Jan 26, 1974 - SIR,-My colleagues and I, who are mem- bers of the Medical ... the Huddersfield Hospitals, have read your ... nam's letter (15 December, p.
BRITISH MEDICAL JOURNAL
26 JANUARY 1974
con tract to the new employing authority on 1 April 1974. Obviously if the statement above is true I cannot do this, and this seems to me to be an opportunity for bringing the sort of contract which I have into line with the previous one, which specified hours to be worked. For good measure, the travelling expenses from home or consulting rooms to hospital should now be allowed for all, not merely those appointed before 1960. There would thus be one type of part-time contract instead of three.-I am, etc., W. MAVOR Department of Pathology, Royal Hampshire County Hospital, Winchester
Towards a Better Service SIR,-My colleagues and I, who are members of the Medical Executive Committee of the Huddersfield Hospitals, have read your leading article (10 November, p. 309) entitled "Towards a Better Service." While we support the principle of a reduction in working hours for junior doctors, we should like to make the point that the only people who have an open-ended 168hours-a-week contract are consultants, and in particular whole-time consultants, and this could have been mentioned in the article.
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Earlier observations suggested that pulmonary oedema of altitude occurred mainly in young, fit males, perhaps because being in good condition they tend to exercise with less restraint than older people. However, when pulmonary oedema does occur in older people the outlook tends to be worse because they do not tolerate a low Po2 as well J. H. RUSTAGE as young people, and the relative anoxia Hon Secretary, may precipitate a cardiovascular or cerebroMedical Executive Committee, Huddersfield Group of Hospitals vascular catastrophe....
We note your final paragraph, in which you say that a squeeze on management by juniors is likely to increase the burden on hardpressed consultants. While consultants are negotiating a new contract it seems to us that too little attention is paid to the burdens they carry already.-I am, etc.,
Royal Infirmary, Huddersfield
Pensions and War Service SIR,-I wish to support Dr. W. P. Sweetnam's letter (15 December, p. 679) advocating that doctors in the N.H.S. should receive concessions for war service in the armed Forces similar to those granted to teachers. In fairness such concessions should also apply to two other groups: those who were invalided out of the armed Fcrces and who then served in E.M.S. hospitals and those who initially were declared unfit for war service and who likewise served in E.M.S. hospitals.-I am, etc., D. J. AP SIMON Church Crookham, Hants
Points from Letters Practice Expenses Dr. T. D. RIcHARDs (Pucklehurst, near Bristol) writes: There is ample evidence for the B.M.A. negotiators on behalf of general practitioners to seek an early interview with the Review Body with the intent to see that
mask of approximately 501./min, which is still greater than the total flow of the 28 % mask with its recommended 41./min oxygen flow. We have demonstrated that the effectiveness of the 24% Ventimask in producing a 24% inspired oxygen concentration is not impaired by this reduced flow1 2....
the current rises in expenditure are reflected in appropriate increases in practice allow- 1 Bethune, D. W., and Colis, J. M., Thorax, 1967, 22, 221. ances to offset the present inflation. The Re- 2 Bethune, D. W., and Collis, J. M. Anaesthesia, 1967, 22, 43. view Body must know that the last award of approximately 4-5°% against a current yearly inflation rate of 10% is derisory and needs to be corrected quickly. . .. Hazards of High Altitude Trekking Dr. A. P. HAINES (Britain-Nepal Medical Trust Ltd., Panchali, Biratnagar, Nepal) Shortage of Plastics writes: There has recently been a tremenDr. A. S. GARRETT (Reepham, Norfolk) dous increase in the number of tourists visitwrites: Dr. C. J. R. Hart's letter (22 ing the Everest region of Nepal and walking December, p. 741) about plastics shortage is at altitudes of over 11,000 feet (3,350m) for much to the point, but within the medical considerable periods. Many seem totally unsphere there could be great savings. Our 2- aware of the dangers of unregulated exerand 10-ml syringes are surrounded by about cise at high altitudes and in consequence their same weight of plastic packaging. Our there have been many severe cases of pulneedles used to come in thin but very monary oedema due to altitude with several adequate tubes and are now more difficult deaths and others saved only by fortuitious to extract from plastic containers about five helicopter evacuation. Many travel agents involved give no clear or six times the weight.... warning about the dangers of altitude. Tourists are flown in to an airfield at 7,000 feet (2,130m) or another at over 11,000 feet Noisy Oxygen Therapy (3,350m) from whence they are expected to Drs. D. W. BETHuNE and J. M. COLLIS walk up, over short periods of a few days, (Papworth Hospital, Cambridge) write: We to altitudes of up to 18,000 feet (5,490m). appreciate the sentiments expressed by Dr. The tourists are quite frequently middleJulian M. Leigh on the noise levels of oxy- aged or elderly and many seem generally ungen masks operating on the venturi principle fit to begin with, so it is not surprising that (15 December, p. 652). The sound level from morbidity and mortality are common. Many the noisiest masks, those producing 24% people who have experience of trekking in inspired oxygen concentration, can be greatly other mountainous regions, such as the Alps, reduced by running them on oxygen at 21./ imagine that the conditions in the Khumbu min rather than the manufacturers' recom- region are similar. The altitude factor, howmended 41./min (Ventimask). Oxygen at ever, makes vigorous exercise without careful 21./min produces a total flow through the acclimatization an extremely risky business.
Pancreatitis from Oral Contraceptives Mr. R. S. MURLEY (Radlett, Herts) writes: Your (leading article, 22 December, p. 688) asks, "What is the relationship between oestrogen-containing oral contraceptives, hyperlipaemia, and pancreatitis?" Having postulated a possible mechanism in hyperlipaeniic patients you go on to admit that hyperlipaemia is equally well known as an effect of pancreatitis. . . Partial pancreatic infarction can be caused by thrombosis in a pancreatic artery or vein. In view of the considerable volume of published data conceming the increased incidence of thrombotic disorders in women on the contraceptive pill I suggest that pancreatic venous or, less often, arterial thrombosis should be seriously considered as a cause of acute pancreatitis in these patients. I have observed venous thrombosis in hypothermic patients affecting the veins of both the gut and pancreas.... In this connexion I note that Professor A. N. ExtonSmith (22 December, p. 727) points out that necropsy examination of elderly patien-ts who have died of accidental hypothermia often shows acute pancreatitis. I believe that the acute pancreatitis in these cases may often be due to vascular thrombosis too. . ..
Malignant Carcinoid Tumour with Gangrene of Small Intestine Mr. R. T. BuRxirr (Ashford Hospital Middlesex) writes: I read with interest the article by Dr. I. M. Murray-Lyon (29 December, p. 770) and would like to add a further case. Twenty years ago when working in Nairobi I operated on a patient and found almost six feet (1-8 m) of gangrenous small intestine. There was no evidence of any other disease in his abdomen and there had never been anything to suggest a carcinoid syndrome.... I was subsequently amazed at the histological report which stated that the cause of the infarction was a mesenteric occlusion due to a lymph node at the root of the mesentery heavily infiltrated with malignant carcinoid tumour. The patient made an uneventful recovery and went back to work.... He continued to live a fully active life for another 10 years, when he died of something in no way connected with his previous operation. Unfortunately no postmortem was performed....
Digressions around a Medal Dr. W. B. GOUGH (Birmingham) writes: It gave me great pleasure to read "Digressions around a Medal" (22 December, p. 724) by Dr. G. Gramiccia, and I must thank him for introducing me to Voltaire's splendid
