1032
NEWS
BRITISH MEDICAL JOURNAL
15
OCTOBER
1977
AND NOTES
Views "Genetics can be taught as well on man as on the pea," said Sir Peter Medawar in his British Postgraduate Medical Federation lecture, "Biology and Medicine"; and he expressed scorn for the view that no one can treat patients before his teachers have taken him on a conducted tour of the animal kingdom. Nevertheless, his thesis was that biology can make an important contribution to medical problems. He amply vindicated this by returning to the idea of a "cancer vaccine," mimicking the immunological effects of youthful childbearing in protecting women against breast cancer and other tumours (10 September, p 712). The idea that early childbearing might lead to immunisation with embryonic antigens is not far-fetched because normal pregnant animals can show such an immune reaction. Sir Peter described experiments suggesting that previous inoculation with fetal tissue does indeed protect mice against one tumour (induced by a chemical, methylcholanthrene). But later inoculation, after the malignant transformation must have taken place, is actually good for tumours: is this an analogue of the increase in breast cancer in women who have their first baby after 32 and who fare even worse than the childless ? The immunological arguments, he maintains, point to a natural defence against cancer; some people would be more resistant than others as a result of their constitution and life history. And some tumours do regress naturally-especially, said Sir Peter, now that this is known to be scientifically respectable.
Antimedicine writers often assert that mortality has hardly altered this century for middle-aged citizens of Western countries. They are wrong. The latest figures from the Metropolitan Life Insurance Company show that in 1900 the mortality rate in 45-yearold men in the United States was 12 611000 and for their wives it was 10 6. Now the figures are 4-9 and 2 7, and there has been an increase in life expectation of 4 3 years for men and 9 3 years for women. If Minerva became so stressed that she could spare only three minutes' reading time each week to keep up to date she would choose Newsweek, whose medicine section is always accurate and selects the important events with consistent reliability. For instance, it picked up the important controlled trial of coronary bypass surgery published in the New England Journal of Medicine (1977, 297, 621)-which showed that after three years patients treated by bypass for chronic stable angina had done no better than those given beta-blockers-and quoted Eugene Braunwald of Havard as guessing that the finding would "put a damper on the almost explosive rise in this operation and save patients about $500m in medical bills." On the defensive after attacks on their advertising in developing countries, the Nestle Company have produced a booklet explaining that for many years now their radio campaigns in Africa have stressed that breast-feeding is best, and that their posters do the same. Clearly it is wrong to blame the milk companies for the decline in breast-feeding throughout much of the world, but the very ubiquity of bottle feeding must suggest to young mothers that it is acceptable and even preferable-yet another issue in which there is no black and white-only shades of grey.
Minerva usually enjoys trips to Holland and the joint BMA/ Royal Netherlands Medical Association meeting at Leiden (see p 1012) was no exception. But why did so few Dutch doctors attend ? One explanation could be that they were suspicious of British motives: the programme included sessions on the Dutch medical system and visits to a group practice and local hospitals. Were the innocent visitors mistaken for undercover agents inspecting a possible new territory for disenchanted medical migrants ?
Amiiong the talking points of the meeting was a suggestion by a Dutch geriatrician that both psychosis and denientia in the elderly were sometimes due to the strains of a long-endured marriage. Once separated froni their spouses these patients recover, he explained: but unfortunately, there was then little alternative but a reunion and a relapse. Neutron activation analysis of King Charles II's hair suggests, like his clinical history, that he died of mercury poisoning (he was an amateur alchemist who distilled mercury). This is one of the fascinating facts in "Hair and history," a paper by Professor J M A Lenihan summarised in Medical History (1977, 21, 192). Hair analysis, Minerva was cheered to learn, suggests that the "internal" environment is now cleaner than in past centuries: preoccupation with the side effects of modern drugs makes us forget perhaps the arsenic, mercury, and lead of former medical practice. Hair is also being analysed for heavy metals to screen various occupational groups (including dentists as well as industrial workers) and to check on environmental contamination in water supplies and elsewhere.
Disposable syringes make splendid water pistols-as many doctors' children know-but their popularity may lead to clandestine searches of medical dustbins by enterprising youngsters. The hazard, of course, is the needles, for hepatitis is only one gloomy possibility. Refuse containers need to be child proof if medical waste is put in them. Nice to see in the British Journal of Venereal Diseases a complimentary review of How to Have Sexual Intercourse Without Getting Screwed (Madrona, Seattle)-an accurate account of sexually transmitted diseases combining sense with style: "after a week's abstinence altruism starts to give way to lust." There are few texts giving practical advice to the promiscuous, so this is a welcome exception.
Housework has never been Minerva's favourite pastime and she particularly sympathises with disabled people who find it difficult to do their normal household chores or cannot afford paid help. From 17 November, however, about 40 000 disabled married women will be able to claim 110 50 a week tax free. Perhaps a "daily" will be able to come in more often or the money saved for a fully automatic washing machine. All women under 60 who have been continuously incapable of work and household duties for at least 28 weeks and who do not qualify for full-rate- sickness or invalidity benefit because they do not have enough National Insurance contributions are eligible to apply now. MINERVA
BRITISH MEDICAL JOURNAL
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15 OCTOBER 1977
MEDICOLEGAL Annual Report of Medical Protection Society FROM OUR LEGAL CORRESPONDENT
Year after year the defence societies have repeated their warnings that skimped or inaccurate records may lead to malpractice actions being lost or having to be settled which otherwise could have been successfully defended. Sometimes it has almost seemed as though repetition had damaged the value of the advice, but this year's report of the Medical Protection Society contains accounts of two cases from which the message emerges loud and clear. To make the moral yet more pointed, both stemmed from the same cause, the development of kernicterus in neonates. In the first case patchy records contributed to there being an award of damages of £20 000, while in the other a potential liability for damages of £54 000 was avoided because the judge preferred the account of the child's condition portrayed in the notes to that given by the mother. In both cases complaints were made that serum bilirubin tests should have been performed earlier. In the first case the baby developed jaundice on day two, and kernicterus had set in (with subsequent brain damage) by day four when he was given an exchange transfusion. The plaintiff sought successfully to persuade the judge that the serum bilirubin test should have been done on day three. The defence was run on the basis that until day four the baby's condition was consistent with mild physiological jaundice and that the kernicterus was the result of a sudden acute infection developing on that day. The mother, however, gave evidence that the child's jaundice got worse between day three and day four, and this could hardly be disproved from the records of the paediatric house officer. In his clinical notes there was no mention of jaundice on day two, though it was mentioned in the nursing notes. On day three the house officer recorded "jaundice getting less" and on day four "jaundice same." In conflict with this was what he had written in his letter referring the child for exchange transfusion. There he had said that the jaundice had diminished on day two and day three, but that on day four the child had been found to be more jaundiced. Not surprisingly the court found against the defendant. No recollection
In the second case the clinical notes were critical since the action came to trial 11 years after the events, and neither the ward sister nor the paediatrician had any recollection of what had occurred. In evidence the West Indian mother of the child (who had a G6PD deficiency) stated that her son's jaundice worsened progressively after birth until discharge on day eight. It was three days later that the child was readmitted with kernicterus. In contrast to the mother's account the notes showed that jaundice which had developed on day four was fading by day eight. A Coombs test had been negative, and the consultant paediatrician who saw the child on the day of discharge noted that he had regained his birthweight of 7 pounds. In the judge's view the silent evidence of the notes was more convinc-
ing than the mother's story, and the MPS funds were saved from having to make a very substantial payment. As it was, during the calendar year 1976 total MPS indemnities to members for costs and damages rose to £619 000 from the previous year's figure of £434 000. Legal costs actually went down from £217 000 to £ 177 000. The society's accumulated funds now amount to C2-2m as against an estimated contingent liability of f1 6m in respect of claims notified up to 31 March 1977. (The equivalent figures for the Medical Defence Union are £3 2m and £2 4m respectively.) Like the MDU, the society has benefited from the increase in subscription income (up from £1 2m in 1975 to £1 6m), and it was able to make a contribution of £450 000 out of income to its provision for indemnity in the accumulated funds. This contribution was £200 000 more than that in 1975, and the treasurer states that the full effect of the increase in subscriptions will not become apparent until the 1977 accounts are complete.
The perennial bugbear of what and how much to tell the patient was raised in another case successfully defended by the MPS. The plaintiff had undergone tubal ligation and after histological confirmation of excised portions of the Fallopian tubes she had asked the registrar whether it meant that she would have no more children. Perhaps a little delphically he replied: "as far as I am concerned, you won't come back." Two years later the woman was pregnant again, and it was contended on her behalf that she should have been told that tubal ligation had a 1 in 300 failure rate so that she could have considered contraception. At the trial, as the experts debated the issue, it appeared that how much the patient was told varied widely. The judge ultimately accepted the word of an expert witness who said that, while he did not volunteer information about the failure rate, he did not lie if asked about it. The judge considered that what the registrar had said was in accordance with this practice.
High settlement
Accepted medical practice
The menace of inflation in awards of damages means that there is always a temptation to harp on the most costly cases in the report, and 1976 saw the society's most expensive indemnity to date, a payment in Australia of approximately £110 000 (less a hospital contribution of £7200). The settlement followed the perforation of the bowel of a small girl during sigmoidoscopy and rectal biopsy. Unfortunately for the consultant surgeon concerned, the light of the sigmoidoscope had gone out, and rather than inflict a second anaesthetic on the child, he decided to continue with a hand torch, whose beam was apparently not much less than that of the sigmoidoscope. A day later the child had developed septicaemic shock, and after a colostomy during the day, that evening she had fits and became cyanosed. She was left in a vegetative state. The MPS took the point that perforation of the bowel could occur without negligence, so that what had happened did not speak for itself, but its Australian solicitors believed that the case was hopeless and ought to be settled. It was obviously highly relevant both to liability and to the level of damages that the trial was to have been before a jury. Though neither defence society ever says so outright, a reader of their reports over the years cannot avoid the impression that in countries like Ireland and Australia where members face trial by jury, actions have to be settled which would be defended (perhaps successfully) before a dispassionate English judge. By way of example, in 1976 the MPS succeeded in the High Court in showing that footdrop after osteotomy of the hipjoint was a recongised hazard and that it did not follow from its appearance after the operation that its member had been negligent. A jury might not have received the argument so sympathetically, especially if one of the members knew that a protection society would hold the doctor immune from any award of damages.
The result of this case shows that malpractice actions do turn directly on the practice of the profession and the standards of the responsible practitioner. Not warning patients of the slight risk of conception after tubal ligation may have its critics, but that was not the point. The issue was whether the lack of a warning was consonant with accepted medical
practice. The most anxious questions of how much to tell a patient arise in relation to possible side effects or hazards of treatment. Here again the courts have been sympathetic to doctors. In 1975 Mr Justic Bridge held1 that it was reasonable not to have told a patient of the relatively remote risk of neurological complications during an aortogram. The judge was conscious that full disclosure might both alarm the patient and put him in a position where he felt that he and not the better qualified doctor must take the decision whether to proceed. The MPS Report contains a host of useful warnings for the profession. Articles on the danger of dismissing employees without first giving both oral and written warnings and on prescribing hazards in paediatrics (by Professor A B M Campbell) deserve careful attention and cannot be done justice in condensation. A particularly important warning concems the prescription of drugs by those only temporarily registered with the GMC. Such doctors must not use FPlO forms and they may only use FP1OHP forms in cases of emergency. They may prescribe only for patients whose care comes within the terms of their registration and then only on the hospital forms. Finally, the past year has seen the passage through Parliament of the Criminal Justice Bill 1977, clause 39 of which abolishes the coroner's power to commit for murder, manslaughter, and infanticide. This is a reform which has been urged for years and was recommended in the report2 of the Brodrick Committee in 1972. Since then both the MDU and the MPS have had a case in which members
1034 were committed for trial by a coroner for manslaughter only for no evidence to be offered by the Crown at the trial. In one case a child had died during an anaesthetic, and in the other two doctors: in the West Country diagnosed gastroenteritis in a child with appendicitis. The Joint Co-ordinating Committee of the three British defence societies forwarded details of the two cases to the Home Secretary, who by then had already given an undertaking to introduce legislation. The reform now comes over 40 years after it was first suggested by the Wright Committee in 1936.
BRITISH MEDICAL JOURNAL
later on to those who hav.e successfully com- A supplement ( 1 50) lists awards at British pleted the first year. universities open only to academic staff from non-Commonwealth universities.
Health and Safety Commission
Association of Clinical Pathologists
A five-year work programme covering a wide spectrum of health and safety at work activities is set out in the first report of the Health and Safety Commission, for 1974-6 (HMSO, C2). The 140 specific projects in the plan of work-to be carried out by the Health and Safety Executive, the Commission's operational arm-range from the preparation of new regulations on carcinogenic substances, O'Mallev-Williams z' National Hospital for Nervous to help reduce serious long-term health hazards Diseases, British Aledical 7ournal, 1975, 1, 635. 2 Report of the Committee on l)eath Certification and to workers; to preparing regulations for the Coroniers, Cmnd 4810. London, HMSO, 1972. safe handling and housing of bulls; and producBritish Medical Jornal, 1975, 3, 108. ing a safety assessment of the commercial fast-breeder reactor. The report also contains an outline of the Commission's future strategy, which has three main elements: a comprehensive review and updating of existing health and safety legislation; promoting positive attitudes towards health and safety at work; and improving the collection and dissemination of information. Central Health Services Council
MEDICAL NEWS
Health authorities should not be advised at present to give priority to developing mobile coronary care units, in the view of the Central Health Services Council's Standing Medical Advisory Committee, while there is no firm evidence of their value as life-saving measures; but such units should be evaluated. At the same time greater emphasis is needed on preventing coronary heart disease and on ways of reducing the delays in seeking and obtaining help when an attack occurs. This is one of the many subjects considered by the council and its committees and standing advisory committees that are touched on in the annual report for 1976 (HMSO, 60p). Particular mention is given to priorities in the health and personal social services and sharing resources for health; preventive medicine arrangements for health care in residential homes for the elderly; management arrangements for longstay psychiatric hospitals; vaccination; and drinking and driving.
15 OCTOBER 1977
Medical Research Council
The outlook for funding new medical research is becoming brighter, according to the press notice issued with the MRC's Annuiiial Report 1976-77. Although the council had a difficult year, there is now a real prospect of greater financial stability. The report (published by HMSO at L2 25) is cautiously optimistic about the council's ability to increase the value of awards, particularly for short-term grants, and universities have been told that new proposals for long-term grants can now be considered. Despite the economies of recent years the number of university scientists supported by the MRC has not declined. The past year has seen steady progress on a wide front, the report states. The report touches on immunological approaches to contraception, tests for coeliac disease, plasma exchange in glomerulonephritis, molecular mechanisms of thalassaemia, the endorphins as naturally occurring pain killers, and the overlapping genes of the School of Community Paediatrics, bacteriophage (I)X174. The council is particularly keen to support good new work on, Edinburgh among other things, cardiovascular disease, Britain's first School of Community rheumatism and arthritis, gastroenterology, Paediatrics, founded by the Scottish Home nutrition, dentistry, aspects of cancer, skin and Health Department, was officially opened diseases, allergy, the dementias, deafness, by Professor Sir John Brotherston on 7 toxicology, and accidents. October at 18 Millerfield Place, Edinburgh 9. Its purpose, a press statement comments, is to produce the new type of child-oriented Awards for Commonwealth university doctor needed for the integrated child health staff service envisaged in 1973 by the department's Except in Nigeria, there are fewer opporreport Towards an In tegrated Child Health Service. Its function is also in line with the tunities now than 10 years ago for those who recommendations for England and Wales wish to do long-term research or teaching in a made in the Court Committee's report, Fit Commonwealth country other than their own. for the Fiture. Full-time students on the first But there are many short-term possibilities: course will spend two days a week on lectures hundreds of fellowships and visiting lectureand background information. The other three ships for the staff of universities in Britain will be spent at schools, child health clinics, and other Commonwealth countries are listed residential homes, and special schools for in a guide published by the Association of handicapped children; attending specialised Commonwealth Universities (36 Gordon clinics of the Royal Hospital for Sick Children; Square, London WC1H OPF) at £2 75. This and attached to doctors specialising in paediat- provides information about sources of financial ric work in the community and to general aid for academic and administrative staff who practitioners. Part-time students can be wish to undertake research, make study visits, accepted. A further course may be offered or teach in another Commonwealth country.
At the annual general meeting of the association, held on 15 September with the retiring president, Dr C L Greenbury, in the chair, the following were elected-Professor H A Sissons, president; Professor Norman Ashton, president-elect; Dr H M Rice, Dr C Giles, vice-presidents; Dr A G Marshall, chairman of council; Dr A C Hunt, honorary secretary; Dr G W Pennington, honorary treasurer; Dr G S Anderson, Dr E W Bell, Dr J Burston, Dr Heather M Dick, members of council for 1977-80.
Anna Monika Foundation competition
Three British scientists have received prizes in the sixth competition of the Anna Monika Foundation, Dortmund, West Germany, which was endowed in 1965 to award a biennial prize for investigations on the physical substrate and functional disturbances of endogenous depressions. Professor Sir Martin Roth, then at the University of Newcastle upon Tyne, won first prize for his study on the nosology and classification of affective disorders. Dr A R Green and Professor D G Grahame-Smith, University of Oxford, jointly won second prize for their investigation on the interaction between serotonergic and dopaminergic neurones in the central nervous system. Kidney transplants The number of kidney transplants undertaken in the United Kingdom and Republic of Ireland for the month ending 30 September 1977 was 73, and the number of potential recipients on file was 1222. Corresponding figures for the previous month were 58 and 1213.
People in the news Professor Sir Cyril Clarke, FRS, emeritus professor and honorary Nuffield research fellow, department of genetics, University of Liverpool, is one of the 1977 winners of the Gairdner International Awards for outstanding contributions to medical science.
COMING EVENTS Royal Society of Tropical Medicine and Hygiene-Symposium on immunology of parasitic infections, 27 October, London. Details from the Society, Manson House, 26 Portland Place, London WIN 4EY. (Tel 01-580 2127.) Bone and Tooth Society-Autumn meeting, 11 November, Cardiff. Details from Dr Maureen Owen, MRC Bone Research Laboratory, Nuffield Orthopaedic Centre, Headington, Oxford. Faculty of Homoeopathy, Midlands Branch3rd annual symposium on homocopathic medicine, 12 November, Birmingham. Details from Dr R A F Jack, The Limes, Lydiate Ash, Bromsgrovc, Worcestershire B61 OQL. (Tel 021 453 3170.) Royal College of General PractitionersAnnual symposium "Standards and settings in general practice," 20 November, London. For details sec advertisement at p xiii.
BRITISH MEDICAL JOURNAL
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15 OCTOBER 1977
Society for Psychosomatic Research-21st annual conference, "Thc coming agc of psychosomatics," 21-22 November, London. Details from Dr Peter Mellett, Horton Hospital, Epsom, Surrey KT19 8PZ. (Tel Epsom 29696, ext 286.) Third therapeutics conference-25 November, London. Details from the Co-ordinator of Studies, St Christopher's Hospice, 51-53 Lawrie Park Road, Sydenham, London SE26 6DZ. (Tel 01-778 9252.) "Family with a mentally handicapped member"-Symposium, 25 November, Southport. Details from Dr R P Arya, Greaves Hall Hospital, Banks, Southport, Merseyside PR9 8BP. (Tel 0704 27451.) Institute for the Study and Treatment of Delinquency-W'cekend discussion course, 25-27 November, Rugeley. Details from the Institute, 34 Surrey Strcet, Croydon, Surrcy CR0 IRJ. (Tel 01-680 2068.) Association for the Study of Medical Education-Joint meeting with the Society for Research in Higher Education "Approaches to curriculum dcsign and evaluation: the medical experience," 30 November, London. Details from Mrs M Clothier, BLA'I' Centre for Health and Medical Education, BMA House, Tavistock Square, London WC1H 9JP. (Tel 01-388 7976.) International Study Group for Steroid Hormones-VIII meeting, 5-7 December, Rome. Details from Professor C Conti, Istituto di Patologia Medica II, Policlinico Umberto 1,
Rome, Italy. Tumour Ultrasound '77-International symposium, 5-7 December, London. Details from Dr Ralph McCrcadv, Department of Nuclear Medicine and Ultrasound, Royal Marsden Hospital, Doxwns Road, Sutton, Surrey. (Fel 01-642 6011.) New York Academy of Sciences-Conference "Primary hcalth care in industrialised nations," 12-14 Decembcr, Ncwv York. Details from Confcrcnce Department, New York Academy of Sciences, 2 East 63rd Street, New York, N.uw York 10021, USA. (Tel 212 838 0230.) "Paediatric nephrology v nephrotic syndrome, current concepts in diagnosis and management"-Mecting 4-7 January 1978, Miami. Details from ComprchensiPve Children's Kidney Center, Department of Pediatrics, University of Miami, School of Medicine, PO Box 520875, Biscaync Annex, Miami, Florida 33152, USA. The British Council-Details of the followring mcetings on "The liver," 25-27 January, London and Bristol, "Paediatric nephrology," 15-28 Januarv, London, "Neonatal surgery," 22 January3 February, ILondon, "Clinical respiratory physiology," 22 January-3 February, Penarth and London, "Paediatric gastroenterology," 12-25 February, Birmingham, and "Calcium and phosphate mctabolism," 5-18 March, Lceds, are now available from the director, Courses Department, The British Council, 65 Davies Street, London W 1 Y 2AA. (Tel 01 -499 8011.) International Seminar on Clinical Oncology -8-12 February 1978, Spain. Details from the Spanish Society of Cancer Chemotherapy, Seminario Internacional de Oncologia Clinica, Villanuecva 11, Madrid 1, Spain. Institute of Dermatology-Advanced seminar in dermatology "Reccnt advances in immunology of skin diseases," 17-21 April 1978, London. Details from the dean, Institute of Dermatology, St John's Hospital for Diseases of the Skin, Lisle Street, Leicester Square, London WC2H 7BJ. (Tel 01-437 8383.) Centre for Postgraduate Psychiatry-Details and copies of the programme for October and November are now av,ailablc from the Centre,
Uffculme Clinic, Queensbridge Road, Mosclcy, Birmingham. (Tel 021 449 4481.) University of Dundee-Details and copies of the programme of postgraduate mcdical education for the 1977-8 session are now available from Dr Hamish Watson, Postgraduate Dean, Ninewells
Hospital and Medical School, Dundee DD1 9SY. (Tel 0382 60111.)
SOCIETIES AND LECTURES 1For attenidinig lectuires mnarked * a fee is charged or a ticket is required. Applicatilons shouild be ttmade first to the itistitiutin concertned.
Tuesday, 18 October INSTITUTE OF DERMATOLOGY-4.30 pm, Dr I Sarkany: Psysiology of itching. INSTITUTE OF NEUROLOGY (QUEEN SQUARE)-5.30 pm, IProfessor J C Gautier (Paris): Cerebral embolism. WESTMINSTER MEDICAL SCHOOL-5.15 pm, Mr E M Thomas, surgical conferenice: The diabetic foot.
Wednesday, 19 October INSTFITUTE OF NEUROLOGY ,QUEEN SQUARE)-SandoZ Foundation lectures, 6 pm, Professor J C Gautier Paris>: Pathology of cerebrovascular disease. 7 pm, Professor John Marshall: Clinical diagnosis of cases of stroke. INSTITUTE OF ORTHOPAEDIcs-6 pm, Dr R N Mainii: Basic concepts of clinical immunology. 7 pm, Dr A T Richardson: The use of local steroids. INSTITUTE OF PSYCHIATRY-5.30 pm, Dr J D Stephenson: rhe neuropharmacological basis for the use of imipramine in enuresis. ROYAL FREE HOSPITAL-5 pm, Professor J T Galambos !USA): The metabolic consequcnces of shunt surgery. UNIVERSITY OF OXFORD-At Radcliffe Infirmary, 5 pm, Professor Sheila Shcrlock: Chronic hepatitis. WEST LONDON HOSPITAL-5.30 pm, 30th Alex Simpson Smith Memorial lecture by Mr J D At-well: Changilng patterns in paediatric surgical care.
Thursday, 20 October LONDON
HCSI'ITAI
MiEDICAL
COLLEGE-5.30
imperative.
ROYAL COLLEGE OF: PHYSICIANS OF LoNTDON-5 pm, Teal lecture by P'rofessor H ' ILambert: Rational antimicrobial drug policies for infections of childhood. ROY-Al, SOCIETY OF TROPICAL A.M.NEIDICINE AND HYGIENE6 pnm. presidential addrcss by D)r S G Browne: Tropical medicinc-facinig today's dilemmas. ST MARY'S HOSPITAL MI5IEICAL SCIIOOL-5.15 pm, Aleck Boiurne lecture by Mr 1) 13 Painiinii: Counselling in legal abortion.
Friday, 21 October EINGINEERING Sor(:Ii>T'Y-At University College, London. 6 pm, Woolmer .Memorial leCtuLre by P'rofessor D C Simpson: Arms: natural and articiai. WORTHING; IPOSTGRADUATE MEDICAL CENTRE-1 pm, 2nd L-conard Simpson lecture bv Professor G M Besscr: Prolactii and gonadal function. BIOLOGI(AL
BMA NOTICES Diary of Central Meetings OCTOBER
19 Wed 19 19 20 24
Wed W'ed Thurs Mon
24 Mon
25 Tues 25 Tuoes 26 Wed
Scottish Committee for Hospital Medical Services 7 Drumsheugh Gardens, Edinburgh EH3 7QP'l, 10.45 am. Negotiatinig Subcommittee C(CHMS), 10 am. Central Ethical Committee, 10.30 am. Occupational Health Committee, 10.30 am. General Medical Services Committee, 10 am. Scottish Council 7 Drumsheugh Gardens, Edinburgh EH3 7QP), 10.45 am. Medical Academic Staff Committee, 2.30 pm. Joint Consultants Committee "Royal College of Surgeons of England, Iincoln's Inn Fields, Iondon WC2), 9.30 am. Negotiating Subcommittee (CCCM), 10.30 am. BMA Council Executive, 10 am.
Division Meetings to be Held Alfepnbers proposing to attenid mneetings marked * are usked to notifAv i't advance the hotnorary, secreturyP concerned. Aldershot and Farnham-At Frimley Park Hosautumn clinical
pital, Wednesday, 19 Octobcr, 7 pm,
meeting. *
APPOINTMENTS CITY AND EAST LONDON AREA HEALTH AUTHORITY IKTEACHING)-Dr M R Bligh (consultant child psychiatrist). NORTH-EAST FHAMES RHA-Dr Zoe Fi Slattcrv 1consultant psychiatrists with a special interest in the c1derly). 'N'ESSEx RHA-Dr BP Moorc (consultant psychiatrist).
pm,
Schorsteiin Memorial lecture by Professor K W Investigating the new-born-the ethical
Cross:
18 Tucs
Manchester-At Boyd House, Tuesday, 18 October, 8 for 8.30 pm, Professor A M Breckenridge: "Treatment of hypertension." * Northampton District-At Cripps Postgraduate Medical Centre, Thursday, 20 October, 7.30 for 7.45, French evening, followed by medicopolitical discussion 9 pm.* North Tyneside-At Winthrop Laboratories, Gosforth, Thursday, 20 October, 1 pm, visit.* North Warwickshire-At Chase Hotel, Nuneaton, Thursday, 20 October, 8 for 8.30 pm, annual valedictory dinner and ladies' night, guest speaker Sir Derrick Dunlop.* (Guests are invited.) Roehampton-At Queen Mary's Hospital, Monday, 17 October, 8.30 pm, wine tasting.* (Friends are invited.) South-west Durham-At Bishop Auckland General Hospital, Tuesday, 18 October, 8 pm, Dr P H Thomas: "Fire problems and research." South-west Wales-At All Saints' Church, Llanelli, Sunday, 16 October, 11 am, annual St Luke's service. (Guests are wclcome.) Tunbridge Wells-At Postgraduate Centre, Saturday, 22 October, Ladies Guild dinner and dance.* Woking and Chertsey-At St Peter's Hospital, Wednesday. 19 October, 8.30 pm, Professor Rogcr Dyson: "The place Trade Unions occupy in the NHS today and their anticipated role in the future, with particular reference to the implications this may have for the medical profession." (Members of adjoining divisions are inivited.)
Buckinghamshire-At White Swan Hotel, Aylesbury, Wednesday, 19 October, 7.30 for 8 pm, invitation from Buckinghamshire Branch, Pharmaceutical Socicty of Great Britain, to the film "'Thrombolvtic therapy," produced by Kabi Vitrum.* Hastings-At Royal East Sussex Hospital, Tuesday, 18 October, 7.15 pm, IPresidenit's evcning with Mr Michael Devas: "Orthopacdic shop window." Huddersfield-At Royal Infirmary, Monday, 17 October, 8.15 pm, agm. Leeds-At Leeds General Infirmary, W'ednesday, 19 October, 8.15 pm, Mr John Stevenson: "The doctor and the P'ress."
Corrections Industrial action The hirst resolution of the Kingston, Richmond, and Epsom Division in the letter from Dr E G Cohlen (27 August, p 583) should read: "(1) That under no circumstanccs would doctors be willing to withdraw any of their services under the NHS. For, 2; against, the rest." Prospective trial of oestrogen and calcium in postmenopausal women In the paper by A Horsman and others (24 September, p 789) the following sentence was omitted: "In the trial, calcium was administered as calcium galactogluconate kindly provided by Sandoz Laboratories."
Reptilase time in cirrhosis and hepatocellular carcinoma We rcgret that an error occured in the short report by Dr P J Johnson and others (1 October, p 869). In the second paragraph of Patients, methods, and results the third sentence should not have included a reference to a figure. Notice to authors When original articles and letters for publication are not submitted exclusively to the British Medical Yournal this must be stated. For detailed instructions to authors see page 6 of the issue dated 1 January 1977. Correspondence on editorial business should be addressed to the Editor, British Medical J1ournal, BMA House, Tavistock Square, London WC1H 9JR. Telephone: 01-387 4499. Telegrams: Aitiology, London WC1. Communications will not be acknowledged unless a stamped addressed postcard or an international reply coupon is enclosed. Authors wanting reprints of their articles should notify the Publishing Manager, BMA House, Tavistock Square, WC 1H 9JR, on receipt of proofs. i( British Medical Journal 1977 All Rights Reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means,
electronic, mechanical, photocopying, recordirng or otherwise, without the prior permission of the
British Medical 7ournal.
NEWS
BRITISH MEDICAL JOURNAL
15
OCTOBER
1977
AND NOTES
Views "Genetics can be taught as well on man as on the pea," said Sir Peter Medawar in his British Postgraduate Medical Federation lecture, "Biology and Medicine"; and he expressed scorn for the view that no one can treat patients before his teachers have taken him on a conducted tour of the animal kingdom. Nevertheless, his thesis was that biology can make an important contribution to medical problems. He amply vindicated this by returning to the idea of a "cancer vaccine," mimicking the immunological effects of youthful childbearing in protecting women against breast cancer and other tumours (10 September, p 712). The idea that early childbearing might lead to immunisation with embryonic antigens is not far-fetched because normal pregnant animals can show such an immune reaction. Sir Peter described experiments suggesting that previous inoculation with fetal tissue does indeed protect mice against one tumour (induced by a chemical, methylcholanthrene). But later inoculation, after the malignant transformation must have taken place, is actually good for tumours: is this an analogue of the increase in breast cancer in women who have their first baby after 32 and who fare even worse than the childless ? The immunological arguments, he maintains, point to a natural defence against cancer; some people would be more resistant than others as a result of their constitution and life history. And some tumours do regress naturally-especially, said Sir Peter, now that this is known to be scientifically respectable.
Antimedicine writers often assert that mortality has hardly altered this century for middle-aged citizens of Western countries. They are wrong. The latest figures from the Metropolitan Life Insurance Company show that in 1900 the mortality rate in 45-yearold men in the United States was 12 611000 and for their wives it was 10 6. Now the figures are 4-9 and 2 7, and there has been an increase in life expectation of 4 3 years for men and 9 3 years for women. If Minerva became so stressed that she could spare only three minutes' reading time each week to keep up to date she would choose Newsweek, whose medicine section is always accurate and selects the important events with consistent reliability. For instance, it picked up the important controlled trial of coronary bypass surgery published in the New England Journal of Medicine (1977, 297, 621)-which showed that after three years patients treated by bypass for chronic stable angina had done no better than those given beta-blockers-and quoted Eugene Braunwald of Havard as guessing that the finding would "put a damper on the almost explosive rise in this operation and save patients about $500m in medical bills." On the defensive after attacks on their advertising in developing countries, the Nestle Company have produced a booklet explaining that for many years now their radio campaigns in Africa have stressed that breast-feeding is best, and that their posters do the same. Clearly it is wrong to blame the milk companies for the decline in breast-feeding throughout much of the world, but the very ubiquity of bottle feeding must suggest to young mothers that it is acceptable and even preferable-yet another issue in which there is no black and white-only shades of grey.
Minerva usually enjoys trips to Holland and the joint BMA/ Royal Netherlands Medical Association meeting at Leiden (see p 1012) was no exception. But why did so few Dutch doctors attend ? One explanation could be that they were suspicious of British motives: the programme included sessions on the Dutch medical system and visits to a group practice and local hospitals. Were the innocent visitors mistaken for undercover agents inspecting a possible new territory for disenchanted medical migrants ?
Amiiong the talking points of the meeting was a suggestion by a Dutch geriatrician that both psychosis and denientia in the elderly were sometimes due to the strains of a long-endured marriage. Once separated froni their spouses these patients recover, he explained: but unfortunately, there was then little alternative but a reunion and a relapse. Neutron activation analysis of King Charles II's hair suggests, like his clinical history, that he died of mercury poisoning (he was an amateur alchemist who distilled mercury). This is one of the fascinating facts in "Hair and history," a paper by Professor J M A Lenihan summarised in Medical History (1977, 21, 192). Hair analysis, Minerva was cheered to learn, suggests that the "internal" environment is now cleaner than in past centuries: preoccupation with the side effects of modern drugs makes us forget perhaps the arsenic, mercury, and lead of former medical practice. Hair is also being analysed for heavy metals to screen various occupational groups (including dentists as well as industrial workers) and to check on environmental contamination in water supplies and elsewhere.
Disposable syringes make splendid water pistols-as many doctors' children know-but their popularity may lead to clandestine searches of medical dustbins by enterprising youngsters. The hazard, of course, is the needles, for hepatitis is only one gloomy possibility. Refuse containers need to be child proof if medical waste is put in them. Nice to see in the British Journal of Venereal Diseases a complimentary review of How to Have Sexual Intercourse Without Getting Screwed (Madrona, Seattle)-an accurate account of sexually transmitted diseases combining sense with style: "after a week's abstinence altruism starts to give way to lust." There are few texts giving practical advice to the promiscuous, so this is a welcome exception.
Housework has never been Minerva's favourite pastime and she particularly sympathises with disabled people who find it difficult to do their normal household chores or cannot afford paid help. From 17 November, however, about 40 000 disabled married women will be able to claim 110 50 a week tax free. Perhaps a "daily" will be able to come in more often or the money saved for a fully automatic washing machine. All women under 60 who have been continuously incapable of work and household duties for at least 28 weeks and who do not qualify for full-rate- sickness or invalidity benefit because they do not have enough National Insurance contributions are eligible to apply now. MINERVA
BRITISH MEDICAL JOURNAL
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15 OCTOBER 1977
MEDICOLEGAL Annual Report of Medical Protection Society FROM OUR LEGAL CORRESPONDENT
Year after year the defence societies have repeated their warnings that skimped or inaccurate records may lead to malpractice actions being lost or having to be settled which otherwise could have been successfully defended. Sometimes it has almost seemed as though repetition had damaged the value of the advice, but this year's report of the Medical Protection Society contains accounts of two cases from which the message emerges loud and clear. To make the moral yet more pointed, both stemmed from the same cause, the development of kernicterus in neonates. In the first case patchy records contributed to there being an award of damages of £20 000, while in the other a potential liability for damages of £54 000 was avoided because the judge preferred the account of the child's condition portrayed in the notes to that given by the mother. In both cases complaints were made that serum bilirubin tests should have been performed earlier. In the first case the baby developed jaundice on day two, and kernicterus had set in (with subsequent brain damage) by day four when he was given an exchange transfusion. The plaintiff sought successfully to persuade the judge that the serum bilirubin test should have been done on day three. The defence was run on the basis that until day four the baby's condition was consistent with mild physiological jaundice and that the kernicterus was the result of a sudden acute infection developing on that day. The mother, however, gave evidence that the child's jaundice got worse between day three and day four, and this could hardly be disproved from the records of the paediatric house officer. In his clinical notes there was no mention of jaundice on day two, though it was mentioned in the nursing notes. On day three the house officer recorded "jaundice getting less" and on day four "jaundice same." In conflict with this was what he had written in his letter referring the child for exchange transfusion. There he had said that the jaundice had diminished on day two and day three, but that on day four the child had been found to be more jaundiced. Not surprisingly the court found against the defendant. No recollection
In the second case the clinical notes were critical since the action came to trial 11 years after the events, and neither the ward sister nor the paediatrician had any recollection of what had occurred. In evidence the West Indian mother of the child (who had a G6PD deficiency) stated that her son's jaundice worsened progressively after birth until discharge on day eight. It was three days later that the child was readmitted with kernicterus. In contrast to the mother's account the notes showed that jaundice which had developed on day four was fading by day eight. A Coombs test had been negative, and the consultant paediatrician who saw the child on the day of discharge noted that he had regained his birthweight of 7 pounds. In the judge's view the silent evidence of the notes was more convinc-
ing than the mother's story, and the MPS funds were saved from having to make a very substantial payment. As it was, during the calendar year 1976 total MPS indemnities to members for costs and damages rose to £619 000 from the previous year's figure of £434 000. Legal costs actually went down from £217 000 to £ 177 000. The society's accumulated funds now amount to C2-2m as against an estimated contingent liability of f1 6m in respect of claims notified up to 31 March 1977. (The equivalent figures for the Medical Defence Union are £3 2m and £2 4m respectively.) Like the MDU, the society has benefited from the increase in subscription income (up from £1 2m in 1975 to £1 6m), and it was able to make a contribution of £450 000 out of income to its provision for indemnity in the accumulated funds. This contribution was £200 000 more than that in 1975, and the treasurer states that the full effect of the increase in subscriptions will not become apparent until the 1977 accounts are complete.
The perennial bugbear of what and how much to tell the patient was raised in another case successfully defended by the MPS. The plaintiff had undergone tubal ligation and after histological confirmation of excised portions of the Fallopian tubes she had asked the registrar whether it meant that she would have no more children. Perhaps a little delphically he replied: "as far as I am concerned, you won't come back." Two years later the woman was pregnant again, and it was contended on her behalf that she should have been told that tubal ligation had a 1 in 300 failure rate so that she could have considered contraception. At the trial, as the experts debated the issue, it appeared that how much the patient was told varied widely. The judge ultimately accepted the word of an expert witness who said that, while he did not volunteer information about the failure rate, he did not lie if asked about it. The judge considered that what the registrar had said was in accordance with this practice.
High settlement
Accepted medical practice
The menace of inflation in awards of damages means that there is always a temptation to harp on the most costly cases in the report, and 1976 saw the society's most expensive indemnity to date, a payment in Australia of approximately £110 000 (less a hospital contribution of £7200). The settlement followed the perforation of the bowel of a small girl during sigmoidoscopy and rectal biopsy. Unfortunately for the consultant surgeon concerned, the light of the sigmoidoscope had gone out, and rather than inflict a second anaesthetic on the child, he decided to continue with a hand torch, whose beam was apparently not much less than that of the sigmoidoscope. A day later the child had developed septicaemic shock, and after a colostomy during the day, that evening she had fits and became cyanosed. She was left in a vegetative state. The MPS took the point that perforation of the bowel could occur without negligence, so that what had happened did not speak for itself, but its Australian solicitors believed that the case was hopeless and ought to be settled. It was obviously highly relevant both to liability and to the level of damages that the trial was to have been before a jury. Though neither defence society ever says so outright, a reader of their reports over the years cannot avoid the impression that in countries like Ireland and Australia where members face trial by jury, actions have to be settled which would be defended (perhaps successfully) before a dispassionate English judge. By way of example, in 1976 the MPS succeeded in the High Court in showing that footdrop after osteotomy of the hipjoint was a recongised hazard and that it did not follow from its appearance after the operation that its member had been negligent. A jury might not have received the argument so sympathetically, especially if one of the members knew that a protection society would hold the doctor immune from any award of damages.
The result of this case shows that malpractice actions do turn directly on the practice of the profession and the standards of the responsible practitioner. Not warning patients of the slight risk of conception after tubal ligation may have its critics, but that was not the point. The issue was whether the lack of a warning was consonant with accepted medical
practice. The most anxious questions of how much to tell a patient arise in relation to possible side effects or hazards of treatment. Here again the courts have been sympathetic to doctors. In 1975 Mr Justic Bridge held1 that it was reasonable not to have told a patient of the relatively remote risk of neurological complications during an aortogram. The judge was conscious that full disclosure might both alarm the patient and put him in a position where he felt that he and not the better qualified doctor must take the decision whether to proceed. The MPS Report contains a host of useful warnings for the profession. Articles on the danger of dismissing employees without first giving both oral and written warnings and on prescribing hazards in paediatrics (by Professor A B M Campbell) deserve careful attention and cannot be done justice in condensation. A particularly important warning concems the prescription of drugs by those only temporarily registered with the GMC. Such doctors must not use FPlO forms and they may only use FP1OHP forms in cases of emergency. They may prescribe only for patients whose care comes within the terms of their registration and then only on the hospital forms. Finally, the past year has seen the passage through Parliament of the Criminal Justice Bill 1977, clause 39 of which abolishes the coroner's power to commit for murder, manslaughter, and infanticide. This is a reform which has been urged for years and was recommended in the report2 of the Brodrick Committee in 1972. Since then both the MDU and the MPS have had a case in which members
1034 were committed for trial by a coroner for manslaughter only for no evidence to be offered by the Crown at the trial. In one case a child had died during an anaesthetic, and in the other two doctors: in the West Country diagnosed gastroenteritis in a child with appendicitis. The Joint Co-ordinating Committee of the three British defence societies forwarded details of the two cases to the Home Secretary, who by then had already given an undertaking to introduce legislation. The reform now comes over 40 years after it was first suggested by the Wright Committee in 1936.
BRITISH MEDICAL JOURNAL
later on to those who hav.e successfully com- A supplement ( 1 50) lists awards at British pleted the first year. universities open only to academic staff from non-Commonwealth universities.
Health and Safety Commission
Association of Clinical Pathologists
A five-year work programme covering a wide spectrum of health and safety at work activities is set out in the first report of the Health and Safety Commission, for 1974-6 (HMSO, C2). The 140 specific projects in the plan of work-to be carried out by the Health and Safety Executive, the Commission's operational arm-range from the preparation of new regulations on carcinogenic substances, O'Mallev-Williams z' National Hospital for Nervous to help reduce serious long-term health hazards Diseases, British Aledical 7ournal, 1975, 1, 635. 2 Report of the Committee on l)eath Certification and to workers; to preparing regulations for the Coroniers, Cmnd 4810. London, HMSO, 1972. safe handling and housing of bulls; and producBritish Medical Jornal, 1975, 3, 108. ing a safety assessment of the commercial fast-breeder reactor. The report also contains an outline of the Commission's future strategy, which has three main elements: a comprehensive review and updating of existing health and safety legislation; promoting positive attitudes towards health and safety at work; and improving the collection and dissemination of information. Central Health Services Council
MEDICAL NEWS
Health authorities should not be advised at present to give priority to developing mobile coronary care units, in the view of the Central Health Services Council's Standing Medical Advisory Committee, while there is no firm evidence of their value as life-saving measures; but such units should be evaluated. At the same time greater emphasis is needed on preventing coronary heart disease and on ways of reducing the delays in seeking and obtaining help when an attack occurs. This is one of the many subjects considered by the council and its committees and standing advisory committees that are touched on in the annual report for 1976 (HMSO, 60p). Particular mention is given to priorities in the health and personal social services and sharing resources for health; preventive medicine arrangements for health care in residential homes for the elderly; management arrangements for longstay psychiatric hospitals; vaccination; and drinking and driving.
15 OCTOBER 1977
Medical Research Council
The outlook for funding new medical research is becoming brighter, according to the press notice issued with the MRC's Annuiiial Report 1976-77. Although the council had a difficult year, there is now a real prospect of greater financial stability. The report (published by HMSO at L2 25) is cautiously optimistic about the council's ability to increase the value of awards, particularly for short-term grants, and universities have been told that new proposals for long-term grants can now be considered. Despite the economies of recent years the number of university scientists supported by the MRC has not declined. The past year has seen steady progress on a wide front, the report states. The report touches on immunological approaches to contraception, tests for coeliac disease, plasma exchange in glomerulonephritis, molecular mechanisms of thalassaemia, the endorphins as naturally occurring pain killers, and the overlapping genes of the School of Community Paediatrics, bacteriophage (I)X174. The council is particularly keen to support good new work on, Edinburgh among other things, cardiovascular disease, Britain's first School of Community rheumatism and arthritis, gastroenterology, Paediatrics, founded by the Scottish Home nutrition, dentistry, aspects of cancer, skin and Health Department, was officially opened diseases, allergy, the dementias, deafness, by Professor Sir John Brotherston on 7 toxicology, and accidents. October at 18 Millerfield Place, Edinburgh 9. Its purpose, a press statement comments, is to produce the new type of child-oriented Awards for Commonwealth university doctor needed for the integrated child health staff service envisaged in 1973 by the department's Except in Nigeria, there are fewer opporreport Towards an In tegrated Child Health Service. Its function is also in line with the tunities now than 10 years ago for those who recommendations for England and Wales wish to do long-term research or teaching in a made in the Court Committee's report, Fit Commonwealth country other than their own. for the Fiture. Full-time students on the first But there are many short-term possibilities: course will spend two days a week on lectures hundreds of fellowships and visiting lectureand background information. The other three ships for the staff of universities in Britain will be spent at schools, child health clinics, and other Commonwealth countries are listed residential homes, and special schools for in a guide published by the Association of handicapped children; attending specialised Commonwealth Universities (36 Gordon clinics of the Royal Hospital for Sick Children; Square, London WC1H OPF) at £2 75. This and attached to doctors specialising in paediat- provides information about sources of financial ric work in the community and to general aid for academic and administrative staff who practitioners. Part-time students can be wish to undertake research, make study visits, accepted. A further course may be offered or teach in another Commonwealth country.
At the annual general meeting of the association, held on 15 September with the retiring president, Dr C L Greenbury, in the chair, the following were elected-Professor H A Sissons, president; Professor Norman Ashton, president-elect; Dr H M Rice, Dr C Giles, vice-presidents; Dr A G Marshall, chairman of council; Dr A C Hunt, honorary secretary; Dr G W Pennington, honorary treasurer; Dr G S Anderson, Dr E W Bell, Dr J Burston, Dr Heather M Dick, members of council for 1977-80.
Anna Monika Foundation competition
Three British scientists have received prizes in the sixth competition of the Anna Monika Foundation, Dortmund, West Germany, which was endowed in 1965 to award a biennial prize for investigations on the physical substrate and functional disturbances of endogenous depressions. Professor Sir Martin Roth, then at the University of Newcastle upon Tyne, won first prize for his study on the nosology and classification of affective disorders. Dr A R Green and Professor D G Grahame-Smith, University of Oxford, jointly won second prize for their investigation on the interaction between serotonergic and dopaminergic neurones in the central nervous system. Kidney transplants The number of kidney transplants undertaken in the United Kingdom and Republic of Ireland for the month ending 30 September 1977 was 73, and the number of potential recipients on file was 1222. Corresponding figures for the previous month were 58 and 1213.
People in the news Professor Sir Cyril Clarke, FRS, emeritus professor and honorary Nuffield research fellow, department of genetics, University of Liverpool, is one of the 1977 winners of the Gairdner International Awards for outstanding contributions to medical science.
COMING EVENTS Royal Society of Tropical Medicine and Hygiene-Symposium on immunology of parasitic infections, 27 October, London. Details from the Society, Manson House, 26 Portland Place, London WIN 4EY. (Tel 01-580 2127.) Bone and Tooth Society-Autumn meeting, 11 November, Cardiff. Details from Dr Maureen Owen, MRC Bone Research Laboratory, Nuffield Orthopaedic Centre, Headington, Oxford. Faculty of Homoeopathy, Midlands Branch3rd annual symposium on homocopathic medicine, 12 November, Birmingham. Details from Dr R A F Jack, The Limes, Lydiate Ash, Bromsgrovc, Worcestershire B61 OQL. (Tel 021 453 3170.) Royal College of General PractitionersAnnual symposium "Standards and settings in general practice," 20 November, London. For details sec advertisement at p xiii.
BRITISH MEDICAL JOURNAL
1035
15 OCTOBER 1977
Society for Psychosomatic Research-21st annual conference, "Thc coming agc of psychosomatics," 21-22 November, London. Details from Dr Peter Mellett, Horton Hospital, Epsom, Surrey KT19 8PZ. (Tel Epsom 29696, ext 286.) Third therapeutics conference-25 November, London. Details from the Co-ordinator of Studies, St Christopher's Hospice, 51-53 Lawrie Park Road, Sydenham, London SE26 6DZ. (Tel 01-778 9252.) "Family with a mentally handicapped member"-Symposium, 25 November, Southport. Details from Dr R P Arya, Greaves Hall Hospital, Banks, Southport, Merseyside PR9 8BP. (Tel 0704 27451.) Institute for the Study and Treatment of Delinquency-W'cekend discussion course, 25-27 November, Rugeley. Details from the Institute, 34 Surrey Strcet, Croydon, Surrcy CR0 IRJ. (Tel 01-680 2068.) Association for the Study of Medical Education-Joint meeting with the Society for Research in Higher Education "Approaches to curriculum dcsign and evaluation: the medical experience," 30 November, London. Details from Mrs M Clothier, BLA'I' Centre for Health and Medical Education, BMA House, Tavistock Square, London WC1H 9JP. (Tel 01-388 7976.) International Study Group for Steroid Hormones-VIII meeting, 5-7 December, Rome. Details from Professor C Conti, Istituto di Patologia Medica II, Policlinico Umberto 1,
Rome, Italy. Tumour Ultrasound '77-International symposium, 5-7 December, London. Details from Dr Ralph McCrcadv, Department of Nuclear Medicine and Ultrasound, Royal Marsden Hospital, Doxwns Road, Sutton, Surrey. (Fel 01-642 6011.) New York Academy of Sciences-Conference "Primary hcalth care in industrialised nations," 12-14 Decembcr, Ncwv York. Details from Confcrcnce Department, New York Academy of Sciences, 2 East 63rd Street, New York, N.uw York 10021, USA. (Tel 212 838 0230.) "Paediatric nephrology v nephrotic syndrome, current concepts in diagnosis and management"-Mecting 4-7 January 1978, Miami. Details from ComprchensiPve Children's Kidney Center, Department of Pediatrics, University of Miami, School of Medicine, PO Box 520875, Biscaync Annex, Miami, Florida 33152, USA. The British Council-Details of the followring mcetings on "The liver," 25-27 January, London and Bristol, "Paediatric nephrology," 15-28 Januarv, London, "Neonatal surgery," 22 January3 February, ILondon, "Clinical respiratory physiology," 22 January-3 February, Penarth and London, "Paediatric gastroenterology," 12-25 February, Birmingham, and "Calcium and phosphate mctabolism," 5-18 March, Lceds, are now available from the director, Courses Department, The British Council, 65 Davies Street, London W 1 Y 2AA. (Tel 01 -499 8011.) International Seminar on Clinical Oncology -8-12 February 1978, Spain. Details from the Spanish Society of Cancer Chemotherapy, Seminario Internacional de Oncologia Clinica, Villanuecva 11, Madrid 1, Spain. Institute of Dermatology-Advanced seminar in dermatology "Reccnt advances in immunology of skin diseases," 17-21 April 1978, London. Details from the dean, Institute of Dermatology, St John's Hospital for Diseases of the Skin, Lisle Street, Leicester Square, London WC2H 7BJ. (Tel 01-437 8383.) Centre for Postgraduate Psychiatry-Details and copies of the programme for October and November are now av,ailablc from the Centre,
Uffculme Clinic, Queensbridge Road, Mosclcy, Birmingham. (Tel 021 449 4481.) University of Dundee-Details and copies of the programme of postgraduate mcdical education for the 1977-8 session are now available from Dr Hamish Watson, Postgraduate Dean, Ninewells
Hospital and Medical School, Dundee DD1 9SY. (Tel 0382 60111.)
SOCIETIES AND LECTURES 1For attenidinig lectuires mnarked * a fee is charged or a ticket is required. Applicatilons shouild be ttmade first to the itistitiutin concertned.
Tuesday, 18 October INSTITUTE OF DERMATOLOGY-4.30 pm, Dr I Sarkany: Psysiology of itching. INSTITUTE OF NEUROLOGY (QUEEN SQUARE)-5.30 pm, IProfessor J C Gautier (Paris): Cerebral embolism. WESTMINSTER MEDICAL SCHOOL-5.15 pm, Mr E M Thomas, surgical conferenice: The diabetic foot.
Wednesday, 19 October INSTFITUTE OF NEUROLOGY ,QUEEN SQUARE)-SandoZ Foundation lectures, 6 pm, Professor J C Gautier Paris>: Pathology of cerebrovascular disease. 7 pm, Professor John Marshall: Clinical diagnosis of cases of stroke. INSTITUTE OF ORTHOPAEDIcs-6 pm, Dr R N Mainii: Basic concepts of clinical immunology. 7 pm, Dr A T Richardson: The use of local steroids. INSTITUTE OF PSYCHIATRY-5.30 pm, Dr J D Stephenson: rhe neuropharmacological basis for the use of imipramine in enuresis. ROYAL FREE HOSPITAL-5 pm, Professor J T Galambos !USA): The metabolic consequcnces of shunt surgery. UNIVERSITY OF OXFORD-At Radcliffe Infirmary, 5 pm, Professor Sheila Shcrlock: Chronic hepatitis. WEST LONDON HOSPITAL-5.30 pm, 30th Alex Simpson Smith Memorial lecture by Mr J D At-well: Changilng patterns in paediatric surgical care.
Thursday, 20 October LONDON
HCSI'ITAI
MiEDICAL
COLLEGE-5.30
imperative.
ROYAL COLLEGE OF: PHYSICIANS OF LoNTDON-5 pm, Teal lecture by P'rofessor H ' ILambert: Rational antimicrobial drug policies for infections of childhood. ROY-Al, SOCIETY OF TROPICAL A.M.NEIDICINE AND HYGIENE6 pnm. presidential addrcss by D)r S G Browne: Tropical medicinc-facinig today's dilemmas. ST MARY'S HOSPITAL MI5IEICAL SCIIOOL-5.15 pm, Aleck Boiurne lecture by Mr 1) 13 Painiinii: Counselling in legal abortion.
Friday, 21 October EINGINEERING Sor(:Ii>T'Y-At University College, London. 6 pm, Woolmer .Memorial leCtuLre by P'rofessor D C Simpson: Arms: natural and articiai. WORTHING; IPOSTGRADUATE MEDICAL CENTRE-1 pm, 2nd L-conard Simpson lecture bv Professor G M Besscr: Prolactii and gonadal function. BIOLOGI(AL
BMA NOTICES Diary of Central Meetings OCTOBER
19 Wed 19 19 20 24
Wed W'ed Thurs Mon
24 Mon
25 Tues 25 Tuoes 26 Wed
Scottish Committee for Hospital Medical Services 7 Drumsheugh Gardens, Edinburgh EH3 7QP'l, 10.45 am. Negotiatinig Subcommittee C(CHMS), 10 am. Central Ethical Committee, 10.30 am. Occupational Health Committee, 10.30 am. General Medical Services Committee, 10 am. Scottish Council 7 Drumsheugh Gardens, Edinburgh EH3 7QP), 10.45 am. Medical Academic Staff Committee, 2.30 pm. Joint Consultants Committee "Royal College of Surgeons of England, Iincoln's Inn Fields, Iondon WC2), 9.30 am. Negotiating Subcommittee (CCCM), 10.30 am. BMA Council Executive, 10 am.
Division Meetings to be Held Alfepnbers proposing to attenid mneetings marked * are usked to notifAv i't advance the hotnorary, secreturyP concerned. Aldershot and Farnham-At Frimley Park Hosautumn clinical
pital, Wednesday, 19 Octobcr, 7 pm,
meeting. *
APPOINTMENTS CITY AND EAST LONDON AREA HEALTH AUTHORITY IKTEACHING)-Dr M R Bligh (consultant child psychiatrist). NORTH-EAST FHAMES RHA-Dr Zoe Fi Slattcrv 1consultant psychiatrists with a special interest in the c1derly). 'N'ESSEx RHA-Dr BP Moorc (consultant psychiatrist).
pm,
Schorsteiin Memorial lecture by Professor K W Investigating the new-born-the ethical
Cross:
18 Tucs
Manchester-At Boyd House, Tuesday, 18 October, 8 for 8.30 pm, Professor A M Breckenridge: "Treatment of hypertension." * Northampton District-At Cripps Postgraduate Medical Centre, Thursday, 20 October, 7.30 for 7.45, French evening, followed by medicopolitical discussion 9 pm.* North Tyneside-At Winthrop Laboratories, Gosforth, Thursday, 20 October, 1 pm, visit.* North Warwickshire-At Chase Hotel, Nuneaton, Thursday, 20 October, 8 for 8.30 pm, annual valedictory dinner and ladies' night, guest speaker Sir Derrick Dunlop.* (Guests are invited.) Roehampton-At Queen Mary's Hospital, Monday, 17 October, 8.30 pm, wine tasting.* (Friends are invited.) South-west Durham-At Bishop Auckland General Hospital, Tuesday, 18 October, 8 pm, Dr P H Thomas: "Fire problems and research." South-west Wales-At All Saints' Church, Llanelli, Sunday, 16 October, 11 am, annual St Luke's service. (Guests are wclcome.) Tunbridge Wells-At Postgraduate Centre, Saturday, 22 October, Ladies Guild dinner and dance.* Woking and Chertsey-At St Peter's Hospital, Wednesday. 19 October, 8.30 pm, Professor Rogcr Dyson: "The place Trade Unions occupy in the NHS today and their anticipated role in the future, with particular reference to the implications this may have for the medical profession." (Members of adjoining divisions are inivited.)
Buckinghamshire-At White Swan Hotel, Aylesbury, Wednesday, 19 October, 7.30 for 8 pm, invitation from Buckinghamshire Branch, Pharmaceutical Socicty of Great Britain, to the film "'Thrombolvtic therapy," produced by Kabi Vitrum.* Hastings-At Royal East Sussex Hospital, Tuesday, 18 October, 7.15 pm, IPresidenit's evcning with Mr Michael Devas: "Orthopacdic shop window." Huddersfield-At Royal Infirmary, Monday, 17 October, 8.15 pm, agm. Leeds-At Leeds General Infirmary, W'ednesday, 19 October, 8.15 pm, Mr John Stevenson: "The doctor and the P'ress."
Corrections Industrial action The hirst resolution of the Kingston, Richmond, and Epsom Division in the letter from Dr E G Cohlen (27 August, p 583) should read: "(1) That under no circumstanccs would doctors be willing to withdraw any of their services under the NHS. For, 2; against, the rest." Prospective trial of oestrogen and calcium in postmenopausal women In the paper by A Horsman and others (24 September, p 789) the following sentence was omitted: "In the trial, calcium was administered as calcium galactogluconate kindly provided by Sandoz Laboratories."
Reptilase time in cirrhosis and hepatocellular carcinoma We rcgret that an error occured in the short report by Dr P J Johnson and others (1 October, p 869). In the second paragraph of Patients, methods, and results the third sentence should not have included a reference to a figure. Notice to authors When original articles and letters for publication are not submitted exclusively to the British Medical Yournal this must be stated. For detailed instructions to authors see page 6 of the issue dated 1 January 1977. Correspondence on editorial business should be addressed to the Editor, British Medical J1ournal, BMA House, Tavistock Square, London WC1H 9JR. Telephone: 01-387 4499. Telegrams: Aitiology, London WC1. Communications will not be acknowledged unless a stamped addressed postcard or an international reply coupon is enclosed. Authors wanting reprints of their articles should notify the Publishing Manager, BMA House, Tavistock Square, WC 1H 9JR, on receipt of proofs. i( British Medical Journal 1977 All Rights Reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means,
electronic, mechanical, photocopying, recordirng or otherwise, without the prior permission of the
British Medical 7ournal.
