr. Whittaker (April 22, p. 757) incorrectly abbreviate a report 1 of my remarks at the British Association meeting last year which was already too condensed to be accurate. These anaemias are a " mixed bag " and the response to vitamin B12 varies widely. It is true that megaloblastic anaemias of pregnancy and the puerperium in temperate climates did not respondbut Patel and Kocher3 report good results in a tropical variety of the syndrome. Megaloblastic anaemias associated with intestinal disorders-even those encountered in this country-ha,ve not always failed to respond to vitamin B12.45 On the other hand, a state refractory to vitamin B12 may exist temporarily even in a patient presumed to have gastric atrophy. Such cases are rare. In one instance the ansemia became responsive to vitamin B12 only after small amounts of folic acid had been supplied.4 This recalls the pigs of Heinle, Welch, and Pritchard,6 which were so depleted of hæmopoietic factors that folic acid had to be given before liver extract would work, and vice versa. The Royal Victoria Infirmary, C. C. UNGLEY. Newcastle upon Tyne.
RELIEF OF PAIN IN RHEUMATOID ARTHRITIS WITH TETRAETHYLAMMONIUM BROMIDE
SIR,—In your issue of April 1, Dr. F. Heyman and his describe their experiences with tetraethylammonium bromide. That relief of pain, and therefrom increased motility, should be given by this remedy is in complete harmony with the theory of pain production which I give in the second edition of my Treatment of Some Chronic and Incurable Diseases (1947). This is an extension of Mackenzie’s theory to embrace the autonomous system, especially its vasomotor system. The whole is too long to embody in a letter, but an important paragraph is :
colleagues
" Now it
was pointed out above that pain stimuli pass also the autonomous nerves which are present in all tissues ; it is the stimuli which are conducted by them which I think important as pain producing, for they induce vaso-constriction in the myotome concerned and so tend to produce this local ischaemia of the nerve endings which, as a result, register
by
pain " (p. 260). My thesis is,
in
brief, that local
trauma induces
an
adrenergic overplay causing ischaemia in the affected myotome ; thus also giving a reason for so-called referred pain. In addition the theory gives help in the understanding of relief of arthritic pain from ascorbic acid with deoxycortone, both of which would tend to correct overplay of the adrenal medulla by assisting the cortex-i.e., Hallion’s
"
law " : the administration of a extract causes increased action of that gland. In two cases of Addison’s disease I found that massive ascorbic acid resulted in considerable lightening of pigmented skin and mucosa.
gland
1. 2. 3. 4. 5.
Brit. med. J. 1949, ii, 646. Ungley, C. C., Thompson, R. B. Ibid, April 22, p. 919. Patel, J. C., Kocher, B. R. Ibid, p. 924. Ungley, C. C. Proc. R. Soc. Med. (in the press). Cooke, W. T., Peeney, A. L. P., Hawkins, C. F.
6.
April 29, p. 834. Heinle, R. W., Welch, 1948, 33, 1647.
A.
D., Pritchard,
J. A.
Lancet,
J. Lab. clin. Med.
particularly interested in Mr. Mitchiner’s letter last week because the association of which I have the honour to be president is most concerned with this problem at the moment. SIR,—I
was
Registrars at non-teaching hospitals, though they gain large experience, find that when they apply for promotion to a consultant post, even in a non-teaching hospital, they are severely handicapped as the appointment committee is very largely composed of teachers, and if a registrar from a non-teaching hospital is competing against a registrar from a teaching hospital the latter, though possibly junior and with less practical experience, will probably get the job. Young men tend, therefore, to hang about the teaching hospitals fearful to venture into the periphery lest they quit irrevocably the ladder of promotion. If this state continues the tion-teaching hospitals, in spite of the practical experience they afford, will be unable to get satisfactory applicants for registrar posts, and a general decline in efficiency will result. Furthermore, the disadvantages of inbreeding within the teaching hospitals will be accentuated. I am sure it would be a great advantage to both teaching and non-teaching hospitals if consultants on both had the widest experience, and I feel that registrars should be encouraged to widen their experience by a term of service in a regional hospital, not because of pious exhortations to clear the congestion at the centre and by so doing diminish the field of applicants for promotion, but because such experience would be regarded as an asset, if not an essential qualification, when appointments of consultant rank were made in either teaching or non-teaching hospitals. a
very
H. J. MCCURRICH 45, Lincoln’s Inn Fields, W.C.2.
President, Regional Hospitals’ Consultants and Specialists Association (Non-Undergraduate Teaching Hospitals).
SIR,—Mr. Mitchiner’s letter last week is of importance
only to registrars but also to all those who are concerned with the staffing of medical posts abroad. In the past such posts have very largely been filled by men who chose to spend twenty or thirty years of their lives in Africa, India, or the East. Similar posts are available now. Most posts advertised for short terms of service are unattactive owing to the uncertainty as to what will happen when the contract ends. But there are, I believe, some posts-and the number of these may increase-to which those who have special experience and higher qualifications would be welcomed for periods of from four to six years. I am thinking particularly of general physicians, general surgeons, orthopaedic and ophthalmic surgeons, gynæcologists, anaesthetists, psychiatrists, and those who practise physical medicine. Here again the main problem is that of reabsorption in this country when their period of foreign service is over. I can only suggest that some or all of the regional boards, with the concurrence of the Ministry of Health, might be willing in the interests of British medicine to increase their specialist or consultant establishments to include some supernumerary posts, so as to allow of secondment of a limited number at a time for work abroad. This would involve financial arrangenot
being worked out between the two employers. But it is no new thing to second men in established posts in Government service in this country to Government ments
931
posts abroad for limited periods without loss of status on return. It might even be and pension rights, &c., possible for one particular regional board in this country to develop a special liaison with one Dominion, Colonial, Protectorate government on these lines. The matter is urgent and demands very early consideration, though some delay seems inevitable until the various regional boards have at last been able to declare their consultant establishments. H. C. SQUIRES or
Consulting Physician to the Sudan Government.
London, «’.1.
Public Health Epidemics
in Schools
IN 1929 the Medical Research Council appointed a committee to investigate epidemic and other illness in schools. An interim report, based on detailed morbidity statistics from a number of boys’ and girls’ public schools and some Naval schools, was published in 1938.1 An analysis of the data collected during the years 1935-39 now appears as a sequel.2 Taken together, the two reports present a detailed picture of the illnesses that affected a sample school-age population during ten years. Some of the most interesting findings relate to the large, ill-defined, and ubiquitous group of nasopharyngeal infections. Influenza is shown to have been an epidemic disease essentially belonging to the spring term, with a universally high attack-rate in 1937 : this presumably reflected a generalised epidemic since Influenza Deaths in Great Towns showed a corresponding peak. There was no evidence that infection in this year conferred any immunity towards a second epidemic two years later. Other nasopharyngeal infections (sore throat, colds, chills, coughs) were the commonest causes of sickness, and these also showed highest attack-rates during the spring term. An interesting finding here was an attackrate on girls’ schools 150-300% higher than on boys’ schools ; the difference was especially evident in the A high case of colds and did not apply to sore throat. correlation was shown between the attack-rates of otitis media and sore throat in both boys’ and girls’ schools, and between otitis media and all nasopharyngeal infections in boys’ schools. In girls’ schools, however, there was a negative correlation between otitis media and all nasopharyngeal infections. The incidence of sinusitis showed a precisely similar behaviour. The report suggests that these apparently anomalous findings were connected with the much higher attack-rate, already mentioned, in girls’ schools of nasopharyngeal infections ; the coughs and colds were perhaps treated more seriously and in consequence the complications were fewer. Nonmuscular rheumatism, though often associated in the individual case with a history of sore throat, did not show a correlation with attack-rates of sore throat ; but scarlet fever and non-muscular rheumatism showed a high correlation. In this connection it seems a great pity that no test for correlation between sore throat and scarlet fever was made, since the occurrence of cases of scarlet fever a,s incidents in a wider epidemic of infectious sore throat must be a common experience. Turning to the exanthemata and mumps and whoopingcough, it is shown that these occurred more often in the spring and summer terms than in the winter term, with the exception of chickenpox. The sex-incidences did not differ significantly, except in the case of whoopingcough which occurred more often in girls. Measles showed a significantly larger number of single-case outbreaks in girls’ than in boys’ schools ; the report 1. Spec. Rep. Ser. med. Res. Coun., Lond. no. 227. 1938. 2. Epidemics in Schools. Spec. Rep. Ser. med. Res. Coun., Lond. 1950. Pp. 96, 3s. no. 271. H.M. Stationery Office.
that this again is connected with the higher incidence of nasopharyngeal infection, already noted, in girls’ schools : if the minor catarrhs are put to bed earlier, cases of measles will be more often isolated in the early infectious stages. The association between herpes zoster and chickenpox was again observed. Another finding worth mentioning was the much lower incidence of tinea cruris in those schools that practised isolation of this complaint. The sceptical, however, may ask whether the latter finding is not due to a high rate of concealment, since isolation for what is usually a trivial complaint will not appeal to the
suggests
schoolboy. On the whole it must be admitted that this report does not throw much new light on the general problems of epidemiology. Perhaps one reason for this is that the residential school is a semi-isolated community " only in a very limited sense, since its inmates form part of the general community for a third of the year ; and no epidemic runs a natural course, because of the disruption of the community at the end of term. On the other hand the report (with its predecessor) fulfils two important purposes. In the first place it provides statistical proof of a number of phenomena which, though well recognised by many workers in school medicine, have existed only as general impressions unchecked by figures. In the second place it provides a work of reference of great value for all future workers in this field. "
Smallpox Certain cases of smallpox or suspected smallpox have come to light: 1. A girl who arrived in this country by air from Switzerland on April 28 attended the outpatient department of a London
teaching hospital with a generalised rash which raised a suspicion of smallpox. All precautions were taken accordingly, pending laboratory investigations. These ultimately proved the case to be one of generalised vaccinia. 2. On May 5 a man was taken off an aeroplane due to depart from Northolt for Renfrew, with signs and symptoms of an acute illness accompanied by a rash. The airport medical officer considered there was the possibility of the case being one of smallpox, and the man, after being seen by a smallpox This man had earlier was removed to isolation. the same day landed at London Airport from Calcutta, which he had left on May 3. All the necessary administrative action was taken, including notification of the circumstances of the case to countries to which contacts were proceeding. Laboratory examinations do not confirm the original suspicion, and the case is not now regarded as one of smallpox. 3. On May 4 and 5 two patients from Halifax and one from Sowerby Bridge, adjacent to Halifax, were taken into isolation as cases of smallpox. The normal preventive measures were at once put in hand by the local authorities concerned.
consultant,
Infectious Diseases in
England
and Wales