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not only up-dated the content and expanded discussions on various topics but has also included a number of corrections. The first chapter of only 15 pages summarizes the history of cerebral neurophysiology and the early studies in electroencephalography. While a great deal has been written about electrical fields at cerebral level it is refreshing to see that the authors emphasize the lack of electrical field spread in cerebral tissue, implying that the activity picked up by a cortical electrode derives from the tissue in its imunediate neighbourhood. "Similarity of activity of two cortical electrodes separated by more than a few millimetres is probably due to the neurones in the vicinity of each electrode being 'driven' by a common source, or because there are interconnecting physiological pathways between the two regions." This is a point rarely mentioned in many textbooks on electroencephalography and explodes some of the more oDmplex or fantastic theories which bear no relationship to basic cerebral neurophysiology.
The section on electrodes is also very good and pays appropriate tribute to the work of L. A. Geddes on electrodes and the measurement of bioelectric events. Some statements in the short chapter on visual analysis of the E.E.G. seem to need additional clarification, such as "it is an interesting empirical observation that the amplitudes of E.E.G. rhythms tend to be inversely related to their frequency." The same applies to various statements on "moving potential fields," and it is unclear whether the term "field" is employed here as a general term or in the stricter sense used at the bottom of page 10. An important subsection is devoted to recording the E.E.G. in intensive care units and some practical hints are offered, even if some points are debatable-for example, that where possible, sections of the recording should be carried out at a sensitivity of one microvolt per millimetre pen deflexion. The data on "overnight sleep recording" are rather limited. The section on other biological signals such as polygraphic
15 MARCH 1975
recording of eye novement, respiratory excursions, and skin potential changes could be enlarged as has been done for the recording of evoked responses (visual, somatosensory, and the contingent negative variation). Some information is also given on various techniques of telemeteTring and telephonic transmission of the E.E.G. The last chapter on "E.E.G. signal analysis" attempts to give a nonmathematical introduction to a variety of methods used in the analysis and display of E.E.G. phenomena. The authors predict a rapid increase in the use of digital methods not only for special devices having limited functions (but also for general purpose application. Tihe authors' final comment is certainly sound. They stress tLhe need for cautious and intelligent use of oomputer facilities "lest the electroencephalographers be engulfed by the data they generarte." G. PAMPIGLIONE
NEWS AND NOTES EPIDEMIOLOGY Bacteraemia The following notes are compiled by the Epidemiological Research Laboratory of the Public Health Laboratory Service from reports submitted by public health and hospital laboratories in the United Kingdom and Republic of Ireland. The routine reporting by laboratories of significant positive blood cultures began in 1972. During that year 2671 reports were received. Staphylococci were isolated from 698 patients (26%), of whom 556 were infected with Staphylococcus aureus and the other 142 with Staph. epidermidis. In general Staph. epidermidis was most frequently isolated from neonates, infants, and ci&ldren, and Staph. aureus from adults 45 years of age or more. Streptococci were found in 607 cases (23%); most of these infections (159) were due to S. pneumoia or "viridans" streptococci (157). As with Staph. aureus, most of these infections were in adults, especially those over 44 years of age. Escherichia coli was isolated in 564 cases (21%). Though bacteraemia from this organisim was more conmon in adults than in cildren, 10% of all E. coli isolations were from neonates-a hibgher proportion thn with any other organism. Indeed, about a third of all bacteraemia in neonates was due to E. coli. Similar pattens of infection
were found in most other bacteraemias due to Gram-negative bacilli except the salmonellas, which affected as many children as adults. Only 88 reported cases (3%) of ibacteraemia were caused by Neisseria spp. but case,s in whic the organism was isolated both from cerebrospinal fluid and blood are not induded in tlhis analysis. Most of the isolations were N. meningitidis, but eight were N. gonorrhoeae and two were reported as Neisseria sp. Tihough most N. meningitidis bacteraemias were in children, especially those under 1 year of age, neonatal infection was very unconmon. This age distribution is siimilar to that seen in meningoooccal meningitis. The eight reported isolations of N. gonorrhoeae from blood were in persons aged between 15 and 64. Of 72 (3%) Haemophilus bacteraemias 62 were due to H. influenzae, five to H.
parainfluenzae, one to H. parahaemolyticus,
and four were reported as Haemophilus sp. Fifty-two patients (75 %) were less than 5 years old, though, as with N. meningitidis, infection in neonaltes wasunconxmnonly reported. Deaths Of the 2671 patients with bacteraemnia reported during 1972 a fatal outcome was reported in 355 (13%). But probaibly deaths
were underreported and the true rate was somewhat higher. As expected, the greatest mortallity was in people of 65 or older (20%) and in neonates (17%). The lowest mortality (2%) was in the 5-14-year age group. The death rate for males and females was similar. The proportion of deaths was greatest in bacteraemia caused by Pseudomonas sp. Of the patients whose blood cultures grew organisms of this group, 38%, mostly those over 65, died. A thigh proportion of deaths (29%) was also reported in patients with clofstridial bacteraemia. Many of them had coexisting gastrointestinal or gynaecological illnesses, and the bacteraemia often followed an operation for such an illness. Only one reported case was assoiated with gas gangrene. In most other ibacteraemias between 10 and 20% were reported to have proved fatal, and only with those due to Staphylococcus, Haemophilus, and Corynebacteria were the percentages less than 10%. The age distribution and the outcome of these bacteraemia cases has probably been influenced by the coexisting clinical condition. A preliminary analysis of the clinical data given in the reports suggests, for example, that the ae distribution of the patients with staphyloocal bacteraemia reflects in par,t that of osteomyelitis and leukaemia, and of E. coli bacteraemia that of patients with urinary infections.
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15 MARCH 1975
MEDICOLEGAL Negligence Speaking for Itself FROM OUR LEGAL CORRESPONDENT
Even the best regulated medical treatment goes wrong from time to time, and when an accident occurs the patient often considers himself entitled to compensation. Naturally the courts are not unsympathetic to such plaintiffs, and in the past the success of certain actions has led some doctors to feel that judges are only paying lip-service to the doctrine that negligence alone justifies damages and that in the process the oourts have become heedless of professional reputations. Bricks Without Straw Plaintiffs' lawyers faced with the task of making bricks without straw often rely on the maxim res ipsa loquitur to try and found a case of negligence where strict proof by the plaintiff is impossible. In some cases the matter does, indeed, speak for itself, and the happening of the accident-even if its causes are unknown-will point remorselessly to negligence of some unspecified nature on the part of the doctor. So, in the fa-mous case where six bags of sugar tumbled from a warehouse onto the head of a customs officer, a Victorian Chief Justice' conmmented: "if the accident is such as in the ordinary course of things does not happen if those who have the management use proper care, it affords reasonable evidence, in the absence of an explanation by the defendant, that the accident arose from want of care." In the past it has been doubted whether res ipsa loquitur could apply to surgeons. It was even doubted by Lord Justice Scott in a swabs case: "how can the ordinary judge have sufficient knowledge of surgical operations to dTraw such an inference," he asked,2 "what does he know of 'the ordinary course of things' in a complicated abdominal operation?" But, proceeding with caution, since the last war the courts have found the maxim of help in dealing with cases involving the exercise of professional skill.3 A particularly well-known example was the case' in 1951 of Mr. Cassidy, who had undergone an operation to remedy Dupuytren's contraction of the tird and fourth fingers of one hand. Wlhen he left hospital the two original fingers were still bent and stiff, as were by then the two good ones as well. The trial judge found himself quite unable to detect any negligence on the hospital's part and gave judgement for them -a decision the Court of Appeal reversed. Lord Justice Denning thought that the patient was quite entitled to say: "I went into hospital to be cured of two stiff fingers. I have come out with four stiff fingers and my hand is useless. That should not have happened if due care had been used. Explain it if you can." If the Lord Justice's reasoning in Cassidy's case was a little abrupt, three years later he showed himself well aware that all surgery was attended by risks. It was easy, he mnxmented, to be wise after the event and condemn as negligence what was only
misadventure. The courts hbad always to be should not have continued trying to get into their guard against tat (tendency, the artery when the plintiffs pain should have warned him it was high time to stop. especially with doctors.5 The judge accepted that even severe pain was by no means unconmon wiith aortaChanging Attitudes grams under local anaesthesia and thought that if, as the evidence shuowed, the pain In the 20 years since then, the feeling has came after the penetration of the artery, grown in some quarters of the medical prowas no need for Dr. Bland to desist. fession that the judiciary has relaxed its there Having failed to make out a positive case of and the vigilance against perils hind-sight, of negligence, the plaintiff's counsel also sometimes recently the medical deece societies have settled cases not because they argued that the case wais a classic example of ipsa loquitur. Adopting Lord Justice thought that the plaintiff could prove res Denning's in the Cassidy case, he negligence, but because they doubted that pointed outwords that the plaintiff had gone into they could show what had really happened. A recent case6 brought against the hospital for an x-ray of his arteries and had come out with serious neurological injury Governors of the National Hospital for ito his right hand and am. Nervous Diseases ought to reassure those Mr. Justice Bridge dismissed that line of with fears about the way that mlpractice argument as well. The witnesses before him actions in this country are multiplying. Mhe not disputed that no matter how skilplaintiff had sought treatment at the hos- had fully an axillary aortagram was canied out, pital in 1968 after he had been afflicted by was always a danger of injury to the recurrent episodes of loss of vision in the tfhere nerves of the arm, since the axillary artery right eye. Stenosis of the right carotid at the point of puncture in the arm-pit is artery was diagnosed, and to confirm the extremely close to the nerves of the brachial diagnosis the hospital decided to perform plexus. Res ipsa loquitur, said the judge, an aortagram. They considered that if surcould be of no application where the injury gery was going to be necessary it was better sustained by the plaintiff was of a kind to have available the extensive information as an inherent risk of the treata-bout the condition of the cerebral arterial recognized system that was yielded by an aortagram, ment undergone. rather than the more limited informtion provided by a direct carotid arteriogram. Warning of Risks
on
The judge then dealt with what he said was a peripheral matter in the case, though it Tihe task of performing the investgation is of considerable importance to the progenerally: was there a positive duty fell to a senior registrar, Dr. Bland. The fession the part of the doctors to warn the plaintrial judge, Mr. Justice Bridge, found that on tiff of the risk of injury implicit in an he had set about it entirely in acoordance aortagram? The plaintiff argued that it was with proper practice in 1968. The plaintiff negligence not to have warned him of the vas given a normal dose of premedication recognized risk of the process. He said that and the operation was done under local he wa's accomplished pianist and that had anaesthesia. Dr. Bland successfully punctured he beenanwarned risk, he would have the the femoral artery in patient's right declined to have ofthetheinvestigation. groin with the Seldinger needle, but then The only evidence-and that uncontromet an obstruction before the guide-wire verted-before the judge on this matter was had travelled more than 5 or 6 inches up that of the physician in charge of the plaintiff. the artery. He therefore abandoned the He said that he saw no reason to tell the femoal route and decided to insert the pliaintiff of the possible neurological comcatheter by way of the right axillary artery. plications. Mr. Justice Bridge conmented But before that artery was successfully that if the risk was relatively remote, then punctured, Dr. Bland had to make a num- there were obvious disadvantages in warning tber of passes and the plitiff suffered a patient: "on the one hand you alam considerable pain: towards the end it was him unnecessarily, and on the other hand, almnost intolerable. you may put him in a position where he The aortagram showed that the plaintiff's feels that he should take the decision, alibeit condition could be treated with anti- the doctor is obviously nmuch better qualicoagulants and the trouble with the vision fied to weigh up the advantges and the in his right eye was successfully brought desirability of the proposed operation as under control. However, unfortunately, there against the risks." were serious neurological complications: the The judge, viewing the matter simply as plaintiff suffered pain in the right arm for one of negligence, concluded that a failure some months, but was left with a permanent to warn of remote risks, where the patient loss of function in the right ulnar and had not raised the question, could not be median nerves, which led to partial paralysis said to be lack of care. On the other hand of the right 'hand coupled with loss of in a New Zealand case7 in 1965, the defendFacts of Case
sensation.
ant surgeon gave a
patient albout to undergo
Mr. Justice Bridge dismissed the plain- an aortagram an answer to a question about tiffs primary contention that Dr. Bland the risks "Iso reassuring as to be capable of
636 the construction that thetre was no risk." The court found that fel somewhat short of the truth. The Chief Justice ruled that a doctor was bound to use due care in answering a question put to him by a patient where the patient, to the doctor's knowledge, intends to rely on that answer in deciding whether to accept the treatment to which he is being asked to consent. If the doctr answers negligently, said the New Zealand court, and the patient suffers injury from the treatment, then the doctor will be liable if the evidence shows that if the proper answer had been given the patient would have refused the treatment. In a matter of such daily importance to the medical profession, it is regrettable to find the law so sketchy and uncertain. It has even been suggested 8 9 tht an untruthful or evasive answer by the doctor might be justified in extreme circumstances. The issue in the reported cases has always been treated as one of negligence, rather than as of assaul or trespass to the person. It does not seem to have been decided in a reported ma!pTactice case in this country that the consent to the operation was vitiated by its not being properly informbed consent ;so as to make the operation an assault. Lord Justice Ornnod mooted the issue of patient's rights in an addwrss1 to the Royal College of General Practitioners in 1967. Tihe patient, he thought, was entitled to demand a bona fide statement in boad terms of the risks to life or future health or of min or discomfort in the contemplated procedure, and the greater the risk, the greater the obligation on the doctor to ensure that he understands. But it was pedantic to insist that the patienrt be fully informed of a mass of facts he cannot assimilate or assess. In the instance at the National Hospital the docor, in the a;bsence of any question from his patient, decided that there was no reason to mention the possible complications. All the same, Whether there is a positive duty on doctors to keep their patienits informed of all aspects of their treatment, even when they pose no queries, is an issue of some importance to the profession and one that some day wil have to be faced head-on. Is it right, in Lord Justice Ormrod's words, that the patient 'shoulud be treated as a responsible adult whose right it is to make his own decisions, unless there is some good reason to believe that he is in some real sense incapacitated from doing so"? 1 Erle, C.
2
3
4 5
6 7
8 9
10
J., in Scott v. London and St. Katherine Docks (1865) 3 H.&C. 596.
Mahom v. Osborne: (1939) 2 KB at page 23. MacKinnon and Goddard L.J.J., both thought that leaving a swab in a patient's body shifted the burden of proof onto the defendant to show that his negligence had not caused the accident. Salmond: Law of Torts. 16th edition, p. 242. London, Sweet and Maxwell, 1973. Cassidy v. Ministry of Health: (1951) 2 KB at p. 365. Roe v. Ministry of Health: (1954) 2 QB at p. 83. The plaintiffs suffered spastic paraplegia after phen,ol entered nupercaine ampoules (with whlch they were injected) through micro'copic flaws. O'MaMey-Wilamns v. Board of Governors of the National Hospital for Nervous Diseases. 7 October 1974. Smith v. Auckland Hospital Board: (1965) NZ
BRITISH MEDICAL JOURNAL
15 MARCH 1975
PARLIAMENT Consultants' Dispute In a further statement on 10 March to the House of Comions Mrs. BARBARA CASTLE (Secretary of State for Sodial Services) referred to the exchange of letters on the consultants' dispute beween the profession and the Prime Minister (see p. 642). Commenting on his reference to the interests of patients being damaged she said she regretted that this situation was arising in many parts of the country. She also hoped that "having studied the Prime Minister's replies and the assurances they contain the consultants will decide to drop sanctions and get round the negotiating table." Dr. G. F. VAUGHAN (an Opposition spokesman on social services and a consultant himself) was disappointed with her statement and the Prime Minister's replies. He saw nothing that would help to resolve the present dispute with waiting lists increasing to "a most dangerous extent." There was a l%kelibood of serious damage to the care of patients in the N.H.S. The major difficulty now, he claimed, was that many leading consultants had no confidence in her at all. He suggested that she reopened negotiations, oir failing that handed over discussionis to an independent arbitrator.
Not Acting Personally In reply, Mrs. CASTLE called on consulitants "to withdraw sanctions in the certain knowledge, as the Prime Minister has stated, thait in this matter I have not been acting personally but with the full authority and knowledge of the Cabinet, and recognizing tmhat there are no grounds left that would prevent a settlement if the consultants wecre at least wilding to sihow a shade of compromise." Dr. MAURICE MILLER (Lab., East Kilibride) claimed there was a growing body of opinion among consultanits "irritated, annoyed, and impatient with the small group of consultants who out monetary advantage above the necessity to do their best for their patients." Mrs. CASTLE then referred to a tele-vision interview in wvhich Professor Mcoll, of Guy's Hospital, had said "there would be a riot if vou took away the extra paymenit" [he had been referring to the current differential in favour of the whole-time consultant]. It was clear, she said, that the profession was divided on this issue.
Freedom of the Consultant Mr. PAuL DEAN (Con., North Somerset) declared that the dispute was "not fundamentally about pay but about the freedom of the consultant [A Labour M.P.: 'To make more money'] to do their duty to patients without political interference." He asked for independent arbitration. What would such a person be asked to arbitrate about? Mrs. Castle replied. She continued: "It could not be about pay 191. Speller: LaW Relating to Hospitals, 5th edition, because that is for the independent review p. 107. London, H. K. Lewis, 1971. per Dnng, L. J., obiter in summing up to the body and is currently before it. I-t would be juy in Hatcher v. Black: The Times, 2 July necessary, therefore, to define exactly what 1954. British Medical 7ournal: 6 April 1968, p. 7: the the arbitrator would arbitrate about. The Lord Justice seems primarily to have been co-n- ocmsultants have never made that clear cerned with patient's rights in the context of because in their own minds they are divided experiments and organ trnsplants.
and confused." Later in ithe debate she claimed that a lage number of the profession deplored ithe consultants' action. Mr. NoRmAN FOWLER (Opposition spokesman on social services) asked whether Mrs. Castle was claiming that Professor McColl spoke for all consultants. "Is her understanding of the dispute so smrall that she does not understand the real feeling which exists among consultants?"
Conflict of Interests Mrs. CASTLE admitted that no individual spoke for all consultanrts. There was a conflict of interest between whole-time and maximum part-time consultants, "between," she said, "the man who can and does earn large sums from private practice and those other consultants in the Cinderella areas and neglected specialties, who depend totally upon the whole-time emolument. I am defending the whole-time emolument. I am and will defend a proper reward to those who are devoting themselves full-time to the health service in areas where there are not fat pickings to be made. The best way the Conservatives can bring this dispute to a oonclusion is to stand up and condemn the intolerable behaviour being indulged in by so many consultants."
MEDICAL NEWS Anglo-Soviet Health Agreement On the occasion of the Prime Minister's recent visit -to the Soviet Union an agreement on co-operation in the field of medicine and public health has been issued. The main points of the agreement are undertakings for collaborative research, particularly in control of conmunicable diseaseis; excihanges of medical personnel and infonmation on new equipment, tedhnological developments, and pharmaceutical products; and immediate medical treatment when in the other's country under the same terms as the citizens of the country coneerned, the expenses being borne by the appropriate authorities of the country where they arise. Abortion (Amendment) Bill Committee Tihe names of the Members of Parliament appointed to serve on the select coumnittee on the Abortion (Amendment) Bill have been announced. Eleven tnen and four women are to be members, and according to the announcement they include some supporters of the Bill, some opponents, and some who did not vote when the Bill came up on 7 February -at which time the voting for a seond reading was 203 in favour and 88 against. Dr. Maurice S. Miller is the only medical member of the committee.
"World of Learing" Te 25th edition of The World of Learning is in two volumes, as were the previous
BRITIShI MEDICAL JOURNAL
15 MARCH 1975
three editions, and contains information on 35 new universities in addition to its standard features. The contents of the two volumes are changed slightly; the chapter previously headed Great Britain in volume one has been moved to voliume two as the United Kingdom. For the first time, chapters on the Baihamas, Bahrain, Botswana, Brunei, Oman, and the United Arab Emirates are included. Volume two ends with a 140-page index on institutions. The World of Learning 1974-75, 25th edn. Europa Publications Ltd., London. £18-50 two-volume set.
Medical Photography The annual exhibition of the Medical Group of the Royal Photographic Society is now on show in the C-laire Wand Gallery, B.M.A. House. The exhibition was opened on 6 March by Sir Ronald Tunbridge, president of the B.M.A., and will continue until 25 April. The British Medical Journal award was won by Mr. R. Williams for his demonstration of Lichtschnitteverfahren and the Lancet trophy by Miss J. Fendick for the illustrations she prepared for A Colour Atlas of Forensic Pathology.
Resignations from G.P.s Well over 10000 unda-ted resignations from the N.H.S. signed by general practitioners had been received by the B.M.A. at the end of last week. As we went to press the resignations were arriving at B.M.A. House at the rate of 1000 a day.
COMING EVENTS Biological Engineering Society (Ultrasound and Blood Flow Groups).-Open day discussion meeting, "Haemodynamic Assessment by Ultrasonic Techniques in Clinical Practice," 27 March, Harrow. Fee £1 75 (including lunch). Applications to L. H. Light, Bioengineering Division, Clinical Research Centre, Northwick Park Hospital, Watford Road, Harrow, Middlesex HAl 3UJ. (Tel. 01-864 5311.) British Small Animal Veterinary Association.-Annual congress, 4-6 April, Kensington, London. Details from Mr. T. M. Eaton, 5 St. George's Terrace, Cheltenham, Glos. Society for Drug Research.-(1) Day symposium, "Prolactin," 8 April, Chelsea College, Manresa Road, London S.W.3; (2) symposium, "Inflammation," 10-12 July, Nottingham University. Details from the secretary, Dr. Alma B. Simmonds, at Chelsea College. International Symposium on Pyrogens.8-9 April, University College, London, organized by the Pharmaceutical Society of Great Britain. Fee £15 (including refreshments). Details and application forms from Mr. R. E. Marshall, at the society, 17 Bloomsbury Square, London WC1A 2NN. Institute of Practitioners in Work Study Organization and Methods (Health Services Specialist Group).-Spring conference, 9 April, Walsgrave Hospital, Coventry. Details and application forms from Mr. M. W. Goad, Regional Management Services Officer, North-west Thames Regional Health Authority, 40 Eastbourne Terrace, London W.2. (Tel. 01-262 8011.) "Communication and the X-ray Depart. ment."-Symposium, 9-11 April, Keele University. Fee £18-50. Details from Dr. A. W. O'Malley, X-ray Department, North Staffs Royal Infirmary, Princes Road, Hartshill, Stoke-on-Trent, ST4 7LN, Staffs. Association of Anaesthetists of Great Britain and Ireland.-Annual scientific meeting for junior anaesthetists, 9-12 April, Birmingham University. Details from the secretary, Association of Anaesthetists, Room 475/478, Tavistock House South, Tavistock Square, London WC1H 9JP. (Tel. 01-387 4782.)
637
Welsh National School of Medicine.-Day symposium, "Hypertension in the Older Patient," 11 April, University Hospital of Wales, Heath Park, Cardiff CF4 4XW. Applications to Dr. M. S. Pathy, at the hospital. (Tel. 0222 755944.) Royal College of General Practitioners.Annual spring general meeting, 11-13 April, Dundee. Details and application forms from the honorary secretary, East Scotland Faculty, R.C.G.P., Kinnessburn, Kennedy Gardens, St. Andrews, KY16 9DJ. "Diffusion in Pharmaceutical Formulation and Packaging."-Postgraduate school, 14-18 April, London, organized by the School of Pharmacy, London University, and Pharmaceutical Society of Great Britain. Fee £60. Details and application forms from the school secretary, Mr. R. E. Marshall, Department of Pharmaceutical Sciences, Pharmaceutical Society of Great Britain, 17 Bloomsbury Square, London WC1A 2NN. Biochemical Society.-Meeting, 15-16 April, Aberystwyth, programme includes colloquium on "Biochemistry of Blue-green Bacteria." Details from the society, 7 Warwick Court, Holborn, London WC1R 5DP. (Tel. 01-242 1076.) U.K. Liaison Committee for Sciences Allied to Medicine and Biology.-Congress on "Scientific Aids in Hospital Diagnosis," 15-17 April, Oxford. Details from Mr. R. E. George, S.A.M.B. Publicity Officer, Department of Clinical Physics and Bioengineering, Guy's Hospital, London SE1 9RT. (Tel. 01-407 7600, extn. 326.) "Forensic Psychiatry."-Intensive residential course, 21-24 April, Birmingham University. Fee £25 (£16-50 non-residents). Details from the director, Board of Graduate Clinical Studies, Medical School, Birmingham B15 2TJ. (Tel. 021-472 1301.)
ABERDEEN Appointments-Mr. J. R. C. McLauchlan (lecturers, surgery).
Logie,
Mr.
J.
ROYAL COLLEGE OF SURGEONS IN IRELAND F.R.C.S.I.-A. El T. El Tahir. J. Harty, Rosaleen E. Healy, F. Mosawi, M. J. Murphy, K. N. Rao, S. S. Surasi, A. U. I. Yakubu.
ROYAL COLLEGE OF SURGEONS OF EDINBURGH At a meeting of the council of the college held on 7 March the following were admitted to the fellowship: C. K. Aravindakshan, M. Chellappa, W. R. Chen, G. On Tong, D. Hung-Fai Cheng, Hing-Piig Chow, Hoi-Chu Fung, Hon-Lau Ho, Kam-Hing Lam, R. Kwok-Ming Pbon, R. A. Che-Wai Wong, M. F. I. Abdel-Rahman, N. K. Agarwala, W. 0. Aina, N. A. Akingbehin, M. Akram, M. A. J. Al-Ani, S. S. AlKaragully, S. S. Asmr, R. Aryanpour, M. A. Athar, N. A. Attar, S. S. Aujila, J. S. 0. Aunallah, S. Bagchi, F. S. Bassili, M. H. A. Beg, S. Bhattacherjee, D. A. Birrell, R. Bose, J. B. Brew, A. K. Chakraborty, R. E. Cheeks, P. M. H. Cherry, S. L. Chhabra, A. K. Chowdhury, M. R. Clarke, M. A. Coe, G. F. Crisp, J. L. Croser, G. Dattani, E. F. D'Costa, S. N. Deliyannis, B. A. Deshmukh, J. P. Dhasmana, R. A. Dimitri, P. C. Dobson, J. N. D'Souza, Angela M. Dunham, Margaret J. Elliot, M. M. H. El Maaita, J. V. Forrester, I. S. Fyfe, I. R. Gough, C. K. Goyal, A. M. Greenberg, M. F. Guirgis, M. A. Habib, M. A. Haddadin, N. Y. Hamadalla, A. I. Hashmat, R. Hettiarachi J. R. Hindmarsh, Deirdre J. Holding, A. D. HoltWilson, B. R. Jaidev, H. K. Jalan, A. B. Jatoi, L. Jha, W. G. Jhagroo, J. John, D. T. Johnson, A. G. Jones, H. B. Kapila, A. I. G. Kerr, M. M. Y. Khadaroo, H. I. M. Khamnuash, P. Kollintzas, S. Lall, E. R. Levy, P. N. Luthra, 0. K. Malla, N. R. Maximose, M. Mendhi, J. S. Morcous, A. A. Morgan, R. A. M. Myers, Evelyn P. Nackasha, J. F. O'Brien, A. O. A. Olusanya, A. F. C. Pinto, F. Portelli, K. A. Qidwai. S. M. Qureshi, V. K. Raju, N. Ramanathan, V. P. V. Rao, K. K. Ray, J. M. Read, A. K. Rohatgi, H. T. Saad, S. K. Sabharwal, M. McG. Scott, R. K. Seal, G. R. Sethi, SOCIETIES AND LECTURES A. V. Shah, S. Shanmugham, R. Shome, B. L. Shrestha, A. P. Sinha, M. S. Sisay, R. B. Spooner, For attending lectures marked * a fee is charged E. D. J. Stone. K. J. Sunderland, Myo Swe, A. R. M. T. Thoung, M. G. Thuse, P. N. Tiwari, Taylor, or a ticket is required. Applications should be B. H. Valentine, P. Vijayan. R. B. Warne, M. R. made first to the institution concerned. Weedon, D. LI. Wiliams, W. F. Wong, H. I. A. Yagi, 0. B. Yahaya, P. T. L. Yong, Q. Zaman. Tuesday, 18 March LONDON SOCIETY OF FAMILY PLANNING DOCTORS.At Royal Society of Medicine, 1 Wimpole Street, W1, 8.15 p.m., meeting: Current Approaches Treatment of Sexual Inadequacy.
to
Corrections General Medical Council: Tests for Overseas Doctors In the General Medical Council's report on tests Wednesday, 19 March for overseas doctors (8 March, p. 588) it was inINSTITUTE OF DERMATOLOGY.-4.30 p.m., Dr. M. correctly stated that the tests would be considered Feivel: Xanthomatosis. centres situated in London, Edinburgh, and PHARMACEUTICAL SOCIETY OF GREAT BRITAIN.-7 at Glasgow. The sentence should have read "The p.m., Dr. J. Taylor: Role of Forensic Laboratory tests will be conducted at centres situated in in Cases of Poisoning. ROYAL COLLEGE OF SURGEONS OF ENGLAND.-4 p.m., London, Edinburgh, and Glasgow." COLLEGE.-5 p.m., Dr. C. A. H. Watts: Depression, a Protean Syndrome.
ROYAL
ARMY
MEDICAL
Frederic Hewitt lecture by Professor A. Crampton Smith: The Business of Anaesthesia. ROYAL POSTGRADUATE MEDICAL SCHOOL.-2 p.m., Professor I. Phillips: Antimicrobial Susceptibility of Anaerobes.
Central Committee for Hospital Medical Services In the report of the meeting of the C.C.H.M.S. ROYAL SOCIETY OF MEDICINE: SECTION OF COMPARA- (1 March, p. 529) Mr. D. H. Teasdale reported the TIVE MEDICINE.-2.30 p.m., joint meeting with of a meeting of consultants. This meeting outcome Royal Society of Tropicall Medicine and Hygiene: was attended by 60 members of the North West Prevention and Control of Parasitic Diseases. WILLESDEN GENERAL HOSPITAL.-8.30 p.m., Dr. M. Regional Committee for Hospital Medical Services Newton: The Ins and Outs of Salt Balance. and the Hospital Consultants and Specialists Association. The 60 represented over 800 consultants. We apologize for this omission. Thursday, 20 March FACULTY
OF
HOMOEOPATHY.-5
p.m.,
Richard
Hughes memorial lecture by Dr. Kathleen G. Priestman: Comments on Some Homoeopathic Remedies.
Friday, 21 March INSTITUTE OF LARYNGOLOGY AND OTOLOGY.-5.30 p.m., Mr. E. J. Radley Smith: Fractures at Base of Skull.
ROYAL POSTGRADUATE MEDICAL SCHOOL.-1l a.m.,
Research in
progress:
Endocrinology.
Saturday, 22 March COLLEGE OF SURGEONS OF ENGLAND.-12 noon, Webb-Johnson lecture by Sir Terence Ward: Closing the Gate to Pain.
ROYAL
Notice to Authors When original articles and letters for publication are not submitted exclusively to the British Medical Journal this must be stated. Correspondence on editorial business should be addressed to the Editor, British Medical Journal, B.M.A. House, Tavistock Square, London WC1H 9JR. Telephone: 01-387 4499. Telegrams: Aitiology, London, W.C.l. Authors wanting reprints of their articles should notify the Publishing Manager, B.M.A. House, Tavistock Square, WC1H 9JR, on receipt of proofs.
C British Medical Journal 1975 All Rights Reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, CA,MBRIDGE electronic, mechanical, photocopying, recording M.D.-K. R. Hunter, I. C. Gregory. M.CHIR.-M. R. Colmer, Lynn E. Edwards, or otherwise, without the prior permission of the British Medical Journal. M. G. W. Kettlewell, R. W. Marcuson.
UNIVERSITIES AND COLLEGES
BRITISH MEDICAL JOURNAL
not only up-dated the content and expanded discussions on various topics but has also included a number of corrections. The first chapter of only 15 pages summarizes the history of cerebral neurophysiology and the early studies in electroencephalography. While a great deal has been written about electrical fields at cerebral level it is refreshing to see that the authors emphasize the lack of electrical field spread in cerebral tissue, implying that the activity picked up by a cortical electrode derives from the tissue in its imunediate neighbourhood. "Similarity of activity of two cortical electrodes separated by more than a few millimetres is probably due to the neurones in the vicinity of each electrode being 'driven' by a common source, or because there are interconnecting physiological pathways between the two regions." This is a point rarely mentioned in many textbooks on electroencephalography and explodes some of the more oDmplex or fantastic theories which bear no relationship to basic cerebral neurophysiology.
The section on electrodes is also very good and pays appropriate tribute to the work of L. A. Geddes on electrodes and the measurement of bioelectric events. Some statements in the short chapter on visual analysis of the E.E.G. seem to need additional clarification, such as "it is an interesting empirical observation that the amplitudes of E.E.G. rhythms tend to be inversely related to their frequency." The same applies to various statements on "moving potential fields," and it is unclear whether the term "field" is employed here as a general term or in the stricter sense used at the bottom of page 10. An important subsection is devoted to recording the E.E.G. in intensive care units and some practical hints are offered, even if some points are debatable-for example, that where possible, sections of the recording should be carried out at a sensitivity of one microvolt per millimetre pen deflexion. The data on "overnight sleep recording" are rather limited. The section on other biological signals such as polygraphic
15 MARCH 1975
recording of eye novement, respiratory excursions, and skin potential changes could be enlarged as has been done for the recording of evoked responses (visual, somatosensory, and the contingent negative variation). Some information is also given on various techniques of telemeteTring and telephonic transmission of the E.E.G. The last chapter on "E.E.G. signal analysis" attempts to give a nonmathematical introduction to a variety of methods used in the analysis and display of E.E.G. phenomena. The authors predict a rapid increase in the use of digital methods not only for special devices having limited functions (but also for general purpose application. Tihe authors' final comment is certainly sound. They stress tLhe need for cautious and intelligent use of oomputer facilities "lest the electroencephalographers be engulfed by the data they generarte." G. PAMPIGLIONE
NEWS AND NOTES EPIDEMIOLOGY Bacteraemia The following notes are compiled by the Epidemiological Research Laboratory of the Public Health Laboratory Service from reports submitted by public health and hospital laboratories in the United Kingdom and Republic of Ireland. The routine reporting by laboratories of significant positive blood cultures began in 1972. During that year 2671 reports were received. Staphylococci were isolated from 698 patients (26%), of whom 556 were infected with Staphylococcus aureus and the other 142 with Staph. epidermidis. In general Staph. epidermidis was most frequently isolated from neonates, infants, and ci&ldren, and Staph. aureus from adults 45 years of age or more. Streptococci were found in 607 cases (23%); most of these infections (159) were due to S. pneumoia or "viridans" streptococci (157). As with Staph. aureus, most of these infections were in adults, especially those over 44 years of age. Escherichia coli was isolated in 564 cases (21%). Though bacteraemia from this organisim was more conmon in adults than in cildren, 10% of all E. coli isolations were from neonates-a hibgher proportion thn with any other organism. Indeed, about a third of all bacteraemia in neonates was due to E. coli. Similar pattens of infection
were found in most other bacteraemias due to Gram-negative bacilli except the salmonellas, which affected as many children as adults. Only 88 reported cases (3%) of ibacteraemia were caused by Neisseria spp. but case,s in whic the organism was isolated both from cerebrospinal fluid and blood are not induded in tlhis analysis. Most of the isolations were N. meningitidis, but eight were N. gonorrhoeae and two were reported as Neisseria sp. Tihough most N. meningitidis bacteraemias were in children, especially those under 1 year of age, neonatal infection was very unconmon. This age distribution is siimilar to that seen in meningoooccal meningitis. The eight reported isolations of N. gonorrhoeae from blood were in persons aged between 15 and 64. Of 72 (3%) Haemophilus bacteraemias 62 were due to H. influenzae, five to H.
parainfluenzae, one to H. parahaemolyticus,
and four were reported as Haemophilus sp. Fifty-two patients (75 %) were less than 5 years old, though, as with N. meningitidis, infection in neonaltes wasunconxmnonly reported. Deaths Of the 2671 patients with bacteraemnia reported during 1972 a fatal outcome was reported in 355 (13%). But probaibly deaths
were underreported and the true rate was somewhat higher. As expected, the greatest mortallity was in people of 65 or older (20%) and in neonates (17%). The lowest mortality (2%) was in the 5-14-year age group. The death rate for males and females was similar. The proportion of deaths was greatest in bacteraemia caused by Pseudomonas sp. Of the patients whose blood cultures grew organisms of this group, 38%, mostly those over 65, died. A thigh proportion of deaths (29%) was also reported in patients with clofstridial bacteraemia. Many of them had coexisting gastrointestinal or gynaecological illnesses, and the bacteraemia often followed an operation for such an illness. Only one reported case was assoiated with gas gangrene. In most other ibacteraemias between 10 and 20% were reported to have proved fatal, and only with those due to Staphylococcus, Haemophilus, and Corynebacteria were the percentages less than 10%. The age distribution and the outcome of these bacteraemia cases has probably been influenced by the coexisting clinical condition. A preliminary analysis of the clinical data given in the reports suggests, for example, that the ae distribution of the patients with staphyloocal bacteraemia reflects in par,t that of osteomyelitis and leukaemia, and of E. coli bacteraemia that of patients with urinary infections.
BRITISH MEDICAL JOURNAL
635
15 MARCH 1975
MEDICOLEGAL Negligence Speaking for Itself FROM OUR LEGAL CORRESPONDENT
Even the best regulated medical treatment goes wrong from time to time, and when an accident occurs the patient often considers himself entitled to compensation. Naturally the courts are not unsympathetic to such plaintiffs, and in the past the success of certain actions has led some doctors to feel that judges are only paying lip-service to the doctrine that negligence alone justifies damages and that in the process the oourts have become heedless of professional reputations. Bricks Without Straw Plaintiffs' lawyers faced with the task of making bricks without straw often rely on the maxim res ipsa loquitur to try and found a case of negligence where strict proof by the plaintiff is impossible. In some cases the matter does, indeed, speak for itself, and the happening of the accident-even if its causes are unknown-will point remorselessly to negligence of some unspecified nature on the part of the doctor. So, in the fa-mous case where six bags of sugar tumbled from a warehouse onto the head of a customs officer, a Victorian Chief Justice' conmmented: "if the accident is such as in the ordinary course of things does not happen if those who have the management use proper care, it affords reasonable evidence, in the absence of an explanation by the defendant, that the accident arose from want of care." In the past it has been doubted whether res ipsa loquitur could apply to surgeons. It was even doubted by Lord Justice Scott in a swabs case: "how can the ordinary judge have sufficient knowledge of surgical operations to dTraw such an inference," he asked,2 "what does he know of 'the ordinary course of things' in a complicated abdominal operation?" But, proceeding with caution, since the last war the courts have found the maxim of help in dealing with cases involving the exercise of professional skill.3 A particularly well-known example was the case' in 1951 of Mr. Cassidy, who had undergone an operation to remedy Dupuytren's contraction of the tird and fourth fingers of one hand. Wlhen he left hospital the two original fingers were still bent and stiff, as were by then the two good ones as well. The trial judge found himself quite unable to detect any negligence on the hospital's part and gave judgement for them -a decision the Court of Appeal reversed. Lord Justice Denning thought that the patient was quite entitled to say: "I went into hospital to be cured of two stiff fingers. I have come out with four stiff fingers and my hand is useless. That should not have happened if due care had been used. Explain it if you can." If the Lord Justice's reasoning in Cassidy's case was a little abrupt, three years later he showed himself well aware that all surgery was attended by risks. It was easy, he mnxmented, to be wise after the event and condemn as negligence what was only
misadventure. The courts hbad always to be should not have continued trying to get into their guard against tat (tendency, the artery when the plintiffs pain should have warned him it was high time to stop. especially with doctors.5 The judge accepted that even severe pain was by no means unconmon wiith aortaChanging Attitudes grams under local anaesthesia and thought that if, as the evidence shuowed, the pain In the 20 years since then, the feeling has came after the penetration of the artery, grown in some quarters of the medical prowas no need for Dr. Bland to desist. fession that the judiciary has relaxed its there Having failed to make out a positive case of and the vigilance against perils hind-sight, of negligence, the plaintiff's counsel also sometimes recently the medical deece societies have settled cases not because they argued that the case wais a classic example of ipsa loquitur. Adopting Lord Justice thought that the plaintiff could prove res Denning's in the Cassidy case, he negligence, but because they doubted that pointed outwords that the plaintiff had gone into they could show what had really happened. A recent case6 brought against the hospital for an x-ray of his arteries and had come out with serious neurological injury Governors of the National Hospital for ito his right hand and am. Nervous Diseases ought to reassure those Mr. Justice Bridge dismissed that line of with fears about the way that mlpractice argument as well. The witnesses before him actions in this country are multiplying. Mhe not disputed that no matter how skilplaintiff had sought treatment at the hos- had fully an axillary aortagram was canied out, pital in 1968 after he had been afflicted by was always a danger of injury to the recurrent episodes of loss of vision in the tfhere nerves of the arm, since the axillary artery right eye. Stenosis of the right carotid at the point of puncture in the arm-pit is artery was diagnosed, and to confirm the extremely close to the nerves of the brachial diagnosis the hospital decided to perform plexus. Res ipsa loquitur, said the judge, an aortagram. They considered that if surcould be of no application where the injury gery was going to be necessary it was better sustained by the plaintiff was of a kind to have available the extensive information as an inherent risk of the treata-bout the condition of the cerebral arterial recognized system that was yielded by an aortagram, ment undergone. rather than the more limited informtion provided by a direct carotid arteriogram. Warning of Risks
on
The judge then dealt with what he said was a peripheral matter in the case, though it Tihe task of performing the investgation is of considerable importance to the progenerally: was there a positive duty fell to a senior registrar, Dr. Bland. The fession the part of the doctors to warn the plaintrial judge, Mr. Justice Bridge, found that on tiff of the risk of injury implicit in an he had set about it entirely in acoordance aortagram? The plaintiff argued that it was with proper practice in 1968. The plaintiff negligence not to have warned him of the vas given a normal dose of premedication recognized risk of the process. He said that and the operation was done under local he wa's accomplished pianist and that had anaesthesia. Dr. Bland successfully punctured he beenanwarned risk, he would have the the femoral artery in patient's right declined to have ofthetheinvestigation. groin with the Seldinger needle, but then The only evidence-and that uncontromet an obstruction before the guide-wire verted-before the judge on this matter was had travelled more than 5 or 6 inches up that of the physician in charge of the plaintiff. the artery. He therefore abandoned the He said that he saw no reason to tell the femoal route and decided to insert the pliaintiff of the possible neurological comcatheter by way of the right axillary artery. plications. Mr. Justice Bridge conmented But before that artery was successfully that if the risk was relatively remote, then punctured, Dr. Bland had to make a num- there were obvious disadvantages in warning tber of passes and the plitiff suffered a patient: "on the one hand you alam considerable pain: towards the end it was him unnecessarily, and on the other hand, almnost intolerable. you may put him in a position where he The aortagram showed that the plaintiff's feels that he should take the decision, alibeit condition could be treated with anti- the doctor is obviously nmuch better qualicoagulants and the trouble with the vision fied to weigh up the advantges and the in his right eye was successfully brought desirability of the proposed operation as under control. However, unfortunately, there against the risks." were serious neurological complications: the The judge, viewing the matter simply as plaintiff suffered pain in the right arm for one of negligence, concluded that a failure some months, but was left with a permanent to warn of remote risks, where the patient loss of function in the right ulnar and had not raised the question, could not be median nerves, which led to partial paralysis said to be lack of care. On the other hand of the right 'hand coupled with loss of in a New Zealand case7 in 1965, the defendFacts of Case
sensation.
ant surgeon gave a
patient albout to undergo
Mr. Justice Bridge dismissed the plain- an aortagram an answer to a question about tiffs primary contention that Dr. Bland the risks "Iso reassuring as to be capable of
636 the construction that thetre was no risk." The court found that fel somewhat short of the truth. The Chief Justice ruled that a doctor was bound to use due care in answering a question put to him by a patient where the patient, to the doctor's knowledge, intends to rely on that answer in deciding whether to accept the treatment to which he is being asked to consent. If the doctr answers negligently, said the New Zealand court, and the patient suffers injury from the treatment, then the doctor will be liable if the evidence shows that if the proper answer had been given the patient would have refused the treatment. In a matter of such daily importance to the medical profession, it is regrettable to find the law so sketchy and uncertain. It has even been suggested 8 9 tht an untruthful or evasive answer by the doctor might be justified in extreme circumstances. The issue in the reported cases has always been treated as one of negligence, rather than as of assaul or trespass to the person. It does not seem to have been decided in a reported ma!pTactice case in this country that the consent to the operation was vitiated by its not being properly informbed consent ;so as to make the operation an assault. Lord Justice Ornnod mooted the issue of patient's rights in an addwrss1 to the Royal College of General Practitioners in 1967. Tihe patient, he thought, was entitled to demand a bona fide statement in boad terms of the risks to life or future health or of min or discomfort in the contemplated procedure, and the greater the risk, the greater the obligation on the doctor to ensure that he understands. But it was pedantic to insist that the patienrt be fully informed of a mass of facts he cannot assimilate or assess. In the instance at the National Hospital the docor, in the a;bsence of any question from his patient, decided that there was no reason to mention the possible complications. All the same, Whether there is a positive duty on doctors to keep their patienits informed of all aspects of their treatment, even when they pose no queries, is an issue of some importance to the profession and one that some day wil have to be faced head-on. Is it right, in Lord Justice Ormrod's words, that the patient 'shoulud be treated as a responsible adult whose right it is to make his own decisions, unless there is some good reason to believe that he is in some real sense incapacitated from doing so"? 1 Erle, C.
2
3
4 5
6 7
8 9
10
J., in Scott v. London and St. Katherine Docks (1865) 3 H.&C. 596.
Mahom v. Osborne: (1939) 2 KB at page 23. MacKinnon and Goddard L.J.J., both thought that leaving a swab in a patient's body shifted the burden of proof onto the defendant to show that his negligence had not caused the accident. Salmond: Law of Torts. 16th edition, p. 242. London, Sweet and Maxwell, 1973. Cassidy v. Ministry of Health: (1951) 2 KB at p. 365. Roe v. Ministry of Health: (1954) 2 QB at p. 83. The plaintiffs suffered spastic paraplegia after phen,ol entered nupercaine ampoules (with whlch they were injected) through micro'copic flaws. O'MaMey-Wilamns v. Board of Governors of the National Hospital for Nervous Diseases. 7 October 1974. Smith v. Auckland Hospital Board: (1965) NZ
BRITISH MEDICAL JOURNAL
15 MARCH 1975
PARLIAMENT Consultants' Dispute In a further statement on 10 March to the House of Comions Mrs. BARBARA CASTLE (Secretary of State for Sodial Services) referred to the exchange of letters on the consultants' dispute beween the profession and the Prime Minister (see p. 642). Commenting on his reference to the interests of patients being damaged she said she regretted that this situation was arising in many parts of the country. She also hoped that "having studied the Prime Minister's replies and the assurances they contain the consultants will decide to drop sanctions and get round the negotiating table." Dr. G. F. VAUGHAN (an Opposition spokesman on social services and a consultant himself) was disappointed with her statement and the Prime Minister's replies. He saw nothing that would help to resolve the present dispute with waiting lists increasing to "a most dangerous extent." There was a l%kelibood of serious damage to the care of patients in the N.H.S. The major difficulty now, he claimed, was that many leading consultants had no confidence in her at all. He suggested that she reopened negotiations, oir failing that handed over discussionis to an independent arbitrator.
Not Acting Personally In reply, Mrs. CASTLE called on consulitants "to withdraw sanctions in the certain knowledge, as the Prime Minister has stated, thait in this matter I have not been acting personally but with the full authority and knowledge of the Cabinet, and recognizing tmhat there are no grounds left that would prevent a settlement if the consultants wecre at least wilding to sihow a shade of compromise." Dr. MAURICE MILLER (Lab., East Kilibride) claimed there was a growing body of opinion among consultanits "irritated, annoyed, and impatient with the small group of consultants who out monetary advantage above the necessity to do their best for their patients." Mrs. CASTLE then referred to a tele-vision interview in wvhich Professor Mcoll, of Guy's Hospital, had said "there would be a riot if vou took away the extra paymenit" [he had been referring to the current differential in favour of the whole-time consultant]. It was clear, she said, that the profession was divided on this issue.
Freedom of the Consultant Mr. PAuL DEAN (Con., North Somerset) declared that the dispute was "not fundamentally about pay but about the freedom of the consultant [A Labour M.P.: 'To make more money'] to do their duty to patients without political interference." He asked for independent arbitration. What would such a person be asked to arbitrate about? Mrs. Castle replied. She continued: "It could not be about pay 191. Speller: LaW Relating to Hospitals, 5th edition, because that is for the independent review p. 107. London, H. K. Lewis, 1971. per Dnng, L. J., obiter in summing up to the body and is currently before it. I-t would be juy in Hatcher v. Black: The Times, 2 July necessary, therefore, to define exactly what 1954. British Medical 7ournal: 6 April 1968, p. 7: the the arbitrator would arbitrate about. The Lord Justice seems primarily to have been co-n- ocmsultants have never made that clear cerned with patient's rights in the context of because in their own minds they are divided experiments and organ trnsplants.
and confused." Later in ithe debate she claimed that a lage number of the profession deplored ithe consultants' action. Mr. NoRmAN FOWLER (Opposition spokesman on social services) asked whether Mrs. Castle was claiming that Professor McColl spoke for all consultants. "Is her understanding of the dispute so smrall that she does not understand the real feeling which exists among consultants?"
Conflict of Interests Mrs. CASTLE admitted that no individual spoke for all consultanrts. There was a conflict of interest between whole-time and maximum part-time consultants, "between," she said, "the man who can and does earn large sums from private practice and those other consultants in the Cinderella areas and neglected specialties, who depend totally upon the whole-time emolument. I am defending the whole-time emolument. I am and will defend a proper reward to those who are devoting themselves full-time to the health service in areas where there are not fat pickings to be made. The best way the Conservatives can bring this dispute to a oonclusion is to stand up and condemn the intolerable behaviour being indulged in by so many consultants."
MEDICAL NEWS Anglo-Soviet Health Agreement On the occasion of the Prime Minister's recent visit -to the Soviet Union an agreement on co-operation in the field of medicine and public health has been issued. The main points of the agreement are undertakings for collaborative research, particularly in control of conmunicable diseaseis; excihanges of medical personnel and infonmation on new equipment, tedhnological developments, and pharmaceutical products; and immediate medical treatment when in the other's country under the same terms as the citizens of the country coneerned, the expenses being borne by the appropriate authorities of the country where they arise. Abortion (Amendment) Bill Committee Tihe names of the Members of Parliament appointed to serve on the select coumnittee on the Abortion (Amendment) Bill have been announced. Eleven tnen and four women are to be members, and according to the announcement they include some supporters of the Bill, some opponents, and some who did not vote when the Bill came up on 7 February -at which time the voting for a seond reading was 203 in favour and 88 against. Dr. Maurice S. Miller is the only medical member of the committee.
"World of Learing" Te 25th edition of The World of Learning is in two volumes, as were the previous
BRITIShI MEDICAL JOURNAL
15 MARCH 1975
three editions, and contains information on 35 new universities in addition to its standard features. The contents of the two volumes are changed slightly; the chapter previously headed Great Britain in volume one has been moved to voliume two as the United Kingdom. For the first time, chapters on the Baihamas, Bahrain, Botswana, Brunei, Oman, and the United Arab Emirates are included. Volume two ends with a 140-page index on institutions. The World of Learning 1974-75, 25th edn. Europa Publications Ltd., London. £18-50 two-volume set.
Medical Photography The annual exhibition of the Medical Group of the Royal Photographic Society is now on show in the C-laire Wand Gallery, B.M.A. House. The exhibition was opened on 6 March by Sir Ronald Tunbridge, president of the B.M.A., and will continue until 25 April. The British Medical Journal award was won by Mr. R. Williams for his demonstration of Lichtschnitteverfahren and the Lancet trophy by Miss J. Fendick for the illustrations she prepared for A Colour Atlas of Forensic Pathology.
Resignations from G.P.s Well over 10000 unda-ted resignations from the N.H.S. signed by general practitioners had been received by the B.M.A. at the end of last week. As we went to press the resignations were arriving at B.M.A. House at the rate of 1000 a day.
COMING EVENTS Biological Engineering Society (Ultrasound and Blood Flow Groups).-Open day discussion meeting, "Haemodynamic Assessment by Ultrasonic Techniques in Clinical Practice," 27 March, Harrow. Fee £1 75 (including lunch). Applications to L. H. Light, Bioengineering Division, Clinical Research Centre, Northwick Park Hospital, Watford Road, Harrow, Middlesex HAl 3UJ. (Tel. 01-864 5311.) British Small Animal Veterinary Association.-Annual congress, 4-6 April, Kensington, London. Details from Mr. T. M. Eaton, 5 St. George's Terrace, Cheltenham, Glos. Society for Drug Research.-(1) Day symposium, "Prolactin," 8 April, Chelsea College, Manresa Road, London S.W.3; (2) symposium, "Inflammation," 10-12 July, Nottingham University. Details from the secretary, Dr. Alma B. Simmonds, at Chelsea College. International Symposium on Pyrogens.8-9 April, University College, London, organized by the Pharmaceutical Society of Great Britain. Fee £15 (including refreshments). Details and application forms from Mr. R. E. Marshall, at the society, 17 Bloomsbury Square, London WC1A 2NN. Institute of Practitioners in Work Study Organization and Methods (Health Services Specialist Group).-Spring conference, 9 April, Walsgrave Hospital, Coventry. Details and application forms from Mr. M. W. Goad, Regional Management Services Officer, North-west Thames Regional Health Authority, 40 Eastbourne Terrace, London W.2. (Tel. 01-262 8011.) "Communication and the X-ray Depart. ment."-Symposium, 9-11 April, Keele University. Fee £18-50. Details from Dr. A. W. O'Malley, X-ray Department, North Staffs Royal Infirmary, Princes Road, Hartshill, Stoke-on-Trent, ST4 7LN, Staffs. Association of Anaesthetists of Great Britain and Ireland.-Annual scientific meeting for junior anaesthetists, 9-12 April, Birmingham University. Details from the secretary, Association of Anaesthetists, Room 475/478, Tavistock House South, Tavistock Square, London WC1H 9JP. (Tel. 01-387 4782.)
637
Welsh National School of Medicine.-Day symposium, "Hypertension in the Older Patient," 11 April, University Hospital of Wales, Heath Park, Cardiff CF4 4XW. Applications to Dr. M. S. Pathy, at the hospital. (Tel. 0222 755944.) Royal College of General Practitioners.Annual spring general meeting, 11-13 April, Dundee. Details and application forms from the honorary secretary, East Scotland Faculty, R.C.G.P., Kinnessburn, Kennedy Gardens, St. Andrews, KY16 9DJ. "Diffusion in Pharmaceutical Formulation and Packaging."-Postgraduate school, 14-18 April, London, organized by the School of Pharmacy, London University, and Pharmaceutical Society of Great Britain. Fee £60. Details and application forms from the school secretary, Mr. R. E. Marshall, Department of Pharmaceutical Sciences, Pharmaceutical Society of Great Britain, 17 Bloomsbury Square, London WC1A 2NN. Biochemical Society.-Meeting, 15-16 April, Aberystwyth, programme includes colloquium on "Biochemistry of Blue-green Bacteria." Details from the society, 7 Warwick Court, Holborn, London WC1R 5DP. (Tel. 01-242 1076.) U.K. Liaison Committee for Sciences Allied to Medicine and Biology.-Congress on "Scientific Aids in Hospital Diagnosis," 15-17 April, Oxford. Details from Mr. R. E. George, S.A.M.B. Publicity Officer, Department of Clinical Physics and Bioengineering, Guy's Hospital, London SE1 9RT. (Tel. 01-407 7600, extn. 326.) "Forensic Psychiatry."-Intensive residential course, 21-24 April, Birmingham University. Fee £25 (£16-50 non-residents). Details from the director, Board of Graduate Clinical Studies, Medical School, Birmingham B15 2TJ. (Tel. 021-472 1301.)
ABERDEEN Appointments-Mr. J. R. C. McLauchlan (lecturers, surgery).
Logie,
Mr.
J.
ROYAL COLLEGE OF SURGEONS IN IRELAND F.R.C.S.I.-A. El T. El Tahir. J. Harty, Rosaleen E. Healy, F. Mosawi, M. J. Murphy, K. N. Rao, S. S. Surasi, A. U. I. Yakubu.
ROYAL COLLEGE OF SURGEONS OF EDINBURGH At a meeting of the council of the college held on 7 March the following were admitted to the fellowship: C. K. Aravindakshan, M. Chellappa, W. R. Chen, G. On Tong, D. Hung-Fai Cheng, Hing-Piig Chow, Hoi-Chu Fung, Hon-Lau Ho, Kam-Hing Lam, R. Kwok-Ming Pbon, R. A. Che-Wai Wong, M. F. I. Abdel-Rahman, N. K. Agarwala, W. 0. Aina, N. A. Akingbehin, M. Akram, M. A. J. Al-Ani, S. S. AlKaragully, S. S. Asmr, R. Aryanpour, M. A. Athar, N. A. Attar, S. S. Aujila, J. S. 0. Aunallah, S. Bagchi, F. S. Bassili, M. H. A. Beg, S. Bhattacherjee, D. A. Birrell, R. Bose, J. B. Brew, A. K. Chakraborty, R. E. Cheeks, P. M. H. Cherry, S. L. Chhabra, A. K. Chowdhury, M. R. Clarke, M. A. Coe, G. F. Crisp, J. L. Croser, G. Dattani, E. F. D'Costa, S. N. Deliyannis, B. A. Deshmukh, J. P. Dhasmana, R. A. Dimitri, P. C. Dobson, J. N. D'Souza, Angela M. Dunham, Margaret J. Elliot, M. M. H. El Maaita, J. V. Forrester, I. S. Fyfe, I. R. Gough, C. K. Goyal, A. M. Greenberg, M. F. Guirgis, M. A. Habib, M. A. Haddadin, N. Y. Hamadalla, A. I. Hashmat, R. Hettiarachi J. R. Hindmarsh, Deirdre J. Holding, A. D. HoltWilson, B. R. Jaidev, H. K. Jalan, A. B. Jatoi, L. Jha, W. G. Jhagroo, J. John, D. T. Johnson, A. G. Jones, H. B. Kapila, A. I. G. Kerr, M. M. Y. Khadaroo, H. I. M. Khamnuash, P. Kollintzas, S. Lall, E. R. Levy, P. N. Luthra, 0. K. Malla, N. R. Maximose, M. Mendhi, J. S. Morcous, A. A. Morgan, R. A. M. Myers, Evelyn P. Nackasha, J. F. O'Brien, A. O. A. Olusanya, A. F. C. Pinto, F. Portelli, K. A. Qidwai. S. M. Qureshi, V. K. Raju, N. Ramanathan, V. P. V. Rao, K. K. Ray, J. M. Read, A. K. Rohatgi, H. T. Saad, S. K. Sabharwal, M. McG. Scott, R. K. Seal, G. R. Sethi, SOCIETIES AND LECTURES A. V. Shah, S. Shanmugham, R. Shome, B. L. Shrestha, A. P. Sinha, M. S. Sisay, R. B. Spooner, For attending lectures marked * a fee is charged E. D. J. Stone. K. J. Sunderland, Myo Swe, A. R. M. T. Thoung, M. G. Thuse, P. N. Tiwari, Taylor, or a ticket is required. Applications should be B. H. Valentine, P. Vijayan. R. B. Warne, M. R. made first to the institution concerned. Weedon, D. LI. Wiliams, W. F. Wong, H. I. A. Yagi, 0. B. Yahaya, P. T. L. Yong, Q. Zaman. Tuesday, 18 March LONDON SOCIETY OF FAMILY PLANNING DOCTORS.At Royal Society of Medicine, 1 Wimpole Street, W1, 8.15 p.m., meeting: Current Approaches Treatment of Sexual Inadequacy.
to
Corrections General Medical Council: Tests for Overseas Doctors In the General Medical Council's report on tests Wednesday, 19 March for overseas doctors (8 March, p. 588) it was inINSTITUTE OF DERMATOLOGY.-4.30 p.m., Dr. M. correctly stated that the tests would be considered Feivel: Xanthomatosis. centres situated in London, Edinburgh, and PHARMACEUTICAL SOCIETY OF GREAT BRITAIN.-7 at Glasgow. The sentence should have read "The p.m., Dr. J. Taylor: Role of Forensic Laboratory tests will be conducted at centres situated in in Cases of Poisoning. ROYAL COLLEGE OF SURGEONS OF ENGLAND.-4 p.m., London, Edinburgh, and Glasgow." COLLEGE.-5 p.m., Dr. C. A. H. Watts: Depression, a Protean Syndrome.
ROYAL
ARMY
MEDICAL
Frederic Hewitt lecture by Professor A. Crampton Smith: The Business of Anaesthesia. ROYAL POSTGRADUATE MEDICAL SCHOOL.-2 p.m., Professor I. Phillips: Antimicrobial Susceptibility of Anaerobes.
Central Committee for Hospital Medical Services In the report of the meeting of the C.C.H.M.S. ROYAL SOCIETY OF MEDICINE: SECTION OF COMPARA- (1 March, p. 529) Mr. D. H. Teasdale reported the TIVE MEDICINE.-2.30 p.m., joint meeting with of a meeting of consultants. This meeting outcome Royal Society of Tropicall Medicine and Hygiene: was attended by 60 members of the North West Prevention and Control of Parasitic Diseases. WILLESDEN GENERAL HOSPITAL.-8.30 p.m., Dr. M. Regional Committee for Hospital Medical Services Newton: The Ins and Outs of Salt Balance. and the Hospital Consultants and Specialists Association. The 60 represented over 800 consultants. We apologize for this omission. Thursday, 20 March FACULTY
OF
HOMOEOPATHY.-5
p.m.,
Richard
Hughes memorial lecture by Dr. Kathleen G. Priestman: Comments on Some Homoeopathic Remedies.
Friday, 21 March INSTITUTE OF LARYNGOLOGY AND OTOLOGY.-5.30 p.m., Mr. E. J. Radley Smith: Fractures at Base of Skull.
ROYAL POSTGRADUATE MEDICAL SCHOOL.-1l a.m.,
Research in
progress:
Endocrinology.
Saturday, 22 March COLLEGE OF SURGEONS OF ENGLAND.-12 noon, Webb-Johnson lecture by Sir Terence Ward: Closing the Gate to Pain.
ROYAL
Notice to Authors When original articles and letters for publication are not submitted exclusively to the British Medical Journal this must be stated. Correspondence on editorial business should be addressed to the Editor, British Medical Journal, B.M.A. House, Tavistock Square, London WC1H 9JR. Telephone: 01-387 4499. Telegrams: Aitiology, London, W.C.l. Authors wanting reprints of their articles should notify the Publishing Manager, B.M.A. House, Tavistock Square, WC1H 9JR, on receipt of proofs.
C British Medical Journal 1975 All Rights Reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, CA,MBRIDGE electronic, mechanical, photocopying, recording M.D.-K. R. Hunter, I. C. Gregory. M.CHIR.-M. R. Colmer, Lynn E. Edwards, or otherwise, without the prior permission of the British Medical Journal. M. G. W. Kettlewell, R. W. Marcuson.
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