466
Twenty centres are taking part-sixteen in the United States and four in the U.K. (London, Hull, Glasgow, and Aberdeen). The coordinating centre is under the Eegis of the Maryland Medical Research Institute in Baltimore. Supervision of the trial is in the hands of a policy board of scientists and lay members who are not otherwise participating in the study. Boehringer-Ingelheim, the developer of persantin, has provided financial support but is not involved in the design and conduct of the trial. One of the goals of the study is to serve as a model of an objective, high-quality drug trial conducted completely independently of the pharmaceutical company supporting it. Recruitment began in March, 1975, and was completed in June, 1976. Men and women aged 30-74 with at least one myocardial infarction during the preceding five years were eligible to participate. Excluded were patients who have had cardiac surgery, who were in cardiac decompensation or who have had other life-shortening diseases, or who suffered from a condition precluding the regular use of platelet-affecting drugs. Each patient who gave informed consent for participation and who was judged eligible by a study physician was randomly allocated to one of the three treatment groups-aspirin alone, dipyridamole and aspirin, placebo. Patients are seen every four months. Neither the study physician nor the patient knows the content of the assigned tablets. The trial is scheduled to terminate in July, 1977, so that all patients will be followed for one or two years. However, if the results justify it, the trial may be extended. The feasibility of the trial depends on the cooperation of patients and their referring physicians. The PARIS research group seeks the cooperation of the medical profession during the follow-up phase. During the follow-up physicians should not
prescribe platelet-affecting drugs
to
PARIS
Division of Clinical Investigation, Department of Social and Preventive University of Maryland,
A. S. DOUGLAS, Steering Committee
THOMAS C. CHALMERS, PARIS Policy Board
Mount Sinai Medical Center, New York, N. Y. 10029, U.S.A.
Medicine,
Baltimore, Maryland Department of Community Health and Preventive Medicine, Medical School, Northwestern University, Chicago, Illinois
Medical Unit, St Mary’s Hospital Medical School, London W2
DAVID GORDON PETER S. SEVER
participating patients
and should reinforce the request that patients refrain from non-prescription use of aspirin or aspirin-containing drugs. Participants are being supplied with paracetamol (acetaminophen) for use as an analgesic. Department of Medicine, University of Aberdeen, Foresterhill, Aberdeen AB9 2ZD
and adduction is impossible with a fourth-nerve lesion.’ Alternatively, they may find that the eye cannot be moved down and out if the superior oblique is paralysed.6 We might expect enlightenment from neurologists, but, alas, no: they are also divided between those that state that the eye ball is turned down and out by the superior oblique’ and those who write of movement down and in.8 Unfortunately, many neurology texts cover this point in prose so opaque that it is difficult to be sure of their opinion. One can even find a book with the text presenting one view, and illustrations seeming to show the opposite.9 Accounts of admirable claritylO 11 suggest that the explanation of this confusion is that the superior oblique acting alone produces abduction and depression of the eye, but that this action can be mimicked by simultaneous contraction of the inferior and lateral recti. Thus there may be no diplopia on downward and outward gaze despite a fourth-nerve lesion. However, the insertions of the inferior rectus and the superior oblique are such that the superior oblique is a much more efficient depressor when the eye is adducted, the inferior rectus working best with the eye in the neutral position. Hence there may be failure of depression of an adducted eye when contraction of the superior oblique is defective, while no defect in movement of the eye down and out from the neutral position can be detected. May we invite all authors to emulate the lucidity of the exposition in Gray’s Anatomy?10
CHRISTIAN R. PARIS
KLIMT,
Coordinating
Center
JEREMIAH STAMLER, PARIS Steering Committee
ON THE FOURTH CRANIAL NERVE
SIR,-What are our students to believe is the function of the superior oblique muscle or the sign of a lesion of the trochlear nerve? When they study their anatomy books they may read that the superior oblique produces depression and abduction of the eyeball, moving the line of sight down and out.’ This is confirmed by a text on anatomy for use in the clinical years.2 However, when introduced to the methods of clinical examination, they learn that the superior oblique depresses the eye when the globe is adducted,34and that combined depression 1 Basmajian, J. V. Grant’s Method of Anatomy; p.497. Baltimore, 1975. 2. Ellis, H. Clinical Anatomy; p.354. Oxford, 1971. 3. Bomford, R., Mason, S., Swash, M. Hutchinson’s Clinical Methods;
London, 1975. 4. Mawdsley, C. in Clinical Examination (edited by J. Edinburgh, 1976.
G.
p.219.
Macleod); p.250.
JUNIOR DOCTORS’ CONTRACT SIR,- The Marsden Group,12which has well over 1500 signatures from hospital doctors, still holds that a contract with a predominant emphasis on hours is undesirable. However, because overtime was an effective means for obtaining adequate remuneration under the pay policy and was a concept that non-medical workers most readily understood, and because the Government at that time failed to appreciate the amount of hours doctors actually worked, a contract such as the present one was introduced. The pricing, however, is at 30% or 10% of normal rate,so that the amount gained by claiming on the basis of hours has not been excessive. Certain doctors have been able to obtain a reasonable salary if they work in a clinically acute situation, Because of the low pricing of overtime, those doctors in less hours-oriented work have not been left too far behind. However, further emphasis on hours would widen the disparity between doctors working directly with patients and those working in a supportive specialty. Services such as radiology and pathology are an invaluable part of the team without which clinicians nowadays would be helpless. Many of the more intelligent and well-considered approaches to a clinical problem are suggested by these workers. They have the opportunity to widen their knowledge of disease processes and the problems of differential diagnosis far above the ward doctors, who have no such time allotted because of their preoccupation with treatment and the hecl1c day-to-day control of matters directly concerning the patient Havener, W. H. in Physical Diagnosis (edited by J. A. Prior and J S. Silberstein); p.90. St. Louis, 1973. 6. Naish, J. M., Read, A. E. A. The Clinical Apprentice; p.119. Bristol, 1971 7. Brain, Walton, J. N. Brain’s Diseases of the Nervous System, p.75. London, 1969. 8. Matthews, W. B. Practical Neurology; p.174. Oxford, 1970. 9. Spillane, J. D. An Atlas of Clinical Neurology; pp.65 and 66. London, 1968 10. Warwick, R., Williams, P. L. Gray’s Anatomy; p.1124. Edinburgh, 1973 11. Davson, H. The Physiology of the Eye; Edinburgh, 1972. 12. Tasker, P. R. S., and others. Lancet, 1976, i, 34. 5.
467 Poor remuneration and a contract based only on hours in these specialties will have the following effects: 1 Discouragement to doctors entering these specialties. 2 Enlistment of doctors with a 9-5 attitude. 3 Emigration of doctors established in these specialties,
and hence loss of the more valuable element. 4) Discouragement of temporary passage in these specialties of those clinicians trying to widen their view. This will further hamper attempts to train the physician to work as part of a team and in cooperation with those in these specialties. The result--a lower quality of medical staff in these supporting services and further handicaps to the physician. The basic salary, thankfully, still takes into account qualities in medicine that are worth the money-namely, experience and grade. Having gained under the new contract, we should direct future negotiations towards increases in the basic salary and not to overtime. The real issue in the current dispute between the junior hospital doctors and the Department of Health has not been brought out clearly in the Press. The issue is not the futile question of supplementary money not being paid for annual and study leave, but the unilateral inclusion of the clause, concerned with this, by Mr David Ennals and his Department, into our contract without prior agreement with the profession. The excuse, the pay policy, is not valid, because the contract was agreed under the pay policy in February. The step taken sets a precedent whereby employers can insert at random any alterations thev like into a contract. The Marsden Group supports the one-day stoppage on Aug 31 recommended by the B.4.A, only because it is clear that this step has been taken as a last resort. Without intervention at this time, further negotiations would be meaningless. P. R. S. Roval Marsden Hospital, London SW3 6JJ
TASKER,
Chairman, National Committee of the Marsden Group,
CALL TO YOUNG SURGEONS
SIR,-The gloom in the hospital services of the N.H.S. is nowhere more obvious than amongst young consultants. These men and women have seen spectacular and justifiable improvements in the pay and conditions of hospital junior staff, whilst their own income and professional status within the hospital community have steadily deteriorated. These young consultants represent the future basis for hospital care in the U.K., and the increasing frustration they experience in applying their talents-talents gained after many years of intensive training-must result in lower standards of hospital care. This situation must not continue, and we are appealing for support from a selected group—namely, fellows of the Royal College of Surgeons of England who obtained their fellowship between the years 1963 and 1973, since this group will represent the greater body of young consultant surgeons or those soon to achieve consultant status. However, any other fellow of the College may if he wishes, be included in the discussions that it is hoped this group will be having. We urge all young fellows to attend the annual general meeting of the Royal College of Surgeons in Leeds on Friday, Sept. 24. At ’this meeting Ae are putting forward the motion that: "The young fellows of this College protest their right to a career in surgery. They earnestly request the President and Council to convey to the Rova) Commission on the National Health Service their mounting concern at the erosion of their freedom and incenvaes to practise their profession to the highest standards". Those who cannot attend are asked to communicate with us s) that their views may be presented in absentia. Our aim is ". :nabte the President and Council to bring home to the Royal Commission the dangers of the continued unrest and job dissataction that exist amongst surgical trainees and young con- ants The President has kindly agreed to meet separately
with ances
representatives of the young fellows, to hear their grievin more detail. It is anticipated that further meetings will
be held with other interested bodies. Many associations are making attempts, notably through the Royal Commission, to influence Government opinion, but we believe that this loosely defined association of young surgeons will provide the means of delivering a sharp warning that, unless something is done soon, the long-term effects of unrest amongst young consultants, and surgeons especially, may have serious consequences for the N.H.S. St. Martin’s Hospital, Bath BA2 5RR
PATRICK SMITH
University Hospital of South Manchester, Manchester M20 8LR
DAVID SKIDMORE
WHOSE RIGHT TO INFORM?
SIR,-Your editorial (Aug. 14, p. 351) quite rightly implied that all rights come with responsibilities-and prescribing can be no exception. I doubt if any of your readers disagrees with your expression of such a principle, but I think you inadver-
tently referred to a far more fundamental one. You reported that the Government’s first effort to persuade the profession to be more responsible in its own prescribing has already been undertaken and involves the free distribution of the independent--and indeed excellent-fortnightly Drug and Therapeutics Bulletin to many thousands of senior medical students and hospital junior doctors. In these difficult economic times I am surprised to learn that the D.H.S.S. is using taxpayers’ money in this way at the same time that its Minister of State, Dr David Owen, is urging the pharmaceutical industry to reduce its promotional expenditure in a number of ways, one of which proposes a scheme which would penalise pharmaceutical compnaies who spend money on advertising "in journals which do not derive a substantial proportion of their revenue from subscriptions". While the D.H.S.S. might claim that it sees no paradoxes in these two methods of prosecuting its aim to reduce the N.H.S. drugs bill, is it not alarming that a Government Department is moving in a direction which will bring it nearer to approving, even controlling, the sources of information available to doctors? Is the right to inform a professional group of people soon to be Government-given? .
Medical Education 73 Wells Street, London W1P 3RD
(International) Ltd,
IgE, PARASITES,
SIMON CAMPBELL-SMITH
AND ALLERGY
SIR,-I was interested to read of Dr Lasch’s experience in Gaza (July 31, p. 255), where he finds asthma to be common among a heavily parasitised population. He is right to criticise a generalisation about the relationship between allergy and parasites based on any single study. Nevertheless, apart from my study in the Gambia,l there have also been reports of a low prevalence of allergic illness in rural communities of several countries, among them EthiopiaRhodesia,3 and New Guinea.4In a recent Nigerian study6 the majority of asthmatics were found to have urban or Europeanised backgrounds. Where IgE levels have been measured, they have invariably been higher in rural normal controls than in
asthmatics, whatever their background. 1. 2. 3. 4. 5. 6.
Godfrey, R. C. Clin. Allergy, 1975, 5, 201. Johansson, S. G. O., Mellbin, T., Vahlquist, B. Lancet, 1968, i, 1118. Merrett, T. G., Merrett, J., Cookson, J. B. Clin. Allergy, 1976, 6, 131. Woolcock, A. J., Blackburn, C. R. Aust. Ann. Med. 1967, 16, 11. Anderson, H. R. Clin. Allergy, 1974, 4, 171. Warrell, D. A., Fawcett, I. W., Harrison, B. D. W., Agaman, A. J., Ibu, J. O., Pope, H. M., Maberley, D. J. Q. Jl. Med. 1975, 44, 325.
Twenty centres are taking part-sixteen in the United States and four in the U.K. (London, Hull, Glasgow, and Aberdeen). The coordinating centre is under the Eegis of the Maryland Medical Research Institute in Baltimore. Supervision of the trial is in the hands of a policy board of scientists and lay members who are not otherwise participating in the study. Boehringer-Ingelheim, the developer of persantin, has provided financial support but is not involved in the design and conduct of the trial. One of the goals of the study is to serve as a model of an objective, high-quality drug trial conducted completely independently of the pharmaceutical company supporting it. Recruitment began in March, 1975, and was completed in June, 1976. Men and women aged 30-74 with at least one myocardial infarction during the preceding five years were eligible to participate. Excluded were patients who have had cardiac surgery, who were in cardiac decompensation or who have had other life-shortening diseases, or who suffered from a condition precluding the regular use of platelet-affecting drugs. Each patient who gave informed consent for participation and who was judged eligible by a study physician was randomly allocated to one of the three treatment groups-aspirin alone, dipyridamole and aspirin, placebo. Patients are seen every four months. Neither the study physician nor the patient knows the content of the assigned tablets. The trial is scheduled to terminate in July, 1977, so that all patients will be followed for one or two years. However, if the results justify it, the trial may be extended. The feasibility of the trial depends on the cooperation of patients and their referring physicians. The PARIS research group seeks the cooperation of the medical profession during the follow-up phase. During the follow-up physicians should not
prescribe platelet-affecting drugs
to
PARIS
Division of Clinical Investigation, Department of Social and Preventive University of Maryland,
A. S. DOUGLAS, Steering Committee
THOMAS C. CHALMERS, PARIS Policy Board
Mount Sinai Medical Center, New York, N. Y. 10029, U.S.A.
Medicine,
Baltimore, Maryland Department of Community Health and Preventive Medicine, Medical School, Northwestern University, Chicago, Illinois
Medical Unit, St Mary’s Hospital Medical School, London W2
DAVID GORDON PETER S. SEVER
participating patients
and should reinforce the request that patients refrain from non-prescription use of aspirin or aspirin-containing drugs. Participants are being supplied with paracetamol (acetaminophen) for use as an analgesic. Department of Medicine, University of Aberdeen, Foresterhill, Aberdeen AB9 2ZD
and adduction is impossible with a fourth-nerve lesion.’ Alternatively, they may find that the eye cannot be moved down and out if the superior oblique is paralysed.6 We might expect enlightenment from neurologists, but, alas, no: they are also divided between those that state that the eye ball is turned down and out by the superior oblique’ and those who write of movement down and in.8 Unfortunately, many neurology texts cover this point in prose so opaque that it is difficult to be sure of their opinion. One can even find a book with the text presenting one view, and illustrations seeming to show the opposite.9 Accounts of admirable claritylO 11 suggest that the explanation of this confusion is that the superior oblique acting alone produces abduction and depression of the eye, but that this action can be mimicked by simultaneous contraction of the inferior and lateral recti. Thus there may be no diplopia on downward and outward gaze despite a fourth-nerve lesion. However, the insertions of the inferior rectus and the superior oblique are such that the superior oblique is a much more efficient depressor when the eye is adducted, the inferior rectus working best with the eye in the neutral position. Hence there may be failure of depression of an adducted eye when contraction of the superior oblique is defective, while no defect in movement of the eye down and out from the neutral position can be detected. May we invite all authors to emulate the lucidity of the exposition in Gray’s Anatomy?10
CHRISTIAN R. PARIS
KLIMT,
Coordinating
Center
JEREMIAH STAMLER, PARIS Steering Committee
ON THE FOURTH CRANIAL NERVE
SIR,-What are our students to believe is the function of the superior oblique muscle or the sign of a lesion of the trochlear nerve? When they study their anatomy books they may read that the superior oblique produces depression and abduction of the eyeball, moving the line of sight down and out.’ This is confirmed by a text on anatomy for use in the clinical years.2 However, when introduced to the methods of clinical examination, they learn that the superior oblique depresses the eye when the globe is adducted,34and that combined depression 1 Basmajian, J. V. Grant’s Method of Anatomy; p.497. Baltimore, 1975. 2. Ellis, H. Clinical Anatomy; p.354. Oxford, 1971. 3. Bomford, R., Mason, S., Swash, M. Hutchinson’s Clinical Methods;
London, 1975. 4. Mawdsley, C. in Clinical Examination (edited by J. Edinburgh, 1976.
G.
p.219.
Macleod); p.250.
JUNIOR DOCTORS’ CONTRACT SIR,- The Marsden Group,12which has well over 1500 signatures from hospital doctors, still holds that a contract with a predominant emphasis on hours is undesirable. However, because overtime was an effective means for obtaining adequate remuneration under the pay policy and was a concept that non-medical workers most readily understood, and because the Government at that time failed to appreciate the amount of hours doctors actually worked, a contract such as the present one was introduced. The pricing, however, is at 30% or 10% of normal rate,so that the amount gained by claiming on the basis of hours has not been excessive. Certain doctors have been able to obtain a reasonable salary if they work in a clinically acute situation, Because of the low pricing of overtime, those doctors in less hours-oriented work have not been left too far behind. However, further emphasis on hours would widen the disparity between doctors working directly with patients and those working in a supportive specialty. Services such as radiology and pathology are an invaluable part of the team without which clinicians nowadays would be helpless. Many of the more intelligent and well-considered approaches to a clinical problem are suggested by these workers. They have the opportunity to widen their knowledge of disease processes and the problems of differential diagnosis far above the ward doctors, who have no such time allotted because of their preoccupation with treatment and the hecl1c day-to-day control of matters directly concerning the patient Havener, W. H. in Physical Diagnosis (edited by J. A. Prior and J S. Silberstein); p.90. St. Louis, 1973. 6. Naish, J. M., Read, A. E. A. The Clinical Apprentice; p.119. Bristol, 1971 7. Brain, Walton, J. N. Brain’s Diseases of the Nervous System, p.75. London, 1969. 8. Matthews, W. B. Practical Neurology; p.174. Oxford, 1970. 9. Spillane, J. D. An Atlas of Clinical Neurology; pp.65 and 66. London, 1968 10. Warwick, R., Williams, P. L. Gray’s Anatomy; p.1124. Edinburgh, 1973 11. Davson, H. The Physiology of the Eye; Edinburgh, 1972. 12. Tasker, P. R. S., and others. Lancet, 1976, i, 34. 5.
467 Poor remuneration and a contract based only on hours in these specialties will have the following effects: 1 Discouragement to doctors entering these specialties. 2 Enlistment of doctors with a 9-5 attitude. 3 Emigration of doctors established in these specialties,
and hence loss of the more valuable element. 4) Discouragement of temporary passage in these specialties of those clinicians trying to widen their view. This will further hamper attempts to train the physician to work as part of a team and in cooperation with those in these specialties. The result--a lower quality of medical staff in these supporting services and further handicaps to the physician. The basic salary, thankfully, still takes into account qualities in medicine that are worth the money-namely, experience and grade. Having gained under the new contract, we should direct future negotiations towards increases in the basic salary and not to overtime. The real issue in the current dispute between the junior hospital doctors and the Department of Health has not been brought out clearly in the Press. The issue is not the futile question of supplementary money not being paid for annual and study leave, but the unilateral inclusion of the clause, concerned with this, by Mr David Ennals and his Department, into our contract without prior agreement with the profession. The excuse, the pay policy, is not valid, because the contract was agreed under the pay policy in February. The step taken sets a precedent whereby employers can insert at random any alterations thev like into a contract. The Marsden Group supports the one-day stoppage on Aug 31 recommended by the B.4.A, only because it is clear that this step has been taken as a last resort. Without intervention at this time, further negotiations would be meaningless. P. R. S. Roval Marsden Hospital, London SW3 6JJ
TASKER,
Chairman, National Committee of the Marsden Group,
CALL TO YOUNG SURGEONS
SIR,-The gloom in the hospital services of the N.H.S. is nowhere more obvious than amongst young consultants. These men and women have seen spectacular and justifiable improvements in the pay and conditions of hospital junior staff, whilst their own income and professional status within the hospital community have steadily deteriorated. These young consultants represent the future basis for hospital care in the U.K., and the increasing frustration they experience in applying their talents-talents gained after many years of intensive training-must result in lower standards of hospital care. This situation must not continue, and we are appealing for support from a selected group—namely, fellows of the Royal College of Surgeons of England who obtained their fellowship between the years 1963 and 1973, since this group will represent the greater body of young consultant surgeons or those soon to achieve consultant status. However, any other fellow of the College may if he wishes, be included in the discussions that it is hoped this group will be having. We urge all young fellows to attend the annual general meeting of the Royal College of Surgeons in Leeds on Friday, Sept. 24. At ’this meeting Ae are putting forward the motion that: "The young fellows of this College protest their right to a career in surgery. They earnestly request the President and Council to convey to the Rova) Commission on the National Health Service their mounting concern at the erosion of their freedom and incenvaes to practise their profession to the highest standards". Those who cannot attend are asked to communicate with us s) that their views may be presented in absentia. Our aim is ". :nabte the President and Council to bring home to the Royal Commission the dangers of the continued unrest and job dissataction that exist amongst surgical trainees and young con- ants The President has kindly agreed to meet separately
with ances
representatives of the young fellows, to hear their grievin more detail. It is anticipated that further meetings will
be held with other interested bodies. Many associations are making attempts, notably through the Royal Commission, to influence Government opinion, but we believe that this loosely defined association of young surgeons will provide the means of delivering a sharp warning that, unless something is done soon, the long-term effects of unrest amongst young consultants, and surgeons especially, may have serious consequences for the N.H.S. St. Martin’s Hospital, Bath BA2 5RR
PATRICK SMITH
University Hospital of South Manchester, Manchester M20 8LR
DAVID SKIDMORE
WHOSE RIGHT TO INFORM?
SIR,-Your editorial (Aug. 14, p. 351) quite rightly implied that all rights come with responsibilities-and prescribing can be no exception. I doubt if any of your readers disagrees with your expression of such a principle, but I think you inadver-
tently referred to a far more fundamental one. You reported that the Government’s first effort to persuade the profession to be more responsible in its own prescribing has already been undertaken and involves the free distribution of the independent--and indeed excellent-fortnightly Drug and Therapeutics Bulletin to many thousands of senior medical students and hospital junior doctors. In these difficult economic times I am surprised to learn that the D.H.S.S. is using taxpayers’ money in this way at the same time that its Minister of State, Dr David Owen, is urging the pharmaceutical industry to reduce its promotional expenditure in a number of ways, one of which proposes a scheme which would penalise pharmaceutical compnaies who spend money on advertising "in journals which do not derive a substantial proportion of their revenue from subscriptions". While the D.H.S.S. might claim that it sees no paradoxes in these two methods of prosecuting its aim to reduce the N.H.S. drugs bill, is it not alarming that a Government Department is moving in a direction which will bring it nearer to approving, even controlling, the sources of information available to doctors? Is the right to inform a professional group of people soon to be Government-given? .
Medical Education 73 Wells Street, London W1P 3RD
(International) Ltd,
IgE, PARASITES,
SIMON CAMPBELL-SMITH
AND ALLERGY
SIR,-I was interested to read of Dr Lasch’s experience in Gaza (July 31, p. 255), where he finds asthma to be common among a heavily parasitised population. He is right to criticise a generalisation about the relationship between allergy and parasites based on any single study. Nevertheless, apart from my study in the Gambia,l there have also been reports of a low prevalence of allergic illness in rural communities of several countries, among them EthiopiaRhodesia,3 and New Guinea.4In a recent Nigerian study6 the majority of asthmatics were found to have urban or Europeanised backgrounds. Where IgE levels have been measured, they have invariably been higher in rural normal controls than in
asthmatics, whatever their background. 1. 2. 3. 4. 5. 6.
Godfrey, R. C. Clin. Allergy, 1975, 5, 201. Johansson, S. G. O., Mellbin, T., Vahlquist, B. Lancet, 1968, i, 1118. Merrett, T. G., Merrett, J., Cookson, J. B. Clin. Allergy, 1976, 6, 131. Woolcock, A. J., Blackburn, C. R. Aust. Ann. Med. 1967, 16, 11. Anderson, H. R. Clin. Allergy, 1974, 4, 171. Warrell, D. A., Fawcett, I. W., Harrison, B. D. W., Agaman, A. J., Ibu, J. O., Pope, H. M., Maberley, D. J. Q. Jl. Med. 1975, 44, 325.
