Anal Irritation

BRITISH MEDICAL JOURNAL

VOLUME 287

described under up to 10 fields of the user's choice and provides macros, which, among other functions, allow editing, sorting, merging, indexing, producing a vocabulary of words in a chosen field (with or without counting), automatically entering non-trivial words from a title field into the keyword field, searching the keyword field for any combination of words, and printing out a listing of all or selected parts of the bibliography. There is no restriction in the number of records; individual records are limited to a maximum of 4000 characters. Famulus is extremely easy to use, once one is familiar with the system. I keep all necessary control programs in a permanent library on the ICL 2980; to update a bibliography by adding a new data file of references, resorting, indexing, listing, and returning to magnetic tape storage only takes five minutes of interactive editing at the terminal followed by a single line "run job" instruction. A simple manual giving a full description of the system for users is available from the University of London, Computer Centre, Guildford Street, London WC1. A J WADE The London Hospital Medical College, London El 2AD

Causes and management of anal irritation SIR,-Mr John Alexander-Williams (19 November, p 1528) rightly emphasises the parts to be played in anal irritation by inadequate hygiene and by contact sensitisation due to perfumes, detergents, and a legion of other medicaments obtainable over the counter, such as local anaesthetic creams. Unfortunately, having made this point, he then goes on (rule 3) to recommend medicated wipes such as Wet Ones or Baby Wipes for "away from home cleansing." Many of these medicated wipes contain sensitisers. For instance, Boots Baby Wipes contain 0 5%/0 cetrimide and Cosifit Poppets are "impregnated with lanolin for softness." In addition, most contain ethyl alcohol, which may irritate broken skin, and are perfumed, another source for sensitisation. We believe, therefore, that use of these tissues should not be encouraged in the management of anal irritation. In addition, in rule 8 he suggests using crotamiton as an antipruritic in unbroken skin. In our experience this has not been a successful treatment for perineal itch, other than in that secondary to infestations. In our opinion these points detract from an otherwise useful article for the "obsessive personality" with anal irritation. STEPHEN JONES VALERIE DOHERTY Department of Dermatology, Western Infirmary, Glasgow GIl 6NT

ANGELA FORSYTH Contact Dermatitis Clinic,

Belvidere Hospital, Glasgow

New criteria and classification for diabetes mellitus

SIR,-Two comments in your correspondence columns of 15 October (p 1142) relate to the criteria and classification for diabetes mellitus recommended by the British Diabetic Association.

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10 DECEMBER 1983

Mr C Sanderson quite rightly points to a possible anomaly in the operation of these new recommendations-diabetes mellitus may be diagnosed with either a raised fasting or a raised two hour value in the oral glucose tolerance test, so that a "normal" fasting value may accompany a diagnostic two hour value. This is a very unlikely event, however; by the time the two hour concentration is in the diagnostic range for diabetes the fasting value is almost invariably raised too. Of more concern perhaps is diagnosis based on a raised fasting blood sugar concentration alone. Not everyone obeys the injunctions to eat and drink nothing on the morning of the test, and a brisk emotional response to the sight of syringe and needle may itself raise blood glucose concentrations. All this reinforces the advice not to rest the diagnosis on a single measurement of blood glucose concentration unless the value is so high and the accompanying circumstances so suggestive that it would be overcautious (or perhaps even dangerous) not to do so. To the point made by Mr Hindle and Mr Rostron about anhydrous and hydrated glucose, we agree that the difference in the quantity administered if 75 g of each were consumed is small and insignificant in individual diagnosis. For epidemiological study, however, some differences might be attributable to systematic variation in dose. We were aware of this problem, and reference has been made to it earlier. A simple defence is that when we said glucose, we meant glucose and not glucose monohydrate: 75 g of glucose would be equivalent to 82 5 g of glucose monohydrate; or perhaps more practically 75 g of glucose monohydrate would be equivalent to 68-2 g of glucose. We would prefer the more literal interpretation. H KEEN A BLOOM P WATKINS British Diabetic Association, London WIM OBB

A better deal for overseas doctors

SIR,-The proposed sponsorship scheme for overseas doctors outlined by Mr InnesWilliams and Dr Paton (19 November, p 1492) is one of the most promising recent developments in medical manpower. The inordinate difficulty that overseas doctors have in acquiring good training in Britain has been a matter of concern to the profession, and particularly to the Hospital Junior Staff Committee, for some time. This problem shows every sign of worsening, and as the number of unemployed doctors increases, overseas doctors are suffering particularly severely. Although many details of the scheme remain to be worked out it has the enthusiastic support of the Hospital Junior Staff Committee in principle. There is, however, an important misconception emerging that the scheme can solve our intractable career structure problems. In the last paragraph of the leading article the authors say: "Allocating the excess posts to sponsored overseas trainees would be much more sensible than reducing numbers.... In many specialties the excess of registrars over likely career vacancies is about five or six to one. It would clearly be unacceptable to patients, government, and the profession if 80% or more of our registrars were to be

sponsored overseas doctors. So few posts would be available to British graduates that massive unemployment would result, while funds that are vitally needed for consultant expansion would be tied down. A change in the proportions of consultants and registrars is inescapable, and a Joint Consultants Committee working party is near to agreeing a mechanism for bringing this about that should be acceptable to all parties. This, in coniunction with the sponsorship scheme, holds out the hope of a solution to the current problem; the sponsorship scheme on its own cannot provide such a solution. STEPHEN BREARLEY Chairman Hospital Junior Staff Committee, BMA House, London WC1H 9JP

SIR,-Mr David Innes Williams and Dr Alex Paton (19 November, p 1492) highlight clearly the problems of overseas doctors and also suggest a solution through a National Overseas Doctors' Sponsorship Organisation. While fully supporting such scheme I nevertheless believe that posts created under the sponsorship scheme could work out to the advantage of overseas doctors only if equal opportunity and equal responsibility are attached to these posts; otherwise such a scheme will create the same parallel unattractive training for overseas doctors it is designed to eliminate. To my mind one way of safeguarding against this possible outcome would be to have a regular and organised rotation between the parallel posts in the particular specialty concerned. Moreover, though such a sponsorship scheme is a welcome suggestion for the future, I am afraid the immediate problem faced by many hundreds of overseas doctors is their five years' limited registration which will finish in February 1984; the irony of it is that if by that time they fail to obtain full registration they will cease to have any registration at all. Unfortunately, many of these doctors have held temporary and then limited registration for 10 to 12 years already, providing indispensable service to the National Health Service, and fell into the five year rule of limited registration only in 1979. Perhaps it may be practicable for an overseas doctor to return to his country of origin after five years, but I am not sure he could do so after 10 or 12 years and I feel that such overseas doctors also deserve a better deal from the

profession. M SHAUKAT ALI President, Bangladesh Medical

Association in the UK

Greenwich District Hospital, London SE10 9HE

SIR,-Besides failing to address themselves to the career problems harassing the overseas doctors already working in this country, Mr David Innes Williams and Dr Alex Paton have contradicted themselves in prescribing their utopian deal for overseas doctors. The central theme of their proposals is the availability of "an excess of junior posts with training facilities," but by their own admission, "if more British doctors continue to enter popular specialties ... overseas doctors will be forced into taking posts which are not of their choosing." What mechanism, may I ask,