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if inflamed ; (3) that a circulating carcinogen may becomconcentrated in an inflamed tissue ; (4) that when appliesdirectly to an inflamed surface a carcinogen may bretained there ; and (5) that the appearance of a tumouin an already predisposed tissue may be accelerated b,inflammation of that tissue. Pullinger 4 has recentlydescribed some experiments in which she combined smalexcisions of skin with applications of 0-05% benzpyren4to the same areas on the mouse’s back, and her result!support the conclusion of other workers using othe:methods that repeated inflammation encourages th<

development of epithelioma in skin which has beer

subjected to a carcinogen. She found that a singlEexcision combined with applications of benzpyrentincreased the tumour-incidence by less than 1 %, whereasmultiple excisions in otherwise similar conditions causeda twofold or threefold increase in the incidence oftumours.To the references which PuIlinger has appended to

her useful papers might be added Burrows’s summary ofinformation on the localisation of substances from theblood-stream by inflamed tissues and Brunelli’s paperson the concentration of intravenously given cestrone-itself a carcinogen-in the inflamed subcutaneous tissuesof the rabbit.6

AN ARCHITECT’S VIEW OF A HEALTH SERVICE

WE are beginning to realise that pooled experiencederived from many minds can often turn out a betterjob than the limited experience of one mind, or even ofone trade or profession : Mulberry and Pluto showed asmuch. Nowadays housewives are being asked their

opinion about the convenient placing of household

equipment, teachers offer their views on classroom

design, and’doctors -often describe their ideal healthcentres. Mr. Hjalmar Cederstrom, chief architect of.the Southern Hospital, Stockholm, whose article on

planning a hospital service appeared in our columns lastyear,7 has lately published in a Swedish journal 8 hisviews on the part this great hospital may hope to playin the health service of his country, not only as a centreof social welfare but also as a model for other regionsand perhaps for other countries. The Southern Hospital-the Sodersjukhus-is designed to be comprehensive,offering preventive and welfare advice, treatment for bothacute and chronic cases, and aftercare. This presentsspecial problems for the architect, who must have inmind both administrative convenience in designing hisblocks and also the dangers of infection which arisewhen large numbers of people are gathered together inbuildings. Cederstrom thinks there should be two mainblocks, one for examination and treatment, and one forbed-patients. The outpatient department should bein the treatment block, outpatients needing specialinvestigations travelling vertically to the various depart-ments by lifts or stairways. The bed-patients visit thesame departments, but travel there horizontally alongcorridors from the bed block, and the paths of the twogroups of patients never cross. In the same way, the wardsin the bed block belonging to the ear, nose, and throatdepartment are connected by a separate corridor withthe operating-theatre in the treatment block. As he

points out, these special plans for limiting the risk ofinfection as far as possible are bound to raise buildingcosts ; but he thinks them a good investment. Heconsiders that once the diagnosis has been made, andtreatment established, inpatients should be transferredto aftercare blocks in the hospital grounds where treat-ment can be continued ;- and such blocks, he says, can

4. Pullinger, B. D. J. Path. Bact. 1945, 57, 467, 477.5. Burrows, H. Some Factors in the Localisation of Disease,

London, 1932.6. Brunelli, B. Arch. int. Pharmacodyn. 1935, 49, 214, 243, 262, 295.7. Lancet, 1945, ii, 571.8. Svenska L&auml;kartidningen. Nov. 30, 1945, p. 3005.

Le be inexpensively run. The suggestion is tempting,d especially where the hospital stands in open airy country,Ie as the Sodersjukhus does ; but it would be difficult toLr apply in our crowded metropolitan hospitals where spacey is at a premium and it is hard to find enough room eveny for acute cases.11 Cederstrom goes on to suggest that an experiment ine social security should be tried in a social investigations district-what he calls a " social city "-where peopler should be distributed according to their occupationse and social diseases-textile workers with tuberculosisn being grouped together, for example. He seems toe advocate that village communities, like Papworth,e should be formed in different parts of the city, but hes does not develop this interesting proposal at all fully.1 On the face of it, the experiment could only succeed iff tried in an unnaturally docile and cooperative society.

DAMAGES FOR SHOCK[ SINCE the Medico-Legal Society last considered the question of judicial damages and compensation for’

nervous shock, the courts have several times had it

brought to their notice.In the discussion held by the society on Jan. 24 the

present position was reviewed. Judge W. G. Earengey,K.c., recalled that the foundation of all damages is thatif one person in breach of his duty to another causesdamage to the other, he is liable to pay compensation.The cause of action relied on is nearly always negligence-the breach of a duty to take care. The test of culp-ability is whether an ordinary reasonable person wouldhave foreseen that the act or default might probablycause damage. The earlier attitude of the law wasthat it could not value mental pain or anxiety andwould only award damages for a material injury. Thedecisions.of the last generation, culminating in the Houseof Lords case Hay v. Young (1943) A.c.92, have mademental or nervous injury as good a ground for a claimas physical injury. In both classes of injury super-sensitivity only comes into account in so far as the courtmust be satisfied that an ordinary average person wouldhave suffered some damage ; if he would, then com-pensation is based on what the supersensitive personactually suffered and not what an ordinary person wouldhave suffered. The present position, as stated byJudge Earengey, seems to be that a wrongdoer shouldforesee the risk of shock to a person within the area ofpotential danger caused by reasonable fear of danger ofinjury to that person or to his close relations. Therecent Australian Act establishing nervous shock as acause of action lays down a long list of relatives, fearfor whose safety may be the cause of actionable shock-a list roughly corresponding to the degrees of affinitywithin which marriage is prohibited.

Mr. Zachary Cope, dealing with the medical aspect,emphasised the misfortune by which the word " shock,"which has become familiar as meaning a condition oflowered vitality resulting from the application of harmfulstimuli to the body, has been attached by lawyers to theentirely different condition which he regards as practicallyidentical with anxiety neurosis. Mental shock, he -said,is rare in persons who have suffered severe physicalinjury, common in those who have suffered none. Itis increased and prolonged out of all proportion by thesuspense associated with litigation, and seldom developsafter accidents in which no question of compensationarises, or in persons who are completely responsible forthe mishap. The average person does not, Mr. Copebelieves, develop mental shock merely from seeing orhearing something terrible on one occasion. Thosewho framed the Emergency Legislation had wiseadvisers, he thought, when they decreed that the Stateshould not compensate for war injuries which were notphysical. He sees need, in the assessment of damages

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for mental pain and anxiety, for a skilled psychiatristof long experience who can estimate the nature and degreeof the disability and its probable duration. Difficultyin assessing damages, as Sir Roland Burrows, K.c.,observed, is no good reason why damages should not begiven if someone by a wrongful act causes in somebodyelse, to whom he owes the duty of care, an anxietyneurosis. -

The position therefore seems to be that, by whatevername the mental or nervous injury is called, it is at timesa real injury for which the law ought to award damageswhen the person causing it is legally culpable. In

determining, however, whether a compensable mentalinjury has been caused, and to what extent it is due to thewrongful act of another, and what it is worth in terms ofmoney damages, the court is really almost entirely in thehands of the medical witnesses. One of the reasons whythe courts are still groping in more than semi-darknessin dealing with such claims is unfortunately the paucityof medical understanding of the mental facts. If

psychiatrists were available who could give a sensibleestimate of damages, the courts might, as they havethe power to do, use them for that purpose. The troubleis that the psychiatrists themselves are by no means onfirm ground. The problem is not an academic one, forneuroses, and hence susceptibility to nervous injury, aresteadily increasing in the population. One great advancewould undoubtedly be to get rid of litigation in thisconnexion. If persons who were mentally injured byaccident could avail themselves at once of proper medicaltreatment and no question of compensation arose, therewould be far less residual nervous injury. The ideal

may be that the State should undertake the reablementof the victim and that the wrongdoer should- pay com-pensation to the State. Such an arrangement, however,lies in the unpredictable future, and for the present it isincumbent on psychiatrists and others to study the syn-drome of nervous shock at first hand so that they areable to enlighten the court more precisely about its

importance in a given case.DIAGNOSIS OF RHEUMATIC FEVER

THE querulous comment is often heard these days that" rheumatic fever is changing," and the papers byBarber and Sheldon in our last issue might be held togive substance to this belief. The truth is that the useof diagnostic labels changes, and that, with the growthof knowledge, the symbol " rheumatic fever " has cometo embrace a far wider range of disease-pictures than itdid thirty years ago.

It is believed today that a patient suffers from thisdisorder because his tissues react to infection by theh&aelig;molytic streptococcus in a different fashion from thoseof other people. The manifestations are thus allergicand, since many of the general features of the allergicreaction are non-specific, it would be surprising if similarsyndromes, unrelated to streptococcal infection, werenot encountered. Sheldon has reminded us that tuber-culosis may elicit such a response, a fact less well known,perhaps, to British than to French clinicians. It has beennoted too with syphilitic infection ; and there are

parallels in the common serum-sickness and in the

syndrome of bronchial asthma with polyserositis, myo-carditis, and polyarthritis described by Harkavy 1in 1941. Through this familiar guise of the allergicreaction can be seen other features, the sign manualof the specific allergen responsible ; to identify this

agent in the patient confronting him is the task of thephysician. There is usually no difficulty in the diagnosisof rheumatic fever, and a recent history of infection ofthe upper respiratory tract may facilitate diagnosiswhen the clinical picture is unusual. Barber remindsus that the h&aelig;molytic streptococcus commonly gives

1. Harkavy, J. Arch. intern. Med. 1941, 67, 709.

rise to pharyngitis two or three weeks before the appear-ance of rheumatic symptoms. When " rheumatic fever "

occurs below the age of five years, or when pericardialeffusion and polyarthritis are not accompanied byendocarditis, suspicions should be entertained of the

allergen being the tubercle bacillus or its product.Sheldon’s experience well illustrates this point ; it alsoillustrates the renaissance of the " constitutional "

concept in medical thought-the diseased body, no

longer a passive substrate for the pathogenic agent,is allowed full partnership in determining what formits malady shall take.

BERNHEIM’S SYNDROME

CONTINENTAL (especially French) and South Americanclinicians have for long attached importance to a syn-drome first described by Bernheim 1 in 1910. This

syndrome, sometimes referred to as " isolated rightheart failure," is characterised by systemic venous con-gestion without pulmonary congestion, and occurs inpatients with left ventricular enlargement from -anycause, such as hypertension, chronic nephritis, or com-bined aortic and mitral valvular disease. Bernheim’sattention was first drawn to the condition by his findingat necropsy that many patients who had died with theclassical manifestations of right-sided heart-failure hadstenosis of the right ventricle, and not dilatation as wouldbe expected. In all these cases there was hypertrophyand dilatation of the left ventricle, and the stenosis ofthe right ventricle was due to encroachment of the hyper-trophied interventricular septum ; so pronounced wasthis encroachment in some cases that the septum almosttouched the lateral wall of the right ventricle. Clinicallythese patients show signs of systemic congestion in

hepatic enlargement and distended neck veins, withoedema which is often gross, but have no pulmonary con-gestion or dyspnoea except as terminal phenomena.Bernheim explained these findings on the basis ofobstruction to the blood-flow through the right ventricle.

. Of three examples of this syndrome reported by ’

Russek and Zohman,2 two were diagnosed during life ’

and one at necropsy. The two cases diagnosed clinicallywere both in hypertensive subjects, and the third was acase of combined aortic and mitral valvular disease.In spite of their oedema and venous congestion thesepatients could lie flat in bed and engage in moderate

activity without much respiratory distress. The com-bination of a raised venous pressure with a normal arm-

to-tongue circulation-time is an important diagnosticfeature. In spite of the clinical evidence of left ventri-cular hypertrophy, the electrocardiogram shows eitherright ventricular preponderance or no axis-deviation.

Radiologically, enlargement of the left ventricle and

right auricle is highly suggestive.The curious lack of British and American references

to this condition is difficult to explain, especially whenan experienced clinician such as Fishberg 3 refers to the"

many necropsies " in which he has noted well-markednarrowing of the right ventricle by a bulging septum.Fishberg has gathered the impression that the syndromeis commoner in young subjects than in elderly ones, andboth the cases diagnosed clinically by Russek and Zohmanwere in their early forties. Probably the post-mortemfinding of a " stenosed right ventricle " is much morecommon than functional obstruction to the blood-flow.

Sir JOHN BROADBENT, consulting physician to St.Mary’s Hospital, died at his home at Wendover onJan. 27. He was 80 years of age.

Major-General EDWARD PHILLIPS, C.B.E., D.s.o., M.c.,director of medical services, 21st Army Group, has beenpromoted R.B.E.1. Rev. M&eacute;decine, 1910, 30, 785.2. Russek, H. I., Zohman, B. L. Amer. Heart J. 1945, 30, 427.3. Fishberg, A. M. Heart Failure, London, 1940, p. 447.