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reconsidered. Dr. Fry sees the outpatient departmentsfilling three main roles-that of consultation centre, thatof diagnostic centre, and that of supplying specialinvestigations and treatment.

Dr. Emslie emphasised that outpatient work shouldinclude radiological and pathological investigations; andthe almoner service is another important element. Dr.Fry pointed out there is considerable variation betweengeneral practitioners in the number of patients they referto consultants. Do these differences depend, he asked, onindividual factors such as the doctor’s age, his education,the size of his list, or his family responsibilities ? Thediscussion showed that we really need to know more of themedical, social, and other factors that may influencereferral. The average family doctor refers to the con-sultant in hospital only some 10% of his cases; but whereradiological and pathological facilities are afforded to

general practitioners these facilities are extensively used.Fry himself, out of about 5000 patients at risk in any oneyear, refers 450 to a consultant, either as outpatients or asinpatients, and a further 320 directly to the radiologicaldepartment and 375 to the pathological department.There is no doubt that the use of outpatient depart-

ments will increase in the future; and it seems sensible tofoster this increase by devoting capital money to the con-struction or extension of these departments. Allowancewill have to be made for further special facilities-includ-ing provision for electrocardiographic examinations andinvestigations with radioactive isotopes. In time the out-

patient department may establish itself as the main linknot only between the general practitioner and the hospitalbut also between the preventive services, directed by themedical officer of health, and the hospital. Those partici-pating in the discussion agreed that outpatient facilitiesshould be associated with existing hospitals, and somedoubt was expressed as to the value of " peripheralclinics " for diagnosis and consultation. There is much

scope for research in the design of outpatient depart-ments-including if possible the provision of outpatientbeds in addition to casualty-recovery beds where patientscan be retained for six to eight hours for observation orfor minor surgical or medical procedures.

1. Paget, S. Lancet, 1886, i, 732.2. Robinson, J. R. Surgery, 1955, 38, 703.

POSTOPERATIVE PAROTITIS

PAROTITIS not due to mumps was recognised as a com-plication of febrile illness, notably typhus, by StephenPaget. 1 He recorded that parotitis, sometimes with

suppuration, might follow diseases in the abdomen orpelvis without any signs of pyxmia or septicaemia. Pagetand some of his contemporaries believed that this com-plication arose because of some complex connectionbetween the parotid gland and the peritoneum and

generative organs-a development of the observation byHippocrates that orchitis was a complication of mumps.

Parotitis sometimes follows operation. The exact patho-genesis is uncertain; but the infection, which is usuallystaphylococcal, probably reaches the gland by way of theparotid duct. Dryness of the mouth resulting from a poorflow of saliva and lack of attention to oral hygiene arerecognised predisposing factors. In 1955 Robinson 2

concluded, from a survey of hospital records, that parotitishad practically disappeared as a postoperative complica-tion. He observed that the incidence of this complicationdid not decline until the advent of antibiotics, though themortality from it fell after the introduction, about 1930, of

radiotherapy as a remedy. Robinson held that the freeuse of antibiotics after operation probably accounted forits almost complete disappearance, and that better controlof fluid and electrolyte balance and improved oral hygienewere minor factors. He argued in favour of antibioticprophylaxis, but foresaw the potential danger of thispractice in a warning that antibiotic-resistant staphylo-cocci might, in the future, give rise to a rebirth of thecondition; and now Brown et a1.3 have reported a twelve-fold increase in the incidence of postoperative parotitisat the U.S. Naval Hospital, San Diego, California.The incidence rose from 2 in 171,826 operations in

1949-56 to 7 in 47,947 operations in 1956-57. Of the 7affected patients 3 died, and parotitis was twice held partlyresponsible for death. This serious complication wascommoner in patients who had a stormy postoperativecourse, but it could be the only incident in an otherwiseuneventful convalescence. Staphylococcus aureus was

isolated from the parotid gland in 5 of the 7 cases; in theother 2 patients the lesions were aborted by early treat-ment. Unfortunately the antibiotic-sensitivity pattern ofthe staphylococci was not recorded. Brown et al. believethat this complication is likely to be related to the increas-ing number of carriers of antibiotic-resistant staphylo-cocci in every hospital community. In fact, however, theyreport that only 7 of 136 cultures of nasopharyngealsecretions from hospital workers yielded Staph. aureus-acarriage-rate of only 5%. (This is an astonishingly lowfigure; the rate is usually about 50%). But nasal carriageis by no means the only important factor in the spreadof staphylococci in hospitals.4We have deplored the abuse of antibiotics in prophy-

laxis 5; and these substances have no part to play in theprevention of surgical parotitis. It can only be hoped thatthis dangerous complication may be avoided by common-sense attention to fluid balance and oral hygiene, and byenergetic measures to restrict the spread of hospitalstaphylococci.4-6 Staphylococcal parotitis, once estab-

lished, can progress so quickly that early diagnosis andtreatment are essential. An antibiotic to which the hos-

pital staphylococcus will probably be sensitive-chlor-amphenicol, erythromycin, or novobiocin-should be

administered, and, in the experience of Brown et al. earlyradiotherapy is still of value. If these measures fail tolimit the infection, surgical drainage should be establishedwithout delay. It remains to be seen whether parotitis isto become yet another manifestation of the staphylo-coccus plague. 7

3. Brown, J. V., Sedwitz, J. L., Hanner, J. M. U.S. Armed Forces med. J.1958, 9, 161.

4. Lancet, March 8, 1958, p. 515.5. ibid. Jan. 4, 1958, p. 37.6. ibid. Feb. 8, 1958, p. 301.7. ibid. 1957, i, 723.

RETINAL PHOTOGRAPHY

SKILLED ophthalmoscopy yields information not onlyabout local conditions but also about general disorders.But the technique is not easily mastered, and even anexperienced ophthalmoscopist finds difficulty in describinghis observations. A short period in an ophthalmic depart-ment is enough to impress beginners with the differencesbetween reports on a single fundus by a group of experts;and serial observations of a progressive fundus lesion,made in ignorance of previous records, show how opento error the method is. Many progressive retinopathies,such as those associated with hypertension, diabetes, andsuspected intracranial tumours, demand more accurateobservation than is possible with ophthalmoscopy; and

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ophthalmologists are therefore turning to photography forobjective records.The Zeiss-Nordenson retinal camera, introduced in

1915, depended for its light source initially on a carbonarc and later on a filament lamp.An image of this source was formed by optical means at the margin

of the dilated pupil and a cone of light entered the eye and illuminatedan area of the retina. An aerial image of the illuminated fundus wasformed within the instrument by a powerful convex lens as inindirect ophthalmoscopy; and this aerial image was photographed bya built-in camera designed on the principles of a single-lens reflexcamera.

The Zeiss-Nordenson camera gave good monochromaticphotographs of the retina with exposures of a tenth to atwenty-fifth of a second; but such long exposures wereliable to cause failures due to blinking and ocular move-ments ; and with colour photography (calling for exposuresof a half to a fifth of a second) failures were even commoner.Modern developments in lighting have led to successfulcolour photography with fast exposures.

1-4 For this

purpose a high-speed electronic discharge flash-lamp hasbeen incorporated in the Zeiss-Nordenson camera, or thiscamera has been adapted to a xenon-arc lamp. But thereis a great demand for entirely new models; and Hansell 5describes seven which have appeared in the last year or so.Most are based on the Gullstrand ophthalmoscope andZeiss-Nordenson camera.

Illumination for focusing is usually independent of that for

photography. In most, colour photographs can be taken by rapidexposure with an electronic flash. One camera compensates not onlyfor refractive errors including astigmatism but also for chromaticaberration in the human eye. 35 mm. film is standard, and mostmodels have standard detachable camera bodies which may be

interchanged with other instruments.

Despite all this effort, retinal photographs, even incolour, leave much to be desired; and it remains moredifficult to recognise a retinal condition from a photographthan from an artist’s painting. Admittedly this may bepartly because the artist, like the ophthalmologist, haspreconceived notions which bias his observations; butthe artist can give a satisfying Mercator-like projection ofthe fundus which resembles the subjective impression onexamining the retina. It is difficult to imagine an opticaldevice which could do this--or a suitable method ofillumination. In this respect modern retinal cameras areless satisfactory than the original Zeiss-Nordensoncamera; for with them the photograph records a smallerarea of fundus, and consequently a clinician who needs arecord of, say, the whole length of a retinal blood-vessel,must take serial photographs and piece them together.Some of Leishman’s excellent illustrations are composedof eleven separate photographs. A further difficulty forthe clinician wishing to use the retinal camera as a researchtool concerns magnification. The size of the retinal detailsdepends not on refractive error but on the total refractivepower of the eye. For example, the optic disc will besmaller in a photograph of a large emmetropic eye thanof a small emmetropic eye. One type of camera makescertain compensations for refractive power; but thismodification is intended to give constant size of field-not to compensate accurately for differences in refractivepower. No doubt in time these difficulties will be sur-mounted ; but meanwhile we are a long way from achievingthe perfect retinal camera.1. Boort, H. J. J. van, Warmoltz, N. M., Winkelman, J. E. Med. & Biol.

Illustr. 1956, 4, 166.2. Meyer-Schwickerath, G., Niesel, P. Photogr. u. Forsch. 1954, 6, 73.3. Loisillier, F. Arch. Ophtal., Paris, 1955, 15, 395.4. Hansell, P., Beeson, E. J. G. Brit. J. Ophthal. 1953, 37, 65.5. Hansell, P. Med. & Biol. Illustr. 1957, 7, 91.6. Leishman, R. Brit. J. Ophthal. 1957, 41, 641.

MEDICINE IN ASIA: ORGANISATION ANDEDUCATION

IN Europe there are about 930 people to every doctor;in Asia the corresponding figure is more than 6400, andin some parts of Asia it is higher still-e.g., over 70,000 inIndonesia and over 174,000 in Nepal. But medicalservices are expanding fast: before the late war there wasbut a handful of health centres in all Asia, but at the endof last year there were 7251 multi-purpose centres,excluding those in Japan (about 900) and China. AsDr. John B. Grant points out in a report to the RockefellerFoundation, such swift expansion causes difficulties in

organisation, and inquiries are needed into what adminis-trative machinery should be provided. Lack of suchinquiries, he says, is leading to administrative chaosin several countries. As the best solution to the problemsof organisation, he suggests a regionalisation of serviceson the lines lately begun in Puerto Rico.!Even more important is the shortage of doctors and

health workers, and the fact that the graduates of manyof the present medical schools (and other traininginstitutions) are not really competent to staff the newhealth centres-a situation necessitating hurried coursesaimed at giving the graduates training in the work theywill do. The purpose of undergraduate medical education,as Dr. Grant sees it, is:

" To train an undifferentiated physician, competent to

undertake general practice in his own community. A largepart of general practice in Asian countries is to staff andadminister peripheral health centers. The undergraduatemedical curriculum of these countries is patterned on curriculaof the United States and of the United Kingdom and entirelyunoriented towards the health care service demands of theseAsian countries. It is true that the quality of medical educationshould not in any way be endangered by service pressures.However, undergraduate medical education unorientedtowards local needs is not quality education in the true

sense."

It will not be easy, he says, to provide such education;experiments must be made in the extension of trainingbeyond the universities’ own ward and outpatient servicesinto the community. The universities must control theirown community agencies, such as health centres, wherethe medical clerk and the intern can have facilities to trainthemselves in what increasingly is becoming generalpractice in their community. But this must await theestablishment of accepted standards of service in thesecentres-as yet there are none.

In some countries the necessary expansion and changeis held up, not by lack of funds, but by conservatism inthe faculty. Dr. Grant cites Calcutta, where none of thefour medical schools has established a chair of social and

preventive medicine, despite the Government’s offer topay the whole capital cost and half the running costs forfive years. The solution, he thinks, is for each countryto use its new medical colleges to establish a progressivecurriculum, to serve as an example to the others. Asuccessful demonstration is the best means of persuasion.The All India Institute of Medical Sciences, founded twoyears ago in New Delhi, will, it is hoped, provide sucha demonstration. Moreover, each country needs an agency,representing the Ministries of Health and of Education,to plan medical education and serve as a liaison betweenthe Government and the peripheral institutions. Such anagency could disseminate new ideas and recommendationsin medical education.

1. See Lancet, Feb. 22, 1958, p. 440.