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mere sensation of fright lest, as was said in VictorianRailways Commissioners v. Coultas (1888), a widefield should be opened to imaginary claims. Mrs.Coultas saw a train approaching at a level crossing ;being put in peril by the railway’s negligence, shethought she was going to be killed. The Privy Councilheld that damages arising from mere sudden terror,unaccompanied by any actual physical injury butoccasioning a nervous or mental shock, could not bedeemed legally to flow from the railway servant’snegligence. A different view was taken in Pugh v.London and Brighton Railway (1896) where a signal-man was incapacitated through shock due to theexcitement and alarm of successfully averting a trainsmash. He was never in personal danger himself buthe was held to have been incapacitated from employ-ment by reason of accident. In 1901 the decision inDulieu v. White awarded damages to a woman whowas sitting behind the bar in a public-house when ahorse-van, negligently driven by defendant’s servant,dashed into the premises. She was untouched, butshe sustained shock and gave birth to a child pre-maturely. She succeeded in her claim though therewas still a hint that she would have failed if she hadproved no more than a " merely transitory mentalemotion." There may be other faulty conduct onthe part of a defendant, apart from negligence.Wilkinson and Wife v. Downton (1897) was a case

of a silly practical joke. Defendant, as the juryfound, falsely and maliciously told a woman thather husband had met with a bad accident andbroken both his legs; she suffered a severe shockon hearing the news, and was held entitled tosucceed. Somewhat similar was the decision inJanvier v. Sweeney and Barker (1919). Sweeney,a private detective, instructed Barker to endeavourto induce Mlle. Janvier to show him certaindocuments. Barker tried to achieve his objectby threats and false statements. He pretended hecame from Scotland Yard. " You are the woman wewant," he said ; "you have been corresponding witha German spy." Plaintiff said she had so bad ashock that she suffered from neurasthenia and shingles.She sued for damages and succeeded, the jucigesdefinitely discountenancing the decision in VictorianRailways Commissioners v. Coultas, on which thedefendants relied.We see therefore that A may owe a duty to B

not to inflict a mental shock on him or her and, if Anevertheless inflicts the shock on B and physicaldamage ensues, B may have a legal right of actioneven though (in Lord Phillimore’s words) " the mediumthrough which the damage has been inflicted is themind." One interesting case raises wide questions.In Hambrook v. Stokes Bros. (1925) a lorry hadnegligently been left on a slope at Folkestone withthe wheels straight and the engine running. It startedoff by itself and injured a little girl. Her motherknew the girl was in the road ; the mother did notsee the accident but she heard the progress of thelorry, which eventually came to a stop close to her ;when told by a by-stander of the little girl’s injuryshe knew it was her child. The mother became

hysterical through shock and died ten days later inhospital. The judge told the jury that unless deathwas due to shock caused by fear of harm for herselfas contrasted with fear of harm for her child, damageswere not recoverable. The Court of Appeal, by amajority decision, held that this was a misdirection.The husband could recover damages if he could provethat his wife’s death resulted from shock caused bythe lorry running away, that the shock came fromsomething she either saw or realised by her unaided

senses and not from something which someone toldher, and that the shock was due to a reasonable fearof immediate personal injury either to herself or toher children. It was, we must suppose, natural thata mother should be anxious for her child ; the mother’sshock would be a reasonable consequence of the

lorry-driver’s negligence. Atkin, L. J., went further.He was prepared to allow a right of action even to apasser-by on the road " who receives injury in the sameway from apprehension of, or the actual sight of,injury to a third party." This opens a wide prospectindeed. A negligent motorist whose driving leads to agruesome accident at Charing Cross might be sued bydozens of spectators on a crowded pavement. Thisextension of the law was not necessary to the decisionin Hambrook’s case, and it must not be taken as an

established principle. ,

PREVENTION AND TREATMENT OF

WHOOPING-COUGH

IN a recent communication P. Stocks, discussingthe epidemiological features of whooping-cough,expressed the opinion that in London it must nowbe regarded, in terms of mortality, morbidity, andloss of school attendance, as the most expensiveepidemic disease of childhood. Since the diseaseis only notifiable in certain of the London boroughsits real ravages can only be surmised, but, even so,it is noteworthy that at the present time, as the

weekly returns show, considerably more than 600cases are at present under treatment in the infectioushospitals of the London County Council. Amongthe common acute specific infections the case-mortalityof whooping-cough is rivalled only by that of measles,and for the same reason, the frequency of the secondaryinfection of broncho-pneumonia. In an addressdelivered to the Royal Statistical Society on Feb. 21stMr. A. Bradford Hill, D.Sc., called attention to theheavier mortality of female children, and to the

unexplained fact that the death-rates of illegitimatechildren of 3 months and under are less than those of

legitimate children.THE CAUSAL ORGANISM

What is the primary infection ? Most workers

accept the Bordet-Gengou bacillus (Haemophiluspertussis) as causal. A. D. Gardner and P. H.Leslie 2 consider that there is " no longer any roomfor doubt" that it is the true and sole cause, and

they give several reasons for this conclusion. Othersare not so sure. A. R. Rich does not think thatthe bacillus represents the whole story, and in thishe is not alone. Rich points out that interstitial

pneumonia which is characteristic of whooping-cough occurs also in measles and influenza, diseasesin which there are strong reasons for suspecting thesetiological rôle of filtrable viruses, and further,that the mononuclear-cell infiltration of the bronchialwalls which is to be seen in sections of interstitialpneumonia also occurs in pertussis uncomplicated bypneumonia. He thinks that the true cause of

whooping-cough may be a filtrable virus, the Bordet-Gengou bacillus being a secondary invader, and

supports his view by adducing distemper in dogswhich pertussis " resembles in an extraordinarymanner." Distemper is now held to be caused bya filtrable virus, the B. bronchisepticus being merely1 THE LANCET, Jan. 28th, p. 213, and Feb. 4th, pp. 265 and 257.

2 Ibid., 1932, i., 9.3 Bull. Johns Hopkins Hosp., 1932, li., 346.

435

a concomitant invader. Rich suggests that this

organism, the Bordet-Gengou bacillus, and theinfluenza bacillus tend to localise in the cilia of thetrachea and bronchi, and provoke coughing by theirritative effect of their presence in this sensitivesite. Whether or not HaemophiZus pertussis is thecausal organism, Gardner and Leslie were able todetect it in at least three out of four cases in theearly stages of the disease by a single examination,using the cough-droplet or cough-plate methodand the Danish modification of the original Bordet-Gengou medium ; these results are comparable withthose of H. Madsen (1924) and Sauer and Hambrecht(1930) in a much longer series of cases. A. R.

Thompson,4 on the contrary, with the same methodand the same medium, freshly prepared, obtainedonly 7 positive results out of 64 cultures taken duringthe catarrhal and early spasmodic phase. A. Sundal5 5

commonly uses two plates for each child, since he hasfound that colonies may develop upon one and notupon the other.With the proviso that a negative result is not

conclusive, the cough-droplet method may be acceptedas a valuable means of diagnosis of the disease at aperiod of great infectivity, and when signs and

symptoms present nothing characteristic. It istrue that leucocytosis, with relative lymphocytosis,occurs quite early in whooping-cough, but even iffacilities are available, a high lymphocyte countin very young children may be no more than

suggestive, whereas recovery of the H. pertussisis conclusive of infection. In the spasmodic phasethe diagnosis can hardly be in doubt, but R. Neurath 6draws attention to the difficulties in infants andadults in whom the disease may remain quite atypicalbut nevertheless infective.

PROPHYLAXIS

There is difference of opinion as to the prophylacticvalue of vaccines prepared from H. pertussis.H. Madsen and his co-workers have reported a con-siderable measure of success upon a large scale, andR. Steindler mentions a number whose experiencehas been similar ; others, however, have had nosuccess at all. Gardner and Leslie point out thatunless the vaccine is prepared from organisms in thecorrect antigenic phase it is useless, and it is note-

worthy that those who have reported favourablyupon vaccine prophylaxis have either obtained theproducts of certain laboratories or have taken greatcare to see that they used freshly prepared vaccinesfrom suitable strains. Old stock vaccines are

valueless. Sundal gives an instructive account ofvaccine prophylaxis in a children’s home at Oslo.There were 32 children in the home, of whom 10had a previous history of the disease. Two childrenbegan to cough; the plates were positive. Fromthe organisms so recovered a vaccine was prepared{1000 millions per c.cm.) and injected both into thesetwo children and into the remaining 20 susceptiblesin a first dose of 0-5 c.cm. and two succeeding dosesof 1-0 c.cm. at intervals of four days. The twochildren were not isolated, but played and ate withthe others. These two developed marked coughwith vomiting shortly after the last injection. Fourothers, between one and two weeks after the last

injection, developed conjunctivitis and a cough withoutwhoop. The other 16 children remained free from

symptoms. Sundal thinks that it is not reasonable

4 Ann. Rep. M.O., London County Council, 1930, vol. iv.(Part 3), p. 129.

5 Acta Pædiat., 1932, xiv., 104.6 Wien. klin. Woch., 1933, xlvi., 113.

7 Med. Klin., 1932, xxviii., 1709.

to suppose that without the vaccine these children,with no previous history of infection, could haveremained exposed to massive infection withoutevident whooping-cough developing. L. Sauer,s usingonly vaccines prepared from recently isolated stronglyhaemolytic strains grown upon human blood and thelike, has injected, during the last four years, about300 non-immune children without any untoward

symptoms. Sauer finds that the vaccine, like the

disease, produces a high lymphocytosis. Discussingresults, he distinguishes carefully between " certain

"

and merely " probable " exposure. Only when thepatient disseminates the bacilli, and the exposedchild in the immediate environment (within a footor two) aspirates the germ, does actual exposure occur.Sauer gives details of eight injected children of fivefamilies and six non-immune controls. All six controls(and a mother) " developed unquestionable whooping-cough from two and a half months to three yearsafter their brothers and sisters had been injected."With one possible exception none of the injectedchildren developed any sign or symptom, althoughthey were daily exposed to the patients throughoutthe incubation, catarrhal, and paroxysmal stages.Amongst 127 injected children who experiencedtransient or accidental exposure none developedwhooping-cough. Further work with suitablevaccines under adequately controlled conditions is

clearly called for.THERAPEUTICS

A sure sign of the weakness of the therapeuticcase is the employment of a multiplicity of dissimilarremedies for the same disease. In the therapy ofwhooping-cough, counsel is darkened by prematureenthusiasm for this specific or that. Steindler recallsthe advice of Reitschel, that judgment of anywhooping-cough remedy should only be based uponthe results obtained in infants and children up to2 years of age observed under proper clinical condi-tions, older children and ambulant cases beingexcluded from consideration. Several recent writersstress the psychological effect of injections in olderchildren. W. Kaupe,9 like Steindler, is favourablyimpressed with the therapeutic value of vaccines,and thinks that any psychological influence is purelysecondary, since he has obtained good results ininfants. W. Bayer asserts, upon the same page,that he has seen equally good results follow injectionsof distilled water. H. Steurnthal10 has had suchmarked success with intramuscular injections of

quinine combined with a small amount of oil of

turpentine that he has not found it necessary to tryvaccines. Some years ago J. Audrain advocatedintramuscular injections of ether, and undoubtedlysome cases respond temporarily, but ether injectionsare not only painful, but are generally held to beliable to cause abscesses, although this is not the

experience of Sundal. E. Lorenz 11 tried Goldbloom’smethod of rectal injections of ether in olive oil (2 c.cm.of anaesthetic ether in 15 c.cm. of oil twice daily). Heobtained no significant results after a fortnight’streatment of a series of 21 children. Others howeverhave had partial and temporary success with thismethod, but, in order to be effective for more thana day or two, it is necessary steadily to increase thedose of ether.As Neurath remarks, the pharmacology of the treat-

ment of whooping-cough fills volumes. It is clearthat the last volume has not yet been written. The

8 Jour. Amer. Med. Assoc., Jan. 28th, 1933, p. 239.9 Med. Klin., 1932, xxviii., 1640.

10 ibid., p. 1425.11 Deutsch. med. Woch., 1932, lviii., 1443.

436

experienced practitioner realises that there is as yetno specific, and falls back, as he must, upon suchsymptomatic treatment as, in his experience, has

procured alleviation in some at least of his cases.

There are only two sheet anchors-sunshine and anabundance of fresh air-but, for only too many children,neither of these is obtainable. For others theseconditions are not even sought, because whooping-cough, like measles, is considered as a disease which

Ican be treated without medical advice, or this maybe enlisted only at a stage when it can be of little Iavail.

IRELAND

(FROM OUR OWN CORRESPONDENT).

REFORM IN NATIONAL HEALTH INSURANCE SYSTEM

THE approved societies are concentrating theirforces in opposition to the proposals for reform in theNational Health Insurance Scheme which are expectedto come before the Dail in the near future, and thedaily press has been giving expression to their views.

The change to which most grave objection is takenis the amalgamation of all the existing approvedsocieties-65 in number-into one " National HealthInsurance Unified Society." It is stated that theBill will provide for equal benefits for equal con-tributions for all insured persons between the agesof 16 and 70, who are not earning an income exceedingi:250 a year, and all such employed must be insured.Manual workers must be insured, irrespective ofincome. It is pointed out that 43 of the 65 approvedsocieties give additional benefits at present, theadditional benefits being of varied nature. It is

suggested that these additional benefits which thebetter managed societies have been able to providewill disappear in the future, and that, in fact, thestronger societies will be compelled to carry theworker on their backs. Despite the protests of theapproved societies, it is unlikely that the Governmentwill alter its intention concerning insurance. Theconcentration of the manifold, but, at present,scattered influences of the several approved societiesinto one society is not attractive to the medical

profession, whose interests up to the present havereceived* little respect from the societies.

THE DOCTOR’S DAY

11 come, tell me how you live," I cried," And what it is you do !

"

XVI.-METROPOLITAN HEALTH OFFICERTHE medical officer of health of a metropolitan

borough shares responsibility for the health of alarge and populous area’ with the chief medicalofficer of the London County Council. The latter isresponsible amongst other things for the provisionof institutional medical treatment and the medicalinspection and treatment of school-children. Myborough is a fairly typical one, but administrativearrangements differ greatly in the London boroughs.I live about a mile from my office, which opens at9 A.M. ; it is not necessary for me to arrive before9.30 A.M., by which time my correspondence has beenopened and sorted, all letters of importance beingready for me to read. Amongst those requiringimmediate attention are the " complaints," thatis, information as to insanitary conditions requiringto be investigated. Some complaints are anonymous ;these are not ignored, but entered with the others ina register, so that they may all be accounted for indue course. Notifications of infectious diseases areentered in a register and handed to the sanitaryinspectors, unless I decide to visit personally.

I ring for the typist and dictate some letters.Others will be drafted for me by my chief clerk.By this time there is ready for me a report on thedisinfections performed on the previous day. Ialso read over a summary of each health visitor’sand sanitary inspector’s previous day’s work andinterview any of these officers that wish to consultme. This will be for the purpose of seeking myadvice or to arrange for me to visit premises. Iam well isolated from telephone interruptions, buthere is a doctor put through to me. He saw a womanyesterday with a sore-throat which he diagnosed astonsillitis ; before leaving the house he decided totake a throat swab ; he informs me that the swabhas been reported positive to diphtheria but that hesaid nothing to the patient about this possibility andfeels in a difficulty. My obvious course is to visit thepatient, advise as to diagnosis, and smooth away anydifficulties. It is sometimes forgotten that to swab asore-throat is to suspect diphtheria, and that a suspectdiphtheria must be treated as such until the contraryis proved.

SOME CALLERS

It is now after 10 o’clock and there are personswaiting for interview. The first is a boarding-

house keeper. It appears that rats are reported in theneighbourhood and that an inquisitive boroughcouncil workman has been creeping along the sewer.He reports that the drain from her house is an oldbrick one, which has collapsed, thus enabling ratsto leave the sewer. She has learnt to her dismay thatshe is responsible for the repair of the drain, not onlyon her premises, but as it proceeds under the road tothe sewer. The estimated cost of the repair is jE50,but she has fallen on lean times and cannot find themoney at once. After some discussion it is agreedthat the council will do the necessary repairs andthat she will repay the cost by instalments. Thenext caller is an irate father who complains to meabout a call paid to his house by a uniformedN.S.P.C.C. inspector. He cites one of my healthvisitors as being responsible for this invasion of hisprivacy and appeals to me to protect him fromfurther molestation. The corpus delicti is produced,in the person of little Henry. He is pale and flabby,and has bandy legs. His mother, under my cross-examination, admits that the child has not been tohospital about his legs for two months. I speakforcibly to the parents and approve of the healthvisitor’s action. I think I have done Henry a goodturn.Next my old friend Councillor - comes in. He

is retired and has plenty of time to spare. He ismuch concerned about the welfare of his fellow men,and 20 minutes of my valuable time pass by pleasantly.I next find that a mother and her child with a runningnose are waiting to see me. This child was in hospitalfor three months with scarlet fever. Seven daysafter its return another child in the family sickenedwith the disease. I called to see the motheryesterday but she was out, so that she is asked tocall here by appointment. There is nothingapparently wrong with the child except the nasalcondition. I advise the mother to keep it to itselfas much as possible and to take it to the localchildren’s hospital. She is too poor to go to a privatedoctor. This child is probably a carrier of scarletfever infection and I detail a woman sanitary inspectorto keep it under observation.

OUTDOOR VISITS

It is now 11 A.M. and I have several visits to pay.My first visit is to a room in a respectable working-class street. Here I meet a woman sanitary inspectorand see a very old woman more or less confined tobed with some form of paralysis. The neighbours