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Annotations

TREATMENT OF OFFENDERS

THE Home Secretary’s Advisory Council on theTreatment of Offenders has been considering the border-land between sanity and insanity, and what should be,done with offenders who inhabit this borderland. Theirconclusions are published on p. 1123. In brief, they arein favour of a special penal institution for the mentallyabnormal criminals who are not insane. Those guilty ofless serious crime, who are willing to undergo treatment,’should be dealt withby probation and outpatient psychia-tric treatment under Section 4 of the Criminal JusticeAct. In 1939 Norwood East and Hubert 1 advised thatthe minimum period of imprisonment in which psycho-therapy could- be of any help was four months (i.e., asix-month sentence with the usual two months’ remission)and Prison Commission experience confirms this. Sincethe maximum period of psychiatric detention should notbe longer than the maximum legal sentence for the

particular crime, no crime meriting less than six monthsshould be rewarded by treatment in the special penalinstitution. Though quarter sessions and assize courtsshould pronounce sentence to the institution, the powerof admission would in fact rest with the psychiatristsof the Prison Commission. No court would be permittedto pronounce such a sentence without a report from thecommission on the prisoner’s mental state, and thecommission would have the right to reject in advanceany candidate on the grounds of unsuitability. Further,the commission would have power to transfer appropriateprisoners from ordinary prisons to the new institution.

Wisely, the council makes no attempt to define thepsychiatric clinical types who would be collected. Therecan, however, be little doubt that many would be psycho-paths of the most difficult kind. How far physical andpsychological therapy is able to assist such people is

something we can only find out by trying. The council’sproposals are well designed to collect all whom thePrison Commission desire to be drawn into the net, andto exclude the unsuitable. Though such an institutionwill have more in common with a hospital than a prison,it must clearly be run on maximum security lines. Ifit is too pleasant, and if release is often quicker thanfrom an ordinary prison, we shall get every defendingcounsel with a hopeless case trying to prove his clienta psychopath. Danish experience 2 suggests that theonly hope for the criminal psychopath is the indeterminatesentence-that unless the psychopath is forced to try tochange himself, as a condition of release, he does not do so.On this, the council hedge ; though treatment mayrequire a longer time than the maximum legal sentencefor the particular offence, they feel that they wouldnot carry public opinion with them in proposing morethan the existing maximum.

Only experience can show whether the absence of thisprovision is as fatal to success as the Danes maintain.The proposals for the collection of psychopaths are anadvance on Danish law. It remains to be seen whetherwe need more than an institution to achieve the Danish50% recovery-rate.There is one further practical point. If the Prison

Commission is to provide reports of any value beforesentence, the accused must be remanded in custody. At

present, some accused persons are reported on to highercourts, with regard to their suitability for Borstal orcorrective training, by prison medical officers and

governors who have never had an opportunity of seeingthem.

1. East, W. N., Hubert, W. H. de B. The PsychologicalTreatment of Crime. London, 1939.

2. Taylor, S. Lancet, 1949, i, 32.

VIBRIO FETUS AS CAUSE OF HUMAN ABORTION

BECAUSE of the attention given to Brucella a6oMsas a cause of human infection one is apt to forget thatthis is only one of the many organisms known to produceinfective abortion in cattle ; nearly forty years agoM’Fadyean and Stockman 1 drew up a list of thosewhich might be found. Among these was the Vibriofetus ovis, which has hitherto been looked on as patho-genic to cattle and sheep, though the infection of theseanimals is widespread in only Europe and the U.S.A.Evidence is now accumulating that the infection can betransmitted to pregnant women and that its abortifacientaction is in many respects similar to that in animals.Whether men can also be infected is uncertain, but a caseof ankylosing arthritis in Paris suggests that pregnancyis not essential for infection. This case is cited byVinzent and colleagues in their vivid account 2 of threefurther cases seen since the first description of thehuman disease 3 in 1947.The infection affects women in the later months of

pregnancy and takes the form of an acute septicaemia.The diagnosis is made by blood-culture, the most

satisfactory culture medium being citrated meat peptonebroth containing 1% gelatin, since morphologicallythe organism resembles V. cholerce. After an invasiveperiod of about 24 hours, a severe illness develops withintense headache, remittant fever, and a fleeting pneu-monia ; nevertheless, the patient’s general conditionremains good. There is a well-marked secondary anaemiaand a moderate leucocytosis with about 80% polymorphs.After an illness lasting up to 4 weeks the symptomsdisappear, usually with spontaneous expulsion of theuterine contents. Oddly enough, it may be possible toobtain a viable infant ; the explanation may be thatthe infection is mainly a " placentitis," and the histo-logical findings certainly substantiate this view. The

placenta, whether human or in animals, is characterisedby a patchy necrosis associated with an infective throm-bosis of the arteries supplying the affected cotyledons,and the infection clears up rapidly once the placenta isexpelled. Normal conception is possible subsequently.The pathogenicity of the infection, judged by fatality-rates, may not be high, but it can produce an alarmingillness while it lasts. Serological changes persist for lessthan a year after the infection and are specific to theparticular strains of V. fetus, so agglutination reactionsshould be performed with multiple strains.4 4 In futureit may be worth while to include V. fetus in the routineseries of serological tests applied to patients with obscurefever. As regards treatment, clinical improvement seemsto follow a dosage of 400,000 units of penicillin dailytogether with one of the more active sulphonamides.V. fetus is fairly sensitive in vitro to both penicillinand streptomycin. German veterinary surgeons haveclaimed good results in cattle with neoarsphenamine,and this drug might well be tried in human cases.How human infection occurs is unknown but it is

reasonable to suppose that the bovine organisms mightbe spread by dairy products. Cattle can certainlybe infected by mouth. All attempts to culture the

organism in milk have been unsuccessful and no-oneknows how long a previously infected cow may remaincontagious. It is somewhat remarkable that of the threeFrench cases described by Vinzent et awl. one was in thewife of a doctor and one in a midwife. So far, no humancases have been reported in Great Britain, but thismay be because they have not been looked for. There1. M’Fadyean, J., Stockman, S. Report of the Departmental

Committee on Epizootic Abortion. Board of Agriculture andFisheries. London, 1913.

2. Vinzent, R., Delarue, J., Hebert, H. Ann. Méd. 1950, 51, 23.3. Vinzent, R., Dumas, J., Picard, N. Bull. Acad. nat. Méd. 1947,

131, 90.4. According to its most recent list (1948), the National Collection

of Type Cultures maintains 3 strains of V. fetus.

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are still some severe septicaemias that defy all attemptsat exact diagnosis. And it might be profitable to findout whether V. fetus infection takes any part in thecausation of that 25% of all abortions which are said tobe unexplained.

MEDICAL PATENTS

AMONG doctors the habit is to share knowledge freely :what is learnt by one is made known to all. Desire to

preserve this open communication and to avoid harmfulmonopolies underlies the precept that no medical manshould take out a patent in respect of a medical invention.In abstract this isa sound, and even a noble, idea ; butin the context of a warmly competitive world marketit has proved increasingly detrimental to those whom itis meant to protect-the public. Accordingly, in theirannual report 1 the council of the British Medical Associa-tion recommend that, subject to certain conditions, adoctor should be allowed to patent an invention.Patentable discoveries derive from the work not of

clinicians but of research-workers, who nowadays areassociated with chemists, physicists, engineers, andothers. A special committee which the council appointed,with Dr. Robert Forbes as chairman, notes that " thereimmediately arises the possibility of a moral obligationupon the non-medical specialist to avoid patentingwhere formerly he would have patented, and it may beincumbent upon the medical profession to make con-cessions in departing from the custom that formerlyprevailed." There are further, and perhaps weightier,arguments for a change of attitude. Where an inventionis not protected by a patent, a manufacturer wouldnormally refuse to handle it, lest others took the oppor-tunity of profiting freely by his development of the

discovery. More important still, observance of the

no-patenting rule may tell hard on the whole country,particularly where a " central " patent is vacated : theBritish consumer now pays royalties to American firmsfor penicillin manufactured in this country.Some years ago the British Medical Association pro-

posed that doctors should be enabled to dedicate patentsto the public. There are precedents for such usage. TheDicks patented their scarlet-fever toxin and antitoxin,but delegated their rights to a special committee. The

patent for Sir Frederick Banting’s process for preparinginsulin was taken out in the name of the University ofToronto, but the British rights were vested in the MedicalResearch Council. The way to delegation in the publicinterest has now been opened by the Development ofInventions Act, 1948, under which the National ResearchDevelopment Corporation was set up as an independentbody to which medical patents might be assigned. As

regards reward to the inventor, none would be paid bythe Corporation to anyone who is another man’s servant-for instance, a Crown servant, who in any eventwould be precluded by his contract from deriving anybenefit from his invention (though he might receive anaward from the Departmental Awards Committee). Therelationship between the corporation and a sole workernot employed by an organisation who wished to assigna patent and claim an award would be one of buyerand seller ; but, says the B.M.A. report, "in the caseof a medical man the Corporation would not take anyaction that would conflict with a policy laid down bythe profession as a whole." When the association’sRepresentative Body meets next month it will be askedto approve the conclusion that " in the opinion of theAssociation there is no longer any objection to the

patenting of inventions for which members of the medicalprofession are responsible, provided such patents are

assigned to the National Development Corporation with aview to their administration in the best interests of theDublic as a whftjf " This Hfma a raH).:) enl"tinn.

1. Brit. med. J. suppl. June 10, p. 276.

THE THYROID AND LACTATION

THE lactation-stimulating (galactopoietic) effect of

thyroid-active preparations seems to have been first

suggested in 1896 by an experiment of Hertoghe,lwho increased the milk yield of a cow by feedingit dried thyroid gland. This effect of dried thyroidwas later independently rediscovered -and extendedto thyroxine by Graham,2 and soon the results of

Folley and White 3 in lactating cows clearly demon-strated the considerable galactopoiesis produced byinjections of crystalline thyroxine. Interest in the

possible applications of this discovery in dairy farmingremained lukewarm for some years, mainly because ofthe belief that the effectiveness of thyroxine by mouthwas so low that it would be uneconomic to give it to

milking cows except by injection, which would obviouslybe impracticable. And dried thyroid gland, though fullyactive by mouth in cows, was not plentiful or cheapenough to be a practical alternative. At the beginningof the late war, however, Ludwig and von Mutzen-becher 4 discovered that a thyroid-active protein effectiveby mouth could be prepared by the iodination of casein.Improved methods of cheap large-scale production weresoon devised, so that extensive researches could bebegun on the various uses of this artificial thyroid-activeprotein in agriculture, mainly for increasing the milkyield of cattle, but to a less extent for stimulating egg-production in hens and accelerating growth in youngpigs. 5

Lately the wheel has come full circle, bringing syntheticthyroxine back into the picture. A new synthesis ofl-thyroxine has been worked out 6 which seems capableof large-scale development so as to supply the synthetichormone in considerable amounts at relatively low cost.Following this, Bailey, Bartlett, and Folley have shownthat l-thyroxine by mouth is a good deal more activein stimulating lactation in milking cows than hashitherto been believed. The optimum oral dose of thesynthetic hormone for this purpose (about ten times thatby the subcutaneous route) is such that, in view of itsrelatively low cost of production by the new method, itis likely to be at least as cheap to use as iodocasein, andin practice it has some important advantages. Thus,the crystalline l-thyroxine is virtually tasteless, whereasiodocasein preparations are often so unpalatable thata significant proportion of cows will refuse to eatrations containing them. Perhaps its most valuablefeature is that, being a pure crystalline substance, itdoes not need to be standardised by bio-assay, a trouble-some and unsatisfactory procedure which has proveddifficult from the very outset of the experiments withiodocasein in this country. Provided the long-termexperiments now in progress under the auspices of theAgricultural Research Council show that the repeatedadministration of thyroid preparations in successivelactations does no harm to the health or reproductiveabilities of the cattle, synthetic thyroxine is likely to bechosen for general use.The thyroid treatment of hypogalactia in women also

dates back to Hertoghe, but the modern clinical investi-gations can be said to have started with the work ofRobinsoii,8 who reported successful though variableresults in hypogalactia by feeding either dried thyroid1. Hertoghe, E. Bull. Acad. Méd. Belg. 1896, ser. 4, 10, 381.

See Robertson, J. D. Lancet, 1946, i, 978.2. Graham, W. R. jun. J. Nutrit. 1934, 7, 407 ; Biochem. J. 1934,

28, 1368.3. Folley, S. J., White, P. Proc. roy. Soc. B. 1936, 120, 346.4. Ludwig, V., von Mutzenbecher, P. Hoppe-Seyl. Z. 1939, 258,

195.5. See Reineke, E. P. Vit. & Horm. 1946, 4, 207. Young, F. G.

Brit. med. Bull. 1947, 5, 155.6. Chalmers, J. R., Dickson, G. T., Elks, J., Hems, B. A. J.

chem. Soc. 1949, p. 3424.7. Bailey, G. L., Bartlett, S., Folley, S. J. Nature, Lond. 1949,

163, 800.8. Robinson, M. Lancet, 1947, ii, 385.