928 THE CHARACTERISTICS OF HYPOCHONDRIA.

disciplinary machinery of the Acts is unfortunately ’,foreshadowed in the proposals, but as Dr. DAIN ipointed out, this machinery is the price paid by the profession in return for freedom to go on and offthe panel at will. Some of the alternatives advocated,such as the appointment of special certifying doctors,or the direct employment of practitioners by approvedsocieties or by the Ministry, would be even moreobjectionable. The present system is so nearly idealin so many ways that it is well worth preserving, andin considering the diifering views and suggestions ofthose who would like to change it, we feel that panelpractitioners should congratulate themselves on beingrepresented by such men as Dr. DAIN and his col-

leagues. If the service is to develop usefully it can only be by the labours of those who combine clearsight with a strong sense of the responsibilities of theprofession.

THE CHARACTERISTICS OF HYPOCHONDRIA.ONE use of the classification of diseases is to put

our own conceptions into ordered form and to compelattention to the significance of words that, withoutan occasional survey of our ideas, may come to possessvery different meanings for different people. Hypo-chondria belongs to the name-group that includesmelancholia and hysteria and it has survived in ourterminology perhaps because, by the divorce betweenetymological meaning and clinical application, it haslent itself to the expression of views that, by thenature of the subject. could not easily be expressedin a word of definite diagnostic or symptomaticsignificance. This has. however, resulted in such aloose use of the word and its derivatives that clarifica-tion has become necessary. Hypochondria has beenconfused with hysteria and neurasthenia : a patientwho is " sorry for himself

"

is called hypochondriacal,whilst at the other extreme we find that psychiatristsrecognise a hypochondriacal melancholia or even

paranoia. Thanks to modern psychopathology, ourconception of hysteria is becoming more definite thanit was, and from neurasthenia have been separatedthe anxiety and obsessional states, which are capableof clinical differentiation and differ from each otherin their pathology and readiness of cure, a small groupof cases of unified type being all that is left to whichthe term neurasthenia may be usefully applied. Thetime has obviously come for a consideration of theposition of hypochondria, and Dr. R. D. GILLESPIE

opened a discussion on that subject on Oct. 23rd atthe Royal Society of Medicine, as reported in ourlast issue. He took up the position, not unknown ingeneral medicine, that although in mental disordersthere are no diseases, only diseased people. yet it isconvenient and useful to put cases into groups sothat we can easily sum up our ideas regarding suchmatters as aetiology, treatment, and prognosis. Recentwork as Pinsent-Darwin research student at Cam-bridge University leads him to believe that thereis a type of case, admittedly rare, in which existsa symptom-complex with well-defined characters andthat this type of case can be classified as hypochondria.The patient shows a persistent preoccupation coii-

cerning bodily health in excess of what would bejustified by any physical disturbance that happens tobe present, with an emotional attitude best describedas interest with conviction, anxiety (in the sense ofa fearful apprehension of disease) being absent. Theabsence of anxiety is, it may be deduced, an importantdiagnostic criterion and should exclude those casesin which a continued emotional state producesvisceral disturbances upon which the attention of the

patient and others may be wrongly fixed; cardiac-and digestive troubles of this nature are to be recog-nised by the concomitant symptoms of pathological’anxiety, which exclude them from Dr. GILLESPIE’S

category. He excluded visceroptosis with a mentalfixation upon abdominal symptoms, and it may benoted that some psychopathologists believe that

visceroptosis itself may be the result of a continuedasthenic emotional state. Hypochondria lie placesupon the intellectual rather than the emotional level,the only emotion being that attached to certaintyof belief. It differs essentially from hysteria in thatit serves no secondary purpose; the hypochondriacdoes not use his disease to influence his environment,and except for his insistence upon treatment and uponoperations it interferes little with happiness. Onespeaker, indeed, frankly advised letting the patientalone in his happy preoccupations. Dr. GriLLEgpiE

agreed with FREUD’s observation that the hypo-chondriac shows the character traits of orderliness..parsimony, and obstinacy, and noted that theabsence of psycho-analytical views about aetiologywas due to the inaccessibility of the patient to.

analytical procedure. This inaccessibility, which is.related to an insusceptibility to the influence ofreassurance, marks off the condition from thepsychoneuroses, which are called transference neurosesby FREUD because of the ease in setting up thatrelationship with physician or analyst which permitsof suggestive influence or analytical therapy. Thereseems to be a deep alteration of personality which.implies a relationship with the major psychoses, all

implication strengthened by the occurrence of hypo-chondria as an early symptom in dementia præcox,although it is characteristic of typical hypochondriathat it is not accompanied by intellectual or emotionaldeterioration. The characteristics of this form ofmental disorder seem to preclude satisfactory treat-ment when once gross organic disease has been provedabsent ; the best we can do for the patient is to save-him from quacks and protect him from his owninsistence upon operations ; but in spite of—indeed,because of-this unsatisfactory conclusion, it is the-more necessary that recognition of the disordershould be made certain and that our conception of itshould be made clear. The paper and subsequentdiscussion have greatly helped in that direction.

PUBLIC HEALTH AND LOCAL GOVERNMENT.THE Second Report of the Royal Commission on.

Local Government 1 covers, amongst other matters,two principles discussed in our columns last week inconnexion with Sir GEORGE NEWMAN’S annual reviewof the state of public health—namely, the organisationof local government in larger units, and the concentra-tion of all health services in one administrative unitin each area. Some of the figures submitted to the-Commission by the Ministry of Health were striking.Last year there were 66 boroughs, 302 urban districts,and 126 rural districts with a population of 5000 orless ; in the large majority of these a penny rate

produces less than £100. It is no reflection upon thezeal and capacity of the members and officials of thesebodies to say that their standards of public healthservice must suffer if their financial resources are solimited. Nobody desires to strike a blow at an

institution so national and characteristic as localself-government in England, nor to sap the confidenceof the ratepayers in their elected representatives y

1 Cmd. 3213. H.M. Stationery Office. 1s. 6d.

929PUBLIC HEALTH AND LOCAL GOVERNMENT.

but a too parochial organisation is umtuiLeM to modernconditions. In the provision of isolation hospitals,for example, there is undoubtedly a shortage ofaccommodation which may not unfairly be called apublic danger ; many county districts are admittedlyquite unsuited citlLcr in respect of population or

finance to provide and maintain their own hospital ;much has been done by joint action, but the progressin this direction is merely a proof that the local

government unit for this purpose is too small.The present system of allocating health functions

between the various local authorities can in certaininstances be criticised as arbitrary, illogical, anduneconomic, though any plan for redistributing thosefunctions must be careful not to disparage the workand irritate the temper of the members of localbodies who have given their services with so muchpublic spirit in the past. The Notification of BirthsActs may be selected as one such instance. Thesestatutes do not merely exist for the compilation ofstatistics ; they should ensure that the occurrence ofa birth attracts the attention of the local authorityresponsible for maternity and child welfare arrange-ments. Yet there are areas where the working ofthe Notification of Births Acts is in the hands oflocal bodies which are not the bodies responsible formaternity and child welfare. The urban districtcouncil may be the authority for school medicalservice aud maternity and child welfare work, whilethe county council is the

" local supervising authority ’’under the Midwives Acts. Up to the birth of thechild, therefore, the urban district council is entrustedwith the welfare of the mother and the unborn child.At birth the midwife takes charge and the responsi-bility for supervision passes to tlie county council fora brief period. Eventually the urban district councilresumes control in its capacity of school medical

authority, but meanwhile there has been a break inthe continuity of supervision. County councils, andnot district councils, are, in the great majority of

county districts, the local authority for the purposesof the Midwives Acts and for maternity and childwelfare. Yet the Public Health (Ophthalmia Neona-torum) Regulations direct the attendant practitionerto notify first the medical officer of health for the

county district wherein the case has occurred ; the

county medical officer is merely entitled to a copy ofthe notice within the next 24 hours.The reshuffling of functions is naturally no easy

matter. It would, for example, be dangerous to

tamper with existing arrangements for school medicalservices because it would mean reopening questionsof responsibility for elementary education which werenone too easily settled in 1902. The Royal Commis-sion’s recommendations are sensible and discreet. It

proposes that the 1902 arrangement be left undis-turbed ; that school medical authorities not now

responsible for maternity and child welfare workshould be empowered to represent to the Minister ofHealth that they should undertake that responsibility ;and that county councils should be empowered torepresent to the Minister that maternity and childwelfare authorities which are not local educationauthorities should hand over their maternity andchild welfare work to the local education authority.This transfer, it is recommended, should be madepossible by an order of the Minister. As regards theNotification of Births Acts it is recommended that theauthority responsible for working those Acts shouldbe obliged to send forthwith a duplicate notificationto the local maternity and child welfare authority.Here the Minister had suggested that the same

authority should exercise both functions, but the

Royal Commission hesitates to go quite so far. Its,

proposals as to the Midwives Acts are as follows :the maternity and child welfare authorities, if theyemploy a whole-time medical oiliccr, should be

empowered to represent to the Minister that theyshould he constituted " local supervising authorities

"

under those Acts ; before he makes an order to thateffect, the Minister, it is suggested, should have

regard to the size, equipment, and resources (includingthe provision for training midwives) of the applicantunit ; county councils, it is further proposed, shouldbe empowered to represent to the Minister at anytime that on administrative grounds the duties of alocal supervising authority under the Midwives Actsshould be retransferred to themselves. As to theascertainment and treatment of ophthalmia neona-torum it is recommended that the responsibility beassigned to a single authority in each area-namely,the authority for maternity and child welfare ; andit is proposed that notifications should go in the firstinstance to the local authority which gives the treat-ment, whether or not it is also the " local supervisingauthority." The report shows an appreciation.throughout of the need of the power to stimulate abackward authority and to deal with default. Thecounty council, it is suggested, should have the dutyof seeing that adequate provision exists for isolationhospitals in the county ; it should draw up a schemein conference with all local authorities concerned, and,if it is satisfied that provision in any area is

inadequate or ill-arranged, it is to frame proposals forreorganisation or rearrangement subject to a right ofappeal by a local authority to the Minister. Small-poxhospitals are apparently regarded as capable ofdifferentiation from other infectious diseases hospitals.The Commission recommends that the task of

providing and maintaining them be given to the

county councils, but that existing arrangements,where satisfactory, should not be disturbed.From these recommendations it will be seen that

the Royal Commission generally favours elasticityrather than rigidity. The countryside will have somesay in the rearrangement of its -local government ;it is not to be the victim of a Parliamentary Procrustes.Other matters worth study will be found in theSecond Report-proposals, for instance, for large-scalewater-supply and sewerage where there is a commoninterest in such services. One final point may be-mentioned in conclusion, a point already raised inSir GEORGE NEWMAN’s recent summary. The RoyalCommission definitely approves, wherever possible,the appointment of whole-time medical officers ofhealth, and the progressive acceleration of such

appointments whenever individual vacancies occur.

They recommend that every county council, in

consultation with the county district councils, shouldframe a scheme of whole-time appointments for the-county, statutory provision being made for this

purpose. As vacancies occur in part-time posts incounty districts, the district council should appoint amedical officer either solely or jointly with the countycouncil or other local authorities on terms which

preclude the medical officer from engaging in privatepractice. The Royal Commission adds that in specialcircumstances the Minister of Health should be

empowered to waive this requirement on a representa-tion from the county council or other local bodiesinterested. But the report stipulates that such anexception should only be made if the Minister thinksinsistence on a whole-time appointment is " forthe time being" unreasonable. We are evidentlyapproaching the moment when the requirement will beuniversal.

930 TUBERCULIN TESTING OF CATTLE.—THE DEATH CERTIFICATE.

Annotations.11 Ne quid nimis."

TUBERCULIN TESTING OF CATTLE.

WITH the assistance of the Medical Research Councilas a coordinating centre the tuberculin test is attaininggreat accuracy and precision in the diagnosis of bovinetuberculosis. Two reports have been issued by theTuberculin Committee of the Council, which has nowbeen at work for eight years. In the former of these, 1dated 1925, the Committee found the subcutaneoustest to be satisfactory enough under laboratory con-ditions, but subject on the farm to many fallaciesand defects of interpretation. They were concernedtherefore to introduce a modification of the intra-dermal test which would be suitable for ordinaryfield work. This has now been done and the doubleintradermal test, as it is called, is the subject of thereport 2 before us, the technique being described indetail in an appendix. The report is based upon theexperience of 77 veterinary surgeons who replied toa questionaire, drawn up by Prof. Buxton andDr. MacNalty, which comprised 11 questions designedto elicit not only the surgeon’s experience of the testbut also his views on the problems and difficultiesarising in the conduct of the test. The replies admitof compact summary, for it appears that the newmethod is being increasingly used and approved byveterinary surgeons throughout the country for thetesting of graded herds ; its trustworthiness has beenamply confirmed by the results of post-mortemexamination. Put in a few words, the double intra-dermal test is simple, clean, and easily performedunder farm conditions, its technique is easily acquired,it saves the time of surgeon and stock-owner, it doesnot disturb farm routine, it has little or no effectupon milk yield, and it may be applied without riskto pregnant cows and to very young animals. Onesurgeon describes it as a real godsend to the single-handed country practitioner. It is true that a certainpercentage of doubtful reactions have occurred, theproportion varying widely in individual practice, butthe Committee explain these doubtful reactions as

due on the one hand to concentration on local reactionto the exclusion of such clinical factors as pain, heat,and tenderness, and on the other to the well-knowninsensitiveness to tuberculin of animals with chronicadvanced tuberculosis. The former difficulty is to besurmounted by acquiring a sense of proportion, thelatter by finding gross signs of tuberculosis on physicalexamination. In the small percentage of cases whichmay still appear doubtful, the proposal is to retestby the double intradermal method using sterile brothas a control. It may prove possible to render the testmore conclusive by increasing the strength of tuber-culin employed, this to be done without increasingthe bulk of the present dose (0-1 c.cm.). One greatadvantage of the experience gained is the eliminationof other tuberculin tests ; the ophthalmic test is nowregarded as untrustworthy, and other subsidiary testsare left to the discretion of the veterinary surgeon.And, finally, the intradermal test is comparativelylittle influenced by the previous application of othermethods of testing, which is as much as to say thatthe practice of

" doping " or " faking " a suspected cowwith tuberculin before submission to the veterinarysurgeon will now be futile. Apart from its applicationto veterinary medicine the work of Prof. Buxton andDr. MacNalty will most certainly react on the use oftuberculin in human practice where a higher standardof scientific precision is equally to be desired.

1 See THE LANCET, 1925, i., 831.2 The Intradermal Tuberculin Test in Cattle. By J. Basil

Buxton and A. Salusbury MacNalty. Medical Research Council,Special Report Series No. 122. H.M. Stationery Office. 1928.Pp. 64. 1s. 6d.

THE DEATH CERTIFICATE.

WHEN the law of death certification was alteredtwo years ago, the changes failed to satisfy thosereformers who wanted something more than half aloa,f. Their criticisms of the present system, with itsserious risk of premature burial and the non-detectionof crime, did but repeat what had already been saidby a Select Committee of the Ilouse of Commons in1893 and by a Departmental Committee in 1910. A

vigorous pamphlet by Sir George Greenwood,1 whosedeath occurred suddenly last week, now sums upthese criticisms afresh. He cites an answer givenby the Minister of Health in the House of Commonsin 1923 to the effect that in the previous five years31,332 deaths had been uncertified in Englandand Wales; he mentions the recent estimate ofa London coroner that some 5000 people are buriedevery week in England and Wales whose deathcertificates have been given without the body beingseen by the certifying doctor ; and he recalls thesaying of Dr. Richardson some 40 years ago that hedid not know one medical man of extensive practicewho, in the course of it, had not met with a case ofsecret murder. What the reformers wanted, of course,in 1926 was not the Government’s Births and DeathsRegistration Bill (which was passed into law at theend of that year), but the Bill framed by the SpecialCommittee of the Federation of Medical and AlliedServices. The latter Bill proposed to enact that amedical certificate of the fact of every death or still-birth must be given by a registered medical practi-tioner who has viewed and examined the dead bodyand is satisfied that life is extinct. The most audibleobjection to this proposal was the difficulty of findingthe money for the doctor’s fee. The relatives wouldnot object, replied the reformers, if the fee for thispost-mortem visit were made recoverable like thefees for- visits during the patient’s life-time ; thecases of poor people could be met by a simple exten-sion of the panel system or the poor-law rules. Thereformers, however, were defeated ; some of themedical members of the House of Commons trans-ferred their support to the Government’s Bill, andSir Kingsley Wood declared that a complete medicalexamination in every case, as the reformers desired," would mean very considerable expense and wouldset up a universal and compulsory requirement for avery small chance indeed." A much less drasticchange was made. The form of medical certificate ofthe cause of death now shows the date when thecertifying doctor last saw the deceased alive, andfurther shows whether or not he saw the deceasedafter death. Regulations under the Act of 1926require that the registrar shall report to the coronerinter alia any case where the deceased was not attendedby a registered medical practitioner during his lastillness and also any case where it appears that thedeceased was seen by the certifying doctor neitherafter death nor within 14 days before death.

Sir George Greenwood’s lively pen attacks theMinister of Health, the Registrar-General, and allbureaucrats in Government offices because the lawdoes not go far enough and because its provisionsare to be sought in a multiplicity of statutes andstatutory rules and orders. Legislation in advanceof public opinion is unlikely, and, unless some sensa-tional case occurs, the education of public opinion isa slow process. The Acts are certainly in a dismaltangle, but the new code of statutory regulations,long as it is, is a vast improvement on its predecessors.As a former member of the House of Commons SirGeorge Greenwood will know that Parliament nolonger seems willing to find time to legislate directlyupon such matters as that code contains. To thatextent his allegation of bureaucracy comes too latein the day. Indeed, the public may see a less offen-sive bureaucracy in the present system than in theproposed intrusion into their homes of the doctor

1 The Law of Death Certification. By Sir George Greenwood.Humphrey Milford, Oxford University Press. 1928. 2s 6d.