388 SPECIAL ARTICLES

Within the treatment wards or units the problems aredifferent. The careful selection of staff is, of course, aprerequisite for good treatment, but it is not enough.Staff meetings and tutorials are necessary for the dis-cussion of emotional involvements of staff in the work aswell as for the communication of information relevantto treatment. The reluctance of many doctors to giveup their prerogatives of unquestionable authority hashampered these collaborative procedures. The sharingof perplexities, anxieties, and so on with the lowerechelons of the staff has many mutual benefits. It freesthe flow of useful communications to the psychiatrists,and increases the clinical teams’ effectiveness. TheLancet, referring to the difficulty of recruiting andretaining mental nurses in even our most famous teachinghospitals, recently quoted the report of the Maudsleyand Bethlem Royal Hospitals on the function and

training of mental nurses which suggests that everystudent nurse might with advantage be attached to apsychiatric firm. This would, it is hoped, allow her agreater share in treatment and improve communicationsbetween nurses and doctors. Experience suggests thatgood rather than harm results from this collectiveapproach which lessens the gulf between doctors andnurses in most of our psychiatric hospitals. The nurse,whether experienced or not, is helped to find a treatmentrole and feels that she has a special contribution to makethrough her greater contact with the patient. This is

why she came to nursing and it is difficult to see why sheshould not play a useful part from the day she arriveson the ward, if interest and guidance is available throughfrequent staff seminars. For many of the problemsof nursing recruitment we have only ourselves toblame.

The changes needed to reform the mental hospitalsystem can succeed only with the support and good will ofsenior administrative personnel. Physician-superinten-dents, matrons, and others cannot give up their privilegeddefences unless they feel secure enough to expose them-selves to the disruptive consequences of a permissivesystem. The delegation of authority to semi-autonomoustreatment units will raise new problems of intra-hospitaladministration, and these, like the others, can onlybe worked through by critical self-appraisal, and freedomof communications from those most concerned-the

patients and treatment staff.We are indebted to Dr. Louis Minski, physician-super-

intendent at Belmont Hospital, and to Miss P. Arnold,Matron, for their cooperation in the development of socialpsychiatric practice and research at the social rehabilitationunit.

BIBLIOGRAPHY

1. Caudill, W., Redlich, F. C., Gilmore, H. R., Brody, E. B.(1952) Amer. J. Orthopsychiat. 22, 314.

2. — (1953) In Kroeber’s Anthropology Today. New York.3. Goldhamer, H., Marshall, A. (1953) Psychosis and Civilisation.

Glencoe, Ill.4. Hollingshead. A. B., Redlich, F. C. (1953) Amer. Sociol. Rev. 18,

169.5. Hyde, R. W., Solomon, H. C. (1950) Dig. Neurol. Psychiat.

18, 201.6. Jones, M., Rapoport, R. N. (1955) Psychiatric Rehabilitation.

Yearbook of Education. London.7. — (1953) Social Psychiatry. London.8. — (1954) Lancet, ii, 1277.9. Lancet (1955) i, 753.

10. Milbank Memorial Fund (1953) Interrelations between theSocial Environment and Psychiatric Disorders. New York.

11. Rose, A. (1955) Mental Health and Mental Disorder. NewYork.

12. Ruesch, J., Bateson, G. (1951) Communication : the SocialMatrix of Psychiatry. New York.

13. Simmons, L., Wolff, H. (1954) Social Science in Medicine.New York.

14. Stanton, A., Schwartz, M. (1955) The Mental Hospital. London.15. Weinberg, S. K. (1952) Society and Personality Disorders.

New York.16. World Health Organisation (1953) Technical Report Series,

no. 73. Geneva.

JOINT CONSULTANTS COMMITTEEA MEETING of the Joint Consultants Committee was

held in London on July 27 under the chairmanship ofSir Russell Brain.The committee received from a subcommittee a report

on exploratory discussions which had taken place withthe Ministry of Health a few days earlier on the subjectof hospital medical staffing. At the beginning of thesediscussions the Ministry had made the reservation thatplans for reorganising the medical staffing structureshould not be used as a means of securing salary increases,which were a matter for Whitley negotiations. Themembers of the subcommittee had replied that, as

adequate recruitment of hospital medical staff was oneof the fundamental problems, the question of salaryranges was entirely relevant and could not be ignored.Apart from this disappointing beginning, the discussionshad been useful and constructive.One of the major points made by the subcommittee

had been that the rigid training ladder should be abol-ished, and appointments made according to the needs ofthe hospital. To secure adequate training through experi-ence in suitable appointments would be the responsibilityof the aspirant to consultant status. There would be nolimitation of the number or variety of posts he mighthold, and he would not lose his prospect of promotionsolely by the operation of a time factor. Appointmentswould be renewable in competition, or in some cases (inthe higher posts) of indefinite tenure ; and posts com-parable with the present senior-registrar posts might betemporarily upgraded as necessary to retain the servicesof promising men, pending opportunities of appointmentto consultant vacancies.The Ministry had been critical of the suggestion that

there should be a comprehensive central review ofestablishments. The previous reviews had not provedentirely satisfactory, and the Ministry thought that thechanging needs should be kept under continuous reviewlocally and only special problems referred for decisioncentrally. The subcommittee had agreed that theinitiative should be taken at the hospital level, but

thought that past experience pointed to the need forover-all planning.Among other matters which had been discussed with the

Ministry were the machinery for making appointmentsand the means of attracting practitioners back into hos-pital appointments after completion of National Service.The Ministry had undertaken to put its own views on

hospital medical staffing into writing as a basis forfurther discussions.The committee also received a report of a meeting with

the chairmen of the Regional Hospital Boards in Englandand Wales, at which the main subject discussed hadbeen the development of suitable medical advisorymachinery at the regional-board level. The views

expressed on behalf of the Joint Committee at this

meeting were published in these columns on Aug. 6.It was reported that, after discussions between repre-

sentatives of the Joint Committee and the Ministry onthe retiring age and superannuation benefits of mental-health officers, the Staff and Management Sides ofCommittee B of the Medical Whitley Council had agreedto delete from the terms and conditions of service theprovision requiring hospital medical staff classified asmental-health officers to retire at the age of 60. The effectof this is that mental-health officers will retain their

special superannuation benefits but may continue in thehospital service until 65 if they so desire.A request was considered for the views of the com-

mittee on the practice adopted by a number of non-teaching hospitals of offering facilities for senior medicalstudents to obtain additional experience during theirholiday periods. While reaffirming the opinion previouslyexpressed to the Ministry that the employment of students

389CONFERENCES AND CONGRESSES

as house-officers should in no circumstances be allowed,the committee considered that the granting of facilitiesto students to gain additional experience as studentsshould be encouraged in every way. Some hospitalauthorities were tending to discourage this practicebecause of the fear of litigation, but legal advice which thecommittee had obtained made it clear that the liabilityof a non-teaching hospital in respect of such studentsdiffered in no way from that of a teaching hospital.Resolutions were received from the dermatologists’

and venereologists’ groups of the British Medical Associa-tion which urged that combined appointments in thetwo specialties should be opposed. These resolutions hadbeen endorsed by the Central Consultants and SpecialistsCommittee, and the Joint Committee agreed that,although in some areas there might be difficulty in

making satisfactory arrangements for the staffing ofvenereal diseases departments, the solution of the

problem did not lie in the combination of venereologywith dermatology. It was decided that the matter shouldbe discussed with the Ministry.

Other matters discussed included the proposals for

. statutory registration of medical auxiliaries, the operationof the " moral obligation " clause in paragraph 16 of theterms of service, and the expansion of the senior-registrarestablishment in anaesthetics and certain other specialties.

Conferences and CongressesCLINICAL ENDOCRINOLOGY IN U.S.A.THE 37th annual meeting of the Endocrine Society

of the United States was held at Atlantic City on June 2-4,under the presidency of Dr. ALLAN T. KENYON. The

papers were strictly limited to ten minutes each, andthis demanded not only rapid reading but also highreceptivity in the audience, 24 papers being read on thefirst day alone. The mental receiving-sets in the audienceavoided fatigue by practising selectivity, and there wasmuch coming and going in the large auditorium.The following is an abstract of some of the papers

of most clinical importance.The Thyroid

Thyropituitary Relations in Creti-t-asm and HypothyroidismA. M. DIGEORGE, S. A. D’ANGELO, and K. E. PASCHKIS

(Philadelphia) had demonstrated, by tadpole bio-assay, that,while the thyroid-stimulating-hormone (T.S.H.) levels were

frequently raised in hypothyroidism, in some cases they werelow or even absent. Therefore a reduced or negative T.S.H.level cannot be taken to indicate a pituitary origin for thehypothyroidism. In some cases T.s.H. returned after thyroidtherapy had been started, which suggested that the synthesisor release of T.S.H. may sometimes require the presence ofthyroid hormone. In the discussion Dr. Paschkis observedthat all functions of the pituitary may not be equally affected,since a high output of F.S.H.may occur in hypothyroidism.Therapeutic Implications of the Avidity of Solitary ThyroidNodules for 131I

.

M. PERLMUTTER and S. L. SLATER (New York) had com-pared the uptake of 1311 in non-toxic nodules with the uptakein a non-nodular area of thyroid tissue in the same patient.The nodule was described as " hot " if the uptake was higherthan that of the surrounding tissue, and " cold " if the uptakewas identical with the thyroid uptake. The 22 malignantnodules thus assessed were " cold." Of the 97 non-toxicnodules 65 were " cold " and 32 " hot."In the discussion Dr. E. B. ASTWOOD observed that it was

the ’’ cold" " nodules-those not avid for iodine-whichresponded best to thyroid therapy.The ingestion of thyroid hormone significantly decreases

the thyroid uptake of 131I in 95% of euthyroid subjects and inonly 3% of thyrotoxic patients. Dr. Perlmutter and Dr. Slaterhad therefore applied this test to thyroid nodules. All thetoxic " hot " nodules and half the " hot " non-toxic nodules

1. This is the basis of S. C. Werner’s test for thyrotoxicosis. (Bull.N.Y. Acad. Med. 1955, 31, 137.)

showed no depression of 1311 uptake after thyroid hormone.While definite depression of the uptake curve indicates euthy-roidism in nodular goitre, an unvarying uptake does notindicate hyperthyroidism.Deiodination of Thyroxine to Triiodothyronine by KidneySlices of Rats with 17 arying Thyroid lJ’unction

F. C. LARSON, K. TOMITA, and E. C. ALBRIGHT (Madison)concluded, from their researches with kidney slices in rats,that there is a deiodinating system in the tissues which con-verts thyroxine to triiodothyronine ; and they postulated thatthis enzyme system is adaptive, since deiodination is enhancedby increasing the amount of thyroxine present in the tissue.Metabolism of Triiodothyronine and Thyroxine in Plasma,Pituitary, and Oentral Nervous System of the Rabbit

J. GROSS, D. H. FORD, and M. POSNER (New York) hadshown, by injecting rabbits with 13’I-labelled triiodothyronineand killing them at various intervals after injection, that theplasma activity fell rapidly and at four hours was predomin-antly in the form of iodide. There was, on the other hand, arapid entry of radioactivity into the pituitary and the dien-cephalon. The concentration of 1311 was highest in the posteriorpituitary and lower in the anterior lobe, which respectivelyattained over 20 and 7 times the plasma-1311 concentration atfour hours. Most of the concentrated radio-iodine was identi-fiable as triiodothyronine. Dr. Gross emphasised that theseresults did not necessarily apply to other animals in the samedegree. When labelled thyroxine was similarly injected, theconcentration of radio-iodine was demonstrable only in theposterior pituitary.A Study of Endemic GoitreM. ROCHE, F. DE VENANZI, J. VERA, E. COLL, and M. S.

BERTI (Merida) reported a survey in a goitrous region in theVenezuelan Andes. Palpable thyroids were found in 84-5%of 718 adults examined and in 83-0% of 641 school-children.In 44-2% of the adults and 31-4% of the children the goitreswere visible as well as palpable. Radio-iodine tests showedthat the glands were avid for iodine : the forty-eight-hourradio-iodine uptake in 100 adults averaged 74% and in 28children 79%. No statistical difference in the iodine-uptakecurves could be demonstrated between those adults with agoitre and those without. Potassium perchlorate in doses of300 mg. two hours after administration of 131l decreased the

radioactivity in the thyroid of 11 out of 13 goitrous subjectstested-a result which suggested that part of the thyroidiodine in endemic goitre is in the unbound state.’

The Pituitary ,

Analysis of the Polyuria Produced by Hypophysectomyin man

M. B. LIPSETT, J. P. MACLEAN, M. C. Li, C. D. WEST,B. S. RAY, and 0. H. PEARSON (New York) reported thatpolyuria occurred in 67% of cases in which a complete hypo-physectomy had been performed, but it was not seen whenthe pituitary stalk remained intact. They did not report thesucceeding oliguric interphase described by Ikkos, Luft, andOlivecrona 3 ; nor did they observe that the subsequentpolyuria depended on the presence of cortisone.

Effect of Partial Hypophysectomy on Adrenocortical,Thyroid, and Gonadal Fnctio-rz in the DogW. F. GANONG and D. M. HUME (Boston) confirmed the

clinical observation that, in lesions destructive of the pituitary,gonadal function was depressed first, then thyroidal, andfinally adrenocortical. They removed varying amounts ofpituitary tissue in 31 dogs. More than four-fifths of the

pituitary was removed before any abnormality could bedemonstrated in the target glands. For complete suppressionof adrenocortical activity it was necessary to remove thewhole pituitary, and minute fragments remaining were

capable of supporting significant compensatory hypertrophyin the adrenal cortex.

Reproduction and Sex HormonesCongenital Gonadal Dysgenesis, Ovarian Agenesis, MalePseudohermaphroditism : the Relationship to Theories

of Human Sex DifferentiationM. M. GRUMBACH, J. J. VAN WYK, and L. WiLKiNS (Balti-

more) had investigated 17 patients with ovarian agenesis by2. These results are similar to those reported by J. S. Stanbury

(J. clin. Endocrin. 1953, 13, 1270) in a goitre survey in westernArgentina.

3. J. clin. Endocrin. 1955, 15, 553.