305 possible by the physical activity typically involved. (This kind of analysis would be more difficult in the future because the General Register O...

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possible by the physical activity typically involved. (This kind of analysis would be more difficult in the future because the General Register Office were reducing the number of occupations from 600 to 200 and thus increasing the heterogeneity of many.) The main result was that light workers show similar death-rates at 45-54 years of age, whatever their class, and similar rates in classes I,11 and III at 55-64. Mortality among active workers does not vary at all with social class; and among heavy workers there is a strong relationship only at 55-64 years of age: MORTALITY FROM CORONARY HEART-DISEASE ACCORDING TO OCCUPATION

Rates per 100,000 men,

Wales, 1949-53. That is to say, there is no trend with social class apart from physical activity of job at 45-54, and at 55-64 an important one only in heavy workers. (Nor does inclusion of deaths from so-called " myocardial degeneration " make any difference.) The class distribution seems to be mainly dependent on the proportion of light and heavy workers in each class. A reduction of muscular effort in work is one of the striking features of both industrial revolutions and part of the change underlying all the other changes.




As the diseases of poverty, ignorance, and malnutrition recede, we confront problems that are manifestly as closely linked to the mode of life-but not in such manifest ways. Moreover, there is no comfort that further social progress-a rising standard of living-will in time mitigate and abolish our problems. Here is considerable scope for the expansion of social-medical inquiry, and Dr. Morris appealed to his hearers to help.

Smog ACCORDING to some observers, the smog in parts of the North-West of England last week was the worst in living The demand for hospital beds increased memory.

sharply. In Salford the foggy period was characterised by a widespread smoky haze with a visibility of never more than 200 yards; the smoke averaged 120 mg. per 100 c.m. and sulphur dioxide 35 parts per 100 million. Late on Jan. 29 the average smoke content was 415 mg. per 100 c.m. After being left overnight the smoke stains were too dense to permit of measurement, but the amount of sulphur dioxide was found to be 109 parts per 100 million-i.e., about six times normal. On the morning of Jan. 30 the smoke and sulphur dioxide levels


478 mg. per 100


and 164 parts per 100 million

-i.e., about eight times the normal January average. The demand for hospital beds necessitated putting into "

emergency " plans whereby hospitals refused certain non-urgent cases. The demand for beds was particularly great in respect of elderly women. Moreover, acute respiratory disorders in patients already occupying beds in acute hospitals resulted in an increase in the number of " blocked " beds. The public are increasingly conscious of the nuisance of loss occasioned by smog; and, if newspaper columns are an indication, public opinion is now decisively in operation

favour of a speed-up in the implementation of the Clean Air Act, 1956. But, curiously enough, the " black areas " -where fogs are most frequent and where the mortality and morbidity from chest disease is highest-are the areas where there have been fewest applications to the Minister of Housing and Local Government for confirmation of " smoke control " orders. Smoke Control Mr. Henry Brooke, Minister of Housing and Local Government, would like to make faster progress in removing the smoke pall from the " black areas " of England and Wales. He has asked councils in these areas to inform him by the end of June how long it will take to deal with their domestic smoke problems, what smoke-control orders will be needed, and their order of priority. He is asking for five-year phased programmes. In the last two years more than 125 local authorities in England and Wales have decided to use their powers under the Clean Air Act to make smoke-control orders. 33 of these orders are now in operation, and over 190 more have been confirmed by the Minister or are being prepared. Nearly 232,000 buildings and some 39,000 acres of land are, or will be, covered by them.

The Widdicombe File LII. MY DEAR



I was sorry to hear that you hadn’t been appointed to the job at the Elsewhere General Hospital-though for their sake, not for yours. Their hierarchical system may be defensible in theory, but it means that one can be on the staff for thirty years before having full clinical responsibility for one’s patients. You’d have been just the man to challenge that idea, but your chances of success would have been slim. Even if you’d won, the victory would have been pyrrhic, and the ulcer you’ve developed in your seven years as Senior Registrar would have become intolerable. Allow me to congratulate you on what I hear privately was a narrow escape. Even the best of friendships can’t stand the strain of much good advice, but do accept this piece-you really must see the place before you apply. I know it means travelling all over the country, and that not many Regional Boards will pay for your expenses on a preliminary survey. So you’ll be out of pocket, and the children may have to go without new shoes for another month. All the same, the money will be well spent. "


going to get a job ? you ask. You’ve had your Fellowship ten years, and a respectable Mastership for three, and your academic record is good. You’ve been long enough at a good provincial centre to have lost the fine gloss of your London teaching hospital, and to have developed an appetite and considerable ability for hard work. I think you must be 37 or 38, and so long as your present chief is prepared to push hard (some aren’t, you know) the outlook should not be too bad. For one thing, you’ve been on the market so long that When



your continued presence is an embarrassment to your seniors. This may be turned to account by appearing at meetings and conferences. If you can read a paper, so much the better. If not, you can tactfully remind various people of your existence. Of course one can’t please everyone. For some time I

nothing, because I’d nothing worth writing. My then chief pointed out the great gap this left in an application, so I dutifully scraped out the bottom of the bucket, wrote


and various editors published the stuff. You may not be shortlisted if you haven’t published a paper or so; but when you’re interviewed, some committee member will almost certainly ask why you wrote that paper, or how you found time to produce this. They won’t have read the papers, and it’s always easy to sneer at something one doesn’t know. They’ll also ask why you want this particular job. The reply to this’is simple. They know it and you know it, and they know that you know that they know it. The answer is in two parts: 1. I have a wife and four children, a mortgage, an overdraft, peptic ulcer, and a widowed mother, and I don’t want to emigrate. 2. I have been saying yes-sir, no-sir, three-bags-full-sir to a

my seniors for fifteen years, and


fed up with it.

You may have the courage to say this. I didn’t. I’ve long thought that candidates should not appear in person, but be represented by counsel. Don’t be too upset at being rejected. After a while one realises how profound a truth lies in the apparent cynicism of the saying " Blessed is he who expecteth nothing, for he shall not be disappointed ". From a long experience I can testify that that is the sovereign safeguard against disappointment. Your visit to the Board’s sumptuous headquarters and the cup of British-Railways-type tea will impress on you the sort of disease service to which you are committing yourself. You’ll get the latest news from the grapevine, and may even hear of a promising death vacancy before You’ll have excellent the obituary is in the press. the higher variety of Lifeopportunities for practising manship on your fellow candidates. (A play will one day

be written about what goes

on in the anterooms of However wet the day and grey the soup, you can console yourself by thinking that at last Mr. Blank will have to do his own outpatient clinic. One of his colleagues the other day finished off a conversation on Senior Registrars by saying brightly " Ah yes, but they all get jobs eventually; or they emigrate ". Eventually. If forty years in the wilderness was good enough for Moses, what are you bleating about ? They emigrate. As one who nearly did, I wonder if these comfortable gentlemen know the heart-searching, the uncertainty, the ache of torn-up roots, the bitter taste of failure and disillusionment, or the courage in those words. Your wife, though she does not feature in your application form, is one of your greatest assets. I have the greatest respect for all like her. I married one. They accept us on the strength of some dubious promise, they fulfil all their vows, for better for worse, for richer for poorer, in sickness and in health. They continue to believe in us when we have lost faith in ourselves and in

Regional Boards.)



Seen from the other side, committees realise that when they appoint a man they also appoint his wife, and I am told that one committee chartered a bus to bring all the candidates and their wives to the hospital. The selection of an applicant for a permanent post is a grave matter, which may explain if not excuse the devious practices of some Boards. Some candidates put themselves out of the running by the lack of order in their applications. Some are so full of panache and stuffing that they’re thrown out, and some so reticent about their achievements that they do themselves no justice. To

these I recommend the saying of Artemus Ward " Whoso bloweth not his own horn, that horn will not be blown ". Having selected the applicants from this written record, one must choose one from the short list. The methods in use can be applied singly or in combination: The Interview There is considerable evidence that one short interview is an extremely unreliable way of choosing a candidate. (2) The Ward Round Under pretence of showing candidates the department, one conducts a full ward round, pumping them tactfully. Only the most naive will be taken in by this. (3) 7he Sherry Party Provide a few bottles of sherry and mingle the existing consultants with the candidates. This is agonising. The teetotaller will be suspect, and the pint-of-bitter man will be unhappy with Tio Pepe. He may even commit the social crime of preferring a sweet sherry. On such small matters great ones depend. Everyone is ill at ease. One does not even get enough sherry. Canvassing is prohibited. Anyway, it is not only illegal but unnecessary. Nobody would canvass when there are so many other ways of getting on. To have married the external assessor’s daughter a decent time before is an


advantage. One has sometimes felt that the University Representative in fact represented the successful candidate, and should have been asked to declare his interest. A few sheep have been appointed, because they undeniable

known to be docile and to have no chance or desire compete in private practice. Having been at the right medical school seems to help-" You can always tell a man, but you can’t tell him much ". Conversely, knowledge of how to escape appointment is worth having. One day you may find yourself dangerously near getting the job you don’t want, having discovered its drawbacks too late. This nearly happened at Elsewhere, though at the time you didn’t know it. In such circumstances, throw away your carefully nurtured conformity. It’s just as damaging to say that in your spare time you are a lay preacher as that your two mistresses really leave you no spare time at all. Appointment committees do have a very hard and thankless task. Out of fifty applicants, probably twenty are well trained, fifteen excellently, and five superbly. Any one of forty could do the job well, and the moans always come from those who aren’t appointed. One imagines, despite all previous experience, that getting a consultant job solves all problems. But, if you look back at any achievement, you will remember that all it did was to raise you a little higher, so that your horizon was farther off. The problems solved are replaced by different and larger ones. The door which will one day open for you won’t be only that of the Staff Common Room at St. Somebody’s, with its view of the colleagues with and against whom you must work for twenty-seven years, but the entrance to opportunity. " It is not given to man to command success, but to deserve it ". When the door does open, you’ll have to think what you mean by success, and in the process will probably discover yourself, and that’s what makes all the waiting worth while. If you didn’t live so far away, we could have said all this over a glass of ale and saved’ you the trouble of reading it. Greetings to Mary and the children.




Your affectionate