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routine. The newly diagnosed consumptive has a difficultphase of psychological adjustment to his disease, andone of the most important aspects of his managementcomprises wise and helpful guidance through this stage.Admission to sanatorium or hospital and contact withother patients or staff familiar with the new mode oflife, may, (or may not!) help a great deal in attainingthe necessary reorientation. A retreat is provided fromthe problems of everyday life which is of real therapeuticvalue in some instances. On the other hand, a patientcan benefit greatly from the satisfaction of a loyalfamily rallying to his succour, and the determination torecover may be better fostered in such an atmosphere.It is a very real criticism of the present tendency to retainpatients in sanatoria for many months that such pro-longed segregation from the realities of life may engendera sense of lost social security on discharge. Such a

dependent outlook on life readily leads to hypochon-driasis, family disagreements, and a fear of resumingwork, all of which detract substantially from the benefitof successful treatment for the purely organic aspect ofthe illness.

* * *

It should be a sobering thought for every tuberculosisphysician that if a quarter of the treatable cases he

diagnoses (a conservative estimate) could adequatelyhave three-quarters of their treatment at home, sana-torium waiting-lists would disappear and a bed would beimmediately available for every patient whose illness

required it. It is well for us to remember the end, aswell as the beginning, of Hippocrates’s famous aphorism :

" It is the duty of the physician not only to do thatwhich immediately behoves him, but to secure the coäpera-tion of the sick, of those in attendance, and all externalagents."

NEW HEALTH DIRECTOR IN NEW ZEALAND

FROM OUR NEW ZEALAND CORRESPONDENT

THE impending retirement on superannuation of Dr.T. R. Ritchie, who has been director-general of health forthree years in succession to Dr. M. H. Watt, has led tothe designation as his successor of Dr. John Cairney bythe Public Service Commission. The appointment is

subject to the usual public service appeals. The com-mission was advised by a special committee consistingof Sir Charles Hercus, Dr. E. H. M. Luke, Mr. DouglasRobb, and Mr. P. E. Stainton.

Dr. Cairney, who is 51 years of age, is at presentmedical superintendent-in-chief to the Wellington Hos-pital Board, in whose service he has been since 1936.

Previously lie was medical superintendent of Hawera

Hospital, and still earlier, demonstrator, lecturer, andfinally associate professor of anatomy in the Otagomedical school. He thus approaches his new task withfull experience-and a great reputation-in the hospitalfield. This is recognised as at once the largest fieldwithin the department’s duties, and the one requiringmost attention. For years the machinery has been

creaking, and coordination between the department andthe local boards has been inadequate.

Dr. Cairney faces a formidable task. Not only thehospital system but also the hygiene work throughoutthe country needs improved conditions and organisation.In addition there has never yet been set up a structureto handle the numerous and important matters arisingout of social-security legislation in New Zealand-nowalmost ten years old. His plans, therefore, will befollowed with interest and hope by many. He has a

great opportunity for achievement, and he has the

general good will of the profession and the publicbehind him.

In England NowA Running Commentary by Peripatetic CorrespondentsTHE doctor on the telephone was worried. " I’m sure

they must come in ; they’re not unconscious but they’reataxic, talking rubbish at the top of their voices, andquite uncontrollable." They were admitted as emer-gencies-two nice little boys, brothers, of eight and ten.When the H.P. saw them their condition had changed toextreme somnolence. There was no doubt about theirprevious condition, however, for their father gave agood history, summing up by saying, " Of course I knowit couldn’t be, doctor, because they’ve never even

tasted it, but it seemed just as though they weredrunk."Further inquiry established that an hour before their

illness started the district nurse had given them both aninfusion of quassia enema for threadworms. It seemedinnocuous enough; but our H.P. pursued the subject andfound that there are two infusions of quassia-onecontaining alcohol. The chemist dispensing the infusionhadn’t known what it was for, the doctor hadn’t specifiedwhich (did you know there were two ?), so they reallywere under the influence. They were much better nextday, though they had rather a morning-after look aboutthem, and we all felt a little sorry that they hadn’t evenhad the pleasure of drinking the stuff.

Perhaps there is compensation in being the first tohave this complication of threadworms, and perhaps thefirst to become drunk per rectum. But were they drunk ?Or does the term imply that the- alcohol was swallowed?

I must find out, too, what happened to the threadworms* * *

Thank goodness that the oral examinations for theG.N.C. " Prelim " are to be abolished. I am convinced thatthe fee I earn for examining in them does not compensatefor the disruption of my ordinary medical work, the travel-ling, the living in hotels, the physical strain of beingimmobilised on a (usually) hard seat for several hours oilend (so to speak), and the mental strain of trying to coaxanswers from unresponsive candidates. And it is astonish-ing how unresponsive many of them can be. At one time Iused to think this shortcoming was due to large classes orindifferent teaching, but now I am sure that the inabilityof candidates to satisfy the examiners (and some aresatisfied with little) is due to lack of concentration on,and interest in, the subjects to be studied. How elsecan one explain such staggering errors as " the femurhas an atmospherical head " ; " the anus is guarded bya spinster " ; " the cows are examined by a tuberculousveteran " ; and " one of the pigments is called bileyvirgin." In some years of teaching experience I havefound only a mere handful of nurses who lacked thenecessary intelligence to pass the Prelim. These can beexcused. The real heart-breaking failures are the oneswho could do well, but who " couldn’t care less."Only twice have I had candidates who scored no

marks at all in anatomy and physiology, though in allfairness I should add that one of them correctly identifieda large and life-like model of the human eye. The restwas silence and darkness over all.The following conversation, which took place in a

recent " oral," is a good example of cruelty to examiners.Me: .- "What germs might be found in contaminated

water ? "

Candidate (after deep thought) : *’ bacteria."Aft : " Well then, what bacteria might be found &c., &c. ?"Cayzdidate : " Miero-organisms."Me (determined to see this through) : Well, what micro-

organisms, &c., &c. ?"Candidate (triumphantly) : " Germs ! "

This is where I came in, I thought, as I passed her overto my colleague-a gentle middle-aged lady-who wassoon informed that to pasteurise milk " you boil it at105° to kill the bacteria," but with commendablerestraint she did not fall into the trap by asking " whatbacteria."As a welcome relief from the girl (the G.N.C. says we

must not say " nurse ") who does not know the ischial

tuberosity from the olecranon, comes the rare and

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brilliant-shall I say ?-" examinee." This type can berecognised in thirty seconds. The thing to do then isto frame a question requiring a lengthy answer, such as" Describe the gastro-intestinal tract." The wearyexaminer can then snatch four minutes’ complete relaxa-tion and be fighting fit when the bell goes for the nextcandidate. I was amazed when one such nurse (I meanexaminee), asked to describe the formation of urine,gushed out, " Oh, I’m so glad you asked me that !I’ve been willing you to do it." Shades of the Piddingtons!She was a bonny girl (and I don’t mean examinee), andthough I stuck strictly to the syllabus she was blushingwhen she went out. I wonder if there is anything in thisthought-transference business ?The grounds of the hospitals where the examinations

are being held are plentifully signposted with the word" To the State Examination," complete with little arrow.It has happened that outpatients have been misled inthis way, and have presented themselves for examinationat the Prelim room. One old lady, indignant and voluble,was heard to demand a private examination. ’’ Nobody’sgoing to State examine me," she shouted, as she wasled away to the proper place.

I am always grateful to the sister tutors and hospitalstaff who so ably cope with the steady flow of candidatesand ply the wilting examiners with frequent cups of tea.They too must be glad when the bell goes for the lastround, and the examiners fold up their papers and stealaway, leaving the hospital to the comparative peaceof its normal routine.

* * *

A fine sense of exhilaration possessed us four booncompanions as we ambled along through East Angliain the crisp clear November air. Crowded surgeries,certificates, and " bob prescriptions

" mattered not atall. Soon, but not too soon, we had thirsts and appetitesbecoming English gentlemen and were glad when wehappened on a goodly hostelry. As we filed into the cosyspotless dining-room a big log fire in a Gothic archedbrick fireplace gave a more than friendly welcome, andthe menu-mushroom soup, jugged hare with red-currantjelly, biscuits and Stilton cheese-and a pint of localcider bespoke a gracious meal. Looking around for thewaiter to take the order, we became aware that there wasno servery to the dining-room but only two entrancesrespectively marked Ladies and Gentlemen. In answerto the bell an immaculate waiter emerged through theGentlenten (fair enough ). Having placed the order wewould wash our hands ; still one of the graces beforemeat. We opened our door and discovered

" It " immedi-ately through a door to the right, while the kitchen andservery occupied the opposite wall beyond. On the jobwe chuckled, rather self-consciously I admit, for we wellrealised that our D.P.H. was now rather shabby andoutmoded, derived as it had been by way of miasmas,epidemiology, and sanitary science, whereas this is theera of positive health, gerontology, and social medicine.Chadwick rather than Ryle was our mentor. When wereturned to the dining-room the most venturesomemember of the party could not resist the impulse toopen the Ladies, but, confronted only by a flight of stairs,the ready words " Sorry, Sir " died on his lips. There-after followed a merry lunch during which all agreedthat the English hostelry still retains an indefinableatmosphere. Quite by accident we had enriched ourspeech by a new idiom. And so, after the port and coffee(if your panel cheque still permits such hospitality toyour friends) : " Before we join the ladies, would any ofyou gentlemen like to see the kitchen ? "

* * *

They’d all gone and I was propping up Miss JoannaWalker’s R.G.50 against the ashtray when the waiting-room door opened and in he popped, the grocer’s lad.A simpleton, so ’twas said. "Do ee treat they LandGirls at Moor House ? " he asked. " Yes, why ? "" Do ee know Daisy ? " " Daisy who ? What’s hersurname ? " "That be what I want to find out."" Why 2 " (I didn’t like the sound of this. The usualtrouble I shouldn’t wonder.) " ’Cos I want to send ’era postcard." I was sorry I couldn’t oblige. But I musttell Daisy she has a smart lad as an admirer.

Letters to the Editor

REHABILITATION

SiR,—Rehabilitation is a popular word today ; butto most of us it remains no more than a word tacked onto the trilogy of Diagnosis, Prognosis, and Treatment.It should mean much more to every doctor practisingclinical medicine. Despite our excellent schools of

physiotherapy, it is still only too common to meet andhear of patients whose invalidism is increased becausedoctors ignore the principles of rehabilitation.

In a recent lecture, Dr. Howard Rusk, of New York,emphasised that the first aim of rehabilitation should beto make the patient independent. This may seemobvious, but unless we devote more time and work tomaking sure that each patient is helped to use his

remaining powers fully and imaginatively, it cannot beachieved. Our aim must be to concentrate on details ofthe care of patients which will enable them to lead anindependent and profitable life with minimum disability.When this aim is realised, perhaps one will not find in atop-floor room a young recent hemiplegic, with a reason-able prognosis for life, attending a London teachinghospital for electrical treatment, who has had no re-educa-tion in walking or speaking, whose joints are stiff, andwho has never been given a stick to help him walk.Perhaps then one will not meet an adult who has latelyhad poliomyelitis, leaving him with an extensive trunkweakness, whose only treatment in an orthopaedic hospitalwas a weekly communal-exercise class and who was

discharged more or less straight from bed with no trunksupport, no aftercare suggestions, and no introduction tothe difficulties of resuming life at home. Perhaps thenone will not read in your disability series of a doctor witha minimal spinal fracture having no physiotherapy andbeing quite unnecessarily confined to bed and an

invalid’s life for some months.It is not only in such orthopaedic cases that rehabilita-

tion can help the individual and the community. For

example, instruction in simple abdominal exercises andpostural exercises can remove the need for thousands ofspecially prescribed corsets ; perineal exercises afterdelivery can restore the normal function of the pelvicfloor, and save much misery. The list is long. The lessonit teaches is that it is a doctor’s responsibility to teachhis patients how to help themselves. Where patientshave the good fortune to be cared for by enlighteneddoctors -and good physiotherapists, their whole outlookis altered and their prognosis for effective recoveryimmeasurably improved. We must have more contactwith our patients. Today I believe there is a temptationand a tendency to leave the patient’s side and study the --

problem from afar.Rehabilitation calls for the direct relationship-the

human touch and the infectious determination which willanimate patients and society and convince them thatrestoration of function for big and little disabilities isworth doing and can be done.London, N.2. JEAN LAWRIE.

THE DISTINCTION AWARDS

SiR,-Dr. Walshe says that " To allow governmentto be our principal paymaster is one thing, but it is

quite another to permit it to impose upon us a crude,arithmetical classification of all those imponderables thatmake up true distinction in our profession." But arewe doing so ? ’? If we look objectively at the proposedterms, a part-time consultant, professionally assessed,will earn from the Government by doing hospital sessionspaid at a rate based on representations made by theprofession to the independent Spens Committee. He willearn also by domiciliary work according to his meritin the eyes of general practitioners. To this may be