393

been started, with the purpose of establishing the causeof this remarkable- finding. From Arizona the public-health commissioner, Dr. Clarence G. Salsbury, has

reported 12 somewhat similar findings, with reference tocancer generally, among the Navaho Indians. Apparentlycancer is hardly ever found in the 75,000 Navahos. Ina study of the records of all hospitals serving thesepeople, Salsbury and his associates discovered in 1953that 60,000 admissions had included only 208 cases ofcancer; and the 118 cases in females included no morethan 3 instances of cancer of the breast. Salsburybelieves that the Navaho diet may be the key to thecomparative lack of cancer. Highly refined foods areabsent from the typical diet, which " consists mainly ofmeat, corn, squash, some fruits and nuts, herbs, nativetea and squaw bread ’-a type of crisp panbread."

12. Ibid, Dec. 28, 1954.

PIONEERS IN PSYCHIATRY

THREE years after the fall of the Bastille, PhilippePinel struck the chains from the lunatics in the ParisBicetre. To the student of medical history-as thediscussion at a meeting on Jan. 8 of the section of

psychiatry of the Royal Society of Medicine showed-his action is significant not only as a landmark in thedevelopment of psychotherapy but also as a reflectionof the spirit of his age. Indeed, all his achievementsbear witness to the influence of that " Age of Enlighten-ment." As Prof. Aubrey Lewis pointed out, Pinelrealised early the importance of applying the mathematicalmethods of the exact sciences, then making their appear-ance in medicine. He was among the first to evaluatethe effects of treatment statistically, and to appreciatethe need for accurate case-records, regular progress-notes,and carefully controlled therapeutic trials. In the fieldof psychology Pinel was much indebted to British writers-particularly Locke-and by his humane treatment ofthe mentally ill he set an example which was followedthroughout Europe.One of Pinel’s most enthusiastic disciples was the

versatile James Cowles Prichard, who combined an

extensive knowledge of ethnology and philology with anunderstanding of insanity well in advance of his times.His best-known medical work, the Treatise on Insanity(1835), owed much to French influence, and in particularto Pinel’s brilliant pupil Esquirol. Dr. A. D. Leigh,speaking of Prichard’s contributions to British psychiatry,recalled that he was the first to distinguish

" moral

iusanity " from other forms of mental disorders-a con-troversial concept that has since received little favour.Prichard showed the influence of his Quaker upbringingin his persistent attempts to secure more humane con-ditions in asylums, and in his ardent support of the anti-slavery movement. In 1816 he became physician to theBristol Infirmary, where his learning, skill, and energymade him well known as a physician with enlightenedviews on psychiatry.Both Pinel and Prichard had advocated a humane

policy in the treatment of the insane ; William Browne,the medical officer of Crichton Royal Hospital, Dumfries,carried this into effect and amplified it with outstandingsuccess. Dr. James Harper, discussing Browne’s thesis,What Asylunts lI’ere, Atie, and What They Ought To Be,showed how closely Browne’s conception of a mentalhospital resembled that of modern times. Browneproposed that mental hospitals should be well planned,spacious, and beautiful-" like the palace of a peer "-with extensive gardens and fields in which patientscould enjoy sunshine and fresh air, and the freedomto which they were entitled. He appreciated to thefull the value of occupational therapy : his patientsat the Crichton Royal were provided each day with adetailed programme of activities, including games,lectures, dancing, exercises in the open, and even the

production of plays. He was, moreover, an excellentclinician, keeping copious notes on the progress andtreatment of each of his patients, making systematicrecords of their dreams, and including in each case-

history a " philosophical analysis of the patient’s mind."

Browne held that the staff of mental hospitals should bethe companions, friends, and teachers of their patientsas well as their guardians ; and he continually recom-mended " moral treatment of the most extended and

exquisite form." In his hands the methods championedby Pinel and Prichard at last found full and practicalexpression.

1. See Lancet, Feb. 12, 1955, p. 337.2. Ibid, 1954, i, 661.3. Friedgood, C. E., Ripstein, C. B. J. Amer. med. Ass. 1955,

157, 309.4. Scholer, J. F., Code, C. F. Gastroenterology, 1954, 27, 565.5. Visscher, M. B., Fetcher, E. S., Carr, C. W., Gregor, H. P.,

Bushey, M. S., Barker, D. E. Amer. J. Physiol. 1944, 142, 550.6. Cope, O., Blatt, M. H., Ball, M. R. J. clin. Invest. 1943, 22, 111.7. Howard. J. M. Surg. Gynec. Obstet. 1955, 100, 69.

CHLORPROMAZINE FOR HICCUP

IT is not surprising that chlorpromazine should betried in the treatment of hiccup ; for the drug powerfullyinhibits many central reflexes,l and hiccup may some-times represent the motor component of a reflex pathway-although there is good evidence that this is not alwaysso.2 Certainly the results now claimed by Friedgoodand Ripstein 3 are impressive. 50 patients with hiccupattributed to various causes ranging from coronarythrombosis to thoracic, abdominal, and urologicaloperations were treated with chlorpromazine, and in 41a single intravenous dose of 50 mg. stopped the hiccups.Some of these responses can best be described by thefavoured epithet,

" dramatic " ; for example, in a managed 57 who had had hiccups for nine days after anoperation for cancer of the rectum, the hiccups stoppedthree minutes after the injection of chlorpromazine anddid not return. Chlorpromazine will presumably nowtake its place in the list of remedies to be tried in thetreatment of intractable hiccup.

WATER ABSORPTION

WHEN heavy water is placed in the stomach or smallbowel, serial samples of arterial blood show the presenceof deuterium within a few minutes. The level of deuteriumin the arterial blood reaches a peak at about ten minutesafter intestinal administration, but at thirty minutesafter gastric administration. The disappearance of intra-venously injected deuterium can be estimated, and usedto correct the curves obtained after alimentary adminis-tration, so giving a measure of the rate of absorption.By such studies Scholer and Code 4 estimate that mod-erate quantities of water placed in the stomach are

absorbed at a rate of 2-5% of the dose per minute ;absorption from the small bowel is much more rapid-26-1% per minute. They point out that water in thestomach remains in a "puddle," demonstrable bysuspended barium ; whereas water introduced into theintestine is rapidly dispersed over a large mucosal surface.Even allowing for this, the absorptive activity of thesmall intestine, which has been shown to be an activeprocess,5 is probably greater than that of the stomach ;the demonstration that appreciable water absorptiongoes on in the stomach confirms in man the findings inisolated gastric pouches in the dog.6The deuterium method of studying water absorption

has been applied to the practical problem of whether togive water by mouth to patients with abdominal andother injuries. This work, reported by Howard,7 mayhave set up a record in long-range collaboration ; forthe deuterium was given in Korea and was estimated inWashington, D.C. The assessment of absorption in thisstudy was based, not on the form of the early arterialcurves, but on the time taken to reach equilibrium,judged by constancy of the deuterium level in venous

394

plasma. In healthy controls equilibration was completein two hours. In patients with chest and limb injuriesequilibrium was somewhat delayed, but this may havebeen due to delay in distribution of absorbed deuterium ;for deuterium given intravenously left the circulationmore slowly in injured patients. In the patients withchest and limb injuries fluid given by mouth was effectivein controlling thirst and maintaining the output of urine.By contrast, in patients with abdominal wounds equili-bration after oral administration of heavy water wasgrossly delayed ; the delay in absorption was greatestwhen the patient was shocked, but persisted in somedegree for a few days after shock had been corrected.More-direct evidence of interference with water absorp-tion was found at operation, when the bowel was oftendistended with unabsorbed fluid ; and patients withabdominal injuries commonly vomited if given water inany quantity.

This type of study cannot tell us whether delayedabsorption of water is due to diminished peristalsis, todiminished blood-flow, or to a specific impairment of

water-absorption by the intestinal mucosa ; but it

justifies the practical recommendation that fluid shouldnot be given by mouth to patients with major abdominalinjuries. With extra-abdominal injuries there may besome delay in water absorption ; but this is of no prac-tical importance, and the patients can be given enoughwater by mouth to relieve thirst and maintain urinevolume. This advice should perhaps be qualified by thereminder that oliguria is to be expected for twenty-fourto forty-eight hours after a severe injury, and waterintake should not be excessive during this period, in viewof the risk of water intoxication. 8

8. Wynn, V., Rob, C. G. Lancet, 1954, i, 587.9. Dykes, R. M., Grundy, F., Lewis-Faning, E. Brit. J. prev. soc.

Med. 1953, 7, 31. See Lancet, 1953, ii, 439.10. Spence, J., Walton, W. S., Miller, F. J. W., Court, S. D. M.

A Thousand Families in Newcastle upon Tyne. London, 1954.See Lancet, 1954, ii, 371.

11. The Health and Growth of the Under-Fives. By a Joint Com-mittee of the Institute of Child Health (University of London),Society of Medical Officers of Health, and Population Investiga-tion Committee. National Survey of the Health and Develop-ment of Children, London School of Economics and PoliticalScience, 13, Endsleigh Street, London, W.C.1. Pp. 17.

HEALTH AND GROWTH OF THE UNDER-FIVES

COMPREHENSIVE long-term field studies in human

biology and sociology are now yielding rich harvests.Nowhere is this approach providing more valuableinformation than in the field of child health, where threesuch surveys have attracted wide attention. The firstwas the Luton survey 9 of 1498 children born there in1945 ; of these, 1322 were followed up for the first fiveyears of life. The second survey began in 1946 when ajoint committee of the Institute of Child Health (Univer-sity of London), the Society of Medical Officers of Health,and the Population Investigation Committee inaugurateda nation-wide survey based on 5386 of the children bornin the first week of March of that year ; this studycontinues and the children are to be followed up to the

age of 12 years. A third field study, conceived by thelate Sir James Spence, began in Newcastle upon Tyne 10in 1947 with the enrolment of the 1142 children born inthat city in May and June ; this study, which alsocontinues, is especially important since it embraces thefamily of each child.The nation-wide survey has already led to the publi-

cation of fifteen reports on various aspects of maternaland child health. The latest report 11 summarises someof the findings relating to the first five years of life.Low social class, high parity of the mother, and prematurebirth are all shown to impose a handicap on health.It was also found that in passing from the lowest tothe highest social group the number of families withfour or more children fell rapidly. Although later-bornchildren tended to be heavier at birth than the earlyones, by the age of 2 years they had fallen behind in

weight and they remained behind at 4 years ; they werealso smaller than first-born children at these ages.A comparatively high proportion of the underweightchildren were the later-born children of large families.The lower social groups thus provided more than theirfair share of stunted and underweight children andproportionately fewer physically superior children. Thereasons are not discussed in the preliminary summary,but genetic factors and, particularly, nutritional factorswill probably both prove important.

Children in large families and lower social groups rana much greater risk of contracting infectious diseasesearly in life-when the consequences are likely to bemore serious. Overcrowding was an important con-

tributory factor, for among the families of manualworkers lower-respiratory infections in the first 2 yearsof life were one and a half times more frequent in homeswith two or more persons to a room than in those withone to a room or one to more than one room. Over.

crowding is still much more prevalent in Scotland thanin England, and this probably explains the considerablygreater hospital-admission rate for respiratory infectionsin Scotland. By the age of 5 years one child in fivehad been admitted to hospital at least once, and later-born children were admitted more often than first-born.Rather unexpectedly accidents were as frequent inwell-to-do as in poor homes and in small families as inlarge ones.About 25% of the mothers did-some paid work, and

the effect of the opposing influences of increased familyincome and deprivation of continuous maternal care

were studied. There is no evidence so far that the healthof the children suffered when mothers went out to work,except for a greater incidence of infection at an earlyage caused by a higher proportion of such children beingcared for in day-nurseries. The psychological traumainduced in these circumstances by separation from themother is not discussed in the preliminary report, butis no doubt receiving attention.The survey has confirmed the general impression that

the mothers who use child-welfare clinics are the mostcareful and conscientious and those who least needadvice, and that it is the mothers of large families whomake least use of such centres. In all social classesfirst-born children were the most likely to be taken,while those in families of three or more children werethe least likely to be taken ; such children were not

given regular medical supervision until they went to

school. It is easy to appreciate the difficulty of takingthe younger children to a clinic when there are severalin the family, and it is understandable that the motherof several children may feel that she no longer needsadvice. But the much lower rate of diphtheria immuni-sation in the younger children of large families is a goodexample of the less satisfactory care given to suchchildren : whereas 80% of the first-born had beenimmunised by the age of 2 years, only 50% of the youngerchildren of large families were so protected. 11% ofthe mothers were considered to be giving their childrenonly fair or poor care ; they came from the poorest andmost overcrowded families with many children and rarelywent to child-welfare clinics.The full significance of the facts that are being

collected in the survey will not be apparent until it is

possible to look back and see events in the life of thechild as components of a continuous chain.

THE INDEX and title-page to Vol. II, 1954, which wascompleted with THE LANCET of Dec. 25, is now in

preparation. A copy will be sent gratis to subscriberson receipt of a postcard addressed to the Manager ofTHE LANCET, 7, Adam Street, Adelphi, W.C.2. Sub-scribers who have not already indicated their desireto receive indexes regularly as published should do sonow.