1081
tragastric inoculation of cultures of C. perfringens together with sweet potato leads to infection of the small intestine, whereas inoculation of the organism alone, or with boiled sweet potato, produces no infection. He sweet potato to the presence of inhibitor which prevents inactivation or destrypsin truction of the beta toxin of C. perfringens type C by the normal proteolytic enzymes of the intestine. In rabbits this beta toxin paralyses the motor activity of the intestine," and it is possible that an initial villous and segmental gut paralysis would allow attachment and multiplication of the organism, thus enabling the disease to gain a hold. Like C. perfringens type C, C. difficile is part of the normal gut flora 14-16 and Dr Larson and his colleagues found it in healthy neonates. Presumably under normal circumstances the growth of the organism is limited by the other intestinal flora and any small amounts of toxin produced by the organism are destroyed by the digestive enzymes, or possibly by metabolic products of the intestinal flora. Alterations of the physiology of the bowel, by antibiotics or other means, allow the organism to escape from normal controlling mechanisms, to multiply, and to produce toxin. The enterotoxtmias of C. perfringens and other clostridia begin with intestinal stasis due to a change in diet. A change in the intestinal flora ensues, with production of toxin and clear signs of infection. But the effect of C. difficile is more subtle: understanding of the precipitating circumstances requires a deeper knowledge of the interactions within microbial populations in the gut. Maybe the sporadic nature of the cases reflects the rarity of human colonisation by the organisms, as evidenced by the small number of isolates from normal individuals.16,1’ But it is noteworthy that Lawrence and Walker18 had to resort to the fluorescentantibody technique to identify C. perfringens type C in the intestines of normal individuals, the ordinary methods of isolation being too insensitive to be successful. If, as Dr Larson and his co-workers suspect, C. difficile is not a normal intestinal inhabitant, specific fluorescent labelled antisera may well be helpful in detection. The next question is: are the toxins produced by C. difficile directly responsible for the symptoms, or do they have a more indirect effect--operating, for example, via production from trypsin of the powerful inflammatory agent p-cresol?
attributed the effect of a
THE NEWBORN IN HOSPITAL
ALTHOUGH the most recent United Kingdom national survey of births showed a reduction in perinatal mortality to 23/1000 total births from 33/1000 reported twelve years earlier,2 it revealed many deficiencies in
perinatal care. The National Health Service provides maternal and infant services for the whole community, yet perinatal mortality in social classes IV and V is nearly double that in social class I. It is hard to get the most disadvantaged women to accept the services on offer. Another disturbing feature of the perinatal scene is the scant provision made by many maternity hospitals for care of the infant at a time when it is most vulnerable. Calls for improvement have come time after time-in the Peel report,3 the Sheldon reportthe Oppe reportand the Court report,6 to say nothing of The Lancet.7-9 Now an important discussion document10 has been produced by a liaison committee of the British Paediatric Association and the Royal College of Obstetricians and Gynxcologists. The level of provision in the U.K. has fallen behind that of many other countries, the document says, because of failure to recognise that the newborn infant requires at least the same standards of medical care as any other individual in the community. Attitudes which promoted survival of the fittest created more rather than less handicap in the survivors. Prompt correction and prevention of metabolic problems such as hypoxia, hypoglycaemia, acidæmia, cerebral oedema, hypocalcxmia, hyperbilirubinaemia, and haemorrhagic disease, together with early surgical correction of congenital anomalies and provision of an appropriate environment and adequate nutrition, can prevent death and cerebral damage in the most immature infants. Detailed recommendations are given as to how best to improve neonatal services. The combined initiative of obstetricians and paediatricians involved in preparing this practical guide to the professions and administrators deserves our full support. Who will deny that an ounce of prevention (of death and handicap) is worth a pound of cure (for cure read "care of the handicapped", for there is no cure)? The BPA/RCOG document is being circulated.
FACULTY OF OCCUPATIONAL MEDICINE THE formation of the Faculty of Occupational Medicine within the Royal College of Physicians of London marks an important stage in the development and indeed the recognition of this branch of the profession. Occupational medicine is concerned with all aspects of the two-way relationship between health and-work-in other words, not merely toxicology and industrial diseases or accidents but also matters relating to job placement and working capacity after illness or injury. The term industrial is now outmoded since the specialty is concerned with all occupations-agriculture and fishing, commerce, and the large services sector of the economy which includes transport and communication, 3.
Report
of the Sub-Committee of the
Standing Maternity Advisory
Com-
mittee, Central Health Services Council. H.M.Stationery Office, 1970. 13. Parnas, J Zentbl. Bakt. ParasitKde, 1976, 234, 243. 14 Hall, I.C.,O"Toole,E. Am J. Dis. Child.1935, 49, 390. 15. Snyder, M. L. J. infect. Dis. 1937, 60, 223. 16 George, L. W., Sutter, V. L., Finegold, M. S. ibid. 1977, 136, 17. Keusch, G. T., Present, D. H. ibid. 1976, 133, 584. 18. Lawrence, G., Walker, P. D. Unpublished. 1
4. 5.
Rep. publ. Hlth med. Subj. no. 127. 1971. Report of the Working Party on the Prevention of Early Neonatal Mortality and Morbidity. Department of Health and Social Security, 1975. 6. Report of the Committee on Child Health Services. Cmmd. 6684, H.M Sta822.
Chamberlain, R., Chamberlain, G., Howlett, B., Claireaux, A. British
1970: vol. I, First Week of Life. London, 1975. 2. Butler, N. R., Bonham, D. G. Perinatal Mortality, First British Perinatal Mortality Survey. Edinburgh, 1963.
Report
Births
of the 1958
tionery Office, 1976. 7. Lancet, 1974, i, 437. 8. ibid. 1975, i, 1227 9. ibid. 1976, i, 729. 10. Report of a BPA/RCOG Liaison Committee on Recommendations for the Improvement of Infant Care during the Perinatal Period in the United Kingdom. London, 1978.
1082
education, central and local government, and the health services. At the inception of the National Health Service, and later before the Employment Medical Advisory Service was established, the Royal College expressed its concern at the isolation of occupational medicine, which was hampering the specialty’s professional and academic development. The recognition by the Joint Committee on Higher Medical Training (J.C.H.M.T.) of occupational medicine as one of the clinical specialties marked a turning-point, while the implications of the Health and Safety at Work Act have made both management and unions, more aware of their needs for expert advice on the ever-increasing range of health problems at the workplace. The College of Physicians set up a standing committee, including doctors from the Society of Occupational Medicine, to consider how the professional needs of occupational medicine could best be met. The committee reported that, although occupational medicine involved the largest group of clinicians outside the N.H.S., there was no authoritative organisation empowered to develop and maintain high standards of training, of competence, and of professional ethics in this sphere. The creation of a faculty would provide best for the protection of people at work and at the same time preserve the principle of self-regulation, jealously guarded by the medical profession. Doctors will be able to follow the programme of higher specialist training laid down by the J.C.H.M.T. in order to become full-time specialists, but this scheme is not applicable to the many who move into occupational medicine in mid-career; nor will the J.C.H.M.T. be concerned with the numerous doctors who work part-time in this branch of medicine. The establishment of the new faculty will do much to enhance the standing of occupational medicine in Britain, and one of its tasks will be to assist in developing closer links with other branches of the medicine. Presumably the minimum standards of competence that will be laid down will meet any future requirements of the Health and Safety Commission. A discussion document issued last year by this Commission stated that less than half the doctors working full-time in occupational health services and only 13% of part-timers, had specialist qualifications in occupational medicine. The document made several suggestions for further action, including a review of "ethical questions affecting occupational health services". The new faculty will need to look at these suggestions since it will be expected to provide a lead for all doctors concerned with protecting the health of people at work. We wish it well.
WHEN IS A CONTRACT AJAR? THE Government has accepted the recommendations in the latest reportZ (see p. 1107) of the Review Body on Doctor’s and Dentists’ Remuneration, which includes an estimate of the percentage increase (28.5%) needed to
1. Health and Safety Commission (Prevention and Health). Occupational Health Services: the Way Ahead. H.M. Stationery Office, 1977. 2. Review Body on Doctors’ and Dentists’ Remuneration. Eighth Report. 1978. Cmnd 7176. H. M. Stationery Office. £1.60.
bring doctors’ and dentists’ pay back to a "proper relationship" with comparable occupations. The first 10% will come at once and the remaining 18.5% will emerge in two stages, to be completed not later than April 1, 1980. The first of the extra money for hospital doctors be distributed as 10% for all. As a step towards restoring order to the pay structure, consultants will get a bigger percentage than junior staff; and there is no doubt that this had to happen if the anomalies which have been damaging the N.H.S. for so long are to be eliminated. Though the juniors will not like it (and they will enjoy it even less if inflation fails to abate), they must recognise the irresistible claim of the consultants that the negative differential in some parts of the scale had to be abolished. In acknowledging without reservations the justice of the case of all doctors for a substantial rise, as upheld by the Review Body, the Government has done what it could, within the restraints it is continuing to impose, to restore a sense of well-being among the profession. Moreover, the valuable mechanism of control by Review Body has been preserved for the time being: anything less generous than the new report and the Government’s acceptance of it might have precipitated a return to the painful days of face-to-face direct bargaining between professions and Government. The scene is now more hopeful than seemed likely earlier in the year, though it will not remain so if others employed in the N.H.S. take the doctors’ deal as a text for disruptive action in support of their own claims. And, like all settlements, this one will produce sustained satisfaction only if the campaign against inflation succeeds. This award of more money follows closely upon the new contract offered to N.H.S. consultants3 and now to be put to ballot, accompanied by the commendation of the Central Committee for Hospital Medical Services. Again, this news has received a quietly contented welcome. A compromise has been reached over the contentious total-commitment issue, which disrupted negotiations a few months ago. Some of the deficiencies in an earlier proposed contract4 have been remedied, but we note with dismay the retention of the plan for emergency recall fees-a deplorable step into the bog of itemof-service payments and all the supervision and the alleged abuses they can entail. It would have been better to increase the on-call sessional payments ’rather than tread further down this risky path. The consultants’ negotiators had to secure a new contract which was less open than the existing one (which can be retained, with advantages, by those who wish it), but this is too closed for our liking. It is, in fact, said to be "ajar", and that is certainly preferable to total closure and an itemised payment for everything thereafter. Nevertheless, before they vote consultants should meditate upon the hazards of the recall fees. When the contract (if it is approved) is priced, the rewards available to some consultants from recall fees may turn out to be less ample than some expectations-indeed, the whole new contract may then lose some of its lustre. It remains to be seen how the Review Body will achieve the reconciliation between the consultant scales in its latest report and the pricing of a new will
not
ajar contract.
3. See Lancet, May 6, 1978, 4. ibid. 1977, ii, 1266.
p. 1056.
tragastric inoculation of cultures of C. perfringens together with sweet potato leads to infection of the small intestine, whereas inoculation of the organism alone, or with boiled sweet potato, produces no infection. He sweet potato to the presence of inhibitor which prevents inactivation or destrypsin truction of the beta toxin of C. perfringens type C by the normal proteolytic enzymes of the intestine. In rabbits this beta toxin paralyses the motor activity of the intestine," and it is possible that an initial villous and segmental gut paralysis would allow attachment and multiplication of the organism, thus enabling the disease to gain a hold. Like C. perfringens type C, C. difficile is part of the normal gut flora 14-16 and Dr Larson and his colleagues found it in healthy neonates. Presumably under normal circumstances the growth of the organism is limited by the other intestinal flora and any small amounts of toxin produced by the organism are destroyed by the digestive enzymes, or possibly by metabolic products of the intestinal flora. Alterations of the physiology of the bowel, by antibiotics or other means, allow the organism to escape from normal controlling mechanisms, to multiply, and to produce toxin. The enterotoxtmias of C. perfringens and other clostridia begin with intestinal stasis due to a change in diet. A change in the intestinal flora ensues, with production of toxin and clear signs of infection. But the effect of C. difficile is more subtle: understanding of the precipitating circumstances requires a deeper knowledge of the interactions within microbial populations in the gut. Maybe the sporadic nature of the cases reflects the rarity of human colonisation by the organisms, as evidenced by the small number of isolates from normal individuals.16,1’ But it is noteworthy that Lawrence and Walker18 had to resort to the fluorescentantibody technique to identify C. perfringens type C in the intestines of normal individuals, the ordinary methods of isolation being too insensitive to be successful. If, as Dr Larson and his co-workers suspect, C. difficile is not a normal intestinal inhabitant, specific fluorescent labelled antisera may well be helpful in detection. The next question is: are the toxins produced by C. difficile directly responsible for the symptoms, or do they have a more indirect effect--operating, for example, via production from trypsin of the powerful inflammatory agent p-cresol?
attributed the effect of a
THE NEWBORN IN HOSPITAL
ALTHOUGH the most recent United Kingdom national survey of births showed a reduction in perinatal mortality to 23/1000 total births from 33/1000 reported twelve years earlier,2 it revealed many deficiencies in
perinatal care. The National Health Service provides maternal and infant services for the whole community, yet perinatal mortality in social classes IV and V is nearly double that in social class I. It is hard to get the most disadvantaged women to accept the services on offer. Another disturbing feature of the perinatal scene is the scant provision made by many maternity hospitals for care of the infant at a time when it is most vulnerable. Calls for improvement have come time after time-in the Peel report,3 the Sheldon reportthe Oppe reportand the Court report,6 to say nothing of The Lancet.7-9 Now an important discussion document10 has been produced by a liaison committee of the British Paediatric Association and the Royal College of Obstetricians and Gynxcologists. The level of provision in the U.K. has fallen behind that of many other countries, the document says, because of failure to recognise that the newborn infant requires at least the same standards of medical care as any other individual in the community. Attitudes which promoted survival of the fittest created more rather than less handicap in the survivors. Prompt correction and prevention of metabolic problems such as hypoxia, hypoglycaemia, acidæmia, cerebral oedema, hypocalcxmia, hyperbilirubinaemia, and haemorrhagic disease, together with early surgical correction of congenital anomalies and provision of an appropriate environment and adequate nutrition, can prevent death and cerebral damage in the most immature infants. Detailed recommendations are given as to how best to improve neonatal services. The combined initiative of obstetricians and paediatricians involved in preparing this practical guide to the professions and administrators deserves our full support. Who will deny that an ounce of prevention (of death and handicap) is worth a pound of cure (for cure read "care of the handicapped", for there is no cure)? The BPA/RCOG document is being circulated.
FACULTY OF OCCUPATIONAL MEDICINE THE formation of the Faculty of Occupational Medicine within the Royal College of Physicians of London marks an important stage in the development and indeed the recognition of this branch of the profession. Occupational medicine is concerned with all aspects of the two-way relationship between health and-work-in other words, not merely toxicology and industrial diseases or accidents but also matters relating to job placement and working capacity after illness or injury. The term industrial is now outmoded since the specialty is concerned with all occupations-agriculture and fishing, commerce, and the large services sector of the economy which includes transport and communication, 3.
Report
of the Sub-Committee of the
Standing Maternity Advisory
Com-
mittee, Central Health Services Council. H.M.Stationery Office, 1970. 13. Parnas, J Zentbl. Bakt. ParasitKde, 1976, 234, 243. 14 Hall, I.C.,O"Toole,E. Am J. Dis. Child.1935, 49, 390. 15. Snyder, M. L. J. infect. Dis. 1937, 60, 223. 16 George, L. W., Sutter, V. L., Finegold, M. S. ibid. 1977, 136, 17. Keusch, G. T., Present, D. H. ibid. 1976, 133, 584. 18. Lawrence, G., Walker, P. D. Unpublished. 1
4. 5.
Rep. publ. Hlth med. Subj. no. 127. 1971. Report of the Working Party on the Prevention of Early Neonatal Mortality and Morbidity. Department of Health and Social Security, 1975. 6. Report of the Committee on Child Health Services. Cmmd. 6684, H.M Sta822.
Chamberlain, R., Chamberlain, G., Howlett, B., Claireaux, A. British
1970: vol. I, First Week of Life. London, 1975. 2. Butler, N. R., Bonham, D. G. Perinatal Mortality, First British Perinatal Mortality Survey. Edinburgh, 1963.
Report
Births
of the 1958
tionery Office, 1976. 7. Lancet, 1974, i, 437. 8. ibid. 1975, i, 1227 9. ibid. 1976, i, 729. 10. Report of a BPA/RCOG Liaison Committee on Recommendations for the Improvement of Infant Care during the Perinatal Period in the United Kingdom. London, 1978.
1082
education, central and local government, and the health services. At the inception of the National Health Service, and later before the Employment Medical Advisory Service was established, the Royal College expressed its concern at the isolation of occupational medicine, which was hampering the specialty’s professional and academic development. The recognition by the Joint Committee on Higher Medical Training (J.C.H.M.T.) of occupational medicine as one of the clinical specialties marked a turning-point, while the implications of the Health and Safety at Work Act have made both management and unions, more aware of their needs for expert advice on the ever-increasing range of health problems at the workplace. The College of Physicians set up a standing committee, including doctors from the Society of Occupational Medicine, to consider how the professional needs of occupational medicine could best be met. The committee reported that, although occupational medicine involved the largest group of clinicians outside the N.H.S., there was no authoritative organisation empowered to develop and maintain high standards of training, of competence, and of professional ethics in this sphere. The creation of a faculty would provide best for the protection of people at work and at the same time preserve the principle of self-regulation, jealously guarded by the medical profession. Doctors will be able to follow the programme of higher specialist training laid down by the J.C.H.M.T. in order to become full-time specialists, but this scheme is not applicable to the many who move into occupational medicine in mid-career; nor will the J.C.H.M.T. be concerned with the numerous doctors who work part-time in this branch of medicine. The establishment of the new faculty will do much to enhance the standing of occupational medicine in Britain, and one of its tasks will be to assist in developing closer links with other branches of the medicine. Presumably the minimum standards of competence that will be laid down will meet any future requirements of the Health and Safety Commission. A discussion document issued last year by this Commission stated that less than half the doctors working full-time in occupational health services and only 13% of part-timers, had specialist qualifications in occupational medicine. The document made several suggestions for further action, including a review of "ethical questions affecting occupational health services". The new faculty will need to look at these suggestions since it will be expected to provide a lead for all doctors concerned with protecting the health of people at work. We wish it well.
WHEN IS A CONTRACT AJAR? THE Government has accepted the recommendations in the latest reportZ (see p. 1107) of the Review Body on Doctor’s and Dentists’ Remuneration, which includes an estimate of the percentage increase (28.5%) needed to
1. Health and Safety Commission (Prevention and Health). Occupational Health Services: the Way Ahead. H.M. Stationery Office, 1977. 2. Review Body on Doctors’ and Dentists’ Remuneration. Eighth Report. 1978. Cmnd 7176. H. M. Stationery Office. £1.60.
bring doctors’ and dentists’ pay back to a "proper relationship" with comparable occupations. The first 10% will come at once and the remaining 18.5% will emerge in two stages, to be completed not later than April 1, 1980. The first of the extra money for hospital doctors be distributed as 10% for all. As a step towards restoring order to the pay structure, consultants will get a bigger percentage than junior staff; and there is no doubt that this had to happen if the anomalies which have been damaging the N.H.S. for so long are to be eliminated. Though the juniors will not like it (and they will enjoy it even less if inflation fails to abate), they must recognise the irresistible claim of the consultants that the negative differential in some parts of the scale had to be abolished. In acknowledging without reservations the justice of the case of all doctors for a substantial rise, as upheld by the Review Body, the Government has done what it could, within the restraints it is continuing to impose, to restore a sense of well-being among the profession. Moreover, the valuable mechanism of control by Review Body has been preserved for the time being: anything less generous than the new report and the Government’s acceptance of it might have precipitated a return to the painful days of face-to-face direct bargaining between professions and Government. The scene is now more hopeful than seemed likely earlier in the year, though it will not remain so if others employed in the N.H.S. take the doctors’ deal as a text for disruptive action in support of their own claims. And, like all settlements, this one will produce sustained satisfaction only if the campaign against inflation succeeds. This award of more money follows closely upon the new contract offered to N.H.S. consultants3 and now to be put to ballot, accompanied by the commendation of the Central Committee for Hospital Medical Services. Again, this news has received a quietly contented welcome. A compromise has been reached over the contentious total-commitment issue, which disrupted negotiations a few months ago. Some of the deficiencies in an earlier proposed contract4 have been remedied, but we note with dismay the retention of the plan for emergency recall fees-a deplorable step into the bog of itemof-service payments and all the supervision and the alleged abuses they can entail. It would have been better to increase the on-call sessional payments ’rather than tread further down this risky path. The consultants’ negotiators had to secure a new contract which was less open than the existing one (which can be retained, with advantages, by those who wish it), but this is too closed for our liking. It is, in fact, said to be "ajar", and that is certainly preferable to total closure and an itemised payment for everything thereafter. Nevertheless, before they vote consultants should meditate upon the hazards of the recall fees. When the contract (if it is approved) is priced, the rewards available to some consultants from recall fees may turn out to be less ample than some expectations-indeed, the whole new contract may then lose some of its lustre. It remains to be seen how the Review Body will achieve the reconciliation between the consultant scales in its latest report and the pricing of a new will
not
ajar contract.
3. See Lancet, May 6, 1978, 4. ibid. 1977, ii, 1266.
p. 1056.
