appearing on a programme live or to insist, as you suggest, that programmes should have some sort of informed monitoring before they are shown. DAN TUNSTALL PEDOE


as they do about the patient. The purpose of the individual medical record is to act as an aid to memory and clear thinking. Any value it may have for subsequent research does not depend upon its remaining in the writer's possession. It is not, as Professor Richard Beard implies in the same article, a necessary method of communication between doctors about a particular patient but without the latter's participation. This is better done by personal contact-by telephone or preferably by talking face to face. The modern practice of "referral" is a poor substitute for the older practice of "consultation." The practice of circulating copies of specialists' reports to other medical authorities than the referring doctor is not confined to paediatrics, Dr A B David (1 July, p 56). It has also happened in psychiatry within my experience and this raises similar ethical problems. I have known a lay member of a hospital management committee to read a patient's notes without medical authorisation; and of course intelligent patients will often read their own notes if they get the opportunity. As a result I have learnt to write in case notes only things which I am prepared for anyone else to read. If people were encouraged to keep their own records no doubt some few would lose them and some fewer might falsify them; but for most people, being trusted to act responsibly would be the best way of learning to act responsibly. It is essential that doctors should make records, but the reasons why it should be medical men or institutions which maintain possession of them need reexamination. Our present practice is expensive and inefficient and breeds mistrust. It extends our power over patients in a way we do not need and ought not to have. JAMES MATHERS

29 JULY 1978

parents at the end of a child's period of assessment in the child development centre at this hospital. We are indebted to Miss Rosemary Evans and to Professor John and Dr Elizabeth Newson of Nottingham University for introducing us to this idea. Department of Cardiology, St Bartholomew's Hospital, After the case conference, which is attended London EC1 by parents, we prepare a discharge summary in the usual way, but the last sectiondiagnosis and management-is written with Confidentiality of medical records the top copy as a letter to the parents. With their permission copies of this are sent to SIR,-Your legal correspondent (8 July, p 135) individuals to whom it would be inappropriate refers to a recent ruling on appeal to the to send the full medical summary. This is an House of Lords about the entitlement of ideal way of re-explaining difficult concepts, patients engaged in litigation to receive copies putting into perspective the various componof their hospital medical records. Concern ents of-a complex problem such as language had already been expressed at this ruling delay or autism, and helping to establish the when it was discussed at a recent meeting of balance between optimism and realism. Goals the Joint Medicolegal Subcommittee of the and limitations of treatment are noted and, if Joint Consultants Committee and the Central relevant, genetic aspects are discussed. Committee for Hospital Medical Services of By sending copies of this letter to the health the BMA. visitor, social worker, etc, their work is The case of Mclvor v Southern Health and simplified and made more productive. In Social Services Board (NI) was the subject educational problems communication between of the appeal to the House of Lords and the parents and teachers can often be smoothed ruling established that the normal procedure when the viewpoints of each are summarised in cases of litigation whereby patients' in a letter. Possibly the greatest advantage confidential records may be passed in is that all the professionals involved with the confidence to a medical adviser appointed by child know exactly what the parents have been law in was not the plaintiff or his solicitor told. justified. While acknowledging that it might The preparation of these letters is initially not be always in the interests of the patient time-consuming, but speed comes with that he should have access to notes on his practice. The content and vocabulary must own case, the decision of the House of Lords be tailored to the education and background was that patients or their legal advisers could of the parents. It is not easy to discuss emoin appropriate circumstances and by due tional and behaviour problems in writing and process have access to the patients' medical to ensure that this is done in a constructive records. rather than in a critical way. Possible medicoWe know that some health authorities have legal risks have been raised, but one is expressalready interpreted this decision as meaning ing considered opinions already recorded in that patients or their legal advisers must be the medical notes and therefore this risk is on records clinical their to given access Hay-on-Wye, minimal. application. This is not the case. The defence Hereford DAVID M HALL societies are now consulting the Health Morley, D, Pediatric Priorities in the Developing HUGH JOLLY Departments about this judgment and will 1973. Butterworths, London, et seq. World, pp 148 Department of Paediatrics, be issuing advice to their respective members. Charing Cross Hospital, Meanwhile I hope that the contents of this London W6 letter will provide some help and reassurance SIR,-I was interested by Dr A 0 Staines's confidentiality about 206) p July, (15 letter to doctors. The most important point to stress-to colleagues and to administrators- of children's medical records. His local Snakes and snake bite is that the House of Lords decision does not paediatric department told him that parents' create a precedent whereby clinical records consent is always asked for before passing on SIR,-My review of Snakes and Snakebite by must automatically be released to patients: information to others. Unfortunately this John Visser and David S Chapman (13 May, it has established that relevant records can rule is certainly not followed elsewhere. Not long ago I took one of my children to p 1269) has provoked comments from two be ordered to be released, but only if the a local paediatrician and was amazed when, correspondents (15 July, p 203). see application for such release is justifiable In reply to Mr J-J Brossy, the dangers of from before the High Court. Any doctor who is a few days later, a non-medical person pressure-relieving fasciotomies after snake bite she me that me told up, hall rang town the medical to access involving in a case involved include bleeding prolonged by venom-induced records is advised to consult the British had a copy of the paediatrician's letter to the coagulopathy, secondary infection, delayed for the name and asked practitioner, general Medical Association or his medical defence of the school to which the information con- recovery, and damage to nerves and vessels. society. Sites such as the anterior tibial compartment E GREY-TURNER tained in it could be sent. In my view it should be an invariable rule and digital pulp space' may create special Secretary, British Medical Association that parents are asked for their agreement problems, but in the experience of a number BMA House, before any information obtained at a consulta- of clinicians,3 including Professor Chapman London WC1 tion is passed on to non-medical people. and myself, fasciotomy has never proved Sadly, there is far, far too much disregard of necessary in patients given adequate medical treatment. The use of tourniquets in human SIR,-Perhaps the most effective way of the principle of confidentiality these days. victims of snake bite remains controversial a of patient's the confidentiality maintaining DAVID DELVIN because of the lack of direct evidence. Animal medical record would be for the patient (or, experiments suggest, however, that tight if a child, his parent) to keep it. Such a system Bromley, Kent (arterial) tourniquets might delay fatal enis used for children in developing countries' following elapid bites,4;5 allowing venoming Shaw July, (15 says Kathleen Miss and if, as the patient to reach hospital alive. There is p 191), some pregnant women are allowed to Help for parents of the handicapped evidence that specific antivenom prevents carry their case notes around their locality they might just as well keep them altogether. SIR,-Mr Colin Appleton (20 May, p 1348) local necrosis if given intravenously within It would mean that doctors would have to be emphasises that many parents of handicapped six hours of a puff adder bite.6 Antivenoms careful about what they write in them, but children would welcome a written report of have been shown to 7 counteract other local this would be no bad thing: case notes often their child's condition. This has prompted us to effects of venoms.5 The indications for tell quite as much about the writers of them report our experience of writing letters to antivenom were mentioned in my review.



29 JULY 1978

Antivenom should be used only by medical staff who are able to recognise and treat serum reactions. I disagree with the routine use of "high-dosage cortisone" before antivenom, advocated by Mr Brossy. 8 Early reactions occur in less than a quarter of the patients and so it seems unreasonable to expose all to the general dangers of corticosteroids9 and possibly to increased venom toxicity."0 Corticosteroids are not always successful in preventing early serum reactions, but these reactions can be safely and effectively treated with adrenaline, 0 5 ml of 0 1°% solution by subcutaneous injection.2 The incidence of reactions due to anticomplementary activity may be reduced by diluting the antivenom and by giving it by slow intravenous infusion." In reply to Mr M J Gilkes, the evidence that venom from the spitting cobra frequently causes corneal ulceration and may be absorbed to cause hypopyon and anterior uveitis is based on my own experience of 11 cases, nine of which have been reported, and on published observations on patients and animals which have been reviewed.'2 1'1 Urgent, generous irrigation with water is the best first aid, as with other irritant chemicals. In the hospital or dispensary the cornea should be examined daily for at least three days, by fluorescein staining or preferably slit lamp, to detect ulceration, which occurred in five of my patients. The greatest danger is infection, so it seems rational to treat the eye locally with an antimicrobial and to close it with a pad. Despite what he writes in his letter, Mr Gilkes's paper'4 records that he did exactly what I have recommended! I agree with him that there is inadequate evidence to justify the use of topical antivenom, although this deserves to be properly investigated.

the role of many responsible parents and, by encouraging irresponsibility in others, leave many children unprotected against sexual exploitation by adults. As examples of "official" organisations undermining the family we will briefly mention some of the promotional/educational activities of the Family Planning Association (which handed over almost all its clinics to the NHS in 1974) and of the Family Planning Information Service, together with some of the controversial educational and clinic activities of the Brook Advisory Centres. The Family Planning Association is a charity which is in receipt of large sums of public money and which runs its own contraceptive business, Family Planning Sales Ltd. It publishes and promotes a large quantity of aggressively permissive literature for young people-for example, "Learning to Live with Sex," published in 1972 for children of 13 years upwards. This booklet, which is claimed by the FPA to have a very large circulation, has the following emphases: (1) it describes sexual intercourse in terms of "boys and girls," which implies an acceptable code of behaviour; (2) there are six full pages on contraceptive methods; (3) there are 10 lines on "responsibility," which is equated almost entirely with the use of contraceptives. (4) there is no section on marriage. (5) It does not mention the positive health and social advantages of self-control, nor does it mention the failure rates of contraceptives, the association of cancer of the cervix with early adolescent intercourse, and the cruel consequences of abortion for many girls who have their first

Sexual pressures on children SIR,-Over the last year there has been increasing public awareness of sexual pressures on children, with all the consequent health damage to the individuals involved. We wish to draw the attention of the profession both to the Government funding of organisations which promote juvenile sex and to the environmental health hazards of the behavioural attitudes promoted and encouraged by much of the contents of teenage magazines, many with massive circulations, which reinforce the callous advice of these official bodies. It is our experience that the long-term effects of these influences undermine

S E ELLISON Chairman,


pregnancies terminated.

The Family Planning Information Service is Government sponsored and funded and administered by the Health Education Council and the Family Planning Association. It claims to have sent out millions of copies of a leaflet, "Straight Facts about Sex and Birth Control." This leaflet describes sexual intercourse in terms of a boy-girl partnership, it advertises the FPA DAVID A WARRELL mail order business, and tells of special places where one can get contraceptives where "older Radcliffe Infirmary, relatives and neighbours will not be present." Oxford The Brook Advisory Centres specialise in Warrell, D A, et al, American Journal of T7ropical providing contraceptives and (more recently) Medicine and Hygiene, 1976, 25, 517. abortions for young girls and believe that adoles2 Reid, H A, Tropical Doctor, 1972, 2, 159. 3Russell, F E, et al, Journal of the American Medical cent sexual intercourse is acceptable provided that contraceptives are used. It has long been their Association, 1975, 233, 341. Fairley, N H, Medical Journal of Australia, 1929, policy not necessarily to inform parents of their 1, 377. Christensen, P A, South African Medical Jrournal, adolescent children's difficulties. Recently the Department of Health and Social Security has 1969, 43, 1253. Warrell, D A, et al, British Medical Journal, 1975, provided L21 000 a year for three years towards 4, 697. Theakston, R D G, and Reid, H A, Lancet, 1976, their headquarters' administrative costs. 2, 121. However, perhaps the most damaging Brossy, J, South African Medical Jrournal, 1977,

51, 390. W T, Toxicon, 1977, 15, 473. lo Jerushalmy, Z, et al, Coagulation, 1970, 3, 267. Sutherland, S K, Medical Journal of Australia, 1977, 1, 613. 12 Warrell, D A, and Ormerod, L D, American_Journal of Tropical Medicine and Hygiene, 1976, 25, 525. 13 Payne, T, and Warrell, D A, Archives of Ophthalmology, 1976, 94, 1803. 14 Gilkes, M J, British Journal of Ophthalmology, 1959, 43, 638.

Defence Union have advised that the parents of a child of whatever age should not be contacted by any staff without his or her permission even though as a matter of clinical judgment the refusal of permission to involve parents may affect the nature of the advice given to the child." As a direct result of this document planning guidelines have now been issued to health authorities drawing attention to the "need" to provide special family planning services for the young. We fear that in addition to undermining our professional standing with parents, who will inevitably learn of our complicity in their deception, these clinics will follow the recognised Swedish pattern-namely, an increase in juvenile sexual activity with a consequent rise in venereal diseases, illegitimate pregnancies, and abortions among young adolescents. Not only should our profession protect its own integrity and resist these unhealthy trends-and in doing so protect the health of vulnerable teenagers-but also the time has come for the British Medical Association to question publicly the nature of the pressure groups which, having so devastatingly eroded our ethics and authority in health matters, have already seriously undermined our capacity to care adequately for the defenceless.

influence on young adolescents' sexual health comes from the teenage magazines. Much of the advice given by some of the journalists employed by these periodicals can only be described as "sick." The seriousness of the damage to children's health caused by these magazines was clearly recognised in April, when the National Council of Women in conference assembled, perturbed by the nature of the material appearing in magazines for teenage girls, called for tighter implementation of the Children and Young Persons (Harmful Publications) Act 1955 and urged the Home Office and the Williams Committee on Obscenity to investigate the resultant effects on the physical, emotional, and psychological health of young teenage girls. In view of these physical and emotional dangers it is of the utmost importance that parents should be aware of and defend their children against such pressures. Here again the Department of Health and Social Security further undermined parental influence when on 6 May 1974 it issued the now infamous memorandum, Guidance on Family Planning Services, No 32, which states that "the Medical


The Responsible Society, and 147 other members of the medical profession

London WI

Maternal nutrition and infant birth weight SIR,-I read with interest the article by Dr J R Sibert and others entitled "Maternal and fetal nutrition in south India" (10 June, p 1517). I do not disagree with the authors' suggestion that "an adequate maternal diet is necessary for adequate fetal growth," but I do not feel that their data show this. Firstly, the food intake of the non-paying (poorer) patients studied is merely described as "inadequate" and no precise information about maternal nutrition either before or during pregnancy is provided, nor are we told the maternal weight of either group, nor their weight gain during pregnancy. Secondly, although the well-known association between maternal height and infant birth weight1 2 has been confirmed by the authors in their total study group, they appear to have ignored the fact that the non-paying mothers were significantly shorter than those who paid for their care and that the two groups studied were therefore not comparable for this most

important characteristic. Thirdly, the observation that the maternal skinfold thickness in the non-paying group was less than that of the paying patients just before delivery is not necessarily solely due to differences in maternal nutrition during pregnancy but quite possibly reflects prolonged nutritional deprivation over many years (as suggested by the difference in the heights of the two groups). This is important, as maternal prepregnancy weight displays a highly significant positive correlation with infant birth weight2 3which is independent of the effect of maternal weight gain during pregnancy.3

Snakes and snake bite.

352 appearing on a programme live or to insist, as you suggest, that programmes should have some sort of informed monitoring before they are shown. D...
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