672

1921, in the highest part of the town overlooking thePalace du Peuple, the exact spot where a little Belgianforce defied the German army. No attempt will bemade to reproduce the destroyed building, but everydetail of the new design is Flemish, and brick and stoneof local origin will be used in its construction. In thecompleted building there will be accommodationfor two million volumes, but the English gift will bekept apart both on the shelves and in the catalogue.Thus, the attempt will be clear " to acknowledge ourindebtedness to the incomparably brave nation andtheir valiant Sovereign, who sacrificed all but honourto preserve their independence and thereby safeguardthe liberties of Europe." Although the destruction ofthe Louvain Library has resulted in an irreparable lossto literary history and associations, there is a brighterside to the situation, and this finds expression in Dr.Guppy’s report. A university library is, in a sense, asymbol of education, and education has in moderntimes been completely revolutionised. Many of thebooks which have now found their way to Louvain,replacing works of interest through antiquity andhistorical association, might otherwise never havereached the Belgian University. The reorganisation ofthe Louvain Library, especially in the domain ofinvestigation and research, is an admirable event foreducation.

____

TUBERCULOSIS IN MENTAL HOSPITALS.

IN a paper read recently before the TuberculosisSociety Dr. E. A. Evans, inspector of the Board ofControl, drew attention to the high incidence oftuberculosis in mental hospitals. Apart from Poor-lawinstitutions, naval and military hospitals, and thecriminal lunatic asylum, with none of which, saidDr. Evans, was he concerned that evening, the dailyaverage number of patients resident each year between1910 and 1925 ranged between 87,000 and 106,000.The tuberculosis death-rate per 1000 living had variedamong these patients from 13-8 in 1910 up to 45-6 in1918, and down to 7-3 in 1925, the correspondingdeath-rate for England and Wales in 1920, for agesover 15 years, being 1-3. Since mental hospitals differwidely in size and in type of management the death-rate from tuberculosis is found, as might be expected,to vary with the type of institution-e.g., a muchsmaller death-rate from this disease is found in theestablishments for private patients, and a similardisproportion is believed to exist in the private annexesto rate-aided institutions. In comparing the tuber-culosis death-rate in mental hospitals with that forthe general population several sources of fallacy mustbe borne in mind. For instance, as regards agedistribution, in the general population about 27-4per cent. are under 15, while in the mental hospitals thepercentage for this age-group is about 0-6 ; indeed,nearly 50 per cent. of the population in mentalhospitals are over 45. Again, one might reasonablyexpect that with this high proportion of aged personsin mental hospitals the number of deaths fromrespiratory diseases other than tuberculosis would inthese institutions exceed that for England and Wales,but as a matter of fact the percentage is 7-7 for themental hospitals and 20-2 for England and Wales. I

This discrepancy is accounted for by Dr. Evans bythe greatly preponderating percentage of post-mortemexaminations carried out in mental hospitals. It is

significant that in county and borough mental hospitalsin which the percentage of post-mortem examinationscarried out is 65-5 the tuberculosis death-rate is11-2 per 1000, while in registered mental hospitals witha post-mortem examination percentage of 12-6 thetuberculosis death-rate is only 4-4 per 1000. The

very definite correlation between infrequent post-mortem examinations and low tuberculosis death-ratewould suggest, as Dr. Evans pointed out, that extendedautopsies might reveal more deaths from tubercu-losis among the aged at the expense of the diagnosisof chronic bronchitis.

Dietary defect had, said Dr. Evans, been widelyblamed for this high mortality in mental hospitals.

For the purposes of a research carried out in 1922hospitals were grouped in three classes : (1) those withdietaries of less than 2300 calories ; (2) those between2300 and 2600 calories ; and (3) those over 2600.With each rise in caloric value a correspondingly lowerincidence of tuberculosis was found and, in the caseof males (but not of females), a similar drop in thedeath-rate. Adequate precautions are taken to ensurethat no infected meat is used in mental hospitals,but Dr. Evans regards the milk service as less secure,although an increasing number of hospital authoritiesinsist on periodic guinea-pig inoculations with centri-fugalised milk from every animal of the supplyingherd. Recent substantial improvements in thedietaries have been reflected in the falling incidenceand death-rate of tuberculosis. Another factorinvestigated has been the effect of the size of thehospitals. As a general rule the larger the hospitalthe higher is the death-rate from tuberculosis owing,no doubt, to the congregation of large numbers ofpersons in common rooms and dormitories. For longthe safety of the patients was considered to precludethe free opening of windows, a dislike for prison-likearchitecture also preventing the use of iron bars whichwould have allowed their wider opening. Greaterrisks are now taken, and in many hospitals a wireframe is fixed outside the window, while window blocksare being removed from the upper sashes of groundfloor rooms.The prevalence of tuberculosis varies among the

clinical types of mental disease. Dr. Evans finds adistinct preponderance among the congenital cases,especially those with epilepsy, and among the dementiapraecox or primary dementia patients. In the formergroup the tuberculous disease runs a chronic course,the patients dying only after long residence. Tuber-culous patients suffering from melancholia or dementiapraecox, on the other hand, usually die within fouryears. Dr. Evans believes that there is a definiteimpairment of metabolism due to, or associated with,the impaired mental condition. It is usually necessaryto depend upon the poisonal observation of the medicaland nursing staff for the first signs of illness among theinsane, otherwise patients may be found well advancedin serious illness before any complaint is made. At

present there is an average of about a dozen patientswith active pulmonary tuberculosis in each of thecounty and borough mental hospitals. In aboutthree-fourths of the hospitals special provision, in theshape of verandahs, open-air shelters, isolation blocks,or special wards, is available for the segregation ofthese patients. ____

THE HAND OF MR. F. T. PAUL.

AT the conclusion of the clinical meeting of theLiverpool Medical Institution on March llth, Mr.J. C. M. Given presiding, the members assembledin the lecture theatre to witness an interesting littleceremony-namely, the presentation to the Institu-tion of a bronze cast of the right hand of Mr. F. T.Paul, executed from a cast by Mr. H. Tyson Smith.Mr. Frank Jeans, the donor of the bronze, said thatMr. Paul’s name was known to every surgeon as

a pioneer and an inventor, " Paul’s tube " being asepoch-making an instrument as that of anotherLiverpool surgeon, " Thomas’s splint." Thereforehe thought that, as a remembrance of Paul, a pastpresident of the Liverpool Medical Institutionand a most gifted operator, a cast of his hand wouldbe acceptable to the Institution. " Paul’s operatingin the heyday of his manual efficiency," he said," always made me think that he did with his handswhat Pavlova did with her feet, only Paul’s workwas much more useful. I have an additional reasonfor wishing to pay a tribute to Paul, because it isto him that I owe the continued existence upon thisearth of my wife-but that is a personal matter."Mr. Paul, in acknowledging the courtesy of theInstitution in accepting the gift and the kindness ofMr. Jeans in thinking of it, admitted that at first hehad regarded the matter somewhat as a joke, and,

673

while confessing that he had always been fond ofusing his hands from his earliest years, he remindedthe audience that " a gentle touch comes from theheart rather than from the hands, a touch inspiredby a true sympathy with the patient’s tissue-inthis way only could a man attain the hand of asurgeon." The President then expressed his pleasurein accepting the bronze cast in the name of theLiverpool Medical Institution, and thanked Mr.Jeans most sincerely for his very acceptable gift.All our readers will acknowledge the fitness of theretention in the Liverpool Medical Institution of apermanent memorial of the work of Mr. Paul. Not onlyis he a great as well as a skilful surgeon, but he wasone of the founders of the Liverpool Medical School,and from its earliest days his work has contributedto the building up of the great tradition of thatschool. ____

THE NEEDS OF UNIVERSITY COLLEGEHOSPITAL.

DEVELOPMENT has its embarrassing side for those ’’

who have to find money for the upkeep of their greatpossessions. University College Hospital offers a casein point, and clearly its income must increase to meetexpenditure if the hospital is to make the most of itsnew good fortune. The Rockefeller Foundation’sgrant of Bl,205,000 for the erection of more buildingsand the equipment of research does not affect theordinary income except in so far as it will make foreconomical working, and, unfortunately, the annualdeficit remained at about j611,000 last year. Doubtlessmany subscriptions have been diverted into the fundfor endowing 60 beds in the new maternity block whichthe Prince of Wales is to open on May 28th ; 180,000has been collected for this purpose. The expenses ofthis collection, it is satisfactory to note, were verysmall indeed, and the interest earned on the earliercontributions more than covered the whole cost." We did not advertise for money," says Sir ErnestHatch, the chairman, " we went and fetched it."Besides these maternity wards, now so well pro-vided for, there is a new nurses’ home and medicalofficers’ quarters in Huntley-street, which is alreadycomplete, and the Royal Ear Hospital, which is to beready for use very soon, thanks largely to a gift of65,000 from Mr. Geoffrey Duveen, a member of thecommittee. The hospital’s existing accommodationhad become more and more inadequate, but all theseextensions will furnish 202 additional beds. Mostof them have been furnished indirectly out of theAmerican grant, but the Rockefeller Foundationrightly considers it no part of its work to care for thesick poor, except by research and medical education.London, therefore, must see to it that the fullest usecan be made of what has been provided, and there willbe a ready response to the quiet and inexpensiveappeal which is being launched. Another .615,000a year is needed to bring the ordinary income up toa more satisfactory level, and the fact that a greatfuture is obviously in store for the hospital shouldensure that this sum is found.

CHEWING-GUM AFTER TONSILLECTOMY.

IN a recent number of the Therape1Ûic Gazette(Feb. 15th, 1926), Dr. William H. Spencer, of Phil-adelphia, draws a somewhat lurid picture of the septiccondition of the throat after tonsillectomy, and ofthe systemic absorption of toxins from the " putre-fying mass" which covers the wounds. He is scornfulon the subject of gargles, though he does not mentionthe probability that they do not reach the tonsillarfossse at all, and it would seem that he has noexperience of spraying or syringing the throat in thiscondition. But he is an enthusiastic advocate of the iuse of chewing-gum after operation, and states that" the throats of tonsillectomised individuals usingchewing-gum as an after-treatment do not becomeinfected. Secondary haemorrhage is less frequent."(It is very rare in any case.) " Healing is more rapid.

A full diet being taken, resistance of the individual ismaintained, little or no weight is lost, and no post-tonsillectomy recuperation period is needed." " Chew-ing stimulates the secretion of saliva, which, beingswallowed, laves constantly the wounded surfacesand lubricates the pharyngeal mucosa. The attrition ofswallowing keeps down the membrane formation to aminimum, so that the usual white patches covering thetonsillar fossae, which have often been mistaken fordiphtheric membranes, are in some cases entirelyabsent." Patients might not take so kindly to thismethod here as in a country where they are already usedto it; in the United States, according to Dr. Spencer,"so universal is the habit that it can be chewed inpublic without attracting the slightest attention."Nevertheless, surgeons here who are not satisfied withtheir patients’ convalescence under the usual methods,may like to try this form of after-treatment, which is,at any rate, simple and harmless.

LONDON UNIVERSITY.

THE long expected report! of the DepartmentalCommittee of the University of London appears bya curious coincidence a few days before the surrenderof the promised Bloomsbury site. For it seems

certain that next week the conditional offer of thissite to the University for its central buildings willlapse definitely and its value be claimed by theChancellor of the Exchequer. The event mighthave passed unnoticed had it not been for a demon-stration of students who last week beat the boundsof what was to have been their home on the same dayas a petition signed by over 4400 students and teacherswas handed to the Prime Minister, asking the Govern-ment that all should not be surrendered and thatpart of the site should be reserved for residentialquarters and a students’ Union. Even if no promisehas actually been broken, the students may be rightin claiming that the engagement ring should not bereturned ; and they may take comfort f om the wordsof the Departmental Committee, which states that,wherever the central offices of the University are tobe located, the creation of a strong University Unionis eminently desirable and is a proper charge on thefunds of the University. The report of the Depart-mental Committee differs from the Final Report ofthe Royal Commission of 1910, issued in 1913, andof the Haldane Commission of 1909, in being a readabledocument of 52 pages with 5 pages summarising itsrecommendations. The report makes no attempt topresent a record of the development of the University,nor to discuss in detail its aims or constitution.The Committee frankly regards it as impracticableto give effect to some of the major recommendationsof the Haldane Commission. It has been concernedto devise an immediately practicable scheme forbetter government and organisation, evolutionaryrather than revolutionary, and yet embodying theessentials of a university in a great centre of popula-tion. The fear raised by the Haldane Report of anattack on the system of degree examinations forexternal students is found to be groundless. In theevidence laid before the Committee no responsiblebody claimed the abolition of these degrees andnone of the Committee’s recommendations is designedto restrict the present facilities available for ex-ternal students. The Committee refuses to emphasisethe distinction between external and internal sidesof the work of the University, provided that theauthority of the teachers and of the teaching institu-tions on the academic side is safeguarded. As timegoes on it assumes that internal graduate memberswill gradually outnumber the external graduatemembers, so that the organisation of the externalside will become increasingly dependent upon thesupport of internal graduates. The Committeerecommends no further extension of incorporation

1 Board of Education: Report of the Departmental Com-mittee of the University of London. Cmd. 2612. 1926.H.M. Stationery Office. 1s. 3d.