1967

BLACK BAG

t\ \o o0

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o.

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i.

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7

1

O

chandos Street, Cave.dish Square, Loodon

w1

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1

686

For the cough and congestion of bronchitis and colds

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l0 ng. codâ‚Źine phosphaie. 8,P. ln each 5 ml, N,g. Althouohpseudoephed.i.ecausesvi{u6lly no

oressoreffectin peGons with nornal blood presslte, 'Actifed' Compound Llnctus should be used with cautio. i. palients with @rdiovascular disoiders,

cough'Actifedi,-, Compound Linctus rrhen the complaint is

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CAPTAIN OF THE MEN OF DEATH william Withering's observations on the

"There is a disorder of the h€art marked with strong and peculiar symptoms. consid€r' able for the danger belonging to it, *nd not extremely rare. The seat of it, and the sense of strangling and anxiet', with which it is attended, make it not improPerly be called Angina Pectoris. The termination is r€markable- The patients all suddenly fall down, and

beneficial action of foxglove tea in the treatment of dropsy due to heart diiease are too well-known to be set down here. From this work came the understanding of digitalis and the preparation of refined glycosidet without which progress in the treatment of

perish almost immediately."

fully slow.

This eiegant description of what ii now known a, coronary heart disease came from the hand of the great William Heberden who lived from l7l0 to 1801. Hit was not the first account of angina, nor was he alone in recognitang its melancholy significance. Since Heberden's day the relendess spread of this malady, especially amon€ the richest and most rophisticated.ommunities, has brought it to the front rank of importance and made it truly "one of the captaint of the men of

A fundamentally important discovery had to wait until 1948, the year which Ahlqu:st 'n dual nature of announced his concept of the adrenergic receptors governing sympathetic activity. Fourteen years were to pass before

Tireless efforts

to

understand both its

cauie and its prevention have been rewarded

chronic heart disease would hav€ bee. piti-

rhe introduction of rhe first beta-adrenergic blocking agent opened up new horizons of

hope for patients with angina. Today 'lnderal', the moit recent descendant, has been proved beyond any doubt to reduce the number and s€verity of anginal attacks lnd to extend exercire tolerance of patients with coronary heart direa'e. The pharmacology may be abrtruse- but there is no question whatsover about the practical results.

at firrt slowly but more recently at a -gathering pace. As long ago at 1867 a young house phyrician

at St.

Bartholomew's

Hor

pital, who later became sir Lauder Brunton, discovered thit nitritet were capxble of relieving the agonising pain of myocardial

'

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don_1 nccd !o

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University of Bristo Vol. 23 No. I Vice-Choirmon:

Mr. K. G. Buckler, M.B., Ch.B., D.Obst.,

R.C.O.c., F.R.C.S.

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BLACK BAG

BLACK BAG CONTENT poce

Editorial Depanmental R€view

9

(Cytolo8y)

Retrospe.t Organjsation & Method 1852 Ruptured Uterus Brktol. but where 1 Southm€ad

in

NEWS AND VIEWS SUPPLEI,IENT

l0

ll 15

17

22

26-48 26

lo'eph

Mendel

30

Jones

t1

Annual Meeting of R.C.S.

36

Dr. H. B.

38

srop

Press

4 48

Alumni of Galenicals

19

Alumni News in Brief

52

Bristol-Penh, A P/ofessors Farewell Cancer Proiect

55

60 65

Examinition Results

66

EDITORIAL An editor can n€ver sit back and rest on h;s laurels, but from the overall response to the last edition, I feel that we have rt last produ.ed a magazine with a well balanced

The Newr Supplement'

to be of

has shown itself

conriderable interett

to studert!

it k therefore hoped to enlarge on it in future editions- f4embers of the executive committee of Galenicals, the and staff.

medical students union, have been co-opred

onto the Black Bag editorial committee as news correrpondents. lr is hoped that the Dental Executive Committee will follow suit, and hence news and views from all levels of the student communjty should appear in our futur€ editions. Black Bag i3 the narural medium for conveying student opinion ro the rtaff, b0t as yet its services ar€ nor fully utilised by th€ main bulk of rhe stud€nt population.

The Alumni section. of interest to both prerent and past members ot the Bristol fraternity, continues to flourkh. However, the long sil€nce from the nurses still continues unabated, end if ther€ emerges from this parched oash of literary ability a lingle enthuiiasti. rtudent. she would be welcomed to our.ommirtee (wirh oPen arms).

Thanke to our treasurer, Ri€hard Harding, our accounts are no longer printed in red.

This is encouraging rince w€ can continue to pursue our policy of increased content' in the hope that future editions, like the last, will meet with general apprakal (900 copies sold). We look to you, the reader, to ,uppl/ us with copy, either medical or non-medical. for it is esrentially th€ cortent which makes the magazine a success.

DEPARTMENTAL REVIEW . , . The re.€nt establishment ot a Departm€nt of Clinical Cytolog/ at Bristol

CLINICAL CYTOLOGY

Uniy€rsity emphasis€r it, growing importance in diagnosti€ medicine . . .

JOHN CORNES

malignant cells. Cervi.al smear5 and vaginal aspirate' are also examined for Trichomonas Vaginalis and mofilia, and occasionally for

For more than a century pathologists have known that it is possible to recognise certain diseases from th€ appearance of €xfoliated celk. The first consistent attempt to diagnose gynaecoloSical cancer by cervical cytology war made by Georg€ Baber in Albania, and later by hir colleague George Papanicolaou who had emigrated to the United Stat€s and taken up r parhology appointment in New York. By I950 most of the teaching hospitals in the Unit€d States had organised clinical cytology d€partments and cervi€al cytology had become a standard procedure in most

enddrine arsessment in patients with amenorrhoea, habitual abortio'rs and infertility. Gistric wirhings may help to distin-

gui5h carcinomas from peptic ulceration.

Urine cytology may help to establish the diagnosis of early bladder cancer. sputom cytology may help to elucidate lesionr foond on ch€st x-ray, and establish the diaSnosis of peripheral tumours of the lung. But it is ln gynaecology thet cytology is particularly

gynaecological clinlcs.

clinical cytology rervice in gristol was first organis€d by Prof€tsor Lennon and I'lr' M. B. Wingate in 196,t using funds provided by the reseerch committee of the United Bristol Hospitali, ln the first eight months cervical smears were examined from 862 patients attending gynaecological clinics at

At the General Hospital over 100 pati€nts ar€ tr€ated every year for carcinoma of the cervix, and some 30"50 patients are treated

A

for carcinoma of the endometrium. ln thh country one in €very s€venty women develoPt carcinoma of the cervix and one in every hundr€d di€s from this disease. Clini€al cytology har shown that there are at least two typ€s of cervical cancer : a slowly progressive form seen in women b€tween the ases of 18"50, and a mor€ rapidly progre'sive 50 y€ars of age. form seen in Routine cervical smears can pick up precancerous and early cincerous changes of the

rhe General Hospital and ant€-natal clinics at rhe Profesrorial tJnit. Twenty.two patients were found to have malignart cells jn their

.ervicel smears. and a further sev€nteen patients had dyskaryotic or Precancerous changes in their exfoliated cervjcal cells.

This pilot study showed that there was a place for cervicil cytology in Bristol, and in 1965 the Board of Governors of the [Jnit€d Bristol Hospitals ertablished a cytology department at the Brirtol General Hospital.

cervix in young women befor€ the disease has become invasive. The number of patients wirh carcinoma-in{itu rreated at the General Hoipital has risen sreadily in the last few years from none in 1963, one in 1964, seven in 1965, to nineteen in 1956. ln addition an lncreasing number of patients with clinical stage one carcinoma of the cervix are being treated by radiotherapy and surgery. We hope that the next few /ears will show an appreciable drop in the death rate from

Last yeir similar departments were started in Bath, Trunton, Southmead and Exerer, and there is now a comprehensive €ytology ser' vice covering most of the West Country.

At the General Hospital pleural and peritoneal effusions, sputa, gastric washings, urine specimens, cervical smears and vaginal aspirates are examined for the presence of t0

SoutlmeuD

in

llhrftoeprct

(or @bdtrtri$ fn .r nutdloll)

Driving rlowly along Southmead Road inro view on my right came the ominous entrance to Southmead Hospital. Turning into and continuing along the drive, I turned sharp left at the end and trayell€d slowly onvrards past th€ car park. A final right ed then left turn ended the compl€x procesr of reaching Tyndall House. I stopped and gazed at my perman€nt r€rid€nce for th€ next three

ll

Tlndall Hoose. recently built ro

rePlace

the

previous subsrandard accommodation presents an exrerior which is of the same design. high s.andard as that of rhe 'nrerior by well Set in irs own grounds, surrounded kepr lawns, lt provides adequate facilities for mos. sports. Adjacent ro the building rhere is ample garage space fo. both s.odenrs and

staff (a consideration rarely Siven

!o

students). lnside, rhe cenrral heating Pro vides a high temperature rhroughout rhe coldesr wi.ter months. The studenr bed rooms, desisned for o.e, now sleeP iwo. and alrhough this is nor ideal, the size and fac liries of the rooms compensate to some exrent. There is ample wardrobe rPace even for two. The rooms are carpeled and reasonably sound proofed. The walls are b.ightly

painred and the wood finirh adds a Scan dinavian too.h ro rhe firments. Each room has a sink, heater and inrernal telephone. whlch after a short sray can develoP horn' as it rings regardless of time. The Problem of sharing rooms ir that although 5tudying

Relaxing in the Common Room

Dining-room

iries are excellenr for one they are inadequate for rwo, also,leeP is disturbed

faci

twice as often by the ringing Phone Both srudenrs and staff each have

again brightlY

a

decorated,

carpeted and with modern furnishings and firments. For several, even more imPortant is

the provlsion of a television, which i'

in

constant use. Each floor has two with baths. showers and toilets- There are also Laundry facilities and a small kilchen bathrooms

with provisions for makine rea or coffee (for rhe more adventurous rhere are seve.al PUbs within walking dlstance). Ihe dining-room is spacious and modern in design and the srandard of food is far aboYe tha! of the other hospitals which I have experienced The kitchen sraff are extremely friendly and will go out of thelr wa) to prePare a meal for you at almos! any time of the day- In the space of three monrhs sruden!s can easily fors.t how to fend for rhemselves t7

-lowev"r a'l \ no aa! ng . rleep,-g and watching relevision , fo. afrer w rnesring Uve de iveries and three slitchings lnd rotas nre Ptt up. Patienrs are distr buted and mu5t be clerked and followed up during ther ante srudenrs are ready to start,

na.al and posr-natal sray in hosp ta . Each srudenr musr atrempr ro carry oor at least rwelve nordal de iveries. which musr be wrirlen up The sruden6 work on two marernlrf blocks. b ock A (Profesor al) and block S (lYr Crossley, Mrs. BennerI, lvlr.

Abbas) a.d for each block lhere are three srudenrs on call each day (and nghr). Firot call is for emerge.cy deliverics. second is for srirching, ind rhird for fly ng s!uad on A block and for disrr cr deliverie, o. B block.

The main problem ar present is that the overcrowd

ng curs down th. n!mber

of

deliveries available io ea.h stude.r. and with

the yearly inrake ncrearing rapidly to the p.oposed leve of 120 st!de.rs the probcm s not likely to be alleviared by the evenrlal u.rangli.g of the curriculum. The n!-sinE sraff with few excepron5 are helpful.

The week ir r r. flled r! th x well organised course of lectures a.i totorials of an insrrucrive and comprehensive nrtore.

DurinE rhe final month normal deiveries should have been completed, and the time s spenr witnessing ab.ormal neliveries and complering an Obstetri< project. S ncc srudenrs ofte. have diff<!lry wirh thcir proje.ts a.d in many cas-"s do nor con:plete rhem unril man/ months afrer cavine sourhfread. r would possibly be hclpiul if regular rurorials were hed to dii(uss the proSress of srudenr proje.ts. dor n8 rhe nnal

On-Call for an earl), delivery (Dave rhornroi

)

ln rerrospect. the obv ous conceri shovi in order ro prov de excelle.t livl.g Iacilities and a well organised course for the studenrs, ls ample evidence that rhe admirstririve abiliry of Professor Le..o. wi I be Freany missed when he eaver for Perth, in the

ll

THE SOCIETY MEDICAL PROTECTION FOUNDED I892 MEIlBERSHIP EXCEEDS MehbeBhlp

se.!r$ protedion of

45OOO

bf a peBonal adrhory demnity against legal costr and dah.gs.

prolessional interests

servi.e and the prcvision of lnlimited

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THE MEDICAL PROTECTION SOCIETY 50 HALLAM STREET . LONDON . W.I L,epior. LANGHAi1 92,t1

BUYINGACAR? Then qet details of the special hire-purchase terms olfered to the prolession by

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Med'casicknesAnnu|'andL'f

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oillIl-

- - - --

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|

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3. Daily prayers will be held each morn;ns in the main ofiice. The clerical staff will be

ORGANISATION

4. Clothing must be of a sober nature. The clerical st1ff will not disport themsetves in raiment of bright colours.

5, Overshoes and rop coats mry not be worn in the office, but neck scarves and headwear may be worn in ;nclement weather.

METHOD

A stove is provided for the benefit of the clencal staff, coal and wood must be kept in the locker. lt;s recommended that each 6.

t

852

member of the clerical suff bring four po',nds of coal erch day during the cotd

7. No member of the staff may leave the room without permksion from Mr. Rogers.

Th€ calk of nature are permitt€d and ctericat rtaff may use the gard€n below the second

8a.e. This area must be kept in good order.

8. No talkinS is allowed during

Buried deep in the demolition rubble of on elderly build-

9. Th€ craving of tobacco, wines or spirjts is a human weakners and ai su.h i! forbidden to all menbers of the ctericat staff.

ing in Lichfield, Stoffs. wos this gem directed ot clericol stoff who hod just " bene{ited

"

business

10. Now that rhe hour! of business have beei drartically reduced th€ partaking of food i! allowed between ll.!0 a,m. and noon, but work will not on any account ceas€.

from the new Lobour

Lows of the dcy.

I

l.

Members af the clerical stafi witt provide

will nomjnate a renior cterk be responsible for the cleantinerr of the main omce and the private ofiice. AIt boys 12. Mr. Rogen

to

and juniors will report ro him 40 minutes before pnyers and will remain after closing hourr for similar work. Brushes, brooms, scrubbe.s and soap are provided b), the

L Godiiness, cleanliness and punctualitl are the necessities of a good business.

2. Thas firm has r€duced the hours of work and the clerical staff will now only have to be present betlveen the hours of 7 a.m, and

The owners recognise the generosity of

the new Labour Laws, but will expect a great rise in output of work to compensate for these near Utopian conditions.

I5

This llentist is taking a far f,astern Gruise.

And he's taking his patients with him.

H.w

hnl

prot€ssio.al exp€rience as you ravcl

And onc thing yo! can bc s!rc of.s a nclcl JcnrJl sur8con rhc lics lron lour sursery Ln t Lhe ledl sJssorlq

you likc ro srcp into a "o!ld Drrcrice.nd erin your r.,hly-n,nlc You can as a Dcntal Omccr in rlle Nrvy. You donl misou! onyourprG lcsionil p.ogr6s and you rrcnl ticd dowr as you would be wirh a civilirn practiL!. Thcrc s plcnry ollime tosetllc dovn when youte our oiyou. ntcntics.

1o

rrkc cnrc of thai, and lo assist

Dcnrsl CadchhiDs. cr.rd,h,F

"-

ln the Navy, youtc not only a den-

.".-*i.md

* F!

r"d n.J * '-d

oft(^

tist,you rca Nav l Omcer.This, incvi-

tably, mc.ns wid.r rcsponsibility and a broader life, sine you will bc @ncemcd *nh characier rairins, Ieadership and thc {orld{vide rolc of rhc Royal Nx\y. As. Jenusr, you enlountcr a fu I nnac ol clin cdl Drohlcmi, You lvitl have a sursery a upto-dale

sur*mo crDr"in (D) F.L.Hall, o.B.r.,

as in any crvrlnn pd{ie, plus the brckins ol r lull t.m ol.onsullanLs.

[oDr6

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You

donl

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sDen

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n;$ oi

lre

rime dml-

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hale A rai.ed Wren or Meili€l A$is-

I6

sr lre

auiuinei

Londob,

<d

s\v6

RUPTURED

UTERU$

AII

OBETETBIC

CA$E N$TONY On Thursday 28.7.66 at 10.10 p.m., Sourhmead Hospital ( B.istol) Obstetric Flying Squad was called ro a patient who had collapsed at home in early labour, arriving at I0.25 p.m, On examination, the patientt

Past Medi(al History Mrs. X. war well Minor (hildhood aitmenrs only. Periods commenced ar Il years and were regular 5/30- L.M.P. l5-10.65, E.D.D. 71.7.66. There was no family history of T.8., Diabetes, Hypertension or Twins, and a were well. All rhree previous pregnancies, the first one of which was a hospital confine-

blood pressure and pulse were unrecordable: abdomen wai tender but not atonic. The

foetal heart was not heard. Two pints of blood were transfused before transferring the patient to Southmead with ? ruptured

ment, labours and puerperia were normal.

The patient's previous notes were available at the was first seen at the hospital ante-natal clinic on 9th june, 1966. She had preferred home confinernent but from rhe 34th week of pregnancy she was b@ked for hospital delivery b<ause of:

l.

Mrs. X. had attended her own doctor from 24.3.66 (l7th week) and hrd felt foetat movemenG for one month- On booking, blood pressure (8.P.) was l2sl80 m.m. Hg, Urine N.A.D.. wt. l0 st. 4 lbs., Hb. 82%,

Blood Group 0 Rh. Positive with Anti-A/ AntiB haemolysins. This was to be checked again at 34 weeks when she attended the

Multiparity, Gravida lV.

2. Age,35 years.

3. Gap of ll years since lasr confinement.

4. Stature 4 ft. I l+ ins.

hospital clinic. Patient remained well during Pregnancy.

for Early Home Nursing had been arranged providing no complications arose.

At 28 weeks the uterus appeared targe for of amenorrhoea, At 14 weekr the fundal height equalled 36' weeks aestatiotr_ Her doctor queried the possibility of a twin

Discharge

weeks

Early ante-natal care to be given by a General

Practitioner Obstetrician.

l7

Pregnancy and although no posiiive abdominal signs were found, she was ref€rred to

2A-7.66

ln the afternoon a medical induction was given by the District l'lidwife who then stayed with Mrs. X. Contractions commenced at 6,0 p,m. Maternal and foetal conditions

the Consultant Clinic.

9.6.66. 34th we€k.

Seen at Southmead Hospital Antenatal clinic. B.P. 135/85 (rise or 5 m.m. Hg. in the diastole), Urine N.A.D., wt- ll st, F.H.H. Hb remained at 82% aDd the haemolysint had not increased in dtre and were of no .linical significance in regard to this preg-

Mrr. X. attended her doctor and

appeared satisf:ctory and labour progressed normally. Membranes ruptured 8.35 p.m., contactions ceased 9-20 p.m. Patient collapi€d ruddenly at l0-0 p.m. General Practi-

tioner and 'Obrtetric Flying Squad' called.

The Obstetri. Flying Sqlad team irrived at 10.25 p.m. One pint of plasma and one pint of blood 0 rh+ were immediately tranr fused. B.P, row 70150. A further pint was iransfused during the patienCs t.ansfer to hospit3l by ambulance, accompanied by the 'Obttetric Flying Squad'. The theatre was in rddiness when the patient arriv€d.

On admission .t I l-10 p.m. Mrs. X.'s con, dition was .ritical; conrent for operation of Caesarian Section I Hysterectomy was obtrined from the patient's husband who had

the

Hospital Clinic on alternate we€ks. P.egnancy Progressed satisf.ctorily until 227,55, when,

apparendy

at term.nd as labour had not

commenced, she was admifted ro the hospital

for x-ray, to confirm mrturity, and probable i.duction of labour.

Or 71.7.66 at 11.30 a.m. the patient was admitted under the care of the Consultant Obstetrician. Her condition was satisfactory, B.P. 120/80 Urine N.A.D. 97.8"F,

no

a(companied her.

Temp€ratur€

On ex.mination

oedema present. Abdoninal examination-Fundus at term with normal sized foetus, cephrlic presenration, R.O.P., head free but will go down into pelvis, F.H.H. The p:dent was transferred to an ant€-natal ward and later x-ray was performed. This showed gestation of 38-39 weeks.

B.P. 80/55, Puke

serious physical condition.

entiil

diagnosis

of

A

120,

possible differ-

matsive concealed acci-

dental haemorhage was conridered by the Consult'ant Obstetricaan. At middight, B.P. 80/55, Puke 124. Patient was again review€d

by Consultant Obstetrician. Last meal taken early on Thursday, 28.7.66.

Mrs. X- was prepared and taken to theatre at 12.30 a.m., 29.7.65 for Caesarian Section

2t-7-66

Surgical induction was not attempted is the heid was well above the pelvic brim and, as rh€ patient was anxious ro be home, she was discharged for the weekend to retu.n on 26.7.66 for surgical induction of labour-

under General Anaesthetic.

Op€ration and Procedure

A midline sub umbilical in.isio^ was mide. which was later extended above th€ umbilicus and diagonally towards the left costal margin.

This was necesrary to gain access to a bleed-

8J.66

ing point, high on the posterior abdominal

The patient was seen again by her doctor.

B.P. 120/80, Urine N.A.D., cephalic presentation, head not engaged, F.H.H. Mrc. X. said that she wanted a home .onfinement instead of hospital admission the following day. lt was lrnneed for her to have a medical

Findin8t

Stillborn male foetus (8.15 oz5.)

and

placenta free in the abdominal ca'/ity. Long tear in anterior wall of uterus which extended from the mid-pan of the body of the

inductio: within the next 2-3 days at home. t8

side ward with the thirtieth pint of blood in progress. Post operative condition remained

uterus down to and including the upp€r part vagina. Large volume of blood free

of the

in abdominal cavity. Foetus and placenta were removed from abdominal cavity and blood sucked out. Total hysterectomy wai

and 200 c.cs. frank haematuria

Throughout this time, blood was being forced under prersure into a vejn in the right antecubital fossa. During the hysterectomy, cardiac arrest occurred and external

commended and output cirefully observed for quantity and colour. A careful watch was

A self-retaining Foley s catheter was

passed

obtain€d.

Thir war due to the platelet deficiency, which then responded when further fresh blood was given. Continuous bladder drainage wat

€ardiac masage was performed succe'sfullI. Following the removal of the uterus, profuse bleeding continu€d and tamples of venous blood failed to clot in a plain tube. Fibrinogen estimation after blood transfusion of l8 pints showed marked fibrinogen insufilcienq.

The pati€nt was, therefor€, transfused with

kept on the fluid intake and output, and 2,500 c.cs. of fluid in all was prescribed for the first 2,{ hours. Hydrocortisone therapy, 100 mgm., commenced during operation war continued six hourly with de.reasing doses.

An cesophageal tube war pasred and small amounts on aspirare obtained hourly; 30 cc's. of water wer€ allowed hourly by the mouth. bur rhis was diftlcult to limit.s the patient complained of continual thirst.

At 7.0 a,m. R.P. I30/90 m.m. Hg., Temperature 89"F., Puke 88, Respirations 48.

Half hourly observations were continued. A

2 grmi. fibrinogen at 1.0 a.m. followed b), I4 more grms. during operative procedur€s.

A further episode of ble€ding was traced by extending the abdominal incision and found to be from a branch of th€ ovarian artery.

A cut-down lnro fhe radial artery in the l€ft wrht starred a s€cond infution of blood to run simulraneously with thc first. Arterial spasm was overcome by tranrfusinS under pressure maintained by Higginson's Syringe.

Careful observation wes kept throughout io se€ that no air €nt€red the blood vessel.

Blood war rtill not clotring and a further

loading dose of 600 mgms. l/M Crystam/cin.

300 mgm, was continued b.d. for five days.

PatienCs general condition was now more

satisfactory-though tigns of discomfort were shown-l/M Omnopon was given at

At midday B.P. 135/90 m.m. H.G., Temperature 98F., Pulse 84, Respirations 24, which showed som€ improvement,. Vit Kl l0 mgm. and Hydrocortisone 75 mcs. alro given. All nurring care was given with special 9.30 a.m.

2 grmr. of

fibrinogen was transfused. Since the massive transfusion of 27 pints of blood, ,1 pints of plasma (3 double strength) and 16 grms, of fibrinoSen hed caused a Platelet deficiency in the patient's circulatioh,6 pints of fresh blood were transfused. This was readily availiblc as the Regional Blood Transfusion Centre is at this hospital. After this

attentioh to oral and vulval toilet. By this time, 960 c.c's. of urine has been passedwith some degree of haematuria. LV. infusion into right wrist satisfactory and the 33rd pint of blood commenced.

the patient! blood started to clot, haemosrask was secured and the abdominal wall closed in the normal way. The infusion also included 50 grms. of Rheomoacrodex,5 g.

Epsik:pron and calcium Gluconate l0 ccs.

6.0 p.m.

B.P. 135/80 m.m. Hg.. Temperature 100 F.,

Pulse 92, Respirations 24. The last piit of blood was completed and foliowed by 500

given p.r.n.

c.ck. of Dextrose 5%, alternating with Dextro'e sodium Chloride,2; litres being

5,30 a.m. B.P. 95/75, Puke 100-110, Temperature 98'F (per axilla)r l/M OmnoPon l0 mgs. given, and the patient moved to a

given in 24 hours.

t9

Urinary output totalled 2,300 mls.

i.

6.0 p.m.

the

first twentyjour hours. The patient's level of cons.iousness llghtened during the day.

Crystamy.in I vial and Omnopon l0 mgt. repeated. PatienCs bladder Gtheterised at 9.0 p.m.-200 mh. haematuria obtained. S.G. 1022. Patient was settled and had a com-

She was speakinC frequently and asking ques-

tionr, mostly concerning her baby. lt

was

explained gently and simply what had occurred, although thL did not always appear to

fortable night.

register. lndeed, the patient told us she remembered nothing from the Thursda/ morning at home until Sunday, when she was uP for the first time.

Her husband vkited on the llrst afternoon and evening, and continued to spend his rpare time at his wife, bedside. He was

3lit luly-6

B.P. I10/80, T. 98.4,F., P. r02, R. 20. l/V infurion.ontinued +2 G KCI, plus Parentrovite I+2 (high potency). Oral fluids in.reasing,200 mls.;n past 24 hourr. Ryles tube removed- Patient satkfactory ahd up for bed

ind€ed a constaht source of reassurance and encouragement to her. f'1r5. x continued to improve and no complications occurred.

making.

Biochemical r€rults improved-Potassium

3.3 mEq/litresi Chlorides 100/l,lEq/litre.

Evening t€mperature rose to I00'F. Crystamycin 300 mgm. increased to six hourly.

8.0 p.m.

B.P. 130/80, T. I00 F., Pulse 80, Respirations 20, l/14 Omnopon l0 mgs. was giv€n to s€tde and r€peared at 1.0 a.m, The Patient had a rerttul night. Hb. e!timation 92%, Prothrombin lnd€x 59%, Blcod Urea !9 mg.

Urinary cath€ter removed again during the dayi patient now pasting urine satisfacrorily. l/M Omnopon I0 mg'. given at 10.30 p.m. for the night.

Total fluidr-l/V 2,000+ 1,556 orali Outpur 2,325+

30th ,uly 6,0 a.m.

B.P. I30/90, T. 99.4F, Pulre 80, Respirarion 2,{, Hydrocorthone 25 mgs. wat Biven and I vial Crystamycin. The pati€nt war bed

+.

1.8.66.

General condition much improved. Oral fluids encourag€d and taken well, l/V trans-

bathed and oral and vulval toilet 8iven.

During the day oral fluid intak€ was increased to 60 mls. hourly, diminishing aspirate only obtained. l/V fluids were concinu€d, I G Potassium Chloride (KCl.) and Parentrovite being inrtilled into l/V fluids to correct deficiencies. Hb. 86% Blood urea

fusion dircontinued 8.0 p.m. The patient was much mor€ cheerful-though distressed at

tim€i by incompl€te bladder and bowel control, Recordings satisfactory.

5.8.66.

Mn. X. was now getting up for

50 mgs. Serum Potassium 2.8 mEq/Lr S€rum

Chlorides

a.m.

short

periods every day and physiotherapy continued. lmprovement maintained. Crystamycin discontinued and Ampi€illin 250 mgr. commenced q.d.s. for 5 days. B.P. 130/80, T. 100,F. P.80, R.20. l+-2 litres taken orally

98 mEq/L showed biochemical

9.0 a.m.

T 99.4F., P. 80, R. 24. removed-I'40 mls. pased.

Urinary .atheter a comfortable morning during Patient had physiotherapy was Omnowhich siven. Ul'l pon l0 mgs. given at midday. Four hourly recording satkfactory.

B.P. r40/r00,

daily, good urinary output

maintain€d.

Electrolytes normal, blood urea 29 mgs. Hb. 1009a. Some haemorrhagi€ discharge rrom wound, small haematoma found, dry dressing applied.

20

warm da/s. The

9-8.56.

remaining

removed and apan from a slight discharge, eyer/thing was ratirfactory. Consultants and nuring staff began talking of Mrs. X. going

Mrs. X. was seen b) Consultant Obstet.i(-

ian who was delight€d with her progrers.

Alternate sutures removed from abdominal wound and routine treatments continued-

A family holiday had been

r0.8.66.

previously

for the third week in August and Mrs. X. was finally discharged on 17.8.65, twenty &F after her emergency admissionshe war aga;n seen at the follow up

arranged

Condition satisfactory. ME. X. complained of some chest pain. Chest x-ray and E,C.G, performed and blood taken for prothrombin time. X-ra/ showed some areas of lobar collapse otherwise N-A-D. E.C.G,-N.A.D. Prothrombin normal- No specific treatment

Gynaecologi<al Clinic on 28th September when she was well, apart from some granulation tissue at the upper end of the abdominal wound. This was removed and treated with

given. l'4rs.

X. was moved to join other mothers in three bedded ward and was generally happier for this. We en.ourag€d Mrs. X. to 80 ou$ide as much as possible on the iine

silver nitrate cautery- Her Hb. was

also

At the three monthly check-up the patient was both physi€ally and mentally well.

I

I

Th€ " Ultimate Det€rrent "-Sn|d€nt pla.ed stat€gicallt in Out Patien6 (COPYRIGHT DR. METCAIF)

2t

BRISTOL, but WHERE? Herewith the second reries of picturB of Bristol landmarks. Unfortlnately, the rive photoSraphs printed in the last series did not

reyive sufficiently interesting

melr'ories

to spur them into conyeying their literary talen6<r perhaps ruch memoris are bst not printed. lt it hoped thal this seri6 will stimulate a greatâ&#x201A;Źr response. So pleae, if rhey reyive memoris oI incidenis from the past, write and tell us amon8st our readeE

Our next seri6 will be ' New Bristol, but ? ' So don't mks the next edition.

where

*A -=:

.&&

ANSWERS

r. The

:

Paragon

2. Yiew lrom Cabot Tower 3. The Suspension Bridge

4. Wilb Memorial Building

PHOTOGRAPHY GARNER

LATEST

L'Y'NGSIONf

A

EOOKS

DEMONSTRATIONs OF OPERAIIVE SURGERY HAMILTON BAILEY. AEViSEd bY A, R. ISAAC

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MANUAL OF SURGICAL ANATOTiY SIR .IOHN BRUCE. C-B.E.. T.D., ioBiFT wALMsLEY and J. A. Foss. M.B.E 574 paqes 307 illus. Papertack Edition 3Os DISEASES

Of

AND

THE NOSE'

EAR

an l Ptactitone's A Handbook lot Studenls'HROAT L S. HALL and B- H. COLMAN Eighth Edition, 442 paqes, 111 illus. 3Os.

THE EYE

c, F. s.

IN GENERAL PNACflCE JACKSON

Fdurrh Edilion. 182

pass

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pags

415

itlus.

Anxiety, that's what I get.

And have a good time making

PSYCHOLOGY IN RELA'ION TO MEDICINE F- M- MOWBRAY and T- F. FODGEF C B E_ Sâ&#x201A;Źcond Edition, 420 pages, 50 illtis. 40s. approx.

274

I never regret, I feel guilty : And if I should vacuum the hall, wash the woodwork and such And not mind too much, Am I tidy I Compulsive, that\ all

lf I m happy, I must be euphoric : lf I go to the Stork or the Ritz

Tevthook lot Studqts and Doctots bv feachers ot the Eclinbutgh Medical Sch@l Edited by J. MACLEOD Second Ediiion. 596 pag6, 235 illus. '?l5s

a

pags,

I never get mad-l get hostile: I never feel sad, I'm depressed. lf I sew and I knit and enjoy it a bit, I'm not handy, I'm merely obsessed.

lf I'm choosing a hat, I have conflict, With ambivalent feeling towards it: I never get worried, or

CIINICAL EXAMINATION

Thirteenth Edit'on. 402

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15 5s.

Futthet details supplie.! oh tequ$t E. & S. LIVINGSTONE LTD. IS - 16 - 17 TEVIOT PLACE' EDINBURGH

PUns

or

a

I am manic and maybe a schiz

lf I think that rhe doorman was nasty, I'm paranoid obYiously.

And if I take a drink without stoPPing Alcoholic, Anne Weschler, thaCs me

I

lf l tell you you re right

I m submissive Repressive and passively, too :

And when I disagree, I'm defensive. you

And proiecting my symPtoms to

You

I love you, but that h rransference With Oedipus rearing his head: My breathing asthmatic is Psy.hosomatic'

A rear of exclaiming " DroP Dead

!"

I'm not lonely, I'm simply dePendenr: My doe has no fleas, iust a tic : So if I seem a cad, never mif,d, iust be glad

That I'm not iust a stinker : I'm s;ck

!

2ntr @bition

fr"tws

& Fitns

Supplemrnt

VIM PROMOVET INSITAM

VIEWPOI NT STUDENT

OPINION REVEALS

by the EDITOR

In

December 1966 a survey was

a. Studâ&#x201A;Źnlstaff relalionship,

b. The function

aar ed out by a sub-committee of Galenicals

in an attempt to bring

the curriculum suryey

of

1965 up to

medicat prac,

Students were questioned on how they thought that Student-Staf relationrhip could

date. The survey included two gen-

be improved. Of the 58 studenrs who

eral questions in order to determine overall student opinion on

of the

titioner in the community. c. Whether our training provided sufficient baric experience of community

answered the quesrion 24 per cent thought the present relationship was reasonabl/ good,'

:76

2- The reduction of the number of studentr on firms to between six and eight (mentioned in 2l per ce.t of

but 76 per cent thought it was not. Analysis of the answers obtained showed

th.t

students'

opinion was genenlly uniform and that several important changes are thought to be needed to improve the present situationThese are as follows :-

l.

l.

l.lore extentive use of tutorials by all departments for teaching purposes.

The numbers of students at tutoriak should not ex.eed three to four. and b) this method of personal tuition

The necessity for more social mixing at all levek. There were many who suggested a bar where rtudents and sr.ff could mix, also a .ommon diningr@m instead of the present modified

segregation at meal times. Several students felt that more use could be made of the firm party which often depends purel), on students' initiative.

There was some feeling that a party at the start of a firm might be benefidal in helping students and staff to

the staff would better understand student difilculties and so modify teachinS. Where mentioned, the Present tutor sFrem, instituted to improve StudeDt-Statr relataonship, was.ited as inetrective. (The need for tutorials was mention€d in 26 per cent of answers.)

baome acquainted. (The need for mde sdial mixing was mentioned in 24 per cent of answen.)

Close lndividuol ottention

on Word

Rounds.

(COPYRIGHT DR, METCALF)

27

of the

community. The need for pr€ventive medicine wa5 stressed, also accurate diagnosit

4. More attempt should be made to make the student feel Part of the

and correct treatment of disease- The need for proper ur€ of hospital statr wis widely

hospital team giving in.reased resPon-

sibility, although

I

Per cent thought

with the necersity for improYed relationshipr between the two groupt of

that this situation was being imProv€d

mentioned

increated responsibility was men'

Whereas it was generally thought that medital stud€nt traininS €quipped us with the nec€ssary basic facts and el€m€ntary skills to continue after qualification on the hospital ladd€r th€re was widerpread dissaiisfaction with the training for general practice. The course at Present contains a two we€k optional cours€ in general practice, which seems hardly sufiicient reaiising that over 50 per c€nt of medical students will eventually become medical practitioners.

Sev€ral mentioned the posrible use of.h€ Local Authority Health Clinic as a basG for a general pra€ti.e firm lasting at leatt three months. There was some feeling that a more seneralised course in the formative years of medi.al trainins was necessary with scope for extra-mural study, and courses in human biology and psychology. (Unfortu.ately it seems that the present trend k in the oppotite direction with more intensive specialitation at all l€velt.)

by the receht alteratioht in the living-in system. (The need for tioned ln 14 per cent of answerr,) 5. The general attitude of the ttaff towards the students n€eded imProvln8 wkh particular exc€Ption to the Public and Mental Health firms' where student-Staff relationship was Sener' ally praised. (Mentioned in 9 Per cent of answ€rs.)

6. The need for improv€ment of teaching technique and better integration of lectures and clinical work. (f4entioned in 9 per cent of answers-) Obviously there is a personal element to this problem and the relationship will depend to a great extent on the individual member of staff or the student. However, the survey reveals that improvements in teaching organisation and technique with emphasis on the turor system, reduction in firm numbers and more social mixing, are prime fa.tort in

improving Student-Stafi retationshiP5 as

rugSested, it is not only the training but also our own life experihospital ences which equip us with the necessary

a

As many

Se.ondly, students were ask€d what they thought was the function of the medicai practitioner in the community and whether or not their training €quiPPed them adequat€ly for thii. Again 58 students answered both parts of this qlestion and of these 23 p€r €ent thought their training an adequat€ besis to meet rh€ medical requirements of

ability to deal with the type of problems which mighr be net whiht practhing community medicine, However, it is realittic to asrume that since the function of the course is to provide us with baric experience in all branchei of m€dicine, it must provide ut with a more €xtentive experience of com" mtlnity medicine. This would help to balance the dhtorted picture that hospital training alone is likely to give. Th€ resul$ would be both ben€ficial to those who will ev€ntually become general practition€rr as well as to future memb€rr of the ho'pital staff and would, perhaps. institute a better relationthip between the two f:ctiont.

th€ community, whereas 77 per cent thought

The responre to the question at to the fun{tion of $e medical pracritioner was largely influenced by Public Health teaching, xnd war gen€rally defined as the attemPt to improve the physi€al, mental and social health 28

How you can see the world and gain valuable medical experience (before you settle into general practice)

wiqh, Jou .on apply lor . PeF meen( Comm^soo alrer I year.

)uu

w.dld vou like to se the Far [asl. thc Me.he;anean or the West lndresl'

Laier, you can study (with hnaDcial

Srudv rhc new sienes ol .virlnn. und€iwaler or nucleu medicrnc? Haw comDlctc clnNdl tredom. modern

backing) lor hisher des@. and you could ann for onsultanr stalus.

meJ;(.lequrpmcnrand lheoppor runrly

toDracrEa re^ wideand !ariedfreldot medicine? Lead an adive. excitins ourdoorlifeasainstaworld-wideblckcloth?

'.L..o'

Tnes d€ some olthe opponunnlet open to you as a Medical Odlcr in todal

.

modern

dd

For.uxr ninel;d $oEcn do!,o6 Lh.E u r

erpan'lins Royal

Narv DLrinq a 5.yed

Shorr Seftic

Cotuhlssion you er sain valuablc Dracrcal medical experiene, rrelins borh RoyalNavy persomel

ll

ed

adirr*" bdov. *irhc

d.dh d yor 4. ad

cn ilian Th€ M€dicsl Direck'..G€neral

of world telbre you *nlc into And you

;,";ad,you.*.""ry.

s@ something

of

the the

routinc ol seneral pracli@. You eiu be well paid. wilb a slartins salary high€r than tiar ofacivilian h osp ital rcgistra.

MairileE and olhd allowares eo add

considerablt to your income. Add.

&. Nr'y. DepL 26FR2!

lmprsstar€

il

29

B

lding, LoniloL SW6

Professor Yofiey (centre) relaxes at the

Galeni.ah Ball

.lose;lh llenrlal YofiepPIIOI.DSS()R of ANITO^\|f RRISTOL I'NIYBIISITI I94I.I!167 The râ&#x201A;Źtirement thk summer of Prof. Yoffey from the Chair of Anatomy after a quatter of a.entury is a Sreat los to the Unive6ity and a source of great regrei to his many friends in Bristol. He will be remembered with affe.tion by the ver/ manl students who have passed through his department durin8 hk tenure of the Chair.

Professor Yoffey,.he eldesr son of a family

with a distinguBhed hlsrory of scholarship. was oriâ&#x201A;Źinally in.ended for a Rabbiiical cnreer, but after an oursrandinC school his

iory at

M3nchester Grammar School

he

decided ro do l.4edic ne and graduared from I'lanchesler UniveBir/ ln 1924. He spen..he next four years laying.he roundarion for rhe 30

and one Demonstrator Miss Llewelln, a porter Mr. Hanks, tubstituting for the

to make him world famous by carryins out basic research on the blood cells of fishes. He discovered amongrt other things rh:t some of them had triangular red cells a.d first considered the possibility that all the cells of the blood might have a com' mon origin. For this work he was awarded an M.D- with commendation in J928, only four years after qualificationAt this ttage he was nearly wooed from his love of resear.h by the offer of several lucrative openings in General Practice but these he steadfasdy refused only to succumb to th€ temptation to become a Surgeon. He rapidly obtained the necessary qualifications reeearch that was

steward, l.'lr. Dann, away at the war, and a part time se.retary, Miss Lloyd.

Professor Yoffey immediately set about obtaining additional accommodation and equipment for research and great was the celebration when the first Rer€arch Microscope wat obtained (Prof- had brought his own frst class instrument bought out of his

first earnings after qualification) and

their cotree amongst the experimental animak, the animal hous€, at least 8 ft. square was a converted yard, and an autoclave war on the landins (fortunately as it turned out, as it later blew up blowing i large hole in both the ceiling and floormost impressively)-still it was a start- The Department rapidly €xpanded, in accommo'

adding both the Primary and the Final Fellow-

to his list of successes within the next four years. However, he could not long remain awa) from his first love, Research, and took up an appointment as a lecturer ship

in Anatomy at Cardiff to €ontinue his work on blood, bone marrow and his favourite for the role ot the elusive Stem Cell, the

dation, equipment, staff and research outputln spite of the spate of papers from Bristol Professor Yotrey was a lone voi.e extolling the lmportance of the lymphocyte whilst the

LY14PHOCYTE.

After two years at Harvard

THE

RESEARCH LABORATORY became available. True the roof leaked and the staff had

University,

reit of the world pooh-poohed the idea that degenerateJooking .ell could do anything but die. lt was not until

from which visit was born the first edition of 'Dr'nker & Yoffey', Lymphat;cs, Lymph and L)mphoid Tissue, the standard reference on the subje€t until it was replaced by 'Yoffey and Courtice' the 2^d Edition in 1956i he returned to England to marry Betty Gillis in 1940, a year later accept€d the Chair of Anatom/ at Bristol and wis 1937-39,

this rmall round

the late 501 that the essential correctnes5 ot

Yoffey's view gradually began to be accepted, first in America then in thii country, and with the discovery that phytohaemagglutinin could st;mulate this 'degenerating' cell into a burst of synthetic

in 1942.

Professor Yoffey is only the third holder of the Chair here, succeedins Professors Fawcett and Whitnall. When he took over the Chair the Department was Iiteraily in ruins, having been burnt out during the

awarded his D.Sc. (Manchester)

and mitotic activit), Professor Yoffey's nick

name'Mr. Lymphoc/te'

became

a tide of

distinctioo, and he wat even pretented with

the only haematological tie in the v/orld, silk-covered with hand p:inted lymphocytes. ln the last ten years, the Prof. has been besieged with requests to lecture all over the

Blitz. The dissecting room had been virtually completel) dettroyed and had lallen through on to the Geogriphy Deparment below. After rapid temporary rebuilding (which was to last for twenty years) enough of the damage was repaired to receive studerts again in October 1941. He then had a staff of three.

world from South America to lapan, ro chair innumerable Symposia, to write reviews for uncountable numbers of Journah from the seriously scientific to the popular educa-

tional, and a visit to Bristol

embarking

himself, Dr- Baxter, later Professor at Carditr,

3l

on any project

before involv;ng

T

lymphocytes baame a sine qua non. Perhaps the culmination of his career, during which he has been thr* times elected Hunterian Professor of the Royal College of Surgeons, been made a Knighr First Class of the Order of Danneborg for arnnging for Danish students to €ome to Bristol to do something which is illegal in thei. own country and is beginning to be considered (by some) unnecessary here,

to

dissect; came

in

1966

assembling in gristol of perhaPs the most distinSuithed gathering of Research

with the

work€.s i' the field of 'lymphocytology' that the world h3s ever known to take Part in a Symposium on 'The Lymphocyte in lmmunology and Haemopoiesis'. Participant5 came mostly at their own exPense from all over the world, many had to be regretfully turned away as the Conference was ;n danger of extending into term time In.identally a number of the particiPants thought that 'Lymphocyte Bristol ' was a sufiicient telegnphic address.

At th€ Symposium it s@n became clear that th€ techniques and lines of research first deyeloped in what was in hct a very active of

Experimental Haematology established by Professor Yoffey here in Brittol have spread all over the wqld. ln addition, School

trained here in Brittol have set up their own a.tive Research centres both in Eneland and abrotd. There are people like Dennit Otmond at Mccill, Peter Roylance at the Royal Marsden, Philip Hafis at Shemeld, David Thomas at Birminghsm, all continuing and expanding work begun here in Bristol. Needless to say the Conference was a great success and the book of the preeedings has just appeared in the Research workers

ln spit€ of his tremendous Research output and his in€redible grasp of the reserrch literature, second ro none ;n the Lymphocyte

field, and the pressure put on him by publishers to prepare new editiont of his bookr, ' Lymphati€s, Lymph and Lymphoid Tissle', ' Quantitative Cellular Haematology ', ' Bone

Marrow Reactions' and the se€tion he con-

tributed

to 'Human Anatomy'.

Professor

Yoffey is by no means a narow man. He is a noted Hebrew scholar substituting occasionally for the Rabbi in the Eristol synagogue, is fond of and knowledgeable about clarsical

well v€rs€d in world atrairs

on

which he holds notably Liberal views and

has

music, is

ro l@k after the ;nterests Medical Teachers on the appropriate B.M.A. €ommitee, on which he has been an even found time

of

active and key member for a number of years.

Yet he still remains essentially a family man always insistent on spending as much time at home with his wife and three daughters as

LookinS through

this brief account of

Professor Yoffey's .areer I see much that I have omitted-his famous teaching film; his foresight and wisdom in the planning of the Anatomy Depanment of the new Medical School, beins alone in foreseeins the vast in.reai€ in student numben whi.h w. ndw have at a time when the Willink Committee had reported that we had too many D(tors:

hir consideration, thoughdulness and helpfulness to all memben of his staff, technical,

academ;c or secrerarial, his av.ilability to staff or student at all times (that is when he is in Bristol); his ready advice on research problems, Living Anatomy-the list is a long one. We shall all miss Professor Yoffey. I cannot say we wish him well in his retirement as he tells me that he is not retiring. merely changing his venue. He plans to join his eldert daughter and establish himself in a home in lerusalem before accepting innumerable invitations to join research groups as a v:siting worker, principally in Australia and America. He envisages another ten or fifteen years active research before settling down

into retirement- Whatever he does will certainly be a success end we wouldn't have

W K

METCALF

Socrerv RepneseNTATtoN The relationship between medical students and the University Union hat always been rather liquid; the liquids concerned being

mainly water in the University Pool and bitter in the Union Bar. We pride ourselves on beirg a rather independent if not anarchistic lot, and like to stand aloof from the infighting of politict, whether it be (udent politics, medi.al politics or indeed national politics. lt was not surprising then that when an obscure cyclostyled noti.e aPPeared in the student common room annou.cing the formation of a society rePresentative council

it was largely

ignored.

Union Council is to us a breeding ground for Arts and Law students who wish to appear on University Challenge' of to obtaln employment as sheepskin coated newsreel int€rviewers with Southern Television. lt took the more worldly and regimented mind of a dentist to spot that Union

council is also the seat of Power amongst students, being able to make representations to senate. and that the members of

?

by Terry Homblin The

frst

meeting

of this <ommittee took

place last term and I was privileged to attend

along with eighteen other people. We decided that the committee would be €alled

the Society

Representative Council and should comprne one member from each departmental lociety in the University. We elected Peter Richardson chairman and the member from the Politi.al society as secretary and the member from th€ Hispanic Sociery as P.R.O. We then proceeded to toss a f€w iargon phraset around like terms of reference' and 'proportional representa' tion' and two thirds majority' and I must .onfess to some regret that I allowed myself to be talked into going.

However it seems that we did decide that the ,unction of the societl was fourfold

l.

To represent to union councilall depart-

mental affairt relevant

to union

affairs.

Union Council were elected on minute Polls, often comprising under one third of the students eligible to vote.

L

dissem;nate decisions of union council to departmentai societies.

To represent to union <ouncils all complaints of a departmental or personal nature from our members.

a foot'ng was Union Council, and perceiving the unfairness of a system whereby members of the l'4edical Faculty were without influence, and with an eye no doubt on Harold Wilson\ teeth, Peter

4.

To

Seeing how unfirm

Richardson, secretary of the Dental Students' Society, gathered about him a hort of mem_ berr of his society, numbering nine score and six. and conveyed them to a Union General

Meeting. Here in a fascinating examPle oJ power politics he forced through a motion requ,ring tha( a comm;ttee should be set uP ro give representauve power to chore people who worked from nine 'til five (meaning us !) and were consequendy prevented from partaking in present student Politics

2.

To

examine

the

business

of

union

There were dark hints that this council might not always be so subservient to Union Council, but none so concrete as to prov;de the launching pad for a rebellion at present.

Galenicals, while remaining an aUliated society to the Union has alwayt maintained a good deal of autonomy and expresed indiflerence (o wha( goes on in that 'Scandrnavian Airport' in Que€ns Road.

However. wrth tne advent of rhts ner council there rs d need to re-e,am;ne our tEdrrional isolaronur attitude, panicularll in the lignt of recent dbcu$ion on a staff/ student liaiton committee-

i..(

I

l

o.i

:1 oo.

3

(JF

<!: o< t

;>

u::ii t,

e

q Fo

;XD ad.E oo ; .9p

I o

..d

A*

Royal College of

of

Su

rgeons

England ANNUAL MEETINC

OF FELLOWS TxE

AND MEMBERS

b€rs

tunual xeeting or Fellows and Mem-

of the

Royal Colleg€

of

Surgeons ot

England is normally held on the College'r own premis€r in Lincoln's lnn Fieldt, London.

This was only the fifth occasion on which the Meeting was held at a provincial ceni"€.

Preyious meetingr wer€ in Manchester, Cardifi, Shefii€ld and Birmingham. Thus we I€lt honoured in Bristol to acr ae hosts for this padicular meetinS.

HELD

Prior to the Annual General Meeting on

l6th December, Scienview in the Anson on tific Hall and f|eeting Room I of the new Friday afternoon the

IN

Exhibits were

University Union. These were presented by Surgeons, Dental Surgeons, and Anaeithetists from Bristol, South West England, and South Wales. Prominent amongst the exhibits was work from the Department of Surgery,

BRISTOL

Univeristy of Bristol, on portal hypertension,

transplantition of the Iiver, treatment of liv€r disease, and immunologi.al aspects of malignant disease. A total of 97 interesting and varied demonstrations made thk a memorable exhibition.

At the Annual General

l6th t/ lTth

l4eeting the Preli

dent of the College, Professor Hedley Atkins, was accompanied by the Vice-Presid€ntr,

December 1966 36

talking from the other side of the Atlanti..

The rett of this Symposium consisted of papers on the complications of intravenous infusions; portal systemic anastomosis (by Emeritus Professor R. Milnes Walker); treatment of varicose veins; fibrinolysis; pulmonary embolectomy; and the surgery for deep

john Terblanche, Ch.M., F.R.C.5., F.C.5.(s.A,)

Professor Charles Wells, C.B.E., and Professor R. MilDes Walker (Emeritus Protesso. of Surg€ry, University of Bristol), and other f4embers ol Council of the College (including Mr. Robert V. cooke). The Dean of the Faculty of Dental Surgery (Mr. Terence Ward, C.B.E.) and the Dean of th€ Faculty of Anaesthetists (Professor Cecil Gray) w€re

The Faculty of Dental Surgery held

A- l- Darling): and jaw'.

The Fa€ulty of Anaesthetists held a Sym, posium on "Pain", with papers on the problem of pain (by Profe$or l. Clutton, Brock); the problem of assessment of anal, gesicr: the assessment of analgesia in obstetri€s; and regional analgesia in the treatm€nt of pain (by Dr, J. H. Challenger).

also present with Members of the Boards of Faculty. The fact that it was one of the largest gatherings of Fellows and Members ever to attend an Ann'ral General Meeting wat a tribute to the organisers in Bristol.

On Friday evening a yery successful b3nquet was held in the Great Hall of the Universit). Guests included the Lord Mayor and the Sheriff of Bristol, the Chancellor of the University of Bristol (the Duke of Beaufort), the Vice-Chancellor, the Bishop of Bristo:, together with other r€presentatives of civic. .cademic and industrial life of

At

2.00 p-m. on Saturda),, lTth December,

S;r Phillip Morris, K.C,M.c., C.B.E., patt ViceChancellor of the University of Bristol, was

admitted to the Hononn/ Fellowship of the Royal College of Surgeons of England. The ceremony was preceded by an organ recital br Professor Willis Grant, F.R.C.O. (Proressor of Music). The Council of the College entered in procession at 2.00 p.m., and the Vice-Presidents presented Sir Phillip to th€ President Professor R. Milnes Walker, C.B.E., presented the citation which was seconded

by Mr. Roben V. Cooke. The guests at the

Symposia on Medical and Dental subjecB were held in the Univers;ty Union and the Wilk Memorial Building on Saturday, lTth December. The first was a Synposium on '' The Venous System " with a morning and afternoon session, under the Chairmansh;p of S;r James Paterson Ross, Bt., K.C.V.O. Great inter€st was shown in the first paper entitled " Operations on the lnferior Vena CaYa" by Professor M. S- Deweese of Missouri, United States of America. The prper was deliyered live by transatlanti< telephone; the first time this medium has been uted for a medi€al meeting. ln a talk,

well illustnted with slides,

a

Symposium on Some Hereditary Diseases affectiDg the Mouth and Teeth ". The subjects covered were mucosa; teeth (by Profesor

ceremony included the Duke

of

Beaufort,

the Lord Mayor aDd the Sfierif of Bristol, melnbers of Sir Phillip Morris's family and representatives of Senate and Council of the University.

The whole meeting was a resounding in Brastol were proud to be hosts to the Royal College of Surgeons. The meeting was organised by Profersor A. G. Riddell, Mr. J. H, Peacock and Mr. R. V. Cooke arsisted by members of the Departsuccesr and we

Professor

DeWeese described various operat;ons on the inferior vena cava deyised to prevent pulmonary emboli reaching the lungs. The

clarity of the talk made it d;ffcult to real;se that, for Professor Deweese, it was the early hours of the morDing, and that he was

of

Surgery. Student yolunteers also helped to ensure the smooth running of the meeting attended by over 400 people.

ment

37

PANTOMANIA 1966

Cinderella Dental Pantomime Lovelt Roger Webb ar Ugly Siiter l.

The Societ congratrlatcr ibelf on a l.virh production of Cinderell. in €pic form, The rcope ot the production saw an added denand lor tickets and an extra matine€ was Put on at thc la5t mom€nt.

It wai a Srcat ru(ce.s in all r€+Gdi and

approximatcly ll00 har b€€n rai'€d for charity. De+ite the fact that coitr incl'rded Cto for replaccment of ' mirappropriat€d ' rtag€ curtainr from last y€ar.

For this year's panromime at the Dental Hospital, the tradirional srory of Cinderella was chos€n. and with suirable embellishment provided enieftainment for large audien.es at s;x performances. Although 'takings' are perhaps nor a reliable yardstick for judging

the success of any hospital pantomime, this was the most financially rewarding rhow of recent years rnd thk must reflect the obvious enjoyment of the audiences- ln iny pantomime overall impressions are of prime importance, rnd any specific criti<kms must be related to the genenl eff<t created.

l8

Pete Easton and Sheila Reid as the Prince and Cinderella.

mime is not clearly defned but

There was mu€h that could and should be criticised in this show, but there is no doubt that the obvious good humour of the per-

dialogue.

formers was infectious and the audiences went away both amused and entertained. ln using 3ny widely known theme for a pantomime th€re is a considerible risk of losing the attention of the audience, tlnless the script is exceprionally sfong. lt may ultimately be ersier to formulate an original plot and rely on the element of turprise to

which were difiicult

hold attention. There were momentt

or as a defrnite adiunct to the story. The music used ;n Cinderella gave the impression of hav;ng been forced anto th€ production, and left one wondering at to its purpose. However, neither the cast, nor pianist/arranger Dennis Hutchinson can be held responsible for this : perhaPs the baiic fault was in the choice of melodies, many of

tht

as

well

as

:nyone, but the plot was

strongly outlined, and the

characters

a nice

successfully

some simple yet highly efiective scenic derigns, and sets and costumes were both well constructed and srriking, without being

sharply d€fined both in the writing and Per-

formance, There was

to perform

by amateur standardsDespite any criticisms though, thk pantomime was a sutces, and the biggest single reason for this must be the very high technical standard reached. Phil Owen Produced

in

Cinderella where the script laboured, 3nd it was only too obvious that the cast aPPre.i_ ated

it must su.ely

be used either as a method of linkins

balance of

: the burlesque of the Ugly Sisters well compensated for by the suPerbeing of a sarcastic Fairy Godmother, ciliousness writing generally allowed the Proand the and smoothly. to flow natunlly duction w€ll to the performers responded The given, and it is difilcult were material they humour

garish. Eric Nash deserves a special bouquet for attempting the near impossible in lightinS such a nightmare sl:ge, but the considerable amount of work he Put in was well rewarded.

Th€ effi.ien.y and silence of the stage .rew contributed gready to the smoorhness of the production, and the business side of the show was handled with customary expertire

by Suran Hunt, lan Kelly and Des PyPer. However, the major portion of the c.edit

to single out any for special mention This in irself is something of a compliment, as so often ;n the past, hospital shows have been 'carried' by one or two individualt. lt was a plea,ant su.prise to see a Chorus who sung their songs with considerable €usto and movement, and who did more than Provide background decoration for the principak.

There were a number of nicely observed 'cameo' performances notably by lohn Rees,

must ultimately rest with the writing xnd production team. Bob Miller demonstrated the nnge of his talents with his individual acting performancq and was closely con.erned in the writing and production oi the show. David Lewis is certainly no newcomer to the field of hospital pantomimes, and his iniuence could be sen throughout the production. He is a rare type of peBon to find in the amateur theatre; combining consider-

Dan Glover and Cecilia lackson. She;la Re€d and Peter Easton managed to sound convincing in their unenviable rol€s, and Nicky Spencer's overbearing Fairy Godmother

able acting and writing talent with

found a fine sparrirg partner in the Baron, play€d with great aplomb by Norman PraceMuch of the laughter was generated by Roger Webb and Bob Miller as the Ugly Sisters, and both their character and aPpear_ ance wer€ well contrasted. The mxk€'LrP and

an

additional capacity for dealing with organisational and administrative problems.

Perhaps the only way to end such a

criti.km is to congntulate all concerned on 5uch an enjoyable show, and to hope that a tradition wh;ch has been so firmly founded

wardrobe deparrments murt m€rit a sPecial mention in thir retpect The fun.tion of music in a hospital Panto-

over the last three years 40

will be perpetrated

A Ch"itt-"t

Fact'or

Your

Ho* To

Bleeding

Waste

I ime

MEDICS PANTOMIME

Chorus line-up: left to riSht Rosemary Hutton, Mary Pullen, sue Robinson, Janet Butler, hene Fitximmons, ,udy Adams.

rion with a medical bias. The traditional srory of scrooSe lent itself well to adaptation. He was portrayed as a General

The hazards of pantomime produ.rion <an make the life of a houseman seem l;ke a holiday-so it all started in the Quiet Room of the Bristol Royal lnfirmary at a sparsely attended meeting some iwo months before the production. As many of the original group dropped out and new and interested members ioined the production it was the continued efforts of Peter Hammond Evans as author and produ.er thar ensured the high itandard of the final performance.

The scripr provided excellent pantomime

Practi.ioner with a parr rime cons!ltant posi at the B-R.|. (o^e afteriooi a week).

The chorus girls provided an attractive

inftoduction and scene continuity was aided by the verbal eloquenre of Leon Kreitzman as narrator. However. rhe standard of per, formances varied considerably. lt was onl/

b/ rhe final night thar the

production

approached the meri$ of rhe script, and the fluenq of a reasonably polished performan.e was aftained by the casr- Outstanding were

materlal, a serious rheme, humorous elabora-

4l

rhe characterizations by PeEr Cook and rhe highly professional musical accomPaniment

by Graham Steer, Piano; Malcolm Bovce. rrumpeti Myles Fisher, trombone; and David

Shalli,, drums.

lt;s a Pity that

musical

accomPanimen. could not have been used more extensively, Particularly dur;ng scene changes. The cast showed talent for an amateur Produc.ion with versatile Perform

from Terry Hamblin, Bob Price and bu. they were handicaPPed b/ Wyatt, Sue ances

The stage sett'ngs were simPIe and the

sound effecs added humour to rhe s.rrPt ln

spire of its fauhs credit musi go to all \rudents concerned lor Produ'ing a panto mime well worrh seeing

Pete Hammond Evans (as s.roose) and Ram

Narai.

Terry Hamblin and Rosenary Hutton in a scene from 'The Dance of the Dyins Duck '.

Terr/ Hamblin, Fred Hacking and Negus as three drunks.

Andrew

STOP PRESS GALDNICALS

BANQUDT

& BALL

t9,G7 Thir social highligh( of the year will

be

held at the newly decorated Grand Hotel on Tuesday, March 2lst. After an excellent meal music will be played through '(il 2 am. by Dennis M:nn and hi5 orchestre (resident at the Grand Spa). There will be a students .abaret, raffle and tPot Prizes. Send for â&#x201A;Źarly bookings

to:

The New Entertainmenrs Committee' students'Common Room, B.R.l., Bristol 2.

student tickets: (lNCLUslvE OF wlNE) 30/- single Houseman tickett: (INCLUSIVE OF wlNE)

'tol:

Single

Other tickets: (INCLUSIVE oF WNE) 50/Single-

11

The Pre-Clinical Party

The Annual Galenicals Ball 2nd November 1966 The Annual Ball was held once more this year at the Top Rank Ballroom, which it sufficiently spacious to allow some origi'ality on the floor ! As a result of a misunderstanding over booking dates it was only possible to hire the ballroom in the middle of the week. Next year the function will definitel) be arranged for a Friday, as in the past; this we hope will conciliate those with partners lrom afar and that high ProPonion of revell€rs who prefer 'the morning after'

Once again the members of the third a pre-clinical party. Thanks to the help of Dr. Metcalf students were able to enjoy the luxurious setting, for the first time, of the Senior Common Room at Senate House. The evening was a great success as once again the cabaret went nearer ro (or rurther beyond) the line than ever before- lt met with enthusiastic:PProval both from those who were the subject of the rketches and those who were not

year organised

M

CULLEN

Left to right: P€t€r Baylk, Frank Smith and Brue Bryant in €ntertaining fotm at the Galeniels Ball

The cabaret at midnight,

Presented

traditionally by the fourth year, was brief and consisted mainly of songs-audience reaction wat gratifying, but seldom does one have such a sympatheti€ and aPPreciative assembly to perform before.

We were pleased to welcome Professor and Mro. Yoffey as guests at this Ball, a3 the Professor retires from the Anatomy DePartment later this year. Other guests of the Society included Mr. Stanley Robens of the Physiology Department, who for many years has graciously given up his time to showing the slides at Galenical lectures.

There has been some criticism oi the Discotheque atmotPhere Senerated bv the ''Disc Jockey " and recordi as being ;nappropriate to su.h an occasion as this; any orher commenb or su88es(rons for imProving next /ear's Ball will be most welcome.

Electives Srudents interested

:

in spendiig

their

elective period in South Africa should write

Dr. Michael stephens (Graduate

1963),

15, Stromboli,

Nathanial lsaacs Crescent,

North

Beach,

Durban, Natal, He is willing to accommodate a student who ii irtererted in doing an elective at the Department of Medicine of the University

B.M.S.A.

.

The B.!j.S.A- survey on medical students' liYing expenses came at a dme when students were being inundated with suryey

forms.

As a result th€ returns

only

reached 30 per cent. These were duly dispatched to B.f'|.A. House, but the results

of the Natio.-Wide

Suruey have

. At Charing Cross Hospial

Stop

not yet

Press

on the l8th of

November an emergency m€eting was held to consider certain rumours that the Preregistration period was to be increas€d to two years. However, at a meeting on the

followins Thursday, it was

announced

that investigations had proved the rumours

to be unfounded. The meeting went on to discuss conditions of servi.e that would make the move accePtable to medical students- Th€se conditions included short-

ening of the clinical .ourse, instigation of a proPerly organised Post graduate tn'ning scheme, and the provision of adequate

accommodation

for both maried

BOB WILSON.

and

Dental News Mr, lan Kelly wat re ele.ted as president of the ro.iety in succession to Mr.lohn Lucia whom we congratulate on obtaining his News was made last October by Mr. Peter Richardson who investigated a movement in the Union whereby each so.iety gains rePre-

senBtion to Union Council by meant of a sub<ommittee- This has long been awaited esp<ially in faculties such as our own who seem to have little say or fostered interest The aims of the Councit thall be to

(')

lnvestigate and represent directly to

Union Council

all (i) (ii)

Stop Press

.

recommendations

from members of the union. (b) Examine records of Union Proceedings, and investigate this buriness as it comes within the terms of this complaints

Council.

Mr. Michael Goldring regrets that owing to qualifying embarrassments he will not be ible to take up hit appointment as House Officer in the Orthopaedics department

-hi.h hs

been offered

application

to him-another wide

of dentistry

perhaps

!

Vivisection ? a third year student who felt

Recently, strongly about what he called, 'the wastage of animals for teaching purposes ", wrote a long letter to the Evening P6t, explaining the situation as he saw it. The Evening Post in an attempt to determiDe the facts contacted the Physioiogy departmen! and due

to

StopPress...

prompt action by the department and

subsequ€ntly by the author of the letter, the letter was never printed. ln following up the problem, Profersor Buller spent an hour with the members of the year- He explained that w;rh the new tea.hing methods the time

being rpent working wirh 'living material ' wis being reduced to a minimum. However, he expressed his frm belief ihat there was an irreducible minimum o{ live animal work which he thought important for all medical rtudents to do in their preclinical years. He ako dercribed the possib;l;ty of additional experimental work on animals for medical students who wer€ interested, but the work would be yolu.tary. This problem emphasis€s

the

need

for a litde

explanation

of

the

reason' why vivisection ir included in the medical course. lf this were gr'ven at the st.t of the course I am sure many students would

The New Entertainm€nts Committee Do you feel there is a place for more organised entedainment within the Medical Faculty ? during the long summer evenings rnd vacation time, when the doors -Especially of the union might just as well be locked, and social gatherings are limited to " coffee in the flat" or "a pint (or several) in the Hirt ". ln the past all the organised entertainment has depended on the ability and enthusiasm of one student, the Galenic.h Entertainmentt Secretary- This has been an onerous tatk for

a lone operator, so a

rub-committee of

Galenicals har been established to delegat€ some of th€ responsibility. The Committee's function will be mainly that of organising the Annual Ball, the new-style Banquet and Ball, and posdbly a Final Year Ball, in June. ln

Stop ?ress

addition, we hope to organise about six informal Ho'pital Hops each year. Plans are still embryonic but one fact is clear; the success or otherwise of the Committee will be entirely dependent on the support received from all medics.

The New Entertainments Committee: Alan Fishtal (Chairman), Geoffrey Freakley, Peter Hammond Evans, Sue Wyatt, and Angela Knights.

MEDICS

IN ACTION

RUGBY

Captain this year is Ashley l'4urdock, founh year Denrist, and a player of coniiderable experience. Ashley's main efforts sin.e the start of the season have been rc imProve the standard of play of the team. Aided by the arrival of good players from the second year of the dental course the earl) season results were very en.ouraging and enthusiasm rose.

However, the sporadic availability of certain team membero and injuries contributed to a marked deterioration in play. Conseqoently, the Ist XV lost all their matches in the lart month of the term. ln future the imPortan.e

of

choosing enthusiastic and regular players must be emphasised.

Training sessions will be starting in the physiotherapy gymnasium on Mondays at 5 o'clock, where there will be ample opportunity to discuss and practise mat.h tactics.

It has also been decided that .lub ties will only be sranted to those who have played lJ games this season (thus eliminating some of During this, the second season at rhe new

at Brislington,.lub organisation has considerabl) improved. Pitches were

club-house

in use and thanks to female helP food has been arranged for most home matches. We are still pressing for a license to set up a bar at the club-house, fo. at present beer has to be taken out for each

IJ.B.H.

lst Xv

soccER Afrer an enthusiastic and fairl) successful start to the season a decline set in during November from which we never really

to such an extent that it was often impossible ro raise teams for away games, and as a consequence we have had to can.ei a number of good fixtures, making ourselves rather unpopular recovered. Enthusiasm waned

regularly

Or,rr finances have also improved in spite heavy cost of awa/ matches, London {25, l'.lancherter {27, and the outlay of {45

of the

for a new set of jeneys. This term we have 17 fixtures, and will be sending at least one team to the Provincial Hosp;f}ls'Seven-aSide Tournament in Birmingham, on April l5rh.

I would like to ex.end the Club's thanks Bourns, Dr. Tinkler, l"lr. criscuolo and lvr. Bickle, for all their help.

to Mr.

PETER COOK.

A5 with many other clubs the dental contingent has been considerably larger than the

medi.al one; in fact. withour them there woold probably be no team at all. There is an absence of preclinical s.udents in the club. lf rhere are an/ interested in turning our rhey would be welcomed with opened armi. All they need to do is to get in contact with Craig Walton at the Dental Hospital, or myielf at the B.R-j.

The success in finals by gob Binnersley, Graham PlrneU and John Lucia means that rhe team lose three of its stalwarts that have been regulars since the.lub was revived four years ago, We shall miss their skill, but even morâ&#x201A;Ź their keen.ess.

BOB WILSON.

ALUMNI OF

GALE N ICALS EDITOR

RON SIMPSON

It was some years ago that r€marked to me rhat the

demke. Now I have reached rhe rrage where even the Consulrants look young.

Thifking about the s'rbject of age ted me

someone

firlt

sign of getting old is wh€n the policemen start tooking young; this was at abour rhe same time rhar

to study Shakespeare'r,onderful

lhad

alread/ noticed how young medical studentr looked. Since that time, detpit€ a .onstant search, I have failed to 5ee €irher a policeman or a medical student who looks

descrip"

tion of the seven age, of m.n from " As You Like lt ". I hope that lovers of Shakespeare, and the Bard himrelf, will forSive me for desecrating this delaghtful passage, but it only needs a litde adaptation to dercribe the

Unfortunatell the shuation has not

various ages of the modern medicat man:

improved over the years; I have also passed through the stage when hospital registnrs look young. While offering my sincere congratulations to Mr. ,ohn webb ('53), on his

' lvlawlinS

At first the student, the scrums and nestling in the

'n And then the weary house-'urgeon, with

appointment to succeed Mr. Robert Cooke ('26), as Consultant Surgeon at the B.R.t. his appointment seems to have.ompleted my

his retractor.

And unshaven morning face, creeping tike 49

recently ret'red, and to Mr. Robert Cooke, who is due to retire later this year, lam sure all Alumni will join me in wishing them all

Unwillingly to the Morning Round. And (

Pre-

or Post-Resistration), with a woeful

of happy retirement.

Although retiring, it would appear that neither of the latter two distinguished surgeons, (both Bristol graduates). will get much rest in the immediate months ahead.

Mr. Cooke ( 25), has the honour, and the problâ&#x201A;Źms, of being President of the B-M.A. in the year in whi.h Bristol is playing host many years

For keeping his girl-friend waiting once again. Then the Registrar.

Full of strange oathr, striding around the lealous

in

honour, sudden and quick in

(Particularly with fellow comPetitors for

All

to the Association at its ADnual I'leeting this July, At the same time f4r. Angell James ('24), is Chairman of the Bristol Division of rhe B.M.A-, and I also note that he has re.ently been elected Prâ&#x201A;Źsident of the British Assdiation of Otolaryngologists for 1965-67 It seems a ftting tribute to them, and to the Bristol Medical School, that the Annual Meeflng ot the BM.A should be held hete

seeking the bubble rePutation

Especially in the Professor's eye. And then the Consultant. ln fair round belly with good caPon lined' With eyet severe, and ruit of formal cut,

Full of wase saws and modern instances: And so he plays hir part. The sixth age liftt

Him to Dean or Professorial Cha;r, Wirh spectacle' on nose and retinue

by

his tide,

Older Alumni will learn wrth regrer of th. recenr dearh in rhe B R I ol l',1r. H. Chrtt/.

Iime does not allow a full appreciation o' Mr. Chiny s lile and work rn thr! issue of the

The youthful srudents gathered around How they all shrink when his big manl/

Black Bag, Dor would I be competent to wr;te one: however, a former House-surgeon of his, Mr. A. t. Eyre-Brook ( 32). has willingly agreed to do so for the nexi rlue Suffice Ior me ro sa/ that he wai another who belied Shakespeare s seven(h age. lvlr Chirty worked as an Honorary General surgeon at the B.R.l.i he had a special in Orrhopaedi(s and worked at Win'nreres( ford also. Because of the war he carried on his hospiral work beyond reriring age. eventually redring in 1946. To the delight of many, immediately after this, he was ele.ted sheriff of Bristol. That was nearly twenty years ago; his death came at the grand age

Pours scorn on the student who PiPes The wrong answer on his Round-'

Here I musr stop, for ShakesPeare s Last scene of all . . . second chaldishness and mere oblivion' etc. does not seem to apPly

at all to the modern medical man- ln .ecent weeks I have seen Dr. Orr-Ewing, Dr. B;rrell Mr. Hector, Mr. Adami and Mr. ShePherd; all appeared to be in good health and looking not a day older rhan when they retired. I have also heard that Dr. Sutton is making a good recover/ after a recent illness and that Professor Drew-Smythe " looks as young and frisky at ever"- I noticed in a recenr B.M.l. that Professor Milnes Walker Played an important part in the meeting of the Royal College of Surgeons in Bristol in December. Professor Brocklehurst and Professor Neale are also rePorted to be enjoying their retirement. To all these gentlemen, and to f4r. Angell James, who has

of

84.

Younger Alumni will alro learn with regret

that Professor Gordon Lennon has retired prematurely from the Chair of Obitetrics and Gynaecologyi he is emigrating to Perth ro take up appointment a, Dean of the Medical School of the University of western 50

Australia. As

Macaa for omitting h;s rame from the last of membeE in the last issue of the Black

Many students, both Pre-and Post-graduate,

parr and yet it Sives me an excuse for drivi.g a point home. Sandy Macara ir L*turer in Publi< Healthi he qualified at clasgow in 58 and collected his D.P.H. in

thit is an unexpected move I have asked Professor Lennon to exPress his reasons for maki.8 it in r seParate article.

Ba8; this was an unfortunate

teaching at lectures, rounds and Refresher Courses, Also, the Alumni will be losing one of its three Life Members, so I am s'rre you will join me in wirhing he and his wife well in their new ventur€. ln previous articles I have mentioned that a large number of Bristol gnduates have emigrated to Australia; I have also remark€d that very few of them have joined the Alumnj. As many of them have settled in and around Perth I am confident that membership of the Alumni will increase <onsiderably once Professor Lennor arrivs !

will mits his forceful

London in '60 before coming to Bristol- Not only is he a member of our Sdiety, and also

reent contributor to the Black Bag, he has recently been elected an Honorary VicePresident of the Galenicals Society itself for a

To return to my nostrlgic note I

As lwrite thir article lam becoming more and more suspicious that the Uni versir) is playing Musical Chairs. I have iusr herrd that Profestor Yoffey it due ro retire a( rhe end of this Acrdemrc Year. Howeveras he is to speak at our Annual Reunion on Saturday. Apnl 29th, we wrll have a better opportunity of saying far€well (han through

once again, be responsible for the refrethments. Having iust met him once again all I will do here is to marvel at the fact that he is still smiling after coping with the whim' and fancies of the res;dent staff for many years; he has al$ been involYed in mu<h

extra work with the recent extension of Dolphin Hoose, and he also Played a large

far my comments have been confined entirely to members of the staff As I have So

pan in the PreParation of the HotPitals Sports Ground at Brislington. How he finds

received no articles from an) Alumn' I make no apology for this; I doubt if any is neded

in any case as I know that Alumni

time for his two favourite " hobbiet " (the R.N.V.R. at H.M.S. Flying Fox and sardeninS) I do not know. lncidentally, he won the CUP for the best vegetables at the Eristol Flower Show last September for the sixth €onsecutive year. ln <2se you should want to know my reason for visidng him I will tell you: I have asked him to write an article for the next Black Bag on "Some Residents I have known ", I feel it only right to war. you in case an) of you should wish to consult your solicitors straight awaY !

are

always interested in their former tea(hers. lndeed, here lwould lke to take this Poinr furrher and appeal to all members of the consultanr and TeachinC 5(aff ro io;n our Society; we are prepared to overlook the

facr that you mat not be Bristol Srdduates and would welcome your membershiP just the sarne ! If you intend to join, please dont somewhere in (he back of your park the 'dea bus/ mands, but do so shortly so that you can join us rt our fourth Reunion on APril 28th/29th.

At

must

mention one other member of the HosPital Staff who is due to retire in May: Mr. Billy Bickle, Chief Steward and Purser of the Sood ship, Dolphin House. We will have ! better opportuniq of wishing him farewell ar our Reunion on the Friday evening as he will

to you all v;ews and articles for yo'rr new5, again once my address at Cred;t Squeeze th€ Despite Before cl6ing, may lapPeal

previous reunions many mem-

bers have expre$ed disappointment that Profesor/Dr./Mr. , were not presentThk seems to be the right moment at whrch ro s€nd my apologiet to Dr. A. W

the moment is still 144 Stoke Westbury-on-Trym, Bristol 5t

9.

Lane,

NEWS IN BRTEF in the News Mr. Norman c. Ianner ('30). senior

People

surgeon at Charing Cross HosPital, has been made an honorary Fellow of the American

College of Surgeons.

Dr. Fnncis G. Farrell/ (55) has left Britain to join the Government ol Guyana as a psychiatrist in the Ministry of Labour' Health and Housing for a Period of three

years. Recruited by the Minisny of Oversear

Development, Dr. Farrelly, D-P.M , will be stationed at the Public HosPital in George-

Professor

A. M.

Critchley ('27)' M.D.-

D.P.H., D-1.H., has beâ&#x201A;Źn aPPointed Prcfessor of Public Health at Haile Sellassie Inrcrnational University, Addis Ababa, EthioPia'

Congratulations to the following on obaining higher qualifications: M.D.: Dr. R. J. Ancill ('s0)r M.R.C.P.: Drs. H. Steiner ('59), A. G. white ('s9), G. H. Robb ('60); D.P.M.: Dr. A. H. Ogden ('s9)i F.R.c.s.: I. O. S. Okeke ('62), R. W. Hiles ('57), A. Hinchclife ('60), P. l. B. Smith ('62), C. Panahy ('59), P. H. Taylor ('60); F.R.C.S.E.: J. O. s. okeke ('62), s. T. decari' ('s9); D.A.: M. Drion ('62), C. G. Hallward ('62), M- w. lkediie, nee Huggins ('63); D.c.H.: C- A. Matthews ('64); D.Obst.R.C.O.G,: B. Hussins Hanstead ('61), M. w. Ikediie, ('63), R. G. Newhouse ('6a), R. ^ee N. Seymour ('63); F.F.A.R.c,s.: I. A. C. strachan ('59), A. Murray Wilson ( 59); Dip. Path.: R- L A. A. Aubee ('5e).

He joint anorher Briltol graduate there: Professor Coralie Rendle Shon.

Other Newr Profe'sor Milnes Walker, a vice-President,

is rhe Bradshaw

Lecturer

to the

Royal

Surgeons for 1967.

Dr. Barry Hans.ead ('61) is enjoying life in a single-handed Practice at Upminster,

College

Dr. D. I. Mahy ('57), F.F.R.' D.M-R.T. Consultant RadiotheraPist, North Glcu.estershire and Bristol Clinical Areas.

Dr. J. M.

Slater ('59), lect'rrer

in

Obstetrics and Gynaecology, Bri,tol.

Dr. M. Meservy ('62), demonstraror

in

Pathology, Bristol.

Dr. M. O. Symes ('59), lec.urer in o(Perimental surgery, Bristol.

of

Dr. R. T- Marcus has recently returned to Bristol from Ugandr.

Two second sons safely delivered to: Mariorie Leonard, nee creighton ('61), and to Linda Egdell ('62), nee Flint, wife of Duncan Esdell ('61).

Finally, on behalf of all Alumni, may I

send best wishes to three Consultant Surgeonr ar present on Sick Leave : Mr. John Pocock, convalescing after a recent operation, and

to

l'4r. Charles Bartlett and

Mr. Kenneth Malcolmson, both after recent illnesses.

recovering

Common

R. s.

NEW BLACKWELL BOOKS Ne\e an.l Sta dad Titles Symptoms ol Dis€as€ ir Childl€tr D.r's ,-1pril

lLLrNcwoRrE, illustatioB.

196?

Aboul

296 p4es. 4

42s

Lecture Notes on Castroenterology

R. D. ToMtN, 1

illNlmfion.

M.D., r.R.c.P. Septemter 1967. 208 Pagqs

I S. FLEMTNG.

Th. P.€dirt'ri. Pes.ribar

and M, V BRTMBRIEE, F.R.c.s JulY 196?. 256 pag6, 111 i'ius_

Textbook of Pharmacolog/

w C. BowMN. !u.D..

O. B. WEsr, o.sc., itlustmrions.

n.pE^RM.,

M. J. R^M, M.sc., P! D-, and June 1967- 922 pag4, 250 About f5

Clinical Anatomy

E s

398 pases. 208

A

Coulse

G. M.

20s

About 185 6d

L€cturc Notes on Cardiolog/

HAoLD

Schdroth (Zttd tdtion) Hl'@n Mi(oandomy

illustFtions.

in Reml

F.F-c.s.

Thinl Edltion

t966

4)s

6d.

Lecrure Notes on Obsl€t.is

Mussrcre (Seco d Etlition) 25s.

An lntrcducrion ro Sodal

Hmdboot of Obstetrics lnd Benson \seco

d Elitiok)

Hmdb@k ot Pacdirtri6 Silver {,t€vc,tt Eliron)

Dis€ases

BERLTNF, M.B., M.R.c,?. 1966.414

catat Qhht Etlition\ n!

lases, 62 illusbations-

Btuqn (Second E.titio )

BLACXWTTL SCITIITIFIC PIJBLICATIONS I.TD., (IXFORO AI{D EDIIIBUROH

BRISTOL

-

PERTH

A PROFESSOR'S FAREWELL

by G. GORDON LENNON I am proud to have been a speaker at the original meeting of th€ Alumni oI Galenicals, and to be listed as a member although a graduate of another Medical S{hool, Therefore, I could hardly refure Dr. Simp'on's request to write " somethihg " before I leave for good (or bad !) for another part of the 53

As you now know, I am to be full-time Dean of the Medi.al Faculty of the University of Western Australia in Perth. Why leave Bristol ? Let me say at once that I have enjoyed m/ fifteen years here and find departure will be not without sadness. Like the indications in modern obstetrics for Caesarean Section there are many reasons in any partkuhr"cs.

subiecr on which most medical professors could say a lot ! I hope, therefore, as a fulldme Dean, to be able to play my part in helping my colleagues with some of their burdens. I was otrered clinical facilities (and even limited private practice) but these I de.lined for the above reasons. and because it would be untar to the present holder of the Chair of Obstetrics and Gynaecolog/ in

First, and probably most important of all, the po5t appealed to me very much. Only such experience as I have had over the yeaB

Other reasons for leaving are suppl€menmry to the first; the restlesnes of the Scot, the desire for sunshine on one's ba.k during one's later life, and not least the d$ires of one" family to live and work in the " new "

for it- I have had a grounding in committee work, academic, hospilal, and can qualify one

college, and I appreciate British compromise !

There is something in Anthony Sampson's quote in his Anatomy of Britain : "Committees are all r;ght provided I am in the chair and rhe other two memberr are in bed with 'flu ". I have had a long innings at planning, but the runs have not come easily

Perth is a beautiful city of comparable riue to Bristol. Like Avonmouth its port is Fremantle. But the river i5 wide and only slightly tidal. There is no gorge. The Universit)/ is contained within a campus a! will be rhe new Medical Centre and associated horpit:l. The climate is f,lediterranean I

and it has been more a performance of stonewalling without the stones rising in the shape of buildings ! I shall have an opportunity now to help build a new Medical

" lt is not surprising that Australia's poe$ and painters whether Aboriginal or of civil' ised experience have peopled tuch a land

Centre and TeachinS Hospital in Penh. There are only five full-time Deans of Medical Faculties in the United Kingdom so the

opportunity of being one does not come often although it is likely to arise more often in the future- \|r'ith th€ increase in numbers of students and professors in Bristol I predict that Bristol will have a full-time

that. When Time was young. the legend says, the sky prersed opon the earth and men and animals crawled on their bellies. One black

D€an some day.

man, yearning to stand up, contrived to insert a sti.k more or les verti.ally between eanh and sky, and purhed and so was able to stand and walk, but the weight of the sky bent the stick which explains the origin of the boomerang." (The Australians. Goodman R. and lohnston, G-, Rigby, 1966.)

" The modern cl;nical professor has to be

man of many

a

:

clinician, surgeon, teacher, administrator, plannea in leo pirentk, an examiner and diplomatist in many parts of th€ world. The more senior rhe more the extnmural calls on him. The burden is so great that although all these duties may be covered not one of them is necessarily done as well as it might be.

Clinical routine must go on, and this is very much related to staffirg within a unit, a pans

with

rhe figures of myth-titans and shapei in the sky and voices on the wind. Out in that erernal quiet there has never yet really been a place for people. An earlier lodger, the Aborigine, has a legend which expreses

May I convey to all those I have got to know during my stal in Bristol my thanks for all the pleasures I have known, and to Alumni for giving me the oppors4

the breasts or pelvic organsr an), history of cough, low back pain or leg pains; or

history

of

loss

of

appet'te, especaally of

proteins. Examination, which should be done

with the tips of the fingers, by presure between finger and thumb, or betrveen the flat of the hand and the chest wall. rhould

Below we pint o synopsis of o ioint project on Corcinomo of the Bredst

take note of shape, size, contour, colour and surfac€ veins. Oedematous areas may be presenr in the skin, indicating malignant in filtration. Raising the arms above the head xnd cupping the breasts in the hands may show an area of skin retraction- The nipples must be exam;ned closely for fistures or ulcers. Any alteration in the size, angle of

co ied out by lour loufth

year students '{otking on the Surgicol Unitd The popers werc ptesented symposium ottended by stotl members ol the Unit, ond discussion then took ploce-

ot

projection, or shape of the nipple it a sign of great imporrance. Any discharge must be .ollected on a slide and examined microscopi.ally. Attachments should be tested with the patient's hands pressed agaanst her hips, thus tensing the pectoral mu5cles. Possible tites of lymph node metastases must be

D',AGNOs's r'ND sT,AG/NG OF BRfASI CANCER-D. E. P. Gud Early diagnotis is essential

if

examined, and a general examination ma, be necessary, especially of the pelvic organs.

Ir is possible to recognise ce.tain types of mammary carcinoma by signs and symptoms.

any perman-

ent degree of succeis in treatmenr is to be achieved. With early diagnosis there is more likelihood of obtaining an anatomically freely moveable mass with no metastases, weil l@alised and thus curable by surcery or radiotherapy, and of recent histor), biologi

with a ver/ h:rd and :rregular lump, and may be attached to skin, muscle or nipple, with n;pple reraction and peau d omdge. M€dullary car' cinoma is fo'rnd an younger women with well' developed breas6. and the tumour rs cham.terisri(ally firm. Duct carcrnoma causes a blood-stained dis(harge from the nrpple. rnd a mass may be palpable dire(dy behind the areola- Atropic sc;rrhous carcinoma occurs in old women with small breasts and runs a very chronrc course. Mastitis car(inomatosa often presents durinS lactatio. and i! rhe morr malignani. Parn usually presenl: 's rhe nipple ma/ be rerra(ted and rhere may be .utaneous oedema Pyretra and leuco.ytosis are absent. Paget's disease of the nipple may present in older women with a

Scirrhous carcinoma presents

cally

The spread

(a)

of

mammary carcinoma can be

Iocal, invadins other parts of breast tissue and pectoral muscles; (b) lymphatic, b) emboli or permeation to the local nodes; and (c) haematogenous, causing skeletal metastases in the vertebne, ribs, skull and femur, and also liver and lung seconda.ies. ln a routine investigation of a lump in the breast the patient should be asked about alteration in the size of the breast, nipple retraction, etc.; any history of injury io the breastsi an), family history of breast encer; any irregularities in menrtruation; number of pregnancies and the likelihood of an existing pregnancy; any difficulties with the nipples during periods of lactation; the nature of the menopause; any previous operationr on

persisting eczematous cond;tion.

Once the signs have been elicited, th€ lump @n be " staged . Staging i' a method of ariving at exact criteria in order to 55

choose the best mode of treatment. I'lanchester and Steinthal's method is based on signs only; Portman, Richard and Scand's on signs and tumour biopsy histological criteria;

by

mastectomy,

with or without oophore.-

rom), and stages lll and lV by some form of

or medically. This article with the surgical aspects of the

endocrine surgery,

will

and Haageson and Columbias on signs and triple histology of tumour, axillary node and internal mammary node. ln 1958 the l^ternarional Cancer Congress proposd to use the TMN system of staginS for a trial period of five years, starting in 1960. Ihere are three categories, T (: tumour), f,i (:distant metastases), and N (:reeional nod€s), each of which has four grades of severity. Various groups of €rades de^ote the stage, which may be I to IV. Diagnostic aids include: (a) Biopsy and hirtological examination of the Iump. The whole lump js removed in theatre with the patient prepared for mastectomy, and a frozen section made and examined with the patient still on the rable. ln the great majority of cases the surgeon can tell the nature of the lump on inspection of the cut surface. Needle biopsy is not advocated due to dangers of dissemination, and that it sup' plies insufficient material for full examination. (b) Castelais, in 1955, published a series oi 3000 cases of smears made from tumour specimens. He claims that examination of the smear as well as the frozen section increases diasnosric accuracy. (c) Thermography ol the breasts rhows a rise in temperature of at least I'C of the affected breast. k has been shown that the rise in temperature is proportional to the absolute prognosn. (d) X-ray mammography can detect tumours not felt on clinical examination. lt is very accurate but too expensive to be used routinely, and hai lirnited use in diffuse disease. lts main uies are in the detection of tumours in large fibrous b.easts, in the search for the primary centre of a metatasising adenocar cinoma, and to detect an axillary mass.

deal

Every degree. from simple removal of the lump ro super-radical mastectom/, hat its proponents and opponents. The main fact to emerge from the mass of data available is that s-year survival rates for women who have had all degrees of mastectomy for the stage I or ll disease are remarkably constant.

The operations described are: (a) SimPle mastectomy+emoval of the affected breast and pectoral fascia; (b) Extended simple mastectomy-at in (a) plus removal of the axillary nodesi (c) Radical Mastectomy-as in (b) plus removal of the pectoral muscles; (d) Extended radical maste*omy-as ii (c) plus removal of the internal mammary chain of nodes: and (e) Super{adical mastectomy +s in (d) plus removal of the supraclavicular nodes. for all these methods of surgery the s-year survival rate for women operated at stage Iis about 70%. This suggests that 5irnple mastectomy is the only operation justifi able under the.ircrmstances: it .auses much less worry and disability ro ihe patie^t, and can be combined jusr as

easily with subsequent radiotherap) if Endocrine SurgerI. Beatson

in

1896 was

the first to p€rform

endocrine surgery for breast cancer. He performed oophorectomies on premenopautal women and caused regression, or prevention

of

spread,

of

metastases

in a percentage of

to the hormone-dependant or independant tumoors of the breast. About 30 to 40% are hormone-dependant.

The object of endocrine surgery is to cause women for a limhed time. This led

concept

SURGFRY OF BREAST CANCER

of

of metastases in cancers of stage lll and lV. lt is debatable whether stage IV is b€tter treated medically. Mastectomy has regression

R. D. Hoding Clinrcal s6ge land ll are generallr treared 56

to play in the treatment of late breast cancer- The possibilities, endo-

very litde part

crinologically speaking, are

| (a)

Oophor-

ectomy in premenopausal women, with subsequent adrenalectomy

or

hyPoPhysec-

tumy when relapse occurs; ( b) HyPophysectomy, or adrenalectomy-with oophorectomy in the post menopausal patient; (.)

Pituitary destruction by radioactive isotope implantation. Yttrium-90 is generally used.

Forrest favourr implants of radioactive Yttrium-9o by the transnasal route as a method of dertroying the pituitary. The Yttrium is introduced on a 5pe.ial cannula under radiological screening and is x relatively simple operation for the experien€ed turgeon, the patient only being in hospital for 3-4 days. Destruction of the gland k alfrost alwa/s 100%. The disadvantage of this method is that the neighbour;ng chiasma or hypothalamus may be damaged leading to blindness, or disturbed sleep rhythm, voracious appetite, etc. The technique has been modined and complicationt The remistion rates are the s:me as for adrenalectomy. oophorectomy and h/pophyse.tomy.

It has been stated that endocrine surgery ls more effective if there is a one )ear gap, at leart, before metastases appear following mastectom)/; that a Previous resPonse to oophorecromy may indicare a berte. response to subsequent endocrine turgery; that skin and bone meustaser react better than thole

in liver a^d brain; and rhat

endocrine

surgery thould be r€served for patients with

a.tive metastases (FangrieYe).

The most promising branch of retearch inro rhe selecflon ol cares for endocnne surgery using laboratory criteria is that done

by Bulbrook, Hayward and Greenwood. The Discrimanant Function is a mathematical <oncept bated on the urinary €xcretion of l7-h/droryconicosteroids and aetiocholan one. lr a small seriet it was noted that patients with a D.F. above a certain value ( pos,flve) had a be(rer prosnos,s aftehypophysectom/ than patients with negatiye

lt has also been noted in a series of normal volunteers that th€ D.F. is positive in nearly every case, and that it k much more strongly positive in younger women. ln a random sample of patients with D.F.'s.

advanced breast <ancer, 58id had negative D.F-'s and only 42% positive- We can draw the following tentative conclusions: either (a) a nesative D.F. predkposes to breast cancer, and is a he.editary function, or (b) that che D.F. may change from positive to negative in a percentage of cases at the rtart of the direate. Atkins, who has drawn thes€ con€lusions, qualities thir theory b) the

important conditions that l7-OHCS and aetiocholanone excretion varies with emotional rtate and that there is not yet sufflcient experimental evidence. H€ hopes however that Discriminants will form a basis for screening tests in the future. Further rerearch is at present going on in a controlled trial on 5,000 volunteers in Guernsey.

/NEDiCAL TREATTAfNI OF BRfA5I

Cy'NCER-K.

l.

Rogers

Radioth€rapl.

ln a reries from the Univ€r'it), of Birmingham, results were compared of cases treated by surgery alone, surgery and radiotherapy, and radiotherapy alone. (i) surgery alone. 969a w€re Stase I, ll or lllr the s-year survival rate overall was si %. (ii) Sursery and radiotherapy. 65% were I, Il or lll, and 47% lived 5 years. (iii) Radiotherapy alone. 60% were Stage lll or lV, and only l5% survived 5

(ili) were much more advanced o. and hence .ould be expected to have a shorter prognosis. But comparing survival rates for earlier caser, radiotherapy Group

average,

alone offers a worse prognosis than surgery.

It has been suggested that radiotherapy is harmful because results have been reviewed

l@king at s-year s!rvival rates, but ignoring

tion. The

rhe srage at which treatment started. Many rreated till late in the diseaseIt seems however that radiotheraPy imProves

results when mer.stases aPPear Postoperatively. lt aPPears that the mode of action

is ro

Patterson and Russell (1959) in a controlled trial on 1,461 cases comPared the efiect of post-mastecromy radiotheraPy (a)

prophylactically and (b) aPPlied as and when metastases are noticed. No significant difference was noted. Howevtr, couBe (b) is

case

be preferred since it delays for as long as possible any unpleasant side effects irradia-

cases

a short ser'es that

radical mastectomy alone, and radi.al mastectomy and radiation. A slight bllt signilicant improvement in survival rates was

pr"dnr(one

in

adrenal-

advanced

30%. ln a trial on 364 Patients

had suPraclavicular

bY

the American Medi.al Assdiation the mean survival was found to be 27118.2 months if the pati€nt responded, and I0.7t10.7 if there was no response. Premenopausal women do Dot respond. The mechanism it thought to be due to pituitart secretion lf there is a resPonse to treatment an advanced growth of the tumour is nored before the tumour becomes stationary. This may be due to a secretion of mammotroPhic hormone, followed by inhibition as the

involvement, i.e. in many cases there was no point in doing the radical oPeration. Therefore he performed simPle mastectomies with ro aU nodes. Overall high dose 'radiation ruruival ates were 42 and 25% for 5 and l0 year periods. These are not sufficiendy good

of

ooPhorectomy with

( b) Large doses of oestrogens may be used in post menopausal women when the diseas€ is advanced, and causes reqression in

'nvolved,33% and 48% int€rnal mammary involvement

recommend abandonment

therefore

is more etrect've than

ectomy with oophorectomy

noted for stage I cases which had radlotherapy- No ditrerence was noted for patients first treated at stage ll.

Mcwhirter ( 1955) showed that when the

to

is

Prednrsone is more uselul since smaller dores are needed and so there are fewer side effects. lt has been shown (Lemon, 1959) in

a

of

axilla was

render

'n and watet ii thorter ExLess (auset salt

cortisone relieves pain and

stage I and ll cancers' treated by simPle mastectomy and radiation,

of 705

to

retention and may be a dangerous load on rhe (ulation. k is impornnt ro norc [ha(

to

series

be

2. Hormon€ th€rapt(a) Adrenal cortex inhibitors. A high dose, about 200m9 daily, of conisone suPPresses adrenal activity in geneml and oestrogen secretion in particula., but is les efficient than adrenalectomy. The same proportion ol the former case! rea.r, bur the survival

Prevent sPread rather than

Brinkley and Haybiftle (1959) analysed

main

inoperable cases operable in the later ttages

radical

mastectomy as routine.

Rapid radiotherapy in cases of inoPerable breast cancer was used by Edelman (1965) in massive doses (2500r) over 4 days to rumour and nodes. Good local control was obtained in 887" of caset in a series of 47.

Complications were " frozen " shoulder' due io fibrosis; lymphoedemai and symPtomless ndiation pneumonia and Pulmonary fibrosis.

This form of treatment should be reserved for those in the terminal stages ln iummary, there is no clear evidence that rhe prognosir is imProved following irradia-

oestrogen l€vel rises. (c) Androsen therapy causes resression in

25%

of pre or

p6t-menoPausal women-

ir oil 50 to 100 mg three times a week is the mdt effective form of therapy. Those resPonding survived l9-2r12.8 months, those not resPonding 9718.,+. The frequency of remission inTestotterone propionate

creases

with the

Post_menoPausal interYalsalt re-

Disadvantages in<lude virilisarion, 58

tention and increased appetite. Some workers disadvantages outweigh the

cinoma, duct carcinoma. and Paget's disease of the nippl€. Thir criterion depends more than any oth€r on con-

of hormone therapy are useful mainly as a show that they Surgery is preferable if palliative measure.

sistency

feel that the

ln

in observation and standard methods of €lassification. Some microscopical features have been found to

summary, results

correlate with the clinical course of the disease- These are nuclear graditrg,

immune response and sinus histio-

PROGNOS'S BREAST CANCfR A. C. Knights'N

cytosis, and nod€ involvement.

Nu.lear grading. Size variations, promin'

ent nucleoli, chromatin clumping and

Only recently has it been postible to compare statistics from differ€nt series. ln the past inadequately described surgical procedures and variety in.linical selection have

numerous mitoric figures are indications of non-differentiation. The degree of dlfferentiation is related to the percentage of

made comparisons invalid.

Let u5 consider general features that can be applied

prognostic clinical

lmmune response and sinus histiocltosis.

The invasiveness of the tumour and immur' ity of the patient will determine to a great

to all

of the disease(a) Age. Patients over 65 do better in a 5and lo-yea. follow-up than pati€nts under sc.ges

extent the effect of haematogenous and lymphatic €an€er emboli. lt k postulated that

65. This is especially so in advanced but oper-

(b) sid€

involv€d. Location. The left side

regional lymph node enlargement is due in to histio€yte hyperplasia and not only to metastatic enlargement. Sinus histiocytosi' i' a good prognostic sign since

is

involved more often than the right. Haageson showed that upper quadrant tumours had a better proSnosis than tumours in the lower part of th€ breast, probably due to greater ease of palpation and therefore

(c)

it denotes immunolog;cal reaction, and there-

Node involvemenr, due to lymphatic the axillary, mediastinal, or

spread, affects

internal mammarl nodes. Lymphatic spread may be by cells growing along l/mphatact; tumour emboli; or l)mphatic permeation.

Node involvem€nt has b€en cited as the mott important single fa.tor in assessing the pro' gress of the ditease. Axillary node involve' ment, treated by radical mastectomy, gives about a 50% s-year survival rate- lf no nodes are involved. the rate increases to about 90%. Occult metastases have onl) an ll% s-year survival rate. Mo.e time is needed to be certai. of conclusions to be drav/n from lo-year survival rate figures.

Presnan.y and Lactation. Tumours pre-

senting during this period are consistently more advanced at initial examination. and thus have a worse prognosit. (d) AnatomiGl facto6. Carcinomata of the breast are assessed according to their size, atta.hments. and node involvement

(;)

Tumour size. This is not as import-ant

as used to be thought. The Histological character is more relevant.

G€nerally speaking, however, larger

tumours involve more nodes

(ii)

and

hence have a worse prognosn.

ln some series, patients with medial side tumours, and presumably internal mammary

Histological character. Scirrhous and medullary carcinomata have a poorer

node involvement, have suryival rate ar patients

prognosis than

the rarer

adenocar-

disease.

59

lt

the same s,year with iateral side

has therefore been suggested that

the primary lesion and metastases. ln thk group parasternal lymPh node metattatic inc;dence ii low, probably due to simultaneous internal node irradiation. But skin nodes still appear, suggesting that most chest wall recurrences are due to back'flow from the internal mammary chain.

Axillary recurrences are less than l%, ie no axillary radiotherapy need be done as a

the horCs reiistance had been broken down where there was no node enlargement, i.e the poor prognosis of these .ases is a reflection on th€ biological activity of the decided by the stage of the is adopted, a 5year survival rate is no indication of €ureTherapy

ir

disease. Whatever course

One series had 6-year average survival for all treated caies, and a 3.5-year exPectation for untreat€d cases, but it must be remembered that thh included hopeles cases.

It is not possible to assign any order of importance to these factors in assessing prognosis in breast cancer. lndeed, other prognostic facton may exist which have yet

l^ a group who had had radical mastectomies. a correlation could b€ drawn between the site, size and attachments of

BOOK REVIEWS a pity),

Atlas of Normal Anatomy. Lederle Laboratories, Bush House, Aldwych, London, W.C.2.

some

of the parts which

most

students find difticult, e.g. the middle ear,

Free.

Some of the plates contain minor errors. but none that should confuse the student.

Th€re are now so many atlases of anatomy

to the student that he must be that none of them is Perfect. The best aware are large and expensive. At the other books scale there are a few books which end of the are very cheaP, but of no value to the st!dent. This Iittle book is not intended to replace any of the best atlases, but at thii price does it need to ? The question that the reviewer must answer is whether the book will make a useful addition to the standard books which the student has already boughtThere are 48 paintinSs in the atlar and 45 of them represent normal anatomy. The originals were painted by Paul Peck and one can oily congratulate him on their quality and Lederle Laboratories on the beauty of their reproduction. The choice of regions hai been governed by consideration to which parts of the body are most liable to infection while thir inevirably means that some areas of surgical importance have been comPletely ignored (and the reviewer thinks that this is

available

D. ,, Motratt, B.Sc., M.8., ChB.

AnatoD/ and Physiolog/ lor Radiograph€rs.

C. K. Warrick- 2nd Edition. Edwad Atnold

Ltd.3sl-.

This little book is intended to be used by student radiographers working for Part L of the M.S.R. examination. As ;t should be, it is in some aspects too simple and in others too detailed for other medical auxiliaries.

The sections on the anatomy of bones are very nicely produced. f4any of the line diagrams are excellent while radiographs, where used, are mo5rly des.r.b"d wirh the ard of more line diagrams. The rest of the anatomy secrions a.e very nicely illLrstrated but des(nbed in far less deuil. The secrion on che

brain,i

less eood. while

lF mosr 60

lie.

17.2

(P.243) ir

nsrancet physrology. and where

word of warning, particularll to Housemen. should f,ledical Automation be generall)

thought desirable pathology, are described together with the anatomy. Physiology i5 given far less emphasis than anatomy, but the section on the Endocrine system is good.

The section at the end of the book devoted to iurface anaromy is particularly well written for a book of this size.

Overall, a nicely printed and produced book which should suit the student for whom it is intended. lt is. however, disappolnting to see the oculomotor nerv€ consirtently wrongly spelt.

D- ,. Motratt, B.s<., l,i.a., ch.B.

I the medical profession ,,ill have to learn to keep far more accurate and detailed notet if clin'cal dat: are to be acc€pted

effectively utilised by others through the

P. F. I'lillington

lrd. Edition. l. M. A. E. A. Read with a chapter by I. Apley. i. W.isht & sons 2ll-.

The Clini.al Appr€ntica Naish,

The Clinical Apprentice

i!

intended to

introduce the clinical student to the art of medicine and the problems of dif{erential diagnosis. lt is . r€vised edidon of a book which had little populariry amonSst Brastol

An lntrodu.tion to ltledical Automation

by L. C. Payn€. Pitnon Medical Publithing Co. Ltd., London. 1966 (139 pages).

"A small, readable book, please!" ir a frequent request from many who ind their int€rests wide but time limit€d. Obviously, for those who want to make a study of computers and aotomation a more detailed treathe is required. But for mosr people this small book will sumce unril they hav€ to

It i' divided inro rwo sections. rhe first. 'axamination at l€i5ure', teaches the rtudent to ark and rhe signs to look for in his p.tientt. The tecond s€ction deals with a few common system by system the quesrions

medical emergencies and how the teaching of applied.

rhe inrroducrcry chapters can be

com€ to gripr wi(h a system in pra.tic€i and,

Two additional chapterr on r€spiratory, and

it wiil lufilce very well.

The author has set himself rhe task of proving to the reader that Knowledge dispek fear', and he does this in a gentle

water and lah physiology, convey the importance of s€ientific measurement.

Dr. Read! lucid, humorour rtyl€ ir well represenr€d. Although Dr.

conversational manner with oc.asional flashes

Apley! contribu-

into a tingle chapter tion Paediatric Medicine.

Apleyisms' such as on has been condensed

of

humour which make the reader forg€r that he is dealing with a very technical

the 'circ!latory tour'and Apley't cardie€ sign' are rtill to be found.

This small book i! ideal for the b€wildered entrant to clinical medicine. lt ir well presented and with many helpful illustrations makes easy reading. Twenty-one thillings would be well tpent on its purchae.

H. M. Murphl.

rubject. The rmooth way in which Dr. Payne introduce! .omputer terms such as " hardware " and 'software " could only result from many years practice at explaining the new language of automation. lf, addition, he has provided atr excellent short description of the binary system and fiDish€s with a useful slossary of te.mr surrounding computers. But, having proved to the reader the advanfages of automation, the ruthor faik to glve any idea of the costs involved, even for the case of an electronic medical records s)stem which is one of the simpler ideas he

On the liShter ride, there is perhaps

u5e

Practiel Pa€diat'ics. D. Hilson. Stdpres Press.

84 /".

This book provides a concise auide to most practi€al procedures one is likely to encounter in a paediatric unit. However, I feel that this knowledge ir better and more easily

a

6l

Hunan Chromosomer. An lllustrat€d Guide to Human Cytog€netict. A BishoP and P. Cooke. Wit tom Heine on.Il6Most hedial students seem to think thrt they know exactly what k meant by tuch terms as mosaic, non-disfunction, satellites. replicatio, etc., but in fact here is much

acquired on the ward. A basic knowledge of simpler procedures is of great helP before ttarting an appointment and this book dealt

with them

admirablY.

The theory of illustrated diseaset has been set out in a comPact fashion with headings

and lettered lists. The author atsumes some basic knowledge of the subiect and

confusion about genetic terminology and the mechanisms giving rise to 5u<h conditions as Kleinfelter's syndrome and mongolism ln 56 pages. Human Chromosomes defines all the termt one is likely to come across in connection with chromosomes, and with the aid

on.e equiPPed with thit the book is of great ute. EmPhatis is laid on signs, symPtoms and rreatment. with litde reference to aetiology. f,lnemonics are alto included for those who

of

S. A. Fairhan.

numerous diagr:ms, PhotomicrograPhs' and karyotyper, ably explaint the me.hanisms

of cell divirion and many of th€

Public and Cornmunig Health. W. S. Park€r.

Stop/es Press.38/-.

This book is intended as an introduction to Public Health for those needing a ground' in8 in the tubject, eS medical rtudents' nurres and social workers Wi(hin rather

C. str€ak.

A Cour.e ln Renal Diseates. G M. Berlyn€.

Blo.kve . 3116.

This .omprehentive book it written by an aurhor who, thouSh taught in the clastical wa/, re3li3es the n€ed for a modern and mor€ practical epProach to learnins This is

less than two hundred Paget Dr. Park€r manages to leave few rtones unturn€d, and presen$.lmost every facet of Public Healch Ers€ntial d€tail is Preserved in a Precise yel readebl€ fashion. Notable are the chaPtert on the National Health Service' Prevention and Control of Disease, and OccuPaaional Health. However, there is litd€ mention of

a

The author makes the subject interetiing by destroying the fallacy that it it,vnonym6ur wirh sewers , and bv rnvolving the

ol

" programmed learninS' 't€xtbook'

and

qu€srions are asked at regular intervals ll (h€se are antwered incorrectly the reader is referred back to the relevant chePter. lt is a new approach which may not suit all readers' bur ensuret an understanding of the subj€ct The photographs and illusrations are excel' lent and I can r€(ommend this book as an addi(ional purchase to the standard text-

Port Health.

reader both as a citizen and a member medical prof€ssion.

anomalous

conditions which can arise.

rhe

,. lil.

rh. 4.6 of Parliament are explained-quite an achievement The book Ia.ks statrstical referencet. but the author feels, and iustifiably 50, that this information is best found in iournalt As an inffoducrory book ir servet irt purpote adminbly, although, it u a little exoensive. With suPplementatron irom iournak rt should be adequate for final M B' and can be recommended as a rersonable carefullv

Hammond Evans.

How Not to Fail Finak. J. Howkins, H. wickenham Ealme and I. O. Robinson.

Chut.hilt.6l-.

Every student d.eadt the time when he have to face the ment.l and Phytical

will

endunnce rert of ihe Frnal Examination.

Anything which mry helP relieve the burden or raise his failing confidence crn only be welcomed, and that is the object of this little book. lt k not the ultimate synoPsis of th€ medical curriculum. lts function it to oulline

av.l'B. 62

some of the important principles of 'examination technique' and is helpful in this respect. The authors emphasise that the examiners are on the students'side and such reassurance in the pre,exam era makes the book a worthwhile purch:se.

Ethics,

P.

a

A. Riley

all

thoroughly, yet concisely, .onsidered.

There is also a short introductory chapter on the choice of careers in dentistry.

The book deals exclusively with those

and

things whi.h are not normall/ part of a univenity dental course but which are of vital importance to the general dental prac, titioner. k is the sort of book to " read, learn and inwardly digest" and indeed to keep at hand for immediate referenc+ erpecially for those occasions when it may seem that the Dental Estimates Board has been unfairly discerning.

G. Charlton.

l. Cunninsham. Fohet & Fobet.9J6.

This book is claimed by the writers to be reference

for

medical students.

lt

falls

rather short on this point and the dictionary section is more suitable for rhe intelligent layman than the medical student. Many well known diseases and syndromes are omitted,

whilst unimportant and obvious fa.ts

are

The most useful part of the book is the short guide to poisons and dietary requireme^tr contained in the last few pages of the book. These facts, soon forgotten, require frequent reference and thi! section provides

H. M.

medical students is difficult to write and in most caser consists of tabulated fa.tt whote detail is in proportion to the size of the volume. This book has little in addition to merit its purchase by the medical studenr.

to more

Practi.e, By

of Bristol

M.

of A

extensive reading. recommended by it has considerable value.

the author.

Where controveBy exists the

reasoning

for an

acceptable procedure is lucid and simpl) presented. Line drawings in illustration of the text are commendable for their clarity. Some schematic diagrams lose value through sparcity of detail and to the novice it is to be doubted whether photographs of clinical procedures ever :dequately illustrate

R,T.

Treweeke, University

PICKARD'S second edition

MANUAL OF OPERATIVE DENTISTRY has a rearrangement of the text of the fir5t, this, together with the additions made, presents a useful volume for the student commencing " Operative ". The new format makes easy informative reading and as an introduction

ar accurate if undetailed account.

A pocket medical dictionar), useful to

A Guide to Dental

in

Practice, Planning premises, practice organisation, keeping records, patient manaSement, dental emergencies, and financial affairs are

R.H.D.

Fabâ&#x201A;Źr Pocket Dictionary. P.

first asistantship, setting up

B.

Dental

School. Oxford: fhe Pergomon Prers 1966.

Pp. 90. Price 25l-.

This book is the tirst of its kind to be printed in this country and it should fili a long felt want. Senior rtudents and prac, titioners alike will find it to be of the greatest pcssible value, if only because Mr. Treweeke has managed to reduce the mountain of civil service jarson on which the National Health Service is built, to a readable molehill. He quite rightly points out that the main cause of frustntion and time wasting in general dental practice is the la.k of understanding of the N.H.S. regulations and the ways in which they are applied.

The size of this book precludes coverage some advanced techniques required of students, that might be expected from the tide. lt is to be hoped that this omksion may be rectified by a.ompanion volume.

At 30/- OXFORD MEDICAL PUBLICATIONS are to be congratuiated on the high qualit), of their publirhing. Our copy was received by courtesy of OXFORD UNIVER-

of

SITY

PRESS-

L. 63

W.

Deubert.

The symbol of better health Just as a patient needs to have complete confidence in the doctor, so the doctor needs to have confidence in the products he prescribes. Ultimately, this means confidence in the manu-

facturer of pharm a ceutica ls. Such confidence can only be built up over the years. by the profession as a whole, when it has used the products and found them not only effective. but also convenient and consistent in use.

Confidence is a complex phenomenon, but easy to recogniselike the Abbott symbol.

Abbott pharmaceutical products include: AEB()TBOL

ENDUBONYL

IBEROL

PENTHBANE

CATCIDRINE

ERYTHBOCIN

NEMBUDEINE

PENT()THAL

c.v.K.

ERYTHRtlPED

NEMBU-DONNAL

PHENT.IRONT

DAYAIVIIN

EUTONYL

NEMBUTAL

SELSUN

DESBUTAL

FEBBO-GBADUMET N()BIS()DRINE

DI.PARALENE

FERR()GRAD C

PARADIONE

TRIDIONE

ENDURON

HABMONYL

PEGANONE

VI-DAYLIN

SERENESIL

ABBOTT LABORATORIES LIIVITED OUEENBOROUGH KENT 64

H. K. LEWIS & Co. Ltd. BOOXSELLING DEPARTMENT. A laxge stock of text-books ard recent litemturc in a[ branchqs of M€dicirc and Surgery available. Please state particular inter€st. For€igB Bools obtained to oder Catalogue.s otr rcquest.

SECONIIHAND DEPARTMENT. A coDstandy chaDging large stock of Medical

and Scientific Literature otr view, olassifi€d lmder subjects- Old and rare books sought for and report€d. Large md small collections bought -

LENDING LIERARY. Annual subscriptiotr frorn [2 lss.

PRospEcrus posl fr€€ on application, Ust of Nrw BooKs and NEw add€d to Library se post free on application.

EDITToNS

THE LrBR-aRy CArALocuE revised to Decembq 1963. Part L the index o{ Authors and Tides. Part II the index of Sutrjeots. The Catalogue complete in two pa.rts, 11 los. to Librar"y Subscribers; €2 l5s. trEt to non-subscribers: ptxtages 46. 6d.

136 GOWER STREET,

LONDON, W.C.l

Telephone: EUS 442 (7 lin€s)

FOR YOUR REFERENCE

Research papers

by I'lembers of

Stafi

of the oetophagus Proc. Roy. Soc. Med. 1966 59 932-9t1.

A., |'4CCARTHY, C. F., AUSTAD, w., CoRNES, J-, HARRISON. W. J..

BRZECHWA-JDUKlEwlCZ, villous atroPhy, and steatoffhoea- Gtt 1966 7 57a-577.

A. E. A. Carcinoma, and READ, pancreatitis a.d its management. Current Med. and Drugs chronic The nature of BUTLER, T- J., (Nov.) 20-29.

1966 7 CAPPER, W- M.. AIRTH, G. R., KILBY, J. O., A test for pyloric regurgitation. Lancet 1966 ,/ BELSEY, R., Benign strictures

621-523.

CLUTTON-BROCK, J., The Physiolosy of Pain. l. Roy. coll. surg. lreland 2 1966 157-164.

DUNN, P. M., The placental venous pre$ure during and after the third stage of labour following early cord lisation. J. Obstet, Gynaec. Brit. Cwlth. 1966 73 717-756DUNN, P. M., FRASER, l. D., AND RAPER, A.8., lnfluence of early cord ligation on the tran! placentrl passage of foebl cells. J. Obstet. G)'naec. Bti. Cwlth. 1966 73 757-760.

EVANS, K. T., MGCARTHY, C, F., READ, A. E. A., and WELLS, P. N. T., Ultr:sound in diagnosk of liver disease, Bri. Med. J. 1966 tt i368-9 EYRE,BROOK, A. 1., Treatment of conge.ital dislocation or subluxation of the hip in children over the age of three yeaE. j. Bone Jt surg 1966 488 6a2'692 HEATON, K. \^r'., CORNEs,.l. S., and READ, A- E., Diffuse reticulum cell sarcoma of the gastrointestinal tract: A problem in diagnosis. Gut 1966 7 453457 MIDDLEMISS, l. H- rnd RAPER, A. 8.. Skeletal changes in the haemoglobinopathies, J. Bone Jt.

surg. 1966 4€B 693-702.

ROBERTS, J. B. M-, and ROYLANCE, J., Vesico-ureteric reflux in man. Brit- J. Surg. 1956 51 889-892.

65

DECEMBER 1966

Fank Edwin HOIIOWAY Peter Gnh.m KEETON

RESULTS

DISSERIATIONS APPROVID john R'chrrd COLEMAN

Anthont Mi.h.el John LYNN

Third Enmin.tiotr for the Dear.es

St.phen Chir*opher JORDAN The D€sr€€ of Ooctor ol

Roben Charl6 MILLER Arhl.y Mr.l€rn MURDOCK-*/th

DECEMBER T966

DECEMBER T966

ln Part ll (<omDleti.s the

DI5SERIATIONS APPROVED

EXAMINATION

rohn suadoo OODOO

Th. D.rr€e of Do.tor of Medi<ine

Klhrh€nas.IAYASENA Rob.rr Hrrry IOHNSON

il,.ikr2r NrBhidrs MORZARIA

Hiranya Prova KHATANIAR

Muri€l El.ine POWLEY

se.ond E .miMtion tor th€

ln P.rt

I

(Ph:rn.<ologt .nd

Gr.had H.trie! BARTHoIOMEw Stephen Roberr EVANS

Drvid Andr.w

arih:rin. Mrrv

Gilli.n D'AETH

D.vid SPRIGGS

M.rcan DONOVAN

Stu.^ All.. FAllHAll Rob. Antho.y HAWARO Mich..l Rich..d HtllEY

Ansur K..n.th PRIDIE RoP.r Clifford ?RESTON

Gl.h.n Lrnn.y

STEEi SWINGLER

Gordon Ri.h.rd D.vid lohn THORNTON lohn wllli.m WITCHER

REEVES

PYKE

Yvonn. M.ry ROBERT5 Ev. Antionett. 5ARKO D EE-ADOO Rodn€y Brrnnston SMITH T€ren.e Richrrd STONE

Te..n<. R.lph WIILCOCK5

Ennin.tion fot th. D.8re.

l)

ln S.<tlon I (.ompl.ting th.

oEcElGEn ttaa

l.renc. cahDb.ll

Robc.t Donald GOULD

BOYD

Fr.d.rick D.nnir HUTCHINSON Philip lohh STMMONS Anrhony Leon.rd WILD

l.s.cti.n ll (.ohpl.tint th.

P.rer Gordon POWELI O*mo.d Joh. GilBor. PYPER Fin.l Ennin.tlon tor rh. or 8.D5. (s.ction n)

D.tr..

DECET'|8EI 1966

Ann. Llcwelly. EVANS Sufn Mr.crr.! HUNt

of 11.8., ch.6,.

K.ith Willa.m

BROWNE

Anhur FBnl GARNTTT

Sh.k! De.n GASSAMA W.ndy Gn.n. GEORGC GLYNN

j

Thon- Ri.hfd

Potholoqr

of B.o.s. (t..tion

OEGEi'IBER l9aa

Robin

Drrtn.n.n in

Final

Qc.liftirr Exnih.don tor th.

D.ir..t

TOOSMORE

PASS

B.try GEh.m BOWDEN Anthony vivian lohn BUIIER

Willirm

Mt,

DECEMIER 1966

lohn Albe.t BENfORD

COATES

Patrici.

'll Geore€ H.nry HltL fr.nk o.vid How.rd jACKSON

fin.l Ebnin.tlon for th. D.sr..

DECEMBER

Z.n MACKENZIE Adrian Ed*td POINTER

Gr:had Ch.rl6 PURNEtt Mich:el Ari.n RANSON ln S..tion

ll (Conal.ting tte

(t

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REFERRED LIST

Pa!lChrktopher Thom.s

aLLAWAY-Ii

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P.ul Christoph.r Thom.t

Flnel EEmin.tion

Phyrioioty

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DECEMBER T'66

Gdhad iobe( BARKER

Chrntopher Ron.ld BARTON

Rob.ft Willi:m BINNERSLEY Brend. Ce.ili. AURKE

Willi.m J.6.t CAMERON M.din Ri.hard ELLYATT Rriner W.lt.r Cnritoph HACKEMANN

HAWKESSY-MUILINS l.mes Willi.m AnEur HUTTON

Bruc€ Richard BAsNETT

l4rra BEl65

Willi.m Rob.n

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Qu.litins Ehimtion for thc Dc!r..r of r.&, CILB.

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IIST M.ur.€n trene DELVESREFERRED

Rosem.ry Ann CHAPMAN GGofir€y Fnncis DADDY-,;th

Dittin.ti.h in H|non

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Diseos.

Margar.t DICKINSON

P.r.r Adrian

EASTON

P€.elope Sally Suth€rland GLEN Rich.rd Daniel GTOVER

Dian. Eliab.th SMITH

lan Chritroph.r M.rshall SMITH

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