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When this examination is passed, those graduateswho intend to practise will proceed to the resident yearas outlined, before they can become licensed to practiseindependently. Opinions differ as to whether this licenceshould be granted automatically after the production ofcertificates indicating satisfactory performance of dutiesin the posts held or whether in addition a second examina-tion should be passed. Those who are opposed to thissecond examination hold it to be an unnecessary burdenin a career which already contains enough obstacles forthe student. The report however favours a second ex-amination for the following reasons :- .

(i) A second examination, of a purely practical character,seeking to ensure that the candidate has the know-ledge and experience to be entrusted with the inde-pendent care of patients, will make possible thereform of the first examination and of the clinical

undergraduate curriculum.. (ii) The examination will act as a check on the suitability

or otherwise of hospitals providing house appointmentsduring the resident year. It will thus act as a leverto raise the general level of hospital status in thecountry.

The report is signed by Lord Moran (chairman), Dr.H. E. A. Boldero, Prof. Henry Cohen, Dr. J. St. C. Elkington,Prof. H. P. Himsworth, Dr. Charles Newman, Prof. G. W.Pickering (secretary), Dr. J. H. Sheldon, Prof. J. C. Spence,and Sir Henry Tidy.

Special Articles

REHABILITATION IN THE RAFA NEW CONCEPT OF ORDINARY MEDICINE AND SURGERY

It has taken the tragedies of a violent war to stimulate thedevelopment of rehabilitation--and mark you that’s one ofthe few consolations of war;-it has always stimulated theprogress of medicine. But although the importance ofrehabilitation is only now being recognised, the principlewas first taught over 2000 years ago. If you look up thewritings of Plato you will find it: " This is the greatestfault in the treatment of sickness-that there are physiciansfor the body and physicians for the soul-and yet the twoare one and indivisible." (Conclusion of a broadcast byR. Watson-Jones.)

REHABILITATION means much more than simplegymnastics and physical exercise. Recent press pub-licity has unduly emphasised the physical aspect becauseonly this lends itself to illustration. Rehabilitationis not gymnastics alone. It is n6t physical medicine.It is not a new treatment ; certainly not somethingwhich can be purveyed in mobile vans. It is a newconcept of ordinary surgery and medicine, and it includesphysical, psychological and social measures. In ortho-paedic hospitals it has been practised for many yearsin its fullest sense. It has meant continuing treatmentlong after the conclusion of surgical operations, untilfunctional recovery is as complete as possible ; supple-menting surgical measures by active exercises, teaching thepatient to walk, correcting his limp, and so on ; usingrecreational. and educational diversions ; teaching newtrades to those with permanent disability; securingresettlement in industry and, equally important, re-

settlement in the whole life of the community. Althoughgenerally applied in orthopaedic cases of crippling anddisease it was not used in fracture treatment except fora limited period during the last war in the remedialworkshops devised by Sir Robert Jones. It was H. E.More of Crewe who developed the first rehabilitationcentre for industrial injuries in England. With anaverage of only 3 weeks treatment, in a simple gym-nasium, he returned to work 80% of LMS employeeswho had been off work through injury for months oryears. Ten years ago the BMA Fracture Committeeadopted plans which R. WATSON-JoNES had prepared inLiverpool and advocated rehabilitation services andspecial residential rehabilitation centres for all fractureand accident cases. ALEX. MILLER of Glasgow developedthe social service aspect of rehabilitation in the miners ofLanarkshire and had considerable success in a day today, or even once a week, clinic. H. E. GRIFFITHSorganised a non-residential centre at the DreadnoughtHospital, Greenwich ; and E. A. NICOLL a residentialcentre for miners at Mansfield. But in general the

hospital patient with a fracture continued to be dis-charged as soon as his fracture was healed, to rehabili-tate himself as best he could at home, with or withoutthe help of the massage department.

A COMPREHENSIVE SERVICE

The first complete rehabilitation service in this countrywas started by the RAF medical service within a fewmonths of the outbreak of the present war, basedexactly on the plans adopted by the BMA committeein 1935. Since then we have seen the development ofrehabilitation centres for the Army, the Ministry ofHealth centres for EMS patients, and those of theMiners’ Welfare Commission, centres which have inspiredvisiting surgeons from Australia, Canada and the UnitedStates to build up similar organisations in their owncountries.The RAF service was designed to deal net simply

with air-crews but with electricians, engineers, mechanicsand skilled technicians of all trades. To serve thepatients of thirty RAF hospitals, and members of theRAF who had been treated in the early stages in civilianHospitals, twelve orthopaedic, centres were establishedfor the segregation of fractures, wounds, limb and spinalinjuries. In every accident ward in these centres anurse, masseuse or nursing orderly was selected andtrained as the rehabilitation orderly whose sole duty’wasinstruction in early exercise, supervision of exercisesat regular intervals, preparation of special casts and-traction devices for stiff and contracted joints, andgeneral diversional therapy. Special exercises are per-formed hourly ; general exercises, respiratory exerciseand PT in bed are performed daily. Each orthopaedicceptre has its own small rehabilitation centre within afew miles, for interim rehabilitation of long-stay plastercases which return to hospital from time to time, staffedby masseuses, gymnasts and rehabilitation orderlies, °and visited once or twice a week by the orthopaedicsurgeon. All orthopaedic centres are served by fourmajor rehabilitation centres : one for air-crews, one forskilled technicians, one tor omcers ana one tor groundstaffs-in which treatment is continued until the patientreturns to duty. The centres are residential and includeplaying-fields, swimming-pools and gymnasiums withintercommunicating physiotherapy-rooms ; concert-halls, lecture-rooms and recreation-rooms ; plaster-room, X-ray and minor theatre for dressings and mani- Bpulations ; but no other hospital equipment. Thestaff includes masseuses, occupational therapists, physicaltraining instructors, gymnasts, clinical secretary andone orthopaedic surgeon to every 50-100 patients.

In the early stages there is close surgical supervision ;only in the latest stages of final hardening are groupexercises supervised by physical training instructorsContinuity of treatment is assured, because surgeons inthe rehabilitation centres aud in the orthopaedic centresare members of the same team, often interchangingduties, and assisted by the same two consultants. Thesame clinical record with typed notes, X rays and photo-graphs accompanies the patient from orthopaedic centreto rehabilitation centre and when necessary back toorthopaedic centre. Gymnastics, special exercises, recrea-tions, swimming and games are continued throughouta six-hour day, and in the evenings lectures, conperts,dancing and other indoor recreations are continued.From an early stage of treatment patients are re-trainedin their own duty. While still in plaster they attendwireless refresher courses and are given tuition in navi-gation, Link trainer flying, air-craft recognition andgunnery. This is their occupational therapy ; as surgicaltreatment is nearing completion it is intensified, andby the time they are discharged to duty they are noless skilled and up to date than men who have never-been injured.

Functional and emotional problems are pliminated byintimate doctor-patient relationship throughout allstages of treatment. At no stage is one medical officer-expected to supervise the treatment of 500 or 1000 men.-Individual handling is the keynote. A limp is neverallowed to develop from the day the man gets out of bed.. ,

Undue caution is dispelled by encouragement and per-suasion ; fear is eliminated by explanation ; lethargyand indolence are dismissed by firmness and example ;..

enthusiasm and optimism are encouraged by the jealously

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guarded spirit which is the secret of success There is nohappier community in the world than that of patients.recovering from injury in a properly conducted rehabili-tation centre. ’

Problems of resettlement are considered individuallywhile patients are still under treatment in the rehabilita-tion centres. The patients who cannot be made fit f<M*full duty are .re-trained for new jobs. When disabilityis of long standing and a, period of sheltered occupationis necessary, selected worl: is found for them through theMinistry of Aircraft Production, or in factories, on

farms or with the RAF sea-rescue squads. Thesepatients are examined by the orthopaedic surgeons atmonthly or three monthly intervals.

RECORDS AND RESULTS

For every patient there is a continuous record of earlytreatment in orthopaedic centre, interim treatment inminor rehabilitation centre, and later, treatment in majorrehabilitation centres, and in every case this dossier is

finally referred for inspection and filing by the surgeonwho began the treatment. An analysis is also made ofthe patients in rehabilitation centres, and classifiedrecorcts are now available of many thousands of bone andjoint injuries showing the exact nature of the originaldisability, the total incapacity period, the duration oftreatment in rehabilitation centre, and the final resultand disposal. The figures show what a; success thisRAF organisation has proved. Despite the frequencyof severe and multiple injuries with gross contamination,WATSOrr-Jorms can report that less than 5% are in-valided. In one series of 15,000 compound and closedfractures there - were no cases of non-union and anamputation rate of 1 in 1000. Of air-crew memberswith major injuries, 85% regained a flying category, anda follow-up showed that 822% resumed operationaland flying duties.

1. Watson-Jones, R. Fractures and Joint Injuries, Edinburgh,1943, vol. II, p. 875.

FOODIN BRITAIN AND NORTH AMERICA

Two years ago Mr. Roosevelt and Mr. Churchill jointlydeclared that " in principle, the entire food resources ofGreat Britain and the United States will be deemed to bea common pool." An inquiry has accordingly been madeinto the consumption of food by civilians in the twocountries and in Canada.

Fig. 1, taken from the report,! shows that in 1943 theUSA had the highest level of supplies for all food groupsexcept grain products, potatoes and vegetables. 1.1should be noted, however, that the calculations are basedonly on the total amounts of food moving into consump-tion in each country and the number of people to be fed.They take no account of wastage in preparation and

1. Food Consumption Levels in the United States, Canada and theUnited Kingdom. London: HM Stationery Offlce. 1944.2s. Popular edition : What do they Eat in the United States,Canada and Britain Today ? 3 3d.

cooking, which will naturally be less in countries wherescarcity has made consumers more careful.

In calculating whether there is enough food for every-one, attention must also be paid to its distribution : for ifone section of the community can acquire more than itsshare of eggs, milk or fish, the share of others will besmaller than the national average figure suggests.Thus* before the war the food-supplies of Great Britainprovided about 3000 calories per head per day, whichwas more than enough for all. But its distribution wassuch that many people suffered from malnutrition.The margin’ that must be allowed to cover unequal

distribution and wastage varies according to rationingand control and is not easily determined. But ex-perience affords useful information. Thus early in 1941food-supplies in this country provided less than 2700calories per head per day, and " although rationing waswell established, there were indications of impaired healthand working efficiency." Since then, thanks largely toLend Lease, the level has ben remarkably constant at

Fig. I-Supplies moving into civilian consumption in 1943. (Consumptionper head in Canada and United Kingdom shown as percentages of theUnited States.)

Fig. 2-Percentage change in 1943 compared with prewar period.

rather over 2800 calories, whichappears to be sufficient. In otherwords, under existing conditions ofrationing and control, 2800 isenough but 2700 is not. Assumingthat all the adults of the countryare " moderately active," the phy-siologist would put the averagerequirement for the British popu-lation at about 2550 calories, andthis suggests that a national supplylevel of 2800 calories allows amargin of 250 calories per head tocover wastage and maldistribution." In the present circumstances

further appreciable changes of anunfavourable character in the UnitedKingdom diet would give rise to

apprehension about their possibleeffects on the work, output, healthand morale of the civilian popula-tion."

Similar margins are also neededfor nutrients. Judged by thegenerous " recommended dietaryallowances " of the United StatesNational Research Council, currentsupplies are deficient in some re-spects : on this scale Canadacertainly has not enough ascorbicacid and the USA probably hasnot enough ; while Britain is prob-ably short of ascorbic acid andvitamin A, and in all three coun-tries there are possible deficienciesof riboflavin and thiamin. Butapart from ascorbic acid in Canada,the quantities available (if properlydistributed) are believed to meetnutritional requirements on arestricted basis. " So far as vitaminsand minerals are concerned, the