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Annotations

AN INCOME-TAX ANOMALYWE can hardly expect that our laws shall always be

applied equally ; for their application depends on

people, and people, as we know, are various. On the otherhand we are entitled to demand that our statutes shallnot discriminate against any group. A small but import-ant instance of such discrimination is the inequitableincome-tax law which is at present applied to doctorsengaged whole-time in the National Health Service.The law is clear. Doctors who derive a substantial

part of their income from private patients may, underSchedule D, offset against their income the cost of pro-fessional journals and books, and of attending scientificmeetings. The whole-timers (under Schedule E) cannotdo so-unless perhaps their contracts demand that

they shall incur these expenses. The discriminationdoes not end there. For instance, the part-timer canclaim for relief from income-tax the cost of professionalmotor-car expenses not covered by the official allowance :the full-timer cannot. The part-timer can likewiseclaim for some of the cost of entertaining overseas

doctors who are visiting hospitals or attending con-

ferences in this country : the whole-timer cannot.Besides whole-time consultants, other doctors and

other professional groups are victims of this anomaly,which is not new but is felt more acutely than ever beforebecause high rates of tax begin at lower real incomes.Rationally the discrepancy is indefensible. This was

recognised by the Royal Commission on Taxation ofProfits and Income in its declaration that " there isno good reason for treating Schedule E expenses lessgenerously than Schedule D expenses, except to thelimited extent that some difference of treatment isinherent in the nature of the two kinds of income."The Royal Commission concluded that the Schedule-Erule governing deductible expenses should be amendedto permit the allowance of expenditure " reasonablyincurred for the appropriate performance " of the dutiesof the office or employment.Owing to the rapid progress in diagnostic methods

and in therapy, it is quite impossible for doctors to keepup a high standard without having books and journalsat their disposal and without attending meetings ofscientific societies. These expenses are an unfairlyheavy toll on those who, unlike their colleagues, cannotset them against income. We earnestly hope that theChancellor of the Exchequer will find it possible in thecoming Budget to end this inequity.

1. Road Traffic Act (1930), section 15 (2).2. Times, Jan. 31, 1957.

DIABETICS AND DRIVING

THE judgment described on p. 319 arose out of chargesbrought against a diabetic driver under the Road TrafficAct. The Lord Chief Justice said " this section (of theAct 1) was designed for the protection of the public, andif people were in a condition of health which renderedthem subject to comas, or the remedies for which mightsend them into comas, they ought not to drive becauseof the danger which resulted to the rest of Her Majesty’ssubjects."2 Quite so : the relevant section of the Act

says that " any person who when driving or attemptingto drive or when in charge of a motor vehicle on a roador other public place is under the influence of drink or adrug to such an extent as to be incapable of havingproper control of the vehicle shall be liable ..." ; andthere can be no serious contention that Lord-Goddard’sdecision is anything but right in law. The widespreadinterest that his ruling has aroused serves not only towaken public concern over diabetic drivers but also toilluminate a rather unsatisfactory section of an Act whichdaily increases in importance.

How dangerous is the diabetic in charge of a motorvehicle ? ‘ It is clear from the small number of cases thatcome before the courts that few diabetics are, in fact.a serious menace to their fellows. On the other hand.a potential hazard does exist, and it remains to assess

its dimensions. In the first place, only those diabeticswho require and receive insulin by injection are concerned.Despite learned counsel’s contentions, diabetic coma isalways of slow onset, and most drivers would have timeto relinquish charge of a vehicle in the several hours thatpass before consciousness is lost. And insulin-requiringdiabetics make up no more than 20-25% of the totaldiabetic population. Diabetics who do not need insulinmay be given it in error ; but they are notoriouslyresistant to its action, and rarely suffer from hypo-glycsemia. Next, the great majority of insulin-requiringdiabetics are well controlled, and, provided that they taketheir meals regularly and they do not engage in unusualphysical exertion, they are not subject to attacks of coma.It must be remembered that it is no crime to be in chargeof a motor vehicle while under the influence of a drug:it becomes a crime only when the drug’s action preventsthe driver from having proper control of the vehicle.

There are five different types of insulin available, onein three forms, and all in three strengths. Althoughdispensing errors are very uncommon, wrongly measureddoses are by no means rare, and they account for mostreactions in otherwise well-stabilised patients. Rarely,reactions occur for no detectable reason, and they areusually attributed to sporadic endogenous production ofinsulin. There remains a very small group of patients,chiefly young people, in whom control is difficult andwho often suffer from hypoglycaemia and its consequences.It is to these patients that Lord Goddard’s remarks seemjustly to apply.

Diabetics are not alone in their liability to abrupt lossof consciousness. Epileptics, for example, are similarlyafrieted. And since heart-attacks may recur, and oftendo, at moments of stress, should a patient who has hada coronary thrombosis likewise be excluded from driving?What is the position of a patient who has spontaneoushypoglycaemic attacks ? ’? Manifestly, the law needs someinterpretation on this point, and de-jure -recognition ofthis is given earlier in the Act,3 where provision is made

’ for the licensing of handicapped drivers in certain circum.stances-circumstances which would include all but a

< handful of diabetics. Moreover, it receives much widerde-facto recognition from most licensing authorities bythe issue of licences to known epileptics, provided thatthey are reputably certified as having been free fromattacks for at least three years and are otherwise suitablepersons to hold such licences.

Clearly there can be no generalisations about diabetics,even insulin-requiring diabetics ; each case must heconsidered on its own, and although there are certainlysome diabetics who would be a danger to Her Majesty’ssubjects when in charge of a motor vehicle, their numberis undoubtedly small. As the British Diabetic AS&bgr;ocia.tion points out, one of the essentials for safety is thatthe driver should be able to recognise early the symptomsof hypoglycaemia, and those few who cannot do so shouldtake medical advice before applying for a driving licence.In fact, the small number to whom Lord Goddard’swarning applies are usually the first to wish to be pro-tected, and to protect the public, by not driving. Thereremains, however, the isolated instance of the usuallywell-controlled diabetic who has a hypoglycsemic attackat the wheel. Provided it can be shown that the attachwas unusual, unexpected, and in no known way attri-butable to the patient’s negligence, he should not brheld responsible for its consequences, and the Act sho!:Hbe amended accordingly.

3. Road. Traffic Act (1930), section 5 (2b).

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ARTERIAL PUNCTURE

ARTERIAL puncture is being increasingly used in thecourse of diagnosis and treatment, and it is usually freefrom complications. Even when the needle is of smallcalibre and of sound design, there is bound to be sometrauma to the vessel along the track, and Crawford 1has lately examined the way in which such wounds inarteries heal. His material, mainly carotid arteries, wasobtained at necropsy from patients who had been

investigated by carotid angiography 4 hours to 240 daysbeforehand. His findings suggest that the track,temporarily blocked with fibrin, is infiltrated withendothelial cells from the lumen of the artery in modifiedspindle-cell and macrophage forms. These cells form anavascular plug and derive their oxygen and nutrition bydiffusion. The surface is completely endothelialised in6 to 8 days. This avascularity of the endothelial plug isto be expected, since thin-walled capillaries would beunable to withstand the transmitted compressing forceof the arterial blood-pressure near the intimal surface.This type of organisation is comparable to that in a muralthrombosis on a vessel wall. From the adventitial endof the track a more classical picture of repair proceeds,with fibroblasts and capillary loops. As the scar maturesfurther, collagen fibres thicken, and in four specimenswith tracts 44 days or more old, smooth muscle cellswere seen lying irregularly among the collagen fibresin the medial end of the scar : the muscle coat was not,however, truly reconstructed. -

This orderly repair of the damaged artery is veryefficient, and few late complications of arterial puncturehave been reported. When trouble arises, it is usuallybecause a large-bore needle has been introduced into adiseased artery in order to inject a radio-opaque solutionrapidly and under high pressure. Atheromatous plaquesor mural thrombi may be loosened or, more disastrously,if the needle point is accidentally inserted into a branchof the aorta, the whole volume of irritant material maycause sudden thrombosis of the renal, coeliac, or mesen-teric arteries and consequent organ infarction. If theneedle lies in the media of the aorta, the even moredramatic complication of dissecting aortic aneurysmmay ensue. Gaylis and Laws 2 believe that this is notuncommon and that it may account for many of the

complications of aortography previously attributed tothe irritating ox toxic action of the contrast media.Their patients recovered without serious sequelse, thoughinstances of paraplegia and death have been recorded.The greatest care may not always avoid such compli-cations, for Lindgren 3 showed that even when a trialinjection confirms that the needle is in the lumen someof the medium may enter the wall during the maininjection. Aortic pulsation or respiratory movementmay produce a small but vital shift in the position of theneedle; and during forcible injection the needle may bepulled backwards or the chemical qualities of the injectedmedium may cause the artery to contract. Intramuralinjections may well account for some of the femoral,carotid, or brachial thromboses which follow peripheralarteriography. Moreover, it is known that in theoccasional patient the brachial artery responds to

trauma by a segmental spasm. There can be little doubttoo that the toxicity of sodium iodide or high con-

centrations of the organic iodides may cause endothelialor even parenchymatous damage. Though arteries havea great capacity to withstand needling, high-pressureinjection of irritant or bland solutions can be dangerous,and, on all counts, the reasons for advising a patient toMidergo arteriography should invariably be scrutinisedwith care.

1. Crawford, T. J. Path. Bact. 1956, 72, 547.2. Gaylis, H., Laws, J. W. Brit. med. J. 1956, i, 1141.3. Lindgren, E. Acta radiol. Stockh. 1953, 39, 205.

"THE HURT MIND"

THE fear of mental illness derives as much from mis-understanding and magical preconceptions as from simpleignorance. The series of B.B.C. television programmes,which ended on Jan. 29, was designed both to counterold beliefs and to reveal new truths. It is perhaps themost comprehensive attack yet made on the public’sattitude to a medical problem, and it is to be welcomedas a sensible attempt to dissipate prejudice by informa-tion. In introducing the series Mr. Christopher Mayhew,M.p., gave some idea of the size of the problem by pointingout that 1 person in 20 of the population of this countryspends some time of his or her life as a patient in a mentalhospital.The first programme introduced the theme that it is

unjustifiable to look on mental disease as somethingvery different from physical disease. To collect materialfor the series Mr. Mayhew was voluntarily admitted toa mental hospital for a few nights, and his excellentinterviews with his fellow patients, the nurses, and thedoctors helped to dispel the idea that mental patientsare uncontrollable. A modernised mental hospital, withits quiet, orderly wards and free access to the neighbour-hood was contrasted with the old-fashioned institution-of which, unfortunately, there are still examples-withits high walls, locked doors, and patients pacing theairing-courts like captives. Many people believe thatmental patients must go into a mental hospital for treat-ment, but the programme showed that general hospitalsnow give outpatient treatment for mental as well as

physical disabilities.The second programme was the least effective of the

series. It successfully gave an idea of the complexityof the brain by representing the number of its cells.by the grains of salt in a specified number of cartons,but the definitions, couched in psychiatric phraseology,were unlikely to be helpful to many viewers. The thirdprogramme described social and psychotherapeuticmethods of treatment. It showed that the first step inthe reablement of the patient is to restore his sense of-belonging to the community. The fourth programmeshowed physical methods such as modified electrocon-vulsion, insulin-shock therapy, and an ether abreaction :a neurosurgeon described the operation of prefrontalleucotomy and its effects. Patients then recounted theirsymptoms before treatment and after recovery. Thewife of a leucotomised patient gave a relative’s pointof view. This was probably the most successful

programme of the series and brought out clearly thesimilarity with physical disease and the improvingprospects of recovery.

Viewers were asked to send in questions and some2000 did so. In the last programme a panel of expertsanswered a selection dealing with overcrowding inmental hospitals, unsympathetic general practitioners,the possibility of wrongful detention, and reablement,and Sir Geoffrey Vickers added a few words on thefuture of mental research. Summing up, Mr. Mayhewsuggested that, though the social problem is vastand not yet generally recognised, the future lookshopeful.From the technical standpoint, the quality of pro-

duction improved throughout the series. In the earlier

parts there was a tendency to suggest mystery by ahaunting opening sequence and close-ups of tappingfeet and twisting fingers, but later the presentation wasstraightforward and more in keeping with the aim of theseries. In refraining from showing the faces of patients theproducers-inevitably perhaps-were compromising withthe very attitude they were attacking ; for when thecameras recently visited a general hospital no suchrestriction was thought necessary.An associated series of six weekly mental-health broad-

casts will begin in the B.B.C. Home Service on April 17.