reviews
BOOKS • CD ROMS • WEBSITES • MEDIA • PERSONAL VIEWS • SOUNDINGS • MINERVA
Rural Healthcare
Jim Cox, Iain Mungall
Radcliffe Medical Press;
£22.50, pp 184
ISBN 1 85775 267 8
Rating: ★★★
F
or half my working life I was a general
practitioner in inner London. Then I
worked partly in Africa and partly
“locuming” round Britain, from St Austell to
Papa Westray. I found myself in a different
world, one that this book powerfully
reminds me of. The distances; the loneliness,
sometimes welcome, sometimes not; the
independence and self sufficiency of the
people.
“What about the rota?” I asked my first
employer.
The Malthus Factor
Eric B Ross
ZED Books, £14.95, pp 270
ISBN 1 85649 564 7
Rating: ★★★
M
althus’s ideas are still popular
today, and this book tries to
explain why and how. Malthus
offers a political theory of poverty that rests
on two principles: firstly, that poverty is
originated by the poor themselves (that is,
via their reproductive behaviour) and,
secondly, that only external pressures on the
poor can correct any imbalance between
population and resources, namely moral
pressure (sexual restraint) or violent circum-
stances (famine or war). According to Ross,
Reviews are rated on a 4 star scale
(4=excellent)
264
“Well, we don’t actually have a rota,” he
answered apologetically, “but you’ll find the
patients are very good and other doctors
helpful.”
He was right on both counts, although
on Papa Westray there was no other doctor,
which added a extra frisson of anxiety to the
stress of being always on duty.
Ancillary staff rarely get the recognition
they deserve. Before cellphones, reception-
ists received my calls, health visitors and
community nurses took over each other’s
tasks rather than duplicate long visits, and
their intimate knowledge of their commu-
nity was invaluable. The communities them-
selves were helpful; one postmistress put the
daily dose through the letterbox for a
forgetful patient. I found myself doing regu-
lar branch surgeries in front parlours or
church halls, usually loaded down with the
regular medicines dispensed from the main
surgery.
I wish that I had had this book with me. I
ran into no troubles in dispensing practices,
but if I had the regulations are all here. It
also contains good short accounts of rural
diseases, and excellent illustrations of poten-
the decades after Malthus’s essay, first
published in 1798, largely contradicted most
of his observations (partly because he
underestimated the productivity of agricul-
ture). Nevertheless, Malthusianism devel-
oped largely as a political tool for the ruling
elite: it had the appearance of a formal
scientific theory, and it blamed the poor for
their condition, thus avoiding any alternative
explanation of poverty.
Ross also analyses why Malthus’s princi-
ples are still used today in discussions of poli-
cies related to population growth (by inter-
national agencies, for example) or policies
related to immigration (by administration in
the developed world, for example). Perhaps
the most interesting current application of
these principles is environmentalism. This
usually promotes the idea that there is some
fixed mechanical link between population
and resources. Furthermore, there is also a
strong moral component in environmental-
ism, a mixture of blaming every citizen and a
sort of scientific paternalism. Both are
characteristic of Malthus. His memorial tablet
in Bath Abbey interestingly reads: “One of
the best men . . . raised by native dignity of
mind above the misinterpretations of the
ignorant and the neglect of the great.”
Malthus was neither the first nor the best
theoretician of population growth and
resources. His observations were second
tially confusable conditions like ringworm.
More would have been welcome. A section
on animal maladies had me fascinated; the
veterinary term “rattle belly” sounds so
much better than borborygmus.
It is now 10 years since I gave up locum-
ing, and in that time much has changed for
the better, as the second half of the book
makes clear. Problems such as communica-
tions and access to care, which rarely bother
urban practitioners, are discussed, and it was
good to see the formation of a rural practice
group of the Royal College of General Prac-
titioners to discuss issues such as continuing
professional education and research. Espe-
cially welcome was the establishment of the
“associate” scheme, whereby an extra doctor
is appointed to relieve single handed practi-
tioners.
Britain is a small island, but the needs of
people in different areas vary widely, as do
the qualities and training of those who serve
them, something academic departments
should recognise. All rural general practi-
tioners would benefit from this book. The
illustrations alone are worth the price.
Ann Savage general practitioner, London
hand, and both Goldwin and Condorcet had
more thoughtful and complex ideas. How-
ever, the simplicity and the brutality of the
model he proposed have caused his
principles to be used largely as political
tools. In fact, one of the first explicit applica-
tions was the suppression of the poor laws in
the United Kingdom, providing one of the
first modern examples of “evidence based
policy.”
Ross obviously has a fixed opinion on
how to deal with poverty, one that is clearly
different from Malthusianism, but he has
written a well documented book that
addresses key issues in population health
and social medicine. Thus, even those
readers who may have diverging views or
some reserve about particular topics (such
as eugenics) will find refreshing ideas that
are relevant to contemporary issues. Indeed,
Malthus has helped many people elaborate
their own theories, from Darwin (who men-
tioned the influence of Malthus in the early
phase of his work) to Marx (who strongly
criticised Malthus).
Fred Paccaud director, Institut Universitaire de
Médecine Sociale et Préventive, Lausanne,
Switzerland
Readers interested in the original Malthus essay
can find it on the internet at www.trmalthus.
com/essay.htm
BMJ VOLUME 319 24 JULY 1999 www.bmj.com
 reviews

Hamilton Bailey: Gillender, a young professional photo-

grapher who was to act as his lifelong
A Surgeon’s Life
amanuensis. In 1930 he was appointed to
Adrian Marston the Royal Northern Hospital, where he
Greenwich Medical Media,
expanded his reputation as a voracious
£29.95, pp 157
operator, charismatic teacher, and elegant
ISBN 1 84110 024 2
author; on the downside he was domineer-
Rating: ★★★ ing and demanding and had little respect for
authority, few social graces, and almost no
rapport with patients or colleagues.
In 1943 his only child, Hamilton, was
killed at the age of 15 in a horrific railway
accident. From then on his mental health
deteriorated: by 1949 he had had to give up
operating and was eventually admitted to
Graylingwell Hospital, Sussex, where he was
NETLINES
d AIDA on-line is an interesting,
interactive website for looking at the
variables influencing control of insulin
dependent diabetes (www.shodor.org/
aida/index.html). The objective is to
show the effect on diabetic control when a
host of variables such as dose and timing
of insulin are altered by the user. Plenty of
educational value, but the site doesn’t
simulate real life particularly well.
d The United States Navy has produced
a content-rich site called the Virtual Naval
Hospital (www.vnh.org/Misc/Outline.
html). It is a gateway of hypertext links to
substantial resources that could be useful

T
hirty eight years after his death, the incarcerated for three years—manic, para- to an isolated medic in the middle of a
name of Hamilton Bailey is well noid, disruptive, and unresponsive to treat- crisis or conflict. If you can’t find what
known to doctors throughout the ment. He was saved from a prefrontal you’re looking for here, another sector of
world. His reputation rests on three of the leucotomy by a registrar who suggested that the site has an even larger catalogue of
most popular and influential textbooks ever resources at www.vnh.org/Providers.
a new drug, lithium, might help; three
written, all of which are still in print: Demon- html. The collection of listings is so huge
months after starting it, he had made a
strations of Physical Signs in Clinical Surgery that in a time of crisis users might be
(1927), Emergency Surgery (1930-1), and A “miraculous” recovery and never looked overloaded with data and be unable to
Short Practice of Surgery (1932) with R J back. The Baileys subsequently moved to find the required information.
McNeill Love. But what of the man? Adrian Spain, where they continued to produce new d The Faculty of Medical Informatics,
Marston’s immensely readable and minutely editions of half a dozen books until early in part of the Royal College of Surgeons of
researched biography is, among much else, a 1961, when Hamilton Bailey developed Edinburgh, has published an excellent
classic study of mania. symptoms of intestinal obstruction and, collection of surgical links at www.rcsed.
Son of a general practitioner in largely because of his own interference, died ac.uk/fmi/gateway.asp. They are neatly
Brighton and a mentally troubled mother, of postoperative complications. He was catalogued under relevant subject
Bailey went to the London Hospital in 1912 headings, and most surgeons will find
buried in the British cemetery at Malaga.
and served in the Navy in the first world war. something useful in the listings. Not only
He began writing during his surgical Alex Paton retired consultant physician, are there connections to surgical
training and met and later married Veta Oxfordshire resources, but also links to information
technology sites and tourist information
about Edinburgh.
d The Dermatology Online Atlas is a fine
Detaining people with personality disorders This week the Home Office and the example of a good all round dermatology
Department of Health demonstrated their capacity for “joined up government” resource (www.derma.med.uni-erlangen.
by proposing new powers to detain people with personality disorders who are a de/bilddb/index_e.htm). This German
danger to the public. But it’s not good news at www.open.gov.uk: its “What’s new” site (which also has an English version)
page opens with a warning about congestion on its server, which the Government has, not surprisingly, a high visual content
WEBSITE Information Service frankly admits is because of its own inadequate bandwidth. with good pictures of skin lesions. This, of
OF THE Given that its whole information strategy is based around indexing PDFs rather course, has a price; downloading can be
than supplying HTML, it’s not surprising that the service has a few problems. This slow, especially during rush hour on the
WEEK net. The information accompanying the
is apparently being addressed, but for the moment you will have to switch to the
graphics is limited but useful, and this is
text only “no frames” view for a lighter download when you use the site, and
supplemented by links and an option for
spend the long minutes waiting for each differential diagnosis.
page praying that the government’s web
d The web is an excellent medium on
minions are soon allowed to add another
which to publish a database, and there are
couple of quid a day to their phone bill.
now many to choose from. A large
From here, you can link to the Home number, however, have names that are not
Office’s “What’s new” page for details of the particularly descriptive. So the US
consultation paper Managing Dangerous National Library of Medicine has
People with Severe Personality Disorder assembled a helpful page (www.nlm.nih.
(www.homeoffice.gov.uk/new.htm), and the gov/databases/databases.html)
Central Office for Information has the press release (www.nds.coi.gov.uk), describing a selection of online databases
although its Flash graphics are a good example of gimmickry detracting from and linking to them. This gateway page
the usefulness of a site (“Catch our info! Crafting Outstanding Ideas! also indicates the cost of using them,
although most of them are free. Despite
Confidently Organised Intelligence! Central Office for Information!”)
the logical layout of the page, it is still easy
Those who fear that psychiatrists—and, by implication, the whole of the to become overwhelmed by the number
medical profession—are already too deeply mired in penal affairs of the state of databases included.
may like to visit the Thomas S Szasz Cybercentre for Liberty and Responsibility
for some intellectual underpinning (www.enabling.org/ia/szasz/ Harry Brown general practitioner, Leeds
Douglas DrHarry@dial.pipex.com
manifesto.html). The mental health charity Revolving Doors publishes some of
Carnall
BMJ the real life stories of the sort of people Jack Straw is talking about at
We welcome suggestions for websites to be
dcarnall@ www.revolving-doors.co.uk: its message is that appropriate support in the included in future Netlines. Readers should
bmj.com community would prevent many incarcerations, whether penal or psychiatric. contact Harry Brown at the above email.

BMJ VOLUME 319 24 JULY 1999 www.bmj.com 265

reviews
Killing for profit:
where is the outrage?
Tobacco Wars, BBC1, Tuesday at 10 20 pm,
20 July to 3 August
T
his series, presented by journalist
Michael Buerk, claims to “go behind
the battle lines in the tobacco war to
reveal the secrets of a century of smoking.”
The programme style is that of a historical
documentary, chequered with interviews
with “celebrity smokers” such as comedians
Jo Brand and Dave Allen and star of the
Eastenders soap June Brown (Dot Cotton),
and the personal experiences of Michael
Buerk, including undergoing a broncho-
scopy for the programme.
The first programme outlined the
history of tobacco in Britain and the United
States up to 1964. This included some
revealing interviews with current and
former senior employees of the tobacco
industry. For example, Sir Duncan Oppen-
heim (former chairman of British American
Tobacco) expressed his “great shock to find
that tobacco caused lung cancer.” This was
followed by an industry advertising execu-
tive informing viewers (with reference to the
popularisation of filter cigarettes) that, in
reality, “a filter is not a health device, a filter
is a marketing device.”
However, the programme somehow
failed to really get across the extremely cyni-
cal way in which the industry knowingly
used political influence to enable it to go on
marketing “cancer on a stick” to the public.
This point may have been lost because of the
inclusion of scenes such as a general
BBC
Alex Higgins: snookered by the tobacco
industry
266
practitioner who has a magic show based on
his cigarette smoking (“a lot of people
benefit from smoking . . . in terms of their
stress”) and depictions of the production of
“cigarette fetish” videos for men who get
turned on by watching women smoking.
The second programme addressed the
question of whether the industry did
enough to warn consumers about the
dangers of smoking. No prizes for guessing
the correct answer here. One particularly
memorable piece includes footage from the
1970s of the top snooker player Alex “Hur-
ricane” Higgins puffing away between shots,
surrounded by tobacco advertising. This is
followed by a present day interview with
Higgins, now suffering the effects of throat
cancer. His expression of disgust for the
tobacco companies serves as a contrast to
the rather cosy chats with industry execu-
tives and other “celebrities,” which tend to
present cigarettes as “naughty but nice.”
The issue of tobacco sponsorship of
sports also receives considerable coverage in
the programme. The story is told of the
demise of the former Conservative minister
for sport, Richard Tracey, who found himself
dropped from Margaret Thatcher’s cabinet
after taking a relatively tough line on this. It is
implied that the industry used its links to the
cigarette smoking Denis Thatcher to get what
it wanted. This sinister side to the industry is
also demonstrated in interviews with industry
scientists whose research programmes were
shut down when they started producing
evidence of harmful effects of smoking.
Rather than use the data to try to manufac-
ture safer cigarettes, the main tactic used by
the industry was denial of health risks and
oversight of all research and marketing
strategies by lawyers. The opportunity to pro-
duce a truly safer cigarette was rejected—
partly because this might involve the admis-
sion that current cigarettes were “unsafe.”
This second programme is certainly
more effective than the first in portraying
the underhand tactics of the industry, but it
is still rather low key and fails to give the
impression that anything really outrageous
has happened. Michael Buerk’s personal
account of his smoking career adds a certain
human interest, but I wonder whether a
more combative style (such as that of the
investigative journalist Roger Cook) might
have helped to convey the message that
120 000 extra premature deaths a year in
the United Kingdom caused by a legal prod-
uct is really unacceptable and requires more
vigorous opposition. For example, I would
like to see former government officials (such
as Margaret Thatcher) asked about their
eagerness to accept £10bn in tax revenue
from tobacco companies annually and yet
provide almost no help and resources to
enable smokers to quit; I would like to see
Sylvester Stallone asked why he agreed to
smoke a particular brand of cigarette in five
of his films for a fee of $500 000; and I
would like to see more interviews with ordi-
nary smokers who have tried to quit but who
have been unable to do so. The crucial con-
cept of addiction to tobacco has been
BBC
mentioned in the series, but has not yet been
adequately represented.
This series has the potential to make the
public feel outraged at how the industry and
successive governments have colluded over
the past 50 years to allow the premature
deaths of hundreds of thousands of people.
It also has the potential to make many
smokers more determined to quit. The first
two programmes do not quite succeed in
this, but I hope that the third will be more
hard hitting and positively influence who
wins the latest battle for public opinion in
the tobacco wars.
Jonathan Foulds senior lecturer in clinical
psychology, University of Surrey, Guildford
JUNE BESTSELLERS
1 Clinical Governance: Making it Happen
M Lugon, J Secker-Walker
Royal Society of Medicine Press, £17.50,
ISBN 1853153834
2 Withholding and Withdrawing
Life-prolonging Medical Treatment:
Guidance For Decision Making
BMA Medical Ethics Committee
BMJ Books, £9.95, ISBN 0 7279 1456 1
3 British National Formulary No 37
(March 1999)
BMA/Royal Pharmaceutical Society, £15.95,
ISBN 0 85369 434 6
4 How to Read a Paper: The Basics of
Evidence Based Medicine
T Greenhalgh
BMJ Books, £14.95, ISBN 0 7279 1139 2
5 The Impact of Genetic Modification on
Agriculture, Food, and Health:
An Interim Statement
BMA Board of Science and Education, £4.95,
ISBN 0 7279 1431 6
6 Pocket Guide to Critical Appraisal
I K Crombie
BMJ Books, £10.95, ISBN 0 7279 1099 X
7 Oxford Handbook of Clinical Specialties
5th ed
J Collier, M Longmore, T D Brown
Oxford University Press, £15.95, ISBN 019 262 9433
8 Narrative Based Medicine: Dialogue and
Discourse in Clinical Practice
T Greenhalgh, B Horowitz
BMJ Books, £19.95, ISBN 0 7279 1223 2
9 Oxford Handbook of Accident and
Emergency Medicine
J Wyatt, R Illingworth, M Clancy,
C Robertson, P Munro
Oxford University Press, £18.95, ISBN 019 262 7511
10 Practical General Practice 3rd ed with
CD Rom
A Khot, A Polmear
Butterworth Heinemann, £35, ISBN 0 7506 3462 6
BMJ Bookshop
BMJ VOLUME 319 24 JULY 1999 www.bmj.com

PERSONAL VIEW
Old age psychiatry in Swansea
T
his new specialty has many advan-
tages. It is particularly rewarding to
those interested in local history,
social and industrial change, and the history
of the twentieth century. Our patients are
survivors, people who have had long, often
interesting, and sometimes distinguished
lives, people who span the whole of the
social spectrum. My only contact with an air
vice marshall and a Bluebell girl has been as
patients. I have also met the last rat catcher
who worked at the local flour mill.
It is a specialty that bridges the divide
between hospital and community. A large
part of my time is devoted to the latter and
there are many benefits. The key to good
practice is unhurried assessment of patients
in their homes. This approach, although
time consuming, is clinically rewarding, and
there are several hidden gains which are not
obvious until you have worked in the
specialty.
The Easter weekend
was wet and cold. Many
areas had had their first My only contact
covering of snow. The fol- with an air vice
lowing Wednesday was a
glorious day, the sun shin- marshall and a
ing from dawn till dusk. On Bluebell girl has
Gower there was a clear
view as far as the eye could been as patients
see. I was indeed fortunate
in having arranged to see patients in their
homes on this spectacular peninsula on
such a fine day. In 1956 Gower was the first
area in Britain to be designated an area of
outstanding natural beauty. On the south
coast steep cliffs are interspersed with
picturesque bays. To the north there are
extensive marshes, mud flats, and cockle
beds, all forming an area of importance for
wetland birds. I had been to that area on
Easter Monday to see if the herons were
nesting again on a new site.
On another day I saw five patients and
learnt several things in the middle of
spectacular scenery. The first patient was in
her mid-80s, able to give a good history, a
widow who had spent six months in a home
over the winter. She was deaf, her memory
was failing, and she had recently broken her
wrist. She was not contented. She was pining
for her home. If she could be there all would
be well. Was this hiraeth? This Welsh word
has no English equivalent. It is the deep per-
sistent longing for your dear ones, for home,
and homeland. It has a definite Welsh and
Celtic quality of longing for better days. It is
not nostalgia, which is a more superficial
emotion. Was this an appropriate state of
If you would like to submit a personal view please tant to remind ourselves of the benefits
send no more than 850 words to the Editor, BMJ,
BMA House, Tavistock Square, London WC1H
9JR or email editor@bmj.com
BMJ VOLUME 319 24 JULY 1999 www.bmj.com
mind or could it be a depressive symptom:
dysthymia?
This lady told me that she was brought
up in the Swansea valley and that her father
had died young from “Monditis.” This term
is not in the medical dictionary, but Donald
Hunter, his pupils, and the doctors in this
area would know immediately about the
condition. Her father had worked in the
Mond Nickel works at Clydach and no
doubt had developed the severe respiratory
complications associated with the refining of
nickel.
Mid morning I saw the third patient at
Horton, a small village on Gower’s south
coast. I interviewed the patient in the porch
in the strong sunshine. It could not have
been a better day. Afterwards I returned
along Cefn Bryn, the ridge that bisects
Gower from north to south. The view all
around was striking. In a circle you could see
to the north west the Preseli Hills of north
Pembrokeshire, to the east
the Brecon Beacons, to the
south Exmoor, and in the
south west Lundy Island out
in the Atlantic. This island,
the distant hills, and the
mountains can often be
seen, but, on this day, the
view was so much more
impressive as all the high
ground was covered in snow and high-
lighted by the clear spring sunshine.
Naturally, a real bonus of working in
Swansea is the opportunity to meet people
who have had contact with the city’s most
famous son, Dylan Thomas. One of these
was Mrs Trick, whose husband Bert had
played such an influential part in encourag-
ing the young Dylan to write and to publish.
It is also possible to gain insights into two
major formative influences on his work, the
inspiring beauty of Gower and the natural
spontaneity of the people. These two exam-
ples, an obituary notice, and a Valentine
greeting from The Evening Post, could easily
have entered the dramatis personae of
Under Milk Wood.
“Evans, David Martin (Dai Dog), passed
peacefully away.”
“Newman (Granada), I can’t wait to
warm your tootsies in my sleeping bag. I’ll
love you forever. Mrs Morgan.”
There are advantages of working in old
age psychiatry. It is a pleasure to be out and
about seeing interesting patients in splendid
scenery, and Swansea has the added bonus
of its cultural heritage. With the constant
cycle of changes in the NHS and a further
round of reorganisation in Wales it is impor-
gained from our work.
D D R Williams consultant psychiatrist, Swansea
reviews
SOUNDINGS
Who needs Rubik’s
cube?
I read an article by a diabetologist last
week, in which he claimed that in the
next millennium diabetes would remain
one of the most intellectually satisfying
of all illnesses, and that because
diabetes involves all organs and ages it
gives a “wonderful” spectrum for the
clinician.
He didn’t claim that people with
diabetes would be better managed, or
that they would feel better, or have fewer
complications, or live longer and have a
better quality of life, but just that his
work would be a little more interesting
and diverting.
Implicit in this message is that
patients are not real people, but simply
interesting exhibits in a museum,
complex puzzles to be solved (and that
diabetologists are intellectual to begin
with—I mean, how smart do you have to
be prick somebody’s finger and jack up
their insulin?)
But even such an enormous and
offensive conceit contains a cruel truth
for all of us. Sometimes solving the
puzzle is intellectually satisfying, no
matter how dread the prognosis, no
matter how bad the news is for the
patient; it’s an ill wind that turns none to
good.
So much of what we do is just a
kneejerk reflex: antibiotics; asthmatic
attack—steroids; back pain—sickness
certificate; headache—brain scan.
Picking up an atypical presentation,
putting together a jigsaw of obscure
signs and symptoms to come up with a
spectacular diagnosis; these things finally
allow us a chance to utilise all the brain
power and intellectual capability that we
used to have before medical school
flogged it out of us.
The game doesn’t even necessarily
need a cerebral component. A young
man with abdominal pain and nothing
else but your gut instinct; you send him
in as a possible myocardial infarction,
and if your hunch turns out to be right
who can deny the discrete glow of
satisfaction?
Even better if the hospital sends him
home, and he later develops frank signs
and has to be readmitted, or, best of all,
the icing on the cake, croaks in the
ambulance on the way in; that self
righteous exasperation, putting one over
on your colleagues, a bit like taking
another man’s woman; that sinful thrill,
doesn’t it feel good?
Liam Farrell general practitioner, Crossmaglen,
County Armagh
267