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NEWS AND NOTES
Viewzs
In Minerva's medical lifetime the three great causes of death have been coronary disease, stroke, and cancer. The decline in coronary disease in the United States has now been followed (New England Journal of Medicine, 1979, 300, 449) by a drop in the incidence of stroke-attributed provisionally to better control of hypertension and a change in smoking habits. What, however, will be the effect on cancer deaths ? For everyone has to die of something. To what will those spared by vascular disease eventually succumb ? The Eraldin Action Group has helped many patients damaged by side effects of practolol. What a pity that it overstates its case by asserting that thalidomide, practolol, hormone pregnancy testing, and whooping-cough vaccine can all be lumped together as "major drug tragedies."
Can stress cause gastric ulcers even in the fetus ? A baby boy less than a day old died of haemorrhage from extensive ulcers, his 16-year-old mother having had an exceptionally stressful pregnancy (Archives of Disease in Childhood, 1979, 54, 146). She lived with her husband (whom she married because she was pregnant) for only a fortnight before leaving him to escape his drunken assaults, but he continued to distress her with his visits. The authors suggest that the increased secretion of gastrin induced by all this stress may have crossed the placenta to cause the baby's ulcers. A report in the same issue (p 98) shows that babies of low birthweight thrive best on a mixture of curd and whey rather than on unmodified cows' milk, which contains mainly curd. At last Minerva understands the nursery rhyme about Miss Muffet: she was clearly spotted by an astute paediatrician and put on to an optimum diet. Attractive as the theory of immunosurveillance against cancer may have been, the evidence is mounting against it. The latest nail in its coffin comes from Oxford (British Journal of Cancer, 1979, 39, 193), where epidemiologists have shown no significant increase in the risk of cancer in patients with myasthenia gravis treated by thymectomy. "I am happy to tell you that your daughter is a mongol." These words from a paediatrician to Brian Rix and his wife 27years ago have understandably influenced their opinion of doctors' attitudesto the mentally handicapped. Nor, he told a group of medical journalists last week, had things improved 24 years later when friends had a similar experience. Miss Rix is in Normansfield Hospital and her father is chairman of the Friends of Normansfield. When the Friends complained to the AHA (on three occasions)
about staff conduct they were told, firstly, that it was none of their business, and, secondly, that if they left the matter long enough the staff would "hang themselves." In the end it was the AHA which hanged itself. While a few parents may still be expected to attribute fever, irritability, and other more specific symptoms to teething Minerva was surprised to read (Postgraduate Medical Journal, 1979, 55, 24) that in 11 of a series of 50 cases the diagnosis of teething had been made first by the general practitioner.
Crufts dog show was held at Earl's Court for the first time this year. The new venue proved successful; but, says the British Small Animals Veterinary Association, there were some unexpected problems: a few dogs were injured on escalators and some in the bulldog section developed heat exhaustion. Further evidence that the poor always come off worst when health care is quantified: a study (journal of the Royal College of General Practitioners, 1979, 29, 160) by a Scottish geographer has shown that access to GPs' surgeries is most difficult for patients living on deprived local authority estates-just the families with the highest morbidity. What will the GP planners do about that ? The medical campaign in Britain against dextropropoxyphene (better known as Doloxene and as a constituent of Distalgesic) is running in parallel with a similar movement in the United States, where Joseph Califano, the secretary of Health Education and Welfare, is reviewing its safety. Last year, says "Science" (1979, 203, 857), it was the third most prescribed drug in the United States, and since 1957 there have been 20 000 000 000 prescriptions for the Eli Lilly product.
Naturally enough, smokers have seized on the report by Auerbach et al in the New England Journal of Medicine (1979, 300, 381) as evidence that low-tar, low-nicotine cigarettes with filters cause fewer histological changes in the lungs than oldfashioned gaspers. But, as the NE7M points out in its editorial comment, their findings do not show that modem cigarettes are less dangerous-for no one knows how, for instance, smoking increases the risk of heart disease. Journalists who picked up the report gave less emphasis to the cautionary rider.
Anonymity is useful for cloaking an author's identity (as Minerva knows), but in "Strange Encounters"-the new BMJ "fillers" starting on p 734-Will Macredie uses his (or hers ?) to protect other people too. Now read on.... MINERVA
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MEDICOLEGAL Negligence and forceps delivery FROM OUR LEGAL CORRESPONDENT
From time to time a judgment against a doctor in a malpractice action gives rise to widespread concern in the profession whether the courts in compensating the plaintiff have not demanded too high a standard from the practitioner. One such case' 2 occurred in 1968, when a general practitioner had to pay £2500 damages to a patient who contracted fulminating septicaemia in the pueperium, even though two consultant obstetricians and two general practitioners testified that their management of the illness would have been just the same. Similar alarm has greeted the award' by Mr Justice Bush of £l00 000 damages to a 9-year-old boy who sustained severe brain damage in the course of his birth at the Queen Elizabeth Hospital, Birmingham, in January 1970. The obstetrician concerned, Mr Joseph Jordan, said that he had undertaken a trial of forceps before desisting and delivering the baby by caesarean section.
Trial of forceps Inevitably the decision has led to worry that trial of forceps may no longer be legally safe. If that worry was justified, then any ensuing tendency to "defensive medicine" would result in more frequent caesareans with their own different risks to mother and child. An analysis of Mr Justice Bush's 32page judgment shows that it would be wrong to draw too general a conclusion from a particular incident. In contrast to the case of fulminating septicaemia in 1968, Mr Justice Bush was not concerned with adjudicating between two competing schools of thought. His task was to reach a finding on what had occurred during the course of the birth; and, unfortunately for Mr Jordan, the judge was doubtful that there had been a trial of forceps at all, as opposed to an attempt at vaginal delivery which had failed and in the course of which the child had become stuck. He added that even if there had been only a trial of forceps, then Mr Jordan had pulled too hard and too long causing the fetus to become wedged, with ensuing anoxia leading to cerebral palsy. Mrs Whitehouse, the plaintiff's mother, by whom he sued as next friend, was 30 at the time of the birth and a primigravida. According to the judge, she was only 4 feet 10 inches (149 cm) tall, had suffered from irregular menstruation, and was so tense that she developed severe vaginismus in the course of examinations. Antenatal care was also bedevilled by doubt about the maturity of the fetus. On 31 December 1969 (one week before the birth) Mrs Whitehouse was seen by Professor H C McLaren. She declined a lateral x-ray examination (according to the professor's evidence) because she was afraid of damage to the fetal ovaries if the child should be a girl. The professor's notes read: "She declines lateral x-ray so await head fixing. Trial of labour is my guess." As a result of the refused x-ray examination the
size and shape of the pelvis were not established before labour started, but Mr Jordan did not suggest that the absence of x-ray pelvimetry had hampered him because he was able to assess the size of the pelvis by vaginal examination when the mother was under the epidural anaesthetic. Nor was any criticism made by the plaintiff of Professor McLaren's decision to allow labour to proceed under close supervision while a watch was kept for disproportion between the head of the fetus and the pelvis.
Course of labour
from memory. Mr Jordan also gave evidence that the head was not stuck, and, though he believed that it would still have been possible to deliver per vaginam, he decided that it would be too traumatic for mother and child.
Balance of probabilities Mr Justice Bush said that he was satisfied on the balance of probabilities that the plaintiff had suffered intrapartum asphyxia, and he rejected the suggestion made by the defendants that the anoxia giving rise to the cerebral palsy might have been due to other factors, such as brain maldevelopment. The judge then turned to see whether he could accept the defendants' explanation as to the trial of forceps. In reaching a conclusion adverse to Mr Jordan, he mentioned a number of matters, but he considered that "the strongest piece of evidence that something untoward was done" was a report made by Professor McLaren after he had discussed the matter with Mr Jordan. The report stated that "descent did not follow traction and in the interest of the child, the head was disimpacted prior to speedy delivery by caesarean section." The report used the word "disimpact" some three times and was obviously damaging to Mr Jordan's evidence that the head was not stuck. Professor McLaren concluded: "After a reasonable attempt at delivery by forceps, a caesarean section was carried out. The baby, alas, was seriously affected by this well-conducted trial of labour and forceps. Possibly at caesarean section the disimpaction of the head was critical and cerebral haemorrhage followed." Professor McLaren sought to persuade the judge that "disimpaction" did not mean that there had been such wedging that a lot of force was needed to push the head up before the caesarean section started. Nevertheless Mr Justice Bush could not accept this explanation, and, while alive to the point that the report was not the work of Mr Jordan, he clearly thought that Mr Jordan had given the impression to Professor McLaren in their discussion that the baby's head had been stuck. The second major matter that influenced the judge against Mr Jordan was his finding that what finally prevented the baby's head from descending was disproportion between the head and the ischial spines. Mr Justice Bush shared the doubt expressed by Sir John Peel (who was called by the plaintiff) as to why it was necessary to have five or six pulls to test whether delivery per vaginam was possible. The judge commented that if the head were engaged, there would not be far to go before the widest part of the head was at the ischial spines. Mr Justice Bush's belief that the child's head was indeed wedged at the level of the
At 0045 on 6 January 1970 the membranes ruptured, and at 0200 Mrs Whitehouse was admitted to hospital. During the hours before the birth she was seen by the senior house officer, a registrar, a consultant, and another registrar. At 2330 she was examined by Mr Jordan, who had been working on his thesis and was called in by the registrar. By then the cervix was fully dilated and the head was engaged. In his notes made up after the operation, Mr Jordan recorded: "Normal delivery out of the question." Mr Jordan then decided on a trial of forceps, and the judge's finding as to what occurred thereafter was critical. Mr Justice Bush quoted from Sir John Dewhurst, who had written that trial of forceps might be permissible for an experienced obstetrician where there was uncertainty whether there was miid disproportion or not. In words that clearly made their mark on the judge, Sir John wrote: "If advance is maintained, well and good. If not, caesarean section can be carried out immediately. It will be clear that the dividing line here is very narrow. If too great force is exerted, the fetus may be damaged and vaginal delivery may result in a stillborn child or one with cerebral injury." Sir John's "dividing line" was at the centre of the action, for, though Mr Jordan was not criticised for adopting trial of forceps, theplaintiff's case was that it was not a trial, but an attempt at delivery which failed and which, having regard to the fetus's position at midhigh was unjustifiably risky. In the alternative the plaintiff argued that if there was a trial of forceps, then Mr Jordan had pulled too hard and too long, resulting in the child's head becoming wedged. After using Keilland's forceps to turn the child's head into the occipito-anterior position, Mr Jordan applied Simpson's forceps. His notes read: "A very tight fit. No episiotomy. After pulling with 5 or 6 contractions, it was obvious that vaginal delivery would be too traumatic." In evidence Mr Jordan told the judge: "If we accept, say, six contractions, then I would assume that difficulty would be encountered with the fifth pull, that is no descent with that pull, and one would confirm with a further pull with the next contraction." It is clear from this passage of Mr Jordan's ischial spines was influenced by an unfortunate evidence that he was hypothesising as to answer given by Mr Jordan in re-examination what had happened rather than speaking by his own counsel. He was asked whether he
764 had tried to pull past any bony part, and he replied: "My trial by forceps was to overcome what may be minimal obstruction so one did, as it were, pass the level of the ischial spines."
Far-fetched complaints The judge was therefore able to reach a conclusion without relying on the evidence of the mother, who, he said, had made absurd and far-fetched complaints in her attempt to get an inquiry. Mrs Whitehouse gave evidence that when the forceps were applied, she experienced "a deadened electric shock that lifted my hips off the table." The judge said that, while the description might not be exact in clinical detail, he.believed the mother in her account of being pulled towards the bottom of the delivery bed in a manner and with such force as to be inconsistent with a properly conducted trial of forceps. The plaintiff's damages were agreed at £100 000, a figure that had to be approved by the judge. The boy is virtually a helpless cripple
PARLIAMENT Questions in the Commons Hospital staff. At 30 September 1977 172 800 whole-time equivalents were employed in the ancillary staff council grades in the NHS in England. They comprised 21 6°o of the total staff employed and their cost for the year 1977-8 was £548 million. Social Services, 19 February. More eligible for mobility allowance. From 7 March the upper age limit for claiming the £10 weekly mobility allowance will be increased to 60. This means that 8000 more men and women will be eligible. From November 1979 the allowance will be uprated with other social security benefits and inflation Social Services, 23 February. proofed.
BRITISH MEDICAL JOURNAL
with severe mental retardation, though he can see and hear. He is unable to speak or swallow solid food. Nor can he stand himself up, or crawl or walk. He is liable to recurrent chest infection, and the judge thought it unlikely that he would survive beyond the age of 30. His mother's care of her son was described by Mr Justice Bush as heroic.
Effect on obstetrics The judgment in this tragic case ought not to deter the skilled and experienced obstetrician from a trial of forceps. Mr Jordan's misfortune was his inability to persuade the judge that that was what he was doing. It would also be unfortunate if the case were to lead to an increase in the frequency of caesarean operations, for these are not without risks, both major and minor-as was shown in a recent case4 where Mr Justice Jupp awarded £1750 damages to a 3-year-old girl left with a two-inch facial scar after her cheek
(Jay Committee). Thus the caring staff, the report says, will need to be "home makers," working closely with other professionals, parents, and families; and residential care should be provided in small units and as an integral part of the local community. Urging a large increase in the staff caring for mentally handicapped children and adults in hospitals and local authority homes, the committee recommends that there should be twice the present number of staff-an estimated 60 000 in Great Britain. The report also recommends a new training scheme (which for hospital staff would replace the present mental handicap nurse training), responsibility for training being given to the Central Council for Education and Training in Social Work, and autonomous living units with more independent authority for the staff. Mr David Ennals, Secretary of State for Social Services, welcomed the Jay Report's emphasis on the fullest possible integration of mentally handicapped people into the life of the community as a whole, but he emphasised that if the proposals are accepted it will take many years to put them into effect.
MP sponsorship. Mr Roland Moyle denied that there was a direct conflict of interest in his being Minister of State, DHSS, and a The report (Cmnd 7468) is published by sponsored member of NUPE. "Ministers are not employers in the NHS," he said. "Health HMSO in two volumes, price £3 for volume I authorities are employers in the NHS.... My and £4 for volume II. connections with NUPE and my membership of the Government put me in a unique position to understand both sides of this Second postgraduate medicine chair, University of Keele dispute. I would not wish to change it." Social Services, 6 March. Dr Geoffrey Aber has been appointed to the second postgraduate medicine chair at the University of Keele. Dr Aber graduated in medicine from Leeds in 1952, and after house appointments served as medical specialist in Malaya and Singapore during his national service from 1954 to 1956. From 1956 to 1965 he held appointments in the departments of The mentally handicapped and the experimental pathology and medicine in the community University of Birmingham and spent 18 months at the University of McGill in All mentally handicapped people have the Montreal. In 1965 Dr Aber was appointed to right to be treated as individuals, to live life to his present post of consultant physician in the full, and to have access to the same services renal diseases in the North Staffordshire as normal people. This is the philosophy Hospital Centre. Dr Aber's main research underlying the Report of the Committee of interests are the causes and functional Enquiry into Mental Handicap Nursing Care disturbances associated with renal vascular
MEDICAL NEWS
17 MARCH 1979
was inadvertently cut with a scalpel during the course of a caesarean delivery. Most important of all, it should not be thought that liability in the Jordan case followed merely because something had gone amiss. The natural sympathy of the courts for an injured plaintiff in a malpractice action is invariably balanced by an equal reluctance to censure a professional man. In Lord Denning's words' in the septicaemia case: "A doctor is not liable for mischance or misadventure. Nor is he liable for an error of judgment. He is not liable for choosing one course out of two which may be open to him, or for following one school of thought rather than another. He is only liable if he falls below the standard of a reasonably competent practitioner in his field-so much so that his conduct may fairly be held to be-I will not say, deserving of censure, but at any rate, inexcusable." 2
Hucks v Cole (1968) Bar Library Transcript No 181. British Medical Journal, 1967, 3, 624. Daily Telegraph, 2 December 1978. The Times, 18 November 1978.
disorders, and amino-acid metabolism and liver enzyme activity in patients with renal diseases. 1979 Stengel prize The Stengel prize was established from contributions by colleagues of the late Professor E Stengel to mark his retirement from the chair of psychiatry at the University of Sheffield, to be awarded every three years to a doctor or group of doctors for a piece of research related to clinical psychiatry and carried out during tenure of a post in the Trent region. Details from the board of assessors for the Stengel prize, Department of Psychiatry, Whiteley Wood Clinic, Woofindin Road, Sheffield SlO 3TL, telephone 0743 303901. Closing date for applications 30 June.
Cleft Lip and Palate Association A Cleft Lip and Palate Association has been formed by professionals and parents of affected children. The first meeting will be held at 10 am on 5 May in the Kennedy Lecture Theatre of the Institute of Child Health, Guilford Street, London WC1. Anyone interested in attending should contact Mr M Mars at the Hospital for Sick Children, Great Ormond Street, London WC1N 3JH (01-405 9200).
Teaching medical subjects to social workers A liaison committee of the British Association of Social Workers and the Royal College of General Practitioners is considering the requirements for teaching medicine and related subjects during social work training. It would like to hear from doctors who teach in such courses-in particular, about what is taught, by whom, and for how long,'with an assessment of its value. Comments should be addressed to Miss D E Dedman, Department of Social Work, London Hospital, London El 1BB.
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Information, please Anyone interested in investigating epidemic myalgic encephalomyelitis (3 June, p 1436) should contact the epidemic myalgic encephalomyelitis study group through Dr W H Lyle, Courtaulds Ltd, 18 Hanover Square, London WlA 2BB (01-236:8466). The proceedings of a conference on the disease were reported in the November issue of the Postgraduate Medical _Journal. Professor F A Jenner -(Department of Psychiatry, Hallamshire Hospital, Sheffield S1O 2JF) would like to hear of any schizophrenic patients who appear to have responded to gluten-free diets, for a study exploring the possibility of sensitivity to gluten and other proteins. Recollections of Dr John R Heath, who was in practice in Barmouth until his death about 30 years ago and was also a musician, would be appreciated by Dr K Davies Jones (38 Forsythia Drive, Greenways, Cyncoed, Cardiff CF2 7HP) as background for a projected study of his music.
People in the news
ROYAL COLLEGE OF SURGEONS OF ENGLAND-6 pm,
The Rt Hon the Lord Smith of Marlow: Surgery of stones and carcinoma of the biliary tract. ROYAL NORTHERN HOSPITAL POSTGRADUATE CENTRE5 pm, Dr Hans E Einstein (Los Angeles): Fungal infections. Tuesday, 20 March ROYAL COLLEGE OF SURGEONS OF ENGLAND-6 J E Trapnell: Acute pancreatitis.
pm, Mr
Wednesday, 21 March OF DERMATOLOGY-4.30 pm, Dr J Pegum: The apocrine glands. INSTITUTE OF ORTHOPAEDICS-6 pm, Mr P S London and Mr M S Cornah: Tibial plateau fractures. ROYAL COLLEGE OF SURGEONS OF ENGLAND-3 pm,
INSTITUTE
Frederick Hewitt lecture by Professor J Parkhouse:
The journey and the arrival. 5 pm, Arris and Gale lecture by Mr J M A Northover: Damage to bile duct blood supply-a significant cause of postoperative morbidity ? 6.15 pm, Mr P R Hawley: Fistula and other common anal conditions. ROYAL FREE HOSPITAL SCHOOL OF MEDICINE-5 pm, Dr C C Booth: Coeliac disease. ROYAL POSTGRADUATE MEDICAL SCHOOL-2 pm, histopathology course, Dr R Barnard: WHO classification on
CNS
tumours.
WILLESDEN HOSPITAL MEDICAL SOCIETY-At Willesden General Hospital, 8.30 pm, Ray Phillips and Paul Darton: Contemporary medical illustration.
Friday, 23 March INSTITUTE OF LARYNGOLOGY AND OTOLOGY-5.30 pm, Mr A D Cheesman: The management of facial palsy. ROYAL COLLEGE OF SURGEONS OF EDINBURGH-At the University of Newcastle upon Tyne, 5.30 pm, Andrew Lowdon lecture by Professor D N Walder: Caisson disease of bone. ROYAL COLLEGE OF SURGEON; OF ENGLAND-6 pm, Professor K E F Hobbs: The surgery of portal hypertension.
Dr J D Cash has been appointed national medical director of the Scottish National BMA NOTICES Blood Transfusion Service. Dr E J L Lowbury, who retires from the MRC Industrial Injuries and Burns Unit at Central Meetings the Birmingham Accident Hospital at the end of March, has been appointed visiting pro- 22 Thurs MARCH Negotiating Subcommittee (CCHMS), fessor of medical microbiology in the departam. 22 Thurs Hospital Junior Staff Committee, 10 am. ment of pharmacy at Aston University. 28 Wed
29 Thurs
COMING EVENTS Royal College of Obstetricians and Gynaecologists -Scientific workshop on the cryobiology of human semen and its role in artificial insemination by donor, 22-23 March, Loughborough. Details from the secretary of the college, 27 Sussex Place, Regent's Park, London NWI 4RG. University of London-Heath Clark lectures, 22 and 27 March, London. For details see advertisement at p xii.
Institute of Urology-"Ruptured urethra" by Professor J P Mitchell, followed bv discussion of clinical cases, 30 March, London; visitors welcome. Details from the institute, 172 Shaftesbury Avenue, London WC2H 8JE. (Tel 01-836 5361.) Institute of Urology-Seminar on "Reconstructive urological surgery," 9-12 April, London. For details see advertisement at-p xii. Symposium on tardive dyskinesia-7-8 June, New York. Details from the programme assistant, Office of Graduate and Continuing Education, State University of New York, Upstate Medical Center, 750 East Adams Street, Syracuse, New York 13210, USA. National Association for Maternal and Child Welfare-66th annual study course and conference on maternal and child welfare, 27-29 June, London. Details from the association, 1 South Audley Street, London W1Y 6JS. (Tel 01-491 2772.) Medicated IUDs and Polymeric Delivery Systems International Symposium-27-30 June, Amsterdam. Details from the symposium office, PO Box 20, 5340 BH Oss, Holland. British Association of Urological SurgeonsAnnual meeting, 3-6 July, Bristol. Details from Sarah Frost-Wellings, Conference Services Ltd, 43 Charles Street, Mayfair, London WI. (Tel 01-499 1101.) 5th Annual Pediatric Echocardiography Course15-19 October, Tel Aviv, Details from Pediatric Echocardiography Course, 4340 Placita Panuco, Tucson, Arizona 85718, USA.
For attending lectuires marked * a fee is charged or a ticket is required. Applications should be made first to the institutions concerned. Monday, 19 March INSTITUTE OF OBSTETRICS AND GYNAECOLOGY-12.30 pm, Professor Sir John Dewhurst: Recurrent abortions.
General Purposes Subcommittee (CCHMS) 10 am. Consulting Pathologists Group Committee,
10 am. 29 Thurs Consulting Pathologists Group, 2 pm. 31 Sat and Sun 1 Junior Members Forum, University of April Reading.
Division Meetings
The following are the minimum requirements for manuscripts submitted for publication. A stamped addressed envelope or an international reply coupon must accompany the manuscript if acknowledgment of its receipt is desired.
(1) Typing should be on one side of the paper, with double or triple spacing between the lines and 5-cm margins at the top and left-hand side of the sheet. (2) Two copies (or preferably three) should be submitted. (3) Spelling should conform to that of Chambers Twentieth Century Dictionary. (4) References must be set out in the style used in the BM7, and their accuracy verified before the manuscript is submitted. (5) SI units are used for scientific measurements. In the text they should be followed by traditional units in parentheses. In tables and illustrations values are given only in SI units, but a conversion factor must be supplied. For general guidance on the International System of Units, and some useful conversion factors, see The SI for the Health Professions (WHO, 1977). (6) Authors should give their names and initials, their current appointments, and not more than two degrees or diplomas. Each author must sign the covering letter as evidence of consent to publication. (7) Letters to the Editor submitted for publication must be signed personally by all the authors. (8) Acknowledgments will not be sent unless a stamped addressed envelope or an international reply coupon is enclosed. (9) Detailed instructions are given in the BMJ' dated 6 January 1979 (p 6).
Memnbers proposing to attend meetings marked * are asked to notify in advance the honorary secretary concerned. Burnley-At Mackenzie Medical Centre, Wednes-
day, 21 March, 8.30 pm, Dr Francis Pigott: "The
-xpanding trade union activities of the BMA." At Spread Eagle Hotel, Sawley, Friday, 23 March, 8 for 8.30 pm, annual dinner, principal guest speaker Dr R A A R Lawrence.* Bury-At Midway Hotel, Rochdale, Saturday, 24 March, 7.30 for 8 pm, annual dinner dance.* (Guests are invited.) Croydon-At Mayday Hospital, Tuesday, 20 March, 8 pm, buffet supper followed by Mr David Southcott: "Gunshot wounds."* (Royal College of Nursing members invited.) Dewsbury-At Central Restaurant, Cleckheaton, Friday, 23 March, 8 for 8.30 pm, annual dinner, speaker David Ginsburgh, MP.* East Kent-At Postgraduate Medical Centre, Canterbury, TIhursday, 22 March, annual BMA lecture by Dr E Grey-Turner: The future of the BMA. East Surrey-At Redhill General Hospital, Tuesday, 20 March, 7.30 pm, chairman's meeting, Dr Paget Davies: "The first six months of the Redhill coronary care ambulance." Guildford-At Thatchers, East Horsley, Tuesday, 20 March, 7.30 pm, supper meeting, speaker Mr J 0 Robinson: "Nelson and his wounds."* North Northumberland-At Saddle Grill, Alnmouth, Friday, 23 March, 8 for 8.30 pm, annual dinner.* (Guests are invited.)
North Tyneside-At Europa Lodge Hotel, Wallsend, Saturday, 24 March, 7.30 for 8 pm, annual dinner Rochdale-At Midway Hotel, Friday, 23 March, dinner dance.* Sandwell-At Hallam Hospital, Tuesday, 20 March, 8 pm, agm. South Middlesex-At West Middlesex Hospital, Wednesday, 21 March, 7.15 pm, buffet supper followed by Dr N D Ellis: "Industrial relations for doctors." South Tees-At Marton Hotel and Country Club, Wednesday, 21 March, 7.30 for 8 pm, chairman's ladies night. * South Warwickshire-At Charlecote Pheasant, Nr Warwick, 7.30 for 8 pm, joint dinner/lecture meeting dance. *
SOCIETIES AND LECTURES
10
Instructions to authors
with South Warwickshire dentists, speaker Dr Denis Burkitt: "The lymphoma story."* Walsall-At Manor Hospital, Tuesday, 20 March, 7.30 for 8 pm, Dr R S Wilkes: "History of Staffs: Walsall and its canals."
UNIVERSITIES AND COLLEGES CAMBRIDGE MD-T R P Cullinan. LONDON MD-Elizabeth G Bradshaw, M G Cook, D M Geddes, C P Juniper. ABERDEEN
Appointment-Dr J M Rawler (senior lecturer in medicine).
Correction Views In the paragraph on liver metastases in colorectal cancer (24 February, p 560) the reference should be- British Journal of Cancer, 1978, 38, 749. (C British Medical Journal 1979 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 or otherwise, without the prior permission of the British Medical Journal.
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MARCH
NEWS AND NOTES
Viewzs
In Minerva's medical lifetime the three great causes of death have been coronary disease, stroke, and cancer. The decline in coronary disease in the United States has now been followed (New England Journal of Medicine, 1979, 300, 449) by a drop in the incidence of stroke-attributed provisionally to better control of hypertension and a change in smoking habits. What, however, will be the effect on cancer deaths ? For everyone has to die of something. To what will those spared by vascular disease eventually succumb ? The Eraldin Action Group has helped many patients damaged by side effects of practolol. What a pity that it overstates its case by asserting that thalidomide, practolol, hormone pregnancy testing, and whooping-cough vaccine can all be lumped together as "major drug tragedies."
Can stress cause gastric ulcers even in the fetus ? A baby boy less than a day old died of haemorrhage from extensive ulcers, his 16-year-old mother having had an exceptionally stressful pregnancy (Archives of Disease in Childhood, 1979, 54, 146). She lived with her husband (whom she married because she was pregnant) for only a fortnight before leaving him to escape his drunken assaults, but he continued to distress her with his visits. The authors suggest that the increased secretion of gastrin induced by all this stress may have crossed the placenta to cause the baby's ulcers. A report in the same issue (p 98) shows that babies of low birthweight thrive best on a mixture of curd and whey rather than on unmodified cows' milk, which contains mainly curd. At last Minerva understands the nursery rhyme about Miss Muffet: she was clearly spotted by an astute paediatrician and put on to an optimum diet. Attractive as the theory of immunosurveillance against cancer may have been, the evidence is mounting against it. The latest nail in its coffin comes from Oxford (British Journal of Cancer, 1979, 39, 193), where epidemiologists have shown no significant increase in the risk of cancer in patients with myasthenia gravis treated by thymectomy. "I am happy to tell you that your daughter is a mongol." These words from a paediatrician to Brian Rix and his wife 27years ago have understandably influenced their opinion of doctors' attitudesto the mentally handicapped. Nor, he told a group of medical journalists last week, had things improved 24 years later when friends had a similar experience. Miss Rix is in Normansfield Hospital and her father is chairman of the Friends of Normansfield. When the Friends complained to the AHA (on three occasions)
about staff conduct they were told, firstly, that it was none of their business, and, secondly, that if they left the matter long enough the staff would "hang themselves." In the end it was the AHA which hanged itself. While a few parents may still be expected to attribute fever, irritability, and other more specific symptoms to teething Minerva was surprised to read (Postgraduate Medical Journal, 1979, 55, 24) that in 11 of a series of 50 cases the diagnosis of teething had been made first by the general practitioner.
Crufts dog show was held at Earl's Court for the first time this year. The new venue proved successful; but, says the British Small Animals Veterinary Association, there were some unexpected problems: a few dogs were injured on escalators and some in the bulldog section developed heat exhaustion. Further evidence that the poor always come off worst when health care is quantified: a study (journal of the Royal College of General Practitioners, 1979, 29, 160) by a Scottish geographer has shown that access to GPs' surgeries is most difficult for patients living on deprived local authority estates-just the families with the highest morbidity. What will the GP planners do about that ? The medical campaign in Britain against dextropropoxyphene (better known as Doloxene and as a constituent of Distalgesic) is running in parallel with a similar movement in the United States, where Joseph Califano, the secretary of Health Education and Welfare, is reviewing its safety. Last year, says "Science" (1979, 203, 857), it was the third most prescribed drug in the United States, and since 1957 there have been 20 000 000 000 prescriptions for the Eli Lilly product.
Naturally enough, smokers have seized on the report by Auerbach et al in the New England Journal of Medicine (1979, 300, 381) as evidence that low-tar, low-nicotine cigarettes with filters cause fewer histological changes in the lungs than oldfashioned gaspers. But, as the NE7M points out in its editorial comment, their findings do not show that modem cigarettes are less dangerous-for no one knows how, for instance, smoking increases the risk of heart disease. Journalists who picked up the report gave less emphasis to the cautionary rider.
Anonymity is useful for cloaking an author's identity (as Minerva knows), but in "Strange Encounters"-the new BMJ "fillers" starting on p 734-Will Macredie uses his (or hers ?) to protect other people too. Now read on.... MINERVA
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MEDICOLEGAL Negligence and forceps delivery FROM OUR LEGAL CORRESPONDENT
From time to time a judgment against a doctor in a malpractice action gives rise to widespread concern in the profession whether the courts in compensating the plaintiff have not demanded too high a standard from the practitioner. One such case' 2 occurred in 1968, when a general practitioner had to pay £2500 damages to a patient who contracted fulminating septicaemia in the pueperium, even though two consultant obstetricians and two general practitioners testified that their management of the illness would have been just the same. Similar alarm has greeted the award' by Mr Justice Bush of £l00 000 damages to a 9-year-old boy who sustained severe brain damage in the course of his birth at the Queen Elizabeth Hospital, Birmingham, in January 1970. The obstetrician concerned, Mr Joseph Jordan, said that he had undertaken a trial of forceps before desisting and delivering the baby by caesarean section.
Trial of forceps Inevitably the decision has led to worry that trial of forceps may no longer be legally safe. If that worry was justified, then any ensuing tendency to "defensive medicine" would result in more frequent caesareans with their own different risks to mother and child. An analysis of Mr Justice Bush's 32page judgment shows that it would be wrong to draw too general a conclusion from a particular incident. In contrast to the case of fulminating septicaemia in 1968, Mr Justice Bush was not concerned with adjudicating between two competing schools of thought. His task was to reach a finding on what had occurred during the course of the birth; and, unfortunately for Mr Jordan, the judge was doubtful that there had been a trial of forceps at all, as opposed to an attempt at vaginal delivery which had failed and in the course of which the child had become stuck. He added that even if there had been only a trial of forceps, then Mr Jordan had pulled too hard and too long causing the fetus to become wedged, with ensuing anoxia leading to cerebral palsy. Mrs Whitehouse, the plaintiff's mother, by whom he sued as next friend, was 30 at the time of the birth and a primigravida. According to the judge, she was only 4 feet 10 inches (149 cm) tall, had suffered from irregular menstruation, and was so tense that she developed severe vaginismus in the course of examinations. Antenatal care was also bedevilled by doubt about the maturity of the fetus. On 31 December 1969 (one week before the birth) Mrs Whitehouse was seen by Professor H C McLaren. She declined a lateral x-ray examination (according to the professor's evidence) because she was afraid of damage to the fetal ovaries if the child should be a girl. The professor's notes read: "She declines lateral x-ray so await head fixing. Trial of labour is my guess." As a result of the refused x-ray examination the
size and shape of the pelvis were not established before labour started, but Mr Jordan did not suggest that the absence of x-ray pelvimetry had hampered him because he was able to assess the size of the pelvis by vaginal examination when the mother was under the epidural anaesthetic. Nor was any criticism made by the plaintiff of Professor McLaren's decision to allow labour to proceed under close supervision while a watch was kept for disproportion between the head of the fetus and the pelvis.
Course of labour
from memory. Mr Jordan also gave evidence that the head was not stuck, and, though he believed that it would still have been possible to deliver per vaginam, he decided that it would be too traumatic for mother and child.
Balance of probabilities Mr Justice Bush said that he was satisfied on the balance of probabilities that the plaintiff had suffered intrapartum asphyxia, and he rejected the suggestion made by the defendants that the anoxia giving rise to the cerebral palsy might have been due to other factors, such as brain maldevelopment. The judge then turned to see whether he could accept the defendants' explanation as to the trial of forceps. In reaching a conclusion adverse to Mr Jordan, he mentioned a number of matters, but he considered that "the strongest piece of evidence that something untoward was done" was a report made by Professor McLaren after he had discussed the matter with Mr Jordan. The report stated that "descent did not follow traction and in the interest of the child, the head was disimpacted prior to speedy delivery by caesarean section." The report used the word "disimpact" some three times and was obviously damaging to Mr Jordan's evidence that the head was not stuck. Professor McLaren concluded: "After a reasonable attempt at delivery by forceps, a caesarean section was carried out. The baby, alas, was seriously affected by this well-conducted trial of labour and forceps. Possibly at caesarean section the disimpaction of the head was critical and cerebral haemorrhage followed." Professor McLaren sought to persuade the judge that "disimpaction" did not mean that there had been such wedging that a lot of force was needed to push the head up before the caesarean section started. Nevertheless Mr Justice Bush could not accept this explanation, and, while alive to the point that the report was not the work of Mr Jordan, he clearly thought that Mr Jordan had given the impression to Professor McLaren in their discussion that the baby's head had been stuck. The second major matter that influenced the judge against Mr Jordan was his finding that what finally prevented the baby's head from descending was disproportion between the head and the ischial spines. Mr Justice Bush shared the doubt expressed by Sir John Peel (who was called by the plaintiff) as to why it was necessary to have five or six pulls to test whether delivery per vaginam was possible. The judge commented that if the head were engaged, there would not be far to go before the widest part of the head was at the ischial spines. Mr Justice Bush's belief that the child's head was indeed wedged at the level of the
At 0045 on 6 January 1970 the membranes ruptured, and at 0200 Mrs Whitehouse was admitted to hospital. During the hours before the birth she was seen by the senior house officer, a registrar, a consultant, and another registrar. At 2330 she was examined by Mr Jordan, who had been working on his thesis and was called in by the registrar. By then the cervix was fully dilated and the head was engaged. In his notes made up after the operation, Mr Jordan recorded: "Normal delivery out of the question." Mr Jordan then decided on a trial of forceps, and the judge's finding as to what occurred thereafter was critical. Mr Justice Bush quoted from Sir John Dewhurst, who had written that trial of forceps might be permissible for an experienced obstetrician where there was uncertainty whether there was miid disproportion or not. In words that clearly made their mark on the judge, Sir John wrote: "If advance is maintained, well and good. If not, caesarean section can be carried out immediately. It will be clear that the dividing line here is very narrow. If too great force is exerted, the fetus may be damaged and vaginal delivery may result in a stillborn child or one with cerebral injury." Sir John's "dividing line" was at the centre of the action, for, though Mr Jordan was not criticised for adopting trial of forceps, theplaintiff's case was that it was not a trial, but an attempt at delivery which failed and which, having regard to the fetus's position at midhigh was unjustifiably risky. In the alternative the plaintiff argued that if there was a trial of forceps, then Mr Jordan had pulled too hard and too long, resulting in the child's head becoming wedged. After using Keilland's forceps to turn the child's head into the occipito-anterior position, Mr Jordan applied Simpson's forceps. His notes read: "A very tight fit. No episiotomy. After pulling with 5 or 6 contractions, it was obvious that vaginal delivery would be too traumatic." In evidence Mr Jordan told the judge: "If we accept, say, six contractions, then I would assume that difficulty would be encountered with the fifth pull, that is no descent with that pull, and one would confirm with a further pull with the next contraction." It is clear from this passage of Mr Jordan's ischial spines was influenced by an unfortunate evidence that he was hypothesising as to answer given by Mr Jordan in re-examination what had happened rather than speaking by his own counsel. He was asked whether he
764 had tried to pull past any bony part, and he replied: "My trial by forceps was to overcome what may be minimal obstruction so one did, as it were, pass the level of the ischial spines."
Far-fetched complaints The judge was therefore able to reach a conclusion without relying on the evidence of the mother, who, he said, had made absurd and far-fetched complaints in her attempt to get an inquiry. Mrs Whitehouse gave evidence that when the forceps were applied, she experienced "a deadened electric shock that lifted my hips off the table." The judge said that, while the description might not be exact in clinical detail, he.believed the mother in her account of being pulled towards the bottom of the delivery bed in a manner and with such force as to be inconsistent with a properly conducted trial of forceps. The plaintiff's damages were agreed at £100 000, a figure that had to be approved by the judge. The boy is virtually a helpless cripple
PARLIAMENT Questions in the Commons Hospital staff. At 30 September 1977 172 800 whole-time equivalents were employed in the ancillary staff council grades in the NHS in England. They comprised 21 6°o of the total staff employed and their cost for the year 1977-8 was £548 million. Social Services, 19 February. More eligible for mobility allowance. From 7 March the upper age limit for claiming the £10 weekly mobility allowance will be increased to 60. This means that 8000 more men and women will be eligible. From November 1979 the allowance will be uprated with other social security benefits and inflation Social Services, 23 February. proofed.
BRITISH MEDICAL JOURNAL
with severe mental retardation, though he can see and hear. He is unable to speak or swallow solid food. Nor can he stand himself up, or crawl or walk. He is liable to recurrent chest infection, and the judge thought it unlikely that he would survive beyond the age of 30. His mother's care of her son was described by Mr Justice Bush as heroic.
Effect on obstetrics The judgment in this tragic case ought not to deter the skilled and experienced obstetrician from a trial of forceps. Mr Jordan's misfortune was his inability to persuade the judge that that was what he was doing. It would also be unfortunate if the case were to lead to an increase in the frequency of caesarean operations, for these are not without risks, both major and minor-as was shown in a recent case4 where Mr Justice Jupp awarded £1750 damages to a 3-year-old girl left with a two-inch facial scar after her cheek
(Jay Committee). Thus the caring staff, the report says, will need to be "home makers," working closely with other professionals, parents, and families; and residential care should be provided in small units and as an integral part of the local community. Urging a large increase in the staff caring for mentally handicapped children and adults in hospitals and local authority homes, the committee recommends that there should be twice the present number of staff-an estimated 60 000 in Great Britain. The report also recommends a new training scheme (which for hospital staff would replace the present mental handicap nurse training), responsibility for training being given to the Central Council for Education and Training in Social Work, and autonomous living units with more independent authority for the staff. Mr David Ennals, Secretary of State for Social Services, welcomed the Jay Report's emphasis on the fullest possible integration of mentally handicapped people into the life of the community as a whole, but he emphasised that if the proposals are accepted it will take many years to put them into effect.
MP sponsorship. Mr Roland Moyle denied that there was a direct conflict of interest in his being Minister of State, DHSS, and a The report (Cmnd 7468) is published by sponsored member of NUPE. "Ministers are not employers in the NHS," he said. "Health HMSO in two volumes, price £3 for volume I authorities are employers in the NHS.... My and £4 for volume II. connections with NUPE and my membership of the Government put me in a unique position to understand both sides of this Second postgraduate medicine chair, University of Keele dispute. I would not wish to change it." Social Services, 6 March. Dr Geoffrey Aber has been appointed to the second postgraduate medicine chair at the University of Keele. Dr Aber graduated in medicine from Leeds in 1952, and after house appointments served as medical specialist in Malaya and Singapore during his national service from 1954 to 1956. From 1956 to 1965 he held appointments in the departments of The mentally handicapped and the experimental pathology and medicine in the community University of Birmingham and spent 18 months at the University of McGill in All mentally handicapped people have the Montreal. In 1965 Dr Aber was appointed to right to be treated as individuals, to live life to his present post of consultant physician in the full, and to have access to the same services renal diseases in the North Staffordshire as normal people. This is the philosophy Hospital Centre. Dr Aber's main research underlying the Report of the Committee of interests are the causes and functional Enquiry into Mental Handicap Nursing Care disturbances associated with renal vascular
MEDICAL NEWS
17 MARCH 1979
was inadvertently cut with a scalpel during the course of a caesarean delivery. Most important of all, it should not be thought that liability in the Jordan case followed merely because something had gone amiss. The natural sympathy of the courts for an injured plaintiff in a malpractice action is invariably balanced by an equal reluctance to censure a professional man. In Lord Denning's words' in the septicaemia case: "A doctor is not liable for mischance or misadventure. Nor is he liable for an error of judgment. He is not liable for choosing one course out of two which may be open to him, or for following one school of thought rather than another. He is only liable if he falls below the standard of a reasonably competent practitioner in his field-so much so that his conduct may fairly be held to be-I will not say, deserving of censure, but at any rate, inexcusable." 2
Hucks v Cole (1968) Bar Library Transcript No 181. British Medical Journal, 1967, 3, 624. Daily Telegraph, 2 December 1978. The Times, 18 November 1978.
disorders, and amino-acid metabolism and liver enzyme activity in patients with renal diseases. 1979 Stengel prize The Stengel prize was established from contributions by colleagues of the late Professor E Stengel to mark his retirement from the chair of psychiatry at the University of Sheffield, to be awarded every three years to a doctor or group of doctors for a piece of research related to clinical psychiatry and carried out during tenure of a post in the Trent region. Details from the board of assessors for the Stengel prize, Department of Psychiatry, Whiteley Wood Clinic, Woofindin Road, Sheffield SlO 3TL, telephone 0743 303901. Closing date for applications 30 June.
Cleft Lip and Palate Association A Cleft Lip and Palate Association has been formed by professionals and parents of affected children. The first meeting will be held at 10 am on 5 May in the Kennedy Lecture Theatre of the Institute of Child Health, Guilford Street, London WC1. Anyone interested in attending should contact Mr M Mars at the Hospital for Sick Children, Great Ormond Street, London WC1N 3JH (01-405 9200).
Teaching medical subjects to social workers A liaison committee of the British Association of Social Workers and the Royal College of General Practitioners is considering the requirements for teaching medicine and related subjects during social work training. It would like to hear from doctors who teach in such courses-in particular, about what is taught, by whom, and for how long,'with an assessment of its value. Comments should be addressed to Miss D E Dedman, Department of Social Work, London Hospital, London El 1BB.
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Information, please Anyone interested in investigating epidemic myalgic encephalomyelitis (3 June, p 1436) should contact the epidemic myalgic encephalomyelitis study group through Dr W H Lyle, Courtaulds Ltd, 18 Hanover Square, London WlA 2BB (01-236:8466). The proceedings of a conference on the disease were reported in the November issue of the Postgraduate Medical _Journal. Professor F A Jenner -(Department of Psychiatry, Hallamshire Hospital, Sheffield S1O 2JF) would like to hear of any schizophrenic patients who appear to have responded to gluten-free diets, for a study exploring the possibility of sensitivity to gluten and other proteins. Recollections of Dr John R Heath, who was in practice in Barmouth until his death about 30 years ago and was also a musician, would be appreciated by Dr K Davies Jones (38 Forsythia Drive, Greenways, Cyncoed, Cardiff CF2 7HP) as background for a projected study of his music.
People in the news
ROYAL COLLEGE OF SURGEONS OF ENGLAND-6 pm,
The Rt Hon the Lord Smith of Marlow: Surgery of stones and carcinoma of the biliary tract. ROYAL NORTHERN HOSPITAL POSTGRADUATE CENTRE5 pm, Dr Hans E Einstein (Los Angeles): Fungal infections. Tuesday, 20 March ROYAL COLLEGE OF SURGEONS OF ENGLAND-6 J E Trapnell: Acute pancreatitis.
pm, Mr
Wednesday, 21 March OF DERMATOLOGY-4.30 pm, Dr J Pegum: The apocrine glands. INSTITUTE OF ORTHOPAEDICS-6 pm, Mr P S London and Mr M S Cornah: Tibial plateau fractures. ROYAL COLLEGE OF SURGEONS OF ENGLAND-3 pm,
INSTITUTE
Frederick Hewitt lecture by Professor J Parkhouse:
The journey and the arrival. 5 pm, Arris and Gale lecture by Mr J M A Northover: Damage to bile duct blood supply-a significant cause of postoperative morbidity ? 6.15 pm, Mr P R Hawley: Fistula and other common anal conditions. ROYAL FREE HOSPITAL SCHOOL OF MEDICINE-5 pm, Dr C C Booth: Coeliac disease. ROYAL POSTGRADUATE MEDICAL SCHOOL-2 pm, histopathology course, Dr R Barnard: WHO classification on
CNS
tumours.
WILLESDEN HOSPITAL MEDICAL SOCIETY-At Willesden General Hospital, 8.30 pm, Ray Phillips and Paul Darton: Contemporary medical illustration.
Friday, 23 March INSTITUTE OF LARYNGOLOGY AND OTOLOGY-5.30 pm, Mr A D Cheesman: The management of facial palsy. ROYAL COLLEGE OF SURGEONS OF EDINBURGH-At the University of Newcastle upon Tyne, 5.30 pm, Andrew Lowdon lecture by Professor D N Walder: Caisson disease of bone. ROYAL COLLEGE OF SURGEON; OF ENGLAND-6 pm, Professor K E F Hobbs: The surgery of portal hypertension.
Dr J D Cash has been appointed national medical director of the Scottish National BMA NOTICES Blood Transfusion Service. Dr E J L Lowbury, who retires from the MRC Industrial Injuries and Burns Unit at Central Meetings the Birmingham Accident Hospital at the end of March, has been appointed visiting pro- 22 Thurs MARCH Negotiating Subcommittee (CCHMS), fessor of medical microbiology in the departam. 22 Thurs Hospital Junior Staff Committee, 10 am. ment of pharmacy at Aston University. 28 Wed
29 Thurs
COMING EVENTS Royal College of Obstetricians and Gynaecologists -Scientific workshop on the cryobiology of human semen and its role in artificial insemination by donor, 22-23 March, Loughborough. Details from the secretary of the college, 27 Sussex Place, Regent's Park, London NWI 4RG. University of London-Heath Clark lectures, 22 and 27 March, London. For details see advertisement at p xii.
Institute of Urology-"Ruptured urethra" by Professor J P Mitchell, followed bv discussion of clinical cases, 30 March, London; visitors welcome. Details from the institute, 172 Shaftesbury Avenue, London WC2H 8JE. (Tel 01-836 5361.) Institute of Urology-Seminar on "Reconstructive urological surgery," 9-12 April, London. For details see advertisement at-p xii. Symposium on tardive dyskinesia-7-8 June, New York. Details from the programme assistant, Office of Graduate and Continuing Education, State University of New York, Upstate Medical Center, 750 East Adams Street, Syracuse, New York 13210, USA. National Association for Maternal and Child Welfare-66th annual study course and conference on maternal and child welfare, 27-29 June, London. Details from the association, 1 South Audley Street, London W1Y 6JS. (Tel 01-491 2772.) Medicated IUDs and Polymeric Delivery Systems International Symposium-27-30 June, Amsterdam. Details from the symposium office, PO Box 20, 5340 BH Oss, Holland. British Association of Urological SurgeonsAnnual meeting, 3-6 July, Bristol. Details from Sarah Frost-Wellings, Conference Services Ltd, 43 Charles Street, Mayfair, London WI. (Tel 01-499 1101.) 5th Annual Pediatric Echocardiography Course15-19 October, Tel Aviv, Details from Pediatric Echocardiography Course, 4340 Placita Panuco, Tucson, Arizona 85718, USA.
For attending lectuires marked * a fee is charged or a ticket is required. Applications should be made first to the institutions concerned. Monday, 19 March INSTITUTE OF OBSTETRICS AND GYNAECOLOGY-12.30 pm, Professor Sir John Dewhurst: Recurrent abortions.
General Purposes Subcommittee (CCHMS) 10 am. Consulting Pathologists Group Committee,
10 am. 29 Thurs Consulting Pathologists Group, 2 pm. 31 Sat and Sun 1 Junior Members Forum, University of April Reading.
Division Meetings
The following are the minimum requirements for manuscripts submitted for publication. A stamped addressed envelope or an international reply coupon must accompany the manuscript if acknowledgment of its receipt is desired.
(1) Typing should be on one side of the paper, with double or triple spacing between the lines and 5-cm margins at the top and left-hand side of the sheet. (2) Two copies (or preferably three) should be submitted. (3) Spelling should conform to that of Chambers Twentieth Century Dictionary. (4) References must be set out in the style used in the BM7, and their accuracy verified before the manuscript is submitted. (5) SI units are used for scientific measurements. In the text they should be followed by traditional units in parentheses. In tables and illustrations values are given only in SI units, but a conversion factor must be supplied. For general guidance on the International System of Units, and some useful conversion factors, see The SI for the Health Professions (WHO, 1977). (6) Authors should give their names and initials, their current appointments, and not more than two degrees or diplomas. Each author must sign the covering letter as evidence of consent to publication. (7) Letters to the Editor submitted for publication must be signed personally by all the authors. (8) Acknowledgments will not be sent unless a stamped addressed envelope or an international reply coupon is enclosed. (9) Detailed instructions are given in the BMJ' dated 6 January 1979 (p 6).
Memnbers proposing to attend meetings marked * are asked to notify in advance the honorary secretary concerned. Burnley-At Mackenzie Medical Centre, Wednes-
day, 21 March, 8.30 pm, Dr Francis Pigott: "The
-xpanding trade union activities of the BMA." At Spread Eagle Hotel, Sawley, Friday, 23 March, 8 for 8.30 pm, annual dinner, principal guest speaker Dr R A A R Lawrence.* Bury-At Midway Hotel, Rochdale, Saturday, 24 March, 7.30 for 8 pm, annual dinner dance.* (Guests are invited.) Croydon-At Mayday Hospital, Tuesday, 20 March, 8 pm, buffet supper followed by Mr David Southcott: "Gunshot wounds."* (Royal College of Nursing members invited.) Dewsbury-At Central Restaurant, Cleckheaton, Friday, 23 March, 8 for 8.30 pm, annual dinner, speaker David Ginsburgh, MP.* East Kent-At Postgraduate Medical Centre, Canterbury, TIhursday, 22 March, annual BMA lecture by Dr E Grey-Turner: The future of the BMA. East Surrey-At Redhill General Hospital, Tuesday, 20 March, 7.30 pm, chairman's meeting, Dr Paget Davies: "The first six months of the Redhill coronary care ambulance." Guildford-At Thatchers, East Horsley, Tuesday, 20 March, 7.30 pm, supper meeting, speaker Mr J 0 Robinson: "Nelson and his wounds."* North Northumberland-At Saddle Grill, Alnmouth, Friday, 23 March, 8 for 8.30 pm, annual dinner.* (Guests are invited.)
North Tyneside-At Europa Lodge Hotel, Wallsend, Saturday, 24 March, 7.30 for 8 pm, annual dinner Rochdale-At Midway Hotel, Friday, 23 March, dinner dance.* Sandwell-At Hallam Hospital, Tuesday, 20 March, 8 pm, agm. South Middlesex-At West Middlesex Hospital, Wednesday, 21 March, 7.15 pm, buffet supper followed by Dr N D Ellis: "Industrial relations for doctors." South Tees-At Marton Hotel and Country Club, Wednesday, 21 March, 7.30 for 8 pm, chairman's ladies night. * South Warwickshire-At Charlecote Pheasant, Nr Warwick, 7.30 for 8 pm, joint dinner/lecture meeting dance. *
SOCIETIES AND LECTURES
10
Instructions to authors
with South Warwickshire dentists, speaker Dr Denis Burkitt: "The lymphoma story."* Walsall-At Manor Hospital, Tuesday, 20 March, 7.30 for 8 pm, Dr R S Wilkes: "History of Staffs: Walsall and its canals."
UNIVERSITIES AND COLLEGES CAMBRIDGE MD-T R P Cullinan. LONDON MD-Elizabeth G Bradshaw, M G Cook, D M Geddes, C P Juniper. ABERDEEN
Appointment-Dr J M Rawler (senior lecturer in medicine).
Correction Views In the paragraph on liver metastases in colorectal cancer (24 February, p 560) the reference should be- British Journal of Cancer, 1978, 38, 749. (C British Medical Journal 1979 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 or otherwise, without the prior permission of the British Medical Journal.
