April 1967 Correspondence BRITIsH 113

First, even allowing for the reduction in give more details about these items, together The pregnancy populations studied were
the number of consultant posts in infectious with references to published work. In addi- quite unselected, being patients attending the
diseases suggested in the Platt report' the tion, anything known about the L.D.50 in laboratory for Rh antibodies and other blood
number which will be theoretically available animals of their particular preparations should tests ; diabetics were not excluded.
in the near future is far in excess of two. also be published in their literature, because Dr. J. E. Tovey (11 March, p. 635) has
However, in case any senior registrars in this can be very useful. ingeniously accounted for the whole phenom-
other specialties should be dazzled by pro- The information in the literature distri- enon of pregnancy glycosuria in terms of
motion prospects in this field let me explain buted these days by the majority of manu- increased glomerular filtration rate,arebutother he
to them what happens when a consultant in facturing chemists is both comprehensive and must be well aware that there
infectious diseases retires. Frequently he is helpful. However, there are cases in which explanations, such as the increased inlevel of
not replaced ; if he is replaced it may be by the information is inadequate, and one has to corticosteroids well known to occur preg-
a candidate without special knowledge or telephone or write to firms for information nancy. The effect of prednisone, for example,
training in infectious diseases. On occasions which quite often was already available in in promoting the excretion of glucose can be
the original consultant's deputy is privileged their files and which they could have very readily demonstrated, and in a self-experi-
to run the unit in the capacity of S.H.M.O. easily published in their literature.-I am, ment 20 mg. taken orally increased a 24-hour
perhaps " responsible " to some other person etc., excretion of 68 mg. to 900 mg., and induced
without special training in the field. How NOLAN A. WYNNE, a state of strong Clinistix-positiveness in the
Director, Poisons Information Centre. urine for over six hours without producing
has this sad situation developed ? Royal Victoria Infirmary,
There are three main reasons Newcastle upon Tyne. any abnormality in the blood-sugar curve.-
I am, etc.,
Until recently those who have achieved con- Pathological Laboratory, J. FINE.
sultant status in infectious diseases have not Kitwe Central Hospital,
been sufficiently aggressive in bringing these facts Zambia.
to the notice of those who are in a position to Glycosuria of Pregnancy
decide such matters. There is evidence that this
is changing. SIR,-I would appreciate the opportunity
A number of clinicians, mostly general physi- of replying to further criticisms of my article
cians, have been said to resent consultant ap- on the above subject (28 January, p. 205). Vocational Training
pointments in infectious diseases. This may Dr. Rosemary M. Robertson (11 March,
have arisen because some consultants in this field SIR,-Your issue (18 March, p. 693)
were appointed without becoming members of a p. 635) has made the interesting suggestion reported on a conference on the "Future of
Royal College, and the Royal College of Physi- that pregnant women who are Clinistix-nega- British Medicine" held in Newcastle upon
cians has not reorganized the specialty in its tive on random sampling may have the same Tyne on 10 and 11 March. Several of the
training requirements. Resentment may have incidence of diabetes as the group who are
been increased by the fact that infectious dis- Clinistix-positive. This has a certain plausi- speakers were reported as stressing the need
eases units continue to admit a good proportion bility, since the negative group is potentially for special vocational training of general
of highly interesting clinical material. practitioners. This need has been recognized
There is virtually a total lack of appreciation positive, and is only negative by the chances for some time by such bodies as the B.M.A.,
in this country that infections may require of random sampling. Dr. Robertson goes on the Royal Colleges, the Health Departments
special skills for their proper diagnosis and man- to point out that if her assumption was and the like, but there is only limited evidence
agement. Even in units where sophistication in correct the incidence of diabetes in pregnancy that any practical steps have been taken to
most fields is expected the approach to infection as a whole would be the same as that in the
is often Stone Age. One of the difficulties is that positive group-that is, 1.9%, which is provide such vocational training.
infection is extremely common-every doctor approximately the incidence in the general Your readers may be interested therefore
who prescribes antibiotics must realize the truth population. There are reasons, however, to know that a vocational training scheme for
of this. why practice has recently been introduced
the Clinistix-positive group cannot be generalLothians
One regards with envy our Scottish and regarded as identical with the negative group in the in association with the Joint
American colleagues, who realize that the as regards incidence of diabetes. Advisory Committee on health services for
twin sisters of microbiology and infectious It is a matter of common experience that Livingston New Town. The Joint Commit-
diseases cannot be separated, and when they glucose-tolerance tests in diabetes will yield tee represents all aspects of the health service,
are appointed as specialists in these fields a higher percentage of Clinistix-positive urine and has the duty of advising as to how best
assume their deserved status. When students specimens than in renal glycosuria, in which to provide an integrated service in Living-
or house-officers approach me with a view to condition as a rule only one or two samples ston, and sees training for general practice
specializing in infectious diseases I have to out of the six are positive. It would follow as one of the steps towards this goal.
warn them that there is no future for them that random sampling of diabetics will yield The vocational training scheme which was
here. We are expected to teach students but a higher percentage of positives than a advertised recently in the B.M.7. is a three-
not to fire their imagination. similar sampling of non-diabetics. Conse- year course starting at senior house officer
Surely it is time for the Royal Colleges quently, diabetics are more likely to find or registrar level. This course is super-
and the Ministry either to admit that their themselves in the Clinistix-positive than in the vised throughout by the medical adviser to
policy is the present laissez-faire situation in Clinistix-negative group. The two groups, the Livingston Joint Committee. There is a
which all, including patients, suffer, or pro- in short, are not identical in diabetic inci- year's hospital training, a year's general
v1ide a proper career structure as in any other dence. practice training with a prescribed syllabus
specialty ?-I an etc., Attempts to use the diabetes-rich positive of work, three months' training in public
Royal Free Hospital, HILLAS SMITH group for screening would still lead to missed health, and an elective period in which the
Infectious Diseases Unit,
Coppetts Wood Hospital, diabetics, since an unknown percentage of trainee has a wide choice in his last nine
London N.IO. them would-by the chances of random months. A close association with the district
REFERENCE sampling-be lost to the negative group. hospital is maintained throughout the course,
Medical Staffing Structure in the Hospital Service, Incidence of diabetes was not, however, the at the end of which the trainee will be offered
Report of the Joint Working Party, 1961. theme of my paper, and the data obtained a post in general practice in Livingston prac-
H.M.S.O., London. were a mere by-product of the glycosuria tising from a health centre, and also his
studies. The number of diabetics found in association with the hospital will be main-
the population of 2,547 cases of pregnancy tained, if possible by offering him a part-
Drug Literature was 7 (4 known, 3 discovered) or 0.28% ; time appointment.
if allowance is made for the fact that only The Secretary of the Joint Advisory Com-
SIR,-I should like to make a plea through half the glycosurias in the second series of mittee is the Clerk to the Lothians and
the B.M.7. to some of the manufacturers 1,000 had glucose-tolerance tests performed Peebles Executive Council, 25 Stafford
of pharmaceutical preparations to improve the estimated number would be 8, or 0.33%. Street, Edinburgh 2, who will be willing to
the literature that they send out, both with As against this, the control population of 537, supply any further particulars.-I am, etc.,
their preparations and as separate items. I whose glycosurias were all followed up by
am particularly concerned about the informa- glucose-tolerance tests, yielded 9 diabetics (4 JOHN BALDWIN,
Medical Adviser
tion distributed about the side-effects and known, 5 discovered)-1.6% or 5 times the Livingston New Town Advisory
toxic effects of drugs, and would like them to incidence in pregnancy. Committee.
Midlothian.