97
submitted
to
independent arbitration, presided
over
by
a
judge. Gloucestershire Royal Hospital, Gloucester.
GEORGE FEARNLEY.
it-and I cannot be alone-the militant the consultants is a disaster. The N.H.S., of money-ethos with the withdrawal from India the most generous political concept of British public life, is being castrated by many of those who ought to see in it their supreme chance of serving the community. Are British doctors really anxious to join the backwoodsmen of the American Medical Association ? True, we train longer than any other profession. True, we work longer than most other professions. True, we need all the skill, knowledge, and humane understanding to even start countering the threats to health and a full life inherent in diseases and accidents. But we are privileged beyond all other professions by the unlimited variety of challenges, the opportunities for maximum effort, the satisfaction of becoming worthy of
SIR,-As I
see
calling. Changes we need.
our
We have to support a juster provision of livelihood for nurses, even now vastly underrated in their contribution within the cure-and-care team, for physiotherapists and occupational therapists, radiographers, laboratory teclinicians, and secretaries; and for our younger colleagues whose income at a time they start families is still too low. But for consultants to use extreme left-wing tactics to maintain their differentials is shameful, no less. Theyand I was one of them-have an obligation to get rid of the " bull-frog syndrome ", blowing themselves up with selfimportance. No-one who cares for the quality of a life devoted to a worthwhile cause can see his reward in terms of cash. Let those whose work is dull, physically hard, and dangerous seek compensation in wages. Their jobs are uncertain. Ours are not. Let the curing and caring team lead our renaissance in a spirit of service. Do not let the lack of tact of a Minister push us into responses alien to us. We shall be servants of the community or we shall be in contempt of a higher court. 11 a Acol
Road,
London NW6 3AA.
L. S. MICHAELIS.
to my consultant colleagues situation coolly and carefully before
appeal
to
consider the whole a step.
taking such
Walton Hospital,
P. M. ROBB.
Liverpool.
SIR,-Mr Houghton’s letter (Dec. 28, p. 1566) has a wider significance than a casual glance would suggest. General surgery is still an individualistic branch of medicine and this makes it difficult for many surgeons to grasp how complex modem medical practice has now become. It is rubbish to imply that the only doctors who can make valid contributions towards solving the problems of the N.H.S. are those who have patients directly under their care. Analysis of the causes of the present consultant contract chaos reveals that the reverse might almost be true. We have organised ourselves into trade-unions (B.M.A. and H.C.S.A.) and almost immediately they have developed a complication common to such organisations. This it that policy is dictated by a minority group with extreme views. All the recent negotiations have been dominated by surgeons (see composition of negotiating team 1) who often appear to care more about private medicine than about the N.H.S. Probably many of them are part-timers. Like many other trade-unions who find themselves in this situation, we must try to rouse the politically apathetic members of the profession and obtain truly representative negotiators. Many independent observers2 find that the Government’s proposals form a reasonable basis for negotiation; certainly they would satisfy the trade-union requirement that payment would be related to work done. Mr Houghton, battling against the " unpredictable aggression " of disease at the weekend, would be paid extra for his efforts, if this is what he wants. In this particular instance, one of Mr Houghton’s basic assumptions is probably invalid. It may take some time to percolate up the ivory surgical towers, but many hasmaiologists are now caring directly for patients and this may already have happened at his own hospital. Department of Haematology, St. Bartholomew’s Hospital, M. E. J. BEARD. London EC1. SiR,-The Houghton report on teachers’ salaries, which cost the country E432 millions, includes the following
will
" We wish to stress that we believe the salary levels we recommend justify expectation of professional standards of performance in return ", and that the levels were in part " recognition of the fact that the job cannot be compressed within a rigid structure of prescribed duties, hours or days ". It might also be noted that the teachers’ scales include levels well above that of the maximum of the full-time consultant, and periods of leave which doctors comment:
SIR,-My study of the proposed new consultant contract, and of the various documents issued by the B.M.A. and the H.C.S.A., leads me to the conclusion that the main issue which has caused these bodies to recommend their members to apply sanctions is the Government’s proposal to maintain a salary differential between those who make a whole-time commitment to the N.H.S. and those who retain the right to private practice. I see no issue of principle here. Moreover, I believe it is desirable that a whole-time commitment to the N.H.S. should be made more attractive than it is at present in order to stimulate recruitment into those branches of the profession where private practice is not available. I know from personal experience on appointment committees that it is, at present, often difficult to find suitable applicants for consultant vacancies in, for instance, some branches of laboratory medicine. True, there are parts of the proposed new contract that are not acceptable-for instance, the lack of payment for on-call and standby duty, and the failure to make expense allowances for cars and telephones. But these are not issues of principle and are surely negotiable. We are now asked to apply sanctions. Soon we may be asked to resign from the N.H.S. and hire ourselves out to our health authorities through employment agencies. These actions jeopardise the future of the N.H.S. I would
can
only imagine.
we less of a profession that we should scramble for a piece-rate contract simply as a means of obtaining more money ? It is even more inappropriate that full-time
Are
new
consultants should now be asked to support sanctions whose avowed aim is to make complete commitment less attractive-after all, we are given the choice. Bridgend General Hospital, Quarella Road, Bridgend, Glamorgan.
D. E. B. POWELL.
TIGHT GLOVES
SiR,-Dr Morgan (Dec. 21, p. 1510) makes an interesting observation on the association of arthritis and the wearing of tight gloves. She is, however, mistaken in supposing 1. Br. med. J. Nov. 2. Times, Dec. 27,
16, 1974, p. 419. 1974, p. 9.
98 LIVE VARICELLA VACCINE
that barometric pressure is increased in humid weather. Pressure is usually low in such conditions, and therefore this cannot be accepted as an explanation of the association between arthritic pain and humid weather. Hairmyres Hospital, East Kilbride, Glasgow G75 8RG.
SIR,-The administration of a live varicella vaccine to children at this point in time appears to be ill advised. The statement of Dr Takahashi and his colleagues (Nov. 30, p. 1288) that " an attenuated vaccine virus is unlikely to become virulent and cause herpes zoster " is unsupported by data. At present, there is insufficient knowledge concerning the factors which modulate virus latency to intelligently select virus strains for vaccine production. There is no information to suggest, for instance, that viral genes for " attenuation " are linked with those determining persistent infection. Efficacy of any vaccine is judged by comparing the morbidity produced by the natural illness with that resulting from the vaccine. Varicella is usually a relatively mild disease in normal children. As the authors indicate, it can be rather severe in certain types of patients. These patients, however, are usually readily identifiable and can be protected by passive immunisation with zoster immune globulin. During the past decade there have been only approximately 130 deaths annually resulting from varicellai.e., about 4 per 100,000 cases in the United States. It would appear, therefore, that the morbidity produced by varicella is minimal and there exists a means for decreasing it even further. In assessing the morbidity resulting from a live vaccine, one must determine the incidence and severity of zoster as well as varicella. Since there is no way of predicting whether a given vaccine strain might produce zoster more frequently or in a more severe form than the natural disease, one can only carry out the experiment and observe the results. Since zoster usually occurs decades after varicella, the investigators may never learn the outcome of their experiment. One wonders, considering the mildness of varicella and the existing alternative methods of modification, whether the vaccine is worth the trouble and the risk.
B. A. WOODGER.
ASSESSMENT OF THE APGAR SCORE SIR,-Mr Chamberlain and Mr Bank (Nov. 23, p. 1225) have demonstrated courage in their studies of the importance of the various components of the Apgar score. Our own studies showed that the immediate newborn tends to have heart-rates either below 104 or above 144 beats per minute. Since the latter group represents those newborns who have taken their first breath, we likewise concluded that the heart-rate should be given much more emphasis in the evaluation of the immediate newborn infant. In addition to the Apgar score, we would favour the development of a scoring system for the newborn infant’s heart-rate which would discern specific temporal patterns for interpretation. Such a score would be a logical continuation of our present internal and external fetal monitoring. We hope clinicians and investigators will undertake studies similar to those of Mr Chamberlain and Mr Bank. Santa Clara Valley Medical Center, 751 South Bascom Avenue, San Jose, California 95128, U.S.A.
ROBERT C. GOODLIN JAMES R. HARROD.
RATES OF XYY GENOTYPE IN PENAL AND MENTAL SETTINGS
SIR,-Your editorial (Nov. 30, p. 1297) on the XYY male suggests that those detained in maximum-security hospitals do not manifest one end of a continuous spectrum of behavioural problems associated with the genotype, and cites, in support, studies of various delinquent groups, unselected for mental illness or retardation, in which relatively low rates of XYY men were found. While the rates are lower in such exclusively penal settings than in mental-penal settings, they are, however, still higher than the background newborn rate of about 1/900 to 1/1000. In data reviewed at the end of 1972,1 there were 5805 males (unselected for height) in 16 exclusively penal settings who had been studied; 26 XYYs were found yielding a rate of 1/225 affected, about four times " background ". In those five settings studied in the United Kingdom there were 7 XYYs in 2613 males or about 1 in 375 affected. Of interest, the rate of XXY Klinefelter males was also increased over the newborn rate of this genotype (about 1/900) in these institutions but not to the same extent. There were 18 XYYs in all 16 settings (1/322), 5 in the U.K. studies (1/522). (With regard to exclusively mental settings-e.g., mental hospitals without a security requirement-in 2526 males in such 9 settings were there 8 XYYs [1/316] and 10 XXYs [1/253].) These data do not " support the absence of spectrum " of behavioural for either genotype. The 1% risk of an XYY difficulty eventually appearing in a mental-penal setting calculated in your editorial cannot be assumed to be the entire measure of the increased likelihood of future behavioural problems.
New York University Medical Center, 550 First Avenue, New York, New York 10016, U.S.A.
% * Some of the points raised by Dr. Brunell were discussed in an editorial (Nov. 30, p. 1300).-ED. L. SiR,—The report by Takahashi et al.1 on the use of a live varicella-zoster virus vaccine was thought-provoking. While in theory the conquest of viral diseases probably lies in the development of attenuated live-virus vaccines, the effect of this particular vaccine is questionable for a number of reasons. It is unclear whether the vaccine was attenuated or even specifically immunogenic, because of the circumstances under which the vaccine was given. The children who were already immune to varicella were not eliminated from the study group by appropriate serological testing. Neither
history
Birth Defects Institute, New York State Department of ’
Health, Albany, New York 12237, U.S.A., and Department of Pediatrics, Albany Medical College.
ERNEST B. HOOK.
Hook, E. B. Science, 1973, 179, 139.
nor
complement-fixation
tests
are
adequate
to
determine immune status to varicella.2 If the vaccine were administered to immune children one might expect a boost in antibody titre and no evidence of clinical illness. Furthermore, of the 23 immunised children, 2 developed evidence of varicella and it is unclear whether the disease was due to their exposure to chickenpox or to the vaccinaSince not all immunocompromised tion they received. children who contract varicella become severely ill, one cannot conclude that the disease was vaccine-induced because it was mild. In addition, because it is not possible to separate varicella-zoster virus from cell proteins, anti1. 2.
1.
PHILIP A. BRUNELL.
Takahashi, M., Otsuka, T., Okuno, Y., Asano, Y., Yazaki, T., Isomura, S. Lancet, 1974, ii, 1288. Williams, V., Gershon, A., Brunell, P. A. J. infect. Dis. 1974, 130, 669.
submitted
to
independent arbitration, presided
over
by
a
judge. Gloucestershire Royal Hospital, Gloucester.
GEORGE FEARNLEY.
it-and I cannot be alone-the militant the consultants is a disaster. The N.H.S., of money-ethos with the withdrawal from India the most generous political concept of British public life, is being castrated by many of those who ought to see in it their supreme chance of serving the community. Are British doctors really anxious to join the backwoodsmen of the American Medical Association ? True, we train longer than any other profession. True, we work longer than most other professions. True, we need all the skill, knowledge, and humane understanding to even start countering the threats to health and a full life inherent in diseases and accidents. But we are privileged beyond all other professions by the unlimited variety of challenges, the opportunities for maximum effort, the satisfaction of becoming worthy of
SIR,-As I
see
calling. Changes we need.
our
We have to support a juster provision of livelihood for nurses, even now vastly underrated in their contribution within the cure-and-care team, for physiotherapists and occupational therapists, radiographers, laboratory teclinicians, and secretaries; and for our younger colleagues whose income at a time they start families is still too low. But for consultants to use extreme left-wing tactics to maintain their differentials is shameful, no less. Theyand I was one of them-have an obligation to get rid of the " bull-frog syndrome ", blowing themselves up with selfimportance. No-one who cares for the quality of a life devoted to a worthwhile cause can see his reward in terms of cash. Let those whose work is dull, physically hard, and dangerous seek compensation in wages. Their jobs are uncertain. Ours are not. Let the curing and caring team lead our renaissance in a spirit of service. Do not let the lack of tact of a Minister push us into responses alien to us. We shall be servants of the community or we shall be in contempt of a higher court. 11 a Acol
Road,
London NW6 3AA.
L. S. MICHAELIS.
to my consultant colleagues situation coolly and carefully before
appeal
to
consider the whole a step.
taking such
Walton Hospital,
P. M. ROBB.
Liverpool.
SIR,-Mr Houghton’s letter (Dec. 28, p. 1566) has a wider significance than a casual glance would suggest. General surgery is still an individualistic branch of medicine and this makes it difficult for many surgeons to grasp how complex modem medical practice has now become. It is rubbish to imply that the only doctors who can make valid contributions towards solving the problems of the N.H.S. are those who have patients directly under their care. Analysis of the causes of the present consultant contract chaos reveals that the reverse might almost be true. We have organised ourselves into trade-unions (B.M.A. and H.C.S.A.) and almost immediately they have developed a complication common to such organisations. This it that policy is dictated by a minority group with extreme views. All the recent negotiations have been dominated by surgeons (see composition of negotiating team 1) who often appear to care more about private medicine than about the N.H.S. Probably many of them are part-timers. Like many other trade-unions who find themselves in this situation, we must try to rouse the politically apathetic members of the profession and obtain truly representative negotiators. Many independent observers2 find that the Government’s proposals form a reasonable basis for negotiation; certainly they would satisfy the trade-union requirement that payment would be related to work done. Mr Houghton, battling against the " unpredictable aggression " of disease at the weekend, would be paid extra for his efforts, if this is what he wants. In this particular instance, one of Mr Houghton’s basic assumptions is probably invalid. It may take some time to percolate up the ivory surgical towers, but many hasmaiologists are now caring directly for patients and this may already have happened at his own hospital. Department of Haematology, St. Bartholomew’s Hospital, M. E. J. BEARD. London EC1. SiR,-The Houghton report on teachers’ salaries, which cost the country E432 millions, includes the following
will
" We wish to stress that we believe the salary levels we recommend justify expectation of professional standards of performance in return ", and that the levels were in part " recognition of the fact that the job cannot be compressed within a rigid structure of prescribed duties, hours or days ". It might also be noted that the teachers’ scales include levels well above that of the maximum of the full-time consultant, and periods of leave which doctors comment:
SIR,-My study of the proposed new consultant contract, and of the various documents issued by the B.M.A. and the H.C.S.A., leads me to the conclusion that the main issue which has caused these bodies to recommend their members to apply sanctions is the Government’s proposal to maintain a salary differential between those who make a whole-time commitment to the N.H.S. and those who retain the right to private practice. I see no issue of principle here. Moreover, I believe it is desirable that a whole-time commitment to the N.H.S. should be made more attractive than it is at present in order to stimulate recruitment into those branches of the profession where private practice is not available. I know from personal experience on appointment committees that it is, at present, often difficult to find suitable applicants for consultant vacancies in, for instance, some branches of laboratory medicine. True, there are parts of the proposed new contract that are not acceptable-for instance, the lack of payment for on-call and standby duty, and the failure to make expense allowances for cars and telephones. But these are not issues of principle and are surely negotiable. We are now asked to apply sanctions. Soon we may be asked to resign from the N.H.S. and hire ourselves out to our health authorities through employment agencies. These actions jeopardise the future of the N.H.S. I would
can
only imagine.
we less of a profession that we should scramble for a piece-rate contract simply as a means of obtaining more money ? It is even more inappropriate that full-time
Are
new
consultants should now be asked to support sanctions whose avowed aim is to make complete commitment less attractive-after all, we are given the choice. Bridgend General Hospital, Quarella Road, Bridgend, Glamorgan.
D. E. B. POWELL.
TIGHT GLOVES
SiR,-Dr Morgan (Dec. 21, p. 1510) makes an interesting observation on the association of arthritis and the wearing of tight gloves. She is, however, mistaken in supposing 1. Br. med. J. Nov. 2. Times, Dec. 27,
16, 1974, p. 419. 1974, p. 9.
98 LIVE VARICELLA VACCINE
that barometric pressure is increased in humid weather. Pressure is usually low in such conditions, and therefore this cannot be accepted as an explanation of the association between arthritic pain and humid weather. Hairmyres Hospital, East Kilbride, Glasgow G75 8RG.
SIR,-The administration of a live varicella vaccine to children at this point in time appears to be ill advised. The statement of Dr Takahashi and his colleagues (Nov. 30, p. 1288) that " an attenuated vaccine virus is unlikely to become virulent and cause herpes zoster " is unsupported by data. At present, there is insufficient knowledge concerning the factors which modulate virus latency to intelligently select virus strains for vaccine production. There is no information to suggest, for instance, that viral genes for " attenuation " are linked with those determining persistent infection. Efficacy of any vaccine is judged by comparing the morbidity produced by the natural illness with that resulting from the vaccine. Varicella is usually a relatively mild disease in normal children. As the authors indicate, it can be rather severe in certain types of patients. These patients, however, are usually readily identifiable and can be protected by passive immunisation with zoster immune globulin. During the past decade there have been only approximately 130 deaths annually resulting from varicellai.e., about 4 per 100,000 cases in the United States. It would appear, therefore, that the morbidity produced by varicella is minimal and there exists a means for decreasing it even further. In assessing the morbidity resulting from a live vaccine, one must determine the incidence and severity of zoster as well as varicella. Since there is no way of predicting whether a given vaccine strain might produce zoster more frequently or in a more severe form than the natural disease, one can only carry out the experiment and observe the results. Since zoster usually occurs decades after varicella, the investigators may never learn the outcome of their experiment. One wonders, considering the mildness of varicella and the existing alternative methods of modification, whether the vaccine is worth the trouble and the risk.
B. A. WOODGER.
ASSESSMENT OF THE APGAR SCORE SIR,-Mr Chamberlain and Mr Bank (Nov. 23, p. 1225) have demonstrated courage in their studies of the importance of the various components of the Apgar score. Our own studies showed that the immediate newborn tends to have heart-rates either below 104 or above 144 beats per minute. Since the latter group represents those newborns who have taken their first breath, we likewise concluded that the heart-rate should be given much more emphasis in the evaluation of the immediate newborn infant. In addition to the Apgar score, we would favour the development of a scoring system for the newborn infant’s heart-rate which would discern specific temporal patterns for interpretation. Such a score would be a logical continuation of our present internal and external fetal monitoring. We hope clinicians and investigators will undertake studies similar to those of Mr Chamberlain and Mr Bank. Santa Clara Valley Medical Center, 751 South Bascom Avenue, San Jose, California 95128, U.S.A.
ROBERT C. GOODLIN JAMES R. HARROD.
RATES OF XYY GENOTYPE IN PENAL AND MENTAL SETTINGS
SIR,-Your editorial (Nov. 30, p. 1297) on the XYY male suggests that those detained in maximum-security hospitals do not manifest one end of a continuous spectrum of behavioural problems associated with the genotype, and cites, in support, studies of various delinquent groups, unselected for mental illness or retardation, in which relatively low rates of XYY men were found. While the rates are lower in such exclusively penal settings than in mental-penal settings, they are, however, still higher than the background newborn rate of about 1/900 to 1/1000. In data reviewed at the end of 1972,1 there were 5805 males (unselected for height) in 16 exclusively penal settings who had been studied; 26 XYYs were found yielding a rate of 1/225 affected, about four times " background ". In those five settings studied in the United Kingdom there were 7 XYYs in 2613 males or about 1 in 375 affected. Of interest, the rate of XXY Klinefelter males was also increased over the newborn rate of this genotype (about 1/900) in these institutions but not to the same extent. There were 18 XYYs in all 16 settings (1/322), 5 in the U.K. studies (1/522). (With regard to exclusively mental settings-e.g., mental hospitals without a security requirement-in 2526 males in such 9 settings were there 8 XYYs [1/316] and 10 XXYs [1/253].) These data do not " support the absence of spectrum " of behavioural for either genotype. The 1% risk of an XYY difficulty eventually appearing in a mental-penal setting calculated in your editorial cannot be assumed to be the entire measure of the increased likelihood of future behavioural problems.
New York University Medical Center, 550 First Avenue, New York, New York 10016, U.S.A.
% * Some of the points raised by Dr. Brunell were discussed in an editorial (Nov. 30, p. 1300).-ED. L. SiR,—The report by Takahashi et al.1 on the use of a live varicella-zoster virus vaccine was thought-provoking. While in theory the conquest of viral diseases probably lies in the development of attenuated live-virus vaccines, the effect of this particular vaccine is questionable for a number of reasons. It is unclear whether the vaccine was attenuated or even specifically immunogenic, because of the circumstances under which the vaccine was given. The children who were already immune to varicella were not eliminated from the study group by appropriate serological testing. Neither
history
Birth Defects Institute, New York State Department of ’
Health, Albany, New York 12237, U.S.A., and Department of Pediatrics, Albany Medical College.
ERNEST B. HOOK.
Hook, E. B. Science, 1973, 179, 139.
nor
complement-fixation
tests
are
adequate
to
determine immune status to varicella.2 If the vaccine were administered to immune children one might expect a boost in antibody titre and no evidence of clinical illness. Furthermore, of the 23 immunised children, 2 developed evidence of varicella and it is unclear whether the disease was due to their exposure to chickenpox or to the vaccinaSince not all immunocompromised tion they received. children who contract varicella become severely ill, one cannot conclude that the disease was vaccine-induced because it was mild. In addition, because it is not possible to separate varicella-zoster virus from cell proteins, anti1. 2.
1.
PHILIP A. BRUNELL.
Takahashi, M., Otsuka, T., Okuno, Y., Asano, Y., Yazaki, T., Isomura, S. Lancet, 1974, ii, 1288. Williams, V., Gershon, A., Brunell, P. A. J. infect. Dis. 1974, 130, 669.
