- Email: [email protected]
A GENERAL-PRACTITIONER MATERNITY UNIT
998
Views of General Practice
be prepared to give, at the request of the home doctor, any daily treatment he had prescribed; it was to carry out first-aid procedures for minor injury and to provide on-the-spot treatment for any major emergency, such as diabetic coma. The service was to be operated from a centre in the City, eventually serving as many as 10,000 people, and staffed by a medical director, at least one other doctor, and three nursing sisters. Dr. Robinson estimated the running costs at about El 9,000 a year and suggested therefore that firms using the scheme should pay an annual capitation fee of E2 per employee.
to
The council, he said, would have to devote about E36,000 to starting the service but by 1968 it should be paying for itself. This, however, presupposed sufficient support from the City and this the service would have to attract by vigorous selfadvertisement.
This Dr. J.
the plan; but when put before the court of council it provoked vigorous opposition, led by
was
common
Cope.
The
proposed service, Dr. Cope said, was superfluous. The Ministry of Health itself had called it a wasteful reduplication of existing services ". The commuter could already claim adequate medical care under the National Health Service from his own doctor at home and from the London hospitals when at work. St. Bartholomew’s, The London, the Royal Free, and Guy’s hospitals were all close to the City and already provided "
emergency treatment.
Moreover, there
were
57 doctors
practising in and for the City and their services were greatly used by employers. Why, then, should employers prefer paying a high capitation fee for services that might never be required when to pay these doctors for the services they rendered was cheaper? Dr. Cope took final and gravest exception to the advertising on which the financial success of the scheme would depend. Canvassing was contrary to the ethics of the profession and the central ethical committee of the British Medical Association had, he maintained, condemned the type of publicity proposed for the scheme.
The council decided to refer the whole matter back the health committee for further consideration.
to
Botulism in the U.S.A. On Oct. 10 the Public Health Service in Washington reported that 16 persons had contracted type-E botulism from eating smoked whitefish.l 8 have died. Since 1934 there have been 19 reported cases and 8 deaths; in 2 cases the deaths were from eating contaminated tuna fish packed in California. In the current outbreak 14 cases in Alabama and Tennessee were traced to contaminated fish packed in Michigan and sold in supermarkets. A father and his ten-year-old daughter in Knoxville died within fifteen minutes of each other after sharing a whitefish two days earlier. 1. New York Times, Oct. 12, 1963.
Infectious Diseases in
England
and Wales
A GENERAL-PRACTITIONER MATERNITY UNIT Review of One Year’s Work R. H. REYNOLDS Cantab., D.Obst.
M.B.
GENERAL PRACTITIONER, CRAWLEY, SUSSEX
THE unit is part of the first stage of the new Crawley Hospital, and was opened in August, 1961. It has ten beds and is incorporated in the consultant obstetric unit, which was opened at the same time. The generalpractitioner unit has a labour ward of its own, but the whole floor is in the charge of one Sister. All general practitioners within five miles who are on the obstetric list may use the unit. Crawley is a New Town and the practitioners are mostly young. Of 26 who use the unit, 18 have qualified since 1945: 10 hold the diploma in obstetrics of the Royal College of Obstetricians and Gynxcologists, and 1 the membership. The consultant obstetrician responsible for the Crawley Hospital maternity department assumes responsibility for supervision of the general-practitioner unit. An obstetric subcommittee was formed to supervise the detailed running of the unit; and the fact that it has met only twice is a tribute to the amiability of the consultant and the tact of the superintendent midwife. But there is always close contact between the interested parties. Personalities are important in running a unit of this kind, where all grades of staff are constantly rubbing shoulders. The Sister in charge of the unit contributes to the happy atmosphere by studying the personal preferences of the general practitioners and allowing them to indulge their
foibles. Doctors
rules,
using the unit are asked
some
to
subscribe
to
certain
of which follow:
a general anarsthetic is required, a second doctor be called. Anaesthetic cover by consultant anaesthetist or a registrar in anaesthetics is always available if required. Doctors are expected to notify the consultant obstetrician if a situation of particular danger or difficulty is
Where
must
developing. Except in
emergency all breech and twin deliveries should be conducted in the consultant unit. The Sister in charge of the general-practitioner labour ward is directly responsible to the practitioner in charge of the case. She will also inform him when one of his patients is admitted in labour. The obstetric house-surgeon for the consultant unit may not deputise for doctors in the general-practitioner unit, except in dire emergency. Doctors are expected to attend their own patients, when informed that delivery is imminent. Patients found to have rhesus antibodies may not be admitted to the general-practitioner unit. Any case of puerperal sepsis must be reported to the consultant obstetrician so that arrangements for isolation can be made. Cooperation cards, to be in the possession of the patient, should be completed by doctors for all patients booked for the unit.
The services of a
paediatrician are available if requested. BOOKINGS
When the unit was opened, 18 patients per month were booked. This figure has been increased in two stages to
999
he often encourages the practitioner to continue the management of his case-for example, in minor degrees of pre-eclamptic toxcemia-maintaining a watching brief.
personally, and
TABLE I-RESULTS
UTILISATION OF THE UNIT
The
30 per month, giving at least an 80% bed utilisation. Two categories of patient are given priority-namely (1) normal primigravidx, and (2) normal multigravidee with social reasons for hospital confinement. This priority consists in booking at the tenth instead of twelfth week of pregnancy. No priority is given on medical (obstetric) grounds: these cases are booked for the consultant unit. The unit aims at uncomplicated midwifery, and selection starts as soon as the patient visits the doctor’s surgery She then makes a booking visit to the hospital where she is seen by the consultant. If he decides that she is a suitable case, he does not see her again except on direct request from the general practitioner. This booking visit is very important, and is welcomed by practitioners. A number ofmultigravidae are booked on " minor " obstetric grounds and the consultant’s assessment of the history is very valuable. The demand for general-practitioner beds has always been greater than the supply: until recently a " suitable " case for the general-practitioner unit has often been unable to get in, and has had to be booked for the consultant unit. This is a slightly paradoxical situation, for a consultant is hardly required to look after a normal multigravida-in fact it is a waste of his valuable time. Table i shows the results of the
year’s work.
In addition there was 1 multiple delivery. There were no stillbirths but 1 neonatal death due to intranatal asphyxia, in which, after an apparently normal delivery, a full-term infant 1 unbooked failed to respond to resuscitative measures. patient was admitted after delivery; 4 primigravidae and 3 multigravidx showed signs of pre-eclamptic toxaemia. 6 patients were transferred to the consultant unit in the antenatal period-I multiple pregnancy, 3 with pre-eclamptic toxaemia, and 2 with antepartum haemorrhage. 5 more were transferred during labour, 2 because of uterine inertia and 3 with breech presentations.
These results suggest that the method of selection
was
satisfactory. The low incidence of postpartum haemorrhage (defined as 20 oz or more) deserves mention.‘ Syntometrine ’ (’Sytocinon’ [oxytocin] 5 units and ergometrine 0-5 mg.) by intramuscular injection with the delivery of the anterior shoulder is routine procedure. Only 1 postpartum haemorrhage required transfusion, and the rate for manual removal of the placenta (under 0-5%) speaks for itself.
indications for confinement in the generalpractitioner unit were: primigravidx, 93; medical, 51; social, 73. The 51 patients booked on medical grounds were of course seen by the consultant at the booking visit, and although not strictly eligible were accepted. These indications were: grand multiparx, 12; previous forceps, 10; previous pre-eclamptic toxxmia, 7; previous manual removal of the placenta, 3; previous postpartum
haemorrhage, 4; miscellaneous, 15. The 73 normal multigravidx admitted on social grounds present a problem-should they have been confined in hospital at all ? Social indications are difficult to define. Poor housing conditions and inadequate facilities were mentioned on 4 occasions only, since this unit is chiefly used by New Town residents whose housing conditions are uniformly good. 2 bookings were requested because it had proved impossible to make arrangements for looking after the rest of the family. There were no unmarried mothers. 22 patients were booked by their doctor on unspecified " social " grounds. One can only guess at these reasons, and my own experience suggests that they can vary from a husband out of the country to inability to meet the cost of home confinement, which would include the services of a home help at 4s. an "
"
"
"
hour. This leaves 45 cases for which no reason for hospital confinement was put forward, plus an unknown number accepted for the consultant unit because the generalpractitioner unit was full. The doctors booked these patients with letters saying" " we would like to look after in the G.P. Unit ", or I feel... is a suitable case for the G.P. Unit ". Two put the case directly "... cannot face the thought of home confinement " and I believe that this is behind a large number of the unspecified cases. Before the Crawley general-practitioner unit was opened, one had to indulge in sales talk about the benefits of home confinement; but now that beds are available the demand is obvious-both from patients and from their doctors. ...
EFFECTS OF THE OPENING OF THE NEW UNITS
The opening of the general-practitioner unit and the consultant unit (thirty-two beds) has had a startling effect on the proportion of women confined in hospital (table n). TABLE II-HOME AND HOSPITAL CONFINEMENT BEFORE AND AFTER THE OPENING OF THE NEW HOSPITAL
The eleven transfers to the consultant unit were in accordance with the policy of eliminating foreseeable complications in the general-practitioner unit. The close association of one unit with the other makes this simple, The change has taken place despite adequate housing, and the general practitioner is encouraged to follow his excellent domiciliary services of high reputation including patient’s progress, thus learning much. The use of the home helps, and a tradition " of home confinement. same building encourages the practitioner to pay a call on Table ill shows the figures for my own practice. those of his patients who are in the consultant unit. The figures in parentheses refer to percentages in a Chatting with the obstetric house-surgeon, the nursing staff, and the consultant is a very valuable form of post- previous series of 250 confinements in my practice before graduate instruction (mutual ?). A request for help by a the opening of the new hospital. At this time the congeneral practitioner is always dealt with by the consultant sultant unit was seven miles away and the general"
1000 TABLE III-PLACE OF CONFINEMENT OF 100 CONSECUTIVE CASES IN A GENERAL PRACTICE
*
Home confinement was reluctantly agreed: in fact the patient had a postpartum haemorrhage, manual removal of the placenta, and puerperal pyrexia. Even so, it was difficult to persuade her to accept hospital confinement for her second baby.
practitioner
unit
(not used now)
seven
miles in another
direction. COMMENT
If a happy atmosphere of cooperation is maintained between consultant, general practitioners, and nursing
Conferences NATURAL HISTORY OF AGGRESSION ARRANGED by the Institute of Biology, this symposium held in London on Oct. 21-22 with Prof. G. E. Blacker, Sir Julian Huxley, Dr. John Bowlby, and Sir Solly Zuckerman as chairmen.
was
AGGRESSION IN ANIMALS
Dr. JAMES FISHER said that in birds aggression is strongly associated with territorial rights, and is evoked by " releaser " mechanisms (for instance in one case the model head of a cuckoo). The releaser’s efficacy might vary according to the excitability of the bird. The capercaillie at the height of the breeding season might attack a person or a car as a rival, in mistaken identity. Dr. Fisher suggested that preservation of the species was served by the way in which aggression operates; and he indicated how it may also lead to species formation when two not-too-dissimilar races are living in proximity. He concluded with the hypothesis that " human beings behave like birds undergoing speciation ".
Dr. D. WALLIS spoke next on his studies of aggression in the social insects. Some of the experiments involved artificial estrangement of an ant to its own colony, others the introduction of a stranger. Odoriferous secretions seemed to determine admission or rejection. The secretions varied genetically and environmentally, notably with diet. Dr. HARRISON MATTHEWS pointed out that, in mammals, hostility leading to death of the fighting animals is almost unknown within a species. Fatal aggression was avoided by ritualisation, which consisted in prolonged pre-combat or early combat behaviour in a set pattern, followed by inhibited, attenuated, or shortened combat, flight, and half-hearted pursuit. The welfare of the species as a whole seemed to be served by this, but not necessarily survival of the best genotype; thus occasionally " evolutionary nonsense " could occur, such as the weighty and almost functionless horns of the extinct giant deer. overt
Dr. KONRAD LORENZ described his observations of ritualisation of fighting in fish, geese, and other creatures, and also the appeasement gestures with which a creature would inhibit aggression in the attacker. Prof. K. L. HALL had studied aggression in subhuman Each different type showed a different group structure, and corresponding differences in the nature of the aggressive response-for instance in the extent or complexity of the patterns of ritualisation. In a single species differences of habitat seemed to produce differences of levels of aggression.
primates.
The
ethologists
were
thus in general agreement.
staff, there are definite advantages in the close integration of consultant and general-practitioner units. The number of normal multigravidx now accepted for hospital confinement suggests that the demand for it is increasing both to reduce perinatal mortality and on social or domestic grounds. It is our duty to meet the changing demands of society in this matter. There is a need for more hospital maternity beds, and the majority of these could well be in general-practitioner units. My own partnership (a group practice) boasts 21 children. These were high-risk cases certainly; but none were born at home. Does this illustrate the trend ? My thanks are due to Mr. N. G. Gourlay (consultant obstetrician to the Redhill Group of Hospitals) for his help and encouragement with this paper; to Miss Beryl Thomas (superintendent midwife) for much of the information; and to Dr. T. McL. Galloway (county medical officer of health for West Sussex) for details of births in Crawley in the years under consideration.
Intra-species aggression is common in the animal world, but under natural conditions the aggression is nearly always modified in a way that tends to avoid killing. Modifying factors include ritualisation, appeasement gestures, and redirection of the aggression on to a neutral subject. Although animals hardly ever destroy one of their own kind in the natural state, caged animals or those confined by other pressures such as overpopulation have been seen to destroy themselves utterly and
reciprocally. AGGRESSION IN MAN
Prof. DENIS HILL said that in mental illness the same patterns are seen as in the normal. Human aggression was both innate and subject to environmental modification. Possible responses to an aggression-provoking stimulus would be attack (or rage), displacement (referred to by ethologists as redirection), or inhibition. Inhibition could lead to gradual attenuation, or to chronic resentment, or to the turning inward of the aggression on to the self, causing depression and perhaps suicide. Non-adaptive meaningless aggression sometimes occurred in brain-damaged patients, notably postencephalitics, and it was sometimes possible to trace the pathological lesion anatomically to the posterior part of the limbic system deep to the temporaral lobe. Dr. J. D. FREEMAN, as an anthropologist, maintained that not only aggression but also cruelty, brutality, and cannibalism are innate in man, and also a delight in them. In this he thought there is a phylogenetic difference between man and animals, and he dated its appearance to the Australopithecinae and the first use of tools. Until recently the species had benefited from these traits, but now they appeared not to be beneficial, and perhaps an evolutionary modification might occur. Prof. NORMAN GIBBS was emphatically against assuming that men behave like animals or that it is permissible to draw analogies between observed animal behaviour and that of humans. The history of war depended on documentary evidence, and was related to States rather than human
beings. Dr. A. STORR declared that there is no getting rid of aggression; we are stuck with it, and it is at its most dangerous when repressed. His advice about learning to live with it include encouraging the enjoyment of films of violence, international football matches, and the Space race, all of which provided permissible outlets for aggression that might otherwise end in hostility. Dr. JOHN BURTON again urged caution in interpreting human behaviour, especially at the international level, in the light of animal ethology. He pointed to types of international conflict which had come to be habitually resolved without war, and others which for the moment remained potential causes of war.
Views of General Practice
be prepared to give, at the request of the home doctor, any daily treatment he had prescribed; it was to carry out first-aid procedures for minor injury and to provide on-the-spot treatment for any major emergency, such as diabetic coma. The service was to be operated from a centre in the City, eventually serving as many as 10,000 people, and staffed by a medical director, at least one other doctor, and three nursing sisters. Dr. Robinson estimated the running costs at about El 9,000 a year and suggested therefore that firms using the scheme should pay an annual capitation fee of E2 per employee.
to
The council, he said, would have to devote about E36,000 to starting the service but by 1968 it should be paying for itself. This, however, presupposed sufficient support from the City and this the service would have to attract by vigorous selfadvertisement.
This Dr. J.
the plan; but when put before the court of council it provoked vigorous opposition, led by
was
common
Cope.
The
proposed service, Dr. Cope said, was superfluous. The Ministry of Health itself had called it a wasteful reduplication of existing services ". The commuter could already claim adequate medical care under the National Health Service from his own doctor at home and from the London hospitals when at work. St. Bartholomew’s, The London, the Royal Free, and Guy’s hospitals were all close to the City and already provided "
emergency treatment.
Moreover, there
were
57 doctors
practising in and for the City and their services were greatly used by employers. Why, then, should employers prefer paying a high capitation fee for services that might never be required when to pay these doctors for the services they rendered was cheaper? Dr. Cope took final and gravest exception to the advertising on which the financial success of the scheme would depend. Canvassing was contrary to the ethics of the profession and the central ethical committee of the British Medical Association had, he maintained, condemned the type of publicity proposed for the scheme.
The council decided to refer the whole matter back the health committee for further consideration.
to
Botulism in the U.S.A. On Oct. 10 the Public Health Service in Washington reported that 16 persons had contracted type-E botulism from eating smoked whitefish.l 8 have died. Since 1934 there have been 19 reported cases and 8 deaths; in 2 cases the deaths were from eating contaminated tuna fish packed in California. In the current outbreak 14 cases in Alabama and Tennessee were traced to contaminated fish packed in Michigan and sold in supermarkets. A father and his ten-year-old daughter in Knoxville died within fifteen minutes of each other after sharing a whitefish two days earlier. 1. New York Times, Oct. 12, 1963.
Infectious Diseases in
England
and Wales
A GENERAL-PRACTITIONER MATERNITY UNIT Review of One Year’s Work R. H. REYNOLDS Cantab., D.Obst.
M.B.
GENERAL PRACTITIONER, CRAWLEY, SUSSEX
THE unit is part of the first stage of the new Crawley Hospital, and was opened in August, 1961. It has ten beds and is incorporated in the consultant obstetric unit, which was opened at the same time. The generalpractitioner unit has a labour ward of its own, but the whole floor is in the charge of one Sister. All general practitioners within five miles who are on the obstetric list may use the unit. Crawley is a New Town and the practitioners are mostly young. Of 26 who use the unit, 18 have qualified since 1945: 10 hold the diploma in obstetrics of the Royal College of Obstetricians and Gynxcologists, and 1 the membership. The consultant obstetrician responsible for the Crawley Hospital maternity department assumes responsibility for supervision of the general-practitioner unit. An obstetric subcommittee was formed to supervise the detailed running of the unit; and the fact that it has met only twice is a tribute to the amiability of the consultant and the tact of the superintendent midwife. But there is always close contact between the interested parties. Personalities are important in running a unit of this kind, where all grades of staff are constantly rubbing shoulders. The Sister in charge of the unit contributes to the happy atmosphere by studying the personal preferences of the general practitioners and allowing them to indulge their
foibles. Doctors
rules,
using the unit are asked
some
to
subscribe
to
certain
of which follow:
a general anarsthetic is required, a second doctor be called. Anaesthetic cover by consultant anaesthetist or a registrar in anaesthetics is always available if required. Doctors are expected to notify the consultant obstetrician if a situation of particular danger or difficulty is
Where
must
developing. Except in
emergency all breech and twin deliveries should be conducted in the consultant unit. The Sister in charge of the general-practitioner labour ward is directly responsible to the practitioner in charge of the case. She will also inform him when one of his patients is admitted in labour. The obstetric house-surgeon for the consultant unit may not deputise for doctors in the general-practitioner unit, except in dire emergency. Doctors are expected to attend their own patients, when informed that delivery is imminent. Patients found to have rhesus antibodies may not be admitted to the general-practitioner unit. Any case of puerperal sepsis must be reported to the consultant obstetrician so that arrangements for isolation can be made. Cooperation cards, to be in the possession of the patient, should be completed by doctors for all patients booked for the unit.
The services of a
paediatrician are available if requested. BOOKINGS
When the unit was opened, 18 patients per month were booked. This figure has been increased in two stages to
999
he often encourages the practitioner to continue the management of his case-for example, in minor degrees of pre-eclamptic toxcemia-maintaining a watching brief.
personally, and
TABLE I-RESULTS
UTILISATION OF THE UNIT
The
30 per month, giving at least an 80% bed utilisation. Two categories of patient are given priority-namely (1) normal primigravidx, and (2) normal multigravidee with social reasons for hospital confinement. This priority consists in booking at the tenth instead of twelfth week of pregnancy. No priority is given on medical (obstetric) grounds: these cases are booked for the consultant unit. The unit aims at uncomplicated midwifery, and selection starts as soon as the patient visits the doctor’s surgery She then makes a booking visit to the hospital where she is seen by the consultant. If he decides that she is a suitable case, he does not see her again except on direct request from the general practitioner. This booking visit is very important, and is welcomed by practitioners. A number ofmultigravidae are booked on " minor " obstetric grounds and the consultant’s assessment of the history is very valuable. The demand for general-practitioner beds has always been greater than the supply: until recently a " suitable " case for the general-practitioner unit has often been unable to get in, and has had to be booked for the consultant unit. This is a slightly paradoxical situation, for a consultant is hardly required to look after a normal multigravida-in fact it is a waste of his valuable time. Table i shows the results of the
year’s work.
In addition there was 1 multiple delivery. There were no stillbirths but 1 neonatal death due to intranatal asphyxia, in which, after an apparently normal delivery, a full-term infant 1 unbooked failed to respond to resuscitative measures. patient was admitted after delivery; 4 primigravidae and 3 multigravidx showed signs of pre-eclamptic toxaemia. 6 patients were transferred to the consultant unit in the antenatal period-I multiple pregnancy, 3 with pre-eclamptic toxaemia, and 2 with antepartum haemorrhage. 5 more were transferred during labour, 2 because of uterine inertia and 3 with breech presentations.
These results suggest that the method of selection
was
satisfactory. The low incidence of postpartum haemorrhage (defined as 20 oz or more) deserves mention.‘ Syntometrine ’ (’Sytocinon’ [oxytocin] 5 units and ergometrine 0-5 mg.) by intramuscular injection with the delivery of the anterior shoulder is routine procedure. Only 1 postpartum haemorrhage required transfusion, and the rate for manual removal of the placenta (under 0-5%) speaks for itself.
indications for confinement in the generalpractitioner unit were: primigravidx, 93; medical, 51; social, 73. The 51 patients booked on medical grounds were of course seen by the consultant at the booking visit, and although not strictly eligible were accepted. These indications were: grand multiparx, 12; previous forceps, 10; previous pre-eclamptic toxxmia, 7; previous manual removal of the placenta, 3; previous postpartum
haemorrhage, 4; miscellaneous, 15. The 73 normal multigravidx admitted on social grounds present a problem-should they have been confined in hospital at all ? Social indications are difficult to define. Poor housing conditions and inadequate facilities were mentioned on 4 occasions only, since this unit is chiefly used by New Town residents whose housing conditions are uniformly good. 2 bookings were requested because it had proved impossible to make arrangements for looking after the rest of the family. There were no unmarried mothers. 22 patients were booked by their doctor on unspecified " social " grounds. One can only guess at these reasons, and my own experience suggests that they can vary from a husband out of the country to inability to meet the cost of home confinement, which would include the services of a home help at 4s. an "
"
"
"
hour. This leaves 45 cases for which no reason for hospital confinement was put forward, plus an unknown number accepted for the consultant unit because the generalpractitioner unit was full. The doctors booked these patients with letters saying" " we would like to look after in the G.P. Unit ", or I feel... is a suitable case for the G.P. Unit ". Two put the case directly "... cannot face the thought of home confinement " and I believe that this is behind a large number of the unspecified cases. Before the Crawley general-practitioner unit was opened, one had to indulge in sales talk about the benefits of home confinement; but now that beds are available the demand is obvious-both from patients and from their doctors. ...
EFFECTS OF THE OPENING OF THE NEW UNITS
The opening of the general-practitioner unit and the consultant unit (thirty-two beds) has had a startling effect on the proportion of women confined in hospital (table n). TABLE II-HOME AND HOSPITAL CONFINEMENT BEFORE AND AFTER THE OPENING OF THE NEW HOSPITAL
The eleven transfers to the consultant unit were in accordance with the policy of eliminating foreseeable complications in the general-practitioner unit. The close association of one unit with the other makes this simple, The change has taken place despite adequate housing, and the general practitioner is encouraged to follow his excellent domiciliary services of high reputation including patient’s progress, thus learning much. The use of the home helps, and a tradition " of home confinement. same building encourages the practitioner to pay a call on Table ill shows the figures for my own practice. those of his patients who are in the consultant unit. The figures in parentheses refer to percentages in a Chatting with the obstetric house-surgeon, the nursing staff, and the consultant is a very valuable form of post- previous series of 250 confinements in my practice before graduate instruction (mutual ?). A request for help by a the opening of the new hospital. At this time the congeneral practitioner is always dealt with by the consultant sultant unit was seven miles away and the general"
1000 TABLE III-PLACE OF CONFINEMENT OF 100 CONSECUTIVE CASES IN A GENERAL PRACTICE
*
Home confinement was reluctantly agreed: in fact the patient had a postpartum haemorrhage, manual removal of the placenta, and puerperal pyrexia. Even so, it was difficult to persuade her to accept hospital confinement for her second baby.
practitioner
unit
(not used now)
seven
miles in another
direction. COMMENT
If a happy atmosphere of cooperation is maintained between consultant, general practitioners, and nursing
Conferences NATURAL HISTORY OF AGGRESSION ARRANGED by the Institute of Biology, this symposium held in London on Oct. 21-22 with Prof. G. E. Blacker, Sir Julian Huxley, Dr. John Bowlby, and Sir Solly Zuckerman as chairmen.
was
AGGRESSION IN ANIMALS
Dr. JAMES FISHER said that in birds aggression is strongly associated with territorial rights, and is evoked by " releaser " mechanisms (for instance in one case the model head of a cuckoo). The releaser’s efficacy might vary according to the excitability of the bird. The capercaillie at the height of the breeding season might attack a person or a car as a rival, in mistaken identity. Dr. Fisher suggested that preservation of the species was served by the way in which aggression operates; and he indicated how it may also lead to species formation when two not-too-dissimilar races are living in proximity. He concluded with the hypothesis that " human beings behave like birds undergoing speciation ".
Dr. D. WALLIS spoke next on his studies of aggression in the social insects. Some of the experiments involved artificial estrangement of an ant to its own colony, others the introduction of a stranger. Odoriferous secretions seemed to determine admission or rejection. The secretions varied genetically and environmentally, notably with diet. Dr. HARRISON MATTHEWS pointed out that, in mammals, hostility leading to death of the fighting animals is almost unknown within a species. Fatal aggression was avoided by ritualisation, which consisted in prolonged pre-combat or early combat behaviour in a set pattern, followed by inhibited, attenuated, or shortened combat, flight, and half-hearted pursuit. The welfare of the species as a whole seemed to be served by this, but not necessarily survival of the best genotype; thus occasionally " evolutionary nonsense " could occur, such as the weighty and almost functionless horns of the extinct giant deer. overt
Dr. KONRAD LORENZ described his observations of ritualisation of fighting in fish, geese, and other creatures, and also the appeasement gestures with which a creature would inhibit aggression in the attacker. Prof. K. L. HALL had studied aggression in subhuman Each different type showed a different group structure, and corresponding differences in the nature of the aggressive response-for instance in the extent or complexity of the patterns of ritualisation. In a single species differences of habitat seemed to produce differences of levels of aggression.
primates.
The
ethologists
were
thus in general agreement.
staff, there are definite advantages in the close integration of consultant and general-practitioner units. The number of normal multigravidx now accepted for hospital confinement suggests that the demand for it is increasing both to reduce perinatal mortality and on social or domestic grounds. It is our duty to meet the changing demands of society in this matter. There is a need for more hospital maternity beds, and the majority of these could well be in general-practitioner units. My own partnership (a group practice) boasts 21 children. These were high-risk cases certainly; but none were born at home. Does this illustrate the trend ? My thanks are due to Mr. N. G. Gourlay (consultant obstetrician to the Redhill Group of Hospitals) for his help and encouragement with this paper; to Miss Beryl Thomas (superintendent midwife) for much of the information; and to Dr. T. McL. Galloway (county medical officer of health for West Sussex) for details of births in Crawley in the years under consideration.
Intra-species aggression is common in the animal world, but under natural conditions the aggression is nearly always modified in a way that tends to avoid killing. Modifying factors include ritualisation, appeasement gestures, and redirection of the aggression on to a neutral subject. Although animals hardly ever destroy one of their own kind in the natural state, caged animals or those confined by other pressures such as overpopulation have been seen to destroy themselves utterly and
reciprocally. AGGRESSION IN MAN
Prof. DENIS HILL said that in mental illness the same patterns are seen as in the normal. Human aggression was both innate and subject to environmental modification. Possible responses to an aggression-provoking stimulus would be attack (or rage), displacement (referred to by ethologists as redirection), or inhibition. Inhibition could lead to gradual attenuation, or to chronic resentment, or to the turning inward of the aggression on to the self, causing depression and perhaps suicide. Non-adaptive meaningless aggression sometimes occurred in brain-damaged patients, notably postencephalitics, and it was sometimes possible to trace the pathological lesion anatomically to the posterior part of the limbic system deep to the temporaral lobe. Dr. J. D. FREEMAN, as an anthropologist, maintained that not only aggression but also cruelty, brutality, and cannibalism are innate in man, and also a delight in them. In this he thought there is a phylogenetic difference between man and animals, and he dated its appearance to the Australopithecinae and the first use of tools. Until recently the species had benefited from these traits, but now they appeared not to be beneficial, and perhaps an evolutionary modification might occur. Prof. NORMAN GIBBS was emphatically against assuming that men behave like animals or that it is permissible to draw analogies between observed animal behaviour and that of humans. The history of war depended on documentary evidence, and was related to States rather than human
beings. Dr. A. STORR declared that there is no getting rid of aggression; we are stuck with it, and it is at its most dangerous when repressed. His advice about learning to live with it include encouraging the enjoyment of films of violence, international football matches, and the Space race, all of which provided permissible outlets for aggression that might otherwise end in hostility. Dr. JOHN BURTON again urged caution in interpreting human behaviour, especially at the international level, in the light of animal ethology. He pointed to types of international conflict which had come to be habitually resolved without war, and others which for the moment remained potential causes of war.