660

DISCUSSION

The chronic patients in a hospital may be looked uponas a captive population. For them industrial therapyrepresents a possible way to freedom in the outside world,or it may be used as a means of social containment. In the

community, on the other hand, the patient with chronicsickness or disability presents a different picture-he isnot a captive of a large institution-but frequently ofhimself and his home. This may lead to an unnecessarystate of dependence. The West Ham Centre is still not

widely known locally, and rehabilitation in a communitysetting is a relatively new idea. At first the motives for

coming to the Centre are a desire to escape from boredomand the pressures of home or social agencies, or to obtaina wider range of social contacts. At this stage, financialinducement is not a strong reason for attendance, thoughearnings have to be at such a level that patients are not outof pocket for travel and lunch expenses. After a period atthe Centre, however, different motives become prominent.Patients become interested in financial remuneration as ameasure of individual productivity, and also because theyhave improved their standards of living (e.g., an additionalEl per week without affecting State benefits; State bene-fits may represent a 25% increase in income).

There seems to be a critical period of useful attendanceat a centre of this nature beyond which the balancebetween independence and dependence is adverselyaffected. Close liaison with a sheltered workshop isdesirable. This need is not met locally by Remploy.(There is a long delay in acceptance, earnings are relativelylow, and travelling is fatiguing and expensive). The lessonis clear that there is a definite need for more centressimilar to that in West Ham.

We should like to thank Dr. F. Roy Dennison, medical officerof health for the County Borough of West Ham, for his support andinterest in this project, and to acknowledge our appreciation of thehelp and cooperation we have received from other members of thedepartment’s staff, particularly to Miss J. Capper, Miss A. M.Hinkley, and Mr. G. D. Brown.

Typhoid at HackneyA MAN with typhoid fever was admitted to hospital in

Hackney last week. With him went the rest of his family-hiswife and five children. One daughter and the wife were pro-nounced to be suspected cases. The medical officer of healthfor Hackney, Dr. R. G. Davies, said that contacts were beingtraced. 1

A Long-lived Carrier

Dr. D. Trevor Thomas, medical officer of health forPenarth, Glamorgan, writes:

" An only child, aged sixteen months, living with her parentsand an elderly grandfather, was recently notified as a case oftyphoid fever. Routine investigation revealed Salmonella typhiin the stool of the grandfather. He is an Italian, aged 81, whohad worked all his life as a waiter in many European countriesand Egypt and in later years in some of the largest hotels inLondon. His wife had enteric fever in 1923 and died in hospitalsome years later following an operation for cholecystectomy.

" The grandfather has a good memory and he is certain thathe has never had any serious illness and has never been admittedto hospital. He served with the British Army on the Italianfront during the 1914-18 war and recalls receiving T.A.B.

vaccine at that time. The S. typhi isolated from the blood-culture of the child and the stools of the grandfather are bothstated to be degraded V, strains and the phage-type cannot bedetermined." "

1. Guardian, March 12, 1964.

Conferences

POPULATION PRESSURE AND

INTERNATIONAL RELATIONS

AT a meeting of the Medical Association for the

Prevention of War, held in London on March 7, Dr.BERNARD BENJAMIN pointed out that by the year A.D. 2000world population, now estimated at 3000 million, wouldbe approaching 7000 million if the present rate of increasecontinued.

In A.D. 30, at the peak of Roman civilisation, it was, he said,230 million; and, because of a sustained high death-rate, it took1600 years to double itself. In 200 years it doubled again, butat the present phenomenal rate of increase only 36 years wouldbe required. The chief reason was the success of medicine incontrolling plagues and pestilences. In developing countries,birth and death rates had each been about 40 per 1000; but,with the death-rate dropping to 20 per 1000, the rate of growthwas now 2% per annum (Western Europe 0-8% per annum).Grave shortages of food already existed, especially in Asia; andsoon there would be shortage of space as well, though there wasstill room to spare in Africa and Latin America where therewere respectively 10 and 8 persons per sq. km. (Britain 300per sq. km.). The rate of population growth, however, wasgreatest in Asia, and efforts to increase the standard of livingwere failing to keep pace with the rising population; it was liketrying to run up a descending escalator. Speeding up the rate ofdevelopment was essential, but its effects on population growthwould not be immediately manifest; it had required a genera-tion for the British Education Act of 1870 to diminish the sizeof families. So far only India, Pakistan, and the United ArabRepublic had operated population policies, none with greateffect. In Japan, the Eugenic Protection Law had resulted ina million terminations of pregnancy per annum. Countrieswhich hitherto had objected on religious or political grounds tobirth-control were nevertheless now much more prepared todiscuss the problem.

Dr. ELEANOR MEARS (Family Planning Association) said thateducation and industrialisation brought about a reduction inthe birth-rate. The emerging middle class soon came to

appreciate the benefits of having a smaller family, and theywere followed later by the working class. In birth-control,motivation was more important than methods. Where peoplereally wanted to lirnit their families they found means of doingso; for example France, a predominantly Catholic country, hada falling birth-rate in the 1930s. Methods had to vary accordingto what was acceptable to the peoples concerned. Even inBritain and the United States there were notable differences,women in America playing a much greater part in fertilitycontrol, particularly since the introduction of chemical methods;in this country the male partner, through the use of the condomor coitus interruptus, still carried the main responsibility.Family planning was better than abortion or infanticide,although an increase in the abortion-rate might be the firstindication of a desire to deal with the problem-e.g., in Turkeywhere birth-control had been illegal (it no longer was). Russiaand Japan had found abortion not to be the best method.

There was still no magic method of birth-control, but thepresent

" cafeteria " of methods at least allowed a choice. Useof the contraceptive pill was the most efficient method yetdevised, but it required medical supervision; in 136 problemfamilies in this country where all other methods had failedover a two-year period the pill had proved extraordinarilysuccessful; two-thirds of the women had taken it regularlyand only 2 pregnancies had occurred in the past 3 years. Thepill had also the merit of not having to be used at the time ofcoitus. In Pakistan where it had been introduced, women,who had no calendars and could not understand when theyshould and should not take it, had been instructed to start

taking it with the coming of each new moon and continue for22 days, and this apparently had proved quite successful; they

also attended regularly each month for fresh supplies. Perhapsin the future there might be a pill once a week or an injectiononce a month.Immunological control of fertility held out some promise,

but methods of interfering with spermatogenesis (which lasts60-70 days) were proving difficult, partly because of unpleasantside-effects. Plastic contraceptive devices which could beeasily introduced and remain in the uterus for long periodswithout causing harm were proving reasonably successful andmight even prove better in Asia than the pill. Male sterilisationhad been fairly successful in Madras, after the male fear oflosing libido had been dispelled; but it was perhaps best

regarded as an emergency measure.The possession by a man of four or more wives

did not help. The fact that people were marryingyounger also meant that they could have more children,who would also grow to marriageable age earlier than theywould have done had their parents married later. The

general insecurity and malaise prevailing in the nuclearage might also play a part. Perhaps the best goal wasthe creation of a stable world society.

661

Medicine and the Law

Natural Justice Undisturbed by Procedural ErrorA DOCTOR preferred a complaint against the applicant,

mother doctor. The complainant died before the hearingby the Disciplinary Committee of the General MedicalCouncil. At the hearing, counsel, then instructed bysolicitors acting for the complainant’s personal repre-sentatives, said that the proper procedure (by rule 18 ofthe General Medical Council Disciplinary Committee(Procedure) Rules, 1958) was for him to be instructed bythe solicitor to the General Medical Council. That was

thought to be unnecessary and the committee directedthat counsel should continue as instructed. Some ofthe charges were proved and the applicant’s name wasdirected to be erased from the Register. The applicant’sappeal to the Judicial Committee of the Privy Council wasdismissed and his name was duly erased from the Register.The applicant then applied for an order of certiorari to

quash the determination of the Disciplinary Committee,alleging for the first time that the committee had lackedjurisdiction to proceed with the inquiry because counselwas instructed by the personal representatives of the

complainant and not by the solicitor. The DivisionalCourt dismissed the application. The applicant appealed.Lord Justice DIPLOCK said that it was conceded before

the Court of Appeal that there was a technical error inprocedure. In all cases of certiorari the Court had adiscretion whether to grant it or not. Where, as in thepresent case, there was an irregularity of procedure by aninferior tribunal acting within its jurisdiction, the primaryconsideration was whether the party aggrieved had beenprejudiced by the irregularity. In the present case, theprocedure was in no way contrary to natural justice andthe applicant was not in the least prejudiced by it. Anyone of the matters taken into consideration by theDivisional Court justified their refusal to grant an order ofcertiorari. Cumulatively they made the present appeal ashopeless in law as it was in merit and his Lordship woulddismiss it. Lord Justice WILLMER and Lord JusticeDANcKwERTS agreed.

Regina v. General Medical Council. Court of Appeal: Willmer, Danck-werts, and Diplock, L.JJ. March 9, 1964. Counsel and solicitors: DingleFoot, Q.c., and T. 0. Kellock (Hatchett Jones & Co.); Peter Boydell’Waterhouse & Co.). C. J. ELLISBarrister-at-Law.

C. J. ELLISBarrister-at-Law.

1. See Lancet, 1963, ii, 246.

In England Now

A Running Commentary by Peripatetic CorrespondentsI AM worried. Have I committed a grave breach of medical

etiquette ? At my favourite village pub, the Black Horse, thehost’s wife had just reappeared behind the bar after some littleillness. In the course of the conversation she said, " This iswhat puts me on my feet "-planking down a bottle-" Whatdo you think of it, doctor ? " I looked at it: Uputone (let uscall it), a mixture of glycerophosphates, strychnine, and Vit. Bl." Absolute rubbish, just a witches’ brew! " " Oh, but it wasprescribed in the hospital! " " Plenty of rubbish is prescribedin hospitals. As a taxpayer I rather resent all those millionsdown the drain." I cannot tell a lie; but which has beenpunctured: her faith in that hospital, or her esteem for me ?An old friend from whom I sought reassurance wrote: " That

woman at the Black Horse just thinks you are a poor old fuddy-duddy who’s forgotten anything he ever knew about medicine.I have been losing face, practice, and money in precisely thatway for years. Never heard of it,’ I say, handing back thepills with the fancy names."So complex has treatment with drugs become, and so strongthe passion of the British for them that, if you do a casual locum,you may well find almost every other patient demanding aprescription for, or a repeat of, something you have either neverheard of, or strongly disapprove of.Here is a simple example. You are relieving Dr. Blink. One

of your first visits is to little Cyril, measles. You give yourinstructions, tell the mother you will call in a week, she can letyou know if she’s worried. " But, Doctor, what about hispenicillin?" (or it might be chloromycetin, or tetracycline)."Penicillin?" "Yes, Doctor, when Peter and Sandra hadmeasles Dr. Blink gave them penicillin, he said it was most

important to prevent complications." What do you saynext ?

.

Though young men may be able to take this sort of thing aspart of the game, to me it is intolerable : and this may be onereason for the shortage of locums. I won’t do any except,perhaps, for old fogies on the same wave-length.

One of the consequences of my translation from East to Westwas that I lost my extremely efficient and comfortably decora-tive secretary. In her place I have inherited a piece of gun-metal hardware that emits a drone when it is working, winksits wicked eye at me when I am being received loud and clear,and screams at me when it has got as much on to its rotatingblue (or red) cuff as it can carry. What the infernal contraptioncould not do made me realise what a gem a real live humansecretary is. The machine can’t take messages for me, it can’tremind me about this or that, it can’t rearrange letters in orderof priority, it can’t fetch notes that are wanted suddenly, it can’task how words are spelt or point out that that last sentence hadno verb. Above all, it can’t help me in the 101 little ways thathide from the world around (and sometimes even from me) thefact that I make a lot of mistakes, am rather forgetful, andsometimes plain stupid.

Perhaps there is something lost on the other side too. It maybe occasionally frustrating or irritating at times to work forsome doctors and specialists, but this can hardly compare withthe soul-searing boredom of transcribing ill-understood jargonthat has been mumbled into a recording machine by some over-paid moron who has never really learnt how to use it. A com-puter to make the diagnosis for us may be anathema, but atleast it might help us to do our job better. The dictating-machine, on the other hand, replaces something human whowas a real part of the doctor-patient relationship, with a veryinferior substitute. It is a sharp step backwards.

*’ ’*’ ’*’

I see that British consuls are increasingly having to givemoney to stranded travellers. But the only time that I was

stranded, the consulate could not help me. This was in 1958