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NOTES
ViewTs Why were the obstetric services singled out for cuts in the 1976 DHSS prioritics document ? The explanation offered by Margaret and Arthur Wynn is the "continuing underprivileged status of British women." In the Prezention of Preterm Birth (f 3 00), their latest publication for the Foundation for Education and Research in Childbearing (27 Walpole St, London SW3), the Wynns argue that women's organisations have not been vocal enough in demanding better maternity services. Drawing comparisons with other European countries they present a mass of closely argued evidence that Britain could reduce perinatal mortality and the numbers of handicapped children by concentrating research efforts on the prevention of premature labour. They highlight the growing use in Germany of drugs such as salbutamol, but they also point to the women's clinics in Sweden and Finland, which provide very high standards of antenatal care. There is, they argue, a case for an inquiry into atenatal care in Britain: who should provide it and where ? Are doctors doing work that would better be done by midwives ? Should hospital obstetric departments take more responsibility for antenatal care ? But before the questions can be answered more data are needed-a point made earlier this year by Professor Richard Beard (23 July, p 251). What about giving some priority to his plan for a nationally sponsored unit for perinatal epidemiology ? Last week Life (Save the Unborn Child) decidled at its annual conference to write to all gynaecologists threatening prosecuition should evidence comne to light of a termnination of pregnancy after the 28th week. Do supporters of this decision really believe that gynaecologists consider terminating pregnancy late in the secotnd trimiester except for pressing mnedical reasons ? TW"hy do pressure groups of this kind encourage such extremne attitudes? In the past 20 years Denton Cooley and his colleagues in Houston, Texas, have carried out major cardiovascular operations on 542 Jehovah's Witncsses. Mortality within 30 days of operation was 9 4",, ournal of the American Aledical Associationt, 1977, 238, 1256). Three of the 51 deaths werc related directly to the patients' adamant refusal to have transfusions of blood or blood products, and postoperative anaemia was a factor in 12 further deaths: but the Texas team seems to have made its point that the risk of operating without blood is acceptably low. The Pharmacy Practice Research
Grouip
at
Nottinghamn
University is looking at sy7stemns of health care within the Asian inmligrant community, and in particular at practising inmnigrant healers or hakims. Apparently hakimns are to be found in nMost imligrant coimmuinities, antI the prescribed medication (often herbal but somnetines containing heavy metals and arsenic) mnay! give rise to adverse reactions. Anyone with informnation that misght be useful is asked to contact Professor S S Davis. Last year the British ate 13 10 s fish fingers; meanwhile fish and chip shops went out of business at the rate of one every day (Nutrition Bulletinl, 1977, 21, 198). Despite a widespread belief that they are eaten only by children, half the consumption
of fish fingers is by adults, so that it is not surprising that the shortage of Icelandic cod is leading to quiet efforts to find acceptable (or undistinguishable ?) alternative sources of fish. Who would buy dog-fish fingers ?
Anyone who saw James Coburn 's hilarious performnance in "The President's Anal,st" will have doubts about the value of a psychiatrist in the IWhite House, buit Dr Peter G Bourne seems to be giving advice rather than treatmnent to President Carter. The British-born physician, who has puiblished on stress, drug addiction, and anthropology, is trying to persuade the new admninistration to concentrate foreign aid on major illness such as malaria and schistosomiasis while in the Unilted States itself he is pushing for mnore attention to menetal health. Sadly, there is no evidence that the British Governmnent has any equally articulate mnedical adviser to draw its attention to the demnoralising decline in the NHS. When an American asks his doctor for help in giving up smoking he is likely to be advised to use "stimulus satiation"which relies on enforced periods of continuous and rapid smoking at a rate of one puff every six seconds. So horrible is this experience that (in theory) it puts the smoker off for life; but (New England Journal of Medicine, 1977, 297, 590) it may also so disturb his blood gases that dangerous arrythmias may be precipitated in individuals with coronary disease. Mr David Eninals's "good neighbouir" camnpaign to enicourage mnore visiting of the elderly and houtsebouind is nearly one year old; and so far over one miiillion leaflets, 320 000 stickers, and 240 000 call cards havie been i'ssued. Voluntary organisations are now being asked for suiggestions for e\panding and developing the camnpaign.
Boys who survive the childhood hazards of cystic fibrosis are almost always sterile owing to damage to their testes, but the effect on the ovaries is less certain. There seem to be two authenticated cases (Journal of Pediatrics, 1977, 91, 276) of women with cystic fibrosis having children. Both were unlucky enough (the risk is only 2-5",,) to have children affected by the disease. The Private Patients Plan came ouit very well in an assessment of mtiedical insuranice imn the Septemnber issue of "Money lW'hich ?" The article mnade fascinating reading, for, despite all the detail, Minerva couild not understand how the Bristol Contributor+y
WY'elfare Association, a relatively smiiall but well-established concern, could offer rates less than half those charged byi the big two, B UPA and PPP. Quite what significance should be read into the results of research on mice is always arguable; one example is a report in Suirgery (1977, 82, 254) that mice given thiopentone develop a heightened susceptibility to pulmonary metastases from murine fibrosarcoma. Apparently thiopentone suppresses cellmediated immunity-in mice. Does that finding have any relevance for human neoplastic disease ?
MINERVA
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EPIDEMIOLOGY Parasites in dogs and cats scopically for helminth eggs and protozoal cysts in normal saline and in Lugol's iodine and by flotation in saturated sodium chloride solution. Fifty-five dogs were examined; no parasites were found in 15 (27 ,,), whereas in the cats no parasites were found in 23 of 46 examined. A public health laboratory investigated for In 21 dogs Toxocar-a canis was found, in 2 parasites a sample of the dogs and cats in their Toxascaris leoninba, in 7 the canine hookworm, area. It looked especially for toxocara in both Uincinariaastenocephlala, in 17 Dipylidium species of animal and for toxoplasma in cats. ca,iibiuni, and in 3 the eggs of a linguatulid, The animals were obtained for postmortem probably L serrata. In the cats, Toxocara cati examination fcom a dogs' home to which they was found in 13, D caninltont in 6, Taenia had been sent for humane destruction. Thev taeniiformis in 7, and Taenia sp in 1. These results suggest a fairly high incidence included both family pets and strays and were a mixture of breeds, sizes, and ages, including of toxocariasis in both dogs and cats. Canine some puppies and kittens. The heart and great and feline ascarids are the source of human vessels, lungs, bronchi, trachea, liver, gall toxocariasis caused by a larva migrans which bladder, and alimcntary canal from the may reach the eye, causing serious ocular oesophagus to the sigmoid colon were symptoms. Compared with surveys on dogs in examined macroscopically for parasites. The other cities and areas in Britain the infection contents of the stomach and intestine were rate is high but not the highest; most areas sieved. The faeces wxere examined micro- report rates in the range 7 04-160 . Dipylidiu1m
The followiniig nlotes atre comtipiled by the Cornuniiilicable Disease Suirveillanice Cenitre of the Plublic Health Laboratory, Service from reports snibinitted by public health anid hospital laboratories inl the United Kinlgdomi anid Repuiblic of Irelanld.
catinlum, the most ubiquitous cestode parasite of dogs and cats, was also common, but though children can be infected through a swallowed dog or cat flea (the intermediate host) such infections are normally asymptomatic. A careful search for Echinococcus granuxlosus (hydatid cyst) was made but it was never found. These findings indicate the desirability of regular antihelminthic treatment of dogs and cats. Blood from 35 cats was tested for toxoplasma antibodies by the Sabin and Feldman dye test; eleven samples were haemolysed and unsuitable for examination. Faeces from all 46 cats were examined for toxoplasma oocysts using fluorescence microscopy. The serological tests showed that just under a third (10 of 35) had been infected with Toxoplasma gondii; thus their faeces had been infectious at some time in the past. The laboratory failed to find toxoplasma oocysts in the faeces of all 46 cats; this is not unexpected, because infected animals excrete oocysts for only about two weeks.
MEDICOLEGAL Annual report of Medical Defence Union FROM OUR LEGAL CORRESPONDENT
T he past year was an unusually turbulent one for the defence societies, who faced both the prospect of a BMA scheme for commercially backed indemnity insurance and queries raised by the Department of Trade and Industry as to their status in relation to the Insurance Companies Act 1974. The annual report of the MDU for the year ending 31 December 1976 reflects little of the controversy which ebbed and flowed around it, but its contents (as in years past) clearly reveal why there was so little support for the Bowring scheme.
Commercially inexpedient During the year the MDU more than once took up costly and commercially inexpedient battles to vindicate a member's reputation. A South African case dealt with by the Union underlines that clearing a surgeon's reputation may be a Pyrrhic victory when viewed in purely financial terms. After a six-weeks trial in 1975 the court dismissed a claim against a neurosurgeon who administered a 6 00 solution of phenol in glycerine as a block for coccygodynia. The patient, a 25-year-old woman, had subsequently lost control over both bladder and rectum and was also left without sensation in her right leg. The MDU's legal costs exceeded £57 000, of which only £1400 could be recovered from the unsuccessful plaintiff. In England successful defendants often prove unable to recover their costs because the plaintiff is legally aided, and commercial prudence frequently dictates that insurance companies come to pretrial compromises with unmeritorious but penurious plaintiffs, rather
than incur irrecoverable costs by going to court. In describing their defence of a doctor who diagnosed chilblains in a 25-year-old woman with arterial occlusion, the MDU state that "the vindication of a member who has not been negligent will continue to be the overriding consideration." The woman had been taking a contraceptive pill, and when first seen by the doctor after complaining of pain in the right foot she was seated by the only source of heat in the house, a small coal fire. Four days later the hospital diagnosed right femoral artery block, but removal of the thrombus failed to restore circulation and the leg had to be removed above the knee. When a faulty diagnosis is made or treatment has unexpected or disastrous side effects there is always a temptation for lawyers to conclude that the only explanation is negligence. They bolster their reasoning with the Latin tag res ipsa loquitur-the matter speaks for itself. The wife who lost her leg was granted legal aid and brought her action to trial in 1977. The Union's view that the doctor had not been negligent was corroborated by its expert, who said that arterial occlusion was a great rarity and not a generally recognised complication of the pill, like venous thrombosis. A second expert bore out that diagnosis was difficult.
Fair reporting
During the trial the plaintiff's account of the development of her symptoms was discredited sufficiently for her counsel to withdraw the action, but the Union's costs of over £4000
could not be recovered from either the plaintiff or the Legal Aid Fund. There was an interesting footnote to this action: a national newspaper published a report after the first day of the trial, naming the allegedly negligent doctor under the headline "Chilblains wife had leg off." Only after intervention by the Union did the newspaper print a second report with equal prominence giving the result of the action and quoting the judge's words vindicating the doctor. Newspapers are entitled to privilege where they publish daily accounts of each day's proceedings, even though the trial lasts more than a day. Such reports must be fair and accurate with regard to the evidence given on each day and to the trial as a whole up to that point. What has never been decided' is whether the failure to publish the result at the end of the trial renders an earlier report, which would otherwise have been fair and accurate, unprivileged. In principle it ought to do so, but the law is not clear. Editorial policy in Fleet Street, and doubtless that of the Press Council too, is that results vindicating defendants should be publicised, but in the present case the matter was overlooked, even though the reporter had filed copy. The MDU has adhered stoutly to the principle that, with the advance of medical knowledge, what is negligence today may not have been negligence yesterday. In 1971 a doctor who found perineal warts during a postnatal examination prescribed a podophyllum preparation with advice that it be applied sparingly. He warned that there could be an adverse reaction, but in fact the woman suffered severe local inflammation and lost all sexual feeling for her husband. In prescribing
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as he had the doctor had followed the literature Liability) Act 1976, which came into force on available in 1971, but later the makers of the 22 July 1976. ointment had changed their leaflet to emphasise that the ointment should be used only for plantar warts. The trial judge, viewing the Indemnity payments matter as at 1971, held that there had been no negligence. These two large settlements are reflected in the rise in indemnity payments by the MDU in 1976 from £521 000 to £875 000. Legal Familiar trio charges rose from £279 000 to £477 000. Subscription income rose from £1 6m to The familiar trio of hibitane burns during £2-2m, reflecting the increase in annual cautery, operations on the wrong limbs, and subscription to £40, and the surplus for the missed foreign bodies in the eye all make their year was £504 000, only marginally less than annual appearance. A claim by a patient who in 1975. The accumulated funds of the MDU suffered first-degree burns during cautery of now stand at £32m, but the figures for quoted the cervix after the vulval area had been investments and leasehold properties are almost swabbed with hibitane cost over £1000. An certainly on the low side of their current operation for the excision of a toe-nail on the realisable value. wrong toe cost £650. The MDU had to pay Against the accumulated funds stands a £2700 when a yachtsman lost his eye after contingent liability of £2 45m (£1C6m in 1975) being struck in the face by a rope which in respect of cases which will probably or may smashed his glasses. There was a fragment of possibly be settled. The settlement of such glass in the globe which was undetected by the cases may be spread over as much as five years, casualty officer, who failed to take a proper but with inflation affecting awards of damages history, instil fluorescein, test visual acuity, or a review of the contingent liabilities must be take an x-ray film. The damages would have (and is) affected year by year. There is no case been larger but for the likelihood that the eye outstanding where the liability is likely to be would have been lost anyway. exceptional. The Union acknowledges that the statement in last year's report that "glass is almost
invariably radioopaque" was too sweeping, since glass fragments in the orbit do not necessarily show up when radiographs are taken. But unless history, examination, and x-ray are all properly carried out there can be no defence when a foreign body in the eye is missed. During 1976 the Union twice had to pay out sums in excess of £70 000. In July 1966 a 35-year-old man, who had had disseminated tuberculosis at 19, developed epididymoorchitis and was treated with antibiotics without improvement. He became tired and feverish and the inflamed mass of epididymis discharged pus. Two months later he was admitted to hospital with miliary tuberculosis and tuberculous meningitis. He was left virtually blind. Since the tuberculosis should have been diagnosed at the time of the epididymoorchitis or, at worst, when it did not respond to antibiotics, damages of £70 000 and costs had to be paid. The highest settlement of all, one of £78 692, followed a disaster involving a caesarean section on a 35-year-old primigravida. An anaesthetic registrar of three years' experience passed a size 8 endotracheal tube but had difficulty inflating the cuff. The endotracheal tube entered the oesophagus, and the patient then regurgitated and aspirated vomit. The woman was never to recover consciousness and her child, born with signs of hypoxia, was spastic. It had to be accepted that the brain damage to the child had occurred while the fetus suffered hypoxia before delivery, and the case raised the point of law (never before decided in an English court) as to whether at common law a child has a right of action in respect of injuries before birth. It must be almost inconceivable that a court would have decided this point against the child, and the claim in respect of the mother (who died two years after the operation) and the child was settled. A child's entitlement to claim damages for negligent fetal injuries is now put beyond doubt by the Congenital Disabilities (Civil
Financial policy The MDU treasurer estimates that the surplus for 1977 is likely to be in excess of JO5m, so that the Union seems likely to continue its successful policy of building up reserves out of subscription income at the same time as meeting current claims. This policy was obviously vital when the MDU had no reinsurance, but this year's report states that "acceptable terms of insurance" to protect against an exceptional level of claims have been negotiated from 1 January 1977. No mention is made of the ceiling at which the new reinsurance operates, and the Union regards this as a matter to be kept secret from possible competitors. This attitude may be wise or may be not, but it is hardly reassuring to the Union's critics. In the summer of 1976 wild rumours appeared in the press about the Union's ability to meet claims. These stemmed from the fact that the MDU had never brought home to the public that in 1973 (the date has never been disclosed precisely) it had ceased reinsurance. Some of the wilder rumours clearly flowed from those who misunderstood the Union's financial policy of building up a reserve from income, but the critics none the less resurfaced during the BMA debates on the Bowring scheme. The latest accounts ought to still all reasonable doubts and justify the treasurer's assurance that "the Union's financial position is sound." All the same, the coming year sees another hurdle for the MDU. In July this year the Union issued an originating summons in the Chancery Division to determine whether it was an insurance company within the meaning of the Insurance Companies Act 1974, as the Department of Trade was trying to contend. In 1968 the then Board of Trade stated that it did not regard the MDU as an insurance company, but the recent controversy over the Union's affairs led it to take the advice of
1 OCTOBER 1977
leading counsel and the p:-esent proceedings were launched. The issue appears to be whether the Medical Defence Union Ltd, a company limited by guarantee not exceeding £1 per member, is carrying on "insurance business." Like many simple questions, the legal answer is far from straightforward. There is no definition of "insurance business" in any of the numerous insurance Acts, and the courts have never needed to define the term. The leading textbook2 on insurance law concludes, not very helpfully: "the words thus bear their ordinary meaning." Since its foundation in 1885 the MDU has never failed to indemnify its members against awards of damages and costs in civil actions. It has frequently paid their costs (but not any penalties) in criminal cases too. While this may give the appearance of "insurance business," the Union does not appear to be under an enforceable contractual obligation to indemnify members. Each year the MDU Report contains a statement of benefits which may be granted to members. They include "assistance when damages and costs are awarded by a court or settlement is made out of court." The word "assistance" can only have been chosen for its vagueness. In theory the MDU therefore appears to retain a discretion whether to indemnify their members, but in practice it is because they have always done so that it can be suggested that they are an insurance company. The absence of any contractual right on the part of members to an indemnity might, if proved, turn out to be one of the deciding factors, if not the deciding factor, in the case. This would distinguish the MDU from a mutual insurance:' company, where the members are bound to each other by contract to contribute on an agreed basis to the insurance claims of other members. It is irrelevant that the MDU is not in business for profit. Should the MDU fail in its claim, it (and, no doubt, the other defence societies too) would have to seek authorisation to carry on business from the Secretary of State for Trade and Industry under the 1974 Act. There is no reason to think that this would force them to change dramatically the conduct of their affairs, but the MDU would prefer to do without the supervision by the Department of Trade and the auditing that this would entail. On the present accounts the MDU seems well within the solvency margins prescribed by section 4(1) of the 1974 Act-namely, that the value of assets in any given year should exceed liabilities by one-fifth of that year's premium income. The Under-Secretary of State for Trade4 told the Commons in May this year that the defence societies intended to ensure that their financial position was such that they would meet the requirements of the Act, regardless of whether they were obliged to do so. None the less a judicial decision which brought the defence societies within the insurance Acts might at least protect them from the mass of criticism, a great deal less than fair, to which they have been subjected in recent months. Gatley: Law of Libel and Slander, para 631, 7th edn. London, Sweet and Maxwell. 2 MacGillivray: Insurance Law, para 363, 6th edn. London, Sweet and Maxwell. 3 MacGillivray: Insurance Law, para 351, 6th edn. London, Sweet and Maxwell. 4 British MedicalJournal, 1977, 1, 1292.
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MEDICAL NEWS Chair of pathology, University of Newcastle upon Tyne Dr A E Stuart has been appointed to the chair of pathology and head of the department of pathology at the University of Newcastle upon Tyne from 1 January 1978. Dr Stuart, who is 52, graduated from Glasgow in 1948 and after a house appointment at the Western Infirmary, Glasgow, and service with the RAMC, held hospital appointments in pathology in Melbourne and Tasmania. In 1954 he returned to Britain, and after appointments in the University of Glasgow and University of Dundee he was appointed lecturer in pathology in the University of Edinburgh in 1956. In 1958 Dr Stuart was awarded a travelling fellowship to the Institut Pasteur and Broussais Hospital in the University of Paris. From 1960 to 1965 he was senior research fellow in the University of Edinburgh, and was appointed senior lecturer in 1966 and reader in 1967 in Edinburgh. NHS statistics
About 3600 general practitioners (out of the total of 22 000 in England) are now practising from health centres, says the DHSS Anniual Report 1976 (HMSO, £1'40). A further 76 centres were opened in the year, bringing the total to 705. In the hospital service the 5 25 million inpatients treated was the highest total since the start of the NHS, but by December 1976 the total on waiting lists had increased by 3 during the year. The number of hospital beds continued to fall-the reduction in the last ten years is now 12 00, but most of this drop has been in mental illness hospitals or wards, says the report. Day case attendances rose by 15 % compared with the previous year, and the numbers of psychiatric and geriatric day patients rose by 00 and 21 respectively.
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Royal College of Physicians, 11 St Andrew's Place, Regent's Park, London NW1 4LE before 12 December.
COMING EVENTS Lord Nuffield Birthday Centenary scientific meeting-"Pharmacological aspects of pregnancy," 5 October, London. Details from the Royal College of Obstetricians and Gynaecologists, 27 Sussex Place, Regent's Park, London NW1 4RG. (Tel 01-262 5425.) "Diseases of colon and rectum"-Course of morning lectures, 10-14 October, London. Details from Dean of Postgraduate Studies, St Mark's Hospital, City Road, London EC1V 2PS. (Tel 01-253 1050 ext 36.) Medical and Dental Retirement Advisory Service-Symposium on "The health lecture in pre-retirement courses," 26 October, Birmingham. Details from MADRAS, Tavistock House North, Tavistock Square, London WC1H 9JD. (Tel 01387 6869.) Symposium on Current Controversies in Breast Cancer-Organised jointly by the British Medical Association and British Association of Surgical Oncology, 4 November, London. Details from Miss D Warner, British Medical Association, BMA House, Tavistock Square, London WC1H 9JP. (Tel 01-387 4499 ext 129.)
SOCIETIES AND LECTURES For attetndintg lectures marked * a fee is charged or a ticket is reqired. Applications shouild be made first to the institutions concerned.
Monday, 3 October INSTITUTE OF OBSTETRICS AND GYNAECOLOGY-4.30 pm, Mr Jeffrey S Robinson: Growth retardation in fetal lambs. ROYAL COLLEGE OF SURGEONS OF ENGLAND-6 pm, Mr P Goodall: Hernias in the groin.
Tuesday, 4 October OF BIRMINGHAM MEDICAL INSTITUTE SECTION PSYCHIATRY-At Queen Elizabeth Hospital, 7.30 for 8 pm, 26th annual dinner.* ROYAL COLLEGE OF SURGEONS OF ENGLAND-6 pm, inaugural Stanford Cade memorial lecture by Mr
Applications are invited before 31 October for bursaries to be awarded in 1978 to young British doctors under an exchange scheme between the Institut National de la Sante et de la Recherche Medicale in Paris and the Ciba Foundation in London. The grants will be awarded for periods of one to four months for clinical experience or research in France. Preference will normally go to candidates who hold teaching posts or are in positions where they can pass on the experience they have acquired. Application forms from the Deputy Director, Ciba Foundation, 41 Portland Place, London WlN 4BN (tel 01-636 9456). Christmas lectures, Royal College of Physicians of London The Christmas lectures held by the Royal College of Physicians of London, which are open to young people in the 12-18 years age this
"How the blood goes group, round," given by Professor J P Shillingford on 19 December, and "New marrow-a change is as good as a rest-or is it ?" given by Dr Ray Powles on 29 December. Applications for tickets should be sent to the Assistant Registrar, year are
26 Wed
Joint Consultants Committee (Royal College of Surgeons of England, Lincoln's Inn Fields, London WC2), 9.30 am. BMA Council Executive, 10 am.
Division Meetings to be Held Members proposing to attend meetings marked * are asked to notify in advance the honorary secretary concerned. Bristol-At Bristol Royal Infirmary, Wednesday, 5 October, 8.30 pm, agm. Chesterfield-At Shoulder of Mutton Hardstoft, Thursday, 6 October, 7 for 7.45 pm, joint meeting with Chesterfield Law Society, Professor Keith Simpson: "Medicine versus the Law.'* (Buffet supper.) Durham-At Dryburn Hospital, Monday, 3 October, 8.30 pm, agm. Grimsby-At Humber Royal Hotel, Thursday, 6 October, 7.30 for 8 pm, annual dinner.* Guildford-At Bramley Grange Hotel, Wednesday, 5 October, 7.30 for 7.45 pm, joint supper meeting with West Surrey Law Society.* (Guests are invited.) Harrow-At Harrow Hospital, Tuesday, 4 October, 5.15 pm, agm. Northern Region Medical Assistants Group-At Medical Institute, Newcastle upon Tyne, Monday, 3 October, 7 pm, meeting. St Helens and Knowsley-At Whiston Hospital, Saturday, 8 October, 10.30 am, symposium "Conflicts in the care of the elderly."* Wakefield-At South Milford Hall, Friday, 7 October, 7.30 for 8 pm, annual dinner dance.* (Guests are invited.) Wigtown-At Judge's Keep Hotel, Glenluce, Wednesday, 5 October, 7.30 for 8 pm, film meeting.
UNIVERSITIES AND COLLEGES NEWCASTLE UPON TYNE Appointments-Dr M A P S Downham (senior lecturer in the department of child health); Dr D P Forster (senior lecturer in community medicine).
WELSH NATIONAL SCHOOL OF MEDICINE Dr K M Laurence has been granted a personal chair in
applied genetics.
Dr R Harvard Davis has been promoted to reader in general practice. Dr J A Dodge has been promoted to reader in child health. Dr A H Henderson has been promoted to reader in cardiology. LONDON MD-M W Adler, B R 'I Carroll. MS-S G Darke, J A Lynn.
APPOINTMENTS
Gerald Westbury: Soft tissue tumours.
Wednesday, 5 October
Anglo-French exchange bursaries
25 Tues
INSTITUTE OF ORTHOPAEDICS-6 pm, Dr P A Dieppe: Crystal synovitis. 7 pm, Professor Verna Wright: Systemic manifestations of rheumatoid arthritis. ROYAL COLLEGE OF SURGEONS OF ENGLAND-5 pm, Hunterian lecture by Professor J D Stamatakis: The problem of thromboembolism in total hip replacement. 6.30 pm, Mr B T Jackson: Obstructive jaundice. ROYAL FREE HOSPITAL SCHOOL OF MEDICINE-5 pm, Dr A M Adelstein: Measuring disease in the
CITY AND EAST LONDON AREA HEALTH AUTHORITY (TEACHING)-Dr R J Davies (consultant physician in general and thoracic medicine). SOUTH GLAMORGAN HEALTH AUTHORITY-The following consultants have been appointed-Dr J Picton Thomas (physician); Mr I P Griffith (ENT surgeon); Dr I J Kerby, Dr I C M Paterson (radiotherapists); Dr A H Md A H Quoraishi (medical microbiologist); Dr S Wallace (paediatric neurologist).
community.
Notice to authors When original articles and letters for publication are not submitted exclusively to the British Medical Yournal this must be stated. For detailed instructions to authors see page 6 of the issue dated 1 January 1977. Correspondence on editorial business should be addressed to the Editor, British Medical Journal, 7 October Friday, BMA House, Tavistock Square, London WC1H ROYAL COLLEGE OF SURGEONS OF ENGLAND-6 pm, 9JR. Telephone: 01-387 4499. Telegrams: Mr J S P Wilson: The methods of skin grafting. Aitiology, London WC1. Communications will not be acknowledged unless a stamped addressed postcard or an international reply coupon is BMA NOTICES enclosed. Authors wanting reprints of their articles should notify the Publishing Manager, BMA House, Diary of Central Meetings Tavistock Square, WC 1 H 9JR, on receipt of proofs.
Thursday, 6 October
MEDICAL FEDERATION-At Senate House, University of London, 5.30 pm, Professor Sir Peter Medawar, FRS: Biology and medicine. * ROYAL COLLEGE OF SURGEONS OF ENGLAND-6 pm, Professor J C Goligher: Current trends in the treatment of carcinoma of the rectum. BRITISH
POSTGRADUATE
OCTOBER 6 Thurs 6 Thurs 12 Wed 18 Tues 19 Wed 20 Thurs 24 Mon
Hospital Junior Staff Committee, 10 am. Medical Assistants Subcommittee (CCHMS), 10.30 am. Council, 10 am. Scottish Committee for Hospital Medical Services (7 Drumsheugh Gardens, Edinburgh EH3 7QP), 10.45 am. Occupational Health Committee, 10.30 am. General Medical Services Committee, 10 am. Scottish Council (7 Drumsheugh Gardens, Edinburgh EH3 7QP), 10.45 am.
(C British Medical Journal 1977 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, electronic, mechanical, photocopying, recording otherwise, without the prior permission of the
or
British Medical3Journal.
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NOTES
ViewTs Why were the obstetric services singled out for cuts in the 1976 DHSS prioritics document ? The explanation offered by Margaret and Arthur Wynn is the "continuing underprivileged status of British women." In the Prezention of Preterm Birth (f 3 00), their latest publication for the Foundation for Education and Research in Childbearing (27 Walpole St, London SW3), the Wynns argue that women's organisations have not been vocal enough in demanding better maternity services. Drawing comparisons with other European countries they present a mass of closely argued evidence that Britain could reduce perinatal mortality and the numbers of handicapped children by concentrating research efforts on the prevention of premature labour. They highlight the growing use in Germany of drugs such as salbutamol, but they also point to the women's clinics in Sweden and Finland, which provide very high standards of antenatal care. There is, they argue, a case for an inquiry into atenatal care in Britain: who should provide it and where ? Are doctors doing work that would better be done by midwives ? Should hospital obstetric departments take more responsibility for antenatal care ? But before the questions can be answered more data are needed-a point made earlier this year by Professor Richard Beard (23 July, p 251). What about giving some priority to his plan for a nationally sponsored unit for perinatal epidemiology ? Last week Life (Save the Unborn Child) decidled at its annual conference to write to all gynaecologists threatening prosecuition should evidence comne to light of a termnination of pregnancy after the 28th week. Do supporters of this decision really believe that gynaecologists consider terminating pregnancy late in the secotnd trimiester except for pressing mnedical reasons ? TW"hy do pressure groups of this kind encourage such extremne attitudes? In the past 20 years Denton Cooley and his colleagues in Houston, Texas, have carried out major cardiovascular operations on 542 Jehovah's Witncsses. Mortality within 30 days of operation was 9 4",, ournal of the American Aledical Associationt, 1977, 238, 1256). Three of the 51 deaths werc related directly to the patients' adamant refusal to have transfusions of blood or blood products, and postoperative anaemia was a factor in 12 further deaths: but the Texas team seems to have made its point that the risk of operating without blood is acceptably low. The Pharmacy Practice Research
Grouip
at
Nottinghamn
University is looking at sy7stemns of health care within the Asian inmligrant community, and in particular at practising inmnigrant healers or hakims. Apparently hakimns are to be found in nMost imligrant coimmuinities, antI the prescribed medication (often herbal but somnetines containing heavy metals and arsenic) mnay! give rise to adverse reactions. Anyone with informnation that misght be useful is asked to contact Professor S S Davis. Last year the British ate 13 10 s fish fingers; meanwhile fish and chip shops went out of business at the rate of one every day (Nutrition Bulletinl, 1977, 21, 198). Despite a widespread belief that they are eaten only by children, half the consumption
of fish fingers is by adults, so that it is not surprising that the shortage of Icelandic cod is leading to quiet efforts to find acceptable (or undistinguishable ?) alternative sources of fish. Who would buy dog-fish fingers ?
Anyone who saw James Coburn 's hilarious performnance in "The President's Anal,st" will have doubts about the value of a psychiatrist in the IWhite House, buit Dr Peter G Bourne seems to be giving advice rather than treatmnent to President Carter. The British-born physician, who has puiblished on stress, drug addiction, and anthropology, is trying to persuade the new admninistration to concentrate foreign aid on major illness such as malaria and schistosomiasis while in the Unilted States itself he is pushing for mnore attention to menetal health. Sadly, there is no evidence that the British Governmnent has any equally articulate mnedical adviser to draw its attention to the demnoralising decline in the NHS. When an American asks his doctor for help in giving up smoking he is likely to be advised to use "stimulus satiation"which relies on enforced periods of continuous and rapid smoking at a rate of one puff every six seconds. So horrible is this experience that (in theory) it puts the smoker off for life; but (New England Journal of Medicine, 1977, 297, 590) it may also so disturb his blood gases that dangerous arrythmias may be precipitated in individuals with coronary disease. Mr David Eninals's "good neighbouir" camnpaign to enicourage mnore visiting of the elderly and houtsebouind is nearly one year old; and so far over one miiillion leaflets, 320 000 stickers, and 240 000 call cards havie been i'ssued. Voluntary organisations are now being asked for suiggestions for e\panding and developing the camnpaign.
Boys who survive the childhood hazards of cystic fibrosis are almost always sterile owing to damage to their testes, but the effect on the ovaries is less certain. There seem to be two authenticated cases (Journal of Pediatrics, 1977, 91, 276) of women with cystic fibrosis having children. Both were unlucky enough (the risk is only 2-5",,) to have children affected by the disease. The Private Patients Plan came ouit very well in an assessment of mtiedical insuranice imn the Septemnber issue of "Money lW'hich ?" The article mnade fascinating reading, for, despite all the detail, Minerva couild not understand how the Bristol Contributor+y
WY'elfare Association, a relatively smiiall but well-established concern, could offer rates less than half those charged byi the big two, B UPA and PPP. Quite what significance should be read into the results of research on mice is always arguable; one example is a report in Suirgery (1977, 82, 254) that mice given thiopentone develop a heightened susceptibility to pulmonary metastases from murine fibrosarcoma. Apparently thiopentone suppresses cellmediated immunity-in mice. Does that finding have any relevance for human neoplastic disease ?
MINERVA
BRITISH MEDICAL JOURNAL
1 OCTOBER 1977
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EPIDEMIOLOGY Parasites in dogs and cats scopically for helminth eggs and protozoal cysts in normal saline and in Lugol's iodine and by flotation in saturated sodium chloride solution. Fifty-five dogs were examined; no parasites were found in 15 (27 ,,), whereas in the cats no parasites were found in 23 of 46 examined. A public health laboratory investigated for In 21 dogs Toxocar-a canis was found, in 2 parasites a sample of the dogs and cats in their Toxascaris leoninba, in 7 the canine hookworm, area. It looked especially for toxocara in both Uincinariaastenocephlala, in 17 Dipylidium species of animal and for toxoplasma in cats. ca,iibiuni, and in 3 the eggs of a linguatulid, The animals were obtained for postmortem probably L serrata. In the cats, Toxocara cati examination fcom a dogs' home to which they was found in 13, D caninltont in 6, Taenia had been sent for humane destruction. Thev taeniiformis in 7, and Taenia sp in 1. These results suggest a fairly high incidence included both family pets and strays and were a mixture of breeds, sizes, and ages, including of toxocariasis in both dogs and cats. Canine some puppies and kittens. The heart and great and feline ascarids are the source of human vessels, lungs, bronchi, trachea, liver, gall toxocariasis caused by a larva migrans which bladder, and alimcntary canal from the may reach the eye, causing serious ocular oesophagus to the sigmoid colon were symptoms. Compared with surveys on dogs in examined macroscopically for parasites. The other cities and areas in Britain the infection contents of the stomach and intestine were rate is high but not the highest; most areas sieved. The faeces wxere examined micro- report rates in the range 7 04-160 . Dipylidiu1m
The followiniig nlotes atre comtipiled by the Cornuniiilicable Disease Suirveillanice Cenitre of the Plublic Health Laboratory, Service from reports snibinitted by public health anid hospital laboratories inl the United Kinlgdomi anid Repuiblic of Irelanld.
catinlum, the most ubiquitous cestode parasite of dogs and cats, was also common, but though children can be infected through a swallowed dog or cat flea (the intermediate host) such infections are normally asymptomatic. A careful search for Echinococcus granuxlosus (hydatid cyst) was made but it was never found. These findings indicate the desirability of regular antihelminthic treatment of dogs and cats. Blood from 35 cats was tested for toxoplasma antibodies by the Sabin and Feldman dye test; eleven samples were haemolysed and unsuitable for examination. Faeces from all 46 cats were examined for toxoplasma oocysts using fluorescence microscopy. The serological tests showed that just under a third (10 of 35) had been infected with Toxoplasma gondii; thus their faeces had been infectious at some time in the past. The laboratory failed to find toxoplasma oocysts in the faeces of all 46 cats; this is not unexpected, because infected animals excrete oocysts for only about two weeks.
MEDICOLEGAL Annual report of Medical Defence Union FROM OUR LEGAL CORRESPONDENT
T he past year was an unusually turbulent one for the defence societies, who faced both the prospect of a BMA scheme for commercially backed indemnity insurance and queries raised by the Department of Trade and Industry as to their status in relation to the Insurance Companies Act 1974. The annual report of the MDU for the year ending 31 December 1976 reflects little of the controversy which ebbed and flowed around it, but its contents (as in years past) clearly reveal why there was so little support for the Bowring scheme.
Commercially inexpedient During the year the MDU more than once took up costly and commercially inexpedient battles to vindicate a member's reputation. A South African case dealt with by the Union underlines that clearing a surgeon's reputation may be a Pyrrhic victory when viewed in purely financial terms. After a six-weeks trial in 1975 the court dismissed a claim against a neurosurgeon who administered a 6 00 solution of phenol in glycerine as a block for coccygodynia. The patient, a 25-year-old woman, had subsequently lost control over both bladder and rectum and was also left without sensation in her right leg. The MDU's legal costs exceeded £57 000, of which only £1400 could be recovered from the unsuccessful plaintiff. In England successful defendants often prove unable to recover their costs because the plaintiff is legally aided, and commercial prudence frequently dictates that insurance companies come to pretrial compromises with unmeritorious but penurious plaintiffs, rather
than incur irrecoverable costs by going to court. In describing their defence of a doctor who diagnosed chilblains in a 25-year-old woman with arterial occlusion, the MDU state that "the vindication of a member who has not been negligent will continue to be the overriding consideration." The woman had been taking a contraceptive pill, and when first seen by the doctor after complaining of pain in the right foot she was seated by the only source of heat in the house, a small coal fire. Four days later the hospital diagnosed right femoral artery block, but removal of the thrombus failed to restore circulation and the leg had to be removed above the knee. When a faulty diagnosis is made or treatment has unexpected or disastrous side effects there is always a temptation for lawyers to conclude that the only explanation is negligence. They bolster their reasoning with the Latin tag res ipsa loquitur-the matter speaks for itself. The wife who lost her leg was granted legal aid and brought her action to trial in 1977. The Union's view that the doctor had not been negligent was corroborated by its expert, who said that arterial occlusion was a great rarity and not a generally recognised complication of the pill, like venous thrombosis. A second expert bore out that diagnosis was difficult.
Fair reporting
During the trial the plaintiff's account of the development of her symptoms was discredited sufficiently for her counsel to withdraw the action, but the Union's costs of over £4000
could not be recovered from either the plaintiff or the Legal Aid Fund. There was an interesting footnote to this action: a national newspaper published a report after the first day of the trial, naming the allegedly negligent doctor under the headline "Chilblains wife had leg off." Only after intervention by the Union did the newspaper print a second report with equal prominence giving the result of the action and quoting the judge's words vindicating the doctor. Newspapers are entitled to privilege where they publish daily accounts of each day's proceedings, even though the trial lasts more than a day. Such reports must be fair and accurate with regard to the evidence given on each day and to the trial as a whole up to that point. What has never been decided' is whether the failure to publish the result at the end of the trial renders an earlier report, which would otherwise have been fair and accurate, unprivileged. In principle it ought to do so, but the law is not clear. Editorial policy in Fleet Street, and doubtless that of the Press Council too, is that results vindicating defendants should be publicised, but in the present case the matter was overlooked, even though the reporter had filed copy. The MDU has adhered stoutly to the principle that, with the advance of medical knowledge, what is negligence today may not have been negligence yesterday. In 1971 a doctor who found perineal warts during a postnatal examination prescribed a podophyllum preparation with advice that it be applied sparingly. He warned that there could be an adverse reaction, but in fact the woman suffered severe local inflammation and lost all sexual feeling for her husband. In prescribing
BRITISH MEDICAL JOURNAL
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as he had the doctor had followed the literature Liability) Act 1976, which came into force on available in 1971, but later the makers of the 22 July 1976. ointment had changed their leaflet to emphasise that the ointment should be used only for plantar warts. The trial judge, viewing the Indemnity payments matter as at 1971, held that there had been no negligence. These two large settlements are reflected in the rise in indemnity payments by the MDU in 1976 from £521 000 to £875 000. Legal Familiar trio charges rose from £279 000 to £477 000. Subscription income rose from £1 6m to The familiar trio of hibitane burns during £2-2m, reflecting the increase in annual cautery, operations on the wrong limbs, and subscription to £40, and the surplus for the missed foreign bodies in the eye all make their year was £504 000, only marginally less than annual appearance. A claim by a patient who in 1975. The accumulated funds of the MDU suffered first-degree burns during cautery of now stand at £32m, but the figures for quoted the cervix after the vulval area had been investments and leasehold properties are almost swabbed with hibitane cost over £1000. An certainly on the low side of their current operation for the excision of a toe-nail on the realisable value. wrong toe cost £650. The MDU had to pay Against the accumulated funds stands a £2700 when a yachtsman lost his eye after contingent liability of £2 45m (£1C6m in 1975) being struck in the face by a rope which in respect of cases which will probably or may smashed his glasses. There was a fragment of possibly be settled. The settlement of such glass in the globe which was undetected by the cases may be spread over as much as five years, casualty officer, who failed to take a proper but with inflation affecting awards of damages history, instil fluorescein, test visual acuity, or a review of the contingent liabilities must be take an x-ray film. The damages would have (and is) affected year by year. There is no case been larger but for the likelihood that the eye outstanding where the liability is likely to be would have been lost anyway. exceptional. The Union acknowledges that the statement in last year's report that "glass is almost
invariably radioopaque" was too sweeping, since glass fragments in the orbit do not necessarily show up when radiographs are taken. But unless history, examination, and x-ray are all properly carried out there can be no defence when a foreign body in the eye is missed. During 1976 the Union twice had to pay out sums in excess of £70 000. In July 1966 a 35-year-old man, who had had disseminated tuberculosis at 19, developed epididymoorchitis and was treated with antibiotics without improvement. He became tired and feverish and the inflamed mass of epididymis discharged pus. Two months later he was admitted to hospital with miliary tuberculosis and tuberculous meningitis. He was left virtually blind. Since the tuberculosis should have been diagnosed at the time of the epididymoorchitis or, at worst, when it did not respond to antibiotics, damages of £70 000 and costs had to be paid. The highest settlement of all, one of £78 692, followed a disaster involving a caesarean section on a 35-year-old primigravida. An anaesthetic registrar of three years' experience passed a size 8 endotracheal tube but had difficulty inflating the cuff. The endotracheal tube entered the oesophagus, and the patient then regurgitated and aspirated vomit. The woman was never to recover consciousness and her child, born with signs of hypoxia, was spastic. It had to be accepted that the brain damage to the child had occurred while the fetus suffered hypoxia before delivery, and the case raised the point of law (never before decided in an English court) as to whether at common law a child has a right of action in respect of injuries before birth. It must be almost inconceivable that a court would have decided this point against the child, and the claim in respect of the mother (who died two years after the operation) and the child was settled. A child's entitlement to claim damages for negligent fetal injuries is now put beyond doubt by the Congenital Disabilities (Civil
Financial policy The MDU treasurer estimates that the surplus for 1977 is likely to be in excess of JO5m, so that the Union seems likely to continue its successful policy of building up reserves out of subscription income at the same time as meeting current claims. This policy was obviously vital when the MDU had no reinsurance, but this year's report states that "acceptable terms of insurance" to protect against an exceptional level of claims have been negotiated from 1 January 1977. No mention is made of the ceiling at which the new reinsurance operates, and the Union regards this as a matter to be kept secret from possible competitors. This attitude may be wise or may be not, but it is hardly reassuring to the Union's critics. In the summer of 1976 wild rumours appeared in the press about the Union's ability to meet claims. These stemmed from the fact that the MDU had never brought home to the public that in 1973 (the date has never been disclosed precisely) it had ceased reinsurance. Some of the wilder rumours clearly flowed from those who misunderstood the Union's financial policy of building up a reserve from income, but the critics none the less resurfaced during the BMA debates on the Bowring scheme. The latest accounts ought to still all reasonable doubts and justify the treasurer's assurance that "the Union's financial position is sound." All the same, the coming year sees another hurdle for the MDU. In July this year the Union issued an originating summons in the Chancery Division to determine whether it was an insurance company within the meaning of the Insurance Companies Act 1974, as the Department of Trade was trying to contend. In 1968 the then Board of Trade stated that it did not regard the MDU as an insurance company, but the recent controversy over the Union's affairs led it to take the advice of
1 OCTOBER 1977
leading counsel and the p:-esent proceedings were launched. The issue appears to be whether the Medical Defence Union Ltd, a company limited by guarantee not exceeding £1 per member, is carrying on "insurance business." Like many simple questions, the legal answer is far from straightforward. There is no definition of "insurance business" in any of the numerous insurance Acts, and the courts have never needed to define the term. The leading textbook2 on insurance law concludes, not very helpfully: "the words thus bear their ordinary meaning." Since its foundation in 1885 the MDU has never failed to indemnify its members against awards of damages and costs in civil actions. It has frequently paid their costs (but not any penalties) in criminal cases too. While this may give the appearance of "insurance business," the Union does not appear to be under an enforceable contractual obligation to indemnify members. Each year the MDU Report contains a statement of benefits which may be granted to members. They include "assistance when damages and costs are awarded by a court or settlement is made out of court." The word "assistance" can only have been chosen for its vagueness. In theory the MDU therefore appears to retain a discretion whether to indemnify their members, but in practice it is because they have always done so that it can be suggested that they are an insurance company. The absence of any contractual right on the part of members to an indemnity might, if proved, turn out to be one of the deciding factors, if not the deciding factor, in the case. This would distinguish the MDU from a mutual insurance:' company, where the members are bound to each other by contract to contribute on an agreed basis to the insurance claims of other members. It is irrelevant that the MDU is not in business for profit. Should the MDU fail in its claim, it (and, no doubt, the other defence societies too) would have to seek authorisation to carry on business from the Secretary of State for Trade and Industry under the 1974 Act. There is no reason to think that this would force them to change dramatically the conduct of their affairs, but the MDU would prefer to do without the supervision by the Department of Trade and the auditing that this would entail. On the present accounts the MDU seems well within the solvency margins prescribed by section 4(1) of the 1974 Act-namely, that the value of assets in any given year should exceed liabilities by one-fifth of that year's premium income. The Under-Secretary of State for Trade4 told the Commons in May this year that the defence societies intended to ensure that their financial position was such that they would meet the requirements of the Act, regardless of whether they were obliged to do so. None the less a judicial decision which brought the defence societies within the insurance Acts might at least protect them from the mass of criticism, a great deal less than fair, to which they have been subjected in recent months. Gatley: Law of Libel and Slander, para 631, 7th edn. London, Sweet and Maxwell. 2 MacGillivray: Insurance Law, para 363, 6th edn. London, Sweet and Maxwell. 3 MacGillivray: Insurance Law, para 351, 6th edn. London, Sweet and Maxwell. 4 British MedicalJournal, 1977, 1, 1292.
I
BRITISH MEDICAL JOURNAL
1 OCTOBER 1977
MEDICAL NEWS Chair of pathology, University of Newcastle upon Tyne Dr A E Stuart has been appointed to the chair of pathology and head of the department of pathology at the University of Newcastle upon Tyne from 1 January 1978. Dr Stuart, who is 52, graduated from Glasgow in 1948 and after a house appointment at the Western Infirmary, Glasgow, and service with the RAMC, held hospital appointments in pathology in Melbourne and Tasmania. In 1954 he returned to Britain, and after appointments in the University of Glasgow and University of Dundee he was appointed lecturer in pathology in the University of Edinburgh in 1956. In 1958 Dr Stuart was awarded a travelling fellowship to the Institut Pasteur and Broussais Hospital in the University of Paris. From 1960 to 1965 he was senior research fellow in the University of Edinburgh, and was appointed senior lecturer in 1966 and reader in 1967 in Edinburgh. NHS statistics
About 3600 general practitioners (out of the total of 22 000 in England) are now practising from health centres, says the DHSS Anniual Report 1976 (HMSO, £1'40). A further 76 centres were opened in the year, bringing the total to 705. In the hospital service the 5 25 million inpatients treated was the highest total since the start of the NHS, but by December 1976 the total on waiting lists had increased by 3 during the year. The number of hospital beds continued to fall-the reduction in the last ten years is now 12 00, but most of this drop has been in mental illness hospitals or wards, says the report. Day case attendances rose by 15 % compared with the previous year, and the numbers of psychiatric and geriatric day patients rose by 00 and 21 respectively.
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Royal College of Physicians, 11 St Andrew's Place, Regent's Park, London NW1 4LE before 12 December.
COMING EVENTS Lord Nuffield Birthday Centenary scientific meeting-"Pharmacological aspects of pregnancy," 5 October, London. Details from the Royal College of Obstetricians and Gynaecologists, 27 Sussex Place, Regent's Park, London NW1 4RG. (Tel 01-262 5425.) "Diseases of colon and rectum"-Course of morning lectures, 10-14 October, London. Details from Dean of Postgraduate Studies, St Mark's Hospital, City Road, London EC1V 2PS. (Tel 01-253 1050 ext 36.) Medical and Dental Retirement Advisory Service-Symposium on "The health lecture in pre-retirement courses," 26 October, Birmingham. Details from MADRAS, Tavistock House North, Tavistock Square, London WC1H 9JD. (Tel 01387 6869.) Symposium on Current Controversies in Breast Cancer-Organised jointly by the British Medical Association and British Association of Surgical Oncology, 4 November, London. Details from Miss D Warner, British Medical Association, BMA House, Tavistock Square, London WC1H 9JP. (Tel 01-387 4499 ext 129.)
SOCIETIES AND LECTURES For attetndintg lectures marked * a fee is charged or a ticket is reqired. Applications shouild be made first to the institutions concerned.
Monday, 3 October INSTITUTE OF OBSTETRICS AND GYNAECOLOGY-4.30 pm, Mr Jeffrey S Robinson: Growth retardation in fetal lambs. ROYAL COLLEGE OF SURGEONS OF ENGLAND-6 pm, Mr P Goodall: Hernias in the groin.
Tuesday, 4 October OF BIRMINGHAM MEDICAL INSTITUTE SECTION PSYCHIATRY-At Queen Elizabeth Hospital, 7.30 for 8 pm, 26th annual dinner.* ROYAL COLLEGE OF SURGEONS OF ENGLAND-6 pm, inaugural Stanford Cade memorial lecture by Mr
Applications are invited before 31 October for bursaries to be awarded in 1978 to young British doctors under an exchange scheme between the Institut National de la Sante et de la Recherche Medicale in Paris and the Ciba Foundation in London. The grants will be awarded for periods of one to four months for clinical experience or research in France. Preference will normally go to candidates who hold teaching posts or are in positions where they can pass on the experience they have acquired. Application forms from the Deputy Director, Ciba Foundation, 41 Portland Place, London WlN 4BN (tel 01-636 9456). Christmas lectures, Royal College of Physicians of London The Christmas lectures held by the Royal College of Physicians of London, which are open to young people in the 12-18 years age this
"How the blood goes group, round," given by Professor J P Shillingford on 19 December, and "New marrow-a change is as good as a rest-or is it ?" given by Dr Ray Powles on 29 December. Applications for tickets should be sent to the Assistant Registrar, year are
26 Wed
Joint Consultants Committee (Royal College of Surgeons of England, Lincoln's Inn Fields, London WC2), 9.30 am. BMA Council Executive, 10 am.
Division Meetings to be Held Members proposing to attend meetings marked * are asked to notify in advance the honorary secretary concerned. Bristol-At Bristol Royal Infirmary, Wednesday, 5 October, 8.30 pm, agm. Chesterfield-At Shoulder of Mutton Hardstoft, Thursday, 6 October, 7 for 7.45 pm, joint meeting with Chesterfield Law Society, Professor Keith Simpson: "Medicine versus the Law.'* (Buffet supper.) Durham-At Dryburn Hospital, Monday, 3 October, 8.30 pm, agm. Grimsby-At Humber Royal Hotel, Thursday, 6 October, 7.30 for 8 pm, annual dinner.* Guildford-At Bramley Grange Hotel, Wednesday, 5 October, 7.30 for 7.45 pm, joint supper meeting with West Surrey Law Society.* (Guests are invited.) Harrow-At Harrow Hospital, Tuesday, 4 October, 5.15 pm, agm. Northern Region Medical Assistants Group-At Medical Institute, Newcastle upon Tyne, Monday, 3 October, 7 pm, meeting. St Helens and Knowsley-At Whiston Hospital, Saturday, 8 October, 10.30 am, symposium "Conflicts in the care of the elderly."* Wakefield-At South Milford Hall, Friday, 7 October, 7.30 for 8 pm, annual dinner dance.* (Guests are invited.) Wigtown-At Judge's Keep Hotel, Glenluce, Wednesday, 5 October, 7.30 for 8 pm, film meeting.
UNIVERSITIES AND COLLEGES NEWCASTLE UPON TYNE Appointments-Dr M A P S Downham (senior lecturer in the department of child health); Dr D P Forster (senior lecturer in community medicine).
WELSH NATIONAL SCHOOL OF MEDICINE Dr K M Laurence has been granted a personal chair in
applied genetics.
Dr R Harvard Davis has been promoted to reader in general practice. Dr J A Dodge has been promoted to reader in child health. Dr A H Henderson has been promoted to reader in cardiology. LONDON MD-M W Adler, B R 'I Carroll. MS-S G Darke, J A Lynn.
APPOINTMENTS
Gerald Westbury: Soft tissue tumours.
Wednesday, 5 October
Anglo-French exchange bursaries
25 Tues
INSTITUTE OF ORTHOPAEDICS-6 pm, Dr P A Dieppe: Crystal synovitis. 7 pm, Professor Verna Wright: Systemic manifestations of rheumatoid arthritis. ROYAL COLLEGE OF SURGEONS OF ENGLAND-5 pm, Hunterian lecture by Professor J D Stamatakis: The problem of thromboembolism in total hip replacement. 6.30 pm, Mr B T Jackson: Obstructive jaundice. ROYAL FREE HOSPITAL SCHOOL OF MEDICINE-5 pm, Dr A M Adelstein: Measuring disease in the
CITY AND EAST LONDON AREA HEALTH AUTHORITY (TEACHING)-Dr R J Davies (consultant physician in general and thoracic medicine). SOUTH GLAMORGAN HEALTH AUTHORITY-The following consultants have been appointed-Dr J Picton Thomas (physician); Mr I P Griffith (ENT surgeon); Dr I J Kerby, Dr I C M Paterson (radiotherapists); Dr A H Md A H Quoraishi (medical microbiologist); Dr S Wallace (paediatric neurologist).
community.
Notice to authors When original articles and letters for publication are not submitted exclusively to the British Medical Yournal this must be stated. For detailed instructions to authors see page 6 of the issue dated 1 January 1977. Correspondence on editorial business should be addressed to the Editor, British Medical Journal, 7 October Friday, BMA House, Tavistock Square, London WC1H ROYAL COLLEGE OF SURGEONS OF ENGLAND-6 pm, 9JR. Telephone: 01-387 4499. Telegrams: Mr J S P Wilson: The methods of skin grafting. Aitiology, London WC1. Communications will not be acknowledged unless a stamped addressed postcard or an international reply coupon is BMA NOTICES enclosed. Authors wanting reprints of their articles should notify the Publishing Manager, BMA House, Diary of Central Meetings Tavistock Square, WC 1 H 9JR, on receipt of proofs.
Thursday, 6 October
MEDICAL FEDERATION-At Senate House, University of London, 5.30 pm, Professor Sir Peter Medawar, FRS: Biology and medicine. * ROYAL COLLEGE OF SURGEONS OF ENGLAND-6 pm, Professor J C Goligher: Current trends in the treatment of carcinoma of the rectum. BRITISH
POSTGRADUATE
OCTOBER 6 Thurs 6 Thurs 12 Wed 18 Tues 19 Wed 20 Thurs 24 Mon
Hospital Junior Staff Committee, 10 am. Medical Assistants Subcommittee (CCHMS), 10.30 am. Council, 10 am. Scottish Committee for Hospital Medical Services (7 Drumsheugh Gardens, Edinburgh EH3 7QP), 10.45 am. Occupational Health Committee, 10.30 am. General Medical Services Committee, 10 am. Scottish Council (7 Drumsheugh Gardens, Edinburgh EH3 7QP), 10.45 am.
(C British Medical Journal 1977 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, electronic, mechanical, photocopying, recording otherwise, without the prior permission of the
or
British Medical3Journal.
