- Email: [email protected]
PHENOBARBITONE AND THE NEONATE
385
bacteria with,
as
yet, undefined metabolic
Possibly similar carbohydrate malabsorption
capacities.
occurs
in
some
adults with the contaminated small-bowel syndrome but has not been widely recognised since sugar intolerance in older natients uroduces milder svmotoms. Institute of Child Health,
Birmingham
16.
MICHAEL GRACEY VALERIE BURKE CHARLOTTE M. ANDERSON.
TEACHING OF PSYCHIATRY
SIR,-In 1962 you published a short article by my colleagues and me on home visits by medical studients.1 One year later you published our further statement2 on this scheme, in which we described how the tutor in psychiatry had taken on the role of escort on these visits, and how general practitioners and social workers involved in the cases were being invited to teaching conferences. Referring now to your March leader 3 on teaching of psychiatry, we find that the special case study, plus the home visit under skilled escort, plus the conference and elucidation by the tutor in psychiatry, bring into focus the points you mention -i.e., the need for psychosocial assessment and the presentation of alternative treatments. There is also no doubt that the five objectives you list-increase of " psychological perceptiveness ", " a scientific attitude towards behaviour ", "how to relate to patients ", " factual knowledge ", and " treatment skills "-get a great deal of attention in an incidental (though none the less effective) way for many students. In this special area of the teaching of psychiatry to medical students, the staff-student ratio is never less than 3 to 2, the two students being engaged full time in a week’s residential clerkship. The conference comes as a climax to intensive exposure to mental illness. As it is intimate and focused on the " special case ", who has been visited at home, it can become, in the hands of skilled teachers who work well together, a learning experience of some width and depth. Regular assessment forums are held on the psychiatric clerkships, and though we are now in our tenth" year of this procedure, visiting and holding conferences on the special case " is regularly voted " in ". With reference to Dr. Agulnik’s letter4 the above method gives us ample opportunity to interest the student in the patient as a person, and to wean him from an over-use of the medical model. Formal teaching of psychiatry has been reduced to a minimum in the clerkship; but the students certainly acquire a knowledge of psychiatry. The methods described in Dr. Agulnik’s letter are similar to our own. as he suggests, there is a need for a spread of these If, " American " methods in Britain, perhaps more attention should be Daid to what we do in Leeds. University Department of Psychiatry, MARION B. H. WHYTE. Leeds.
CERVICAL CYTOLOGY CONSENT RATE SIR,-In the belief that preventive medicine can economically and easily be incorporated in an industrial health service we have been doinecervical-cytology screening in some of the factories in Slough. It is therefore with interest that I have read recent correspondence and articles in the medical press deploring the poor public response-
screening programmes. Differences in response might be expected to depend, at least in.part, on the degree of involvement of the women rates to
1.
Hargreaves, G. R., Brown D. G., Whyte, M. B. H. Lancet 1962, ii, 141. 2. Brown, D. G., Whyte, M. B. H. ibid. 1963, ii, 193. 3. ibid. 1969, i, 451. 4. Agulnik, P. L. ibid. p. 1020.
themselves in the programme. In factory "A" the women supervisors came to the initial meeting where the campaign was planned, and were, throughout, helpful and enthusiastic. Every female employee over 30 received a letter explaining the test, and was asked to get in touch with the medical department to say whether or not she wished to have it done. 229 out of 252 eligible women (89%) accepted the test. Of these 23% had clinical or cytological abnormalities, including 1 carcinoma-in-situ, and were referred to their general practitioners. A high response-rate was also achieved by the medical department of British Petroleum1 using personal contact between nursing sisters and
employees. In factory "
B
"
no women supervisory staff are employed but in all other respects the approach was the same as in "A". Here, out of 71 eligible women, 50 were tested, a response rate of 70-4%. Of the remainder, 17 (24%) refused, and 4 (5-6%) did not answer the letter. The acceptance-rate of 70-4% compares with the overall response of 72-5% in West Sussex reported by Mr. Saunders and Dr. Snaith
(July 26,
p.
207).
The support and cooperation of the supervisors seems to have been an important factor in achieving an 89% response-rate. Another factor in persuading women to volunteer for this sort of screening programme is the group pressure brought to bear by their peers at work. This is absent in efforts to enrol them in screening programmes run by local authorities or general practitioners. The growing trend for married women to return to work is likely to make screening in the working environment an increasingly profitable and rewarding field. CHRISTINE THOMPSON. Slough Industrial Health Service.
PHENOBARBITONE AND THE NEONATE SIR,-Dr. Wilson (July 26, p. 214) and Dr. Davies (August 2, p. 273) raise fundamental issues with regard to the testing of any drug in pregnant women and newborn infants. The problem is certainly not peculiar to phenobarbitone, nor indeed is it peculiar to drugs in the commonly accepted sense of the word. Almost any therapeutic or diagnostic procedure applied to the unborn or newborn infant may have far-reaching consequences which cannot be fully evaluated. An example that springs to mind is the use of 75Seselenomethionine in placental-function studies and intrauterine transfusions. Even the well-tried procedure of exchange transfusion almost certainly entails more hazards than the generally recognised short-term ones, especially in areas where blood-transfusion services are not well
developed. of phenobarbitone in pregnant women and is scarcely new. Any long-term effects would have to be subtle and unobtrusive indeed to escape notice thus far. The experimental work in animals cited by Dr. Wilson,2 in so far as it suggests the possibility of harmful long-term effects of phenobarbitone, depends to a large extent on dosages in excess of those used in humans.3-5 The applicability of most of the work to the question of untoward effects in man is far from clear. The experiments of Denef and DeMoor 6 with castrated female rats, cited by Dr. Wilson, are susceptible to different interpretations, and their relevance to the point at issue is The
use
neonates
questionable. By all means let us proceed with caution in the evaluation Stonham, D. Occup. Hlth, 1968, 20, 258. Wilson, J. T. Pediatrics, Baltimore, 1969, 43, 324. Becker, R. F., Boneau, C. A., Shearin, C. A., King, J. E. Neurology, 1964, 14, 510. 4. Fahim, M. S., King, T. M. Am. J. Obstet. Gynec. 1968, 101, 1103. 5. Trolle, D. Lancet, 1968, ii, 1123. 6. Denef, C., DeMoor, P. Endocrinology, 1969, 83, 791. 1. 2. 3.
386 of new treatments, especially in unborn or newborn infants. Let us be alert to detect, if possible, the late effects of treatments which in the short term are apparently harmless. It should, however, be borne in mind that one result of conducting careful clinical trials is that the use of the treatment in question is restricted, since the groups in which it may be iustified are defined. G. P. MCMULLIN. Nottingham Children’s Hospital.
WIDENING THE SCOPE OF ANTENATAL DIAGNOSIS SIR,-Techniques of early amniocentesis 12 and of 3
amnion-cell culture 4 now promise the possibility of the antenatal diagnosis of genetic conditions such as trisomy and various biochemical lesions. The procedure in its simple form is limited to those conditions that can be diagnosed by examining amnion cells or amniotic fluid.5 Only a few genetic conditions can be so diagnosed, but the scope of antenatal diagnosis from cells or fluid can potentially be extended to any simple genetic disease by using the phenotype of an enzyme or antigen locus that is known to lie near the disease locus on the same chromosome. This idea, which is not originalis analogous to the proposed use, at non-uterine ages, of a linked marker for the prediction of a genetic disease for genetic-counselling purposes, as in the standard example of Huntington’s chorea. The prediction could be made antenatally, or otherwise, from the phenotype of any suitable marker locus known to lie close by the disease locus, provided (a) that one parent was heterozygous at both loci; (b) that the relative arrangement (coupling phase) of the alleles was ascertainable by a pedigree study; and (c) that, for the marker locus, the allelic contributions of each parent were distinguishable. In favourable cases (perhaps only 1 in 10 of the total) a mother in a pedigree manifesting a simple genetic condition might be informed that her unborn child had a 90% chance (say) of being affected. If the pregnancy was not too far advanced, she could opt for its termination. Such use of linkage information appears to offer a potentially practical approach to the curtailment, once and for all, of the transmission of simple genetic conditions, and one which has no serious personal, medical, or social disadvantages in countries with suitable abortion laws. It may be a vindication of what has long been a matter of faiththat knowledge of human chromosome maps would be of real value in preventive medicine. A new impetus is thus given to the mapping of human chromosomes, which has recently become quite feasible with the increasing availability of marker loci and auxiliary techniques.7-9 The partial prediction of sex by karyotypic analysis of lymphocytes of fetal origin cultured from the maternal peripheral blood at least as early as the 14th week of gestation is perhaps already more than a theoretical possibility.lO The technique, with modification, might be an attractive alternative to amniocentesis for antenatal diagnosis in its direct and indirect (link-diagnosis) forms. The required modification, which would require some development, would be an enrichment of the fetal element 1. Serr, D. M., Margolis, E. Am. J. Obstet. Gynec. 1964, 88, 230. 2. Jacobsen, C. B., Barter, R. H. ibid. 1967, 99, 796. 3. Steele, M. W., Berg, W. R. Lancet, 1966, i, 383. 4. Valenti, C., Schutta, E. J., Kehaty, T. ibid. 1968, ii, 220. 5. Emery, A. E. H. Bull. Europ. Soc. hum. Genet. (in the press). 6. Edwards, J. H. Lancet, 1956, 270, 579. 7. Renwick, J. H. Br. med. Bull. 1969, 25, 65. 8. Kao, F.-T., Puck, T. T. Proc. natn. Acad. Sci., U.S.A. 1968, 60, 1275. 9. Matsuya, Y., Green, H., Basilico, C. Nature, Lond. 1968, 220, 1199. 10. Walknowska, J., Conte, F. A., Grumbach, M. M. Lancet, 1969, i, 1119.
in the lymphocyte culture by selective elimination of maternal cells using an antiserum to a maternal histocompatibility HL-A partigen not present in the fetus. Amniocentesis, with its attendant risk, would then only be required when no such partigen existed. London School of Hygiene and
Tropical Medicine, Keppel Street, London W.C.1.
J. H. RENWICK.
Appointments BAILEY, N. M.,
M.D. Mane., M.SC. Lond., M.R.C.G.P., D.P.H. : deputy county M.o. and deputy principal school M.o., Worcestershire. CHALK, P. A. F., M.B. Cantab., F.R.C.S., M.R.C.O.G. : consultant obstetrician and gynaecologist. Royal Free Hospital, London. DICKINSON, C. J., D.M. Oxon., F.R.C.P. : consultant physician, University College Hospital, London. GRUNEBERG, R. N., M.B. Lond., M.C.PATH. : consultant bacteriologist, University College Hospital, London. Hicxs, R. C., M.B. Lond., D.P.M. : consultant psychiatrist, State Hospital, Carstairs. JANSZ, C. C. A., M.B. Ceylon, D.P.H., D.C.H. : chief health-services officer, London Borough Council of Hammersmith. JOHNSON, A. F., M.B., L’pool, F.F.R. : consultant radiologist, Huddersfield.
Birmingham Regional Hospital Board: HASHMI, F. S., M.B. Punjab, D.P.M. : consultant psychiatrist, Dudley Road (Birmingham) hospital group. Ross, D. M., M.B. Lond., F.F.A. R.c.s.: consultant anaathetist, Coventry hospital group. SLATER, J. J., M.B. Manc., D.P.M. : consultant psychiatrist, Burton-onTrent hospital group. Leeds Regional Hospital Board: BOWKETT, C. M., M.B. Mane., F.F.A. R.C.S. : consultant in thoracic anaathesia, Leeds. BULLOCK, E. K., M.B. Leeds, F.F.A. R.c.s.: consultant aneesthetist, Bradford.
MuKHERjEE, S. K.,
M.B.
Calcutta,
M.R.C.P.E. :
consultant in
geriatrics,
Halifax.
Oxford Regional Hospital Board: CoLE, P. H., B.M. Oxon., F.F.R.: consultant radiotherapist, Northampton General Hospital. MORTIMER, T. F., M.B. Cantab., M.C.PATH.: consultant pathologist, Horton General Hospital. SMYTH, H. G., M.B. Belf., D.P.M. : consultant psychiatrist, Princess Marina Hospital, Upton. Sheffield Regional Hospital Board: BEVERIDGE, MAHALA M., L.R.C.P.E.: consultant venereologist, Doncaster and Rotherham
area.
BLAKE, S. C., M.B. Dubl., F.F.A. R.c.s.: consultant anmsthetist, Doncaster Royal Infirmary. DALTON, B. E., M.B. L’pool, D.P.M. : consultant psychiatrist, Tavers
Hospital, Leicester. JERMAN, R. P., M.B. Durh.,
F.R.C.S. :
consultant general surgeon,
Chesterfield hospital group.
ORWIN, J. M., M.B. Edin., coln hospital group.
F.F.A. R.C.S. :
consultant aneesthetist, Lin-
South West Metropolitan Regional Hospital Board: HANNINGTON-KIFF, J. G., M.B., B.SC. Lond., F.F.A. R.C.S. : consultant anaesthetist, Farnham hospital group. HEWLETT, PATRICIA M., M.B. Edin., M.R.C.P.E., F.F.R.: consultant radiologist, Croydon and Warlingham Park hospital group. HUNTER-CRAIG, I. D., M.CHIR. Cantab., F.R.C.S. : consultant surgeon, Redhill and Netheme hospital group. NELSON, J. D., M.B. Glasg., D.M.R.D.: consultant radiologist, Worthing, Southlands, and District hospital group. NEMETH, WILLIAM, M.B. Sydney, F.F.A. R.c.s.: consultant anaesthetist, South West London hospital group. WILSON, T. D. H., M.B. Dubl., F.R.C.S.E. : consultant E.N.T. surgeon. South West London
hospital
group.
South Western Regional Hospital Board: ALLEN, ELAINE M., M.B. Cantab., M.R.C.P. : consultant in
neuro-
physiology, Plymouth. HAMILTON, S. G. I., M.CHIR. Cantab., F.R.C.S. : consultant general surgeon, Royal Cornwall Hospital. WALTERS, RUTH M., M.B. Brist., D.P.M., D.C.H. : consultant psychiatrist, Stoke Park Hospital, Bristol. WINDSOR, A. C. M., M.B. Wales, M.R.C.P., M.R.C.P.G. : consultant geriatrician, Bath clinical area.
bacteria with,
as
yet, undefined metabolic
Possibly similar carbohydrate malabsorption
capacities.
occurs
in
some
adults with the contaminated small-bowel syndrome but has not been widely recognised since sugar intolerance in older natients uroduces milder svmotoms. Institute of Child Health,
Birmingham
16.
MICHAEL GRACEY VALERIE BURKE CHARLOTTE M. ANDERSON.
TEACHING OF PSYCHIATRY
SIR,-In 1962 you published a short article by my colleagues and me on home visits by medical studients.1 One year later you published our further statement2 on this scheme, in which we described how the tutor in psychiatry had taken on the role of escort on these visits, and how general practitioners and social workers involved in the cases were being invited to teaching conferences. Referring now to your March leader 3 on teaching of psychiatry, we find that the special case study, plus the home visit under skilled escort, plus the conference and elucidation by the tutor in psychiatry, bring into focus the points you mention -i.e., the need for psychosocial assessment and the presentation of alternative treatments. There is also no doubt that the five objectives you list-increase of " psychological perceptiveness ", " a scientific attitude towards behaviour ", "how to relate to patients ", " factual knowledge ", and " treatment skills "-get a great deal of attention in an incidental (though none the less effective) way for many students. In this special area of the teaching of psychiatry to medical students, the staff-student ratio is never less than 3 to 2, the two students being engaged full time in a week’s residential clerkship. The conference comes as a climax to intensive exposure to mental illness. As it is intimate and focused on the " special case ", who has been visited at home, it can become, in the hands of skilled teachers who work well together, a learning experience of some width and depth. Regular assessment forums are held on the psychiatric clerkships, and though we are now in our tenth" year of this procedure, visiting and holding conferences on the special case " is regularly voted " in ". With reference to Dr. Agulnik’s letter4 the above method gives us ample opportunity to interest the student in the patient as a person, and to wean him from an over-use of the medical model. Formal teaching of psychiatry has been reduced to a minimum in the clerkship; but the students certainly acquire a knowledge of psychiatry. The methods described in Dr. Agulnik’s letter are similar to our own. as he suggests, there is a need for a spread of these If, " American " methods in Britain, perhaps more attention should be Daid to what we do in Leeds. University Department of Psychiatry, MARION B. H. WHYTE. Leeds.
CERVICAL CYTOLOGY CONSENT RATE SIR,-In the belief that preventive medicine can economically and easily be incorporated in an industrial health service we have been doinecervical-cytology screening in some of the factories in Slough. It is therefore with interest that I have read recent correspondence and articles in the medical press deploring the poor public response-
screening programmes. Differences in response might be expected to depend, at least in.part, on the degree of involvement of the women rates to
1.
Hargreaves, G. R., Brown D. G., Whyte, M. B. H. Lancet 1962, ii, 141. 2. Brown, D. G., Whyte, M. B. H. ibid. 1963, ii, 193. 3. ibid. 1969, i, 451. 4. Agulnik, P. L. ibid. p. 1020.
themselves in the programme. In factory "A" the women supervisors came to the initial meeting where the campaign was planned, and were, throughout, helpful and enthusiastic. Every female employee over 30 received a letter explaining the test, and was asked to get in touch with the medical department to say whether or not she wished to have it done. 229 out of 252 eligible women (89%) accepted the test. Of these 23% had clinical or cytological abnormalities, including 1 carcinoma-in-situ, and were referred to their general practitioners. A high response-rate was also achieved by the medical department of British Petroleum1 using personal contact between nursing sisters and
employees. In factory "
B
"
no women supervisory staff are employed but in all other respects the approach was the same as in "A". Here, out of 71 eligible women, 50 were tested, a response rate of 70-4%. Of the remainder, 17 (24%) refused, and 4 (5-6%) did not answer the letter. The acceptance-rate of 70-4% compares with the overall response of 72-5% in West Sussex reported by Mr. Saunders and Dr. Snaith
(July 26,
p.
207).
The support and cooperation of the supervisors seems to have been an important factor in achieving an 89% response-rate. Another factor in persuading women to volunteer for this sort of screening programme is the group pressure brought to bear by their peers at work. This is absent in efforts to enrol them in screening programmes run by local authorities or general practitioners. The growing trend for married women to return to work is likely to make screening in the working environment an increasingly profitable and rewarding field. CHRISTINE THOMPSON. Slough Industrial Health Service.
PHENOBARBITONE AND THE NEONATE SIR,-Dr. Wilson (July 26, p. 214) and Dr. Davies (August 2, p. 273) raise fundamental issues with regard to the testing of any drug in pregnant women and newborn infants. The problem is certainly not peculiar to phenobarbitone, nor indeed is it peculiar to drugs in the commonly accepted sense of the word. Almost any therapeutic or diagnostic procedure applied to the unborn or newborn infant may have far-reaching consequences which cannot be fully evaluated. An example that springs to mind is the use of 75Seselenomethionine in placental-function studies and intrauterine transfusions. Even the well-tried procedure of exchange transfusion almost certainly entails more hazards than the generally recognised short-term ones, especially in areas where blood-transfusion services are not well
developed. of phenobarbitone in pregnant women and is scarcely new. Any long-term effects would have to be subtle and unobtrusive indeed to escape notice thus far. The experimental work in animals cited by Dr. Wilson,2 in so far as it suggests the possibility of harmful long-term effects of phenobarbitone, depends to a large extent on dosages in excess of those used in humans.3-5 The applicability of most of the work to the question of untoward effects in man is far from clear. The experiments of Denef and DeMoor 6 with castrated female rats, cited by Dr. Wilson, are susceptible to different interpretations, and their relevance to the point at issue is The
use
neonates
questionable. By all means let us proceed with caution in the evaluation Stonham, D. Occup. Hlth, 1968, 20, 258. Wilson, J. T. Pediatrics, Baltimore, 1969, 43, 324. Becker, R. F., Boneau, C. A., Shearin, C. A., King, J. E. Neurology, 1964, 14, 510. 4. Fahim, M. S., King, T. M. Am. J. Obstet. Gynec. 1968, 101, 1103. 5. Trolle, D. Lancet, 1968, ii, 1123. 6. Denef, C., DeMoor, P. Endocrinology, 1969, 83, 791. 1. 2. 3.
386 of new treatments, especially in unborn or newborn infants. Let us be alert to detect, if possible, the late effects of treatments which in the short term are apparently harmless. It should, however, be borne in mind that one result of conducting careful clinical trials is that the use of the treatment in question is restricted, since the groups in which it may be iustified are defined. G. P. MCMULLIN. Nottingham Children’s Hospital.
WIDENING THE SCOPE OF ANTENATAL DIAGNOSIS SIR,-Techniques of early amniocentesis 12 and of 3
amnion-cell culture 4 now promise the possibility of the antenatal diagnosis of genetic conditions such as trisomy and various biochemical lesions. The procedure in its simple form is limited to those conditions that can be diagnosed by examining amnion cells or amniotic fluid.5 Only a few genetic conditions can be so diagnosed, but the scope of antenatal diagnosis from cells or fluid can potentially be extended to any simple genetic disease by using the phenotype of an enzyme or antigen locus that is known to lie near the disease locus on the same chromosome. This idea, which is not originalis analogous to the proposed use, at non-uterine ages, of a linked marker for the prediction of a genetic disease for genetic-counselling purposes, as in the standard example of Huntington’s chorea. The prediction could be made antenatally, or otherwise, from the phenotype of any suitable marker locus known to lie close by the disease locus, provided (a) that one parent was heterozygous at both loci; (b) that the relative arrangement (coupling phase) of the alleles was ascertainable by a pedigree study; and (c) that, for the marker locus, the allelic contributions of each parent were distinguishable. In favourable cases (perhaps only 1 in 10 of the total) a mother in a pedigree manifesting a simple genetic condition might be informed that her unborn child had a 90% chance (say) of being affected. If the pregnancy was not too far advanced, she could opt for its termination. Such use of linkage information appears to offer a potentially practical approach to the curtailment, once and for all, of the transmission of simple genetic conditions, and one which has no serious personal, medical, or social disadvantages in countries with suitable abortion laws. It may be a vindication of what has long been a matter of faiththat knowledge of human chromosome maps would be of real value in preventive medicine. A new impetus is thus given to the mapping of human chromosomes, which has recently become quite feasible with the increasing availability of marker loci and auxiliary techniques.7-9 The partial prediction of sex by karyotypic analysis of lymphocytes of fetal origin cultured from the maternal peripheral blood at least as early as the 14th week of gestation is perhaps already more than a theoretical possibility.lO The technique, with modification, might be an attractive alternative to amniocentesis for antenatal diagnosis in its direct and indirect (link-diagnosis) forms. The required modification, which would require some development, would be an enrichment of the fetal element 1. Serr, D. M., Margolis, E. Am. J. Obstet. Gynec. 1964, 88, 230. 2. Jacobsen, C. B., Barter, R. H. ibid. 1967, 99, 796. 3. Steele, M. W., Berg, W. R. Lancet, 1966, i, 383. 4. Valenti, C., Schutta, E. J., Kehaty, T. ibid. 1968, ii, 220. 5. Emery, A. E. H. Bull. Europ. Soc. hum. Genet. (in the press). 6. Edwards, J. H. Lancet, 1956, 270, 579. 7. Renwick, J. H. Br. med. Bull. 1969, 25, 65. 8. Kao, F.-T., Puck, T. T. Proc. natn. Acad. Sci., U.S.A. 1968, 60, 1275. 9. Matsuya, Y., Green, H., Basilico, C. Nature, Lond. 1968, 220, 1199. 10. Walknowska, J., Conte, F. A., Grumbach, M. M. Lancet, 1969, i, 1119.
in the lymphocyte culture by selective elimination of maternal cells using an antiserum to a maternal histocompatibility HL-A partigen not present in the fetus. Amniocentesis, with its attendant risk, would then only be required when no such partigen existed. London School of Hygiene and
Tropical Medicine, Keppel Street, London W.C.1.
J. H. RENWICK.
Appointments BAILEY, N. M.,
M.D. Mane., M.SC. Lond., M.R.C.G.P., D.P.H. : deputy county M.o. and deputy principal school M.o., Worcestershire. CHALK, P. A. F., M.B. Cantab., F.R.C.S., M.R.C.O.G. : consultant obstetrician and gynaecologist. Royal Free Hospital, London. DICKINSON, C. J., D.M. Oxon., F.R.C.P. : consultant physician, University College Hospital, London. GRUNEBERG, R. N., M.B. Lond., M.C.PATH. : consultant bacteriologist, University College Hospital, London. Hicxs, R. C., M.B. Lond., D.P.M. : consultant psychiatrist, State Hospital, Carstairs. JANSZ, C. C. A., M.B. Ceylon, D.P.H., D.C.H. : chief health-services officer, London Borough Council of Hammersmith. JOHNSON, A. F., M.B., L’pool, F.F.R. : consultant radiologist, Huddersfield.
Birmingham Regional Hospital Board: HASHMI, F. S., M.B. Punjab, D.P.M. : consultant psychiatrist, Dudley Road (Birmingham) hospital group. Ross, D. M., M.B. Lond., F.F.A. R.c.s.: consultant anaathetist, Coventry hospital group. SLATER, J. J., M.B. Manc., D.P.M. : consultant psychiatrist, Burton-onTrent hospital group. Leeds Regional Hospital Board: BOWKETT, C. M., M.B. Mane., F.F.A. R.C.S. : consultant in thoracic anaathesia, Leeds. BULLOCK, E. K., M.B. Leeds, F.F.A. R.c.s.: consultant aneesthetist, Bradford.
MuKHERjEE, S. K.,
M.B.
Calcutta,
M.R.C.P.E. :
consultant in
geriatrics,
Halifax.
Oxford Regional Hospital Board: CoLE, P. H., B.M. Oxon., F.F.R.: consultant radiotherapist, Northampton General Hospital. MORTIMER, T. F., M.B. Cantab., M.C.PATH.: consultant pathologist, Horton General Hospital. SMYTH, H. G., M.B. Belf., D.P.M. : consultant psychiatrist, Princess Marina Hospital, Upton. Sheffield Regional Hospital Board: BEVERIDGE, MAHALA M., L.R.C.P.E.: consultant venereologist, Doncaster and Rotherham
area.
BLAKE, S. C., M.B. Dubl., F.F.A. R.c.s.: consultant anmsthetist, Doncaster Royal Infirmary. DALTON, B. E., M.B. L’pool, D.P.M. : consultant psychiatrist, Tavers
Hospital, Leicester. JERMAN, R. P., M.B. Durh.,
F.R.C.S. :
consultant general surgeon,
Chesterfield hospital group.
ORWIN, J. M., M.B. Edin., coln hospital group.
F.F.A. R.C.S. :
consultant aneesthetist, Lin-
South West Metropolitan Regional Hospital Board: HANNINGTON-KIFF, J. G., M.B., B.SC. Lond., F.F.A. R.C.S. : consultant anaesthetist, Farnham hospital group. HEWLETT, PATRICIA M., M.B. Edin., M.R.C.P.E., F.F.R.: consultant radiologist, Croydon and Warlingham Park hospital group. HUNTER-CRAIG, I. D., M.CHIR. Cantab., F.R.C.S. : consultant surgeon, Redhill and Netheme hospital group. NELSON, J. D., M.B. Glasg., D.M.R.D.: consultant radiologist, Worthing, Southlands, and District hospital group. NEMETH, WILLIAM, M.B. Sydney, F.F.A. R.c.s.: consultant anaesthetist, South West London hospital group. WILSON, T. D. H., M.B. Dubl., F.R.C.S.E. : consultant E.N.T. surgeon. South West London
hospital
group.
South Western Regional Hospital Board: ALLEN, ELAINE M., M.B. Cantab., M.R.C.P. : consultant in
neuro-
physiology, Plymouth. HAMILTON, S. G. I., M.CHIR. Cantab., F.R.C.S. : consultant general surgeon, Royal Cornwall Hospital. WALTERS, RUTH M., M.B. Brist., D.P.M., D.C.H. : consultant psychiatrist, Stoke Park Hospital, Bristol. WINDSOR, A. C. M., M.B. Wales, M.R.C.P., M.R.C.P.G. : consultant geriatrician, Bath clinical area.