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The request for, and acceptance of, the erect lateralfilm only by the obstetrician must be supported by theknowledge from clinical examination that the lower pelvicstraits are fully adequate concerning the subpubic arch,the ischial spines, and the plane of the lower pelvic sidewalls. Fortunately, significant side-to-side contraction atthe brim (which is very difficult to detect clinically) is

extremely rare. The pelvis deformed as a result of diseaseis now seldom seen, and in practice we are almost whollyconcerned with the healthy woman, without bone disease,whose pelvis shows some relative smallness or some

anatomical peculiarity or variant in developmental shape.It may be argued that lower-strait contraction with an

adequate upper strait is rare, but this is not my experienceat Queen Charlotte’s Hospital. I am not suggesting thatit is common, but it is far from rare. The clinicallyunrecognised lower-strait contraction accounts for a

significant proportion of the more hazardous instrumentaldeliveries.The main practical purpose of the erect lateral examina-

tion concerns the high head, and, per se, it is of littlefurther value in judging the adequacy of the pelvis as awhole. The use of the erect lateral film alone is no sub-stitute for a complete modern form of radiologicalpelvimetry in women of small stature and in women whoare suspected of having an unfavourable lower pelvic straitwith especial emphasis on the narrow subpubic arch.The evidence afforded by the erect lateral film as an

isolated examination is of real and reliable value only whenused strictly in conjunction with the knowledge gainedfrom clinical examination concerning the subpubic arch,the ischial spines, and the pelvic side-walls. In a givencase, if these features cannot be assessed clinically, it isjustified to complete the pelvimetry in a manner by whichthe foetus receives no unnecessary radiation. - -

1. Annual Epidemiological and Vital Statistics, 1955. Geneva: WorldHealth Organisation. 1958. Pp. 699. Obtainable from H.M. StationeryOffice, P.O. Box 539, London, S.E.1. £3.

Public Health

Infectious Diseases in England and Wales

* Not including late returns.

Vital statistics.- The epidemiological and vital statistics ofthe world have again been collected in a single volume inEnglish and French. New features this year include detailedspecific death-rates, by sex and age, for the main sites of

malignant neoplasms, and the distribution of cases of com-municable disease by sex and by age.

In England Now

A Running Commentary by Peripatetic Correspondents

" ONLY another ten minutes, old man," remarked my surgicalcolleague. My newly acquired registrar stirred himself intoactivity. Diplomatically I removed from his reach the syringesloaded with antidotes, and intercepted his message to the wardabout the next " premed ". When will these chaps learn some-thing about the real art of anxsthesia, I asked myself for thehundredth time.

,

How can juniors, so little experienced in The Assessment ofSurgical Statements/ predict accurately the expected durationof required anaesthesia, decide when to administer the nextpremedication (within the limits of effective action), andtransmit correctly (and corrected) the various messages to thewards, the outpatients, and the surgeons’ wives as may berequired of them ?

It is a traditional function of the anaesthetist that all suchcommunications should pass through him. This is based onthe assumption that in the theatre he alone is the person withlittle better to do, or whose occupation is of so little importanceas to stand interruption. If this traditional duty is accepted,it is essential that such messages be passed on in an acceptableform, if only for the sake of good anxsthetic-surgicalrelationships.Long experience has enabled me to evolve the necessary

formula to translate " surgical time " into rational units. Forthe assistance of my less experienced colleagues, I now offerit to all:

I never did have a high regard for examinations as a prepara-tion for life. How often do I seem to recall it being said:

" Nowif the examiners ask you this, you had better play safe and say... but in fact of course most people know very well... " &c.In my young days we had to learn all those silly names ofeye-signs in thyrotoxicosis which no-one ever bothered toelicit, and to have a detailed knowledge of the pathology ofobscure diseases, like chlorosis and amyloid disease, that were,I am told, often seen by my grandfather, but not much since.And Madura Foot-they have pictures of this in textbooksbut one doesn’t see this odd rarity even in Madura nowadays(I’ve looked), let alone in S.E.5. But the medical-degreeexamination is a revelation of concrete value and good commonsense compared with the driving-test, which my wife haslately faced.

In preparation for this ordeal she was taught: " Alwaysstart the car in first ", even though with 18 horses and a fluiddrive any gear below third is superfluous. " Before you start,check handbrake, gear-lever, make your signal, look in themirror, start engine, engage gear, look in the mirror again, letin clutch." We knew one good lady who followed theseinstructions so faithfully that she passed the test first time,but she was so bogged down by this ecstasy of obsessionalbehaviour that the green lights were usually red again beforeshe moved away. Then the questions they ask: The HighwayCode says school signs are a torch, so the examiners expectthis answer, though round here all the torches have been

changed to the kids stepping off the pavement. Crawl at5 M.P.H. round a couple of blocks making wild hand-signals atevery turn and you’ve passed. Drive like an adult human

1. Von Gass, A. W. I. ff. The Assessment of Surgical Statements. 1st (andonly) ed. Gasingham, 1895.

2. Bulsch, A. L. L. Time and Motion Studies in Various Surgical Procedures.1900.

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being without holding everyone else up and you’re failed for nothalting at all cross-roads (doesn’t matter if you can see thestop-lines by the others), looking right, left, and then rightagain. A friend of mine from down under had to take a testhere after some 17 years’ accident-free driving. They askedhim what a filter was and he said " Search me, cobber" orwords to that effect. But he won out in the end by going toEire where, on receipt of a small fee, the greathearted Oirishgave him a licence that would take him where he loiked for as

long as he loiked and be-damned to the Ministry of Transport.* * *

The death of Nugent Monck takes me back to my school-days, forty years ago. He produced the school play, A Mid-summer Night’s Dream. As soon as he heard my voice, hecast me for the Lion and taught me how to roar. He seemedto me to take as much trouble with my part as with any of theothers. Acting does not run in the males of my family. Myson had a similar experience at his school. As soon as the

producer heard his voice he said " The Ghost "; and my son’s" swear " came through the boards as from a sepulchre.

* * *

We have now taken up the study of graphology. Recentlywe attended a convention across the water, and, as is the usualcustom there, we were given a label on which to write our nameand affix to our lapel. Since we spent a major part of our timegazing shifty-eyed, to the strain of our superior oblique, orbent kyphotic-style, at lapels, or trying to ignore the inevitablenystagmoid glares of our colleagues, we were later given toreflect on the graphological clues supplied by the wearers of thename tags.

Broadly speaking (or rather reading), the writing and theamount written seemed to vary with the academic stature andthe confidence of the owner. Perhaps what caught our eyefirst was the clarity or obscurity of the writing, which could bein either script or print. Sometimes we found ourselves staringmyopically at what at first glance seemed to be Arabic. Atother times a parkinsonian-like script seemed to shrink beforeour very eyes, in contrast to the more expansive paretic-likescrawl.Those very confident of being recognised seemed to use the

surname only. BLODTZ proclaimed the bold proud letters.Lower down the scale we found ELMER S. BLODTZ; lower still,ELMER S. BLODTZ, M.D., asserted himself, and for the leastsecure the name bled forth in red. Alas, however, with theincrease in mechanisation, we understand that they type thelabels now.

We, on this side of the Atlantic, seem to approach things ata more genteel level. A modest SMITHERS, J., seems to suffice(to say nothing of those who decline to wear them at all); andwe have noted that, at a recent international conference here,participants wore a carnation to which the label was attached.We enjoyed the guise of sampling the scent while sneaking asurreptitious peep at the tag. (As Goldsmith might have said-those who came to sniff remained to pry.)

Somehow, we don’t really remember seeing any faces at all.* * *

WELTSCHMERZ

Each time that I have shoes to mendThe cobbler shoves his calloused thumb uponThe upper next the sole and squintsAnd says:

" I’m sorry, Sir, the welt has gone."Old friends, old comrades of the road,Who trod the purpled hills from Dee to Don,I love your polished wrinkles still,Can it be true our welt has gone ?Or has the Minister of Shoes

Propounded rules all shoe repairers con ?" Don’t say worn out’, it sounds so rude-The expert view is that the welt has gone."Old shoes, old man, we’re getting onAnd that is why our welt has gone.

Letters to the Editor

SEPARATISM OR REINTEGRATION?

SIR,-All pathologists will be grateful to you for pub-lishing Dr. McMenemey’s 1 presidential address and

your leading article just when we are so seriously con-sidering the formation of a college. But many of us areconvinced that, regrettable though it may be, a College ofPathologists is now a necessity.As Dr. McMenemey said, the two chief aims of a col-

lege would be the running of a higher examination (andtherefore the effective control of training) and the en-franchisement of pathologists. Like many of my colleaguesI spent two frustrating years working for my Membershipwhile training in a laboratory. At the end of it I had fourmore letters, a smattering of physical signs and pharma-ceutics, and a far lesser knowledge than I should havehad of my proper subject. The Membership is an admir-able examination for selecting future physicians; but it isnot satisfactory for selecting pathologists, and no amountof tinkering will make it so. Your suggestion that patholo-gists should be allowed a lower pass-mark in the clinicalsubjects is unworthy of you. Anyone prepared to readmedicine so as to do rather badly in an ill-designed exami-nation is unfitted to be a consultant in any subject. Theexamination must be properly designed, and candidatesmust be required to reach a high standard in all its parts.

It is this that makes enfranchisement so difficult. Ifthe College of Physicians is to speak for pathologists,then we must be adequately represented on its comitia.But the Membership examination is now an essential

prelude to election to the comitia. If therefore a differentexamination were devised as an essential step for patho-logists, we should, unless the physicians recognised it asan entrance examination and not just a diploma, sooncease to be represented at all.

Furthermore, the comitia is a self-electing body. Ifthe college organised, or recognised, a separate entranceexamination for pathologists, our interests would bemuch more closely linked with it than at present; and weshould need to have at least a gentleman’s agreement thatthe fellows would elect a reasonable proportion of patho-logists. Now I believe, and I think most pathologistsbelieve, that the college as a whole takes the narrow viewof the word " physician

" which you deplore. If this is

so, it is most unlikely that we should be accepted on theterms I have outlined, or that if we were the partnershipwould be-a happy one.

Dr. McMenemey’s assertion that the Association ofClinical Pathologists is an adequate representative bodycannot be accepted. The association, largely throughDr. McMenemey’s own labours, has worked wonders forpathology and pathologists, but it is still, unfortunately,by no means all-embracing. Many pathologists, especi-ally in academic circles, have preferred to remain outsideit, and it still speaks mainly for those in the NationalHealth Service. Furthermore, it cannot run a higherexamination, and it seems desirable that examination andrepresentation should be functions of the same body.As Dr. McMenemey points out, the scientific, admin-

istrative, and professional problems of pathologists are inmany ways different from those of their colleagues; andone of their most important duties is the integration oftheir work with that of all other specialties. This inte-

1. Lancet, Oct. 18, 1958, p. 841.2. ibid. p. 835.