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935 By that time we shall have answered the questions that arise from the reading of " The Trauma of Birth "-do these things happen, and if so, what is their import to medicine ? The nature of the answer to these questions cannot be prophesied. The trouble of investigating psychology from this new aspect should not be minimised or attributed only to its unwelcome message ; its exponents are still unable to agree on even the fundamental tenets of the faith. Few of them follow Freud in all his teachings, and it is likely that the pattern ultimately to be woven will be made from many designs which at present seem to clash with one another. Our plea is that in the medical schools some equipment should be given to the student to enable him to follow the developments of Freud’s ideas, and eventually to assimilate those which will help him to understand his patients. ______________ Annotations. PRINCIPLES OF PUBLIC HEALTH DEVELOPMENT. "Ne quid nlmis." AN ordinary industry, as Dr. J. J. Buchan pointed out in his presidential address to the Society of Medical Officers of Health on Friday last, is constantly reviewing its organisation and making any outlay necessary to improve efficiency, maintain position, increase profits, and diminish expenses. Yet, although the only real capital of the State is the health of its people, this vigorous progressive acumen is seldom seen in the department of public health. The public health is a good business proposition, for it has done more in the past to increase capital and diminish expenses than the most successful industrial venture on record. Despite a chaos of patchwork legislation and great inherent difficulties, the rate of progress in recent years calls, as Dr. Buchan pointed out, for some satisfaction, but he laid down certain principles for the future which should ensure a continuance and amplification of the success already attained. We are still far short of making full use of the knowledge we already have and still more wanting in facilities for research. Every up-to-date industrial concern maintains a research institute ; surely the State should not leave the great bulk of research work in health to the self-sacrificing labour of the few and the vicarious generosity of the well-intentioned. Dr. Buchan’s first principle was that the protection and improvement of the health of the people should be regarded by the State as an end worthy in itself. Too often in the past public health has crept in behind the skirts of some other work, as, for instance, the public health services under the poor-law, which were no more than a side-line in the relief of destitution. This has been set right, but similar examples still abound, notably in factory legislation. " Despite a succession of statutes and a multitude of orders," said Dr. Buchan, " factory legislation has continuously failed to meet fully the real health needs of the If whole body of the employed... only some six millions out of sixteen and a half millions of occupied ’, persons come under the Factory Act." He refused, however, to regard the health of the worker as a labour problem to be solved by codification of industrial laws ; the health problem is fundamental and the health of the employed must be brought under the Ministry of Health and not under the Home Office. His second principle was that the people cannot be sectionalised ; evil conditions in one class, at one age, or in one set of circumstances have comparable evil conditions in very different departments. Health in pregnancy, for instance, must be viewed in relationship to the conditions before and after pregnancy, and the more deeply ii we inquire into the health of school-children the I further do we travel from the school. The third I principle was that a central unification and reorganisa- tion of health effort is not in itself sufficient unless. it is accompanied by a similar unification and reorganisation at the points of administration. Health work in this country has always suffered, he maintained, from a lack of well-ordered and well- arranged local government areas. The State should permit no consideration of local history, pride. prejudice, or precedent to stand in the way of securing competent machinery of local administration. His. final principle was the complete freedom of expression of the professional health officer within his own sphere. To be of any service he must be absolutely free to express his opinion on any matter of health, whether it be lead poisoning among painters or the exclusion of school contacts in infectious disease- Any control of this expression’ of opinion must come from within the public health service itself, and not from administrators who have not the knowledge to- control opinion on such subjects. " In no other kind of public activity," concluded Dr. Buchan, " is there such a solidarity of interest for all the people, and in none is their cooperation and help more desirable." This cooperation depends almost entirely upon the- better education of the great mass of the people in matters of health, and for this education the public health officer must rely to a very large extent on the general practitioner, who has it in his power to take- the knowledge of hygienic principles into the homes. and hearts of the people. PERNICIOUS ANÆMIA WHICH RESISTS LIVER TREATMENT. ARE there any cases of pernicious anaemia which will not respond to liver ? The general experience- both here and in America seems to be that there are- not ; but Dr. P. Emil-Weil now publishes1 three cases diagnosed as pernicious anaemia which got no> better under modern treatment. The patients all showed severe anaemia with a high colour-index and some leucopenia ; in one the spleen is said to have been enlarged. Liver was given, both as whole gland and in the form of extracts ; this treatment was. supplemented by frequent transfusions of blood ; ;. yet no improvement followed, and all the patients. died after illnesses of some months. The question naturally arises whether the diagnosis was correct- We have at present three criteria of pernicious. anaemia—namely, achlorhydria, haemolysis, and an increase in the mean size of the red cells. A high colour-index is indirect evidence of the last of these- and it was observed in Emil-Weil’s three cases. But he gives no information about the other two signs, and failing this it would be rash to amend the aphorism ! that anaemia which will not respond to liver is not, pernicious anaemia. JUVENILE RHEUMATISM IN MARYLEBONE. THE St. Marylebone Children’s Rheumatism Super- visory Centre was instituted at the General Dispensary in 1926, and has now published its first report with an analysis of the first 100 cases. An attempt is- being made to combine into a simultaneous objective a clinical inquiry into the prevention of heart disease and a laboratory investigation into the nature of the- rheumatism of childhood. The clothing was good in 71 per cent., fair in 23 per cent., and bad in 6 per cent. The family income was adequate in 79 and inadequate in 21. The housing was good in 23, overcrowded in 32, damp in 8 only, insanitary in 11, and inadequately light in 9. The clinical analysis shows the family and personal history, age, previous infections, early symptoms and state of nutrition, teeth, and blood pressure. The biochemical work includes haematological and chemical examination of blood, urine, and fseces, and certain abnormalities have been found with some consistency. In 75 of the children focal sepsis could be excluded, and the 1 Le Sang, 1929, iii., 426.
Transcript

935

By that time we shall have answered the questionsthat arise from the reading of " The Trauma ofBirth "-do these things happen, and if so, what istheir import to medicine ? The nature of theanswer to these questions cannot be prophesied.The trouble of investigating psychology from thisnew aspect should not be minimised or attributedonly to its unwelcome message ; its exponents arestill unable to agree on even the fundamental tenetsof the faith. Few of them follow Freud in all histeachings, and it is likely that the pattern ultimatelyto be woven will be made from many designs whichat present seem to clash with one another. Our

plea is that in the medical schools some equipmentshould be given to the student to enable him to followthe developments of Freud’s ideas, and eventuallyto assimilate those which will help him to understandhis patients.

______________

Annotations.

PRINCIPLES OF PUBLIC HEALTH

DEVELOPMENT.

"Ne quid nlmis."

AN ordinary industry, as Dr. J. J. Buchan pointedout in his presidential address to the Society ofMedical Officers of Health on Friday last, is constantlyreviewing its organisation and making any outlaynecessary to improve efficiency, maintain position,increase profits, and diminish expenses. Yet, althoughthe only real capital of the State is the health of itspeople, this vigorous progressive acumen is seldomseen in the department of public health. The publichealth is a good business proposition, for it has donemore in the past to increase capital and diminishexpenses than the most successful industrial ventureon record. Despite a chaos of patchwork legislationand great inherent difficulties, the rate of progress inrecent years calls, as Dr. Buchan pointed out, forsome satisfaction, but he laid down certain principlesfor the future which should ensure a continuance andamplification of the success already attained. Weare still far short of making full use of the knowledgewe already have and still more wanting in facilitiesfor research. Every up-to-date industrial concernmaintains a research institute ; surely the Stateshould not leave the great bulk of research work inhealth to the self-sacrificing labour of the few and thevicarious generosity of the well-intentioned. Dr.Buchan’s first principle was that the protection andimprovement of the health of the people should beregarded by the State as an end worthy in itself.Too often in the past public health has crept in behindthe skirts of some other work, as, for instance, thepublic health services under the poor-law, which wereno more than a side-line in the relief of destitution.This has been set right, but similar examples stillabound, notably in factory legislation. " Despite asuccession of statutes and a multitude of orders,"said Dr. Buchan, " factory legislation has continuouslyfailed to meet fully the real health needs of the Ifwhole body of the employed... only some six ’

millions out of sixteen and a half millions of occupied ’,persons come under the Factory Act." He refused,however, to regard the health of the worker as alabour problem to be solved by codification ofindustrial laws ; the health problem is fundamentaland the health of the employed must be broughtunder the Ministry of Health and not under theHome Office. His second principle was that thepeople cannot be sectionalised ; evil conditions inone class, at one age, or in one set of circumstanceshave comparable evil conditions in very differentdepartments. Health in pregnancy, for instance,must be viewed in relationship to the conditionsbefore and after pregnancy, and the more deeply iiwe inquire into the health of school-children the Ifurther do we travel from the school. The third I

principle was that a central unification and reorganisa-tion of health effort is not in itself sufficient unless.it is accompanied by a similar unification andreorganisation at the points of administration.Health work in this country has always suffered, hemaintained, from a lack of well-ordered and well-arranged local government areas. The State shouldpermit no consideration of local history, pride.prejudice, or precedent to stand in the way of securingcompetent machinery of local administration. His.final principle was the complete freedom of expressionof the professional health officer within his ownsphere. To be of any service he must be absolutelyfree to express his opinion on any matter of health,whether it be lead poisoning among painters or theexclusion of school contacts in infectious disease-

Any control of this expression’ of opinion must comefrom within the public health service itself, and notfrom administrators who have not the knowledge to-control opinion on such subjects. " In no other kindof public activity," concluded Dr. Buchan, " is theresuch a solidarity of interest for all the people, andin none is their cooperation and help more desirable."This cooperation depends almost entirely upon the-better education of the great mass of the people inmatters of health, and for this education the publichealth officer must rely to a very large extent on thegeneral practitioner, who has it in his power to take-the knowledge of hygienic principles into the homes.and hearts of the people.

PERNICIOUS ANÆMIA WHICH RESISTS LIVERTREATMENT.

ARE there any cases of pernicious anaemia whichwill not respond to liver ? The general experience-both here and in America seems to be that there are-not ; but Dr. P. Emil-Weil now publishes1 threecases diagnosed as pernicious anaemia which got no>

better under modern treatment. The patients allshowed severe anaemia with a high colour-index andsome leucopenia ; in one the spleen is said to havebeen enlarged. Liver was given, both as whole glandand in the form of extracts ; this treatment was.supplemented by frequent transfusions of blood ; ;.

yet no improvement followed, and all the patients.died after illnesses of some months. The questionnaturally arises whether the diagnosis was correct-We have at present three criteria of pernicious.anaemia—namely, achlorhydria, haemolysis, and anincrease in the mean size of the red cells. A highcolour-index is indirect evidence of the last of these-and it was observed in Emil-Weil’s three cases. Buthe gives no information about the other two signs,and failing this it would be rash to amend the aphorism

! that anaemia which will not respond to liver is not,pernicious anaemia.

____

JUVENILE RHEUMATISM IN MARYLEBONE.

THE St. Marylebone Children’s Rheumatism Super-visory Centre was instituted at the General Dispensaryin 1926, and has now published its first report withan analysis of the first 100 cases. An attempt is-being made to combine into a simultaneous objectivea clinical inquiry into the prevention of heart diseaseand a laboratory investigation into the nature of the-rheumatism of childhood. The clothing was goodin 71 per cent., fair in 23 per cent., and bad in 6 percent. The family income was adequate in 79 andinadequate in 21. The housing was good in 23,overcrowded in 32, damp in 8 only, insanitary in 11,and inadequately light in 9. The clinical analysisshows the family and personal history, age, previousinfections, early symptoms and state of nutrition,teeth, and blood pressure. The biochemical workincludes haematological and chemical examinationof blood, urine, and fseces, and certain abnormalitieshave been found with some consistency. In 75 of thechildren focal sepsis could be excluded, and the

1 Le Sang, 1929, iii., 426.

936

constitutional findings in the remaining 25 providedpresumptive evidence of a rheumatic diathesis witha secondary superadded septic factor. Cardiacinvolvement was found in all the children (60) whoexhibited a lowered alkaline reserve. Cases whichshowed a deviation of the acid-base balance to thealkaline side were eventually classified as non-rheu-matic, both on clinical and on biochemical grounds. Phosphate and sulphate excretion was abnormal inmore than half the cases, and the aromatic sulphatefraction was increased in 30. Calcium excretion waslow in 65, and 70 showed an abnormal carbon-nitrogenratio. No consistent variations from normal werefound in the faeces except for an excessive loss ofcalcium in 40. Some of these findings are suggestive,but the director, Dr. Halls Dally, rightly declines to- draw conclusions at this early stage of the work.

DUTCH MENTAL HOSPITALS.

UF the subcommittees formed by the noyal Medico-Psychological Association there is one which organisesstudy tours and post-graduate education in mentaldisorder. Just a year ago a party visited the mentalhospitals of Holland, and an account of the tourhas now been published in pamphlet form.1 TheDutch Lunacy Law differs from our own in a fewrespects. Until 1906 a patient could only be receivedinto a mental institution on the certificate of anindependent medical practitioner, and the petitionof a relative or of the Public Prosecutor in lieu. Anybuilding where more than two insane persons weretreated was legally an asylum; but in 1906 the lawwas amended so that patients could be received ina university clinic without labelling the building asan asylum. Thus patients can now be taken intothese institutions or into separate blocks in mentalhospitals, called open wards," without the formalityof certification or periodic statutory reports. Thevisitors last year found that 20 per cent. of theinmates of mental wards had been admitted withoutany kind of certification. Many of them were

obviously non-volitional, and isolation, seclusion, orcontinuous bath treatment were ordered for them.irrespective of the basis of admission. There is nolegal provision for single care or for the disposal ofthe income of well-to-do patients. One doctor toevery 175 patients is required in new hospitals. Themedical director is the chief officer, except in RomanCatholic institutions. where the Prior exercises generalcontrol. The State issues a diploma in mental nursing after three years’ training and examination. Theproportion of nurses to patients is about double thatfound in Britain, but Holland experiences the samedifficulty as we do in securing suitable applicants.Assistant nurses are paid from 45 to £60, and nursesholding the diploma £146 to £160 per annum, andthe working week varies from 48 to 60 hours. Femalenursing of male patients is commoner there than inthis country.

Perhaps the most striking feature of the Dutchmental hospital is the application of Dr. Simon’soccupational therapy, which was devised with a

particular view to improving the condition of restless,destructive, or filthy patients in turbulent wards.It is based on pedagogic principles. Four or fivepatients are put together in a little alcove, and stillnessand silence are enjoined. When a new patient joinsthe group the atmosphere of quiet industry has astrong influence. Any patient who becomes noisyis removed to a single room for a period varying fromten minutes to an hour, as a penalty. The work onwhich the patients are employed includes raffia,tearing rags or coir, untying knots in string, rollingstring into balls, envelope-making, cleaning lettersoff three-ply wood tea-chests, rudimentary knitting,rug- and mat-making, tobacco-leaf stripping, bricktrimming, tile-making, and cleaning labels. The

1An Account of a Tour of Dutch Mental Hospitals and Clinics.By A. E. Evans, M.B. Adlard and Son, Ltd., 21, Hart-street,W.C. 1929. Pp. 18. 1s.

articles made by more advanced patients display muchingenuity and activity with every variety of handi.craft, but even the least intelligent can produce wirepaper clips or firelighters made of rolled shavings.Weekly payments are made in recognition of goodbehaviour and regular work, and to promote self-esteem. On July lst, 1928-a day taken at random-1273 out of 1420 patients at Santpoort were doingsome kind of work ; of the remainder, 122 were tooold or ill, and only 25 were unoccupied for mentalreasons. Dr. van der Scheer, of Santpoort, maintainsthat turbulent behaviour is not a part of the psychosis,but arises secondarily from loss of educational andenvironmental influences ; he believes that noisywards will follow mechanical restraint and dark cellsinto oblivion. Padded rooms are unknown inHolland, their place being taken by continuous bathsin which the patient is fixed by a wooden or canvaslid with a padded opening for the neck. Even thisrestraint is now very little used. A method frequentlyemployed for controlling acutely excited or depressedpatients is Klasi’s continuous sleep. Somnifen isgiven orally or by intramuscular injection twice aday, and the patient is kept absolutely quiet. Manic-depressives may be kept under the drug for a fort-night ; dementia præcox patients for a few days.As the somnolence begins to pass off the patient isexercised by two nurses and started on manualoccupation, so that by the time he is fully awakeagain he finds himself engaged in some quiet employ-ment. Sometimes opium is given instead of somnifen.

There is an interesting after-care service inRotterdam. A special practitioner living in the townis selected as outdoor service doctor ; he attends thehospital weekly for a whole day, and so is wellacquainted with hospital routine and problems. Hegets to know the patients before they leave, and hisservices are offered to them for after-care and seldomrefused. He inspects the environment to which theyare returning, and thereafter visits as often as seemsdesirable. A consulting clinic has arisen out of thisservice but was not the primary element of it: thehome visitation is stressed as the most importantand illuminating part of after-care. The service isin close contact with the local welfare society. Sinceits inauguration three years ago the insanity figuresfor Rotterdam have decreased, although the popula-tion has soared, and other cities in Holland show nocorresponding decrease. Thoroughness was thequality in all this work which consistently impressedthe visitors ; therapeutic measures and laboratoryresearch alike are pursued in Holland with energyand application.The committee is doing a great service to

European psychiatry in linking up the work ofdifferent countries by these study tours, and it was ahappy corollary of the visit to publish this accountfor those who were unable to take part.

SCLEROSING INJECTIONS IN THE TREATMENTOF HERNIA.

ScLEROSiNG injections in the treatment of varicoseveins have become deservedly popular; their effec-tive superiority to excision has been proved beyonddispute. It is not surprising therefore that investi-gators have sought to adapt similar methods to thetreatment of other conditions, such as inguinalhernia. It is curious to what extent the sequenceof events corresponds. Injections for the cure ofvaricose veins were employed about the middle oflast century, but were discarded as dangerous largelybecause the fiuids used were unsuitable. Now Dr.J. S. K. Hall 1 reminds us that Velpeau, in 1835, wasthe first to think of an injection method for the cureof hernia, and actually put his plan into practice,using an iodine solution as the fluid. Several othersurgeons followed his lead and good results wererecorded. For some reason, probably because the

1 Medical Journal and Record, 1929, cxxx., 81.


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