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Mauritius is already changing. Soon half the populationwill be dependants under 15 years of age (the comparablefigure in north-west and central Europe is only a

quarter); and to make things worse, the island’s economydepends essentially on ’one crop-sugar. Fluctuatingworld prices and seasonal work bring the paradox ofunemployment and difficulties in securing adequatelabour by the sugar companies. Better health mayincrease the productivity of the male workers, but thisis little help unless there is work for them all the yearround.

Professor MEADE gives helpful advice on the futureeconomic structure of the island, including a veryimportant plea for the maintenance of the quality ofleading administrators and the need for additional

payments by the United Kingdom for expatriateofficials as " one of the most valuable forms of technicalassistance which the United Kingdom can render toMauritius at the present time ". For Professor TiTMUSS,the essential solution lies in family planning, which hestrongly urges despite the fact that nearly half the

population of Mauritius is Roman Catholic. He hasdetailed and valuable proposals on social-securitybenefits, but pleads that unless these are accompaniedby a family-planning service he would prefer to see hisreport rejected. The " three-child family " is the basisof the proposals, with an insistence on later marriageand financial support for families who space their

children, and no additional benefits for dependentchildren in excess of three. The fundamental problemsof medical care and the proposals for an improved andexpanded health service are summarised elsewhere inthis issue (p. 551). Smaller families and healthier people,backed by Professor MEADE’s far-reaching suggestionsfor economic expansion and stability, offer Mauritiusrelief from a grim future.The lessons of these two reports should be widely

studied in other territories for which Britain has an

existing or some continuing responsibility. The Gambiais virtually an island surrounded by foreign territoryand is dependent on the single crop of ground-nuts.Sierra Leone may see its diamond production exhaustedand iron ore worked out. Ghana and Nigeria face thesame sequel to improvement in child health-an increasein population at the non-productive age. All theseterritories are short of medical care and high-qualityadministration. In Mauritius not only are more doctorsneeded but there must also be a raising of ethicalstandards and more control over pharmaceutical pro-ducts. Preventive measures do not necessarily meana fitter and healthier population. But always in thebackground is the fact that " the more successfulmedicine is in controlling the death rate the greaterthe problem becomes of controlling the birth rate ".MALTHUS was concerned with the agricultural aspects ofpopulation changes and these are fully discussed inProfessor MEADE’s report. What was not foreseen wasthe interference by modern medical science in thenatural control of population. Yet the medical professioncannot go into reverse. The dilemma of the present

and future in Mauritius and elsewhere lies just here.Family planning seems the only answer. Will the

community accept this or blindly prefer destructionas deadly as the cyclones, though more prolonged andless spectacular ?

1. Report of the Interdepartmental Committee on the Business of theCriminal Courts. Cmnd. 1289. M.H. Stationery Office, 1961. Pp.143. 7s. The members were Mr. Justice Streatfeild, M.C. (chairman),Mr. J. Roland Adams, Q.c., Mr. T. H. Evans, C.B.E., Dr. T. C. N.Gibbens, Mr. J. G. Harries, Sir David Hughes Parry, Q.C., Prof.W. J. H. Sprott, Baroness Wootton of Abinger, and Miss Nora Wynn,O.B.E., J.P.

2. Lancet, 1960, ii, 1177.

Annotations

TOMORROW’S COURTS

ONE of the defects of our penal system is that treatment,as practised at its best by the prison and probation services,is far in advance of diagnosis, as practised by the criminalcourts. The report of the Interdepartmental Committeeon the Business of the Criminal Courts, a small butadmirably selected body, is therefore opportune. Thefirst official systematic survey of its kind, it is a valuableaddition to the present flow of reformatory documents.

In essence the committee, in official language, chal-

lenge the obstructive " eye-for-an-eye " formula thatdemands the automatic infliction of punishment by" tariff " according to the nature of the crime, withoutregard to the nature of the criminal. They point out that" in a considerable, and growing, number of cases thetariff system’ can no longer be relied on to fit all theconsiderations in the court’s mind. The need to deter orreform the offender, the need to protect society and theneed to deter potential offenders may in a particular casebe conflicting considerations." They press for moreinformation at every stage-before, during, and after trial- to help the court towards the sentence that offers thebest hope of reform, even when this may mean delayingsentence after conviction. These extra tasks will throw a

great deal of work on the probation service, which is

already carrying a heavy burden.The committee are also anxious to educate the " sen-

tencer". They suggest that he should receive a compre-hensive account of what each form of sentence entails,what it was designed to achieve, what in fact it has

achieved, and the results of the latest research. He wouldbe expected to visit penal institutions. Besides being givendetailed information about the circumstances and life ofeach offender, he would receive periodic reports on theprogress of each under treatment and of further con-victions.These proposals, in particular the last (which was lately

discussed in these columns 2), seem to suggest that the" medical" view of crime is spreading.Much of the report is concerned with proposals to

speed the whole judicial process. Eight weeks is suggestedas the maximum time any case should wait betweencommittal and trial. Time in custody should be deductedfrom the eventual sentence (if any). To bring this aboutthe committee want, among other things, a wider range ofoffences to be dealt with by " summary jurisdiction ".This proposal would save money, which might help tomeet the extra cost of some of their other suggestedchanges. They would like to make quarter sessions a"legally continuous court" able to sit as often as

544

necessary, to extend the assize circuits, and to appointfour extra judges of the High Court.

So far as they go, these proposed changes are on theright lines and should be introduced without delay. But thecommittee were only asked to report on arrangements forbringing criminals to trial and for providing the courtswith information. As they note rather sadly, their termsof reference did not cover " the basic procedures fordetermining the soundness of the charges made against anaccused person ", but they do record that many hold thepresent procedure to be outmoded. Perhaps this reportwill stimulate the Home Secretary to arrange for thecritical re-examination of the court as a fact-findinginstrument which Dr. Richard Fox lately proposed.3 Ifthe examination could be made by a committee like thisone, it would be thorough and penetrating.

3. Fox, R., ibid. Feb. 18, 1961, p. 392.4. Steiner, P. E. Cancer, 1960, 13, 1085.5. Davies, J. N. P. Acta Un. int. Cancr, 1957, 13, 606.6. Higginson, J., Oettle, A. G. ibid. p. 602.

LIVER CANCER AND CIRRHOSIS IN AFRICA

Prof. Paul Steiner embarked in 1957 on a study ofliver cancer, cirrhosis, and related diseases in Trans-Saharan Africa and compared the findings with those onsimilar diseases in the European living in Africa and inthe American Caucasoid and Negroid.4 He hoped toshed light on the aetiology and genesis of liver cancer,and especially to distinguish hereditary from environ-mental factors. Much had already been written aboutthese diseases in Africa (Steiner cites 78 papers); but astudy by one man of all the material was called for, andthis task required thousands of miles of travel.

In Africa, postmortem material from 904 cases of livercancer, 943 cases of cirrhosis, and 1000 cases of parasitic,infective, and nutritional liver diseases was examined andcompared with 140 cases of liver cancer and 412 of cirr-hosis from Los Angeles and Chicago. In Africa livercancer is very much commoner than cirrhosis, whereas inAmerica the reverse is the case. Of the 904 cancer patientsin Africa, 876 were " natives " from many ethnic groups,14 were " Cape Coloured ", and 14 " European ". Natur-ally, not all the information required was available inevery case; but great credit is due to the hospital servicesin Africa, and especially to the pathologists, for the

thorough way in which they had collected the materialfor the survey. Although the incidence of disease cannotbe estimated precisely in Africa, it seemed that necropsyrecords of liver diseases did reflect the incidence in the

populations.The livers of Africans with cancer were large, the

average weight being 3390 g., even though Africans areusually of small build and the livers not fatty. Wherecirrhosis was present as well as cancer, the livers were

usually smaller. The cancers were nearly always (97%)hepatocellular and unicentric, cholangiocellular tumoursbeing more infrequent than in the U.S.A. This was

interpreted as indicating that the added cases in Africawere of the hepatocellular type. Davies 5 had previouslyestimated that in males primary liver carcinoma was aboutten times as common in Uganda as in Denmark, wherethe incidence resembles that in the U.S.A., but that adifference for women had not been shown. Higginsonand Oettle 6 found much the same ratio in the Johannes-burg area.The incidence of liver cancer is high among all the

major races of Africa, and as each race includes many

tribes the idea that this is particularly a Bantu diseasecannot be upheld. There was, nonetheless, good evidencethat liver cancer is commoner in some groups than inothers-for example, in Mozambique than in Transvaalnatives and in Ruandi than in Ugandans, and in nativesof all kinds than in Europeans. 87% of all the livercancers were in males, and this preponderance was

universal. Steiner was unwilling to accept this at its facevalue, for males use the hospital facilities more thanfemales. But the disease is common also in European andCape coloured males and in males in the U.S.A. The

average age for the development of liver cancer in Africanswas 38 years-about twenty years earlier than inEuropeans in Africa or in the U.S.A.The relation of liver cancer to cirrhosis has been the

source of much speculation. Steiner claims that livercancer is commoner than pure cirrhosis in all parts ofAfrica, but he includes the 44% of livers with cancer andcirrhosis together among the carcinomas. As 32% ofAfricans with liver cancer did not have cirrhosis, thelatter disease by itself cannot be the sole cause of thecancers. The cirrhosis usually consisted of non-fatty,postnecrotic fibrosis, and the risk of cancer was no

greater in severely cirrhotic livers than mildly cirrhoticones; but the proportion of cirrhotic livers of the severestgrade was highest at Dakar and Stanleyville, where thefrequency of liver cancer seemed also to be the highest.Non-cancerous livers often were very severely fibrotic,which may mean that the period at risk was less. Nor did ’

the presence of cirrhosis hasten the development of

cancer, for the average age of patients with both livercarcinoma and cirrhosis was the same as that of thosewith cancer alone. Steiner suggests that the cause of bothcirrhosis and cancer is the same, resulting sometimes inthe one, sometimes in the other, and sometimes in both,with no evidence that cirrhosis itself is a precancerouslesion. Alcohol and dietary liver siderosis (the latter con-spicuous only in the Transvaal) are dismissed as causesof liver cancer. Nor does Steiner believe that malnutritioncan be a direct cause, since fatty infiltration was not foundin the cirrhosis cases, the cirrhosis did not conform tothe nutritional type, and the patients with cirrhosis werenot undernourished. Moreover, kwashiorkor and livercancer were not associated, and biopsy showed no

sequence from infantile malnutrition to cirrhosis. Thelesions of African schistosomiasis were quite different fromthose of cirrhosis and were not found within the cancers,and in those areas of Africa where malaria was most pre-valent the incidence of liver cancer was lower than usual.

Steiner emphasises that in Africa the cirrhotic liver issmall, non-fatty, and coarsely nodular, with irregularcell-rich scars, designated postnecrotic. This may resultfrom toxic or infectious causes, but it has not yet beenshown to result from malnutrition. The cause is unknown,but Steiner suggests that it may follow viral infections-including Rift Valley fever, Wesselsbron fever, infectivehepatitis, or infection with other viruses. Epidemics ofinfective hepatitis have been reported in Trans-SaharanAfrica,’ 8 and the incidence was high among Americanmilitary personnel in the 1939-45 war in North Africa.Cases of cirrhosis apparently following infective hepatitiswere seen in hospitals and at necropsy in most of the areasstudied-notably in Lagos and Dakar. As cirrhosis isbelieved to be an uncommon sequel of infectious jaundice7. Charmot, G., Camain, R., Giudicelli, P. Bull. Soc. Pat. exot. 1953,

46, 847.8. Hudson, N. P. Trans. R. Soc. trop. Med. Hyg. 1931, 24, 453.