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seniority, can hardly have much appeal for men andwomen who have spent long years in postgraduate train-ing, and may indeed have been senior registrars. More-

ever, the medical-assistant grade looks as though it weregoing to perpetuate the two characteristics that have madeso many people sorry to be a S.H.M.o. First, it is not

designed as the ordinary stepping-stone between thesenior registrar and the consultant, but will instead bearthe old welcoming inscription " Abandon hope, most ofyou who enter here ". And it also seems likely to preservethe enormous disadvantage, for a career grade, that itsmaximum salary will always be a little below the minimumsalary of the consultant. Who, one may ask, is willinglygoing to become a medical assistant-except possibly afew general practitioners, or some married women, whomight take such an appointment part-time ? Before anysuch terms of service are settled, we hope those concernedwill at least reconsider the possibility of overlapping scalesof salary-so that a senior doctor who has worked for,say, twenty-five years in the intermediate grade will earnmore (not less) than a young doctor who has just won hisconsultant spurs.4

Essentially, what is in question is whether the new

grade is to be senior or junior. We remain of the opinionthat a career grade of this kind should be senior. To carrythe appropriate prestige it would need a title less depressing than either " senior hospital medical officer " or

" medical assistant "; and we still favour the title of" specialist " which we have so often proposed.4 Butwhatever the grade is called for administrative purposes,the actual appointments in it should be those of assistantphysician, assistant surgeon, assistant pathologist,assistant psychiatrist, and so on. The fact that some ofthese titles are at present attached to certain consultant

appointments seems to us insufficient reason for preventinga change which would generally be consistent with therealities of hospital life. If it became usual for prospectiveconsultants to move into this intermediate grade as soonas their training was finished, the grade would lose itsdead-end character. And actually, of course, even doctorswho had spent many years in it should still be able to

qualify for a consultant appointment by showing theirfitness for consultant work and their readiness to assumeits responsibilities.

TRACHOMA IN SOUTH AUSTRALIA

THE discovery of active trachoma in quite a number ofpeople in Adelaide, including doctors, has caused surprise;for in Australia this infection was thought to be virtuallyconfined to the outback. Though the disease may seldomor never be serious unless hygienic conditions are bad, itis important enough to justify full investigation of anyflare-up.

Until about 1942 the general belief was that Australiahad little or no active trachoma; but subsequent surveysshowed that this was certainly not true of the aborigines.1-3Thus in one investigation in the Northern Territory 3051were affected out of 4876 examined, while in a smallerstudy, of about 500, 90% showed evidence of infectionand 7 °% were blind in one or both eyes. In other surveys,an equally high proportion of the people showed signs ofpast or present infection, but eyesight was seldom seriouslyimpaired. This raised the question whether Australia mayhave two strains of trachoma organism-a virulent one

1. Webb, R. C. Med. J. Aust. 1957, i, 460.2. Flynn, F. ibid. 1957, ii, 269.3. Yates, P. C. ibid. 1963, i, 828.

possibly introduced with the Afghan camel-drivers whowere brought to Australia about a century ago, and amilder one spread from South-east Asia by Chinese andIndonesians. Flynn 2 seems no need for such an explanation.He points out that both the benign and the destructivedisease begin with a florid infection; but, whereas infavourable conditions this may subside with hardly anysequels, in unfavourable conditions-e.g., secondaryinfection, or exposure to hot dry wind and dust-theresults may be disastrous.That trachoma may have suddenly become epidemic in

Adelaide is suggested by the fact that one ophthalmologist(Mr. D. 0. Crompton) has seen 18 cases in his privatepractice in a single month. Believing that the incidenceof clinical trachoma in South Australia is quite high andis rapidly increasing, he is very properly pressing for asurvey in schools and other institutions, and is urging thatall suspected cases shall be examined by a virologist, andkept under observation so that the effect of treatment canbe judged. Fortunately the Institute of Medical andVeterinary Science at Adelaide is able to undertake the

necessary cytological studies; and it had investigated some600 patients up to last November. Unfortunately, on theother hand, it cannot go on with this work unless a smalladditional unit can be created for this special purpose.We hope this can be done, not only for reasons of publichealth but also because the Adelaide institute is capableof making a positive contribution to the virology of thisdisease.

SPREAD OF VIRUS HEPATITIS

THE two types of acute viral hepatitis differ in the way theyspread: infective hepatitis is almost always an entericinfection, whereas serum hepatitis is conveyed only bythe parenteral route. As might be expected of an infectionconveyed from fasces to mouth, infective hepatitis is farcommoner in children. The incubation period of infectivehepatitis is 15-60 days and that of serum hepatitis is50-160 days. But in other respects-clinical course, bio-chemical derangements in serum and fxces, and histo-logical changes in the liver-they are very similar. The

majority of sufferers, especially children, have a mildform of the disease without jaundice, and this anicterichepatitis may need sensitive liver-function tests for its

recognition. The agents responsible have not beenisolated with certainty; so there are no specific serologicaltests for antibodies. The evidence for infectivity of

specimens and transmission of the disease are based onhuman transmission experiments-a very unsatisfactorystate of affairs. Thus, any data collected from epidemicsare of the greatest value in piecing together the true

picture of spread.Foremost in these laborious epidemiological endeavours

are Moseley and his co-workers who have recentlystudied two epidemics in Des Moines, Iowa. These

epidemics came in cycles; they tended to reach a peak inthe winter; there was a slow rise and fall in the epidemiccurve; and the attack-rate was high in the 5-14 age-group-features attributable to person-to-person spread.An intestinal-oral route was suggested by the lowerattack-rate that accompanied better sanitation, im-

proved socioeconomic status, coupled with better sewagedisposal and removal of privies, and the lessening ofhousehold congestion. Since hepatitis is primarily a

disease of schoolchildren, particular attention was paid to4. Moseley, W. H., Speers, J. F., Chin, T. D. Y. Amer. J. publ. Hlth, 1963,

53, 1603.