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NEWS
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NOTES
Viezvs "Marking" not "celebrating" is what the Government is doing for the NHS's 30th birthday. A seminar on the challenge of the next 30 years; a conference on working together to reach the disadvantaged; an exhibition on 30 years of social security; and a buffet reception at Lancaster House. Minerva also attended a more informal gathering in Mr Ennals's office to launch Professor Brian Abel-Smith's book: "NHS-The First Thirty Years" (HMSO £1 95). Poor Lord Wells-Pestell-none of the Government ministers could be there, so he stepped in, bemoaning that he's never invited any where in his own right. He regards himself as "Lord Substitute" like the people in his house (where he's Government spokesman on health) who are termed Lords Supplementary because they always attach their questions to someone else's. Did Napoleon die of carcinoma of the stomach, some form of liver disease, or arsenic poisoning ? None of these, asserts P J S Dunn, a final year medical student from Birmingham, who produces considerable evidence in favour of chronic brucellosis acquired from the milk of St Helena's goats (Update, 1978, 16, 1349). An intriguing theory but we will probably never know the truth: even at the time of the emperor's necropsy the doctors could not agree (see Anthony Burgess's novel Napoleon Symphony for a witty account of their quarrels). Mention of Napoleon reminded Minerva of the specimen of his intestines said to have been among the exhibits in the museum of the Royal College of Surgeons destroyed in the London blitz. On checking with Miss Jessie Dobson, the former curator, she found however that the story was apocryphal and had probably grown from after-dinner talk about a specimen in Sir Astley Cooper's collection which was labelled as showing lesions like Napoleon's.
People who have never smoked attribute more influence to advertisements and to the media than do smokers themselves (British Journal of Social and Clinical Psychology, 1978, 17, 189). Young smokers believed their family and friends to have been most influential in starting them off. Perhaps the campaign against cigarette advertising is not rationally based-after all, the Russians and even the health-conscious Cubans smoke like chimneys without any commercial encouragement. "In times when nothing stood/But worsened or grew strange": trying to shelter beneath other people's umbrellas at the presentation of the stone flower bowl in Queen Square to commemorate the Queen's jubilee, Minerva was depressed by these lines from Philip Larkin's verse incised in the stone beneath it. What about the people who died of, say, cancer or kidney failure 25 years ago-some of whom would now be saved ? And the pejorative reference to strangeness is sad coming from a poet. But literature for stone is a restricting discipline-which might be salutary for our more prolix medical authors. Will drug sensitivity tests one day be as routine in cancer as in bacterial infections? A promising assay is based on tumour stem-cell colonies (New England Journal of Medicine, 1978, 298, 1321), thus testing the often minute fraction of a tumour that is truly neoplastic. Twenty patients were spared empirical trial of drugs to which they were resistant; 11 out of 12 responded to
the sometimes unlikely drugs selected by the assay. But problems remain, and the authors are cautious in making claims for the method.
Visitors to the Netherlands should make sure that they have been immunised against poliomyelitis: the outbreak that started there in May has continued, with 52 cases. So far 40 patients have had paralytic symptoms. None had been immunised.
Dyslexia is a familiar concept (though paediatricians seem to prefer the term specific reading retardation); but what about children with a similar specific problem with mathematics ? Research in Russia has suggested that there may be some children with an inborn defect for calculation and the spatial thinking crucial to mathematics. As Richard Lansdown says (journal of Child Psychology and Psychiatry, 1978, 19, 181), maths is different from, say, history: it is a hierarchical skill and there is no redundancy, so that once left behind a child may never catch up. Claire Rayner has the knack of knowing what is needed in health education. " The Body Book" (G Whizzard/Andre Deutsch, C2 50) shows how perceptive she is in knowing what children want to find out about their bodies and how to put it across to them. The gastrointestinal system has a chapter entitled "In and Out," while the reproductive system is "Growing and Changing and Making New People." She has not even ducked the difficult problem of growing old and dying. In an effort to avoid technical terms some rather cumbersome phrases have been introduced-the "babymaking hole" is a bit bizarre. Much heart-searching must have gone on before "penis" was allowed to creep in.
Rocky mountain spotted fever has now (Journal of the American Medical Association, 1978, 239, 2763) been added to the list of diseases that can be transmitted by blood transfusion. The donor gave blood three days before onset of the symptoms of his illness, which proved fatal. News of the death was passed on by the blood transfusion service, making early diagnosis-and effective treatment-possible in the recipient.
Echoing the cult film "Close Encounters" a leaflet produced by a Norwich self-help group says "Ask us-you are not alone." In less than 1000 words it gives details, addresses, and telephone numbers of organisations from health visitors and speech therapists to preschool playgroups and the specialist societies for children with eczema, leukaemia, and cystic fibrosis.
Surgeons in Singapore found an "abdominal cocoon" to be the cause of small bowel obstruction in a series of 10 adolescent girls (British Journal of Surgery, 1978, 65, 427). The condition was reminiscent of sclerosing peritonitis but there was no history of drug ingestion, and retrograde menstruation or viral peritonitis are postulated as possible, but so far unproved, causes. MINERVA
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EPIDEMIOLOGY Legionnaires' disease: United Kingdom The following notes are compiled by the Communicable Disease Surveillance Centre (Public Health Laboratory Service) and the Communzicable Diseases (Scotland) Unit fronm reports subnmitted by microbiological laboratories, comnmunity physicianis, and environmenital health officers. A preliminary account of the first cases of legionnaires' disease to be identified in Britain appeared in the BMJ last year.' Laboratory investigations have shown up further cases here and have helped to explain the cause of several previously unexplained outbreaks in the United States.2 3 By the end of March 1978, 43 cases had been identified in Britain on the basis of a four-fold rise or more in indirect fluorescent antibody titre to at least 1 in 128 (16 cases); or a single indirect fluorescent antibody titre of at least 1 in 256 (20 cases); or finding the Legionnaires' bacterium in postmortem lung tissue by immunofluorescent staining (seven cases). An analysis of the cases by age and sex is Legionnaires' disease (1 J7uly 1973-1 April 1978) Age (years)
No of cases identified
Total
Men
Women
20-29 30-39 40-49 50-59 60-69 70-79 Not known
2 6 6 12 3 1 0
0 0 5 1 3 1 3
13
Total
30
13
43
2 6
11 6 2 3
given in the table. The mean age for all cases was 47 years and the range 26-76 years. There were 10 deaths, and an eleventh patient died suddenly six weeks after the onset of his illness, probably from a myocardial infarction, having apparently recovered from his pneumonia. The mean age of the fatal cases was 54 years and the range 26-63 years. Six developed the illness in 1978; 28 in 1977; two in 1976; one in 1975; and two in 1974. Four patients affected by an outbreak of respiratory illness in 1973 among tourists, mainly from Scotland, who stayed in Benidorm, Spain, were later shown to have serological evidence of legionnaires' disease. Review of the geographical distribution of the 36 most recent cases showed that the six Scottish patients lived in or around Glasgow. In England the largest concentration of patients (12) was in Nottingham: in these cases the dates of onset lay between June 1976 and February 1978, and six occurred in a sevenweek period in August and September 1977; a common source was not identified. There were three cases in Preston, two in Bath; 13 other centres had one each. Eight patients developed their symptoms during, or within seven days of returning from, a holiday in Spain. They had stayed in various resorts, three in Benidorm and one in each of five other resorts on the Mediterranean. Two of the patients from Benidorm, who were there in May and June 1977, stayed in the same hotel as the tourists in whom the outbreak of respiratory illness occurred in 1973.1 One other patient, from Nottingham, visited the
same hotel in early March 1977: though he first developed respiratory symptoms three days later, he was not admitted to hospital until May, and the changes in antibody titre suggested that the onset of legionnaires' disease occurred in late April. On this evidence it was concluded that he had probably acquired the infection in Nottingham. Most patients presented with a four to seven day history of fever, malaise, myalgia, and non-productive cough. Other symptoms included breathlessness, pleuritic chest pain, severe abdominal pain, diarrhoea, and vomiting, in that order of frequency. Four patients presented without respiratory symptoms; one of these was admitted to hospital with suspected enteric fever. Two patients had gastrointestinal bleeding shortly before admission to hospital. The typical clinical and radiological findings were of lobar and lobular pneumonia which often became multilobar. Most patients were severely ill and at least nine required assisted ventilation. Twelve became severely confused shortly before or after admission to hospital. Recovery was often slow, with a third of the survivors still showing radiological evidence of consolidation as late as three months after the onset of the illness. As regards treatment, there is evidence that erythromycin is effective and that rifampicin and some tetracycline derivatives may also be useful.
new procedure: firstly, patients who had not even committed themselves to the issue of a writ might try to use the new procedure to fish for evidence to maintain a malpractice action; and, secondly, medical records might be misunderstood, particularly if they were read by laymen.
was not a party but the documents were relevant-for example, where an employee sued his employer for industrial injuries. While doctors may have welcomed these restrictions, they made lawyers feel that they were advising their clients in the dark. The restrictions appeared all the more perverse since in the end (either when discovery was reached in an action against a hospital or at the trial if the hospital was not a party), the plaintiff was going to be entitled to see the whole of the relevant documents anyway. An unsettling case5 occurred in 1974, after the South-west Metropolitan Regional Hospital Board was asked to produce the records of a 12-year-old girl who had attended Worthing Hospital with severe abdominal pains and vomiting. A surgical registrar had diagnosed a ruptured ectopic pregnancy and told her father. This was later found to be wholly wrong, and there followed two laparotomies which failed to uncover any surgical abnormality. Eventually the girl was transferred to the Hospital for Sick Children, London, where she made a full recovery on a graduated bland diet.
I 2
3
British Medical Journal, 1977, 4, 1425. Morbidity and Mortality Weekly Report, 1965, 14, 265.
American-Journal of Epidemiology,
1978, 107, 149.
MEDICOLEGAL Disclosure of medical records [FROM OUR LEGAL CORRESPONDENT]
In an important (and at first sight rather disturbing) decision for the medical profession, the House of Lords has held' that where a plaintiff makes an application for the production of documents pursuant to sections 31 and 32(1) of the Administration of Justice Act 1970 he is entitled to see them himself and that the court has no discretion to confine inspection to the plaintiff's medical advisers. The 1970 Act (and the ensuing amendment to the Rules of the Supreme Court) brought about a revolutionary change in procedure in personal injury actions in that potential plaintiffs could inspect a potential defendant's documents before even issuing a writ. Litigants who had already started proceedings could call for documents from a third party well in advance of the trial. Previously a party to an action could obtain records of this kind only by the issue of a subpoena to produce them at the trial. If the non-party did not co-operate there was no way in which a party could see the documents before the trial. The MDU was quick to warn2 of the dangers and far-reaching implications of the
Who is the applicant? Where a person appears likely to have relevant documents in his possession the words of the 1970 Act allow the court to order that they be produced "to the applicant." None the less, as though in response to the profession's fears, in three separate cases3-5 the English Court of Appeal laid down that the proper course was to confine the production of hospital records, initially at any rate, to the plaintiff's medical advisers and not to permit the plaintiff or his lawyers to have a sight of them. This restriction applied equally to cases where it was sought to sue a hospital for negligence and to cases where the hospital
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The expert advising the plaintiff, to whom the hospital records were shown, condemned the diagnosis of pregnancy in the absence of a laboratory test as most unwise and thought that the possibility of food poisoning was insufficiently considered before the first laparotomy. Nevertheless, he concluded that the performance of the two laparotomies was not necessarily evidence of negligence. The girl's father and her lawyers were naturally disappointed at this advice and asked the court to permit them to see the records. Mr Justice Bristow thought that this was proper and that it would not comply with the purpose of the 1970 Act if lawyers could not see the records and "put their heads together with the medical expert and come to a joint conclusion on what was partly a matter of medical science and partly a matter of law." The judge thought that if the plaintiff could not see the records he could not make a sensible estimate of whether he had been wronged before committing himself to expensive litigation, but his view was overruled by the Court of Appeal. Lord Denning said that the matter could be dealt with by counsel seeing the expert in the ordinary way and asking questions on matters which seemed to require explanation or reconsideration. The expert should then answer the questions, referring to the records if necessary, but with no need to show them to the plaintiff or his advisers. The procedure envisaged by Lord Denning was perhaps artificial with the lawyers being told what was in the documents yet not being allowed to see them. None the less, Lord Denning consistently showed himself aware of doctors' fears that the new procedure might be abused. In one case4 he noted that doctors' records might contain a fleeting thought such as "query-pregnancy" in a girl of 12. He thought it better that doctors should not be restrained from such speculation.
with Mr Justice Bristow, whose views had been overruled by Lord Denning. He believed that no matter how expert and intelligent a medical man might be, he could not by virtue of those qualities alone interpret to lawyers and their clients the probable effect on a judge or jury6 of a finely balanced set of medical facts and opinions, nor should he be asked to do so. The Chief Justice described the English Court of Appeal decision in the case5 of the 12-year-old girl as a "very strong decision." It preserved medical confidence to the obvious detriment of the interests of a minor and potentially in the material interests of a hospital and its medical staff. From the lawyers' point of view there is also a danger that if they do not see the notes their medical expert may fail to see a legal problem or think that there is an obstacle where none exists. Lord Justice Jones in the Northern Ireland Court of Appeal said that as a former leading counsel he would have expressed surprise, to put it at its lowest, had he been told that he could not see very relevant, indeed possibly crucial, details of the case. He added that in the case of an infant plaintiff he could not envisage himself recommending settlement to the court, not on the basis of his own judgment, but "on what he had been told by some doctor." Conflict resolved
With the English and Northern Ireland Courts of Appeal at odds the House of Lords intervened' to resolve the conflict. Unanimously the House held that there was no escape from the wording of the statute and that it was unwarrantable, if the preconditions for making an order were fulfilled, to impose a restriction regarding the person to whom production was to be made. Lord Diplock pointed out that the purpose of early discovery was to provide for the
8 JULY 1978
settlement of personal injuries actions on terms that were fair to both sides. That necessarily meant disclosure to the legal representatives of each party of all the available material relevant to each issue in the case. Lord Diplock also made two further points that doctors should remember when discovery is sought from them; firstly, it is perfectly proper to cover up any irrelevant part of a document that is subject to disclosure. Secondly, if there is a matter which it is better a patient should not know, his legal advisers can take precautions to prevent the information becoming known. Lawyers are quite used to this and doctors should not hesitate to point out to a plaintiff's solicitor when information should be kept from their client. In Lord Diplock's words, the situation can be dealt with by "common sense and humanity." The House of Lords were really concerned only with the wording of the statute, but its decision reflects the common law principle that medical confidentiality must bow to the administration of justice. Doctors should not forget that, regardless of applications under the new rules, there is always a chance that they may be cross-examined in court at some future date on the contents of their notes. The tone of such documents should therefore be "serious and precise'{7; and the defence organisations have warned that letters to other doctors about patients may have to lose the personal touches that once lightened correspondence between colleagues. l Mclvor v Southern Health and Social Services Board (1978) 1 WLR 757. British Medical3Journal, 1972, 1, 565. 3 Dunning v United Liverpool Hospitals Board of Governors (1973) 1 WLR 586; British Medical journal, 1973, 1, 623. Davidson v Lloyd Aircraft Services Ltd (1974) 1 WLR 1042; British Medical3Journal, 1974, 2, 123. Deistung v South West Metropolitan Regional Hospital Board (1975) 1 WLR 213; British Medical Journal, 1975, 1, 465. 6 In Northern Ireland personal injury actions are still heard by juries. British Medical Journal, 1975, 1, 150. 2
Different view
In Northern Ireland the Court of Appeal took an entirely different attitude: in an application for hospital records made by a plaintiff in action arising out of a motor car accident1 the court refused to order that production should be limited. It held that, since the Act spoke of production "to the applicant," there was no jurisdiction to make an order confining production to the medical advisers and excluding the plaintiff and his lawyers. Lord Lowry, the Northern Ireland Chief Justice, dealt with the point that the notes might contain things which it was not good for the plaintiff to know by saying that medical reports to a plaintiff's solicitors often contained material of which the plaintiff was kept in ignorance. "In the same way," he said, "solicitors who inspect hospital records only rarely need to inform their client of bad tidings." Nor was Lord Lowry afraid that patients would be debarred from speaking frankly to doctors or doctors from making frank observations in their notes by the prospect of their being examined in court. "There were other inducements to reticence," he said, "which do not seem to have had an inhibiting effect." It is also true that the new procedure does not entitle a plaintiff to see documents which he could not have seen before at the trial. It merely permits him to see them at an earlier stage in the proceedings. Lord Lowry agreed
PARLIAMENT Questions in the Commons NHS and Health and Safety legislation. The Health and Safety and Work Act 1974 is binding on the Crown, and the Government have given a firm commitment that they will take all the necessary action to ensure that all Crown bodies, including the National Health Service, comply with the Act's provisions. Employment, 13 June.
Small hospitals. The Government's policy is to provide a comprehensive range of specialised services in district general hospitals, but the DHSS sees a continuing need for smaller local or community hospitals to serve patients not requiring the specialist facilities of a district general hospital. Social Services, 13 June. Health expenditure in Wales. Of the extra £3 million allocated for health services in Wales (22 April, p 1062), £2-38 million will
be distributed to areas in proportion to their 1978-9 revenue allocations; CO25 million will be spent on services to kidney patients and the provision of extra kidney machines; and the remaining £0C44 million will be allocated partly to the development of community services for the mentally ill and partly to the funding of improvements in psychiatric institutions. Wales, 13 June.
Prescriptions. The numbers of prescriptions issued (in years for which the latest figures are available) for psychotropic drugs, tranquillisers, and antidepressants are as follows: Psychotropic drugs Sedatives and tranquillisers Antidepressants and antidepressant and sedative/tranquilliser combinations
1975 45 635 000 20 868 000
1976 45 595 000 21 190 000
8 480 000
8 496 000
Social Services, 13 June.
BRITISH MEDICAL JOURNAL
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8 JULY 1978
about services and the best advice. "Should be done," the report asks, "to ensure that prospective residents are fully involved in making such decisions ?" The document goes on to discuss rehabilitaafter a spell of residential care; the usetion Ratios of staff to patients1¶ fulness of short-term and day care; and the OutInDay importance in residential homes of privacy patients* patientst patients+ and freedom of choice, including choice of All hospitals of Drinking and driving. The number diet, clothes, and times of getting up and 1: 11 2 1 17 4 1: 1643 Doctors§ road accidents in which alcohol was implicated going to bed. Other topics covered are 1 1:7 1 159 5 1 :11 Nurses§ Psychiatric preparation for retirement; pension age and in Wales since 1969 was as follows: hospitals income; family and community support; and 1: 4 5 1: 440 4 1: 26 2 Doctors§ 1 03 1 29 0 1: 1 7 Nurses§ health and other services, both statutory and All recorded Drivers voluntary. Comments are invited from those road accidents involved in Column (2) with personal accidents with as a concerned, including the elderly themselves, *Based on average daily bed occupation during 1976. percentage injury or positive (or tBased on total number of day care attendances during by 31 October. failed to of death in 1976. Wales column (1) provide) The publication of this discussion document tBased on total outpatient attendances during 1976 breath tests (new and old patients). coincided with the announcement of an Open (1) (2) (3) §Based on whole-time equivalent staff in post at 30 University course on old age-"What Living September 1976. 33 1969 380 11 538 'IBased on provisional figures for staff in post. Longer Means"-to start next February. Two 12 308 4-6 567 *TIndividual patients may have been in more than one 1970 6-0 11 864 713 1971 other recent publications on old age are The category during the year. 64 12 314 792 1972 Psychogeriatric Problem (the proceedings of a 12 079 7-6 919 1973 Social Services, 13 June. 1974 7-7 11 393 881 seminar, published by the Department of 7-8 11 075 868 1975 Community Medicine, University of Man11 498 729 63 1976 11 460* 6-1* 697 1977 chester) and Population Change and Local Merit awards. Distinction awards for conGovernment (a report based on another seminar, sultants in mental health at 31 December *Provisional figures. published by the Society of Local Authority Wales, 15 June. Chief Executives, Pelham House, St Andrew's were as follows: Lane, Lewes, East Sussex). Number of Percentage Percentage Staff ratios. The ratio of administrative and of total of all awards in Year awards consultants payment clerical staff to doctors in England since 1971 Colonoscopy at St Mark's Hospital in specialty was as follows:
Doctor- and nurse-patient ratios. The doctor- and nurse-patient ratios in all hospitals and in psychiatric hospitals in England in 1976 are set out below.
1975 1976 1977
367
82
11 0
363 378
81
11-2 11-2
82
Social Services, 13 June.
Breast and cervical cancer. There is not yet sufficient evidence of its effectiveness and safety to justify the introduction of a national screening service. Further investigations, designed and controlled to give the maximum amount of information which could prepare the way for the progressive development of a national service if results warrant this, are being conducted. For cervical cancer, a national screening service has been provided under the NHS since 1967. Special emphasis is placed on screening women at highest riskthat is, those aged 35 and over and younger women who have had three or more pregnancies. The service is expanding and in 1976 over two and a half million tests were carried Social Services, 13 June. out in the UK.
Smoking. A study has shown that babies of parents who smoke are more prone to pneumonia and bronchitis in the first year of life than are those of non-smoking parents, and some health authorities are designing their
health education campaigns to make parents aware of the dangers their smoking may hold for young children. To persuade people that smoking in confined public places is antisocial the Government's policy is to increase the provision for non-smokers in public places. Social Services, 15 June.
1971 1972 1973 1974 1975 1976
1970-1 1971-2 1972-3
1973-4 1974-5 1975-6
1976-7
Gross expenditure £ million 4426 4576 4882 4996 4961 5231 5288
..1. .. . .. . .. . .. . .. .
. . . . . .
.. 15-1 1-5:1 1-5:1 1-6:1 1-8:1 1-8:1
. . . . .
The new endoscopy unit at St Mark's Hospital, London, was opened by the Lord Mayor of London on 4 July. Since 1970, when the first fibreoptic colonoscope was introduced there, the service has grown and now over 400 examinations are performed each year, according to the hospital's annual report for 1977.
Problems of old age Over seven million people in England and Wales-14`00 of the population-are over 65, and the proportion is still increasing. The foreword to the Government discussion document A Happier Old Age (HMSO, 95p) describes the Government's aims as, firstly, ensuring that retirement does not mean poverty; secondly, keeping old people as far as possible active and independent in their own homes; and, thirdly (a new aim), giving them "the fullest possible choice and a major say in decisions that affect them." This last issue is taken up especially in the section on residential homes: the decision to enter a residential home should whenever possible be taken by elderly people themselves, after visiting the home and having full information
Charges from pharmaceutical services £ million 33 41 43 42 34 27 24
.. .. .. .. .. ..
MEDICAL NEWS
NHS expenditure in England.
Year
.15.. .15.. .15.. .. .. ..
more
Two groups will benefit from the unit: more patients can be seen in the purpose-built department, and more postgraduates can benefit from the teaching facilities. An Charges from average patient's progress through the preparadental and Other ophthalmic charges tion room and endoscopy theatre and into services million iC recovery is now expected to take between one £C million and three hours, compared with a whole day 58 35 previously. Extensive electronic aids have 72 38 77 38 been installed for teaching during colonoscopy 78 39 sessions, and doctors can also develop prac69 37 53 31 tical skills using the St Mark's colonoscopy 61 30 teaching model. Facilities also exist for upper gastrointestinal endoscopy and endoscopic Social Services, 14 June. retrograde cholangiopancreatography.
138
Regional differences in cancer mortality The regional differences in cancer mortality within Britain in 1971 are discussed in Population Trends 12 (Office of Population Censuses and Surveys; HMSO, £2-25). The death rate from cancer of the stomach was high in the north and north-west, and particularly so in Wales; high rates tended to occur in urban areas, but only in the north. Correcting for social class distributions had little effect on the regional differences. Neoplasms of the rectum had the highest death rates in the west midlands; intestinal tumours, by contrast, showed little regional variation. Lung cancer appeared as predominantly an urban disease; for all cancers of the trachea, bronchus, and lung the rates were highest in the north-west, north, and south-east in men and in the southeast in women. Death rates for bladder cancer were also related to the degree of urbanisation, rates being relatively high in the Yorkshire and Humberside regions and above average in the south-east and north-west; the London borough of Tower Hamlets had a particularly high rate for men. Cervical cancer, unlike tumours of the breast and ovary, showed a north-south gradient and a lesser gradient with the degree of urbanisation; Preston, Halifax, Salford, Teesside, and Liverpool had especially high mortality.
BRITISH MEDICAL JOURNAL Institute for the Study and Treatment of Delinquency-Summer school, 11-15 September, York. Details from the Institute, 34 Surrey Street, Croydon CR0 1RJ. (Tel 01-680 2068.) Association for Medical Education in EuropeAnnual International Conference, 19-21 September, Warsaw, Poland. Details from Polish Association for Medical Education, ul Dfuga 16, 00-238 Warszawa, Poland. National Association for Mental Health-Annual conference "Positive approaches to mental infirmity in elderly people," 12-13 October, London. Details from the Association, 22 Harley Street, London WiN 2ED. (Tel 01-637 0741.) Society for Radiological Protection-Meeting on "Personal protection against air and surface contamination," 23 January 1979, London. Details from Professor J H Martin, Department of Medical Biophysics, Blackness Laboratory, University of Dundee, Dundee DD1 4HN. British Council-Course 924 on "Assessment and managemcnt of pollution," 1-12 April 1979, London: application forms must be received in London by 1 December 1978. Course 922 on "Epidemiological methods," 13-25 May 1979, Southampton: application forms must be received in London by 15 December 1978. Details from the Courses Department, British Council, 65 Davies Street, London WIY 2AA. (Tel 01-499 8011.) British Nuclear Medicine Society-Annual scientific meeting, 9-11 April, London. Details from the secretary of the Society, Dr E P Wraight, Addenbrooke's Hospital, Hills Road, Cambridge CB2 2QQ. Edinburgh and East of Scotland Society of Anaesthetists-Details and copies of the 1978-9 syllabus are now available from Dr J Wilson, 15 Campbell Road, Edinburgh 12. (Tel 031-337 6763.) Medico-legal Society-Details and copies of the 1978-9 programme are now available from the secretary, Medico-legal Society, 71 Great Russell Street, London WCIB 3BZ.
SOCIETIES AND LECTURES International Agency for Research on Cancer
8 JULY 1978
Instructions to authors The following are the minimum requirements for manuscripts submitted for publication.
(1) Typing should be on one side of the paper, with double or triple spacing between the lines and 5-cm margins at the top and left-hand side of the sheet. (2) Two copies (or preferably three) should be submitted.
(3) Spelling should conform to that of Chambers Twentieth Century Dictionary. (4) References must be set out in the style used in the BMJ, and their accuracy verified before the manuscript is submitted.
(5) SI units are used for scientific measurements. In the text they should be followed by traditional units in parentheses. In tables and illustrations values are given only in SI units, but a conversion factor must be supplied. For general guidance on the International System of Units, and some useful conversion factors, see The SI for the Health Professions (WHO, 1977).
(6) Authors should give their names and initials, their current appointments, and
For attenditng lectures marked * a fee is charged or a ticket is required. Applications should be made first to the instittutionis concerned.
not more than two degrees or diplomas. Applications for training fellowships in Wednesday, 12 July Each author must sign the covering letter 1979-80 are invited from junior scientists who ROYAL COLLEGE OF SURGEONS OF ENGLAND-5 pm, as evidence of consent to publication. D E Bernhard lecture Professor M Taylor: Baron by intend to pursue a career in cancer research Surgical science and surgical practice. (7) Acknowledgments will not be sent and who wish to be trained in any aspect of 13 July Thursday, unless a stamped addressed envelope or an clinical cancer esresearch, laboratory or CLUB-At Royal Marsden Hospital, 6.30 pm, pecially epidemiology, biostatistics, or environ- ONCOLOGY international reply coupon is enclosed. Dr Humphrey Kaye: Marrow transplants, present and mental carcinogenesis. Fellowships are awarded future. (8) Detailed instructions are given in the for one year and are tenable in a suitable BMJ' dated 7 January (p 6). institution abroad. Full details and application BMA NOTICES forms are available from the chief of the Research Training and Liaison Unit, InterR G Blumer, A G Bond, H H Broodryk, S Burgin, A B national Agency for Research on Cancer, 150 Central Meetings Byles, W Caplan, M A Carlton, R M Carson, P A F JULY cours Albert-Thomas, 69372 Lyon Cedex 02, Chalk, G V P Chamberlain, A H M T A Chowdhury, 0 Chukudebelu, J A Cooper, W S Crawford, J D W France. The closing date for applications is 11 TuesCrosbie, R A Don, G I Dudgeon, Elizabeth M Edmunds, BMA Annual 14 Fri Meeting, City Representative 31 January 1979. S F El-Katsha, R W Ellwood, R N Fleming, J R H Hall, Cardiff. 13 Thurs
The Dr H M (Bill) Foreman Memorial Fund fellowships
The trustees of the Dr H M (Bill) Foreman fund invite applications for fellowships from medical practitioners in the study of respiratory ;disease. Grants of up to £800 will be available for travel and support for clinical research in countries other than the applicant's own. The awards will be made in October 1978 and applicants should write for further details to Dr B H Davies, Sully Hospital, Sully, South Glamorgan, before 30 August.
13 Thurs
14 Fri 19 Wed
BMA Annual General Meeting, City Hall, Cardiff, 12.30 pm. BMA Adjourned Annual General Meeting and Presidential Address, City Hall, Cardiff, 8.30 pm. Council, City Hall, Cardiff, 3 pm. Negotiating Subcommittee (CCHMS), 10 am.
20 Thurs
General Medical Services Committee, 10 am. General Purposes Subcommittee (CCHMS),
25 Tues
Joint Consultants Committee (British Dental Association, 64 Wimpole Street, London
20 Thurs
10.30 am.
Wi), 9.30 am.
UNIVERSITIES AND COLLEGES LONDON MD-A A Adetuyibi, M W Casewell, P J D Milton. MS-A J M Brodribb, D C S Parsons.
Fliegner, M A Garud, P W Gasson, Susan George. R N Ghosh, A K Ghoshal, J R M Gibson, J D Hamlett. K W Hancock, J J Handler, C S Harison, L P Harvey, G Hasenohr, D M Hay, J F Hennessey, N C Holmes, P W Hoopmann, D C Humphrey, S Jabeen, D M Jenkins, T A Kassaby, I H Kidd, K T Kywe, Catherine M Lamplugh, Pamela M Laurence, A C W Lewis, G D R Lilburne, J K-Y Loh, C Lombard, G F Lukin, H N Macdonald, J McGrath, I A Macisaac, R D McLean, P L Mannion, C G Marrinan, D D Mathews, A D Mehta, G P Mellor, I R Mian, K G Millar, M Mphahlele, D L Morrison, F 0 Negbenebor, H 0 Nicholson, M Notelovitz, B K O'Farrell, H R Owadally, S V Pandya, J F Pearson, S Pharaon, D L Phillips, Florence S Phillips, R Pilkington, P G Puddicombe, D K Quinlan, T A Rahman, R Ramkissoon, Hazel M Rawlinson, H R M Roberts, E G Robertson, Shirley B Robertson, T J F Rockey, A Sen Gupta, M D Simanowitz, D G Simpson, D Smith, J C Stanley, J T Stewart, G J W Stump, T C Svensen, R H Tipton, J D Trelford, I D Truskett, G A Turnbull, B C Uzodike, F W Van Der Westhuizen, Elizabeth H M Walker, H G Wotherspoon.
LIVERPOOL
COMING EVENTS International Union Against Tuberculosis XXXIV World Conference-5-9 September, Brussels. Details from Professor Dr A Gyselen, IUAT, Eendrachtstraat 56, 1050 Brussels, Belgium. Clinical Research Institute of Montreal-International symposium on "Folic acid and the nervous system," 6-8 September, Montreal. Details from the organising committee, c/o Miss Diana Cronin, 110 Pine Avenue West, Montreal H2W 1R7, Quebec, Canada. 10th Congress of the International Diabetes Federation-9-14 September, Vienna. Details from the secretariat, Bosendorferstr 4, A-1010 Vienna, Austria.
Appointments-Dr Jennifer M Hunter (senior lecturer
in anaesthesia); Mr J H Patrick (senior lecturer, clinical, in orthopaedic surgery); Dr D W Day (senior lecturer, clinical, in pathology).
BRISTOL MD-A E B Giddings. ROYAL COLLEGE OF OBSTETRICIANS AND GYNAECOLOGISTS At an extraordinary meeting of the council held on 7 June, the following were admitted to the fellowship of the College-D R Abramovich, W S Adam, T K Agble, A Akinkugbe, C Alexander, S E Ali, D S Bamford, M S Banerjee, Mercia A Barnes, B Barooah, K Basu, S F Begum, S Bhattacharyya, W R S Birrell, Z Bishara,
CONSULTANT APPOINTMENTS MANCHESTER AREA HEALTH AUTHORITY (TEACHING)Mr R J Williams (surgeon). WESSEx RHA-Dr C tI Hall (physician with an interest in
nephrology).
C) British Medical Journal 1978 All Rights Reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in anv form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the British Medical _ournal.
NEWS
BRITISH MEDICAL JOURNAL
AND
8 JULY 1978
NOTES
Viezvs "Marking" not "celebrating" is what the Government is doing for the NHS's 30th birthday. A seminar on the challenge of the next 30 years; a conference on working together to reach the disadvantaged; an exhibition on 30 years of social security; and a buffet reception at Lancaster House. Minerva also attended a more informal gathering in Mr Ennals's office to launch Professor Brian Abel-Smith's book: "NHS-The First Thirty Years" (HMSO £1 95). Poor Lord Wells-Pestell-none of the Government ministers could be there, so he stepped in, bemoaning that he's never invited any where in his own right. He regards himself as "Lord Substitute" like the people in his house (where he's Government spokesman on health) who are termed Lords Supplementary because they always attach their questions to someone else's. Did Napoleon die of carcinoma of the stomach, some form of liver disease, or arsenic poisoning ? None of these, asserts P J S Dunn, a final year medical student from Birmingham, who produces considerable evidence in favour of chronic brucellosis acquired from the milk of St Helena's goats (Update, 1978, 16, 1349). An intriguing theory but we will probably never know the truth: even at the time of the emperor's necropsy the doctors could not agree (see Anthony Burgess's novel Napoleon Symphony for a witty account of their quarrels). Mention of Napoleon reminded Minerva of the specimen of his intestines said to have been among the exhibits in the museum of the Royal College of Surgeons destroyed in the London blitz. On checking with Miss Jessie Dobson, the former curator, she found however that the story was apocryphal and had probably grown from after-dinner talk about a specimen in Sir Astley Cooper's collection which was labelled as showing lesions like Napoleon's.
People who have never smoked attribute more influence to advertisements and to the media than do smokers themselves (British Journal of Social and Clinical Psychology, 1978, 17, 189). Young smokers believed their family and friends to have been most influential in starting them off. Perhaps the campaign against cigarette advertising is not rationally based-after all, the Russians and even the health-conscious Cubans smoke like chimneys without any commercial encouragement. "In times when nothing stood/But worsened or grew strange": trying to shelter beneath other people's umbrellas at the presentation of the stone flower bowl in Queen Square to commemorate the Queen's jubilee, Minerva was depressed by these lines from Philip Larkin's verse incised in the stone beneath it. What about the people who died of, say, cancer or kidney failure 25 years ago-some of whom would now be saved ? And the pejorative reference to strangeness is sad coming from a poet. But literature for stone is a restricting discipline-which might be salutary for our more prolix medical authors. Will drug sensitivity tests one day be as routine in cancer as in bacterial infections? A promising assay is based on tumour stem-cell colonies (New England Journal of Medicine, 1978, 298, 1321), thus testing the often minute fraction of a tumour that is truly neoplastic. Twenty patients were spared empirical trial of drugs to which they were resistant; 11 out of 12 responded to
the sometimes unlikely drugs selected by the assay. But problems remain, and the authors are cautious in making claims for the method.
Visitors to the Netherlands should make sure that they have been immunised against poliomyelitis: the outbreak that started there in May has continued, with 52 cases. So far 40 patients have had paralytic symptoms. None had been immunised.
Dyslexia is a familiar concept (though paediatricians seem to prefer the term specific reading retardation); but what about children with a similar specific problem with mathematics ? Research in Russia has suggested that there may be some children with an inborn defect for calculation and the spatial thinking crucial to mathematics. As Richard Lansdown says (journal of Child Psychology and Psychiatry, 1978, 19, 181), maths is different from, say, history: it is a hierarchical skill and there is no redundancy, so that once left behind a child may never catch up. Claire Rayner has the knack of knowing what is needed in health education. " The Body Book" (G Whizzard/Andre Deutsch, C2 50) shows how perceptive she is in knowing what children want to find out about their bodies and how to put it across to them. The gastrointestinal system has a chapter entitled "In and Out," while the reproductive system is "Growing and Changing and Making New People." She has not even ducked the difficult problem of growing old and dying. In an effort to avoid technical terms some rather cumbersome phrases have been introduced-the "babymaking hole" is a bit bizarre. Much heart-searching must have gone on before "penis" was allowed to creep in.
Rocky mountain spotted fever has now (Journal of the American Medical Association, 1978, 239, 2763) been added to the list of diseases that can be transmitted by blood transfusion. The donor gave blood three days before onset of the symptoms of his illness, which proved fatal. News of the death was passed on by the blood transfusion service, making early diagnosis-and effective treatment-possible in the recipient.
Echoing the cult film "Close Encounters" a leaflet produced by a Norwich self-help group says "Ask us-you are not alone." In less than 1000 words it gives details, addresses, and telephone numbers of organisations from health visitors and speech therapists to preschool playgroups and the specialist societies for children with eczema, leukaemia, and cystic fibrosis.
Surgeons in Singapore found an "abdominal cocoon" to be the cause of small bowel obstruction in a series of 10 adolescent girls (British Journal of Surgery, 1978, 65, 427). The condition was reminiscent of sclerosing peritonitis but there was no history of drug ingestion, and retrograde menstruation or viral peritonitis are postulated as possible, but so far unproved, causes. MINERVA
BRITISH MEDICAL JOURNAL
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EPIDEMIOLOGY Legionnaires' disease: United Kingdom The following notes are compiled by the Communicable Disease Surveillance Centre (Public Health Laboratory Service) and the Communzicable Diseases (Scotland) Unit fronm reports subnmitted by microbiological laboratories, comnmunity physicianis, and environmenital health officers. A preliminary account of the first cases of legionnaires' disease to be identified in Britain appeared in the BMJ last year.' Laboratory investigations have shown up further cases here and have helped to explain the cause of several previously unexplained outbreaks in the United States.2 3 By the end of March 1978, 43 cases had been identified in Britain on the basis of a four-fold rise or more in indirect fluorescent antibody titre to at least 1 in 128 (16 cases); or a single indirect fluorescent antibody titre of at least 1 in 256 (20 cases); or finding the Legionnaires' bacterium in postmortem lung tissue by immunofluorescent staining (seven cases). An analysis of the cases by age and sex is Legionnaires' disease (1 J7uly 1973-1 April 1978) Age (years)
No of cases identified
Total
Men
Women
20-29 30-39 40-49 50-59 60-69 70-79 Not known
2 6 6 12 3 1 0
0 0 5 1 3 1 3
13
Total
30
13
43
2 6
11 6 2 3
given in the table. The mean age for all cases was 47 years and the range 26-76 years. There were 10 deaths, and an eleventh patient died suddenly six weeks after the onset of his illness, probably from a myocardial infarction, having apparently recovered from his pneumonia. The mean age of the fatal cases was 54 years and the range 26-63 years. Six developed the illness in 1978; 28 in 1977; two in 1976; one in 1975; and two in 1974. Four patients affected by an outbreak of respiratory illness in 1973 among tourists, mainly from Scotland, who stayed in Benidorm, Spain, were later shown to have serological evidence of legionnaires' disease. Review of the geographical distribution of the 36 most recent cases showed that the six Scottish patients lived in or around Glasgow. In England the largest concentration of patients (12) was in Nottingham: in these cases the dates of onset lay between June 1976 and February 1978, and six occurred in a sevenweek period in August and September 1977; a common source was not identified. There were three cases in Preston, two in Bath; 13 other centres had one each. Eight patients developed their symptoms during, or within seven days of returning from, a holiday in Spain. They had stayed in various resorts, three in Benidorm and one in each of five other resorts on the Mediterranean. Two of the patients from Benidorm, who were there in May and June 1977, stayed in the same hotel as the tourists in whom the outbreak of respiratory illness occurred in 1973.1 One other patient, from Nottingham, visited the
same hotel in early March 1977: though he first developed respiratory symptoms three days later, he was not admitted to hospital until May, and the changes in antibody titre suggested that the onset of legionnaires' disease occurred in late April. On this evidence it was concluded that he had probably acquired the infection in Nottingham. Most patients presented with a four to seven day history of fever, malaise, myalgia, and non-productive cough. Other symptoms included breathlessness, pleuritic chest pain, severe abdominal pain, diarrhoea, and vomiting, in that order of frequency. Four patients presented without respiratory symptoms; one of these was admitted to hospital with suspected enteric fever. Two patients had gastrointestinal bleeding shortly before admission to hospital. The typical clinical and radiological findings were of lobar and lobular pneumonia which often became multilobar. Most patients were severely ill and at least nine required assisted ventilation. Twelve became severely confused shortly before or after admission to hospital. Recovery was often slow, with a third of the survivors still showing radiological evidence of consolidation as late as three months after the onset of the illness. As regards treatment, there is evidence that erythromycin is effective and that rifampicin and some tetracycline derivatives may also be useful.
new procedure: firstly, patients who had not even committed themselves to the issue of a writ might try to use the new procedure to fish for evidence to maintain a malpractice action; and, secondly, medical records might be misunderstood, particularly if they were read by laymen.
was not a party but the documents were relevant-for example, where an employee sued his employer for industrial injuries. While doctors may have welcomed these restrictions, they made lawyers feel that they were advising their clients in the dark. The restrictions appeared all the more perverse since in the end (either when discovery was reached in an action against a hospital or at the trial if the hospital was not a party), the plaintiff was going to be entitled to see the whole of the relevant documents anyway. An unsettling case5 occurred in 1974, after the South-west Metropolitan Regional Hospital Board was asked to produce the records of a 12-year-old girl who had attended Worthing Hospital with severe abdominal pains and vomiting. A surgical registrar had diagnosed a ruptured ectopic pregnancy and told her father. This was later found to be wholly wrong, and there followed two laparotomies which failed to uncover any surgical abnormality. Eventually the girl was transferred to the Hospital for Sick Children, London, where she made a full recovery on a graduated bland diet.
I 2
3
British Medical Journal, 1977, 4, 1425. Morbidity and Mortality Weekly Report, 1965, 14, 265.
American-Journal of Epidemiology,
1978, 107, 149.
MEDICOLEGAL Disclosure of medical records [FROM OUR LEGAL CORRESPONDENT]
In an important (and at first sight rather disturbing) decision for the medical profession, the House of Lords has held' that where a plaintiff makes an application for the production of documents pursuant to sections 31 and 32(1) of the Administration of Justice Act 1970 he is entitled to see them himself and that the court has no discretion to confine inspection to the plaintiff's medical advisers. The 1970 Act (and the ensuing amendment to the Rules of the Supreme Court) brought about a revolutionary change in procedure in personal injury actions in that potential plaintiffs could inspect a potential defendant's documents before even issuing a writ. Litigants who had already started proceedings could call for documents from a third party well in advance of the trial. Previously a party to an action could obtain records of this kind only by the issue of a subpoena to produce them at the trial. If the non-party did not co-operate there was no way in which a party could see the documents before the trial. The MDU was quick to warn2 of the dangers and far-reaching implications of the
Who is the applicant? Where a person appears likely to have relevant documents in his possession the words of the 1970 Act allow the court to order that they be produced "to the applicant." None the less, as though in response to the profession's fears, in three separate cases3-5 the English Court of Appeal laid down that the proper course was to confine the production of hospital records, initially at any rate, to the plaintiff's medical advisers and not to permit the plaintiff or his lawyers to have a sight of them. This restriction applied equally to cases where it was sought to sue a hospital for negligence and to cases where the hospital
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The expert advising the plaintiff, to whom the hospital records were shown, condemned the diagnosis of pregnancy in the absence of a laboratory test as most unwise and thought that the possibility of food poisoning was insufficiently considered before the first laparotomy. Nevertheless, he concluded that the performance of the two laparotomies was not necessarily evidence of negligence. The girl's father and her lawyers were naturally disappointed at this advice and asked the court to permit them to see the records. Mr Justice Bristow thought that this was proper and that it would not comply with the purpose of the 1970 Act if lawyers could not see the records and "put their heads together with the medical expert and come to a joint conclusion on what was partly a matter of medical science and partly a matter of law." The judge thought that if the plaintiff could not see the records he could not make a sensible estimate of whether he had been wronged before committing himself to expensive litigation, but his view was overruled by the Court of Appeal. Lord Denning said that the matter could be dealt with by counsel seeing the expert in the ordinary way and asking questions on matters which seemed to require explanation or reconsideration. The expert should then answer the questions, referring to the records if necessary, but with no need to show them to the plaintiff or his advisers. The procedure envisaged by Lord Denning was perhaps artificial with the lawyers being told what was in the documents yet not being allowed to see them. None the less, Lord Denning consistently showed himself aware of doctors' fears that the new procedure might be abused. In one case4 he noted that doctors' records might contain a fleeting thought such as "query-pregnancy" in a girl of 12. He thought it better that doctors should not be restrained from such speculation.
with Mr Justice Bristow, whose views had been overruled by Lord Denning. He believed that no matter how expert and intelligent a medical man might be, he could not by virtue of those qualities alone interpret to lawyers and their clients the probable effect on a judge or jury6 of a finely balanced set of medical facts and opinions, nor should he be asked to do so. The Chief Justice described the English Court of Appeal decision in the case5 of the 12-year-old girl as a "very strong decision." It preserved medical confidence to the obvious detriment of the interests of a minor and potentially in the material interests of a hospital and its medical staff. From the lawyers' point of view there is also a danger that if they do not see the notes their medical expert may fail to see a legal problem or think that there is an obstacle where none exists. Lord Justice Jones in the Northern Ireland Court of Appeal said that as a former leading counsel he would have expressed surprise, to put it at its lowest, had he been told that he could not see very relevant, indeed possibly crucial, details of the case. He added that in the case of an infant plaintiff he could not envisage himself recommending settlement to the court, not on the basis of his own judgment, but "on what he had been told by some doctor." Conflict resolved
With the English and Northern Ireland Courts of Appeal at odds the House of Lords intervened' to resolve the conflict. Unanimously the House held that there was no escape from the wording of the statute and that it was unwarrantable, if the preconditions for making an order were fulfilled, to impose a restriction regarding the person to whom production was to be made. Lord Diplock pointed out that the purpose of early discovery was to provide for the
8 JULY 1978
settlement of personal injuries actions on terms that were fair to both sides. That necessarily meant disclosure to the legal representatives of each party of all the available material relevant to each issue in the case. Lord Diplock also made two further points that doctors should remember when discovery is sought from them; firstly, it is perfectly proper to cover up any irrelevant part of a document that is subject to disclosure. Secondly, if there is a matter which it is better a patient should not know, his legal advisers can take precautions to prevent the information becoming known. Lawyers are quite used to this and doctors should not hesitate to point out to a plaintiff's solicitor when information should be kept from their client. In Lord Diplock's words, the situation can be dealt with by "common sense and humanity." The House of Lords were really concerned only with the wording of the statute, but its decision reflects the common law principle that medical confidentiality must bow to the administration of justice. Doctors should not forget that, regardless of applications under the new rules, there is always a chance that they may be cross-examined in court at some future date on the contents of their notes. The tone of such documents should therefore be "serious and precise'{7; and the defence organisations have warned that letters to other doctors about patients may have to lose the personal touches that once lightened correspondence between colleagues. l Mclvor v Southern Health and Social Services Board (1978) 1 WLR 757. British Medical3Journal, 1972, 1, 565. 3 Dunning v United Liverpool Hospitals Board of Governors (1973) 1 WLR 586; British Medical journal, 1973, 1, 623. Davidson v Lloyd Aircraft Services Ltd (1974) 1 WLR 1042; British Medical3Journal, 1974, 2, 123. Deistung v South West Metropolitan Regional Hospital Board (1975) 1 WLR 213; British Medical Journal, 1975, 1, 465. 6 In Northern Ireland personal injury actions are still heard by juries. British Medical Journal, 1975, 1, 150. 2
Different view
In Northern Ireland the Court of Appeal took an entirely different attitude: in an application for hospital records made by a plaintiff in action arising out of a motor car accident1 the court refused to order that production should be limited. It held that, since the Act spoke of production "to the applicant," there was no jurisdiction to make an order confining production to the medical advisers and excluding the plaintiff and his lawyers. Lord Lowry, the Northern Ireland Chief Justice, dealt with the point that the notes might contain things which it was not good for the plaintiff to know by saying that medical reports to a plaintiff's solicitors often contained material of which the plaintiff was kept in ignorance. "In the same way," he said, "solicitors who inspect hospital records only rarely need to inform their client of bad tidings." Nor was Lord Lowry afraid that patients would be debarred from speaking frankly to doctors or doctors from making frank observations in their notes by the prospect of their being examined in court. "There were other inducements to reticence," he said, "which do not seem to have had an inhibiting effect." It is also true that the new procedure does not entitle a plaintiff to see documents which he could not have seen before at the trial. It merely permits him to see them at an earlier stage in the proceedings. Lord Lowry agreed
PARLIAMENT Questions in the Commons NHS and Health and Safety legislation. The Health and Safety and Work Act 1974 is binding on the Crown, and the Government have given a firm commitment that they will take all the necessary action to ensure that all Crown bodies, including the National Health Service, comply with the Act's provisions. Employment, 13 June.
Small hospitals. The Government's policy is to provide a comprehensive range of specialised services in district general hospitals, but the DHSS sees a continuing need for smaller local or community hospitals to serve patients not requiring the specialist facilities of a district general hospital. Social Services, 13 June. Health expenditure in Wales. Of the extra £3 million allocated for health services in Wales (22 April, p 1062), £2-38 million will
be distributed to areas in proportion to their 1978-9 revenue allocations; CO25 million will be spent on services to kidney patients and the provision of extra kidney machines; and the remaining £0C44 million will be allocated partly to the development of community services for the mentally ill and partly to the funding of improvements in psychiatric institutions. Wales, 13 June.
Prescriptions. The numbers of prescriptions issued (in years for which the latest figures are available) for psychotropic drugs, tranquillisers, and antidepressants are as follows: Psychotropic drugs Sedatives and tranquillisers Antidepressants and antidepressant and sedative/tranquilliser combinations
1975 45 635 000 20 868 000
1976 45 595 000 21 190 000
8 480 000
8 496 000
Social Services, 13 June.
BRITISH MEDICAL JOURNAL
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8 JULY 1978
about services and the best advice. "Should be done," the report asks, "to ensure that prospective residents are fully involved in making such decisions ?" The document goes on to discuss rehabilitaafter a spell of residential care; the usetion Ratios of staff to patients1¶ fulness of short-term and day care; and the OutInDay importance in residential homes of privacy patients* patientst patients+ and freedom of choice, including choice of All hospitals of Drinking and driving. The number diet, clothes, and times of getting up and 1: 11 2 1 17 4 1: 1643 Doctors§ road accidents in which alcohol was implicated going to bed. Other topics covered are 1 1:7 1 159 5 1 :11 Nurses§ Psychiatric preparation for retirement; pension age and in Wales since 1969 was as follows: hospitals income; family and community support; and 1: 4 5 1: 440 4 1: 26 2 Doctors§ 1 03 1 29 0 1: 1 7 Nurses§ health and other services, both statutory and All recorded Drivers voluntary. Comments are invited from those road accidents involved in Column (2) with personal accidents with as a concerned, including the elderly themselves, *Based on average daily bed occupation during 1976. percentage injury or positive (or tBased on total number of day care attendances during by 31 October. failed to of death in 1976. Wales column (1) provide) The publication of this discussion document tBased on total outpatient attendances during 1976 breath tests (new and old patients). coincided with the announcement of an Open (1) (2) (3) §Based on whole-time equivalent staff in post at 30 University course on old age-"What Living September 1976. 33 1969 380 11 538 'IBased on provisional figures for staff in post. Longer Means"-to start next February. Two 12 308 4-6 567 *TIndividual patients may have been in more than one 1970 6-0 11 864 713 1971 other recent publications on old age are The category during the year. 64 12 314 792 1972 Psychogeriatric Problem (the proceedings of a 12 079 7-6 919 1973 Social Services, 13 June. 1974 7-7 11 393 881 seminar, published by the Department of 7-8 11 075 868 1975 Community Medicine, University of Man11 498 729 63 1976 11 460* 6-1* 697 1977 chester) and Population Change and Local Merit awards. Distinction awards for conGovernment (a report based on another seminar, sultants in mental health at 31 December *Provisional figures. published by the Society of Local Authority Wales, 15 June. Chief Executives, Pelham House, St Andrew's were as follows: Lane, Lewes, East Sussex). Number of Percentage Percentage Staff ratios. The ratio of administrative and of total of all awards in Year awards consultants payment clerical staff to doctors in England since 1971 Colonoscopy at St Mark's Hospital in specialty was as follows:
Doctor- and nurse-patient ratios. The doctor- and nurse-patient ratios in all hospitals and in psychiatric hospitals in England in 1976 are set out below.
1975 1976 1977
367
82
11 0
363 378
81
11-2 11-2
82
Social Services, 13 June.
Breast and cervical cancer. There is not yet sufficient evidence of its effectiveness and safety to justify the introduction of a national screening service. Further investigations, designed and controlled to give the maximum amount of information which could prepare the way for the progressive development of a national service if results warrant this, are being conducted. For cervical cancer, a national screening service has been provided under the NHS since 1967. Special emphasis is placed on screening women at highest riskthat is, those aged 35 and over and younger women who have had three or more pregnancies. The service is expanding and in 1976 over two and a half million tests were carried Social Services, 13 June. out in the UK.
Smoking. A study has shown that babies of parents who smoke are more prone to pneumonia and bronchitis in the first year of life than are those of non-smoking parents, and some health authorities are designing their
health education campaigns to make parents aware of the dangers their smoking may hold for young children. To persuade people that smoking in confined public places is antisocial the Government's policy is to increase the provision for non-smokers in public places. Social Services, 15 June.
1971 1972 1973 1974 1975 1976
1970-1 1971-2 1972-3
1973-4 1974-5 1975-6
1976-7
Gross expenditure £ million 4426 4576 4882 4996 4961 5231 5288
..1. .. . .. . .. . .. . .. .
. . . . . .
.. 15-1 1-5:1 1-5:1 1-6:1 1-8:1 1-8:1
. . . . .
The new endoscopy unit at St Mark's Hospital, London, was opened by the Lord Mayor of London on 4 July. Since 1970, when the first fibreoptic colonoscope was introduced there, the service has grown and now over 400 examinations are performed each year, according to the hospital's annual report for 1977.
Problems of old age Over seven million people in England and Wales-14`00 of the population-are over 65, and the proportion is still increasing. The foreword to the Government discussion document A Happier Old Age (HMSO, 95p) describes the Government's aims as, firstly, ensuring that retirement does not mean poverty; secondly, keeping old people as far as possible active and independent in their own homes; and, thirdly (a new aim), giving them "the fullest possible choice and a major say in decisions that affect them." This last issue is taken up especially in the section on residential homes: the decision to enter a residential home should whenever possible be taken by elderly people themselves, after visiting the home and having full information
Charges from pharmaceutical services £ million 33 41 43 42 34 27 24
.. .. .. .. .. ..
MEDICAL NEWS
NHS expenditure in England.
Year
.15.. .15.. .15.. .. .. ..
more
Two groups will benefit from the unit: more patients can be seen in the purpose-built department, and more postgraduates can benefit from the teaching facilities. An Charges from average patient's progress through the preparadental and Other ophthalmic charges tion room and endoscopy theatre and into services million iC recovery is now expected to take between one £C million and three hours, compared with a whole day 58 35 previously. Extensive electronic aids have 72 38 77 38 been installed for teaching during colonoscopy 78 39 sessions, and doctors can also develop prac69 37 53 31 tical skills using the St Mark's colonoscopy 61 30 teaching model. Facilities also exist for upper gastrointestinal endoscopy and endoscopic Social Services, 14 June. retrograde cholangiopancreatography.
138
Regional differences in cancer mortality The regional differences in cancer mortality within Britain in 1971 are discussed in Population Trends 12 (Office of Population Censuses and Surveys; HMSO, £2-25). The death rate from cancer of the stomach was high in the north and north-west, and particularly so in Wales; high rates tended to occur in urban areas, but only in the north. Correcting for social class distributions had little effect on the regional differences. Neoplasms of the rectum had the highest death rates in the west midlands; intestinal tumours, by contrast, showed little regional variation. Lung cancer appeared as predominantly an urban disease; for all cancers of the trachea, bronchus, and lung the rates were highest in the north-west, north, and south-east in men and in the southeast in women. Death rates for bladder cancer were also related to the degree of urbanisation, rates being relatively high in the Yorkshire and Humberside regions and above average in the south-east and north-west; the London borough of Tower Hamlets had a particularly high rate for men. Cervical cancer, unlike tumours of the breast and ovary, showed a north-south gradient and a lesser gradient with the degree of urbanisation; Preston, Halifax, Salford, Teesside, and Liverpool had especially high mortality.
BRITISH MEDICAL JOURNAL Institute for the Study and Treatment of Delinquency-Summer school, 11-15 September, York. Details from the Institute, 34 Surrey Street, Croydon CR0 1RJ. (Tel 01-680 2068.) Association for Medical Education in EuropeAnnual International Conference, 19-21 September, Warsaw, Poland. Details from Polish Association for Medical Education, ul Dfuga 16, 00-238 Warszawa, Poland. National Association for Mental Health-Annual conference "Positive approaches to mental infirmity in elderly people," 12-13 October, London. Details from the Association, 22 Harley Street, London WiN 2ED. (Tel 01-637 0741.) Society for Radiological Protection-Meeting on "Personal protection against air and surface contamination," 23 January 1979, London. Details from Professor J H Martin, Department of Medical Biophysics, Blackness Laboratory, University of Dundee, Dundee DD1 4HN. British Council-Course 924 on "Assessment and managemcnt of pollution," 1-12 April 1979, London: application forms must be received in London by 1 December 1978. Course 922 on "Epidemiological methods," 13-25 May 1979, Southampton: application forms must be received in London by 15 December 1978. Details from the Courses Department, British Council, 65 Davies Street, London WIY 2AA. (Tel 01-499 8011.) British Nuclear Medicine Society-Annual scientific meeting, 9-11 April, London. Details from the secretary of the Society, Dr E P Wraight, Addenbrooke's Hospital, Hills Road, Cambridge CB2 2QQ. Edinburgh and East of Scotland Society of Anaesthetists-Details and copies of the 1978-9 syllabus are now available from Dr J Wilson, 15 Campbell Road, Edinburgh 12. (Tel 031-337 6763.) Medico-legal Society-Details and copies of the 1978-9 programme are now available from the secretary, Medico-legal Society, 71 Great Russell Street, London WCIB 3BZ.
SOCIETIES AND LECTURES International Agency for Research on Cancer
8 JULY 1978
Instructions to authors The following are the minimum requirements for manuscripts submitted for publication.
(1) Typing should be on one side of the paper, with double or triple spacing between the lines and 5-cm margins at the top and left-hand side of the sheet. (2) Two copies (or preferably three) should be submitted.
(3) Spelling should conform to that of Chambers Twentieth Century Dictionary. (4) References must be set out in the style used in the BMJ, and their accuracy verified before the manuscript is submitted.
(5) SI units are used for scientific measurements. In the text they should be followed by traditional units in parentheses. In tables and illustrations values are given only in SI units, but a conversion factor must be supplied. For general guidance on the International System of Units, and some useful conversion factors, see The SI for the Health Professions (WHO, 1977).
(6) Authors should give their names and initials, their current appointments, and
For attenditng lectures marked * a fee is charged or a ticket is required. Applications should be made first to the instittutionis concerned.
not more than two degrees or diplomas. Applications for training fellowships in Wednesday, 12 July Each author must sign the covering letter 1979-80 are invited from junior scientists who ROYAL COLLEGE OF SURGEONS OF ENGLAND-5 pm, as evidence of consent to publication. D E Bernhard lecture Professor M Taylor: Baron by intend to pursue a career in cancer research Surgical science and surgical practice. (7) Acknowledgments will not be sent and who wish to be trained in any aspect of 13 July Thursday, unless a stamped addressed envelope or an clinical cancer esresearch, laboratory or CLUB-At Royal Marsden Hospital, 6.30 pm, pecially epidemiology, biostatistics, or environ- ONCOLOGY international reply coupon is enclosed. Dr Humphrey Kaye: Marrow transplants, present and mental carcinogenesis. Fellowships are awarded future. (8) Detailed instructions are given in the for one year and are tenable in a suitable BMJ' dated 7 January (p 6). institution abroad. Full details and application BMA NOTICES forms are available from the chief of the Research Training and Liaison Unit, InterR G Blumer, A G Bond, H H Broodryk, S Burgin, A B national Agency for Research on Cancer, 150 Central Meetings Byles, W Caplan, M A Carlton, R M Carson, P A F JULY cours Albert-Thomas, 69372 Lyon Cedex 02, Chalk, G V P Chamberlain, A H M T A Chowdhury, 0 Chukudebelu, J A Cooper, W S Crawford, J D W France. The closing date for applications is 11 TuesCrosbie, R A Don, G I Dudgeon, Elizabeth M Edmunds, BMA Annual 14 Fri Meeting, City Representative 31 January 1979. S F El-Katsha, R W Ellwood, R N Fleming, J R H Hall, Cardiff. 13 Thurs
The Dr H M (Bill) Foreman Memorial Fund fellowships
The trustees of the Dr H M (Bill) Foreman fund invite applications for fellowships from medical practitioners in the study of respiratory ;disease. Grants of up to £800 will be available for travel and support for clinical research in countries other than the applicant's own. The awards will be made in October 1978 and applicants should write for further details to Dr B H Davies, Sully Hospital, Sully, South Glamorgan, before 30 August.
13 Thurs
14 Fri 19 Wed
BMA Annual General Meeting, City Hall, Cardiff, 12.30 pm. BMA Adjourned Annual General Meeting and Presidential Address, City Hall, Cardiff, 8.30 pm. Council, City Hall, Cardiff, 3 pm. Negotiating Subcommittee (CCHMS), 10 am.
20 Thurs
General Medical Services Committee, 10 am. General Purposes Subcommittee (CCHMS),
25 Tues
Joint Consultants Committee (British Dental Association, 64 Wimpole Street, London
20 Thurs
10.30 am.
Wi), 9.30 am.
UNIVERSITIES AND COLLEGES LONDON MD-A A Adetuyibi, M W Casewell, P J D Milton. MS-A J M Brodribb, D C S Parsons.
Fliegner, M A Garud, P W Gasson, Susan George. R N Ghosh, A K Ghoshal, J R M Gibson, J D Hamlett. K W Hancock, J J Handler, C S Harison, L P Harvey, G Hasenohr, D M Hay, J F Hennessey, N C Holmes, P W Hoopmann, D C Humphrey, S Jabeen, D M Jenkins, T A Kassaby, I H Kidd, K T Kywe, Catherine M Lamplugh, Pamela M Laurence, A C W Lewis, G D R Lilburne, J K-Y Loh, C Lombard, G F Lukin, H N Macdonald, J McGrath, I A Macisaac, R D McLean, P L Mannion, C G Marrinan, D D Mathews, A D Mehta, G P Mellor, I R Mian, K G Millar, M Mphahlele, D L Morrison, F 0 Negbenebor, H 0 Nicholson, M Notelovitz, B K O'Farrell, H R Owadally, S V Pandya, J F Pearson, S Pharaon, D L Phillips, Florence S Phillips, R Pilkington, P G Puddicombe, D K Quinlan, T A Rahman, R Ramkissoon, Hazel M Rawlinson, H R M Roberts, E G Robertson, Shirley B Robertson, T J F Rockey, A Sen Gupta, M D Simanowitz, D G Simpson, D Smith, J C Stanley, J T Stewart, G J W Stump, T C Svensen, R H Tipton, J D Trelford, I D Truskett, G A Turnbull, B C Uzodike, F W Van Der Westhuizen, Elizabeth H M Walker, H G Wotherspoon.
LIVERPOOL
COMING EVENTS International Union Against Tuberculosis XXXIV World Conference-5-9 September, Brussels. Details from Professor Dr A Gyselen, IUAT, Eendrachtstraat 56, 1050 Brussels, Belgium. Clinical Research Institute of Montreal-International symposium on "Folic acid and the nervous system," 6-8 September, Montreal. Details from the organising committee, c/o Miss Diana Cronin, 110 Pine Avenue West, Montreal H2W 1R7, Quebec, Canada. 10th Congress of the International Diabetes Federation-9-14 September, Vienna. Details from the secretariat, Bosendorferstr 4, A-1010 Vienna, Austria.
Appointments-Dr Jennifer M Hunter (senior lecturer
in anaesthesia); Mr J H Patrick (senior lecturer, clinical, in orthopaedic surgery); Dr D W Day (senior lecturer, clinical, in pathology).
BRISTOL MD-A E B Giddings. ROYAL COLLEGE OF OBSTETRICIANS AND GYNAECOLOGISTS At an extraordinary meeting of the council held on 7 June, the following were admitted to the fellowship of the College-D R Abramovich, W S Adam, T K Agble, A Akinkugbe, C Alexander, S E Ali, D S Bamford, M S Banerjee, Mercia A Barnes, B Barooah, K Basu, S F Begum, S Bhattacharyya, W R S Birrell, Z Bishara,
CONSULTANT APPOINTMENTS MANCHESTER AREA HEALTH AUTHORITY (TEACHING)Mr R J Williams (surgeon). WESSEx RHA-Dr C tI Hall (physician with an interest in
nephrology).
C) British Medical Journal 1978 All Rights Reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in anv form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the British Medical _ournal.
