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and his staff so that no-one has an excess of N.11.8.routine and everyone has adequate time for academicuniversity work of teaching and research. In fact theman who pleads hard lines is worthy, in universityterms, of salary deprivation rather than increases.

There is, of course, the strongest possible case forequality of university salaries in all faculties: eachman is an authority in his own subject, more he cannotbe : Lascelles Abercrombie, Gilbert Murray, Sherrington,Osler, Hopkins, Le Gros Clark, Rutherford, Robinson,are equals, not interchangeables.

’

The problem before the University Grants Committeeto which Professor Dible refers is the problem of rewardfor extramural work in the N.H.S., when encroachingon university time and duties, and also the problemof maintenance of a qualified university staff in thefaculty of medicine when they are attracted by outsideinterests of guaranteed high salaries without theadventure and gamble of free-lance business. Thisof course exists in other faculties.

St. Mary’s Hospital MedicalSchool, London, W.2.

A. ST. G. HUGGETT.

SiR,-Professor Dible raises important and controversialpoints, but does little to suggest a solution. A possibleconclusion to be drawn from his article is that theuniversities should have little if anything to do withthe health service-that no possible benefit could accrueto them. Surely this is a defeatist attitude, which froma purely practical point of view could only be consideredin the case of such subjects as pathology and bacteriology.It is hard to believe he advocates that the professors ofmedicine, paediatrics, surgery, obstetrics, and psychiatryshould do no clinical work in their own field. That wouldherald a return to the medicine of the Middle Ages-a barrier of suspicion between the academic and thepractising man. ’Those of us who recently served in theForces discovered that the ideas of the laboratory aredifficult to transmit to the man in the field and vice versa.With rare exceptions such transmission is successfullydone only by a man experienced and active in bothfields. This is equally true of civilian medicine.

In the past the professors and many of non-professorialrank in clinical subjects have been members of hospitalstaffs. Under the National Health Service the funda-mental difference is that the Minister of Health and hisScottish counterpart have decided that those under-taking hospital work should be paid for it. The paymentfor hospital work does not mean that the person paidmust undertake more hospital work than he did in thepast, or serve on innumerable committees. The opinionor advice of a laboratory worker or clinician will oftenba of value to committees, but this surely does not meanthat the only possible person to give such help is theprofessor. The wise professor would delegate some ofhis authority so that he did not become overburdenedby routine clinical work or attendance at committees.Mr. Churchill in his conduct of the recent war showedhow superbly this could be done.

Professor Dible is on sure ground when he states thatexcessive administrative appointments are productiveof verbiage in the form of long memoranda and reports.Associated with this is the excessive use of standingcommittees. For example, in the Act provision is madefor each region to set up a medical education committee.In the regions based on a university this would be aduplication of a committee already in existence-themedical faculty, whose chief if not only concern is medicaleducation. It is probable that other duplication mayoccur, and in that case the universities might well suggesthow some existing committee could fulfil a dual function.

Leaving aside the financial problems which have

already received much publicity, there are many ways inwhich the universities and hospitals can benefit by aclose linkage and mutual sharing of staff. Sir WilliamOsler believed in a quinquennial brain-dusting ; andthere is provision for this in some at least of the temporarycontracts issued by regional boards. It is up to theuniversities to see that their staffs have such a brain-dusting, and up to the professors to see that they are notso overburdened with routine as to have no time forreflection and experiment. This is no time to shrinkfrom responsibility, and provided the universities areever on the alert there seems no reason why they should

not cooperate in every possible way with the regionalhospital boards to keep British medicine in the forefrontof world medicine.Medical School, Dundee. JOHN GRIEVE.

THE GENERAL PRACTITIONER

SiR,—May I say a word about the plight of thewould-be general practitioner ? In order to start his

practice he must obtain two things-a house and theconsent of the local executive council. If he managesto obtain a house he has to sit and wait for the decisionof the executive council. This may take up to 3 monthsor more, and only when the word " go

" arrives can heput up his plate and prepare to receive patients. Hisfirst cheque appears at the end of the quarter, whichmeans that 4-6 months have elapsed before any incomeis obtained. Judging from the comments of establishedgeneral practitioners, this cheque will probably payone month’s rent on his new house.

Suppose, on the other hand, that after the 3 months’wait the executive council refuse to permit him topractise. He appeals to the Minister, who upholds thecouncil’s decision. So at the end of, say, 4 months ourhero-for that is what I think we must call him now-finds himself still unemployed, with a house he does notnow want and the prospect of going through the entireprocedure again in another district.The only work for which a general practitioner is

suited is general practice. If this is denied him he mustremain not only unemployed but also-and especially ifhe -is over 35-unemployable. Assistantships postponebut do not solve the problem. Incidentally the time-interval of 3 months may be an underestimate. I haveso far waited almost 14 weeks, and my letter of inquiryto the executive council written 5 days ago has not yetproduced a reply.

I suggest the solution is to be found in the penultimateparagraph of your leading article of Dec. 4-namely,an increase in the capitation fee and limitation of doctors’lists to provide more openings for new entrants topractice. This would enable executive councils to arriveat a decision after somewhat less lengthy deliberations.

London, N.W.10. DANIEL FELDMAN.

YOUNG SPECIALISTS IN SEARCH OF A JOB

SIR,-" The need is twofold, more specialists and a,

better distribution of them." So said the white-paperwhich preceded the publication of the National HealthService Bill. The Hospital Survey (Sheffield and EastMidlands Area) published in 1945 got down to details :

" One of the most striking points arising from our surveyis the inadequacy of the numbers of available consultants.In Sheffield, not only is the number of consultants toosmall for the town itself, but the problem is made evenmore difficult because these consultants visit a large numberof hospitals within a radius of twenty miles and cannot byreason of their numbers give the desirable amount ofattention to all."

The same report explained why there were too fewspecialists :

" The number of consultants in any area has necessarilybeen determined hitherto by the amount of available privateconsulting practice by which they live."

Its conclusion for this region was :" In general terms it may be said that consultant staffs

could be at least doubled and there is especial need forphysicians and the adequate development of’ medicine.’

"

The Hospital Surveys for the other regions came tosimilar conclusions.

Since July 5 the number of advertised appointmentsfor whole-time or nearly whole-time surgeons andphysicians has been disappointingly small. In spite ofassiduously studying the advertisements in THE LANCET,I have noticed orily one vacancy for a surgeon and onefor a physician in this region since July 5. Surely it istime that some sort of establishment programme wasformulated, preferably centrally and right away fromany possible local " interests." It might be decided,for example, that the normal establishment should beapproximately one full-time surgeon and one full-timephysician for every 40,000 of the population. The

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regional hospital boards and boards of governors shouldthen be asked to staff up to this level as quickly as possibleand thus help to remedy the obvious defects in the

’ specialist services so clearly revealed by the hospitalsurveys. CRITIC.

MULTIPLE ABDOMINAL CATASTROPHES

SIR,-I should like to congratulate Mr. Glaser on thesuccessful result in the case described in your issue ofNov. 27. Both the patient and the surgeon must havehad great courage and staying power.

I was particularly interested in his method of dealingwith intestinal fistulae by a dressing with adequate protein,carbohydrate, and fat so as to use up the enzymes in thesuccus entericus and thus prevent the skin becomingsore. I have not used this method myself but certainlyintend to try it on a case under my care at present.I would strongly recommend, however, the use of con-tinuous suction for treating intestinal nstulse. Anapparatus can quite easily be set up so that the intestinalcontents are immediately sucked away and no appreci-able quantity of them remains in contact with the skin.Should Mr. Glaser have another case of intestinal fistulaI would suggest that he should combine suction withhis method of dressing. The frequent renewals of thedressing to which he refers would not be necessary ifsuction were used, since the bulk of the fluid would besucked away.London, W.I. JOHN HOSFORD.

CANCER AND RADIOGRAPHIC MUSEUMS

SIR,-Much of the ignorance among general practi-tioners about the possibilities of radiography is due tothere being no place where a fully representative collec-tion of radiographs can be viewed. When the G.P.

knows what is suitable for this form of diagnosis, theradiologist will have far less unsuitable material to dealwith.Many hospitals have museums, but these are one-sided,

containing films only. The chief object (as yet unattained)of my book A Descriptive Atlas of Radiographs was theestablishment of such museums. So far as I am aware,none such exists anywhere in the world, the nearestapproach being the Wellcome Museum of MedicalScience, Euston Road, London, W.C., where radiographsare given the necessary background of clinical notes,

DRUM MOUNTED ON TRESTLE

specimens, photographs, and microscopical slides. Yetthis does not profess to be a radiographic museum.The ideal radiographic museum would be a place where

the common, and therefore important, diseases are

depicted. Rarities, save congenital ones, would beshown sparingly. The museum should show routineradiographs since these are the ones which the G.P.

encounters ; perfect radiographs defeat their object.Films alone should be used in making the original diag-nosis, since there is considerable loss in definition inmaking the print-e.g., loss of skin contour, necessitatingsilhouette process. But the fact remains that the G.P.likes to see bones and opaque meals as opacities ratherthan radiolucencies. The ordinary photographic film isa poor thing compared with the print. Prints are mucheasier to display than negatives, which require viewing-boxes for their display. Reduced prints are a necessityowing to the small amount of space available. Theyare quite satisfactory ; unlike publishers’ blocks theyshow a minimum loss of definition and may, withadvantage, be magnified with a lens.A hall at least 60 by 40 ft. is required ; and even

then special features have to be adopted so that allthe pictures may be at eye level. The first essential isthe provision of " photoboards " consisting of sheetsof three-ply wood or of duralumin 5 ft. square hungfrom roof girders 10 ft. high. These boards have ledgesto take half-plate reductions ; each board accommodatestwelve horizontal rows of 8 half-plate radiographs,making 96 for each side. Thus 15 photoboards wouldaccommodate nearly 3000 radiographs. The prints aremounted on aluminium sheets, a layer of paper separatingthe print from the metal, the whole being bound bypasse-partout, with a tag permitting easy removal.Mounted on ledges, each could be taken out easily forcloser inspection. They would be slung at right anglesto the room so as to form bays each lighted by a verticalwindow. The window sills would be used to housespecimen-jars, models, &c., appertaining to the radio-graphs. A chain (thrown over the roof girder) wouldpermit the board to be raised or lowered so that thepictures could be seen at eye level.A knowledge of the normal is imperative ; therefore

radiographs of such are mounted on photoboards andplaced on an easel.’ The easel consists of two stoutuprights secured on a 3-ft. base with metal stays orheavy timber. Two photoboards are slung from the topbar so as to counterbalance one another. They resemblea guillotine, the boards being the knife, moving upwardsand downwards so that the radiograph under examinationis at eye level ; guides are provided to keep them straight.If the easel is likely to be moved from room to room,the uprights are cut in the middle and fitted with hingesand long bolts. By using both sides of the photoboardsnearly 400 reduced prints can be displayed.Another means of displaying the normal is on a hexa-

gonal or octagonal roller, such as shops use for picturepostcards, but lying on its side with its axle supportedon a 5-ft. trestle. Such a drum, 5 ft. long, wouldaccommodate 48 or 64 reduced prints. (I am gratefulto Mr. R. E. S. Ramsay, D.A., for preparing these scaledrawings and for useful suggestions.)The inclusion of the name " cancer " in the title of

these museums should aid in their financing. A specialcancer section would be devoted to pictures and speci-mens of skin cancers and the results of treatment.Internal cancers would take their place in the mainbody of the collection of radiographs.A historical section would show types of early appara-

tus. It is surprising how this apparatus is being forgottenin the mass of beautiful apparatus being turned out bythe manufacturers.A canteen at first sight appears to be ridiculously

unimportant, but this is not so. Often more knowledgeis shared over a quiet cup of tea than is gained from alecture. Hospitals providing tea are more patronised bypostgraduate students than others which do not.

Conclusion.-The creation of radiographic museums atthe teaching hospitals is urgent. For smaller hospitals,often giving much postgraduate teaching, they wouldform useful centres of culture where men could meetand where lectures or, rather, discussions could take place.

Maxwelltown, Dumfries. A. P. BERTWISTLE.