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Annotations.

THE DEVELOPMENT OF MENTAL HOSPITALS.

" Ne quid uimis."

CIRCULARS have been sent out by the Royal Medico-Psychological Association to every mental institutionin England inviting the medical superintendents toafford to their staffs facilities for attending clinicalmeetings in accordance with a plan whose organisationis now under consideration. It is proposed that thesemeetings should be held under the auspices of theassociation, and to encourage the attendance of theworkers in psychiatric establishments the managingbodies will be asked to sanction travelling andother reasonable expenses to their medical officers.The movement is in accordance with the expressedwishes of the Boards of Control in England andWales, and in Scotland. The circular suggeststhat the clinical meetings should not be limited tomembers of the Association, but that all medical men,institutional officers, or private practitioners shouldbe made welcome, and there can be no doubt whateverof the value of such a departure. Such meetingswould stirnulate psychiatric work and further thebetter treatment of cases of mental disorder to thebenefit of the patients and to the instruction of theprofession in directions of particular value for theconduct of practice. A memorandum on the subjectissued by the Association expresses the hope that theremay be 12 meetings a year in each of certain areaswhose size remains for decision, and that a specialpoint at these meetings should be made of the studyof groups of cases presenting similar symptoms. Allwill agree with the implication that the demonstrationof actual cases at clinical meetings is more instructivethan the reading of papers, and the scheme does notdepend for success upon securing large attendances ;small gatherings at which interchanges of personalexperience can take place should give better resultsthan crowded meetings. The existing plan of theAssociation will need dividing into areas in accordancewith the number and situation of the mental hospitals,but the actual scheme has not yet been formulated,and for pecuniary reasons the support of the localauthorities will be required, for it is unreasonable toexpect the medical staffs of the institutions to financea great education design as well as provide for itsscientific and practical working. The most valuableresult of such a scheme would be the relief fromisolation of many medical institutions. Mentalhospitals lack public sympathy and support, and falleasy victims to misrepresentation because much oftheir work is necessarily isolated. But though theycan never be entirely open institutions, it is quitemisleading to describe the insane as being treatedbehind shut doors." This is well shown in animpressive plea for the fuller cooperation of the publicin the life of psychiatric institutions written by thePresident of the Royal Medico-Psychological Associa-tion in aid of the National Council for Mental Hygiene.lLieut.-Colonel J. R. Lord points to the good resultswhich would follow upon the appointment of indepen-(tent, unofficial, and voluntary mental hospital visitorsas an intermediary between patients and their homes,and all who have studied the problems concerned willagree with him that an organisation of such visitorswould be a powerful agency both for Reienc’" andhumanity. ---

KRUKENBERG TUMOURS.

AT a recent meeting of the North of EnglandObstetrical Society Prof. Ulair Bell, who showedthree cases of Krnkenberg tumour in women aged 35,):2. and 32, remarked that these tumours, which wereoriginally described by Krukenberg as primary

1 Mental Hospitals and the Public. Adlard and Son. 1927.1s. 6d.

sarcoma carcinomatodes of the ovary, were nuw

invariably regarded as secondary to gastric or possiblyintestinal carcinoma, as was exemplified in his owncases. Similar views are expressed by Dr. Julius-TtLreho,l attending gynaecologist and obstetrician tothe Sydenham Hospital, New York (’ity-. who lecordsseven cases which he had studied at the Szvent-Istvan Hospital, Budapest. Three of his patientswere operated on for tumours of the adnexa, thematerial removed showing metastatic ovar ian tumours.In two of the three the necropsy revealed gastriccarcinoma, while the third patient was lost sight of.In the four remaining cases the ovarian tumours werenot discovered until the necropsy, and like theother two were found associated with primary gastriccarcinoma. Of the four gastric carcinomata in which ahistological examination was made three consistedof solid groups of epithelial cells, some of whichshowed mucinous changes, while one carcinoma wastibrous and showed no mucinous transformation.On naked-eye examination the ovaries in all the casesshowed typical uniform enlargement with preservationof the normal shape. The cut surface was generallysolid, except for a few discrete cysts. In some areasthe solid tissue appeared gelatinous. Histologically,the tumours presented the usual Krukneberg structure.signet-ring cells being arranged loosely or compactlybetween connective tissue rich in spindle-shaped cells.Two of the ovarian tumours showed irregular gland-like structures resembling adenocarcinoma but intransition, with groups of signet-ring cells. Evidencewas found that the gastric carcinoma had beenpropagated by retroperitoneal lymphatic channels.Dr. Jarcho comes to the conclusion that. in theformation of these ovarian tumours, propagationthrough the lymphatics plays an important part,whereas propagation along the blood-vessels and

implantation are of decidedly less moment.

FOOD HANDLERS.SHORTLY after the war, when new sanitary regula-

tions were being issued.2 the opportunity was taken toinclude measures to prevent the spread of infectionthrough the handling of food by persons carryingthe germs of dysentery and enteric fever. Morerecent regulations require that no person who is awarethat lie is suffering from tuberculosis of the respiratorytract shall take up employment in connexion with adairy which would involve the milking of cows, thetreatment of milk, or the handling of vessels used forcontaining milk ; they also give the local authoritypower to secure the dismissal of any such person alreadyemployed if he is in an infectious sta,te. It has beensuggested that much could be done towards achievingthe object of these latter regulations if employers inthe milk trade, before engaging an employee, requiredthe production of a recent medical certifici’te statingthat the physical condition of the applicant for

employment was such as to satisfy the requirements.Some local authorities have accordingly made arrange-ments for the necessary examination to be made freeof charge by their tuberculosis officers. The medicalexamination of food handlers has been taken verymuch further in the United States of America, whereDr. l’C. James Fine, Director of the TuberculosisDivision, Newark City Department of Health. NewJersey, has recently reperted 4 on the examinations offood handlers conducted in that city of about half 2.million inhabitants. The work was started withrestaurant, employees, and has gradually extended,until at the present time, grocers, confectioners.delicatessen-store workers, and milk handlers are

examined. Owing to the absence of positive results.the routine examination of nose and threa cultureswas discontinued in 1926; cultures are only made

1 American Journal of Obstetrics and Gynecology, March,1927.2 Public Health (Pneumonia, Marlaria, Dy-entery, &c.)

Regulations. 1919. See THE LANCET, 1919, i., 281.3 Public Health (Prevention of Tuberculosis) Regulations, 1925.

4 Public Health Reports of the United States Public HealthService, March 25th, p. 799.

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now if considered necessary after the examinationof the throat. Widal tests fur typhoid fever havebeen discuntinuetl for the same reason. The figuresgiven relate to the years J 920-25, during’ whicli32,188 restaurant employees and 9869 milk dealers wereexamined ; of all those examined, 155 were rejectedby-the health department for tuberculosis, and 45 furvenereal disease. Temporary cards were issued to95 persons who had tuberculosis orvenerea.l disease,but whose condition was not active. Although theexamination is compulsory, probably timse foodhandlers who came to the diagnostic clinic were

persons who felt reasonably certain that they werefree from the evidence of communicable diseases :this self-selectioii undoubtedly had some influencein keeping- down the percentage of tuberculous andvenprent diseased individuals among those examined.Considerable stress is laid upon the importance uf theexamination being made by physicians specially appointed to do tins work ; obviously it relieves the Iprivate doctor of the respmnsibility- of taking away hispatient’s employment. Dr. Fine conjunents upon thesmall number of food handlers rejected by privatedoctors im Newark, Kansas City, and New York City.In Newark itself there have been fewer rejections eachyear since lt)l’0 ; this may be taken as an indicationtha.t as persons with tuberculosis or venereal diseaseknow that they will not be certified fit for cruploy-ment as food handlers, they secure other occupations.Dr. Fine concludes his interesting survey bysummarising the arrangements made for the examina-tion of food handlers in other countries, which he ’,finds very inadequate.

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CREMATION AND DEATH CERTIFICATION.

A CIRCULAR letter will be addressed shortly to Ithe medical profession by the Crematiun Society ofEngland. signed by the Citairiiiai-i of the Society,Prof. Chalmers lllitchell, Sir Thomas Horder, and Mr.Herbert T. Ilerring, honorary secretary of the Society,in which it is pointed out that certain reforms arenecessary in the interests of the medical professionas well as of the public in respect to the disposalof bodies bv cremation. The Births and DeathsRegistration Act, 1926, comes into force next July,and imposes upon the medical practitioner importantpublic duties, without remuneration in the case ofburial, but in the case of cremation procedure iscontrolled by separate regulations. These regulations,which are laid down by statutory rules and ordersunder the Crernation Act, 1902, enact (under Form B)that the body must be seen and identified after death,and the fact of death certified by the registered medicalpractitioner who attended deceased in the last illnessand who can certify the cause of death. This serviceis remunerated as a rule with the fee for an ordinaryprofessional visit. But in disposal of the body bycremation a second medical certificate (under Form C)must be given, in which the identity of the deceased.the fact of death, and other particulars-verifying theanswers set out in Form B—must be given either byan independent medical practitioner, of not less thanfive years’ standing, who has been appointed by thecremation authority for the purpose, or, if such anappointment is not made, by a practitioner of fiveyears’ standing who holds one of the followingappointments : medical officer of health, policesurgeon, certifying surgeon under the Factory andWorkshop Act, 1901, medical referee under theWorkmen’s Compensation Act. or who is physicianor surgeon to a public general hospital containingnot less than 50 beds. It is to the circumstancesconnected with Form C that the circular letter refers,pointing out that the medical man signing it oughtto receive fair remuneration. The Cremation Actrequires the form to be signed by medical practi-tioners of five years’ standing, either appointed by acremation authority or being the holders of certainPublic appointments, and the Cremation Societydesires to bring before the medical profession thenecessity of - increasing the opportunities of the

cremation authorities to use their power of appoint-ment. Cremation is slowly becoming more frequentin this country, where it has always been advocatedby an influential section of the medical profession,so that it is reasonable for the Society to invite theattention of general practitioners to their opportunityof collaboration. The remuneration suggested by theSociety for ceutificates under Form 0 is " the usualfee for a iirst professional visit," and the direct objectof the circular letter is to invite doctors to communicatewith the Cremation Society and signify willingness insuch circumstances to sign these confirmatoy rnedicalcertificates required by the Cremation Act. listscan then be furnished tn the cremation authorities,who will know where to turn in making their appoint-ments. and who will be expected to recognise theresponsibility incurred. and to make their selectionsaccordingly.

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PULMONARY INFECTION FOLLOWING

OPERATION.

IT is not always realised how useful is a patient’sability to cough, and thus expel infective material fromthe lungs and bronchi. If (as is said) there is alwayssome inhalation of septic secretions during anaesthesia,.then a patient’s liability to post-operative pneumoniadepends on the degree to which his power of coughingis conserved. An estimate of this power might thereforebe some guide to whether there was a likelihoodof his contracting the complication. Such an estimateis not impossible, for the efficiency of a cough dependson the depth of the initial inspiration and the forcebehind the succeeding expiratory effort—which isderived almost entirely from the abdominal muscles—and it is just these two factors that are estimated bymeasuring the vital capacity, that is to say, themaximal amount of air that can be breathed outafter the deepest possible inspiration. This essentiallyis the argument which forms the basis of a recentpaper 1 by Dr. E. D. Churchill and Dr. DonaldMcNeil, of Boston. They found that after operationson the right upper quadrant of the abdomen thepatient’s vital capacity was on the average reducedby 70 per cent. on the first day, after which a steadyimprovement took place, until on the fourteenth daythe reduction was only 20 per cent. After cleanappendicectomies and operation for uncomplicatedinguinal herniæ, there was a fall of 50 per cent. on thefirst day, and a normal figure was obtained by theeleventh day ; after non-abdominal operations noreduction was observed. This diminution in vitalcapacity is attributed mainly to the abdominalmuscles being held in voluntary or involuntary spasm,so as to protect the injured part from painful move-ment, and also in part to inspiration being restrictedby a tight abdominal binder ; in a normal individualsuch a binder was found to reduce the vital capacityby 30 per cent. Other less important factors wereposture, the effect of sedative drugs, and abdominaldistension. In support of their findings, Dr. Churchilland Dr. McNeil quote figures given by E. C. Cutlerand A. M. Hunt,2 with whose results their measure-ments closely correspond. They reach the generalconclusion that the chances of pulmonary complica-tions increase as the patient’s preoperative vitalcapacity approaches his theoretical tidal air require-ment, but the evidence they give is insufficient forproof. Cases of cardiac and pulmonary disease wereexcluded from the series, and the height and weight ofpatients, though they were observed, are not recorded.The results of the investigation are what might beanticipated. A tight abdominal binder clearly limitsboth costal and diaphragmatic inspiration, and a fullexpiration is obviously impossible when the abdominalmuscles have recently been incised. Other thingsbeing equal, the postoperative variations observedare probably due to variation in the stoicism of

1 Surgery, Gynecology, and Obstetrics, April, 1927, Part I.,p. 483.

2 Arch. Surg., 1920, i., 114 ; and Arch. Int. Med., 1922,xxix., 449.