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Annotations

CARDIOLOGY AS A SPECIALTY

THE committee on cardiology of the Royal College ofPhysicians has reiterated its opinion, expressed in 1947,2 2that a greater number of

" specialized consultant cardio-logists should be appointed to our hospitals. It saysthat there should be a fully equipped department ofcardiology at a main teaching hospital in every medicalschool; that a cardiologist should be appointed to everymajor hospital centre, where he would have a departmentincluding beds and outpatient sessions; and that one ormore cardiologists should be appointed in every area whereaccess to a major hospital is not easy. The " cardiologist "

is defined as " a physician trained in cardiology ", andrecommendations are made for a period of at least fiveyears’ training after registration.

All will agree with the committee that " cardiology

remains an important part of medicine, and cannot,without danger to its own vitality, allow itself to becomecut off from the larger whole ". But, as in 1947, we fearthat some of its proposals may have just this separatingeffect. The proposed minimum requirements call for nowork outside cardiology at any time after completion of atwo-year registrarship in general medicine. Admittedlythe training period cannot be indefinitely extended toprovide deeper understanding of other subjects; but suchunderstanding could be developed after training is com-pleted. One way of encouraging this would be to appoint-in some of the smaller hospital centres, at least-doctors who would work as general physicians as well ascardiologists. Even for research such appointmentsmight prove fruitful; for progress in this subject, moreperhaps than in most others, depends on knowledge ofgeneral medicine and acquaintance with other disciplines.Clinically, too, there is much to be said for the physician-cardiologist. It is one thing to have a regional cardio-logical centre where surgery is practised, intractableclinical problems are resolved, and research is encouraged.It is another to have pure cardiologists, in every majorhospital centre and in every area where access to hospitalsis difficult. This scheme consorts oddly with the com-mittee’s view that " recognition of specialized consultantcardiologists should in no way reduce the work or diminishthe interest of general physicians in the many facets ofcardiovascular disease." If specialists in cardiovasculardiseases are to be readily available, they will erode thegeneral physician’s already shrunken territory.Has the hospital service of the future any place at all

in fact for the general physician ? This is the underlyingquestion which needs to be deliberately faced. If presenttrends continue, it will answer itself.

1. Royal College of Physicians of London: Committee on Cardiology;report, October, 1958.

2. See Lancet, 1947, i, 873.

TUBERCULOSIS AMONG THE GURKHAS

OF the many ways of judging a medical service, noneperhaps is more valid than to measure it by the trust itinspires in those whom it serves. By this test the schemewhich aims at eliminating tuberculosis among the Gurkhasin the British Army, and which has now been in operationfor some years, ranks high.As part of a campaign to eradicate tuberculosis from the

Brigade of Gurkhas and their families, a Gurkha sana-torium was established at Kinrara, a few miles outsideKuala Lumpur, in 1951 (the Gurkhas serve in Malaya,

Singapore, and Hong Kong). The sanatorium began with18 beds; but within a few years the number of patients,including the families of soldiers, rose to 100 or more.These years of expansion coincided with the rapid increasein the scope and safety of surgery for pulmonary tuber-culosis : and soon the Army authorities realised they mustoffer their patients the benefits of thoracic surgery as wellas those of the sanatorium. This involved the transfer ofselected groups to this country, a task which needed morethan skilled organisation, careful budgeting, and clinicaljudgment. Mackay-Dick recently drew a vivid pictureof some of the many difficulties encountered in getting theGurkha soldier mentally attuned to the idea of having aplanned operation on his chest for a chronic disease,particularly when it involves a journey across the world andremoval of part of his lung. The difficulty was partlyovercome by explaining to him that " we were all in thebattle against the unseen enemy, the germ of tuberculosis,and that operation scars on the chest were really battlescars, the result of victory in the battle against tuber-culosis ". The language may strike the medically sophis-ticated reader as over-dramatic; but it is well understoodby the Gurkha. The emphasis is on the partnershipbetween the patients and the medical and nursing staff,and at no time is this partnership more important than inthe treatment of a chronic illness like tuberculosis-at notime put to a severer test. The patients, on the one hand,must have a clear idea of the difficulties ahead and of thedoctors’ plans for overcoming them, and the doctor, forhis part, must learn to appreciate the personal problemswith which a long illness confronts his patients. Thesuccess of the Gurkha tuberculosis scheme reflects sucha mutual understanding.The first 21 Gurkha patients left Kuala Lumpur by air

in June, 1957, for surgical treatment at the Army ChestCentre in this country at the Connaught Hospital at

Hindhead. 8 were operated on during the followingmonth and could return to Malaya by sea in October;and 7 were accepted for further service in the Army. Sincethen well over 100 cases have been provisionally acceptedfor surgery, almost all for partial lung resection; and atpresent about 8 are being operated on every month. Themedical interest of this work is considerable. All but a fewof those accepted for resection have had at least twelvemonths’ uniform and carefully controlled chemotherapy;and bacteriological examination of the resected specimenshas provided useful information with which to assess thevalue of chemotherapy in sterilising residual caseous foci. 2Some apparently solid areas of caseous or fibrocaseousdisease cleared after twelve months or more of chemo-therapy-an observation of much relevance in decidingwhen to operate, if at all. Chemotherapy is continuedpostoperatively for at least twelve months.Most of the patients are ultimately fit to resume their

career in the Army: they are followed up and, when neces-sary, treated as outpatients. Those who return to Nepalreceive three months’ supply of drugs; and it is hoped thatradiological follow-up will eventually be possible.Mackay-Dick also envisages help from the World HealthOrganisation : " a tuberculin skin-test survey of Nepal,with successful B.C.G. vaccination of all negative reactors,together with chemotherapy for all infants and childrenunder three years (in the absence of evidence of tuber-culosis) would be a great first step in the conquest of

1. Mackay-Dick, J. N.A.P.T. Commonwealth Chest Conference, London,1958.

2. Mackay-Dick, J., Slattery, D. A. D. Brit. med. J. 1958, i, 888.

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tuberculosis in Nepal ".1 Anyone acquainted with thismountainous country, where communications are poorand life rigorous, and where one doctor serves a populationof 174,000, will appreciate the magnitude of this plan-but also, perhaps, its romance.

3. Stott, D. H. Interim Report on the Glasgow Survey of Boys put onProbation during 1957. Issued by the University of Glasgow, 1958.

4. Litauer, W. Juvenile Delinquency in a Psychiatric Clinic. London,1957.

MALADJUSTMENT AND DELINQUENCYTHE relation of the delinquent act to " maladjusted "

or disturbed behaviour has been a talking-point for

many years. These two forms of reaction might bereasonably supposed to stem from similar stresses or

provocations; indeed, it is easy to see them as differentdegrees of the same thing. Society at large tends toregard the problem as one of punishment and deterrence;and it is therefore important to know how far a delinquentis " normal but naughty ", and how far he is ill and need-ing treatment. Stott has put these ideas to the test in a

study of probationers in Glasgow.3He points out that in large cities the incidence of

delinquency is usually high, but that within them areadjacent districts of high or low incidence. In some

places a certain form of delinquency may be acceptableand expected (such as pilfering from Liverpool’s dock-land), whereas other illegal activities are subject to thetaboos usual elsewhere. A stage of such delinquency inthese circumstances can be regarded as " normal "; butStott does not consider that significant antisocial behaviouris a universal episode in which an unfortunate few arecaught. If this were so the areas of high delinquencywhere antisocial acts were the " done thing " should

produce young criminals who were in other respects welladjusted. Conversely it would be expected that theoccasional erring lad from a law-abiding district must bebadly disturbed in other ways to rebel thus against thepattern of culture. Stott’s figures did not bear this out.Although he found a very high positive correlationbetween delinquency and maladjustment, the degree ofadmixture was remarkably constant throughout his

patchwork of good and bad areas. His results, usingdetailed teachers’ ratings on the Bristol social adjustmentguides, showed that stable youths made up 72% of 407controls but only 24% of 417 probationers. 45% of thelatter were definitely maladjusted, compared with 7% of thecontrols; and of all lads graded severely maladjusted therewere 46 on probation, against only 2 controls. It seemedtherefore that delinquency was an index of the factorsproducing maladjustment, and this was confirmed froma study of the controls: as was expected, a higher rate ofmaladjustment among them was found in localitieswhere crime was rife.

This interesting work seems to support what manyworkers have long felt-that the line between the" ordinary " delinquent boy and the " psychiatric " oneis hard to draw, and that psychological aspects are muchneglected. Litauer 4 in his brief comparison of casesreferred for psychiatric opinion with those not so

referred did not discover any pronounced differences.Antisocial behaviour is in most, if not all, cases a symptomof some underlying disorder, a few aspects of which arebecoming mistily discernible. Stott’s work suggests,too, that immediate cultural influences are much less

important than psychological factors in home and

heredity. The influence of " bad company " has evidentlybeen overstressed.

JAUNDICE AFTER INJURY

IT is now well established that serious injuries or

extensive burns may lead to profound disturbances ofmetabolism, usually resulting in a net loss of nitrogen.’It is therefore hardly surprising that the liver, as thecentral metabolic organ of the body, should in such cir-cumstances show evidence of dysfunction such as jaun-dice. 16 cases of jaundice brought about in this way haverecently been reported from the Birmingham AccidentHospital by Sevitt.2 Since in each patient the jaundiceappeared within a few days after blood-transfusion,excessive hxmolysis due to blood-group incompatibilityhad to be excluded before the jaundice could be attributedto hepatic dysfunction. Fairly comprehensive serologicalexamination failed to reveal any evidence either of incom-patibility or of excessive intravascular haemolysis. Thetransfusion of blood stored for over two weeks invariablyleads to increased bilirubin production resulting fromthe breakdown of about 8% of the transfused cells withinthe first twenty-four hours.3 This, as Sevitt has shown,can itself raise the plasma-bilirubin by 14 mg. per 100 ml.and must, therefore, constitute a considerable loadingtest for the excretory powers of the liver. While this loadis readily dealt with when the liver is functioning nor-mally, it may lead to clinical jaundice in the presence ofimpaired hepatic function.

Besides jaundice, the signs of a disordered liver werefairly conspicuous in all 16 patients. Thus the jaundicewas usually preceded by pyrexia, nausea, vomiting, andpain in the right hypochondrium. Bile was invariablypresent in the urine; and the serum gave a direct positivevan den Bergh reaction, indicating the presence of con-jugated bilirubin. A moderate rise in the serum-alkaline-phosphatase confirmed that the jaundice was obstructive,and modest increases in thymol turbidity and zinc-

sulphate precipitation in about half the patients suggestedsome parenchymal damage in addition. In the 1 fatalcase the liver at necropsy was enlarged and swollen, andhistological examination showed swollen parenchymalcells and compression of the sinusoids.The processes underlying the hepatic disturbance

associated with injury or bums are mainly circulatory.These circulatory changes lead to significant reduction insplanchnic 4 and hepatic blood-flow with consequentanoxia of the parenchyma. This results in a considerableuptake of fluid by the affected cells, often producing thepicture of hydropic degeneration.5 Apparently themechanical effect of the swollen cells is the main cause ofthe associated jaundice, since the jaundice is obstructivewith bile pigment in the urine and conjugated bilirubinin the serum. Presumably the rise in pressure within theliver, which is sufficient to produce the compression of thesinusoids seen at necropsy, could seriously embarrass theflow of bile along the intralobular canaliculi. If this is so,the proportion of conjugated to non-conjugated bilirubinin the serum will provide a rough measure of the relativeimportance of the obstructive and metabolic disturbancesthat underlie the jaundice in these patients.

. Mr. ARTHUR JACOBS has been elected president of the

Royal Faculty of Physicians and Surgeons of Glasgow.

1. Selye, H. Textbook of Endocrinology; p. 842. Montreal, 1947.2. Sevitt, S. Brit. J. Surg. 1958, 46, 68.3. Mollison, P. L. Blood Transfusion in Clinical Medicine; p. 11. Oxford,

1951.4. Abell, R. G., Page, I. H. Surg. Gynec. Obstet. 1943, 77, 348.5. Trowell, D. A. J. Physiol. 1946, 105, 268.