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come from the students, who have asked for the subject ofmedical computing and programming to be included intheir curriculum.There is little point in considering priorities until a

sufficiently large body of medical practitioners understandswhat computing is all about. Ask the high-energy-physicsgroups to work without the sort of computer they need,and the questioner would be subject to some very unpleasantreplies. Would we have been given similar answers beforecomputers came generally into use in this subject ? Myguess is no.There are about 48 computers in medical schools and

teaching-hospitals at present, devoted to special projects.However, no machinery has been allocated to medicalschools for teaching purposes. A small computer for eachmedical school for teaching purposes would permit trainingto be carried out before the country was committed to a

given policy. Without such an approach progress will beslow and very expensive.

D. E. CLARK.Medical Computing Unit,University of Manchester.

MILIARY TUBERCULOSIS, TUBERCULOSISOF RIBS, AND HEROIN ADDICTION

SIR,-Blood-borne infections are a common complicationof the self-administration of drugs of dependence by theintravenous routes. Recently we treated a male heroinaddict aged 31 who was found to have miliary tuberculosis,with identifiable lesions in the liver and ribs. Tuberculosisof the ribs is probably haematogenous in origin; its incidencehas been variously stated as ranging from 1 % 1 to 5 % 2 ofall bone and joint tuberculosis. Unlike acute osteomyelitis,tuberculous osteitis may take several months to manifestitself radiologically.3 Usually only one rib is involved andpathological fractures are rare. The accompanying figure1. Wassersug, J. D. Am. Rev. Tuberc. 1941, 44, 716.2. Tatelman, M., Drouillard, E. J. P. Am. J. Roentg. 1953, 70, 923.3. Johnson, M. P., Rothstein, E. J. Bone Jt Surg. 1952, 34A, 878.

Chest X-ray of patient with tuberculous osteititis.

shows osteolytic lesions with " scalloping " of the upperborder of the left fourth rib and bone expansion of theleft sixth rib anteriorly. There is a pathological fracture ofthe right eighth rib posteriorly. No pulmonary lesion isvisible.

This case will be reported in full in the British 3‘ournal ofPsychiatry.

JULIUS MERRYB. M. COMPELS.

Departments of Psychiatryand Radiology,

St. Thomas’s Hospital,London S.E.1.

HOSPITAL STAFFING STRUCTURE

SIR,-The s.H.r2.o. grade was introduced into the

hospital staffing structure as a result of discussions on theSpens Report between the Health Departments and

representatives of the profession. But the responsibilitiesof this grade were never clearly defined, and in 1961 thePlatt Report recommended that this grade be abolished infavour of the medical-assistant grade. Now this too is tobe abolished and replaced by the hospital specialist. But

already the Godber Committee 1 has complained that thedistinction between hospital specialist and consultant isnot clear-the very same defect that led to the abolitionof the S.H.M.O. grade.

If this new staffing structure is to have any chance of

succeeding then not only must the question of clinicalresponsibility be resolved 2 but also the work of the

hospital specialist needs careful definition. In my own

specialty, general surgery, this might not be too difficult.Already 108 surgical operations are officially classified as58 major, 25 intermediate, and 25 minor. The number ofoperations described in a current textbook on operativesurgery is 196.3 The work of a hospital specialist, in

surgery, could be arranged in either of two ways. First, alimited number of operations could be officially tabulated,for each of which the specialist would be personallyresponsible, and general practitioners could refer suitablecases to him direct. Second, the allocation of each

operation to the specialist would be left at the discretionof a consultant as director of the surgical division and

manager of the team to which the specialist belonged.Having decided for which operations the specialist is

responsible, it must be decided to whom he is responsibleand by whom he can be called to account if suspected ofnegligence. In the first alternative the specialist would besued for negligence in civil court; in the second, he mightbe indicted before the director of the division who dele-

gated the operation to him, and punished if considered

guilty by " loss of seniority "; he might be arraignedbefore the reconstituted G.M.C. and punished by havinghis name removed from the vocational register of hospitalspecialists. Or, both the specialist and the consultant

might be sued jointly in a civil court and take part in anundignified wrangle as to whether the consultant was

negligent in delegating the operation to that individual

hospital specialist or not.Personally, I prefer the first alternative because the

work of the hospital specialist is limited in a clearly definedway, and in this limited sphere he is responsible for hisacts in a civil court. This is simple and free from

ambiguity. In my opinion a " team " would tend towardsirresponsibility in its professional actions because of thediminished personal responsibility of each individualmember.

F. S. A. DORAN.Mid-Worcestershire Hospitals ofBromsgrove and Kidderminster.

1. Responsibilities of the Consultant Grade; p. 13. H.M.

Stationery Office, 1969.2. Doran, F. S. A. Lancet, 1969, ii, 1010.3. Rob, C., Smith, R. Operative Surgery. London, 1956.