1044 NEW LIGHT ON SCHIZOPHRENIA.

can only be regarded as reliable if the purchasesdo not diminish in subsequent months. Hitherto thechildren inoculated in private practice have beenthose advised to go to their family doctor by thehealth commissioners. The Commission now urgethat all doctors should familiarise themselves with thetechnique, and should proceed to immunise allchildren in their own families, all those under ten inthe families under their care, and all diphtheriacontacts. If this advice is followed, important datashould be forthcoming as to the results of preventiveinoculation in a large community. All depends onthe continuance of close cooperation between healthofficer and private practitioner. The lesson should beappreciated in other countries, especially in France,where, as our Paris correspondent noted recently, aspecial campaign has been set on foot by Mr. Loucheur,the Minister of Hygiene. In this country, in theabsence of combined effort by the various publichealth services and the medical man in close touchwith the life of the individual, attempts to controldiphtheria have been haphazard and unequal. Thedisease is preventable and best attacked when, as atpresent, it is not very prevalent. How far the planof campaign in New York would be practicable inLondon only experience could show, but as a startpractitioners might be persuaded at least to familiarisethemselves with the technique and to make a practiceof immunising contacts and young children.

THE IMMEDIATE PROBLEMS OF MENTAL

DEFECT.

WE have already commented upon the report ofthe Special Committee of the Board of Education andthe Board of Control, so far as it has been issued,noting as one of its most significant features theestimate of the number of mental defectives in Englandand Wales, made by Dr. E. 0. Lewis and his assistantsin their survey of six selected areas. Part III. of thereport, which has been so far withheld, may appearat any moment ; its imminence has been noted inthe daily press and, inasmuch as it deals with thedefective adult, much writing on the question of com-pulsory sterilisation has resulted. Those who expectto get endorsement in this part of the report of someof the suggestions which have appeared may be dis-appointed to find it contains nothing startling on thematter of sterilisation, dealing rather with questionsof more immediate practical application.

There are grounds for deliberation which are not sufficiently appreciated. A large number of defectivesowe their condition to disease or injury betweenconception and the age of 3 or 4, and their defectsare usually held to be non-heritable. Further, theevidence furnished by Dr. Lewis and his collaborators,as well as that in other reports, shows these secondarycases to be scattered throughout the racial elementsand social strata of this country. Mongols, whoseplight seems to be due to germinal error, are usuallysterile, but a smaller group of defects is due togerminal variation and would be heritable. Thesecases develop more in some family strains than inothers, and one responsible observer has noted thatin the family groups where these defects occur moresuccessful individuals-winners of scholarships andso on-are also found. But the bulk of the cases whichare causing real anxiety are genetically normal; theyexpress the fact that as the conditions of life becomemore complex, their inferior mental attainmentsconduce to inefficiency, while it is these failures whotend to mate with similar failures, owing to theabsence of mutual criticism. Also these are thepersons who have no initiative, and who tend accord-ingly to be left in the isolated areas of the countryin close association with each other, the more

adventurous members of the community havinggone where wider opportunities offer. This is apicture of a lower cultural level rather than of apathological condition, and only when the capacities

of such individuals are markedly inferior and theirwill dangerously weaker does the public ask forprotection from them. A few of them may fall solow as to be certifiable on the present standards,but to check their multiplication by sterilisationwould mean operations more widespread than seemsto be generally recognised. It is hard enough to getsegregation of defectives under the wise measuresalready provided, and it would be harder still if itwere believed that sterilisation would follow-theprocess would not be regarded as preventive butrather as punitive.

I In short, there is need for further inquiry before thedifficult legislation and harsh administration impliedby compulsory sterilisation are put in hand. Theprocedure has many strong claims to support it, butwe feel that further investigation is needed before itsadoption as a practical policy can be considered.The directions in which inquiry could be made areknown, controls could be obtained, and in this way-with no great lapse of time-data would be forth-coming which would make the right policy far morecertain. ’

NEW LIGHT ON SCHIZOPHRENIA.

THE monumental work of Sir Frederick Mott onthe pathology of dementia præcox (schizophrenia)furnished evidence of a generalised anatomicaldegenerative change not only throughout the centralnervous system but in the ductless glands, moreespecially the gonads, suprarenals, and pituitary. Butin spite of these well-marked anatomical changes,repeated observations revealed very little obviousdifference between the resting functions of theschizophrenic and those of the normal subject. Thegroup of workers who have continued the investigationon the pathology of schizophrenia in the CentralLaboratory of the London County Mental Hospitalshave sought for evidence of abnormalities of thephysiological response to conditions exerting somestress on the organism rather than for some staticdifference from the normal state. Unce this methodof investigation was adopted it was found that theschizophrenic physiology showed signs of abnormalitiesof response in every direction. Isabella Robertsonshowed that the vasomotor responses to food, drug,and postural stimuli were inverted ; S. A. Mann andhis co-workers detected abnormalities of the carbo-hydrate metabolism and a failure to respond to insulinin the presence of ingested glucose ; the processes ofoxidation as tested by administration of thiosulphatesand other chemical methods were found to bederanged. Most of the phenomena observed wereexplicable on the theory of a disturbance of the acid-base equilibrium in the psychotic organism, andfollowing up this line of thought it was found thatthere was evidence in the urinary post-prandial andmatutinal reactions of a state of the organism resem-bling very strongly that which obtains in the normalindividual during sleep. Since renal tests cast nosuspicion on the regulating mechanism of the kidneys,it became probable that the primary disturbance ofthe acid-base equilibrium was to be sought in dys-function of the respiratory centre, and it was, in fact,found that the respiratory centre of the schizophrenicresembled that of the normal sleeper in showing adepression of its response to 002, In a paper,published on p. 1032 of our present issue, Dr. Marshpresents further evidence of this depression of therespiratory centre in schizophrenia. Investigating alarge number of cases he finds that at least 88 percent. of them show such a depression and (which isequally important), that it seems to be a generalsymptom of the disease and not merely an expressionof the stuporose state characteristic of so manypatients. The facts now placed before us markanother step in the unfolding of a definite pathologyin one great division of mental disease, though, as

Dr. F. L. Golla pointed out to the Section of Psychiatry

1045THE HEALTH OF THE COUNTRY-TOWN.

of the Royal Society of Medicine on Tuesday, it isas yet too early to draw any conclusions about thenexus between these profound biochemical changesand the disorder of conduct. Information is urgentlyneeded concerning the state of the central nervoussystem with which these disturbances must be insome way connected ; still less have we data on whichto came to a decision on the possibility of a psycho-genic origin for this class of psychosis. Nevertheless,the remissions of the psychosis occasionally associatedwith acute bodily disorders, and those of moretemporary nature which A. S. Loevenhart has beenable to achieve either by stimulating pulmonaryventilation by injection of sodium cyanide or withinhalations of Co., give some ground for hoping thatthe symptoms of dementia præcox may ultimatelyprove in some degree amenable to a therapy based onbiochemical considerations.

CHRONIC PULMONARY SUPPURATION.

THORACIC surgery has achieved notable successesin the treatment of localised pulmonary abscesses.When an abscess, situated in the middle or outer zoneof the lung, has become isolated by the formationof encircling inflammatory tissue, pneumotomy anddrainage may be expected to lead to a cure. Suppura-tion limited to the lung parenchyma is howeverexceptional, for the continuity of lung tissue, bronchi,and pleura commonly leads to a wider spread ofdisease. Once this spread has begun there are nofixed limits to the infected area and a condition aptlydescribed as " rabbit-burrow abscess " results. Thesufferings of the patient with this condition are almostunsupportable: constant cough, foetid breath, theexpectoration of large amounts of stinking sputum,attacks of haemoptysis, and increasing malaise makehim willing to submit to any treatment that promiseseven a slender hope of cure. Pulmonary abscess isusually associated with an infection by spirochætes,and the expectorated pus may contain enormousnumbers of these organisms, almost to the exclusionof other types. A case bearing on this fact is reportedon p. 1037. The discovery of the spirochæte as

the probable infecting agent led to the use of arsenicalpreparations in the treatment of these cases, but theresults have been disappointing, nor has serum

therapy been more effective. Where the physicianhas failed, the surgeon has met with little greatersuccess, for the difficulty he has to face is akin tothat of draining a marsh through a single dyke.Pneumotomy and drainage are insufficient, andlobectomy which involves an operative mortality ofat least 40 per cent. is almost a method of despair,although Evarts-Graham has somewhat lessened therisk by the use of the cautery. The effectiveness ofartificial pneumothorax depends upon securing acomplete collapse of the lung, and this is usuallyimpossible to obtain even when the pleura is free fromadhesions. Should only partial collapse result, nobenefit will accrue and empyema may follow. Phreni-cotomy increases the stagnation in the lung withoutsecuring adequate compression. Leon-Kindberg andhis colleagues think thoracoplasty of value insuppuration of the upper lobe ; lipiodol has, however,shown that the basal bronchi do not ungdergoeffective collapse after this operation. Bronchoscopyand lavage, as practised by Chevalier Jackson, mayrender life supportable by periodic cleansing of theaffected lung. We must, however, admit that we areat present powerless to heal, and can do but littleto lessen the sufferings of the victims of pulmonarysuppuration. It should therefore not be forgottenthat chronic pulmonary abscess is sometimes theresult of previous neglect ; the slightest carelessnessin operations on the upper airways may have tragicconsequences, nor should the risk of lung infectionfrom neglected sepsis in the nasopharynx be forgotten.

1 Léon-Kindberg, M., Delbreil, J., and Lafitte, A. : Archiv.Méd.-Chir. de l’Appareil Resp., 1928, ii., 300.

THE HEALTH OF THE LITTLE

COUNTRY-TOWN.

THE last line of an old jingle which runs : " Thedevil made the little country-town," is usuallyinterpreted as a reflection on the ethical, rather thanthe sanitary, standards of small communities. Arecent discussion in Tidsskrift for den Norslce Laege-forening has centred round the country-town, not asa moral sink of iniquity, but as an area in which theclose contact of a few hundred or thousand personsis not compensated for, from a sanitary standpoint,by the public health machinery with which largetowns are blessed. This discussion arose out of aseries of papers by Dr. E. Andersen, in which he showedhow much greater was the improvement of late in thepublic health of towns than that of country districts.His comparison was intended to promote reforms incountry districts, and one of his recommendations wasthe employment of public health nurses who would,by gentle persuasion and infiltration in the home, seethat the orders or recommendations of the localhealth authorities were translated into action. Hisconclusions as to the relative iniquity of the countryin health matters were challenged by a correspondent,Dr. D. Tornoe, who argued that a factor, whichconferred an undeservedly sinister reputation on

the country, was the inclusion therein of the littlecountry-town. He implied that if only strictly ruraldistricts could be judged on their own merits, theywould not be found to be so unhealthy in comparisonwith the large towns. In answer to this defence ofthe really pastoral country district, Dr. Andersenproduced some interesting statistics in the Tidsskriftfor April 15th. He showed that in the eight countieswith the lowest death-rate (an average of 9’9 per 1000)25-3 per cent. of the population lived in clusters ofhouses in the country-the little country-town. Onthe other hand, in the eight counties with the highestdeath-rate (an average of 11-9 per 1000) only 16-8per cent. of the population lived in clusters. Thesefigures do not of course by themselves acquit thelittle country-town of the accusation of possessing allthe vices of a large town and none of the virtues ofthe country. But they suggest that the little country-town may not after all deserve its lurid reputation,

HYPERNEPHROMATA.

IN all clinical medicine there are no conditions moreinteresting than those in which the whole appearanceand character of the patient are changed, and of thesesyndromes that associated with an epithelioma of thesuprarenal cortex is perhaps the most striking. It ismost common in girls, and the bronzing, hirsuties, andalteration of the figure and mentality of the patienttowards the masculine type go to form a picturethat, once seen, can never be forgotten. But theenthusiasm of the medical man who encounters sucha case in his practice is likely to wane very rapidlywhen he comes to consider treatment. Of the patientsunder 20 from whom such tumours have beenremoved only a very small number have survived, andrecently yet another case of sudden and unexplaineddeath within two days of what seemed to be a per-fectly simple and successful operation has been recordedin France.! In this case the tumour was compara-tively small so that it could not be palpated, althoughits presence was suggested by the clinical condition.It was finally located by radiography, after thepreliminary induction of a pneumo-peritoneum-amethod of diagnosis not very often adopted in thiscountry. No satisfactory explanation of the highmortality in these cases has been put forward. In theone just quoted no autopsy was allowed and theauthors of the report fall back on the supposition thatdeath was due to sudden heart failure, though theygive no reason why this should have happened. In

1 Langéron, L., Decherf, E., et Danes: Bull. et Mém. de laSoc. Méd. des Hôp. de Paris, April 1st, p. 436.