fact that they have disturbed behaviour whether or not they have been abused makes diagnosis even more difficult. The point I wish to make is that special care should be taken when assessing the significance of the behaviour pattern in people with impairments of social interaction and communication. LORNA WING Nationial Autistic Society, London NW2 SRB I MN1cCormack B. Sexual abisec and lcarning disabilities. B13M7 1991;303:143-4. (20 Julv.)

SIR,-Dr Andrew J Wiener,' in commenting on my editorial on the long term effects of child sexual abuse,2 first constructs a straw man of his own making by claiming that my argument against child sexual abuse depends entirely on its propensity to inflict long term harm, then demolishes this thesis to his own satisfaction. I agree that child sexual abuse is an evil irrespective of its long term consequences. In condemning a social evil there is no need to medicalise it by claiming that it causes illness. On the other hand, some social ills-for example, unemploymentprobably do contribute to morbidity and mortality and surely it is permissible to point this out. Dr Wiener rightly raises the possibility that the same social and family factors that predict adult psychopathology may also predict vulnerability to sexual abuse. We are preparing for publication data showing that the sexual abuse itself contributes to adult psychopathology independently of the disrupted and deprived background which enhances the risks of being abused. The law on sexual contact with children could be changed tomorrow and some moral convulsion could conceivably alter the public's attitude to the sexual use of children, but such contact would almost certainly go on producing immediate and long term psychological and emotional damage to those children. Child sexual abuse is in my opinion a medical problem as well as a moral and legal problem, and the clear recognition of this, far from "stunting" our view of the rights of children, as asserted by Dr Wiener, provides information essential for their protection. PAUL MULLEN

Department of Psychological Medicine, University of Otago,

Dunedin, New Zealand 1 Wiener AJ. Consequences of child sexual abuse. BMJf 1991;303: 415. (17 August.) 2 Mullen PE. The consequences of child sexual abuse. BM7 1991;303:144-5. (20 July.)

Availability of cadaver organs for transplantation SIR,-In discussing the availability of cadaver organs for transplantation Dr David J Hill and colleagues question whether current clinical criteria are sufficiently exhaustive to ensure that all brain stem function has permanently ceased. They further claim that in North America theatre staff are concerned that ventilated, beating heart donors are not truly dead when operations to remove organs begin and that the same anxieties exist in the United Kingdom, including among anaesthetists. In support of this contention they quote our review of the management of multiple organ donors as stating that anaesthetists both anaesthetise and paralyse brain stem dead donors. This is misleading. Hypertension and tachycardia are not unusual during organ retrieval, and because of the importance of maintaining haemodynamic stability at this time, we suggested that glyceryl



trinitrate, nitroprusside, or isoflurane (a volatile anaesthetic agent that is a potent vasodilator) could be used if necessary to control these responses.Explanations for these haemodynamic changes have included intact spinal reflex arcs between afferent pain fibres and sympathetic efferent nerves, humoral responses after adrenal stimulation, and residual brain stem function.' Although apparently some anaesthetists are more comfortable if volatile anaesthetic agents are administered during organ retrieval, the vast majority consider that the use of such agents other than to control potentially harmful tachycardia and hypertension is illogical for brain stem dead donors.4 It is also recommended that somatic motor reflexes, similarly mediated at a spinal level, should be controlled with a muscle relaxant simply to facilitate surgery. The presence of these reflex haemodynamic and motor responses to surgical stimulation and the need to control them during organ retrieval do not in our view invalidate the current clinical criteria for diagnosing irreversible damage to the brain stem and thereby establishing that there is no prospect of the patient recovering. A C TIMMINS C J HINDS

Anacsthetic laboratory, St Bartholomew's Hospital, London EC IA 7BE I Hill D)J, Evans 1)W, (Gresham GA. Availability of cadaver organs for transplantation. BMJ 1991303:312. (3 August.) 2 Timmins AC, Hinds CJ. M\lanagement of the multiple-organ donor. Current OpiniOn in Anaestheszology 1991;4:287-92. 3 Wetzel RC, Setzer N, Stiff JL, Roberts MC. Hemodynamic responses in brain dead organ donor patients. Anesth Analg 1985;64: 125-8. 4 Bodenham A, Park GR. Care of the multiple organ donor. Intensive Care Med 1989;15:340- 8.

Antepartum haemorrhage and cervical cancer SIR,-I was interested in the comment from the National Maternity Hospital consultants about bleeding in pregnancy among women with carcinoma of the cervix.' The experience of clinical colleagues must always be respected when discussing clinical matters, but so often a small figure variation may be misleading when unusual conditions are being considered. Mr John M Stronge and colleagues quote their experiences of four women with carcinoma of the cervix presenting in pregnancy at 40, 34, 32, and 36 weeks of gestation. All had "substantial haemorrhage." They do not quote any women with carcinoma of the cervix in this time who presented with lesser bleeding. This is against my clinical experience. While preparing the ABC series I searched my memory and could think of eight to 10 women with invasive carcinoma of the cervix in pregnancy, of whom two had moderate bleeding; the rest had considerably less, some having no real bleeding at all but only spotting. When such small series are examined we must turn to published reports; these confirm that many women with invasive carcinoma of the cervix discovered in pregnancy have little bleeding. Many cases, even of invasive cancer, are diagnosed from cytological screening and subsequent colposcopy of women with an abnormal smear; these women do not bleed much and so would weight the figures. In a series collected by Moore and Gusberg of 22 women with invasive carcinoma of the cervix in pregnancy "most had no symptoms"; two had contact bleeding and three had "some bleeding."2 Hence less than 20% of their series could have been scored as having substantial bleeding. Cromer and Hawkin reviewed 20 women with carcinoma of the cervix in pregnancy; four of these had carcinoma in situ and 16 invasive carcinoma.

Seven of those with invasive carcinoma had some bleeding but only one (6%) had severe bleeding.' A bigger series was collected by Hacker et al, who summarised the findings from other sources and ended with 263 women with invasive carcinoma of the cervix out of 579 795 pregnancies. Of these cancers 168 were diagnosed either in the first trimester or in the postpartum period and are not relevant to this discussion. In the remainder, 35% of the women presented with a discharge or no symptoms and 65% had some bleeding. But the range of the duration of the symptom was 2-5-6-1 months (mean 4 5 months)-the bleeding could not have been substantial or someone would have taken some action. In 1906 Bernard Shaw (born as a breech presentation as a district case in The National Hospital) presented Doctor's Dilemma to the world in London.' In the preface to that book he states, "Even trained statisticians often fail to appreciate the extent to which statistics are vitiated by the unrecorded assumptions of their interpreters." GEOFFREY CHAMBERLAIN

St George's Hospital Mledical School, London SW17 ORE 1 Stronge JM, Boyd W, Rasmussen MiJ. Antepartum haemorrhage and cervical cancer. BAIJ 1991;303:249-50. (27 July.) 2 Moore D, Gusberg S. Cancer precursors in pregnancy. Obstet Gvnecol 1959;13:530-8. 3 Cromer J, Hawkin S. Cancer of the cervix and pregnancy. Obstet Gvnecol 1963;22:346-51. 4 Hacker NF, Berek JS, Lagasse LD, Charles EH, Savage EW, Mioore JG. Carcinoma of the cervix associated with pregnancy.

Obstet Gynecol 1982;59:735-46. 5 Shaw B. Ihe doctor's dilemma. London: I'enguin, 1946:61.

Breast carcinomas diagnosed in the 1980s SIR, -Drs H Joensuu and S Toikkanen compared breast carcinomas diagnosed in the 1980s with those diagnosed in earlier decades.' The histological factors compared in the study included a measurement of the mitotic count and an assessment of the overall tumour grade. We have recently shown that a delay in fixation of six hours produces a reduction of about 50% in the number of observable mitotic figures in breast carcinomas.2' In some tumours the decreased mitotic count can result in change in the overall Bloom and Richardson tumour grade and hence prognostic group.' We believe that it is now essential to include details of tissue fixation in any study comparing breast carcinomas on the basis of mitotic counts, particularly if tumour grade and subsequent prognosis are to be discussed. R D START S S CROSS J H F SMITH Department of Histopathology, Northern General Hospital, Sheffield S5 7AU

1 Joensuu H, Toikkanen S. Comparison of breast carcinomas diagnosed in the 1980s with those diagnosed in the 1940s to 1960s. BMJ 1991;303:155-8. (20 July.) 2 Start RD, Flynn MS, Rogers K, Smith JHF. Delayed fixation significantly decreases observed mitotic figures in breast carcinoma. J Pathol 19911163:1 54A. 3 Start RD, Flynn MS, Cross SS, Rogers K, Smith JHF. Is the grading of breast carcinoma affected by a delay in fixation? Virchows Arch [A] (in press).

Mental health needs of Asians SIR,-Dr Tony Dixon reported the results of a survey, conducted by the Confederation of Indian Organisations, of Asians living in Haringey.' I have analysed preliminary findings of a follow up study of a cohort of first generation immigrants from the Indian subcontinent, all of whom were


diagnosed as having a functional psychosis at Bethlem Royal and Maudsley Hospitals from 1969 to 1983 inclusive. An attempt was made to trace the patients together with a group of controls born in England who had English names and were unlikely to be second generation immigrants; the controls were matched with the Asians for age and year of initial contact with the hospital. The median interval between initial contact with one of the hospitals and follow up was about 12 years. Tracing was done through the hospital records or the NHS central register. Patients were categorised as "accounted for" if they were known to be registered with a general practitioner, to have gone abroad, or to be dead at the time of follow up. They were said to be "unaccounted for" if they were traced to a general practitioner or a family practitioner committee but found to be no longer registered when inquiries were made directly or if they could not be traced at all. The analysis showed that a t,siderably higher proportion of the Asians than ths controls were unaccounted for. This could Aki explained in several ways, including the possibility that the Asians were geographically more mobile (though this would have implications for continuity of care if it was true). The Asian cohort made less use of inpatient psychiatric services at the hospitals during follow up, and this might indicate that the outcome was better in the Asian patients than the controls.2 A more worrying possibility is that a higher proportion of the immigrant group had simply lost touch with medical and psychiatric services, and this would be consistent with the findings of the survey in Haringey, which suggested that a considerable number of Asians are unable or unwilling to ask for help for psychological problems. It also highlights the need to consider specific interventions to overcome barriers to access where they exist.' SUNJAI GUPTA Institute of Psychiatry, London SE5 8AF 1 Dixon T. Mental health needs of Asians. BMJ 1991;302:1420-1.

(15 June.) 2 Gupta S. Psychosis in migrants from the Indian subcontinent and English-bom controls. A preliminary study on the use of psychiatric services. BrJ Psychiaty (in press). 3 Gupta S. The mental health of Asians in Britain. BMJ 1990;301: 240.

Mandatory assessment of patients aged over 75 SIR,-Recently my practice, of about 8700 patients, carried out an audit of the visits made to patients aged over 75 from 1 April 1990 to 31 March this year to fulfil the requirements of the new general practitioner contract. Altogether, 458 patients required visiting. Of these, 403 were visited by the doctor within the year for reasons other than the assessment of patients aged over 75. This assessment was carried out on all our patients by the practice nurse. We used a preset protocol covering sensory functions, mobility, mental condition, physical condition (including continence and general health problems), social environment (including housing and carers), and drug treatment and recommended the follow up required. Seventy nine patients were in hospital or. some other form of care such as sheltered housing or nursing homes. Fifteen patients were identified as having no relatives or regular visitors who lived within the locality, and only three of these had not been seen by a doctor in the past year; all three were very independent and mobile. Forty six patients required follow up: eight required tests for hearing aids; 26 required referral to the occupational health department of the social services for various alterations to and aids in the house; eight were referred to the chiropody 584

department mainly because of difficulty in caring for their own feet owing to poor eyesight; two were referred to the district nursing service for walking aids; one, who needed a wheelchair, was referred to the appliance officer; and one was referred to the doctor because of suspected anaemia, which was confirmed and subsequently treated. No problems were found in relation to drug treatment. This is not surprising as it is assessed by the doctor when he visits the patient and by computer audit. Twenty two patients had to be contacted about the screening by letter, and only one replied. The practice spent about 15 hours a week visiting these patients and collating the data in the first six months and 10 hours a week in the next six months; this, excluding holidays, worked out at roughly 590 hours of work. The only true medical problem was anaemia in one patient, and this would probably have been picked up anyway. In conclusion, this mandatory assessment of patients over 75 years old proved to be an extremely expensive and fruitless waste of skill and time. That it is going to be repeated yearly with even less chance of picking up new referral requirements seems to me to compound this. This part of the new contract is ineffective and should perhaps be replaced by visits from the social services department as most problems seem to be of a social nature. C M CLARK Wishaw Health Centre,

Wishaw, Lanarkshire ML2 7BQ

Health informatics in the undergraduate curriculum SIR,-Professor Enid Mumford states, "Medical and other staffmust carefully and comprehensively analyse their essential information needs. They must also look carefully at the software."' But do they have the skills to do this? Few medical schools in the United Kingdom include health informatics in the medical undergraduate curriculum,2 and the idea of information needs or how to look carefully at the software will be foreign to most undergraduates. A recent survey of medical, dental, nursing, and veterinary undergraduates showed that 16% of students rated themselves as being a complete novice with computers and one in five had not used a computer during the past year.3 Of course, many argue that there is not time in the undergraduate curriculum for new disciplines such as health informatics because "too much attention is paid to instilling and testing recall of factual information"4 and this takes ever increasing accounts of time. Yet if students had better skills in storing, retrieving, analysing, and manipulating information with computers they would need less time to memorise facts and would have more time to "integrate the physical, social, and psychological aspects of clinical practice."4 Few students, for example, have ever used MEDLINE to search the literature.' Other countries have tackled this problem.2 Leiden University in The Netherlands has probably taken the most radical approach, basing the curriculum on the idea of models. For example, in the first year students take a course entitled "Systems and information processing." This includes physiological systems such as the central nervous system; medical systems and the mechanisms that lead to diagnosis and treatment and its effects; and administrative and social systems as well as computer systems. This, however, is probably far too radical for conservative British medical schools to contemplate. Germany has established a chair in medical informatics in every university, and the subject is part of the state regulated degree examinations. Professor Robin C Fraser argues that "much

more attention needs to be given to the development in students of cognitive skills and self learning techniques."4 A theme of health informatics throughout the curriculum, showing students how to handle information, is an essential part of this. RAY JONES

Department of Public Health, University of Glasgow, Glasgow G 12 8RZ 1 Mumford E. Need for relevance in management information systems: what the NHS can learn from industry. BMJ 1991;302:1587-90. (29 June.) 2 Jones RB. Education in medical informatics in the undergraduate medical curriculum: a review. In: O'Moore R, Bengsston S, Bryant JR, Bryden JS, eds. Lecture notes in medical infornatics. Vol 40. London: Springer-Verlag, 1990:422-9. 3 Jones RB, Navin LM, Barne J, Hillan E, Kinane D. Computer literacy among medical, nursing, dental and veterinary undergraduates. Med Educ 1991;25:191-5. 4 Fraser RC. Undergraduate medical education: present state and future needs. BMJ 1991;303:41-3. (6 July.)

Adding up to disaster SIR,-Dr Tony Smith suggests that population growth underlies most of the recent disasters that have occupied our television screens (cholera victims in South America, starving Africans, and cyclone victims in Bangladesh). Population growth is only one of a number of factors affecting human vulnerability to disasters. At a recent conference organised by the Institute of British Geographers' Developing Areas Research Group and the British Geographical Society to look at the human component of "natural" disasters, Dr Cannon of the Institute of Social Studies in The Hague said that "the processes which increase vulnerability are largely the same as those which generate differences in wealth, control over resources, and power, both nationally and internationally." As an example, Dr Cannon cited the need for those dispossessed of land or other income opportunities in Bangladesh to live in the extremely flood prone coastal areas of the river delta. Countries with high population growth rates should not be given help with family planning programmes without addressing the issues of inequalities in wealth, resource distribution, and empowerment. DERMOT MAHER

Department of Genitourinary Medicine, Royal Liverpool University Hospital, Liverpool L7 8XP I Smith T. Adding up to disaster. BMJ

1991;303:317. (3 August.)

Perspectives on public health SIR,-In his review of Health Through Publtc Policy: The Greening of Public Health, edited by Peter Draper, Dr John Ashton expresses disappointment over my chapter on the origins of public health, finding it "selective and somewhat idiosyncratic."' But the only justification he offers for this categorisation is trivial: that I make no mention of William Duncan and that I express criticism of an eighteenth century Liverpool doctor, William Moss. Surely it is Dr Ashton who is being idiosyncratic, for this is a disturbingly arbitrary way to assess an essay that made no pretence of offering a parochial history of public health but represented, rather, a critical analysis of the problematical nature of its origins. But no prospective reader would ever know this, for Dr Ashton is silent on the actual content and purpose of the chapter. The chapter in question, deliberately entitled "The origins ofpublic health: concepts and contradictions," clearly did not live up to Dr Ashton's rather pedantic expectations precisely because it




Mental health needs of Asians.

fact that they have disturbed behaviour whether or not they have been abused makes diagnosis even more difficult. The point I wish to make is that spe...
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