When doctors disagree

x-ray evidence alone, they had insisted that the children's injuries must have been non-accidental.

Instead, the sheriff concluded that the boys had suffered from a rare form of brittle bone disease. Central to the case was the evidence of bone specialist Dr Colin Paterson, reader in medicine at Dundee University. It wasn't the first time Drs Hall and Paterson had crossed swords in court. They have appeared together as expert witnesses in around 30 child abuse cases but only once on the same side. In the remainder Dr Paterson was hired by the defence and Dr Hall by the prosecution.

Dr Paterson maintains that some children are born with temporary brittle bone disease, which makes them liable to suffer fractures spontaneously or with normal handling. Hall argues that if the parents can't explain a baby's fractures, the only credible explanation is child abuse.

Though Dr Paterson says he remains on civil terms with his professional

opponents, there is an increasingly bitter rivalry between them.

Five years ago in a child abuse case in the English high court, Mr Justice Wall concluded his judgment by strongly criticising Dr Paterson as an expert witness. ''His evidence in any case involving the alleged non-accidental injury of infants in the first year of life should, in my judgment, be treated with the greatest caution and reserve,'' he said.

Last October in Hamilton it was the turn of Dr Christine Hall and another expert witness in the case, Dr Stephen Chapman, to face censure. In his damning judgment, Sheriff Stewart accused Drs Hall and Chapman of trying to usurp the court by quoting from a paper they had written aimed specifically at discrediting Dr Paterson. In it they suggest that ''temporary brittle bone'' disease was no more than a label for child abuse adopted by guilty parents trying

to cover up their actions. ''She does not have the right to become judge, jury, and executioner in questions relating to NAI (non-accidental injury),'' said Stewart in his ruling.

These arguments may be rehearsed again if the case goes to appeal. Though the Reporter has given notice of appeal, no date has been set for a hearing.

In an exclusive interview with The

Herald, Dr Colin Paterson explains his views and tackles his critics. He tells why he continues to appear in child abuse cases, despite the vilification of many fellow professionals, and voices his fears that high-profile cases of genuine abuse, like the death of Anna Climbie, will result in innocent parents going to jail.

Meanwhile, Dr Stephen Chapman bitterly contests Paterson's thesis. Perhaps it is not surprising that the debate among the experts is so polarised. There is so much at stake. As Drs Hall and Chapman point out in their contentious paper: ''Overdiagnosis of child abuse is a tragedy for the child who may be taken away from his parents and for the family faced with loss of a family member and the accompanying social stigma, but an incorrect diagnosis of brittle bone disease may put the child's life at risk.''

Cases that come back to haunt

It's hard to believe that this avuncular mild-mannered man with grey hair and velveteen voice could be at the centre of a bitter controversy. He exhibits something of the atmosphere of an absent-minded professor as he potters around his small book-bound office at Ninewells Hospital, Dundee, his base for the past 32 years.

In another age this 64-year-old would be coasting towards retirement, maybe fondly hoping that the aspect of brittle bone disease to which he has devoted many years of his career, might one day bear his name - ''Paterson's Syndrome''.

Dr Colin Ralston Paterson MA, DM, Msc, FRCP, FRCPath, has a long, respectable CV: Brasenose College, Oxford, lecturing posts, articles in journals including the Lancet and New England Journal of Medicine, text books about bone disease, research grants, invitations to adjudicate on doctorial theses, etc etc. Inter alia he was co-founder of the Brittle Bones Society and spent eight years as a Sunday school superintendent. It's the sort of career that under other circumstances would have resulted eventually in a brief respectful obituary in the Scottish press.

Instead, chance and circumstance have dictated that Colin Paterson now spends much of his life flying round the world to give evidence at child abuse trials. The cases he handles are not the sort he can leave safely behind in a filing cabinet. They pursue him home to the village of Longforgan near Dundee and stalk his dreams.

''You don't want to get so involved as to lose your objectivity but, like all human beings, I'm very concerned when peculiarly nasty injustices have occurred.''

He knows that his evidence can decide whether a baby is returned home or taken permanently into care and the parents imprisoned. His claims are considered so controversial by a number of medical professionals that some have attempted to discredit him. One radiologist interviewed by The Herald compared Dr Paterson's evidence to maintaining the earth is flat.

HE began working on bone disease in 1964. Within a decade he had developed a special interest in osteogenesis imperfecta (OI), an inherited disorder of connective tissue. In layman's terms it means a deficiency in the fibrous framework (collagen) that gives bones their strength. Because you can't see collagen on an x-ray, OI is quite difficult to diagnose, though there are tell-tale signs and modern radiology is getting much better at picking them up.

Ignorance has led to some terrible injustices. ''In a case in Wiltshire, a child was in care for three-and-a-half years and kept on fracturing in care but it took them that long to work out that there had been a misdiagnosis of child abuse,'' says Dr Paterson, who has been called in in a number of child abuse cases where OI formed part of the defence. In most cases of OI the child continues to fracture. In the Wiltshire case, for instance, the child went on to fracture nearly 500 times.

Around 1985 Paterson was confronted with two cases that didn't conform to the norm. ''I saw two children - one in England and one in the United States - who had very similar x-rays. Both were found to have large numbers of rib fractures. In both cases the children had been reliably observed to have no evidence of injury by people outside the family. If it had been ordinary OI there would have been further fractures, but there weren't. I couldn't say it was OI but I didn't think it was child abuse, either, because child abuse on that scale with no bruising would have been frankly incredible. In known cases of child abuse, bruising is more common than fractures. In the cases I deal with the reverse is true. I came up with the idea that there might be a temporary form of brittle bone disease, and since then we've seen in the order of 100 more cases,'' he said.

Dr Paterson suggests several types of evidence to support his theory, apart from the absence of bruising. The cases shared other similar features, including the age of the patients (typically three months old), the type of fracture (predominantly rib fractures), vomiting, and diarrhoea, enlarged fontanellas and a family history of double-jointedness. Many were premature babies or twins.

In about 10 cases the fractures happened in hospital or where non-accidental injury could be more or less ruled out. Lastly, though one child died from an unrelated condition, there were no unexplained fractures in children returned to their parents. He has suggested a temporary collagen defect, possibly a copper deficiency, might be to blame.

Radiologists who have testified in child abuse cases that unexplained fractures in babies are de facto evidence of non-accidental injury were quick to respond. ''If you read Dr Paterson's descriptions of so-called temporary brittle bone syndrome, a lot is what you see in non-accidental injury,'' says Dr Stephen Chapman, a consultant radiologist at the Birmingham Children's Hospital and an expert witness in the Lanarkshire twins case.

''If you see all these signs and the parents say 'We don't know how it happened', then accepted medical opinion says they must know.'' Dr Chapman and Dr Christine Hall of Great Ormond Street Hospital in London, who has opposed Dr Paterson in nearly 30 child abuse cases, say premature babies and twins are also more vulnerable to child abuse and maintain that multiple fractures often happen without bruising. They say copper deficiency is extremely rare and that battered babies are less likely to be injured as they get older and stronger, so the subsequent medical history is irrelevant. They also argue that non-accidental injury can occur in hospital.

In a paper on the subject, the two radi-ologists conclude: ''NAI and 'temporary brittle bone disease' are indeed the same condition but with different labels, depending on the credibility of the caretaker's (carer's) explanation.''

The implication is plain. If courts are accepting temporary brittle bone disease as an explanation for what is really child abuse, babies are going home to face the risk of further abuse. Drs Chapman and Hall conclude their paper chillingly by reminding readers that ''an individual is at greater risk of being murdered in the first year of life than at any other age.''

''A lot of what he says seems reasonable but scientifically it's all wrong,'' says Chapman. He adds: ''I can't believe that radiologists around the world are getting it wrong but maybe the world is flat.''

DR PAterson appears remarkably unruffled by such vehement criticism. Both the BMA and the sheriff in the Lanarkshire case have criticised Drs Chapman and Hall for this attempt to brand Dr Paterson as a dangerous eccentric, whose theory is derided by the entire medical establishment. ''An American professor, Marvin Miller of Ohio, and three American bone specialists have come to similar conclusions to me. It's encouraging that I'm no longer a lone voice,'' says Dr Paterson.

Of course, Dr Paterson is vulnerable in a way his attackers are not: ''The ultimate nightmare would be to send a child back to abuse. I only have to get one case wrong and my reputation would be severely damaged. The radiologists may get many cases wrong and nobody but the parents know that they're wrong.''

Dr Paterson says he frequently rejects cases where he can't find enough evidence of temporary brittle bones to make a safe diagnosis. And, though he tends to get referrals from lawyers and social workers who already doubt non-accidental injury, he does sometimes come to the conclusion that the child was, indeed, abused. Conversely, Dr Chapman says in at least one-quarter of the alleged child abuse cases brought to him, he concludes that the fractures were accidental.

Dr Paterson isn't surprised that so few bone specialists are prepared to testify for the defence in child abuse cases, given the vilification they encounter: ''A few colleagues have had such a bad time in court, they've said they won't take any more cases.''

Much of the difference between Dr Paterson and the radiologists is in their approach. Dr Chapman gives evidence on the basis of x-rays alone, arguing that is his area of expertise: ''It's for the judge to decide whether the parents are lying, not me or Dr Paterson. I don't need to see the carpet or the parents or anything else. I don't want to be involved subjectively.''

Dr Paterson also maintains that objectivity is important but makes his diagnosis on the basis of all the factors available to him. That means seeing the child and interviewing the parents: ''I make my own judgments about who's telling the truth but that's a normal part of medical practice.''

So is there an obsession with child abuse in Britain today? Having reared three children of his own, Dr Paterson says he is as upset by high-profile cases like Maria Colwell, Jasmine Backford, and Anna Climbie as anyone else. But he maintains: ''There's absolutely no comparison between those cases and the ones I deal with. Maria Colwell was fresh in people's minds during the first big case I was involved in and I remember one headline - 'Even this nightmare is better than another Maria'. I groan every time there's a case like little Anna because I know that the pendulum is about to swing back and destroy lots of innocent families.''

System failed Sally

Today Sally is a chirpy, confident

12-year old. ''I suppose we've spoiled her a bit, but after what happened you can hardly blame us,'' says her mother, Jane. At six months Sally developed a small wound on her mouth from sucking her fist, and Jane decided to take her to hospital.

''They suggested we see a haematologist. He didn't say much but the next day we were phoned and asked to take her back in. That was when the nightmare started. We were told that she had three broken ribs. We couldn't explain it. After that nothing we said or did made a jot of difference.''

For several weeks Sally was kept in hospital; in December she was put into foster care, where she remained until the following November. Meanwhile Jane and her husband, Neil, went through a series of interviews with police and social workers. They were both arrested. ''It was horrible. They kept on getting us on our own and saying: ' One of you must have done it.' I'm a nurse and did a lot of reading. I kept asking if she had brittle bones but they didn't investigate it.''

The support of friends and neighbours kept them going. It was also important to keep up a semblance of family life for Sally's older brother, Mark. At one point they feared they might lose him as well, though he had never suffered a fracture.

The couple contacted Dr Colin Paterson, via an organisation called Parents Against Injustice, and he agreed to represent them in court. He was convinced Sally suffered from some form of temporary brittle bone disease that was not detectable on x-rays or in blood tests.

The council backed down on the day before the court hearing and allowed Sally to come home under a care order.

The family moved to a new area to try to put their nightmare behind them. ''Our new GP was very supportive. At first social workers kept coming in. Then the care order was changed to a supervision order and finally even that was lifted,'' says Jane. Since then Sally has broken one bone - a finger when she fell while bouncing on her bed.

Jane is still convinced that Sally suffered from a form of brittle bone disease during her first year. The family has never received an apology or an admission that the diagnosis of child abuse was wrong.