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mentally ill ; and an engraving from the IllustratedTirnes of 1858 .shows a ward in Great Ormond Streetwhich has all the loving comfort of a Victorian Nursery.Moreover, only a few children are shown in bed ; mostof them are up and playing on the toy-strewn flooror taking tea round a large family table.The segregation of the chronic sick in separate hospitals,

which has proved such a bad custom, began about 1700,when the pressure on beds in Barts and St. Thomas’s— .the only two hospitals caring for the sick of London-made it necessary to prefer the curable to the incurable,and the rule was made that : " no incurables are to bereceived." The heydey of voluntary foundations wasin the 18th century, when most of the London teachinghospitals and many great hospitals in the provincessprang up. By 1825 no less than 124 hospitals anddispensaries had been established, 10 being in London,the rest in the provinces and Scotland. How fortunatewere our sick that their hour came during the best periodof classical architecture ; and how luckless the mentallyill, who came in for the Gothic revival! The illustrations,at first sight monotonous, prove on closer study to beone of the charms of this book : one beautiful buildingafter another testifies to the taste as well as the bene-volent intentions of the founders of our voluntaryhospitals. In a last chapter Mr. Ives picks out thebest in our tradition, and shows how it is or could be

safeguarded in the new era. We have built, as he sayson an earlier page " a form of organisation which offeredfreedom to the medical men who worked,in the hospitalsand enabled them to bring pressure at first hand uponthose responsible for policy and finance. As in the caseof so many British institutions, the secret was foundalmost by accident. Surprisingly, the system worked ..."

INCIDENCE OF CHRONIC DISEASE

THE dominant factor in forecasts of the country’smedical needs, whether in industry, in local healthservices, or in the hospital regions, is the rising proportionof older folk. This ageing of the population inevitablybrings with it an increase in chronic disabling disease ;yet our ignorance of even the present extent of this isabysmal. We know neither its prevalence (i.e., thenumber of people within each age-group and sex-groupthus affected at any one time), nor its incidence (i.e.,the number of fresh cases arising yearly among peopleof these age and sex categories). The pre-war Scottishreports on sickness among the employed, useful thoughthus limited in scope, have not been revived. There isno sizeable counterpart in Britain to the National Surveymade in the U.S.A. in 1935-36, which showed the

prevalence-rates at various ages in a large sample ofthe American population. This survey did not, however,provide any estimate of the incidence of chronic disease.A useful approach to this aspect of the problem has

been made by Lawrence,! of the U.S. Public HealthService. As chief of familial studies, he has resurveyed1822 white families included in the original Hagerstownstudy, made between 1921 and 1924. The members ofthese families surviving in 1943 were interrogatedabout the presence or absence of such chronic disablingdiseases as mental disorders, sciatica, neuritis, rheuma-tism, chronic respiratory disease, peptic ulcers, hernia,cardiovascular renal disorders, and the results of seriousinjury. The causes of death were recorded for thosewho had not survived the twenty-year period. Fromthese data Lawrence has built up a table giving thetwenty-year rates of incidence of chronic disease, and fromthis, by a mathematical " smoothing

" of the resultantcurve, he has estimated the five-year incidence-rates.These estimates show that up to 25 years of age the rateof occurrence of new cases during a five-year periodincreases slowly to 35 persons per 1000. This implies

1. Lawrence, P. S. Publ. Hlth Rep., Wash. 1948, 63, 69.

that of 1000 men found fit at the age of 25 years, 35 will

probably develop a chronic disability before theirthirtieth birthday. From then on, the rate graduallyrises to about 100 cases per 1000 at age 45. After thisthe five-year incidence-rates rise steeply to nearly 250per 1000 at age 60, 400 at 70, 575 at 80, and 900 at 90years of age. In other words, the provisions for themedical care of people over 65 must assume that at

least half will have some chronic disease.These are, of course, approximations based on a I

relatively small sample of 5027 persons, but their validityis supported by the fact that the chronic morbidityprevalence-rates and the mortality experience providedby the same data agree remarkably well with expectationsbased on a wider national experience. Unfortunately,but inevitably, the original assessments of disabilitydepend on the subject’s testimony and not on physicalexamination. Again, no breakdown by type of diseaseis practicable with such small numbers; yet what theconsultant psychiatrist to a regional hospital board,for example, wants to know is not so much the totalvolume of chronic disability as the proportion of thattotal due to mental disease. For those reasons, amongothers, no direct translation of these results into an

English context is feasible, and we must rely on theconduct over here of similar larger-scale studies to

provide the data without which intelligent planning inthe new service will be impossible.

MEDICAL TREATMENT OF HYPERTHYROIDISMIN the Addison lecture for 1948, delivered on July 9

at Guy’s Hospital, Prof. E. B. Astwood, of Boston,Mass., outlined his original work on goitre which cul-minated in 1943 in the introduction of the antithyroidsubstance, thiouracil, and its derivates. Since then hehas treated 400 unselected cases of hyperthyroidism, ofwhich over 300 received propyl thiouracil. He pointedout that the aims of therapy must always be twofold :to restore normal metabolism promptly, and to secure apermanent remission of symptoms. The first aim canbe achieved in the great majority of cases where’iodinehas not previously been given. Jt is important to spaceout the daily dose of thiouracil throughout the 24 hours,and Astwood stresses the univisdom of alarming thepatient with information about the potential dangers

"

of the drug she is taking. It is sufficient, he believes,to ask the patient to report back only. if she feels ill,and no restriction need be placed on her general activity.As a rule Astwood does not see his patients more oftenthan once a month after the first three weeks of treat-ment. To secure a sustained remission of symptoms,he advocates over-treatment of the patient just to thepoint of subnormal thyroid function. He prefers to keephis patients very slightly pasty and sluggish for as longas six months, over which period the initial dose ismaintained. He does not agree with the general viewthat relapses are commoner in men than in- women.The over-all remission-rate in this series is as high as85%. He finds that menopausal cases respond particu-larly well, and that the foetal thyroid is not endangeredby treatment during pregnancy provided that fullmyxoedema is avoided. Among his most difficult caseshave been children, some of whom had already provedresistant to surgery ; he suspects that the same patientsmay be resistant both to surgery and to the antithyroidsubstances.The surgical members of his large audience were

startled when Astwood quoted the surgical follow-upfigures of Goldman, who noted a complication of onekind or another in 49.9% of his carefully observed series,and obtained lasting relief in only 41-8% of his cases.He quoted another carefully studied series by VanderLaan and Swenson, who claimed wholly satisfactory1. Vander Laan, W. P., Swenson, O. New Engl. J. Med. 1947,

236, 236.

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results from surgery in not more than two-thirds oftheir cases. An equivalent British series is not easy tofind ; but even if the mortality-rate for surgical treat-ment is taken to be at best 1%, it compares unfavourablywith the mortality-rate with thiouracil, which has neverexceeded 0-5%. The deaths have all been from agranulo-cytosis, which occurred chiefly in the early days of thedrug, when higher doses were given. Astwood concludedwith some remarks on radioactive iodine, of which onlya single dose is necessary. In addition to controllingtoxicity, radioactive iodine may cause a reduction insimple diffuse goitre. Serious obstacles, however, arethe necessity for precision instruments to calculate thecorrect dosage, which varies from case to case, and theliability of radioactive iodine to produce myxoedemawithout fully controlling the thyrotoxicosis.As Sir Charles Harington remarked in thanking the

lecturer, a medical world dazzled by the advent of

sulphonamides, penicillin, and streptomycin has notaccorded full recognition to the brilliance of the workwhich goes far, and promises to go still further, towardscomplete success in the therapy of hyperthyroidism.

GLOUCESTERSHIRE MATERNITY SERVICE

THE Ayrshire maternity service, described on anotherpage, has its counterparts, here and there, in other partsof the country. A good one of the kind has been set upin Gloucestershire by Dr. Kenneth Cowan, the countymedical officer of health.’- Centred at the SunnysideMaternity Hospital, Cheltenham, the emergency servicedeals with emergency cases within the borough and overthe northern part of Gloucestershire, and links up withothers operating, from Bristol and from the RadcliffeInfirmary, over the south and south-eastern areas ofthe county. When a call is received one of the residentdoctors and a midwifery sister go by car, taking a

blood-transfusion apparatus, to the patient’s home. If

necessary an ambulance goes as well, and an obstetricconsultant is notified. Trained midwives are scarce,and Dr. Cowan is arranging a part-time scheme in thehope that trained women will help with day work ornight duty. Part-time schemes have a way of succeedingin Gloucestershire, and it will be interesting to see howthis one goes on.

FOOD FOR THE ATHLETE

THE athlete has sometimes been roughly treated

by physicians and physiologists. According to Pliny,he sometimes had his spleen removed to make himrun faster ; and the athletce were given much meat andlittle water-a regimen observed down to the presentcentury. Writing at the end of the 18th century,Sir John Sinclair recorded that the common practice thenwas for the athlete to take an emetic, which was followedby purgatives, and then to eat meat and drink a smallquantity of fluid. A century ago the Oxford system oftraining for rowing included a breakfast of meat, drytoast, and a very small amount of tea, and a lunch andsupper of meat, bread, and a pint of beer ; except forthe watercress which was occasionally included, this wasa scorbutic and dehydrating diet. Today athletes stillaim at a dietary rich in animal protein ; but restrictionof fluid is now recognised as harmful.How far traditional beliefs can be reconciled with

proven facts was discussed by the Nutrition Society ata meeting in London last Saturday. All athletic per-formances demand coordinated and controlled expendi-ture of energy. Alterations in a normal diet cannot beexpected to affect this muscular and nervous coördina-tion ; but changes in diet may affect the amount of

energy, and the rate at which this can be made available,during performance. At the meeting Mr. P. Eggleton,D.SC., emphasised the enormous variation in energy

1. Cheltenham Chronicle, May 8.

expenditure by athletes. Athletic performances can ,

be conveniently divided into four classes : (1) singleefforts, in field events such as the high jump and throwingthe javelin ; (2) sprints and hurdle races up to and

including the furlong ; (3) middle-distance runs from thequarter-mile to the twelve miles ; and (4) those takingmore than one hour, of which the marathon is the best-known example. As Mrs. D. M. Needham and Dr.Eggleton made clear, the muscles obtain energy fromthree main sources : (1) hydrolysis of "

energy-rich "

organic phosphates, (2) conversion of glycogen to lacticacid by hydrolysis, and (3) oxidation of glycogen viapyruvic acid to carbon dioxide and water, throughthe agency of atmospheric oxygen brought to the muscleby the circulatory and respiratory systems. Broadlyspeaking, each of the first 3 classes of performancedepends, respectively, on each of these three sources ofmuscular energy. The 4th class uses energy suppliedby oxidation in the muscles ; but here the rate of energysupply is limited not by oxygen transport but by sub-strates for oxidation by the working muscles. Thereis some evidence that stores of energy may be affectedby variations in diet ; but there is less evidence thatrates of utilisation can be similarly affected. A highcarbohydrate diet favours energetic efficiency andendurance, and certainly leads to a maximal liver-

glycogen level, which may be important for class-4performers. That it leads to an enhanced muscle-

glycogen level is less certain. A high carbohydratediet is perhaps also important for class-3 performances(those limited by oxygen supplies). The calories perlitre of oxygen used at a respiratory quotient of 0-7are 4-69, and at a respiratory quotient of 1.0 are 5.05-a difference of about 7-5%. The classical investiga-tions of Krogh and Lindhard, and reports by laterworkers, on efficiency at various respiratory quotients,show that at 1-0 work is about 8% more efficient thanat 0-7. During oxygen-limited work, therefore, theeffective work yield per litre of oxygen used in oxidisingcarbohydrate is about 15% greater than in oxidising fat;the nutritionist must thus advise the class-3 performerto take a diet that will bring his carbohydrate storesto the maximum.

‘

Recent work in Boston has confirmed Chittenden sbelief that protein needs are not increased by muscularactivity. Possibly, the traditional insistence on meatfor the athlete is related to the " animal factor " and

polypeptides rather than to amino-acids or vitamins.The implication of some vitamins in the enzyme systemswhich partly govern rates of energy supply and utilisa-tion in muscle has stimulated research into the effectof muscular work on the need for vitamins. The main

investigations have been made in the U.S.A., particularlyby Keys in Minnesota and Johnson in Boston. Thereis no evidence that the need for vitamins A, D, and Kis increased by muscular work, and the same is probablytrue of vitamin C. At the meeting Mr. Geoffrey Bourne,D.sc., concluded that there is no convincing evidencethat the addition of any or all of -the vitamins to anormal diet leads to improved muscular performance.He denied that the so-called "

superphysiological "

or

"’ pharmacodynamic" usage of vitamins is desirablefor athletes.

Discussing factors other than the strictly nutritionalwhich affect the suitability of a diet, Sir AdolpheAbrahams pointed out that even in full training theathlete does not do verv much work. The boat-racefrom Putney to Mortlake demands only 400 calories

per man ; and the 7300-ca,lorie diet reported to have beenthe average daily consumption by athletes at the 1936Olympic Games in Berlin he regards as fantastic. Tem-

perament is a dominant factor in deciding nutritionalrequirements ; in general the nervous and excitablesprinter consumes more food-though he does less