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in the revised estimates, which were published last week.3The pharmaceutical services for England, Wales, and

Scotland will thus now cost £43,610,000 insteadof £34,610,000. This heavy increase, a small part ofwhich is due to the recent arbitration award of E800,000to Scottish chemists, is to some extent offset by a fallin the cost of dental services from £39,890,000 to

£36,200,000, and of ophthalmic services from .El 8,610,000to £14,650,000. In his budget speech the Chancellor

suggested that the new charges would bring in jE12million in 1951-52 ; but in the new estimates the totalis set at only £4,750,000 for dentures and E4,700,000for spectacles. Despite the substantial reductions onthe dental and ophthalmic services and a smaller oneof £450,000 in the Scottish hospital services, the newestimates have advanced a further .El, 100,000 ; and thetotal estimate now stands at 399,183,000—perilouslynear the £400 million ceiling.The rising price of drugs and the many new expensive

remedies are bound to make the pharmaceutical serviceincreasingly costly, however economically it is run.

But the medical speakers in last week’s discussion on theestimates in the House of Commons, reported on anotherpage, were manifestly uneasy at the present balance ofexpenditure. There is a danger that the public’s faithin a bottle of medicine may deprive them of moreeffective medical care. For instance, in a written answerthe Minister has announced that half-a-million vitamintablets are dispensed each day (see p. 122) ; and, asDr. Hill pointed out in the debate, we are now spendingnearly as much on drugs as on the whole general-practitioner service. Members were also uneasy that theMinister had left himself so little elbow-room, andMr. Marquand admitted that the estimates did notallow for the possibility of an increase in the remunera-tion of the English and Welsh chemists to match theaward of £800,000 to their Scottish colleagues. Asthe discussion was on the pharmaceutical service theremuneration of general practitioners was not mentioned,but it must have been in the -Alinister’s mind. He stillfelt able, however, to affirm his belief that " we can carryon the National Health Service this year maintaining thehospital, the general-practitioner, and other essential

parts of the service at a reasonable level, within theceiling of E400 million."

PROSPECTS IN PSYCHIATRY

FOR a better understanding of the effects of cerebralshock treatment we wait humbly on the biochemist.Dr. P. K. McCowan, who gave his presidential addressto the Royal Medico-Psychological Association atCrichton Royal, Dumfries, on July 11, has strong linkswith modern research on the biochemistry of the brain,through his former association with J. H. Quastel atCardiff. In Dr. McCowan’s view, all the so-calledshock treatments have in common the productionof cerebral anoxia, whether this is taken to mean simplelack of oxygen, or lack of glucose or of the catalystdehydrogenase. There are grounds for believing thatmetabolism is at a lower level in the psychotic than in thenormal brain, and that a disturbance in cerebral oxida-tion is in some way responsible. This disturbance maybe the continuing result of a cause which has ceased toact. The evidence suggests that shock therapies act

selectively, and that they restore-temporarily at anyrate-the normal level of cerebral metabolism, withresulting improvement of the psychosis. It is not theanoxia, however, which works the change, but the brain’sreaction to it ; and at present it is only possible tospeculate on whether this reaction is mediated throughthe autonomic system, the pituitary mechanism, or thehypothalamus. It seems possible, for instance, as

Selye believes, that in schizophrenia shock treatment3. 1951-52: Civil Estimates (Revised Estimates). H.M. Stationery

Office. Pp. 59. 1s. 6d.

may cause changes affecting the pituitary-adrenaldischarge ; and A.C.T.1-1. and cortisone may be the fore-runners of non-specific shock therapies superior to thosenow used.On the preventive side, Dr. McCowan spoke of the

importance of educating the public in the understandingof mental illness. Preventive mental health workoffers its best prospects of success among children. Henoted that the psycho-analytic approach is not the onlyone available and advocated the use of more lay psycho-therapists working under psychiatrists. Inpatient clinicsfor maladjusted children are beginning to be established,and the first Scottish clinic of the kind was opened atCrichton Royal a few months ago. He believes that wemay need to make greater provision for mental defectivesthan we have done so far. For backward children apractical type of education, not unduly prolonged, isneeded. An investigation in a rural area, made sometime ago, showed that no less than 11% of the school-children could be classed as backward ; but these sub-normal children all grew up to be efficient and contentedagricultural labourers.

CHILDREN IN HOMES

CHILDREN and their mothers are normally answerableto each other for their behaviour ; and when either partyis doing badly the other makes it plain. Like exponents ofother games of skill, those mothers who do best seem touse least effort ; and their success is partly due, no doubt,to confidence in their natural gifts. But when the childis a foster-child, carrying genes of which the mother hasno first-hand experience, and when she must answer forher behaviour not to him but to an official body, shemay become self-conscious and relatively ham-handed.Some foster-mothers in charge of children’s homes havesuch a flair for the job that nothing can spoil their form ;but others need to be told, from time to time, that theyare doing all right, or even how to do all right. A newmemorandum, published by the Home Office, on theconduct of children’s homes sets out what a children’shome-or any home, for that matter-should be like.

It should be, as the Curtis Committee laid down, aplace where children can be sure of affection, stability,and opportunity to make the best of their abilities, andwhere they can share in the common life of a small groupof people in a homely environment. The home may wellbe a house in an ordinary street, taking a family groupof 8-12 children, boys and girls together, ranging in agefrom about 3 to 15 years. The children should mix withother children in the neighbourhood, and be able tovisit their friends and invite them back. The house-mother should be given the fullest possible responsibilityfor her family, and should not be subordinate to the personin charge of some other children’s home. If she ismarried and her husband goes out to work every day fromthe home, so much the better-that completes the familypattern. The staff-the house-mother, and anyone shehas to help her-must keep their pleasure and freshnessin their work ; which means they must have adequatetime off and holidays, and opportunity for outsideinterests. In these respects, indeed, they are probablyrather better off than ordinary mothers. The home, thememorandum says, is to be comfortable, cheerful, andnot at all institutional, but with attractively colouredcurtains and rugs. There must be a playroom for use inwet weather, and a quiet room for those who want toread or draw. A workshop for crafts and hobbies may befixed up in a garden shed if there is no room for it in thehouse ; and there must be a safe place for models andother work in progress which might suffer at the handsof the junior members of the family. In addition everychild must have a place to keep his personal possessions,which should not be disturbed by the staff without hisknowledge. Newcomers should receive special considera-tion, being welcomed and shown round, and taken at once

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to any brother or sister or friend who is already in thehome. The religious upbringing of the children is givengreat importance. It is hardly necessary to say that thehouse-mother and her husband are not to be called the" superintendent" or the " master," or by any suchnames suggesting institutional life. The family atmos-phere can be established particularly well at mealtimes,when the staff should be present and the children shouldtalk freely and learn pleasant and helpful table-manners,as they would in any good-humoured household.The memorandum gives sensible advice on bedwetters,

and particularly notes that children should be warm inbed at all seasons of the year. Clothes and methods of

hairdressing should be diverse and personal; boots ,andshoes should fit the growing feet, and should not behanded down unless in exceptional cases. Children shouldlearn to handle money and have some of their own ; andthey should help in the family chores but " not at the

expense of sleep, meals, education or reasonable recrea-tion." The visits of friends and relatives should be

encouraged, and the ordered routine which gives securityshould be broken reasonably often by the unexpectedtreat which gives zest. Punishment on family lines isdiscussed ; the regulations allow for the maternal slap,and for the caning, by the person in charge of the home,of boys between the ages of 10 and school-leaving age ;but the aim, it is said, should be to bring home to thechild the effect of his action on the group : " Measureswhich are purely punitive in intention and effect makeno contribution to a child’s education."

FURTHER EXPERIENCE WITH TRIETHYLENEMELAMINE

ATTENTION has already been drawn in these columns 1to American clinical trials of triethylene melamine

(T.E.M.) as a substitute for nitrogen mustards in leukaemiaand Hodgkin’s disease. In England, Rose and others 2had shown that the substance exerted a toxic action onsome tissue cells and inhibited some animal tumours;and Paterson and Boland 3 have now published an

interim report of a trial in human malignant disease,leuksemia, and allied conditions. This latest report isbased on only a few cases, and none of the records covermore than a year ; but the results are instructive. One

patient with chronic myeloid leukaemia, previously treatedwith urethane, had a total leucocyte-count of 30,000 perc.mm. ; a single course of 0-22 mg. of T.E.M. per kg., givenintravenously in three daily doses, reduced the white-cellcount to normal and the remission lasted six months ;the improvement is said to be about what would be

expected after a non-repetitive course of X rays or

urethane. A second case of chronic myeloid leukaemiaresponded less satisfactorily. The results in 5 other

patients with different forms of leukaemia and in 1 caseof polycythæmia paralleled those seen with nitrogenmustards. In 3 patients with Hodgkin’s disease, singlecourses of 0-137-0-195 mg. per kg. daily also had muchthe same effects as single courses of nitrogen mustards.In a patient with myelomatosis the drug relieved thepain. It was tried in several types of malignant disease,but, as the Americans found, there was no significantimprovement.On this experience Paterson and Boland do not think

that triethylene melamine is any more effective thanX rays or the established chemotherapeutic drugs inHodgkin’s disease and leukaemias. But they agree thatit deserves further trial because it does not produce theunpleasant side-effects that have made nitrogen mustardsdifficult to use in some patients, and it can be injectedintravenously without fear of local thrombosis. TheBritish workers have not studied its effects by mouth,which were the main grounds for its recommendation in1. Leading article, Lancet, 1951, i, 1111.2. Rose, F. L., Hendry, J. A., Walpole, A. L. Nature, Lond. 1950,

165, 993.3. Paterson, E., Boland, J. Brit. J. Cancer, 1951, 5, 28.

the U.S.A. These preliminary trials will presumablybe followed by an interval while the drug’s long-termeffects are worked out. If these bear out the fairlymodest promise of the earlier observations, triethylenemelamine will probably take the place of nitrogenmustards.

MEDICINE IN OUR TIME"ONLY ignorance is simple," Dr. Russell Brain,

P.R.C.P., remarked over the air last Sunday. He wastalking of the growing complexity of medicine and of ,

that acceleration of scientific progress which, in the last ,

fifty years, has made many feel, with the Red Queen,that it takes all the running they can do to keep in thesame place. At the moment we are managing to hold ourown by using two well-tried methods : specialisation,and team-work. And he drew a picture of the modernhospital, constantly engaged in research, more highlyorganised than ever before, and using more complextechniques and more elaborate equipment; and for theseand other reasons more costly to run than it has everbeen. " What is the effect," he asked, " of all thesedevelopments on the work of the general practitioner "The emphasis, in serious disease, has shifted from thefamily doctor to the hospital. Not only is there dangerof his work becoming less interesting, and less well

thought of, than it used to be, but he has many morepatients to deal with than he had. Yet the family doctor,as- Dr. Brain reminded listeners, knows the patient asthe hospital staff can never know him-as the man" who lays down the law at home, spends Saturdayafternoon cheering the Arsenal or Newcastle United,and whose pigeons won that cup on his mantelpiece."The more specialised medicine becomes the greater theneed for the general practitioner with this special personalknowledge, the natural counsellor, the captain of thehome team as the consultant is captain of the hospitalteam. If, however, the family doctor is to do his jobproperly there must be changes. The more he turns tothe hospital for help in the care of his patients, the closershould be his own links with the hospital. And the

advantages of this association need not be one-sided, forthe general practitioner who can get his diagnostic testsdone easily can often save the hospital beds. But,Dr. Brain believes, if the doctor of tomorrow is to get theworking conditions he deserves we must not forgettoday that " organisation exists for medicine, and notmedicine for organisation."CLINICAL PATHOLOGY CONGRESS IN LONDONSOME 600 delegates from thirty different countries

gathered in London this week for the InternationalCongress of Clinical Pathology. This is the first congressheld under the auspices of the International Society ofClinical Pathology, which was formed in 1947. Inhis presidential address last Monday, Sir Lionel Whitbydeclared that in approaching medicine from the scientificaspect’the quality always required was common sense-’’ the sense which can instinctively distinguish betweena chance error in estimation (the common refuge of theignorant when the estimation runs counter to clinicalopinion) and a true estimation which reveals a rare

chance. Common-sense appreciation of medical sciencemust," he declared, " admit and recognise that thoughmen are all of a pattern the pattern is never the same."

ON July 17 Princess ELIZABETH visited the RoyalCollege of Obstetricians and Gynaecologists, where shewas admitted to the honorary fellowship.ON July 12 Sir CECIL WAKELEY was re-elected president

of the Royal College of Surgeons of England.Dr. J. SIM WALLACE, formerly dental surgeon and

pathologist to the London Hospital and lecturer in pre-ventive dentistry at King’s College Hospital, died on July13 at the age of 82. He was best known for his workon dental caries.