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maintaining standards and making unreasonable demandsis often narrow.The same problems, with modifications, face the

aspiring physician and obstetrician, and the total result isthat a body of highly academic, frustrated, and disgruntledmen are being produced as specialists.

I have no quarrel with the final F.R.C.S. even though acandidate who has been unlucky with his examinationsmay be as good or better than another who has been lucky;yet under the present system his experience and person-ality count for nothing against the printed paper. Clearlyit is not by keeping examinations at sky level that thegenerally high standards of British surgery and medicinewill be maintained but, while accepting these qualificationsas a basis, by ensuring that each surgeon or physician hashad suitable practical experience in his particular field.

In recent years some London teaching hospitals haveadopted a system of rotation of their middle-grade andsenior registrars with peripheral hospitals. This has the

advantage of encouraging registrars to undertake researchin the bigger centres, yet does not deprive them of learningthe art of surgery when they move away from thesecentres. But what of the many hospitals which do notenjoy the privilege of being associated with a teachinghospital ? What of the many overseas doctors who willnever arrive at these privileged situations ? It seems thatserious consideration should be given to the training offuture specialists-specifically whether to combine theacademic emphasis of the English system with the

apprenticeship of the Continental countries, between whichtwo there is wide disparity.

CONCLUSION

Sir George Pickering has drawn attention to the

undesirability of producing a consortium of academicautomatons as the future doctors of this country, and his

warning should be heeded. But whatever the grievancesof doctors with the N.H.S. as a whole, a deepening frustra-tion weighs down the overseas doctors who carry so largeand imp ortant a part of the burden of the service. Manyof them come from places where doctors still enjoy a highsocial status; and, while they submit to being peggeddown, they squirm at being trodden on.

It is easy to reply: " These people come here and musttake us as they find us or leave." Can Britain afford suchan attitude ? Can anyone in the modern world afford-such insularism ? Surely whatever consideration Britainshows to these visitors today can only be a profitableinvestment for tomorrow.

We come in search of teaching, experience, and

enlightenment and receive none. Such teaching as thereis takes no account of the local problems with which mostof us will have to deal in the future. Soon the Common-wealth countries will prevent their best graduates fromgoing abroad; and then, not only will the bottom fall outof the British hospital service, but Britain will have losta great deal of good will.

1. Brit. med. J. 1963, ii, 133.

Special Articles

NOMENCLATURE AND CLASSIFICATION OF

THE DISORDERS DUE TO HEAT

A MEMORANDUM PREPARED FOR THE CLIMATIC PHYSIOLOGYCOMMITTEE OF THE MEDICAL RESEARCH COUNCIL (UNITEDKINGDOM) AND THE SUBCOMMITTEE ON THERMAL FACTORS INTHE ENVIRONMENT, OF THE NATIONAL RESEARCH COUNCIL

(UNITED STATES OF AMERICA) *

IN its nomenclature and classification of the disordersdue to heat, the World Health Organisation’s Manual ofthe International Statistical Classification of Diseases,Injuries, and Causes of Death (I. S.C. 1957) will need

improvement in the revision scheduled for 1967. Militaryand industrial authorities have largely resorted to heat-illness categories of their own design; and in the meantimethe absence of a sound, modern, and internationallyacceptable nomenclature and classification of the heatdisorders is as much a cause as an effect of confusion aboutthe disorders themselves. For this reason a design forrevision of the relevant section of the LS.C. was preparedsome years ago for the Climatic Physiology Committee ofthe Medical Research Council, and later published(Weiner and Horne 1958). This memorandum was dis-cussed at the Sixth International Congresses of TropicalMedicine and Malaria in Lisbon in 1958 (Stamm 1963),and has been the subject also of independent comment(Ellis 1958).*Prepared for publication by Dr. C. S. LEITHEAD. The working

parties concerned were: for the Medical Research Council,Dr. 0. G. EDHOLM, Dr. LEITHEAD, Colonel R. L. MARKS,Surgeon Captain S. MILES, Air Commodore W. P. STAMM,Dr. J. S. WEINER, and Dr. P. J. CHAPMAN; for the NationalResearch Council, Prof. C. P. YAGLOU, Dr. H. S. BELDING,Dr. S. M. HORVATH, Dr. H. L. LEY, Dr. A. H. WOODCOCK,Dr. L. P. HERRINGTON, Dr. W. F. LEINARD, Dr. S. ROBINSON,and Captain D. MINARD.

The present memorandum results from recent andcoordinated reviews of the subject by working partiesestablished for the purpose, on both sides of the Atlantic.It is published in order that its joint proposals, which willbe put before the committee charged with revision of theLS.C., may be given prior consideration and perhaps trialby interested workers.

CURRENT NOMENCLATURE AND CLASSIFICATION

The main faults of the current classification of disordersdue to heat (to be found in categories N981, 714, and318.3 of the LS.C.) are: (1) the now obsolete term sun-stroke is given as a separate entry from heatstroke; (2) nodistinction is permitted between heat syncope and thevarious forms of heat exhaustion now recognised; (3) adisorder identified in troops during the last world war andnow called anhidrotic heat exhaustion is not included;(4) the effects of heat and of insolation are listed together,and therefore sunburn is included; (5) no allowance ismade for possible psychological effects of heat.

REVISION PROPOSED IN 1958

The working party responsible for the 1958 memoran-dum appears to have been guided by two importantconsiderations: first, that the I. S.C. is concerned less witha nomenclature and classification for everyday use bypractising physicians than with sickness records fromwhich to obtain useful information that may be interpretedin a consistent manner; and second, which follows, thatin any attempt at revision the existing classification andcode numbers should be altered as little as possible. Theproposals which were made were therefore essentially theresult of a compromise between past and present ideas,and as such were not wholly satisfactory; for example, nodistinction could be made between heat syncope and heatexhaustion, the term sunburn was retained, and the vexedquestion of tropical deterioration or fatigue was complicatedrather than resolved.

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PRESENT PROPOSALS

The present joint American and British proposals aresummarised in tables i and 11.The two working parties concerned took the view that

the LS.C. nomenclature and classification, when finallyrevised, should be both practical and comprehensiveenough to meet the various needs of Service and industrialmedicine and general practice, since there would then beno advantage in alternative designs which restricted

application and meaning. While it was recognised that thepresent numbering system in the I.S.C. category N981should be retained as far as possible, it was felt that theclarity of the final proposals should not be sacrificed tothis end.

Both additions and alterations are, therefore, proposed.The alterations require the greater consideration, and areas follows:

Category N981 should be changed from Effects of Heat andInsolation to Effects of Heat; within this category, the numberN981.1, now occupied by sunstroke, should be the number forheat syncope; N981.4, now occupied by sunburn, should be thenumber for anhidrotic heat exhaustion; and N981.5, nowoccupied by heat effects not otherwise specified (tentativelydisplaced to N981.8) should be the number for salt and/orwater depletion.

It is proposed that sunburn should be classified as 703.8 incategory 703 (Other Dermatitis).

Category 714 (Diseases of Sweat and Sebaceous Glands) inwhich anhidrosis and prickly heat are already classified, is itselfin need of revision, and the current proposals on the heatdisorders would be served best if 714 were to read: 714.0,anhidrosis, congenital or acquired; 714.1, prickly heat (with thesynonyms miliaria rubra and heat rash); 714.2, other diseases of

TABLE I-PROPOSALS TOWARDS REVISION OF THE NOMENCLATURE AND

CLASSIFICATION OF THE HEAT DISORDERS

Present category in the International Statistical Classification:N981, Effects of Heat and Insolation; proposed category: N981,Effects of Heat.

* Proposed qualification: " This title excludes Chronic Heat Fatigue (318.6)."

TABLE II-DISORDERS OF HOT CLIMATES OR HEATED PLACES MORE APPRO-

PRIATELY CLASSIFIED ELSEWHERE THAN IN 7..C. CATEGORY N981’

* It is recommended that Sunstroke (synonyms: Ictus Solaris, Insolation,Siriasis, and Thermic Fever), which is classified at present underN981.1, is an obsolete term and should be removed from the I.S.C., orclassified elsewhere than in the category N981.

Proposed qualifications: (1) " Due to insolation " (2) " Congenital oracquired " (3) " This Title excludes Transient Heat Fatigue (N981.6) ".

sweat glands; 714.3, acne; 714.4, other diseases of sebaceous glands.Finally, it is proposed that chronic heat fatigue (tropical

fatigue) should be given the number 318.6, so that, if the termis used at all, this condition will not be classified withneurasthenia and similar states now under 318.3.

DISCUSSION

The disorders included in the proposals were defined,adequately in most cases, in the 1958 memorandum, andhave recently been defined again and described in detail(Leithead 1964); there is therefore no need to define themhere.The practice of grouping together heatstroke and heat

hyperpyrexia (at N981.0) has been endorsed in the

proposals; for, although clinically distinct entities, theyare sufficiently related in aetiology and significance to

merit being classed together in any records system; per-haps the only reason for separating them would be for thepurpose of compensation for industrial injury. Heat

syncope is a circulatory phenomenon at once more commonand less significant than heat exhaustion, from which itsseparation is long overdue. Heat cramps has been retainedbecause this condition presents an industrial problem withdifferent manifestations from the salt-depletion heatexhaustion with muscle cramps seen occasionally in menexposed for days or weeks on end to natural and severeclimatic heat. The unqualified title of heat exhaustion isretained in the knowledge that heat exhaustion will con-tinue to be diagnosed without any distinction as to type.For medical officers capable of a more precise diagnosis,anhidrotic heat exhaustion and salt- and/or water-depletionheat exhaustion both require separate code numbers; acase can be made for separating salt-depletion from water-depletion heat exhaustion, but the members of the workingparties were doubtful if many medical officers could do sowith useful accuracy in field conditions. Heat aedema wasincluded in the proposals because, although seldom ofmuch individual or general concern, it occurs to a varyingdegree on naval and other ships in tropical waters.

Transient heat fatigue was thought to be the best termavailable for the deterioration in performance of skilledtasks, which may be observed during short exposures tohigh environmental temperatures in men free from waterand electrolyte imbalance and thermoregulatory failure;the subject has recently been well reviewed by Bell andProvins (1962). Chronic heat fatigue was accepted as thebest available term for the sensations of inefficiency andvague fatigue described, particularly by expatriateCaucasians, at the end of a summer or tour of duty in thetropics, and it was felt that this condition, if it represents a

639

clinical entity, should be clearly separated from the variousneurasthenic states now grouped under 318.3; the evidencefor psychotic breakdowns attributable solely to heat is

inadequate (Sargent 1963)The members of the working parties wish to thank the authors of

the documents which have been quoted and which were available forconsideration, and they are grateful also for advice and commentsfrom Prof. C. H. Wyndham, Dr. M. E. Barry, Dr. B. A. King, andDr. W. B. Roantree, and Surgeon Captain F. P. Ellis.

REFERENCES

Bell, C. R., Provins, K. A. (1962) Effects of high temperature environmentalconditions on human performance. J. occup. Med. 4, 202.

Ellis, F. P. (1958) Heat illness. J. R. nav. med. Serv. 44, 236.Leithead, C. S. (1964) Disorders Due to Heat. In Heat Stress and Heat

Disorders (by C. S. Leithead and A. R. Lind). London.Manual of the International Statistical Classification of Diseases, Injuries,

and Causes of Death (1957). Geneva: World Health Organisation.Sargent, F. (1963) Tropical neurasthenia: giant or windmill? Reviews of

Research in Physiology and Psychology in Arid Zones. Paris: UNESCO.Stamm, W. P. (1963) Nomenclature and classification of the heat disorders.

Proc. 6th int. Congr. trop. Med., Lisbon, 6, 71.Weiner, J. S., Horne, G. O. (1958) A classification of heat illness (Medical

Research Council Memorandum). Brit. med. J. i, 1533.

Conferences

DRUG TREATMENT IN PSYCHIATRYFROM A CORRESPONDENT

IN just over a decade the introduction of modern

psychoactive drugs has transformed psychiatry. The

challenges and difficulties associated with this period ofradical change were discussed by the 150 clinicians,pharmacologists, and biochemists who attended a sym-posium on the Scientific Basis of Drug Treatment inPsychiatry held at St. Bartholomew’s Hospital, London,on Sept. 7 and 8.

Basic ConceptsThe first of four sessions, under the chairmanship of the

principal organiser Dr. LINFORD REES, began with a paper onthe neuroanatomical basis of emotion, by Dr. H. E. HIMWICH(U.S.A.) who outlined the way in which somatic, visceral, andemotional components were integrated into fully motivatedbehaviour by means of feed-back mechanisms between theneocortex, the limbic system, and reticular formation. The

phylogenetically older parts of the brain in the limbic areasnot only contained large amounts of the neurohormones

(noradrenaline and serotonin) but also were exquisitelysensitive to the modern psychoactive drugs, thus ’providing arational hypothesis to account for their effects on electro-cortical activity and behaviour.Methods of assessing the actions of these drugs in man and

animals were considered next. Although Dr. HANNAHSTEINBERG felt that animal experiments were " intrinsicallyinteresting ", she anticipated the doubts of later speakers whenshe advised caution in extrapolating results to explain humanbehaviour even though the animals’ actions could be super-ficially called " neurotic ". Studies of simpler situations

entailing perception, learning, memory, and performancewere likely to be of greater value, particularly when well-proven experimental methods were employed. Within theselimits valuable information could be obtained on dose relation-ships or individual differences in response. Her own work onexploratory activity in rats had strikingly confirmed the olderclinical observation that mixtures of amphetamine andbarbiturate potentiated each other.The difficulties of clinical assessment and response to drugs

were a recurring theme throughout the symposium. Dr. A. C.TAIT (Dumfries) emphasised the semantic difficulties when hedescribed depression as " a damnable word, meaning all thingsto all psychiatrists ". Prof. KENNETH RAWNSLEY (Cardiff)dwelt on the effects of social environment on drug response,and Prof. ARTHUR SUMMERFIELD mentioned the therapeuticmilieu as well as the influence of instructions to the patient and

the nature of any task used to assess the effects of drugs onperformance. To Dr. JOHN DENHAM (Epsom) the abundanceof variables in each individual made every patient a uniqueexperiment and generalisation an almost impossible task, andDr. B. B. BRODIE (U.S.A.) drew attention to enormous

individual differences in the rates of drug metabolism.These difficulties were reflected in the gross discrepancies

between the results of drug trials which Dr. PETER SAINSBURY(Chichester) described as " voluminous, disperse, and in-conclusive in nearly every aspect ". Individual psychiatrists’opinions of particular drugs ranged from enthusiasm to

nihilism. Chlordiazepoxide (’Librium’), which now consti-tutes a third of American psychiatric prescribing, was describedas

" an almost inert substance, with a striking capsule ". If

these difficulties aroused doubt about the scientific basis of

drug therapy, comfort was drawn from the impressive con-tributions of clinical observation to psychopharmacology. Thevalue of drugs is almost invariably appreciated clinically beforeit is explained pharmacologically, and major side-effectscontinue to elude animal screening-tests. Several speakersacknowledged the debt to serendipity by pointing out that eachof the three major groups of psychiatric drugs was discovered inthis way-chlorpromazine in anxsthesia, iproniazid in tuber-culosis, and imipramine initially a tranquilliser and later anantidepressant.From these beginnings a proliferation of psychoactive drugs

has testified to the commercial exploitation of ignorance, andemphasised the need for refined methods of assessment inorder to discriminate between drugs and to direct futureindustrial research. In the continuing absence of any bio-chemical or physiological measure of correlation with mood,Prof. MAX HAMILTON (Leeds) indicated the best methods ofmeasurement at present available to psychiatrists. Any methodwhich did not test a hypothesis by controlled trial betweenat least two substances was " out of date, uninformative, anddangerous ". Great care was necessary in the selection of

patients. Large heterogeneous groups diminished the accuracyof findings, whereas small selected groups restricted the

application of results to a few similar individuals. The correct,but time-consuming, answer was to replicate experiments indifferent subgroups after defining all the variables and cate-gories which might influence response. Rating-scales providedthe best method of assessing change but required considerabletraining. Analysis of the final scores meant the application ofan appropriate " arithmetical trick ". Difference scores,

analysis of covariance, ratio scores, and the use of levels allhad disadvantages, and choice of method depended on theinformation sought.

TranquillisersIt was generally agreed that none of the drugs used in psy-

chiatry had any fundamental effect on the disease processitself; all acted by suppressing symptoms. Dr. JOHN DENHAMpointed out that phenothiazines could arrest or retard the pro-gress of schizophrenia without either curing it or adding suf-ficiently to the patient’s insight to ensure that he continuedtablets after leaving hospital. Choice of a particular pheno-thiazine was less important than an individual doctor’s famili-arity with one or two compounds. In considering the effects ofphenothiazine structure on function Dr. PETER SAINSBURY

agreed that there were no constant characteristic differences inclinical response, but it was better to use an aliphatic compound(such as chlorpromazine) when agitation was marked and apiperazine side-chain (such as trifluoperazine or ’ Stelazine’) ifthe patient was withdrawn or apathetic.The use of other drugs in schizophrenia was dealt with by

Prof. W. H. TRETHOWAN (Birmingham), who felt that to dowithout phenothiazines was like " fighting with one hand behindthe back ". Endocrine therapy with oestrogens, anabolic ster-oids, and thyroid was discredited, and, though insulin deserveda better epitaph, there was little doubt that its efficacy was dueto the increased attention patients had received. Reserpineanalogues and the butyrophenones (such as ’ Haloperidolwere of some value but gave troublesome side-effects.

Dr. DEREK RICHTER (Carshalton) discussed some theoretical