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Annotations

REWARD OF MERITFEW local authorities can rival the hospital services

of the Middlesex County Council, and the new staffingarrangements described on p. 717 have special significanceat the present juncture. One of the interesting pro-posals relates to the recognition of exceptional meritshown by doctors working with the Council. It is oftensaid that a salaried service, in which special effort bringsno monetary reward, encourages nothing but mediocrity :the recipient of a salary does no more than he need. This

argument can easily be carried too far ; for it is absurdto suggest that in medicine there are no major incentivesbeyond the financial. Nevertheless there is a strong casein any salaried service for tangible recognition of workwhose quality is well above what is expected of theworker. Middlesex has now decided that senior clinic-ians who have reached the maximum salary of 1800may, if they give proof of ability above that of theircolleagues, be put on a special scale rising to 2200. Inrecommending this innovation, Dr. H. M. C. Macaulay,the medical officer of health, said that he thought itwould have a stimulating effect on the service, and madeit clear that mere seniority should be no qualification forthe supplement. The London County Council has longhad machinery by which special payment can be madefor special merit ; but we cannot recall that it was everused for the benefit of the medical staff until last week,when the salary of an LCC hospital surgeon was raisedby 1:500 to JE2000 in recognition of his distinguishedattainments. These pieces of news suggest a welcometendency towards flexibility in the management of publicservices. The principle is important, and in a NationalHealth Service it ought perhaps to be carried considerablyfarther.

FILTHY CALCUTTAA COLLECTION of photographs, articles, and letters

republished from the Calcutta Statesman gives a vividpicture of conditions in the city, which is still a great basefor our Forces. It is a picture of appalling squalor.The permanently low standard of living for the generalpopulation is now aggravated by the aftermath of faminein the surrounding country, and the booklet emphasisesthe inefficiency of the administration wielding a skeletonpublic health service. There is no proper disposal ofrefuse in the city. A common sight, here illustrated inphotographs, is a crowd of human scavengers about thedustbins, whose contents are strewn over the streets, oftencontaminating the wares of the roadside vendors of foodand drink. Such a state of affairs is volcanic, and in factCalcutta this year suffered a cholera epidemic which inApril claimed 500 new cases a week. There was also asevere epidemic of smallpox, in the course of which400,000 persons were vaccinated with lymph which,according to the Statesman, was found to be unsafe.The wranglings over the responsibility for thesehappenings occupy much of the space, in the booklet.There seems to be no doubt about the inadequacy of themeasures taken to deal with the situation, nor aboutthe failure of the city’s sanitary services. On the whole theattitude of the newspaper is destructive ; few positivepractical suggestions for improving matters are to befound in its pages. None the less it has performed avaluable service in revealing where the responsibility lies-with the Calcutta corporation first of all, then with theBengal government, and then with the Government ofIndia. Ultimately, the responsibility for the state ofCalcutta is that of the British citizen. Squeamish readershad better avoid this booklet, but it can be recommendedto those who want an unromatically accurate picture oflife in the Second City of the Empire. _

1. The booklet is not on sale, but a few copies are obtainable, free ofcharge, from " The Statesman " Ltd. (Calcutta), 23, FleetStreet, London, EC4.

AMBASSADORS OF SCIENCESir HENRY DALE, PR3, remarks 1 that" the broadly

international character of the aim and the content ofscience should make it a most readily accessible andattractive meeting-ground for the cultural interests of thepeople of different countries." In the Society for VisitingScientists, founded by the British Council in consultationwith the Royal Society, his words find practical and hos-pitable expression. The society’s pleasant premises inOld Burlington Street, London, Wl, whose openingis recorded in the Council’s current annual report,2 havebecome a meeting-place and an information centre, fordistinguished guests from Turkey, China, India, France,and other foreign parts.The end of the war has in fact increased the Council’s

responsibilities. Transport and communication are

easier, and liberated countries are anxious to fill the gapscaused by their involuntary isolation. Requests forinformation are manifold, visitors are of all kinds fromprofessors to school-children, and the flow of studentsgrows faster. Within the framework of the departmentof science the medical division under Dr. N. HowardJones has taken a substantial share in restoring inter-national relations. The Britigh J[edical Bulletin, includ-ing its Spanish, Portuguese, and Turkish editions, has acirculation of over 10,000. The subcommittee on medicalfilms has been reconstituted and now includes representa-tives of the British Medical Association, the MedicalResearch Council, and the Ministry of Health. Dr. A. G.Sanders of the Dunn School of Pathology at Oxford hasjoined the Council’s staff in China as medical officer; theCentro Medico Argentino-Britanico has been set up, withDr. R. Castro O’Connor as its hon. secretary; and manyDominion and foreign graduates are receiving advice andhelp in planning their postgraduate work in this country.

RESEARCH IN THE ROYAL HOSPITAL, CHELSEAAMONG the scientific foundations which distinguished

the reign of Charles II, the Royal Hospital, Chelsea, hasno such obvious claim to be included as has its augustneighbour, the Royal Observatory, farther up the river.Nevertheless it has contributed its quota to medicalknowledge : as a clinical laboratory for the study of oldage, it offers great opportunities which have been used.Brigadier Lipscomb’s book on Diseases of Old Age was aproduct of his term as deputy surgeon there, and nowCaptain T. H. Howell reports valuable observations madeduring his war-time tenure of the same post.3 CaptainHowell has devoted particular attention to cardio-vascular phenomena, and describes a syndrome of pro-gressive cerebral ischoemia, characterised by successivestages of confusion, restlessness especially at night, andthen a terminal coma, with blood-pressure falling steadilythroughout. On the incidence of cancer and of variouscirculatory diseases among the elderly he gives instructivefigures.

- One of the chief difficulties in the study of old agearises from our defective information about the normalphenomena of this period of " late maturity." HereCaptain Howell’s data will help to fill the gap : thus hemeasured the blood-pressure of 120 "tough veterans "

(aged from 65 to 92) admitted to the infirmary, and latermeasured the blood-pressure in 200 healthy pensioners;he also investigated systematically the temperaturevariation in old men. By such studies, and statisticaland other observations of disease like those recorded inthe little book, geriatrics may develop stronger claimsto be regarded as an independent branch of medicinethan it has had hitherto.The book also contains a chapter on the care, comfort,

1. British Council, Science Dept. Outline of Activities. 43, Port-land Place, London, W1.

2. Report of the British Council 1944-45, 3, Hanover Street, W1.3. Old Age. Some Practical Points in Geriatrics. (H. K. Lewis.

Pp. 50. 4s. 6d.)

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and management of the elderly. The precepts showmuch practical sense and kindliness ; they need to beread in conjunction with the invaluable booklet issuedby the Friends Relief Service describing the standards tobe aimed at in hostels for old people.4 The FRS has hadwide experience of running such hostels during the war,and the report is practical testimony to what the Societyof Friends has achieved in this difficult field of socialwork. " Those working in our hostels have, with fewexceptions, no special qualifications for the tasks theyhave undertaken, and the great majority are youngpeople who would in peace-time be engaged in otherwork. This has led to a certain amount of misdirectedeffort and necessarily to a high staffing ratio ; it hasalso sometimes led to a freshness of approach and awillingness to experiment untrammelled by rules andprecedents. True realisation of the worth of everyhuman being and a desire to serve one’s fellow men are,we believe, essential prerequisites for anyone engagingin work with the aged."

’

INGROWING HAIRS

PINKUS says that the root of a white man’s hair isstraight or slightly curved and lies in the skin at a more-or-less acute angle to the surface, An ingrown hair is ashaved-off hair which pierces the side wall of the follicleand enters the cutis instead of emerging at the follicularopening. This happens when a slanting hair has beenshaved off so closely that the pull on the skin duringshaving causes the free end of the hair to slip below thesurface and thus to penetrate integument. The bristle,which has a sharp point, continues to grow but failsto force its way to the surface. An inflammatoryreaction follows, and the patient notices that a smallpimple or boil is continually forming on the same site ofthe beard area, usually on the side of the neck ; occasion-ally several inflammatory papules or pustules appear onthe area. Treatment consists in removal of the hairwhen the inflammation is quiescent, and in advising thepatient not to shave so closely. In some cases removal ofthe bristle may not be necessary ; for the suppuration’may have destroyed the hair root and the follicle, and theremains of the hair may have been evacuated with the pus.Sometimes in severe acne or’sycosis, inflammation and

scarring alters the direction of the hair roots ; the hairsthen curl up in the skin and behave as foreign bodies.Pinkus states that they may reach considerable lengthand may require surgical removal.Many negToes have a chronic papular eruption on their

beard areas, particularly on the lower part of the cheeks.By histological examination of serial sections, and three-dimensional reconstruction on a larger scale, H. -and F.Pinkus 6 have shown that the hair roots of negroid racesare semicircular in shape ; the follicles of the hairs of thebeard are often so curved that the hairs leave the skin in aslanting direction and then curve round, so that their tipspress against adjacent portions of the integument.Hairs which retain their natural soft tip are deflected andgrow up in a horizontal spiral; but bristles-their endssharpened by shaving-may push their way into theskin, burying their tips like an ostrich burying its head.Once penetration has taken place, the hairs growdownwards, inflammation develops, and papules form.On examination it is found that the centre of each papuleis pierced by a hair, which may be lifted out with a forcepswithout any resistance being encountered. If the courseof a hair is traced, the skin against which it has lain maybe grooved, but there is not any inflammation of thefollicle from which originally it emerged from the skin.Pinkus states that the condition occurs in at least 10%4. Hostels for Old People. Published by Friends Relief Service

through Friends Book Centre, Friends House, Euston Road,NW1. Pp. 30. Price 1s. 6d.

5. Pinkus, H. Arch. Derm. Syph., Chicago, 1943, 47, 782.6. Pinkus, H., Pinkus F. Ibid, p. 786.

of negroes who regard it as an inevitable development.In older men, numerous shallow grooves and small scarsmark the sites of the malady ; younger negroes havefewer grooves and more papules. Treatment consistsin removing all the hairs which are growing into the skin,for if their tips are merely pulled out of the papules andthe shafts are left, the hairs will again penetrate theintegument ; X rays may be used for this purpose, butoften manual epilation is sufficient. Antiseptic lotions orsulphur ointment may be used to control the inflamma-tion, and the patient must be advised to shave his beardclosely every day. Pinkus suggests that the term" chronic scarring pseudofolliculitis " should be used todesignate this malady of coloured men.

It will be noted that the advice to be given to whitemen is " don’t shave so closely " whereas for negroes theadmonition must be " shave every day and shavecloselv."

FORTY THIEVES

ANY circumstance which breaks up family life anduproots the first emotional attachments of a child withinthe family group is liable to have an adverse effect on thechild’s emotional development. Studies of the familybackgrounds of maladjusted and delinquent childrenhave revealed that many of them lost their parents orwere the victims of broken family relationships early inlife. In the same way, an unduly high proportion ofadults suffering from psychiatric disorders are found tohave lost one or both parents through illness, death,desertion, legal separation, divorce, or other cause inchildhood. These studies also suggest that the younger,the child when the break in the home occurs, the greaterthe influence it will have on him. Psychological studiesof young children evacuated from dangerous areas inwar-time revealed the adverse effect of abrupt separationfrom the mother in children under five years of age.Burlingham and Freud 1 described refusal to eat andsleep, excessive crying, high susceptibility to minorailments, and failure to recognise the mother throughrejection of the memory of her, in evacuated childrenunder three years. Depression, moodiness, emotionaloutbursts of resentment, and behaviour problems werenoted in the children between three and five. If a childhad to change his foster-parents more than once or twicethere was a danger that he would show an emotionalwithdrawal from the outside world, and become eitherfrighteningly impersonal and devoid of all emotion, orsubject to emotional outbreaks of a hysterical type.Edelston 2 has described how after a period in hospitala child may develop emotional disorders such as anxiety,sleep disturbance, and faulty habits, except wherefrequent visits by the parents are permitted. The

younger the child the more acute were the symptoms.Further evidence of the ill-effects of early interruptions

in home life has been obtained by Bowlby 3 in a study ofjuvenile offenders. The study itself may be criticisedbecause of the selection of cases on a symptomatic basisof theft, " in which stealing was either a serious or atransient symptom " ; the omission of routine physicalexamination ; or the wide age-range (5-16 years inclusive)in comparison with the smallness of the series (44). Inaddition, the classification of the children as normal,depressed, circular, hyperthymic, affectionless, andschizoid characters presupposes a more extensive know-

ledge of character types than has yet been generallyaccepted. Of the 44 child thieves 17 had been separatedfrom their mothers, early and for long periods, comparedwith 2 out of a control group of 44 maladjusted children" who did not steal." Among the 14 thieves whomhe classified as affectionless characters "-that is,

1. Burlingham, D., Freud, A. Young Children in Wartime,London, 1942.

2. Edelston, H. Separation Anxiety in Young Children. GeneticPsychology Monographs, No. 28. Provincetown, Mass, 1943.

3. Bowlby, J. Int. J. Psycho-anal. 1944, 25, 1.