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TRAINING OF HEALTH VISITORS
710 prove it ? " On the contrary, my first statements are ignored, and my repetition of them is met by the complaint that I am becoming a bore by repeating myself. The argument is essentially anatomical, and the trouble is that anatomy is bound by two rigid fetters : the examination system and the dissecting-room. Tl1e first means that it is unfair to one’s students to teach them unorthodox anatomy when they may be examined by an orthodox professor. Hence a further resemblance to the theological atmosphere : not a few of my young men have found themselves in examinations faced with the choice of making a very risky statement which they or of parroting orthodox textbook consider true; anatomy which they consider false. The anatomical limitations of the dissecting-room are even worse. The young do not come there, and the material of study lies stiff and motionless. Dr. Spence’s claim that endocrinologists carefully examine and classify their cases is meaningless unless he states what classification is used. He cannot use mine as, if correct, it destroys his work ; I know of no other. His carrying of an opinion I do not hold to its " logical and ridiculous conclusion " is hardly scientific discussion, and his last paragraph is so loaded with sarcasm that I am unsure of its meaning. But if this is that no substances naturally found in the body can be harmful, he should consider the adrenal and the thyroid secretions. In this business of undescended testicles I still occasionally find diagnosis extremely difficult ; I am still learning; and I still make mistakes. But I am, I honestly think, a long way ahead of those who consider that the testicles they feel above the pubis are in the inguinal canal. And all endocrinologists whose papers I have read do this. DENIS BROWNE. London, W.1. TRAINING OF HEALTH VISITORS on the training of health visitors discussed in your annotation of April 2, merit careful thought. Dr. Davies and Dr. Brockington are right in emphasising the importance of the health visitor and the need for ensuring that her training and qualification command general respect. There is no doubt that she can be employed to further efforts by local authorities in the prevention of illness under section 28 of the Act. To suggest, however, that this, or her duties under section 24, necessitates that three-quarters or more of the time spent in her specialised training should be devoted to a social-science course equally suited to almoners and industrial nurses, seems to me quite unjustifiable. The health visitor is primarily a health educator working among mothers -an adviser, " the counsellor of motherhood." She is amelioration ; and thirdly secondarily an agent for social " an agent for " intelligence on behalf of the health
SiR,-The proposals
department. Rearing healthy children is still the most important work in the world, and it would be a very rash individual who would suggest there are not still fields to be explored in the achievement of health in childhood and adolescence. The health visitor’s influence is due to her being able, by her experience in nursing and midwifery, to give helpful advice to a mother, at a most impressionable stage, on the subject of her greatest concern. The influence of any outsider on the family as a whole is related to, and mainly due to, her influence with the mother. It is not, and never will be, due to any profound knowledge of social science, of economic theory and practice, of legal enactments, and the like. No-one will deny that a knowledge of modern social legislation, of public and voluntary social services, and of the technique of case conference is necessary to a health visitor. But the practical care of the child within the family, the economics and technique of household management, the psychology of childhood and adolescence, the normal physical and mental levels in young life, maturity, and senescence, and the methods of individual and group teaching in the field, are, it seems to me, still the fundamentals in the health visitor’s training. She is still a personal health worker. Let the health visitor’s training and examination Let us encourage entrants with remain specialised. maturity and- yet initiative, knowledgeable in human
experience and suffering, familiar with the evidences of sickness and health, able to advise with authority and to help with sympathy. As regards training, adequate experience of midwifery (on the district) is necessary if the health visitor is to be able to share, even in a limited way, in the mother’s experience, and to appreciate what the newborn baby means to the mother and the mother to the babe. The specialised six-month course and if it be necessary to havea seems too crowded ; university training and diploma, they should be afforded under the aegis of the department of preventive or social medicine-what we seek is the ideals and background of medicine informed by social science. I doubt the need for the university diploma. My own views published in Mother and Child (1943) have changed somewhat, particularly in view of the proposals made by the nurses’ working party. Most will agree that an extension in the duration and content of the health visitor’s training, especially in relation to social work, is necessary, but I am convinced from close knowledge of the work of health visitors that the proposals of Dr. Davies and Dr. Brockington require considerable modification. E. D. IRVINE Medical Officer of Health.
Dewsbury.
CORONARY THROMBOSIS much interested in the letter from Dr. Snowman in your issue of April 2. As a general practitioner I too have once or twice seen death follow rapidly after the administration of morphine in the acute stage of cardiac infarction, but cardiologists appear to doubt that the drug has any part in the fatal outcome. I would suggest, however, that in a condition of acute shock morphine, by producing a further fall of blood-pressure, might tip the scales against the patient. In my experience aminophylline is a much safer drug to employ in the acute stage of the disease ; it appears to be almost as effective in relieving the patient’s distress, particularly if pulmonary cedema and bronchospasm are associated as manifestations of left-ventricular failure. My practice is to give 0.5 g. of the drug intramuscularly or (well diluted and very slowly) intravenously. I would suggest that this drug be given as soon as the diagnosis is made, and that morphine be given if necessary later, when the initial shock has passed off to some extent.
SiR,—I
was
Birmingham.
H. JOSEPHS.
SPECIALIST QUALIFICATIONS SIR,-The leader in your issue of Jan. 8, which has, just reached here, demonstrates a number of the faults of the present British system, but fails, I feel, to point out others. In the greater part of the British Empire the medical degrees of the many universities and the diplomas of the Royal Colleges or similar institutions are recognised as suitable for registration without further examination. This system is greatly superior to that of France, for example, where university graduates are compelled to take the State examination and consequently must all be coached on an identical standard. The British qualifications have a uniform level which nevertheless permits individuality and local emphasis. This cast-iron standardisation of the French is, to a large extent, avoided in America by each State having its own registration examination, with a wide degree of reciprocity. It is unfortunate that at the specialist level British medicine is developing its own bottleneck. At this level the high qualifications of the various examining boards are no longer looked upon as different but roughly equivalent, but the Royal Colleges have almost succeeded in laying down that they alone can issue licences for specialist appointments. This state of affairs is distressing firstly because it gives a grossly unfair advantage to those who, in the junior years, have not the enterprise to move far from the coaching and examining centres, and secondly because it tends to convert British postgraduate teaching into a series of cram classes. Both in India and here I have been distressed to see that the young graduate goes to Britain to collect postgraduate diplomas and goes to America to learn the recent advances-
SiR,-The proposals
department. Rearing healthy children is still the most important work in the world, and it would be a very rash individual who would suggest there are not still fields to be explored in the achievement of health in childhood and adolescence. The health visitor’s influence is due to her being able, by her experience in nursing and midwifery, to give helpful advice to a mother, at a most impressionable stage, on the subject of her greatest concern. The influence of any outsider on the family as a whole is related to, and mainly due to, her influence with the mother. It is not, and never will be, due to any profound knowledge of social science, of economic theory and practice, of legal enactments, and the like. No-one will deny that a knowledge of modern social legislation, of public and voluntary social services, and of the technique of case conference is necessary to a health visitor. But the practical care of the child within the family, the economics and technique of household management, the psychology of childhood and adolescence, the normal physical and mental levels in young life, maturity, and senescence, and the methods of individual and group teaching in the field, are, it seems to me, still the fundamentals in the health visitor’s training. She is still a personal health worker. Let the health visitor’s training and examination Let us encourage entrants with remain specialised. maturity and- yet initiative, knowledgeable in human
experience and suffering, familiar with the evidences of sickness and health, able to advise with authority and to help with sympathy. As regards training, adequate experience of midwifery (on the district) is necessary if the health visitor is to be able to share, even in a limited way, in the mother’s experience, and to appreciate what the newborn baby means to the mother and the mother to the babe. The specialised six-month course and if it be necessary to havea seems too crowded ; university training and diploma, they should be afforded under the aegis of the department of preventive or social medicine-what we seek is the ideals and background of medicine informed by social science. I doubt the need for the university diploma. My own views published in Mother and Child (1943) have changed somewhat, particularly in view of the proposals made by the nurses’ working party. Most will agree that an extension in the duration and content of the health visitor’s training, especially in relation to social work, is necessary, but I am convinced from close knowledge of the work of health visitors that the proposals of Dr. Davies and Dr. Brockington require considerable modification. E. D. IRVINE Medical Officer of Health.
Dewsbury.
CORONARY THROMBOSIS much interested in the letter from Dr. Snowman in your issue of April 2. As a general practitioner I too have once or twice seen death follow rapidly after the administration of morphine in the acute stage of cardiac infarction, but cardiologists appear to doubt that the drug has any part in the fatal outcome. I would suggest, however, that in a condition of acute shock morphine, by producing a further fall of blood-pressure, might tip the scales against the patient. In my experience aminophylline is a much safer drug to employ in the acute stage of the disease ; it appears to be almost as effective in relieving the patient’s distress, particularly if pulmonary cedema and bronchospasm are associated as manifestations of left-ventricular failure. My practice is to give 0.5 g. of the drug intramuscularly or (well diluted and very slowly) intravenously. I would suggest that this drug be given as soon as the diagnosis is made, and that morphine be given if necessary later, when the initial shock has passed off to some extent.
SiR,—I
was
Birmingham.
H. JOSEPHS.
SPECIALIST QUALIFICATIONS SIR,-The leader in your issue of Jan. 8, which has, just reached here, demonstrates a number of the faults of the present British system, but fails, I feel, to point out others. In the greater part of the British Empire the medical degrees of the many universities and the diplomas of the Royal Colleges or similar institutions are recognised as suitable for registration without further examination. This system is greatly superior to that of France, for example, where university graduates are compelled to take the State examination and consequently must all be coached on an identical standard. The British qualifications have a uniform level which nevertheless permits individuality and local emphasis. This cast-iron standardisation of the French is, to a large extent, avoided in America by each State having its own registration examination, with a wide degree of reciprocity. It is unfortunate that at the specialist level British medicine is developing its own bottleneck. At this level the high qualifications of the various examining boards are no longer looked upon as different but roughly equivalent, but the Royal Colleges have almost succeeded in laying down that they alone can issue licences for specialist appointments. This state of affairs is distressing firstly because it gives a grossly unfair advantage to those who, in the junior years, have not the enterprise to move far from the coaching and examining centres, and secondly because it tends to convert British postgraduate teaching into a series of cram classes. Both in India and here I have been distressed to see that the young graduate goes to Britain to collect postgraduate diplomas and goes to America to learn the recent advances-