1536

variable combination of upper gastrointestinal symptoms, including abdominal pain or discomfort. The term organic dyspepsia was recommended for symptoms clearly attributable to identified lesions, and functional dyspepsia (rather than non-ulcer dyspepsia) for symptoms without identifiable abnormalities. The symptom clusters designated reflux-like dyspepsia, ulcer-like dyspepsia, and dysmotility-like dyspepsia by Colin-Jones et all were accepted as legitimate descriptions of symptom patterns in organic, functional, or uninvestigated dyspepsia but they do not correspond closely with particular diagnoses or disorders of gastrointestinal function. Dyspepsia is very common. In the UK, about 10% of patients consulting general practitioners complain of dyspeptic symptoms, and many more individuals with symptoms do not seek medical advice. The average population prevalence from studies in several countries is 32%, of which known ulcer disease represents about a quarter. What do we know of the basis of symptoms in the remainder? Although a clinical diagnosis of "gastritis" is commonly used in some countries as a synonym for unexplained dyspepsia, there is compelling evidence that non-erosive gastritis and duodenitis should not be regarded as a cause of dyspeptic symptoms. The association of active gastritis and duodenitis with Helicobacter pylori infection is beyond doubt but no particular pattern of symptoms has been identified in dyspeptic patients with Helicobacter infection, and infection is too frequent in symptom-free controls for it to be readily accepted as having direct responsibility for symptoms. Although the clinicians may be understandably tempted to attribute dyspepsia to endoscopically and histologically proven gastritis, the logical deduction from existing evidence is that this temptation should be resisted. Abnormalities of gastrointestinal motility have long been suspected as a likely cause of otherwise inexplicable dyspepsia, and it is now clear that abnormal gastroduodenal motility and/or delayed gastric emptying are demonstrable in up to 50% of such patients. Moreover, the frequent occurrence of dyspeptic symptoms (without identifiable upper gastrointestinal disease) in patients with the irritable bowel syndrome accords with the notion that disordered motility may cause upper as well as lower gastrointestinal symptoms. Alas, the cause and effect relations are far from straightforward. None of the motility abnormalities has been found in all patients with unexplained dyspeptic symptoms, and there is often no temporal relation between symptoms and demonstrable abnormalities. There is no consistent pattern of dyspeptic symptoms in the patients with disordered motility, and no specific association of abnormal motility with dysmotility-like dyspepsia has been established. Many physicians believe that psychological factors may be the cause of unexplained dyspepsia, and at the meeting several members of the audience objected to the term functional dyspepsia for unexplained dyspepsia on the grounds that the word "functional" is used to denote a psychogenic contribution to the patient’s complaints. However, although patients with functional dyspepsia exhibit more neuroticism, anxiety, depression, and hypochondriasis than healthy controls, several studies have found no difference from patients with organic gastrointestinal disease. Thus doctors whose clinical experience has convinced them that personality has much to do with functional dyspepsia must consider that the perceived association may arise because (a) the

gastrointestinal symptoms

cause

anxiety and neuroticism

(b) that individuals who are anxious, hypochondriacal, or neurotic are more likely to seek medical attention for dyspeptic symptoms than are individuals of more stoical disposition. Could functional dyspepsia be a disorder of visceral sensation? Support for this contention comes from evidence of lowered sensory thresholds to gastric distension without detectable abnormality of somatic sensation in patients with functional dyspepsia. Other recent evidence supports older rather than the

reverse

and

reports of disturbed visceral sensation in functional gastrointestinal disorders. Overall, little real progress has been made in understanding the mechanisms that cause dyspepsia in individuals who do not have an obvious "organic" cause, categorisation of dyspepsia into reflux-like, ulcer-like, and dysmotility-like dyspepsia assists neither diagnosis in individual patients nor identification of relevant pathophysiology. The practical recommendations for the management of dyspepsia offered by this working group were much the same as those proposed by others.2,3 A trial of therapy, usually H2 blockade, without prior endoscopy or radiography is now well accepted by physicians in many countries for most patients under the age of 45. In functional dyspepsia, clinical trial data have shown that both H2 blockade and treatment with cisapride are better than placebo in achieving symptom relief. For patients with symptoms who have no gastric or duodenal lesions apparent on endoscopy, cisapride is perhaps the more rational first choice. Whichever drug is used first, the other is worth trying if symptoms persist. Royal Infirmary, Edinburgh EH3 9YW

R. C.

Heading

Colin-Jones DG, Bloom B, Bodemar G, et al. Management of dyspepsia: report of a working party. Lancet 1988; u: 576-79. 2. Barbara L, Camilleri M, Corinaldesi R, et al. Definition and investigation of dyspepsia: consensus of an international ad hoc working party. Dig Dis Sci 1989; 34: 1272-76. 3. Colin-Jones DG. Practical guidelines for the management of dyspepsia. Lancet 1990; 1.

336: 301-02. 4.

Talley NJ, Colin-Jones DG, Koch KL, Koch M, Nyren O, Stanghellini V Functional gastroduodenal disorders: guidelines for diagnosis and management. Gastroenterol Int (in press).

Medicine and the Law When should a jury decide negligence is admitted?

damages when

A 27-year-old soldier consulted the Army Medical Service with Peyronie’s disease. He agreed to a test which involved injecting the penis with a saline solution to ascertain the extent of the abnormality. He was then advised that the penile curvature was not severe enough for any treatment at that time. Shortly afterwards, a blister developed at the site of the injection and infection was diagnosed. A skin graft was advised. However, at operation it became clear that a skin graft would be impossible and that there was no alternative to amputating the major part of the penis. The Army Medical Service admitted liability and the question arose as to how damages should be assessed. The plaintiff applied for a trial by jury, and Mr Justice Hutchinson agreed. The defendant appealed. Allowing the appeal and giving the leading judgment of the Court of Appeal, Lord Donaldson MR said it needed little imagination to appreciate the psychological trauma suffered by the plaintiff. He had attempted suicide; he

1537

could not continue in his chosen occupation as a soldier; he had suffered personality changes; he now had a phobia over contact with women; and he lived in social seclusion. Nonetheless trial by jury was not appropriate. Until 1854 all civil cases were tried by juries. However, by 1965 a jury was involved in only 2% of civil cases. Lord Denning MR, in the leading case of Ward v James ([1966] 1 QB 273), explained that damages in personal injury cases could never be truly compensatory and that conventional scales of awards had evolved. It was difficult in practice to inform juries of these scales or to give them sufficient guidance. Lord Denning concluded in a personal injury case a judge ought not to order a trial by jury "save in exceptional circumstances. Even when the issue of liability is one fit to be tried by a jury, nevertheless, he might think it fit to order that the damages be assessed by a judge alone". Since Ward v James, there has been only one reported instance of an order for trial of a personal injury case with a jury (Hodges v Harland & Wolf Limited [1965] 1 WLR 523, where the plaintiff had also had injury to his reproductive organs). When he had granted the request for a trial by jury, Mr Justice Hutchinson had not referred to the fact that both Wardv James and Hodges were decided at a time when there had been no legislative bias against trial by jury. However, the 1981 Supreme Court Act indicated that jury trial was to be considered less preferable than hitherto. The plaintiff argued that the exceptional feature of this claim made it something that a jury could better evaluate than a judge. Lord Donaldson said that the plaintiff’s injuries were indeed unusual and most distressing, but the same could be said of some other cases involving mutilation or gross scarring. Furthermore, the Court was far from convinced that damages for pain and suffering would have been less if, for example, he had been left quadriplegic. Although the scale of conventional awards provides no direct guidance on damages any award to him "should be made against the background of and be compatible with that scale. This is not something which a jury is as likely to achieve as a judge".

The Court of Appeal concluded, reluctantly, that the judge had been wrong. Policy on trial by jury in personal injury cases should be that stated in Ward v James-namely, that a jury is normally inappropriate where the issue is the assessment of compensatory damages. There could still be such an exceptional case where jury trial was appropriate. If, for example, personal injuries resulted from conduct on the part of those who were deliberately abusing their authority, there might well be a claim for exemplary damages, an exceptional category not expressly contemplated in the 1981 Act but not dissimilar from claims on malicious prosecution or false imprisonment. In the USA civil cases are usually tried by jury, but there are complaints that awards are too high and not always consistent.

Diana Brahams

Noticeboard Mattresses and sudden infant death The expert working group set up by the chief medical officer (CMO) in March, 1990, to inquire into the suggestion that toxic gases derived from chemicals in cot mattresses are a cause of sudden

infant death syndrome (SIDS) has concluded that "there is no clear link between the content of a cot mattress or cover or its microbial contaminants and SIDS."’ The original hypothesis came from Mr B. A. Richardson,z a director of Penarth Research International Ltd, Guernsey, who describes himself as a consulting scientist, expert witness, and arbitrator. He claimed that the toxic gases arsine, phosphine, and stibine are produced after breakdown of polyvinyl chloride (PVC) mattress coverings by fungi or bacteria. In-vitro studies in his laboratory with the domestic fungus Scopulariopsis brevicaulis showed stibine and phosphine release

from

mattress

fire retardants such

as

antimony trioxide

and

phosphate plasticisers. However, existing data on the pathological effects of these gases (April 20, p 969) do not support his view that they have a causal role in SIDS-the pattern of tissue damage attributable to such agents is not compatible with that found in cases of cot death. The working group, chaired by Prof Paul Turner, professor of clinical pharmacology, St Bartholomew’s Medical College, London, and chairman of the Committee on Toxicity of Chemicals in Food, Consumer Products, and the Environment, sought independent verification of Richardson’s work from the Laboratory of the Government Chemist and the International Mycological Institute. Infrared spectroscopic techniques failed to identify arsine, phosphine, or stibine after incubation of PVC sheeting with S brevicaulis. 50 cot mattresses were then studied: 19 associated with cases of SIDS, 10 that were new, 20 used mattresses not associated with SIDS, and 1 from a non-SIDS death. With the non-specific methods adopted in Richardson’s laboratory, no consistent pattern of gas production by microorganisms could be shown (positive results in 2 SIDS and 2 new mattresses and in 1 used control). No evidence of toxic gas release was found with gas chromatography and ion-trap detection methods when normal growth media were used. Separate investigation of the extent of microbiological infestation of cot furnishing gave unexpected results. Although S brevicaulis was not found to be the dominant organism on SIDS mattresses, contamination with a wide range of other microorganisms was found, and certain pathogenic fungi were isolated from mattresses and covers associated with SIDS cases. Aspergillus fumigatus (Classified as Advisory Committee on Dangerous Pathogens risk group 2) was found on 6 SIDS case mattresses, but only 1 from a used control, and none at all from new controls. Although these data are preliminary, the working group judged these results to be worthy of further study, and the CMO has asked a group of experts to give advice on further investigations into the importance of such contamination. Furthermore, the group recommended that, in view of the "potential hazard" of these microorganisms, there may be a need for a British Standard for resistance of cot mattresses and their covers to growth of selected organisms. 1. Sudden infant death syndrome (SIDS). Report of the expert working group enquiring

the hypothesis that toxic gases evolved from chemicals in cot mattress covers cot mattresses are a cause of SIDS. London: HM Stationery Office. 1991. Pp 71. ,C6.70. ISBN 0113213905. 2. Richardson BA. Cot mattress biodeterioration and SIDS. Lancet 1990; 335: 670. mto

and

Targets for health A year ago the Faculty of Public Health Medicine set up a working party to identify specific areas where further research and data collection would be particularly helpful in improving understanding of current levels of health in the UK. The working party’s first report,! aimed primarily at directors of public health, who need to set health targets to which to relate their annual reports, suggests goals for improving health in sixteen priority areas, covering lifestyle, the environment, and services provided. The report sets more precise targets than the Government’s discussion document, The Health of the Nation, published last month and, according to Prof Walter Holland, president of the faculty and chairman of the working party, is more optimistic in its assessment of how the health of people in Britain can be improved. Smoking, the single most preventable cause of death in the UK, heads the list of targets to be met by the year 2000, and here the working report sets as a main objective a 30% reduction (from 1988 figures) in ischaemic heart disease deaths. To achieve a 40% reduction in the proportion of smokers aged over 16, the report suggests such measures as a ban on smoking in all enclosed public places (in line with the European Commission resolution), more prominent health warnings on tobacco products, prohibition of cigarette advertising (except at the point of sale), differential insurance rates for smokers and non-smokers, and the recording of patient’s smoking status by general practitioners. The report