SIR,-Your excellent editorial (Nov. 15, p. 963 was timely in view of the interest now being shown in the association between intrauterine contraceptive devices (i.u.c.D.) and ectopic pregnancy. There is one vitally important point, however, which needs to be clarified-namely, the role of pelvic infection in the aetiology of ectopic pregnancy. This was not mentioned in your editorial. Pelvic inflammatory disease in the female can be, and indeed frequently is, asymptomatic. Thus many women with pelvic inflammatory disease never consult a doctor nor are they admitted to hospital. Beral’s’ analysis, based on the Hospital In-patient Enquiry and on morbidity statistics from general practice, is therefore of limited validity. Moreover, a diagnosis of salpingo-oophoritis is frequently based on presumptive evidence. In clinical practice a definite diagnosis based on positive identification of pathogens or on laparoscopy is frequently not made. In our opinion, the conclusion drawn on the different age trends for pelvic inflammatory disease and ectopic pregnancies could be a reflection of a causal association between pelvic inflammatory disease and ectopic pregnancy, and should not be interpreted as implicating the LV.C.D. per se in the causation of ectopic pregnancies. Furthermore, the results of Beral’s survey could quite reasonably be interpreted as showing an indirect causal relationship between the LV.C.D. and ectopic pregnancy, since l.u.c.D. users are at increased risk of salpingo-ophoritis.1-1 Thus, rather than proving an association between the i.u.c.D. per se and ectopic pregnancies, Beral has indirectly highlighted the risk of ascending subclinical infection in I.V.C.D. users. Her paper has also served to re-emphasise the need for strict asepsis when inserting an LV.C.D. Department of Gynæcology, Women’s Hospital, Catharine Street,

Liverpool L8 7NJ


Department of Obstetrics and Gynaecology, University of Liverpool, New Medical School, Liverpool L69 3BX


However, the figures do not show the fact that the situation the country is extremely variable, reflecting staff turnover or the necessity to recruit, as in new medical schools. In 1974 in some established centres, 80% of staff were medically across

while in others there were only 3 medical graduates in a total staff of 19, and one of the new medical schools had been able to recruit only a single medical anatomist. Since 1974 the position has deteriorated still further. Recent returns from the 29 centres indicate that the number of fulltime medical anatomists in post in October, 1975, is 157-a fall of about 10% during the period January, 1974, to October, 1975; 33 of these are over 55 years of age. During the same period the number of non-medical scientists had risen to 92, Because of recent promotion and emigration, the number of experienced medical anatomists in Nottingham, Leicester, and Southampton combined is now only 5. In spite of problems in recruitment, anatomy departments have continued to play their traditional role in postgraduate medical education by offering junior posts (demonstratorships) to medical graduates contemplating careers in hospital medicine, particularly surgery. At present 120 of such posts exist across the country. In the post-Todd era, with shortened undergraduate courses in anatomy, the need for them is probably greater rather than less. Anatomy departments also make one of the biggest departmental contributions to postgraduate medical education in various fields, from surgery to psychiatry, as well as in the training of medical ancillary workers (physiotherapists, radiographers, &c.). If the demands of increased student numbers are to be met, a numerically effective medical presence in anatomy becomes more, rather than less, essential. The problems of retention and recruitment of medical staff by anatomy departments in Britain have been aggravated by the recent salary awards to the medical profession on the one hand, and to universities on the other, which have, in effect, devalued the non-clinical medicals by a further 10%. Furthermore, the narrowing of differentials in salaries between various grades in universities makes it financially almost impossible for experienced people to move even with promotion. The difficulties adversely affect both undergraduate and postgraduate


medical education. These are matters which should concern the Department of Health as well as the universities, and their resolution can probably only be achieved by joint action.



SiR,—During the late

1960s it became apparent that the recruitment of recent medical graduates by departments of anatomy, physiology, and pharmacology was becoming difficult or impossible. This trend coincided with preparations for the establishment of new medical schools. In 1968 a national survey with returns from 21 medical schools showed that 148 of a total of 181 of the permanent staff of anatomy departments were medically qualified-a proportion of 82%. However, all centres reported difficulties in recruitment of medical graduates. Since that time periodic reviews of the staffing position in anatomy have been carried out in cooperation with the Anatomical Society and departments throughout the country. In January, 1974, from returns of all 29 undergraduate departments of anatomy, the composition of the permanent academic staff was:

At that time, medical graduates comprised 68% of the total, but 32 of these were aged 56 years or more.

Department of Human Morphology, University of Nottingham Medical School, Clifton Boulevard, Nottingham NG9 2UH.


SIR,-The cause of Indian childhood cirrhosis (t.c.c.) is still unknown. Nayak et al. postulated a defect in hepatocyte maturation in patients with i.c.c. on the basis of high Y-fetoprotein (A.F.P.) levels, 45% of affected children showing a positive reaction for A.F.P. Aggarwal et al.,2 however, found no positive reactions among their 99 patients. This discrepancy prompts us to report our observations. Among 66 patients (of whom details have been published elsewhere3) only 4 showed a positive reaction by counterelectrophoresis, whereas 98 out of 100 cord sera were positive (see table). With radioimmunoassay, A.F.P. levels in 10 randomly selected patients ranged from 5 to 59 ng/ml (mean 38 ng/ml). Thus, more than 90% of the patients had A.F.P. levels within the normal range. We think that the age-related fall in indLcibility of A.F.P. synthesis,4 rather than an abnormality of the hepatocytes, could explain the high A.F.P. levels found in only a few of our patients. Further, none of the patients’ sibs had 1. Nayak, N.

1. Beral, V. Br.J. Obstet. Gynæc. 1975, 82, 775. 2. Wright, N. H.Am.J. Obstet. Gynec. 1968, 101, 979. 3. Willson, J. R., Ledger, W. J. ibid. 1968, 100, 649. 4. Stewart Taylor, E., McMillan, J. H., Greer, B. E., Thompson, H. E. ibid. 1975, 123, 338.


C., Malviya, A. N., Chawla, V., Chandra, R. K. Lancet, 1972,

i, 68. 2. 3.

Droegemueller, W.,

Aggarwal, S. S., Mehta, S. K., Bajpoi, P. C. ibid. 1974, ii, 175. Aikat, B. K., Bhattacharya, T., Walia, B. N. S. Indian J. med.

62, 953 4. Mawas, C., Buffe,

D. Burtin, P. Lancet,

1970, i, 1292.

Res 1974,

Letter: Ectopic pregnancy and the I.U.D.

1144 ECTOPIC PREGNANCY AND THE I.U.D. SIR,-Your excellent editorial (Nov. 15, p. 963 was timely in view of the interest now being shown in the associ...
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