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were places for them. And East Africa is so thinly popu-lated that in many areas 10,000 people live too far apartfor one doctor to reach them. A further difficulty thatdoes not appear to have been mentioned is that a medicalservice creates its own demand; when a doctor has openedup a new area he soon needs another doctor for the peopleto whom he has shown for the first time what medicalattention means.

Bennett and his colleagues would like to see a medicalschool the size of Makerere in each of the three territories:Uganda, Kenya, and Tanzania. But they do not say howthree schools are to be maintained where even one finds ithard to get its quota of teachers. They rightly point to theneed to " retain and expand the programme for trainingmedical auxiliaries and to ... utilize to the best advantagethe special training of the doctors "-that is, so to placethe doctors that none of their time is spent on work thatless highly trained men could be doing under their

supervision.No two parts of Africa are quite alike in this; there are

differences even among the East African countries. Insome parts of West Africa, general education is far enoughadvanced for a fully professional service to be in sight.But everywhere progress is impeded by lack of money andtrained men. More fortunate countries will have to helpwith both for a long time to come.

THE CONVICTED DRUNKARD

AT least 100 chronic alcoholics are detained in London’s

prisons on any one night, and many of them regularlyreappear on charges. It is not uncommon for one man tohave been to prison fifty times. The care of this small butrecalcitrant group puts considerable strain on police,prison, and probation services, and its members are

unsuitable for ordinary mental-hospital treatment becauseof their severe personality disturbance. They are unableto benefit from the alcoholic units set up by the Ministryof Health; indeed, these units are now unwilling to admitthem. Voluntary agencies have also proved unable to copewith this type of alcoholic. In the United States some suc-cess has been achieved by a special form of hostel treat-ment, based on the exploitation of group-pressures in anopen community. The alcoholic is expected to go out towork as soon as he is physically fit and is allowed, indeedexpected, to make his mistakes and learn from them

(trial-and-error therapy).A working party to discuss the problem was formed last

February after a meeting of the Camberwell Council onAlcoholism. Some twelve members, drawn from the

prison, hospital, probation, and other services met fourtimes with observers from the Home Office, the NationalAssistance Board, and the Ministry of Health, and it

proposes that the American plan should be tried in thiscountry. 1 It suggests that accommodation for 50 menshould be set up under the authority of a statutory body.The two criteria for admission would be five or moreconvictions for drunkenness in the previous year, and theman’s acceptance of a place. There should be no legalcompulsion, for this is ineffectual in an open community.At first men would be sent from Wandsworth or Penton-ville prisons. If a man who had been in the hostel appearedagain before a magistrate, it is hoped that readmission1. The Chronic Drunkenness Offender: A Therapeutic Alternative to

Repeated Imprisonment. Obtainable from " Action on Skid Row ",137, Camberwell Road, London, S.E.5.

would be considered as an alternative to imprisonment.The hostel should have the help of a psychiatrist and apsychiatric social worker, and other staff could includeprison officers, probation officers, and trained mentalnurses. A research-worker should also be provided in thefirst two years to assess the efficacy of the scheme. Thestatutory responsibility for the scheme should belong tothe Ministry of Health, but close liaison should be estab-lished with the Home Office, the National AssistanceBoard, and the Ministry of Labour.

OFFICIOUSLY TO KEEP ALIVE

Clough’s bitter couplet, like the rest of his LatestDecalogue, was directed not at doctors but at what hesaw as a money-loving hard-hearted society. In 1849" to keep alive " could only mean to supply with foodand shelter, and perhaps with nursing when disease, andnot merely hunger and cold, threatened life. The doctor,though he wished to keep death at bay, lacked, almostutterly, specific means to do so. Today it is far otherwise.For twenty years-but little more—effective means toresuscitate, preserve, and prolong life have steadilyincreased and given Clough’s couplet a new look. Nowit seems to refer specifically to our profession, its ironyhas almost disappeared, and on occasion we feel movedto take it literally. Humanity, compassion, our duty toour patient may urge us, not indeed to kill, but to refrainfrom employing or even to cease to employ the wholebattery of devices we now possess for postponingdeath.

The conflict between the duty imposed by conscience,law, and medical ethos-and gladly accepted-to servelife not death, and the duty to do for our patient whatwe should wish done for ourselves can be real and painful-Often enough it seems clear to the doctor that his patient,perhaps with no prospect of further useful, enjoyable, oreven conscious life, perhaps in unrelievable distress orhumiliating impotence, should not be denied the minis-trations of death-the right to die, if possible with

dignity. As life-preserving, or death-postponing, devicesmultiply, so must the cases in which firm grounds fordecision evade us; and some collective examination of the

problem, with its legal, medical, religious, and humanisticaspects and implications, cannot be long deferred.A beginning has been made by the Church Assembly

Board for Social Responsibility, which appointed a

committee with medical, ecclesiastical, legal, and philoso-phical representation, under the chairmanship of the

Bishop of Exeter, to consider this problem of modernmedicine. Their report deserves to be widely read andpondered.’ It is thoughtful, readable, and informed, butit is perhaps too much concerned with the rare, too littlewith the everyday. It emphasises, for example, the

problems sometimes raised by the disputable boundarybetween a state of life and a state of death. Rather

surprisingly, it does not build up the case, made throughthe centuries by the poets and sometimes today byanalysts, for death as a positive end to life-a goal, andnot a mere termination. Nor does it discuss the ethics of

surgical efforts to prolong life by removal of normallyfunctioning organs or by implantation of organs takenfrom the living or the dead.

1. Decisions about Life and Death. Church Assembly Board for SocialResponsibility. (Church House, London, S.W.1.) 1965. 4s. 6d.

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The committee’s positive suggestions are unavoidablytentative, but they are likely to find acceptance withdoctors. A proposal that, when a silent E.E.G. certifiescerebral death, human death should be recognised as

existing surely deserves earnest consideration. In lessdifficult cases many doctors may feel that, though re-sponsibility for decision is heavy, it would be goodfor neither doctor nor patient to invite the Law, or even theGeneral Medical Council, to lift the burden and makedetailed rules with their inevitable sanctions.

TRANSPLANTATION:NEWS FROM BRITAIN AND FRANCE

BECAUSE of its academic and practical importance,organ transplantation is under intense study, and develop-ments are usefully summarised in the British MedicalBulletin. Broadly speaking, those studying transplanta-tion are of two kinds: surgeons who use the technique inhuman patients, and laboratory scientists who analysetransplantation under controlled conditions in experi-mental animals; and, as might be expected in anythingconcerned with transplantation, there are also a numberof hybrids. Both sides of the problem are discussed bycontributors to the Bulletin.

Only two types of homograft are not subject to immu-nological attack and give a high success-rate in man:grafts of cornea and of living cartilage. The clinical andbiological aspects of these are discussed by Rycroft andby Gibson. The most interesting recent advance has beenthe development by Smith and her colleagues of methodsfor freezing corneas or cartilage cells before grafting.2 3

Thus, banks of corneas or cartilage cells can be set up,which (as in blood-transfusion) will simplify the logisticsof obtaining donor material.The present position concerning transplantation of

kidneys is summarised by several contributors to theBulletin (and in an article by Hamburger and his colleaguesin these pages 4). Hamburger et al. selected donors on thebasis of several tests, including leucocyte agglutination,lymphocyte transfer, symbiotic lymphocyte cultures, andskin grafts from recipients to prospective donors. Patientswere prepared by radiation, drugs, or a combination ofboth. Out of 48 patients who had undergone homotrans-plantation, 26 were alive and well at the time of writing;in 12 less than six months had elapsed since the operation,in 5 the interval was six to twelve months, in 4 one to twoyears, in 3 two to three years, and in 2 longer than threeyears. These results and those of others in man and in

dogs suggest that there may be something special aboutkidney homografts which allows them to survive longerthan skin grafts. One possibility is replacement of vascularendothelium of the graft by that of the host, and evidenceis accumulating that the endothelial frontier of the renalhomograft is the chief target against which the immuno-logical attack of the host is directed.With haemopoietic cells there is the additional complica-

tion of graft-versus-host reactions resulting in " secondarydisease ". A great deal of information has accumulatedabout these reactions in experimental animals, including1. Br. med. Bull. 1965, 21, no. 2.2. Smith, A. U., Ashwood-Smith, M. J., Young, M. R. Expl Eye Res.

1963, 2, 71; Meuller, F. O., Smith, A. U. ibid. p. 237; Mueller, F. O.,Casey, T. A., Trevor-Roper, P. D. Br. med. J. 1964, ii, 473.

3. Smith, A. U. Nature, Lond. 1965, 205, 782.4. Hamburger, J., Crosnier, J., Dormont, J. Lancet, May 8, 1965, p. 993.5. Murray, J. E., Ross Sheil, A. G., Moseley, R., Knight, P., McGavic,

J. D., Dammin, G. J., Ann. Surg. 1964, 160, 449.

monkeys, using chromosomal and other markers to

distinguish donor from recipient cells; and the position isreviewed by Loutit in the Bulletin. Despite these seriousobstacles, repeated attempts have been made to use bone-marrow homografts in man, particularly in the hands ofMathe and his colleagues in Parish The most celebratedexample was the infusion of bone-marrow into 5 Yugoslavphysicists who had accidentally received doses of radiationin the lethal range. 4 survived, and from the appearanceof donor-type red corpuscles in the circulation it is clearthat the grafts functioned for some weeks. It is still

argued how much their recovery was attributable to thespecific treatment and how much spontaneous. Treatingsome leukasmic patients with heavy doses of radiationfollowed by marrow infusions from donors, Mathe andhis colleagues have seen secondary disease clinicallyresembling that condition in monkeys. Useful remissionswere obtained in 3 cases, and 1 patient survived for a yearbefore succumbing to generalised herpes zoster infectionwith meningoencephalitis. Of special interest in the lastcase were the choice of a subject not previously transfused,and so not previously sensitised to iso-antigens, and theuse of a panel of related donors to allow for selection invivo for the most compatible cell lines. Indeed, one linepredominated, and a skin graft from this relative wascarried to the patient’s death although other skin graftswere rejected. Thus specific tolerance may have beeninduced. Although there were no clinical signs of second-ary disease, histological evidence of a graft-versus-hostreaction was apparent post mortem and may have con-tributed to the patient’s susceptibility to virus infection.Infusions of marrow have also been used in aplasticanxmia, but have only been successful so far in threepairs of identical twins. 7

Among the notable academic advances are Gowans’sdemonstration of the part played by small lymphocytesin initiating the reaction against graft antigens (perhapsperipherally near the graft, as Simonsen’s evidencesuggests) and Miller’s analysis of the role of the thymusin the development of transplantation immunity. Academicand practical studies converge in examining the efficacyof immunosuppressant drugs. As Berenbaum points out,the toxicity of these can sometimes be alleviated withoutabolishing their immunosuppresive effects-for instance,by combining methotrexate and folinic acid. Althoughthese drugs prolong graft survival, it seems unlikely thatany homograft will persist for the host’s natural lifetimeunless a state of specific immune tolerance can be

developed. Gowland discusses tolerance experimentallyset up in animals by giving high doses of grafted materialwith immunosuppressives. But the work of Mitchison 8 andothers has shown that under certain conditions tolerancecan be induced by chronic exposure to low doses ofantigen. If this could be achieved with homografts, theclinical situation might well be transformed. Mathe’sresults provide a hint that something like this may bepossible. Until the homograft reaction can be abrogatedat will, progress must be limited, and the clinical contri-butions to the Bulletin tell clearly enough the story ofmodest success by a few pioneers faced with formidabledifficulties.

6. Mathé, G., Amiel, J. L. Br. med. J. 1964, ii, 527; Mathé, G., et al.Blood, 1965, 25, 179.

7. Robins, M. M., Noyes, W. D. New Engl. J. Med. 1961, 265, 974;Mills, S. D., Kyle, R. A., Hollenbeck, G. A., Pease, G. L., Cree, I. C.,J. Am. med. Ass. 1964, 188, 1037; Thomas, E. D., Phillips, J. H., Finch,C. A. ibid. p. 1041.

8. Mitchison, N. A. Proc. R. Soc 1964, 161B, 275.