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presence is quickly forgotten. Naturally, the M.w.o. has to bediscreet and tactful. He quickly learns when the flow of his-tory-taking is inhibited by his presence, and he then makesan excuse and withdraws. Similarly, the psychiatrist can

secure his withdrawal by a prearranged signal. But need forwithdrawal has arisen only two or three times in two years.Again, if the patient objects to the M.w.o.’s presence he

withdraws, but this has only happened once.

EARLY ADVANTAGES

In this way, the M.w.o. is in at the beginning of the case;and if, for instance, a social report is needed, he knowsexactly what is wanted. He also knows the treatment

prescribed and often can arrange for adequate supervision,perhaps by explaining the treaxment to relatives or neigh-bours. His presence at the first interview paves the wayfor his acceptance as a friend and counsellor by patient andrelatives. When home visits are necessary, he is acceptedinto the home instead of being kept on the doorstep ex-plaining his presence, or being treated with fear and sus-picion as the official who takes people from their familycircle into a mental hospital. When outpatient electro-plexy is carried out at Fulbourn Hospital, the M.w.o.arranges for transport and explains the treatment to rela-tives. He acts as an essential link between the psychiatristand all the local authority services and departments, in-cluding the police. With the minimum of formality, he canfind out the chances of a patient getting a house, getting ajob, or being arrested.One of the bugbears of clinical psychiatry is assessing

whether a patient’s belief is a delusion or not. Most

psychiatrists have experienced the chagrin of accepting asa delusion something which is fact, and vice versa. TheM.w.o. with his local knowledge can often help the psychia-trist here. For instance, when the seemingly ragged trampstates that he is a wealthy Fen farmer, the M.w.o. can con-firm that this is indeed so, and the good rapport with thepatient is preserved. The M.w.o. knows the district inwhich the patient lives, its culture, and its social mores.He usually knows whether there is mental illness or

deficiency in the family, who is in debt, or behind with therent, or which relative is in jail. All too often, the patientis not an accurate source of facts about himself. The

presence and knowledge of the M.w.o. at the outpatientclinic increases the value of the history, and what he doesnot know he can quickly find out.

AFTERCARE

In remote country districts poorly served by publictransport, there are many patients with whom it is difficultto keep in touch after they have been treated. The M.w.o.makes it his job to keep an eye on these people and hereports their progress, or lack of it, to the psychiatrist.When a patient leaves Fulbourn Hospital, a copy of thedischarge letter to the general practitioner is sent to themedical officer of health for the district, who tells theM.w.o. of its contents, so that he can take any actionrecommended in it. Another of the tasks of the M.w.o. isto support the relatives when a patient is treated at home.Often these patients are old and demented, but with asuitable tranquillising drug, social help, and support, theycan live happily at home. In this area where the M.w.o. isalso the D.w.o., the senile patient who does not needmental-hospital treatment but cannot be looked after athome, can be dealt with under the National AssistanceAct. The dual-purpose M./D.w.o. is able to appreciate allsides of these difficult problems.

The M.w.o. is accepted as a friend and confidante

by many patients-even those whom he has had to removeto hospital under a legal order. When these patientsreturn to the outpatient clinic for follow-up they oftenlaugh with him about their disturbed behaviour. Patientssoon get to know that they will get help and sympathyfrom him, and this is a most useful form of psychiatricfirst-aid. Psychiatric teaching stresses the importance ofenvironmental manipulation in treatment, but it is rare forthe psychiatrist to be in a position to do this effectively.The M.w.o., however, can carry out the psychiatrist’sinstructions and materially alter a patient’s environmentby seeing and advising relatives, employers, supervisors,and others.

The family doctors of the area appreciate the closeliaison between the M.w.o., the psychiatrist, the hospital,and the outpatient clinic; and often, instead of asking forthe patient to be admitted to hospital, they merely requestpsychiatric advice. The M.w.o. also sees that the familydoctor is kept informed of his patients’ progress, thusobviating the need for lengthy reports from the out-

patient clinic. The doctor is also forewarned of an

approaching crisis and of how to cope with it.Whenever the M.w.o. is in doubt, he is at liberty to seek

the advice of the psychiatrist, and many psychoses areaborted and crises averted by prompt action. When com-pulsory admission to hospital seems necessary, he can seekthe psychiatrist’s advice.We have found the work rewarding and we believe that

it has increased the efficiency of the service and its valueto our patients.We wish to acknowledge the sterling work of Dr. F. Houston,

who was the psychiatrist primarily responsible for setting up thiscoordinated psychiatric service.

Dialogues of Today

I’M ALL RIGHT, HIPPOCRATES!SOCRATES: I hear, Glauco, that some doctors say that if the

State refuses to pay them as much as they think they shouldearn, all doctors should refuse to serve the State, and makeother arrangements to treat their patients. Do you approve ofthat ?

GLAUCO: Certainly, Socrates, for surely no one can deny aman’s right to refuse to work for what he regards as an in-adequate reward, and if an employer does not pay enough, heshould not complain if he cannot get people to work for him.Surely to deny that is to deny an elementary principle offreedom!

SOCRATES : And does this principle apply to other workers ?GLAUCO: Certainly.SOCRATES : And I suppose that if there is a dispute in an

industry some workers will withdraw their labour because theyare dissatisfied with their wages, while others, who are moreeasily satisfied, will prefer to remain at work?GLAUCO: They may prefer to do so, Socrates, but if their

leaders decide that all must cease to work, they will all cease towork, whether they want to individually or not.

SOCRATES: No doubt, then, a worker will refuse to join histrade organisation if he thinks it is likely to act against hisinterest ?

GLAUCO: Oh, no. If a worker does not join his trade organi-tion, he will be likely to find it impossible to get work, for hisfellow-workers will refuse to work with him, and an employer,therefore, will employ only those who belong to the tradeorganisation.

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SOCRATES: It seems to me then that no worker is free to

refuse his services, as you said, for the foundation of your" principle of freedom " is that he is first compelled to join anorganisation, and then to do what it orders, whether he likes itor not.

Gt.AUCO : The workers should be prepared to make this

sacrifice, for it is only by such methods that they have beenable to raise their pay and conditions to their present level.

SocttAxs: And if the workers in an industry refuse to work,does that affect only themselves, or others also ?

GLAUCO : Many others, for workers in other industries whichuse their products will soon be unable to work also, andsometimes the life of the whole community will be dis-organised.

SOCRATES: So the freedom of one set of workers to refuse towork means that many others will not be free to work, or evenperhaps to travel to their work ?

Gi,AUCO : That is the inevitable result of social organisation,and, indeed, it is a factor which the trade organisations takeinto account, for they hope that public inconvenience will putpressure upon the employers to give in to them.

SOCRATES: In your opinion, then, the workers who refuse towork rightly disregard the interests of other workers, and of therest of the community ?GLAUCO: I see no alternative, Socrates, which does not inter-

fere with the economic rights of the worker.SOCRATES: Why, then, have not other workers, and, indeed,

the whole community, the right to intervene in a particulardispute if it interferes with their own freedom to work ? If we

apply your principle that one set of workers is entitled to restrictthe freedom of others, why should not the community restrictthe freedom of the workers to organise the withdrawal of theirlabour? But let us apply what you have said to the doctors.Do you think that medical officers of health should withdrawtheir services if those who employ them refuse to increase theirpay ?

GLAUCO : No, for the welfare of the community would sufferif they did so.

SOCRATES: And is the same true of doctors who work in

hospitals ?GLAuco: Yes, indeed; they would not be able to withdraw.SOCRATES : And family doctors ?GLAUCO : They would take good care that no patient suffered

as a result of any alternative arrangements they might make.SOCRATES : And what if a patient who is now paid for by the

State could not afford to pay his doctor ?

GLAuco: The doctor would treat him for nothing.SOCRATES: Is it certain that doctors would earn more if they

were no longer paid by the State ?GLAUCO : By no means.SOCRATES : I am very inexperienced in these matters, Glauco,

but have we not agreed that doctors are to withdraw from theState service because they want more money ?

Gi.AUCO : Certainly.SOCRATES : If it is not certain that they will earn more money

independently of the State, their object in withdrawing must beto compel the State to pay them more, as other workers hopeby withdrawing their labour to achieve this end.GLAUCO: Yes.

SOCRATES: And is it not true that other workers possess two

weapons: their withdrawal of labour makes their employerslose money, and it causes hardship or inconvenience to thepublic ?GLAUCO: Yes.

SOCRATES: But since the State makes no profit out of thehealth service it will not lose money if the doctors withdrawfrom it, but rather the reverse. And you tell me that the doctorswill take care to cause no hardship or inconvenience to their

patients. Why, then, should their withdrawal persuade theState to pay them more ?

GLAUCO : Doctors render services to the State apart fromthose they give their patients, so that though they will not incon-venience their patients they could easily inconvenience theState.

SOCRATES : But of what does the State consist except of

patients and potential patients, and what service does a doctorrender to the State which does not concern patients, and whichhe could withdraw without inconveniencing patients ? Youhave been silent, so far, Eryximachus. Tell us what you think.

ERYXIMACHUS: You began, Socrates, by saying that youassumed that each worker was free to do what he thought right.I think that, whatever happens in industry, doctors wouldexercise that freedom if they were involved in a dispute with theState. I think, too, that many who now say they would with-draw their services would soon find that they had to choosebetween withdrawal and their patients’ welfare, and wouldchoose the latter. For these reasons I think withdrawal wouldfail.

SocRATES: Yes, a sense of service is a serious handicap! Doyou not think, Glauco, that the wisdom and prestige of yourprofession are likely to achieve more than methods which arealready bringing even industrial workers into disrepute ?

Medicine and the Law

Hysterical Amnesia not a Form of InsanityON Sept. 24, 1959, the defendant, one, Podola, appeared

at the Central Criminal Court charged with the capitalmurder of a police officer.

Before he was asked to plead to the indictment his counseltold the judge that evidence was available raising the pre-liminary issue whether he was fit to plead to the indictment onthe ground that he had completely lost his memory for allevents before July 17, the day after his arrest, and that theCrown would contest that issue. The judge ruled that it wasfor the defence to establish that the defendant was insane soas to be unfit to plead to the indictment, and that the burdenof proof would be sufficiently discharged if they could showon the balance of probabilities that he was unfit to standhis trial. Evidence was called by both sides and the juryimpanelled to try the preliminary issue were asked, in the firstplace, to answer the specific question " Is the defendant nowsuffering from a genuine loss of memory covering at leastall events with which he was concerned " during a certainperiod ?The jury answered that the defendant was not suffering

from a genuine loss of memory. The judge directed them thatin view of that answer and in the absence of any other evidence

pointing to the defendant’s insanity it was their duty to saythat he was fit to stand his trial and the jury returned a verdictaccordingly.The trial on the charge of capital murder then pro-

ceeded and the defendant was convicted and sentenced todeath. He did not appeal but, a petition having beensubmitted, the Home Secretary referred the whole caseto the Court of Criminal Appeal for determination undersection 19(a) of the Criminal Appeal Act, 1907. Thedefendant had relied solely on a hysterical amnesia

preventing him from remembering events during thewhole of the period material to the question whether hehad committed the crime alleged; there was no suggestionthat his mind in other respects was not a completelynormal mind, his case being that that defect of memoryrendered him unable properly to instruct his adviserswith the consequence that he could not make " a properdefence ".