236 26 July 1969 M MEDICALRNrLsHIOURNA-L

Correspondence Br Med J: first published as 10.1136/bmj.3.5664.236-a on 26 July 1969. Downloaded from

Letters to the Editor should not exceed 500 words.

The Consultant's Job Pigmentation in Megaloblasic Anaemia Aetiology of Pre-eclampsia G. A. Medhurst, M.R.C.S., and P. S. A. F. Fleming, M.B., and F. A. Ive, G. J. Sophian, F.R.C.O.G...... 241 Andrews, M.D...... 236 M.R.C.P...... 238 Courses for G.P.s Imported Malaria Hypokalaemia after Treatment with R. I. Muir, M.B ...... 241 L. J. Bruce-Chwatt, M.D...... 236 Duogastrone (Carbenoxolone) Adrenal Function and Exogenous A.C.T.H. M. W. Swallow, M.R.C.P...... 239 Prospects in Susan E. Mitchley, M.R.C.S ...... 241 Sir , P.R.C.P., and others 237 Scanning Electronmicroscopy in Annual Representative Meeting Decompression Sickness and Contact Lenses R. E. W. Oliver, M.R.C.S...... 242 A. J. P. Carteaud, M.D ...... 239 J. C. Betts, M.B...... 237 Vocational Training for Medical Teachers Bowel Motility and Colonic Cancer Intermittent Methohexitone A. E. Stuart, PH.D., M.R.C.P.ED...... 242 A. R. P. Walker, PH.D., and B. Faith J. S. Robinson, M.D., F.F.A. R.C.S., and B.M.A. Subscription and Salaries Walker ...... 238 others ...... 240 G. Wiseman, M.D...... 242

The Consultant's Job result of this recently published report.-We are, etc., SIR,-The medical staff of the Kettering great benefit in being fully stretched by the G. A. MEDHURST, and District General Hospital record their exercise of the highest skills and talents, but Chairman disagreement with the report of the working none in being ground down by an ever- Medical Advisory domrrittee. party on the responsibilities of the consultant increasing load of routine chores. P. S. ANDREWS, Chairman, grade' (7 June, p. 588). We insist that in district general hospitals Medical Staff Committee. We realize that the general practitioner's the proper functioning of departments de- Kettering General Hospital, http://www.bmj.com/ first call is to his list patients and not to the pends upon team-work, and that the team Northamptonshire. hospital, and therefore his services cannot be consists of housemen, registrars, and con- REFERENCES The Responsibilities of the Consultant Grade, De- the solution to the present manpower defi- sultants. We dispute the statement in para- partenent of Health and Social Security, De- ciency in the hospital service. We insist that graph 14 that there has been a more than partment of Health for Scotland, 1969. the report is not accepted as it stands, and " H.M. S.0. commensurate" increase in the number of 2 Aledical Staffing Structure in the Hospital Service, that full discussion with widely representative juniors since "Platt "' was implemented. Report of the Doint Working Party, 1961. elements of the profession must take place During these years the junior staff rightly has London, H.M.S.O. before the report is acted upon. been allowed more time to study and their We feel that the working party's composi- hours of duty made realistic and less penal, on 26 September 2021 by guest. Protected copyright. tion was biased in favour of teaching hos- at least in this part of the country. A re- pitals, and therefore the report does not distribution of consultants and junior staff to assess the problem of the staffing structure correspond more evenly and closely with the Imported Malaria within district general hospitals. We realize population served throughout the country SIR,-The comprehensive paper by Mr. that discontent exists among junior staff in would be beneficial to doctors and patients. P. G. Shute and Miss Marjorie Maryon (28 many of the teaching hospitals, but regret We feel that by achieving a free rotation of June, p. 781) is most timely in recalling the that few senior registrars are in rotating posts junior staff between teaching and district past and present records of imported malaria between the teaching hospitals and the dis- general hospitals constant cross-fertilization in the United Kingdom, where the reported trict general hospitals, in which the bulk of of ideas and experience can be realized, with number of 1,036 cases over the past 10 years the N.H.S. hospital work is carried out; great benefits to both types of institution and is probably an underestimate (29 March, therefore they have no experience of the sort the engendering of a genuine partnership, p. 844). of work they will be called upon to perform which we feel to be the way ahead for our The problem is of importance to many when appointed as consultants. Should the National Health Service, which at present other countries and forms one of the aspects report be acted upon, these men will find that is the best of its kind in the world. We of the increased speed and volume of inter- their jobs afs consultants will consist of the would welcome a reshaping of the work-load, national travel. As a result of malaria eradi- work they are at present doing and no more. but do not wish this to be done hastily. cation operations the indigenous disease has To us it is a pointless waste of vocational Finally, lest it be thought that we seek disappeared from Europe, from the U.S.A., training to encourage men to obtain higher housemen and registrars to do the service from most of the U.S.S.R., from South qualifications so that they may do the work work only, we wish to record the achieve- Africa, northern Australia, most of the of juniors during the greater part of their ments of our registrars in obtaining higher islands in the Caribbean, from Chile, Cyprus, working life, from the age of 32 to 65 years. qualifications, and their record is as good as Israel, Japan, Lebanon, Mauritius, Singapore, We expect the Royal Colleges will resent this that of most teaching hospitals. Moreover, and Taiwan. However, the whole of tropical debasement of the consultant's role, and see they return and tell us that their experience Africa, much of Central America, many to it that the standard of the recruits is main- here has made all the difference to their pro- countries of South America (with the excep- tained and the duties of consultants not fessional lives. We do not therefore wish tion of large areas of Venezuela), most of restricted to mere hackwo.rk. There is a to be forced to lower our standards as a the countries of southern Asia and of south- 26 July 1969 Correspondence MEDICAL JOURNAL 237 west Pacific, are still malarious and constitute Prospects in Cardiology will also be needed. Since most of those a reservoir of imported infection. A W.H.O. senior registrars who now hold a post in report' some cases of SIR,-The poor prospects of obtaining a cardiology will ultimately hold Group 1 posts, quoted 1,500 malaria Br Med J: first published as 10.1136/bmj.3.5664.236-a on 26 July 1969. Downloaded from imported into six countries during the past consultant post in cardiology implied in the or in some cases Group 2 or sometimes few years. There were 876 such cases in reports of the Ministry of Health on Medical Group 3 posts, it would appear that the 1963-1965 in the U.S.S.R.' Staffing in Hospitals' 2 are confirmed by the prospects in cardiology implied in the fore- The burden of imported malaria falls now present difficulties experienced by many senior casts by the Department of Health may pre- heavily on the U.S.A., where, since 1966, the registrars trained in cardiology in obtaining sent an unduly gloomy view, and that regis- number of cases rose dramatically from fewer consultant posts. This, together with the trars should not be discouraged from seeking than 100 per annum to 2,855 cases in 1967 evident lack of sufficient consultant appoint- further training as senior registrars in cardio- and to 2,610 cases in 1968, chiefly in the ments in cardiology in the country, suggests logy.-We are, etc., military personnel returning from Vietnam.' the need to investigate and clarify the posi- MAx ROSENHEIM, tion with a view to its improvement. President, Although malaria in the civilians returning Royal College of . to the U.S.A. from tropical areas was seen Such an investigation has been carried out by the Cardiology Committee of the Royal JOHN MCMICHAEL, only in 123 cases, the fact that most of President, them occurred in students and teachers calls College of Physicians of London and the Cardiac co-operation British Society. for special vigilance when it comes to these British Cardiac Society, with the J. F. GOODWIN, and similar occupational groups and par- of representatives of the Department of Honorary Secretary, Health and Social Security. It soon became Cardiology Committee, ticularly Voluntary Service Overseas volun- Royal College of Physicians. teers returning to this country from service apparent that the true number of consultant London N.W.l1. abroad. To this one might add the increas- cardiologists in the country was not known. REFERENCES ing number of far-ranging tourists, and the Many consultants appointed as general physi- 1 British Medical 7ournal Supplement, 1966, 2, 240. cians, and appearing as such in the official 2 British Medical 7ournal Supplement, 1968, 3, 110. following case may serve as a good illustra- 3 Royal College of Physicians of London, Royal tion of hazards of modern version of returns to the Department of Health, are in College of Surgeons of England, Joint Cardio- Innocents Abroad. fact engaged in intensive cardiological work. logy Committee Report, October 1967. Before carrying the investigation further the "A 60-year-old woman living in Hartford, Conn., U.S.A., developed on 7 March 1969 committee agreed to define three categories nausea, vomiting, and diarrhoea. On 9 March her of cardiologicail work: temperature reached 1030 F. (39-40 C.), but be- Group 1.-Investigative cardiological work came normal on the next day, and she was able to in association with a cardiac medical/surgical Decompression Sickness and Contact do some shopping. Three days later she showed centre as outlined in the report of the Joint the same symptoms as before, with the tempera- Lenses ture 1020 F. (38-9' C.) and some disorientation. Cardiology Committee of the Royal College Her found no neurological abnormali- of Physicians and the Royal College of SIR,-A 23-year-old woman wearing ties and prescribed tetracycline, although he was Surgeons.3 micro-corneal contact lenses was one of a told on that day that the patient and her hus- Group 2.-Specialist cardiological work, party of six undergoing a dry dive in a re- band had just returned from a tourist trip to such as acute coronary care, pacemaking, compression chamber. The initial air pres- East Africa, where they spent three weeks with- , etc. sure was equivalent to 200 ft. (66 m.) water out using any prophylactic antimalarials. On 13 Group 3.-The work of a general physi- March the patient continued vomiting and became gauge (89 lb./sq. in,; 20-3 kg./sq. cm.), later dyspnoeic and very weak. She was transported cian with a special interest in cardiovascular dropping slightly to 190 ft. (60 m.) as the to the hospital while comatose and cyanotic. The disorders, including cardiopulmonary and chamber cooled. After ten minutes under blood examination showed 10-20% of red blood occlusive vascular disorders. pressure a decompression according to the cells infected with P. falciparum. She died be- A letter was then sent to the 187 consultant Royal Navy tables was carried out, with fore any treatment could be started."' physicians who are members of the British stops of five minutes at 20 ft. (6 m.) and ten The tidal wave of present mass travel is Cardiac Society asking each to state his (or minutes at 10 ft. (3 m.). On leaving the http://www.bmj.com/ of growing significance. In her) present category in the official return chamber she complained of blurring of the 1967 there were not fewer than 138 million from his major hospital, and also in which vision of her right eye, which appeared to international tourists, and the average annual of the three groups he considered his present have a white film over it, the left eye being growth of this phenomenon was 9% during work to lie. Of the 141 consultants who also slightly affected. the past three years.' Only repeated warn- replied, 47 were officially categorized as On examination with an opthalmoscope, ings addressed to the public and to the cardiologists and 94 as general physicians. a haze of fine bubbles could be seen under medical profession could prevent the repeti- Of the 47 cardiologists 44 were doing her contact lens, which could not be removed tion of tragic cases such as the one quoted Group 1 work and three Group 2 work. either by rinsing and refitting the lens or by above and others discussed by Maegraith and Of the 94 categorized as general physicians changing over lenses. The bubbles could be on 26 September 2021 by guest. Protected copyright. by Watson at the Cardiff Symposium of the 24 were doing Group 1 work and 27 Group 2 seen with the lens removed, the surface of Royal College of General Practitioners.0 work. Thus of 68 members of the British the cornea appearing slightly granular. On Attention shotfld be drawn to the excellent Cardiac Society who are actually doing full replacing the contact lens it could be seen pamphlet' offering general guidance on the investigative cardiological work 24 were that the bubbles remained stationary on the prevention and recognition of imported in- officially categorized as general physicians. surface of the eye, while the lens itself moved fectious disease.-I am, etc., Out of the 30 doing specialist cardiological up and down as the subject blinked. The work 27 were officially categorized as general bubbles slowly diminished in size and after L. J. BRUCE-CHWATT. physicians. This sample, from members of some 30 minutes had completely disappeared. London School of Hygiene and the British Cardiac Society, shows that the There would seem little doubt that the Tropical , Department of Health's figures for the num- bubbles formed in the superficial layers of London W.C.1. ber of consultant cardiologists are consider- the cornea, since blinking and all attempts at REFERENCES ably too low. A further questionary is now mechanical removal were ineffective, and are World Health Organization. Technical Report being sent to consultant cardiologists in order thus of some interest as a visible example of Series, 1967, No. 374. decompression sickness and as a 2 Sergiev, P. G., Dukhanina, N. N., Zhulcova, to detail the number of senior registrars and possible T. A., and Sarikyan, S. Ya., Meditsinskaya their responsibilities in their units. It appears hazard to contact-lens wearers. Presumably, Parazitologiya i Parazitarnye Bolezni, 1966, 35, 444. probable that there should ultimately be a as the cornea is vascular, the condition was 3 National Communicable Disease Center, Malaria larger establishment of senior registrar posts due to surface absorption of nitrogen in an surveillance, Annual Summary, 1968, Atlanta, in cardiology, as these posts provide most im- analogous manner to the production of skin Ga., National Communicable Disease Center. itching work. 4Niational Comimunicable Disease Center, Weekly portant training opportunities for posts in following compressed-air Morbidity and Mortality Reports, 1969, No. 20. any of the categories. Since the cornea is not normally the site s Organization for Economic Co-operation and On the basis of the recommendations for of decompression sickness and the Royal Development, Tourism in O.E.C.D. Member Countries, p. 191, 1968. Paris, O.E.C.D. the staffing of cardiac units suggested by the Navy tables are capable of decompressing 6 Sournal of the Royal College of General Practi- joint committee of the two Colleges there safely a wide range of tissue half times, it tioners, 1968, Supplement No. 2, 1. will be a need for more consultant cardio- may reasonably be inferred that the contact 7 Mnistry of Health, Communicable Diseases Con- lenses were A tracted Outside Great Britain, May 1968, logists doing Group 1 work, and from this responsible. possible explana- London. it follows that more Group 2 cardiologists tion is that there was a certain amount of