670

Annotations."No quid nimis."

THE BATEMAN FUND.

WE publish this week the new subscriptions to theBateman Fund, and are encouraged to bring the salientpoints of the appeal before our readers by the followingletter which we have received, signed " A. Morse,Staunton-street, Deptford," and " written in the nameof Dr. Bateman’s patients and friends." Mr. Morse,addressing the Editor of THE LANCET, writes :

" We allfeel we cannot thank you enough for sending him (Dr.Bateman) back to us so soon. We, the people ofDeptford, know what a valuable friend he has alwaysbeen to the poor. He is called here the poor man’fDoctor. We have read and heard how you are

subscribing to help Dr. Bateman in his heavy expensesfor his trials. God bless you and the medical professionfor their loyalty and kindness to him." We have hadmany letters from members of the medical professionapproving our action in opening this Fund, from whichwe might, with excusable gratification, have extractedsentences for publication, but it is particularly desir-able that readers should understand that, in our view,the appeal was necessary and not the outcome merelyof sympathy in a particular case. This is the reasonwhy the appeal was made. The medical man, andespecially the general practitioner, in the course of bisbusiness must often find himself in a position of th,gravest anxiety, when the procedure that he adopts,his actions, or it may be his inactions, can be placedbefore a jury of laymen in the wrong light. It isneedful, and increasingly needful, that such disastersshould be made as rare as possible. The pecuniar}risk in such circumstances can be avoided for practi-tioners by subscription to one of the two excellen1Defence Funds, and over and over again we have urgedupon our readers to shelter themselves from unavoid-able risks. Many of those who have followed theBateman case must have been led to take this advice,and we bring before them the position of Dr. Batemanas one worthy of their help, if only because his mis-fortune has stimulated them to obtain security.

INTRATHECAL MEDICATION IN MENINGITIS.

’I’HOUG14 tne neeo. lor drainage and tne emcacy 01intrathecal medication in certain forms of meningitisare unquestioned, the attempt to administer serum isoften abandoned if lumbar puncture is for anyreason unsuccessful. Dr. C. Worster-Drought, in thearticle which appears in our present issue of the seriesentitled Modern Technique in Treatment, points outthat even where lumbar puncture fails through thepresence of adhesions or through the progressivethickness of the pus, the subarachnoid space may bedrained and the appropriate serum administeredthrough other regions. Puncture in the thoracicregion is not advisable, since in many normalindividuals a posterior subarachnoid space is absentin this region, owing to adhesions between themeninges and the posterior aspect of the spinalcord. But cervical, cisternal, sphenoidal, or ventricularpuncture are possible avenues of approach, of whichthe first, at any rate, has led to successful results incases of cerebro-spinal fever, reported by severalobservers, including Cantas and Gerard and Dr.Worster-Drought himself. It is essential to gainaccess to the subarachnoid space for the appli-cation of a specific immune serum, since thefull power of the latter can only be exerted whenbrought into contact with the infecting organismsin a concentrated form. For the actual meningitis,serum injected subcutaneously or intravenously is oflittle value ; not only does it undergo an extremelyhigh dilution in the blood-stream, but there is noevidence that it ever reaches the subarachnoid space.Although the lining membrane of the subarachnoid

space is permeable to substances passing from thecerebro-spinal fluid to the blood, it appears quiteimpermeable, except in the case of a few drugs(e.g., hexamine), from blood to cerebro-spinal fluid.On the other hand, the absorption of antibodies fromthe subaiachnoid space is fairly rapid, serum injectedmtrathecally appearing in the blood within 0 minutes’and disappearing entirely from the cerebro-spinalfluid within 24 hours.2 Dr. Worster-Drought throwsdoubt on the practical value of hexamine by themouth in cases of meningitis. It has been given as aroutine on theoretical grounds ; but though it iscertainly one of the few drugs to be even partiallyexcreted by the cerebro-spinal fluid, it must reach theaubarachnoid space only in extremely high dilution.Moreover, hexamine dissociates only in an acidmedium and the cerebro-spina,l fluid is rarely, ifever, acid, even in cases of meningitis. He is probably’ight in considering the therapeutic action of thisdrug on the cerebro-spinal fluid as negligible.

THE MIND OF THE MINER.

THE discontent among coal-miners is no post-waraffair. The coal trade has been for years in a conditionof unrest. Any industrial psychologist who couldoffer constructive suggestions as to how to makejonditions of this work less uncongenial would placeche community as a whole deeply in his debt, forin this country the mining industry is more funda-mental even than that of agriculture. In an article.n last month’s Engl-ish Rel;iew Mr. James A. Bowie1ets out fairly the attitude of owners on the one hand,and miners on the other, and seeks to account forvbat bellicose mental condition of the worker whichappears to be an undeniable factor in the industry.Se points out that from 1904-13 the average annualpercentage of workers in the coal industry, involved.n disputes entailing loss of work, was 21-4 ; next touhese came the textile industry with only 64 per cent.,while the mean average of all trade groups was 4-4.Since the Armistice matters have been worse ; in1920 and in 1921 national stoppages occurred ; in1922 over one million and a quarter working days werelost due to local disputes, and in 1923 the amountwas only slightly less. Yet there has been lessmemployment in recent years in this industry than.n any other, for in December, 1922, the percentageof unemployed among miners was 4-6, as against12-2 in all trades, the corresponding figures for 1923being 2-4 and 10-7. Although coal-mining must fora variety of reasons, such as lack of sunlight, accidentrisk, and dust and dirt, be an unpleasant occupation,,t is not, comparatively speaking, an unhealthy one.r-he general mortality is not unfavourable, and,according to the Occupational Decennial Supplements- ssued by the Registrar-General, has been fallingsteadily, as have also the rates for the chief causes ofdeath among miners. In gold-mining countriessilicosis takes a heavy toll, but the Secretary forMines stated recently in the House of Commons thatchough the alleged prevalence of silicosis among coal-miners in this country has been under considerationby the Health Advisory Committee for about twoyears, the evidence so far laid before the Committeeis quite insufficient to justify any recommendationin respect of compensation. The fear of silicosis,then, in this country can hardly be a factor conduciveto unrest. Moreover, during recent years the accidentmortality-rate in mines has continued to fall from1-6 per 1000 in 1913 to 1-4 in 1918 and to 1-1 in 1923.At the same time, judging from statistics suppliedin the House of Commons on Feb. 24th, great miningdisasters have been fewer in number and have claimedfewer victims.Such records must present a difficulty for any

medical sociologist who holds that social unrest is anexpression of social ill-health. According to Prof.

1 As shown by Debré with the sensitive precipitin reaction fora foreign serum. (Thèse de Paris, 1911.)2 Hohn, Klin. Jahrbuch, 1909, xx., 377.

671

E. L. Collis (T-Fe.ey lVlail, Jan. 21st, 1924), the records Iwithin the industry itself show some confirmation ofthis theory. Mortality records vary widely on thedifferent coal-fields; during over 30 years the com-parative mortality-rates for Lancashire and for SouthWales have been nearly double those for Nottinghamand Derbyshire, and he points out that on all recentoccasions, when ballots of the miners have beentaken, the greatest unrest has been revealed inLancashire and South Wales, and the least inNottingham and Derbyshire. Mr. Bowie suggeststhat a " dungeon complex," comparable to the" prison complex " of the factory hand, is present inthe subconscious mind of those who toil in darknessamid dirt and dust. Support for such a line of

argument comes from the existence among coal-miners of a disease peculiar to them-nyst,a,gmus;a disease which, while it prevails directly as illumina-tion in pits diminishes, is recognised to possess a

pronounced neurasthenic basis. As coal-mines aresteadily being deepened, danger from mine gasesincreases ; hence the use of safety lamps, which giveless illumination than naked lights, has been rapidlyon the increase. Thus in 1907 there were about600,000 safety lamps in use, while in 1923 there wereover 900,000. The solution of problems existent inthe miner’s psychology may possibly be found closelyassociated with the raison d’etre of miners’ nystagmus.This thought is worth pursuit, for provision of betterillumination in our coal-mines would seem to be asimpler expedient than many of the economic andadministrative proposals which to-day are vaunted.

INFECTIOUS DISEASES IN SCHOOLS.

THE closure of any school on grounds of infectious I

disease is usually resented by parents, since theresponsibility for watchful care and possibly forisolation is thrust on them. Their resentment isincreased if they believe economic considerations tobe a factor in the decision to close down. Head-masters of private preparatory schools who are tciiiptedto spare themselves anxiety by packing off the childreneven a few days before the end of any term knowwell that they will not escape abuse unless the stepis taken on the urgent representation of the medicalofficer in charge. It is the latter, therefore, who isusually made responsible for a decision and shouldprepare himself by mastering the complicated issuesinvolved. An attempt to obtain guidance by studyingthe procedure adopted in schools not run for profitshows him that here financial considerations havebeen an important factor in the decision, since grantsfrom the Board of Education depend on the main-tenance of good average attendances throughout theterm. To run the school with a bad attendancesheet for any reason is to run it at serious economicdisadvantage. New regulations, however, have justbeen issued whereby local authorities will, in future,be secured from loss, if the low attendance is dueto the prevalence of infectious disease, and closureof primary schools will only be allowed strictly onmedical grounds. These regulations are set outin a memorandum 1 addressed to medical officersof health and school medical officers. Publishedunder the joint auspices of the Ministry of Health andthe Board of Education, the memorandum includes atheoretical discussion of the principles involved aswell as specific rules for action in particular diseases,and will doubtless be welcomed by medical officersattached to every type of school. It is a new editionof a pamphlet first issued in 1909, and reaffirms theprinciple, then laid down, that if, during epidemicsof infectious disease, the power to exclude individualchildren from school be used to the best advantage,it is only in special and quite exceptional circum-stances that it will be necessary to close a school in theinterests of public health. There will, indeed, be notemptation in the future for local education authori-

1 Memorandum on Closure and Exclusion from School. H.M.Stationery Office. 1925. Pp. 32. 4d.

ties to close down on any other grounds, since securityagainst loss of grant is assured to secondary as wellas primary schools.The mode of procedure recommended is carefully

set out in the memorandum, and the medical officer ofhealth is advised in certain cases to act, not as such,but as school medical officer, since he has greater powersin the last-named capacity. Incidantally, it is againurged that these two offices should be held by thesame person. The general effect of the new regulationsis as follows : (a) Schools or departments may beclosed or individual scholars excluded by the SanitaryAuthority or by any two members thereof acting onthe advice of the medical officer of health. (b) Schoolsor departments may be closed for medical reasonsby the Local Education Authority acting on its owninitiative-i.e., without orders from the SanitaryAuthority-but the closure must be advised oil

approved by the school medical officer on the groundthat such closure is needed for medical reasons.

(c) Individual children may be excluded from schoolby the school medical officer (without special authori-sation by the Local Education Authority in eachindividual case) provided that the Board are satisfiedthat proper arrangements have been made by theLocal Education Authority for this purpose. Generallyspeaking, the advice given in that part of the memo-randum which deals with specific diseases is admirablycomplete. The omission from the discussion of

diphtheria of any reference to the Schick test willdisappoint those who will look for a critical estimateof its value in these pages. The recommendation thatcases of influenza should not be readmitted until acareful examination of the heart and lungs has beenmade to eliminate possible latent complications isa counsel of perfection. There can hardly be a schoolmedical officer who would put such a propositionbefore his Authority during an epidemic, consideringwhat the risks amount to and what the cost would be.The remarks under the heading Acute Poliomyelitisshould receive strict attention. It is emphasisedthat a careful watch should be maintained in non-paralytic cases for the supervention of paralysis, asrecurrent cases occur in which the paralysis is mani-fested after acute symptoms have subsided. Paralyticcases require a long period of school exclusion and areafterwards better treated, if practicable, in specialorthopaedic institutions. In such cases early care andeducational measures maintained over a prolongedperiod may prevent or at least mitigate crippling.Recommendations for the care and after-care ofchildren suffering from encephalitis lethargica con-clude the memorandum. Children exhibiting signs orsymptoms suggestive of a mild or abortive form ofencephalitis lethargica should, it is said, be kept fromschool for a minimum of six weeks. Six months fromthe time of exclusion from school is suggested as theearliest period at which a child who has had encephal-itis lethargica may return to work ; in many cases thisperiod has to be extended to a year or longer. Solittle is known about the epidemiology of this diseasethat more concrete advice is not to be expected.

THE VISIT OF FOREIGN PUBLIC HEALTHOFFICERS.

’1‘HlRTrr. a nations have during the last few weeksbeen represented by their foreign public healthofficers in an official visit to this country under theauspices of the League of 1BTations.i The representa-tives visited certain typical selected centres, such asLeeds and a Yorkshire district, the borough of

Wolverhampton, a large suburban borough, andvarious areas in the counties of Middlesex and London.and under the auspices of the local officials wer2given full information as to national and municipalpublic health organisation. The visit concluded at thebeginning of this week, when the representatives leftfor Geneva, there to present a report to the League,

1THE LANCET, Feb. 14th, 1925, p. 354.