52

For the patient it was submitted that the doctors shouldhave interrupted the procedure for long enough to explainfully what had occurred and provide reasons forcontinuation or, in the face of the language problem andanxiety, it might have been better to have ended the processand consulted Dr Schacter as to whether a third angiogramshould be attempted. However, the Court of Appeal ruledthat in such a case "legal precision must give way to medicaljudgment... To have dumped the problem in her lap at thistime would have been a complete abdication of professionalresponsibility". That judgment had been properlyexercised.

Ciarlariello et al v Schacter et al. Canada: Ontario, Court of Appeal:Fmlayson, McKinlay and Griffiths,71A. Jan 11, 1991.

Diana Brahams

Obituary

A. G. L. Ives

Glen Ives, who died on Oct 1, 1991, was secretary of theKing’s Fund from 1938 to 1960-a period that included theblitz and the first twelve years of the National HealthService. Academic, congenial, and deeply respected by hiscolleagues, he had great influence in his day over thecharacter of health provision.

Ives’ tenure as secretary of the King’s Fund coincided withmomentous changes in health provision. He was involved in theestablishment of the Emergency Bed Service. Upon the outbreak ofthe war, he continued his normal duties but took on additionalwork as secretary to the War Emergency Committee, whichgave him a national responsibility. He helped to plan for themedical care of war casualties and to organise hospital supplies fromAmerica. He also wrote on the use of marginal land for foodproduction.When Bevan’s scheme for post-war reconstruction emerged, the

King’s Fund argued the cause of the voluntary hospitals. Iveswarned of the dangers of management by remote control and theneed to maintain a gap for charitable contributions in the newservice. It was essential, in his view, that competition and variety bekept in the system; therefore, the hospitals should retain as muchindependence and local management as possible. Bevan’sconcessions to the voluntary lobby, especially the retention ofhospital endowments, and the independence granted to the teachinghospitals owed much to the pressure exerted by Ives and hiscolleagues.Although he had argued against the nationalisation of the

voluntary hospitals, Ives came to admire the NHS for extendingequitable health provision to a wider population. What he soughtafter 1948 was a more effective partnership between charitableand government provision. When he helped to establish the

Fund’s pioneering Hospital Administrative Staff College (theKing’s Fund College today) he hoped that it would producehospital managers who would promote flexibility anddecentralisation in the NHS. Ives was unusual amongcommentators on health in having a strong historical sense-aconviction that planning must pay due regard to individualinstitutions and inherited practices.

In his retirement, Ives maintained a lively, humorous interestin many things, despite permanent handicaps stemming fromthe Lewisham train crash. He painted, in water-colour and oils;he was a great gardener; and above all, he was a family man,looking after his wife with great devotion until her death after a longillness in 1987 and taking great delight in his children and

grandchildren.

Robert MaxwellFrank Prochaska

Noticeboard

Foxing the rabies virus

Encouraging results from a Belgian field trial of a new oral rabiesvaccine’ are good news for foxes, the main European reservoir of therabies virus, which are at present being culled in an attempt tocontrol the disease. Good news too for human populations worldwide, for the new, live, vaccine (a recombinant vaccinia viruscarrying the surface glycoprotein of the ERA strain of rabies virus)appears to be effective in a number of animal species, stable, andharmless to both domestic and wild animals, unlike vaccines derivedfrom attentuated rabies virus strains, which are ineffective in somespecies (including the racoon, a common North American vector)and can also revert to virulence.

Efforts to control the European rabies epidemic, which started inPoland in the 1940s, have been directed at reducing fox density tobelow the critical level required for persistence of the infection,thought to be around 0-4 animals per km2. But culling is expensiveand has to be continued even when the disease is rare. Vaccination

coverage needs to be at least 80% if fox culling is to be abandoned,and 90% where fox density is especially high, as in some suburbanareas. In the Belgian trial, which covered a 2200 km2 area of highendemicity and an average fox density of 2 animals per km2, thevaccine (with a tetracycline marker) was distributed in bait, andmean vaccine uptake in foxes inspected was found to be 81 %. Thetrial ran for a year from November, 1989, and no cases of rabies infoxes or domestic animals were reported after June, 1990. Ifvaccination replaces culling, fox density is likely to rise as a

consequence of the reduced incidence of rabies as well as thecessation of culling itself, and in these circumstances vaccinationcoverage may need to be maintained at over 80%.2

1 Brochier B, Kieny P, Costy F, et al Large-scale eradication of rabies usingrecombinant vaccinia-rabies vaccine. Nature 1991; 354: 520-22.

2 Anderson RM. Immunization in the field. Nature 1991; 354: 502-03.

Vitamins and neural tube defects

The Chief Medical Officer of the Department of Health has setup an expert group to consider the dietary implications of the reportfrom the Medical Research Council Vitamin Study ResearchGroup on the prevention of neural tube defects with vitaminsupplements (Lancet 1991; 338: 131-37). Concise writtensubmissions based on reasoned argument and scientific data frominterested parties are invited. Submissions should be sent to Dr P.Clarke, Department of Health, Room 541, Wellington House,133-155 Waterloo Road, London SE1 8UG.

Falls in the elderlyA comprehensive service for elderly persons who fall is being

designed for Camberwell Health Authority. Part of the preparatorywork included an examination of existing service for these people insix similar health districts in Britain and of several centres elsewherethat are investigating innovative schemes.!The survey of British practice was hospital-based and showed

that neither accident and emergency nor geriatric departmentscategorised elderly people who fall as a distinct group for easyidentification, and that there was a tendency, especially in accidentand emergency units, to concentrate on treatment of injuriessustained in the fall, without assessment of the underlying cause oradequate planning for aftercare and prevention of further falls.None of the innovative schemes was comprehensive, though each

had good features. The project in Portland, Oregon, for example,includes group sessions on health education and health promotionaimed at getting patients to modify behaviour so as to minimise riskof fall. Preliminary results indicate that the education measures haveled to a reduction in falls and admission rates.

1. Adams S, Askham J, Glucksman E, Swift C, Tinker A. Falls and elderly people: astudy of current professional practice in England and innovations abroad. LondonAge Concern Institute of Gerontology, King’s College London, London SE18TX. 1991. Pp 55. £5 (incl postage and packing). ISBN 1-872342558.