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movement. Another explanation may be a physiological or

"overshoot" adaptation of the growth plate to the increasedeccentric muscle force that is characteristic of OSD (OSD andmobility secondary to muscle force). A third hypothesis might bethat an idiopathic laxity of the epiphysis alters the distribution offorces in the tibial tuberosity, thus giving rise to OSD (secondaryOSD). Since this lateral mobility of the tibial tuberosity in healthypersons as well as in OSD patients, as far as I am aware, has not yetbeen described, I would like to hear others’ opinions andexperiences of this physical sign.26 Paul Desmondsingel,3069 XT Rotterdam, Netherlands PIETER OUT

1. Ogden JA, Southwick WO. Osgood-Schlatter’s disease and tibial tuberositydevelopment. Clin Orthop 1976, 116: 180-89.

2. Katoh K. An analysis of quadriceps muscle force in boys with Osgood-Schlatterdisease. Nippon Seikeigeka Gakkai Zasshi 1988; 62: 523-33.

Worried obstetricians

SIR,-Mrs Brahams (June 29, p 1597) highlights the concernsthat obstetricians have with increased litigation. Identical anxietieshave been voiced in an editorial in the British Journal of Obstetricsand Gynaecology.l I agree with, for example, the need to expeditethe legal process and to try to make the adversarial process of lawseem fairer to both parties. However, we must look at ways in whichthe problem might be prevented. Unless we modify three majorfactors which predispose families to going to law, I see no alternativeto a rising tide of litigation:

(1) In the vast majority of cases settled out of court or coming tocourt the standard of care has fallen below acceptable standards.Although in some cases this may not have led to neurologicalsequelae, the case would have been much easier to defend had thecare been satisfactory. The difficulties usually arise throughinadequate staffing, in numbers or in seniority. The remedies areobvious, often unpalatable and/or expensive-eg, hiring moresenior staff or closing small, isolated, ill-supported obstetric units.

(2) It is very expensive to look after a profoundly handicappedperson and as more devices are developed to make life for patientsand families more bearable, these costs are going to increase.Awards by the courts of up to ill million are, therefore, entirelyjustified: that is what it costs, especially when one adds in 24-hournursing care after the parents of a profoundly handicapped personhave died. No-fault compensation will not work unless it is verygenerous and compensates to the level of court settlement.1 Untilthat happens those "lucky" enough to have some identifiabledeficiency in their perinatal care will continue to seek restitution inthe courts. This will leave other handicapped patients, with noantecedent medical mistake, hopelessly disadvantaged financially ifall that no-fault compensation offers is something derisory like the10 000 given (unjustifiably in my opinion) to those purportedlydamaged by whooping cough vaccine.

(3) Care for the handicapped in the UK is appalling. Anyone whohas had to battle with, for example, assessors for the AttendanceAllowance Board or with a local authority to get a house altered forthe wheelchair bound fully understand why people go to law.Providing adequate and readily available care for the handicapped iscentral to any reduction in litigation. Those who sue are often notvindictive or adversarial, as is endorsed by the fact that they go backto the same obstetrician and hospital for subsequent pregnancies.They are merely trying to get a decent deal for their handicappedchild, and their justifiable perception of the bureaucracy they face isthat it will continue to fail them-so they turn to the courts in thehope that a large settlement will allow them to look after their childproperly. It is cheaper for the Government to pay out for cases lost,plus legal fees, rather than provide all handicapped children withthe level of care available should they achieve a large court victory. Isthis why they duck the issue?

Rosie Maternity Hospital,Cambridge CB2 2SW, UK N. R. C. ROBERTON

1. Clements RV. Editorial: litigation in obstetrics and gynaecology. Br J Obstet Gynaeol1991; 98: 423-26.

Road accidents in Catalonia

SIR,-During a recent visit to Barcelona a senior physician friendoffered to drive me north to Figueres, to the Dali museum. It beinga Sunday we made a leisurely start after two very pleasant coffeeswell laced with brandy. In the front seat of a large American car myattempt to put on a seat belt caused some hilarity and an indicationthat such behaviour was not expected of real men. We stopped onthe way at an excellent restaurant and had aperitifs and two bottlesof wine between three of us, and after liqueurs we returned to themotorway. This is typical Catalonian hospitality, but could suchgenerosity be at least a partial explanation of the rising death rates inroad traffic accidents (July 13, p 122).

Postgraduate Dean’s Office,School of Medicine,University of Leicester,Leicester Royal Infirmary,Leicester LE2 7LX, UK S. BRANDON

Cosmetic surgery

SIR,-Your note (July 6, p 48) on "A new image for plasticsurgery" refers to an analysis of the average plastic surgeon’sworkload. I see no time allocated to cosmetic surgery-so why dosome plastic surgeons claim that they are the only surgeons who aretrained and adept at these procedures? Some of them have nointerest in cosmetic surgery: they neither approve of it nor practiseit.The British Association of Cosmetic Surgeons (BACS) was

founded over ten years ago by surgeons from various surgicaldisciplines united by an interest in cosmetic surgery as a specialty inits own right. The association was founded to promote the studyand practice of cosmetic surgery and to act as a forum for theinterchange of information and ideas and to promote the higheststandards of surgery. The entry criteria are strict. All members haveto possess the FRCS and have proven competence in cosmetic

surgery. They must do cosmetic surgery as a major part of theirpractice or full time. Many recent advances in this specialty havebeen introduced to the UK by BACS members.

Because there is inadequate training in cosmetic surgery in theNational Health Service and because no accreditation is available,many members of the BACS received their training and experiencein the private sector or overseas.Those who regard cosmetic surgery as "unnecessary, frivolous,

or trivial" are behind the times. There is a great demand forcosmetic surgery, and it has become a well-recognised specialtyfulfilling an important service to the public.Why, suddenly, do plastic surgeons wish to change their image to

one dissociated from cosmetic surgery when for the past few yearsmany of them argued publicly that theirs was the only specialty forthese operations. Some plastic surgeons denigrate colleagues whodo not belong to their associations and who practise cosmeticsurgery full time and have been doing so successfully for manyyears. This is an attempt to prevent others practising in what theyclaim as their territory. The British Association of Plastic Surgeons’questionnaire survey, to which your note refers, shows that there isno basis for this claim.

British Association of Cosmetic Surgeons,17 Harley Street,London W1 N 1 DA, UK

ANDREW SKANDEROWICZ,Secretary

Enterococcus faecium with high-levelresistance to gentamicin

SIR,-Dr Woodford and colleagues report (June 1, p 1356) eightisolates of Enterococcus faecium with high-level gentamicinresistance (HLGR), noting that hitherto there had been only a fewsimilar isolates from the USA, but suggesting that the prevalencemight be wider than it appears. We report that HLGR E faecium isnot only prevalent in Singapore, but is associated with high-levelpenicillin resistance (HLPR; ref 1, 2 and unpublishedobservations).From September to November, 1989, 52 of 898 enterococcal

isolates identified in our laboratory were E faecium,3 showing