VOCATIONAL TRAINING FOR GENERAL PRACTICE

VOCATIONAL TRAINING FOR GENERAL PRACTICE

1425 In A Running Commentary by Peripatetic Correspondents " A MAN is judged by the coat-hangers he keeps," as that mythical personage, my old nurs...

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1425

In A

Running Commentary by Peripatetic Correspondents

" A MAN is judged by the coat-hangers he keeps," as that mythical personage, my old nurse, might have said. I have never knowingly stolen-"’ convey’, the wise it call "-a coat-hanger in my life, yet my wardrobe now holds a collection as evocative as an album of old photographs. " Yeoward Line " must date back to the early 1920s when I went as a ship’s surgeon on a banana boat to the Canaries: the line folded up in the last But I never, no war, most of their ships having been sunk. never, travelled on the Peninsular and Oriental, so how could a P. & 0. hanger have been acquired ? Then there’s " Canadian National Hotels ". Was that Saskatoon, where my wife so nearly got arrested for " consuming liquor in a public place ", having taken the remains of a bottle of local [sic] wine to drink with her picnic in a park ? " Albergo Ciano, Biscioftu " must already have changed its name when I went to Ethiopia for UNRRA. Then there’s one with " Ulla Pederson-Burke " written on it-an adorable Danish domestic who looked like a Botticelli Venus and set the house on fire early one Sunday morning by leaving a portable gas-fire (which she had no business to use anyway) about a foot from the wooden surround of her fireplace. Eheu fugaces But how far back can coat-hangers go ? Are there antique coat-hangers ? Perhaps there is some Shorter History of Coathangers struggling to get out somewhere: or perhaps it has got Did Florence Nightingale use them ? out and I’ve missed it. Or Beau Brummel ? Or Jane Austen ? Probably only Georgette Heyer knows. Did Harvey slip his furred gowne on to one ? Was the lobby of the Roman senate filled with toga-hangers ? The Homeric heroes seem to have worn little but a spear and shield, but Achilles may well have said to Briseis "Bring a coathanger, there’s a dear. I’m going to do a little sulking in my tent and I want to get the creases out of my armour after that scuffle with Hector yesterday". And surely Clytemnestra must have hung up her best welcome-home dress on a hanger before she netted and axed her husband in the bath. But the O.E.D. does not mention them, the V. & A. library has no reference, and three museums specialising in domestic history can throw no light at all on the antiquity of coathangers. May I offer this virgin territory, free of charge, as a subject for a PH.D. thesis ? ...

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To break one’s scaphoid is bad enough. To do it by a mechanism not in the textbooks-all of which adhere to the fall-on-the-outstretched-hand idea-is doubly annoying. But from the first denial that by having one’s hand slip on a wheel wrench it was possible to snap the bone across its waist, I quickly swung to pride that I was unique or, alternatively, that I was making a contribution to medical knowledge. Neither of these views were accepted by my colleagues, who did their best to convince me that I had fallen; this was but the first of a series of encounters with the iron curtain of doctor-disregard for the patient, with me in this instance on the wrong side. Nobody would believe that my first plaster was uncomfortable and that it mattered that I could not get my hand through my coat sleeve. Nobody would credit that I was about to get a pressure-sore over the head of my ulna, my thumb, or my hypothenar eminence. But, as the customer, I was determined to be right, so I went through eight plasters in six weeks, moving my wrist through at least 10° in each direction inside all of them. My fracture healed despite this and my wellestablished scaphoid-neurosis that it would not. I have still to decide whether my colleagues were happier with me in plaster and complaining or out of it and reminiscing ab.out my

experiences. At last, just what we’ve always needed ! " said the social anthropologist in Central Africa, gazing in delight at the title page of The Lancet for March 16, 1968. The item that pleased him ? A Portable Incubator for Long-distance Trans"

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port of Cultures " of

Letters

England Now

course.

to

the Editor

A PREREGISTRATION PROBLEM I draw attention to a social problem which we have created for ourselves within medicine and which it is within our power to correct ? The increasing number of student marriages is creating a situation in which mothers are expected to fulfil the statutory requirement of resident houseappointments in order to obtain registration at a time when they have a young baby or child to look after. As doctors none of us would tolerate for our patients separation of mother and child in this way, particularly at such an early age. To meet the situation some mothers defer their preregistration period until the child reaches nursery age and may be looked after by others; some rely upon their parents to take over the baby; some hire baby-minders. These solutions cannot be regarded as anything but socially and, maybe, morally undesirable. Yet we permit this and allow the position to persist-a situation which may be further aggravated by the proposals of the Royal Commission. We should now seek amendment of the regulation so as to allow mothers to fulfil the requirement for registration by undertaking appointments which are non-resident. Objection to easement of the regulation will come from those who consider that students should not marry, or, if married, should refrain from starting families. But above all there is the child: why should the child pay the forfeit for our regulation ? For it is a forfeit to lose the natural security of family life and maternal care. As doctors we should have no part in separation of a baby from a mother. St. George’s Hospital Medical School, BRYAN N. BROOKE. London S.W.1.

SIR,-May

VOCATIONAL TRAINING FOR GENERAL PRACTICE annotation SIR,-Your (June 15, p. 1299) serves once more to exhibit the lack of acceptance by the N.H.S. of its responsibility for vocational training in medicine. No other industry has ignored ttaining needs for its own future survival in the same way as has the N.H.S. for its medical personnel. The University of Newcastle is to be congratulated on accepting the challenge; indeed only the universities have the foresight and finance to do so. It is, nevertheless, my view that major teaching hospitals are the least suitable centres for the training of general practitioners. They are more suited to the teaching of specialists in hospital disciplines and research-a field in which they have yet to fulfil their accepted role. To add yet another load of postgraduate training will detract from the efficiency of either. The difference in available services between the teaching and district hospitals is in all conscience large enough-the gap between the teaching hospital and general practitioner is unbridgeable. It is this gap which has served to detract, perhaps irrevocably, from the attraction of general practice to a medical student. From my own experience, it is evident that many general practitioners (especially the younger ones) are reluctant to approach anyone senior to a senior registrar in a teaching hospital for information and advice on a N.H.S. patient. Similarly, university general-practice units tend to be idealistic, and bear a tenuous relationship to the conditions of practice in the country as a whole. As such, they are more suited to inculcating ideas in receptive undergraduates, before they are faced with the realities of general practice. It is my view that the district hospital must be the training ground of the general practitioner. The district hospital is approachable, and even visitable. In many, the general practitioner already holds appointments, and indeed the future of general practice will be dependent on the closer integration of the general-practitioner and hospital services. There is a large pool of clinical and teaching expertise in district hospitals and general practices which should be utilised.

1426 If there is to be a future for general practice in this country, the N.H.S.-and hence the regional boards and management committees-must accept this responsibility before it is too late.

A. R. ISAAC.

THE ROYAL COMMISSION SIR,-Having attended a number of discussions on this subject by students a small part of whose training is at district hospitals, and having participated in this training at two district hospitals over a number of years, I do not think it is always realised by the teaching school and the regional hospitals how valuable this can be to the students, as outlined by Professor Black (June 15, p. 1308), and also by myself in an earlier letter (April 27, p. 916). There sometimes seems to be doubt as to how this could be done in practice without interfering with the curriculum of the students at the teaching school, but the solution at one of the hospitals has been fairly simple-namely, getting each medical and surgical teaching firm to agree to two of their students spending 2 weeks of their period at a regional hospital. This has formed a nice balance in their training. It is important however, that resident facilities should be made available at the regional hospitals, for this gives the students the opportunity of seeing emergencies

P. J. W. MILLS.

whether ectopic pregnancy is more or less common following the operation, and of any increased risks during the pregnancy or the delivery because of the operation. Bronglais General Hospital, GEOFFREY FRANCIS WILLIAMS. Aberystwyth, Mid Wales.

SIR,-Having followed up a series of 168 patients in a combined gynaEcoIogicaI/psychiatric survey,! we should like to report that our conclusions were broadly similar to those of Sir Dugald Baird and Dr. Thompson. Only 6 (3-6%) of the 168 patients persistently regretted the operation, though admittedly many others had varying degrees of minor ill-health. 28 (17%) were found to have gynaecological disorders at followup, but there was no evidence that they represented a consequence of the sterilisation procedure. We are not in the least surprised to learn that Dr. Enoch and Dr. Jones (June 8, p. 1247) found a substantial amount of illhealth at follow-up of their 98 sterilised women. The significant area of inquiry is: how much more ill-health might they have had if they had not been sterilised ? In the series studied by ourselves, as well as in that of Sir Dugald Baird and Dr. Thompson (May 11, p. 1023), the women themselves were in no doubt in most instances that sterilisation had been a beneficial

procedure. As stated in our paper: " Sterilization can be expected to improve socioeconomic functioning but has little influence on basic psychiatric problems." Department of Psychiatry, Eastern District Hospital, Glasgow E.1.

FOLLOW-UP AFTER STERILISATION SiR,-Sir Dugald Baird and Dr. Thompson in their interesting follow-up of 186 sterilised women (May 11, p. 1023) show that 8 regretted being sterilised. They also state that this operation is a virtually irreversible measure ". Green-Armytage’s method of tubo-uterine implantation was evolved mainly for interstitial block or block of the first inch of the cornual end of the isthmus. His results1 in 38 patients were fourteen full-term pregnancies with one ectopic gestation and two abortions. He later reported2 50 consecutive cases with a 40% success-rate and was optimistic that a 5000rate was attainable provided the obstruction was limited to the interstitial part of the tube and the rest of the tube was normal. The normal methods of sterilisation leave the fimbriated end plus a certain amount of normal tube. It seems therefore, that these sterilised patients are ideal cases for tubo-uterine implantation, inasmuch as most of them are also known to be very I have been unable, however, to find any series fertile. describing the results of the operation performed on this type of "

THE MUSCLE GLYCOGENOSES read with interest the article by Dr. Salter (June 15, SIR,-I p. 1301) and should like to raise two points. First, in the description and diagrams of the 1-4 and 1-6 glycosidic links the oxygen atom between hexose units was omitted, and thus the distinction between a links (as in glycogen) and links (as in cellulose) is unclear. The glycosidic linkage is due to condensation of two molecules of D-glucose with elimination of one molecule of water. Secondly, the double-glucagon test is usually diagnostic for limit dextrinosis (amylo-1, 6-glucosidase deficiency). Parental glucagon after overnight fasting does not produce a hyperglycsemic response, but a similar " tolerance " test performed two hours after a meal does. These minor points in no way detract from the value of Dr. Salter’s concise and comprehensive survey. Middlesex Hospital Medical School, London W.1.

patient. I have operated on 4 patients who had previously been sterilised-3 of these have become pregnant and were delivered of live children by cxsarean section at term. The 4th, who was operated on in June, 1966, is not yet pregnant, though her tubes are patent as shown by hysterosalpingography in April, 1968. Mr. W. G. Mills (Birmingham)3 operated on 1 patient who was successfully delivered of a live child. A further case of his in which the tube had been divided very near the fimbria was reconstructed by direct anastomosis. This patient reported what she took to be an abortion a few months later, but has been lost to follow-up. No individual consultant can have a large series of these cases. It might be of interest for the Royal College of Obstetricians and Gynaecologists to circulate gynxcologists to find how many of these operations have been performed on previously sterilised women and with what results-negative as well as positive. The problem for the remarried sterilised patient is very real to her. One should be in the position of being able to give her a reasonably accurate assessment of her chances of becoming pregnant ; of the dangers of the operation itself, of 1. Green-Armytage, V. B. J. Obstet. Gynœc. Br. 2. Green-Armytage, V. B. ibid. 1959, 66, 32. 3. Mills, W. G. Personal communication.

Emp. 1957, 64, 47.

W. P. BLACK A. B. SCLARE.

JEANNE A. SMITH.

IgA AND RING-18 CHROMOSOME

SIR,-Dr. Finley artd her colleagues (May 18, p. 1095) report absence of IgA in the serum and saliva of a 14-year-old Caucasian girl with a ring-18 chromosome. We have investigated an 11-year-old boy with an l.Q. of 51, and a ring-18 chromosome present in every cell examined from blood and fibroblast cultures. The results of immunoglobulin estimations (in mg. per 100 ml.) were as follows:

Serum-levels are within normal limits for a boy of this age. Saliva-levels are very variable, and 1 mg. has to be considered within normal variation, though on the low side. It is unusual to have more IgG than IgA in the saliva. This may be connected with the fact that the boy has several attacks of bronchitis every winter, and there may be an isolated defect of salivary

IgA. Ring-chromosome formation follows terminal deletions, and 1.

Black, W. P., Sclare,

A.

B. J. Obstet. Gynœc. Br. Commonw. 1968, 75, 219.