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BROMIDE INTOXICATION
INCENTIVES IN INDUSTRY.-BROMIDE INTOXICATION
incision and drainage has never found favour in this country, and the present support for conservative measures is therefore welcome. In the rare cases where surgical intervention has seemed advisable excellent results have been obtained by simple needling of the globus minor, accompanied where possible by aspiration of pus or inflammatory
surgical
secretion. INCENTIVES IN INDUSTRY
EXPERIMENTS recently carried out by C. E. Mace1 were directed towards determining the efficacy of setting up standards of achievement as an encouragement in the performance of tasks or the learning of them. Measurement of results was necessarily adopted a criterion of comparison between different as standards, and conclusions emerged that should find application in industrial life. The investigation falls into place with other work, such as the study of the actual movements involved in a specific industrial activity, which is aimed at the attainment of optimum results consistent with the comfort and well-being of the worker, without which proviso there is more than a danger that opposition will be aroused against what is regarded as a process of " speeding up." The experimenter in this case is interested in the human side rather than the mechanical, and expresses his appreciation of the larger problems when he hopes that the incentives of industry may ultimately be assimilated more closely to those of professional life. Industry has changed greatly since the bad old days when a worker was paid as little as possible and driven as hard as his physical powers allowed, his need for the necessaries of life being regarded as sufficient incentive to work. That need will always be a primary urge to human endeavour, but man, for good or ill, is driven by so many other motives that industry is compelled to take account of them. It is a commonplace to lament the decay of handicraft with its gratification of the pride of achievement, which Mr. Mace calls upon in his experimental subjects ; and to regret the repetitive processes that accompany mass production and appear to condemn workers to Yet it is a a day of monotony and boredom. that of industrial discovery repetitive psychology work need not be subjectively monotonous or inevitably accompanied by boredom ; human nature is so adjustable that with reasonable conditions of work, including rest pauses, such tasks can be happily performed. Rest pauses were introduced, on obvious physiological grounds, to avoid fatigue, and increased output justified them. But some paradoxical results obtained by Elton Mayo suggest2 that unexpected factors such as a sense of social solidarity in regard to one’s fellows and the management of the firm, rather than diminished physiological fatigue, were the cause of the improved output in a batch of workers who were closely observed over an experimental period of two years. This observation indicates a trend of thought that is coming more and more to influence industrialists, who have passed beyond the stage when Factory Acts were necessary to ensure attention to material safeguards of the health of the
worker, to sanitation, ventilation, protection against accidents, hours of juvenile labour and, in some cases, rates of pay; their chief function to-day is to protect standards from violation, not to establish them. 1 Incentives : Some Experimental Studies. Industrial Health Board Report No. 72. H.M. Stationery Office. 2 The Human Problems of an Industrial Civilisation. New York : The Macmillan Company. 1933.
325
The human and social aspects of industrial organisation are now receiving attention, one sign of this development being the employment of industrial welfare workers in factories and similar establishments. In the beginning welfare workers were expected to supervise matters affecting the comfort and material well-being of employees-canteens, amusements, and the like ; this they still do, but gradually there is emerging the principle that they serve as interpreters between the ideas of the administrative and employing side and the aspirations or even the dissatisfactions of the workers. An essential in the running of an industrial establishment is attention not only to the material but the emotional welfare of the employees, and in this way the difficulty of adjusting the human element to the demands of modern industry may perhaps be overcome. Welfare workers are now sufficiently numerous to have their own organisation and journal, and they are accumulating knowledge as to the mental attitudes and emotional reactions of individual employees which will fit in with the work of the Industrial Health Board and lead us nearer to the ideal of making the worker happy in his work ; for this is, after all, the first condition for the successful working of any system of incentives. BROMIDE INTOXICATION
OF late years several American observers have thought it well to call attention to the prevalence of bromide intoxication among psychotic, neurotic, and epileptic patients. To such patients bromide is often given for its sedative or anti-convulsive action, and mental symptoms due to too much bromide may pass unrecognised through being attributed to the disease that already exists. This is emphasised in a paper by Preu, Romano, and Brownwho describe what they term the symptomatic psychoses of bromide intoxication, and illustrate their description by details of nine cases. General retardation of mental processes, with anorexia and constipation, are well recognised as symptoms of bromism ; but further intoxication may, according to these writers, give rise to insomnia, restlessness, disorientation, and loss of memory, followed by ataxia, tremor, and delirium. Refusal of fluid as well as food is common, and still further aggravates the condition, which indeed is most likely to occur in patients who are cachectic, short of fluid and chlorides, or suffering from renal impairment. Sudden onset of insomnia or delirium in a patient taking bromides should always suggest bromism, and the absence of skin lesions in no way negatives this suggestion. Diagnosis can be made with certainty only by an estimation of the bromide content of the blood. If this exceeds 250 mg. per 100 c.cm., the mental symptoms can with confidence be attributed to bromide intoxication. Once the diagnosis is established the rest is easy. Bromide administration is stopped; fluids are administered in large quantities, together with 2 to 3 drachms of common salt a day ; and under this treatment the symptoms
rapidly disappear. What dosage of bromide is likely to cause this condition ?‘ Unfortunately the evidence on this is point inadequate. In two of the cases the quantity it varied for no very grains long period, but the doses may have been General clinical experience would, indeed, lead us to suppose that they must have been larger, because taken
was
unknown;
from 60 to 115
1 New Eng. Jour.
in the other a
seven
day, generally
Med., Jan. 9th, 1936, p. 56.
larger.
326
VASOMOTOR RESPONSES
very large numbers of epileptics in time past have taken much more heroic doses for prolonged periods without these ill-effects. It may be, however, as Preu and his colleagues suggest, that debilitated patients who for any reason are short of fluid, or whose blood is deficient in chlorides, will react in this unfavourable way to smaller doses. In any case the condition is one which the practising physician should keep in mind.
examined all showed responses exactly similar to those obtained with the normal subject. As the lesions in these patients involved between them all parts of the cerebral hemisphere the authors conclude that lesions of the cerebral hemisphere have no effect on the sympathetic vasomotor control of the extremities. They believe, however, that this control is dependent on the integrity of both preand post-ganglionic sympathetic fibres and on the integrity of the main sensory pathway from the point at which the body is stimulated. The sympathetic vasoconstrictor responses which occurred so constantly in these experiments were apparent in less than 4 seconds after the stimulus was applied. On the other hand, the vasodilator effects produced on warming the body only developed after the rectal temperature had begun to rise.
hemispheres
VASOMOTOR RESPONSES IN the current number of Brain Dr. E. Carmichael and his collaborators report the results of some recent investigations. Their intention was to test the functional capacity of the sympathetic nervous system in normal individuals and in patients suffering from various nerve lesions, particularly cases of hemiplegia. They sought first to ascertain whether there was OWING to the death of King George the annual. any difference between the vasomotor response in the normal and paralysed limb’! Simultaneous dinners of the Hunterian Society and of the Medical temperature readings were taken from the cheeks Society of London will not take place this year. and tips of the digits of the hands and feet by means Mr. C. H. Fagge will deliver the Hunterian oration of thermocouples, rectal temperature being also of the Royal College of Surgeons of England at registered by this method. Changes in the tempera- 4 P.M. on Friday, Feb. 14th, his title being John ture of the body were stimulated by the immersion Hunter to John Hilton. of one or more limbs first in hot and later in cold OWING to inadequate response from candidates, water. The main outcome of these studies was the translations from Latin and Greek will no demonstration that if one or other foot is immersed in optional set in the membership examination of the be hot water the first change observed is a rise of rectal longer Royal College of Physicians of London. More temperature, quickly followed by a rise in the temwill be attached to the translations from importance perature of both right and left hands, the curve French and German, and there will be a definite small of rise being identical for both upper extremities. allotment of marks for these in the total qualifying On transferring the heated limb to a cold bath the marks. They will however remain optional. temperature of the other extremities falls at once THE death occurred at St. Andrew’s on Sunday, Feb. The without any appreciable latent interval. of Mr. FARQUHAR MACRAE, consulting surgeon of in cases are obtained 2nd, responses hemiplegia exactly to the Western Infirmary, Glasgow, and the first the same as those obtained in a normal subject. In a further investigation2 a more delicate method secretary-inspector of the Indian Medical Council. of estimating the vasomotor reaction was employed. WE regret to announce the death of Mr. WILLIAM H. A plethysmograph was applied to a finger or toe in BATTLE, consulting surgeon to St. Thomas’s Hospital, such a way that a slight alteration in the volume of which occurred on Feb. 2nd, at Woking, Surrey. the enclosed digit could be recorded photographically Mr. Battle earned high esteem from the medical by means of a tambour to which was attached a profession both as general surgeon and as specialist mirror reflecting a beam of light on to a moving in more than one important department, while strip of bromide paper. Slight changes in the volume to this journal he rendered valuable service as a of the digits could thus be continuously recorded. collaborator for over twenty years. By this method the results previously obtained were amply confirmed and additional observations were INDEX TO "THE LANCET," VOL. II., 1935 made on the effect produced by various extrinsic THE Index and Title-page to Vol. II., 1935, and intrinsic stimuli. It was found, for example, which was completed with the issue of Dec. 28th, that the sudden application of pain or cold to any is now ready. A copy will be sent gratis to subpart of the skin, or the occurrence of a sudden noise, scribers on of a post card addressed to the receipt produces an almost immediate fall in the volume of the digits in all limbs. This effect is also produced Manager of THE LANCET, 7, Adam-street, Adelphi, Subscribers who have not already indicated by voluntary deep breathing, by mental activity, W.C.2. their desire to receive Indexes regularly as published and by visceral pain. It was shown that this effect do so now. should still occurs when the normal blood-supply of the limb is entirely cut off by a tourniquet. In subjects from whom the sympathetic control to one limb has PORT REGIS PREPARATORY SCHOOL.-At this been either removed by operation or destroyed by school two scholarships of :flOO each are preparatory injury this vasoconstrictor action fails to occur in annually awarded to the sons of medical men. The the affected limb. Further, the stimulus is only school is at Broadstairs, Kent, and the scholarships effective if applied to a part of the body from which were recently founded by Sir Milsom Rees. The next normal sensory nerve conduction is intact. When examination will be held on March 3rd, 1936. Candidates must be under 9 years of age at the time of competing, a painful stimulus is repeated the initial vasoconstrictor effect gradually passes off, even though and the scholarships are normally tenable till the holder leaves the school. The holders will be selected at an the last stimuli are as painful as the first. The interview in London from among those boys who have 23 patients suffering from lesions of the cerebral done best in some examination conducted in or
simple
their houses. Applications for the scholarships must be addressed to the headmaster, Port Regis School. Broadstairs, from whom full particulars may be obtained. The applications must be made not later than Feb. 20th.
near 1
Uprus, V., Gaylor, J. B., Williams, D. J., and Carmichael, 1935, Iviii., 448. 2 Sturup, G., Bolton, B., Williams, and Carmichael: Ibid.,
.
E. A.: Brain,
’
p. 456.
incision and drainage has never found favour in this country, and the present support for conservative measures is therefore welcome. In the rare cases where surgical intervention has seemed advisable excellent results have been obtained by simple needling of the globus minor, accompanied where possible by aspiration of pus or inflammatory
surgical
secretion. INCENTIVES IN INDUSTRY
EXPERIMENTS recently carried out by C. E. Mace1 were directed towards determining the efficacy of setting up standards of achievement as an encouragement in the performance of tasks or the learning of them. Measurement of results was necessarily adopted a criterion of comparison between different as standards, and conclusions emerged that should find application in industrial life. The investigation falls into place with other work, such as the study of the actual movements involved in a specific industrial activity, which is aimed at the attainment of optimum results consistent with the comfort and well-being of the worker, without which proviso there is more than a danger that opposition will be aroused against what is regarded as a process of " speeding up." The experimenter in this case is interested in the human side rather than the mechanical, and expresses his appreciation of the larger problems when he hopes that the incentives of industry may ultimately be assimilated more closely to those of professional life. Industry has changed greatly since the bad old days when a worker was paid as little as possible and driven as hard as his physical powers allowed, his need for the necessaries of life being regarded as sufficient incentive to work. That need will always be a primary urge to human endeavour, but man, for good or ill, is driven by so many other motives that industry is compelled to take account of them. It is a commonplace to lament the decay of handicraft with its gratification of the pride of achievement, which Mr. Mace calls upon in his experimental subjects ; and to regret the repetitive processes that accompany mass production and appear to condemn workers to Yet it is a a day of monotony and boredom. that of industrial discovery repetitive psychology work need not be subjectively monotonous or inevitably accompanied by boredom ; human nature is so adjustable that with reasonable conditions of work, including rest pauses, such tasks can be happily performed. Rest pauses were introduced, on obvious physiological grounds, to avoid fatigue, and increased output justified them. But some paradoxical results obtained by Elton Mayo suggest2 that unexpected factors such as a sense of social solidarity in regard to one’s fellows and the management of the firm, rather than diminished physiological fatigue, were the cause of the improved output in a batch of workers who were closely observed over an experimental period of two years. This observation indicates a trend of thought that is coming more and more to influence industrialists, who have passed beyond the stage when Factory Acts were necessary to ensure attention to material safeguards of the health of the
worker, to sanitation, ventilation, protection against accidents, hours of juvenile labour and, in some cases, rates of pay; their chief function to-day is to protect standards from violation, not to establish them. 1 Incentives : Some Experimental Studies. Industrial Health Board Report No. 72. H.M. Stationery Office. 2 The Human Problems of an Industrial Civilisation. New York : The Macmillan Company. 1933.
325
The human and social aspects of industrial organisation are now receiving attention, one sign of this development being the employment of industrial welfare workers in factories and similar establishments. In the beginning welfare workers were expected to supervise matters affecting the comfort and material well-being of employees-canteens, amusements, and the like ; this they still do, but gradually there is emerging the principle that they serve as interpreters between the ideas of the administrative and employing side and the aspirations or even the dissatisfactions of the workers. An essential in the running of an industrial establishment is attention not only to the material but the emotional welfare of the employees, and in this way the difficulty of adjusting the human element to the demands of modern industry may perhaps be overcome. Welfare workers are now sufficiently numerous to have their own organisation and journal, and they are accumulating knowledge as to the mental attitudes and emotional reactions of individual employees which will fit in with the work of the Industrial Health Board and lead us nearer to the ideal of making the worker happy in his work ; for this is, after all, the first condition for the successful working of any system of incentives. BROMIDE INTOXICATION
OF late years several American observers have thought it well to call attention to the prevalence of bromide intoxication among psychotic, neurotic, and epileptic patients. To such patients bromide is often given for its sedative or anti-convulsive action, and mental symptoms due to too much bromide may pass unrecognised through being attributed to the disease that already exists. This is emphasised in a paper by Preu, Romano, and Brownwho describe what they term the symptomatic psychoses of bromide intoxication, and illustrate their description by details of nine cases. General retardation of mental processes, with anorexia and constipation, are well recognised as symptoms of bromism ; but further intoxication may, according to these writers, give rise to insomnia, restlessness, disorientation, and loss of memory, followed by ataxia, tremor, and delirium. Refusal of fluid as well as food is common, and still further aggravates the condition, which indeed is most likely to occur in patients who are cachectic, short of fluid and chlorides, or suffering from renal impairment. Sudden onset of insomnia or delirium in a patient taking bromides should always suggest bromism, and the absence of skin lesions in no way negatives this suggestion. Diagnosis can be made with certainty only by an estimation of the bromide content of the blood. If this exceeds 250 mg. per 100 c.cm., the mental symptoms can with confidence be attributed to bromide intoxication. Once the diagnosis is established the rest is easy. Bromide administration is stopped; fluids are administered in large quantities, together with 2 to 3 drachms of common salt a day ; and under this treatment the symptoms
rapidly disappear. What dosage of bromide is likely to cause this condition ?‘ Unfortunately the evidence on this is point inadequate. In two of the cases the quantity it varied for no very grains long period, but the doses may have been General clinical experience would, indeed, lead us to suppose that they must have been larger, because taken
was
unknown;
from 60 to 115
1 New Eng. Jour.
in the other a
seven
day, generally
Med., Jan. 9th, 1936, p. 56.
larger.
326
VASOMOTOR RESPONSES
very large numbers of epileptics in time past have taken much more heroic doses for prolonged periods without these ill-effects. It may be, however, as Preu and his colleagues suggest, that debilitated patients who for any reason are short of fluid, or whose blood is deficient in chlorides, will react in this unfavourable way to smaller doses. In any case the condition is one which the practising physician should keep in mind.
examined all showed responses exactly similar to those obtained with the normal subject. As the lesions in these patients involved between them all parts of the cerebral hemisphere the authors conclude that lesions of the cerebral hemisphere have no effect on the sympathetic vasomotor control of the extremities. They believe, however, that this control is dependent on the integrity of both preand post-ganglionic sympathetic fibres and on the integrity of the main sensory pathway from the point at which the body is stimulated. The sympathetic vasoconstrictor responses which occurred so constantly in these experiments were apparent in less than 4 seconds after the stimulus was applied. On the other hand, the vasodilator effects produced on warming the body only developed after the rectal temperature had begun to rise.
hemispheres
VASOMOTOR RESPONSES IN the current number of Brain Dr. E. Carmichael and his collaborators report the results of some recent investigations. Their intention was to test the functional capacity of the sympathetic nervous system in normal individuals and in patients suffering from various nerve lesions, particularly cases of hemiplegia. They sought first to ascertain whether there was OWING to the death of King George the annual. any difference between the vasomotor response in the normal and paralysed limb’! Simultaneous dinners of the Hunterian Society and of the Medical temperature readings were taken from the cheeks Society of London will not take place this year. and tips of the digits of the hands and feet by means Mr. C. H. Fagge will deliver the Hunterian oration of thermocouples, rectal temperature being also of the Royal College of Surgeons of England at registered by this method. Changes in the tempera- 4 P.M. on Friday, Feb. 14th, his title being John ture of the body were stimulated by the immersion Hunter to John Hilton. of one or more limbs first in hot and later in cold OWING to inadequate response from candidates, water. The main outcome of these studies was the translations from Latin and Greek will no demonstration that if one or other foot is immersed in optional set in the membership examination of the be hot water the first change observed is a rise of rectal longer Royal College of Physicians of London. More temperature, quickly followed by a rise in the temwill be attached to the translations from importance perature of both right and left hands, the curve French and German, and there will be a definite small of rise being identical for both upper extremities. allotment of marks for these in the total qualifying On transferring the heated limb to a cold bath the marks. They will however remain optional. temperature of the other extremities falls at once THE death occurred at St. Andrew’s on Sunday, Feb. The without any appreciable latent interval. of Mr. FARQUHAR MACRAE, consulting surgeon of in cases are obtained 2nd, responses hemiplegia exactly to the Western Infirmary, Glasgow, and the first the same as those obtained in a normal subject. In a further investigation2 a more delicate method secretary-inspector of the Indian Medical Council. of estimating the vasomotor reaction was employed. WE regret to announce the death of Mr. WILLIAM H. A plethysmograph was applied to a finger or toe in BATTLE, consulting surgeon to St. Thomas’s Hospital, such a way that a slight alteration in the volume of which occurred on Feb. 2nd, at Woking, Surrey. the enclosed digit could be recorded photographically Mr. Battle earned high esteem from the medical by means of a tambour to which was attached a profession both as general surgeon and as specialist mirror reflecting a beam of light on to a moving in more than one important department, while strip of bromide paper. Slight changes in the volume to this journal he rendered valuable service as a of the digits could thus be continuously recorded. collaborator for over twenty years. By this method the results previously obtained were amply confirmed and additional observations were INDEX TO "THE LANCET," VOL. II., 1935 made on the effect produced by various extrinsic THE Index and Title-page to Vol. II., 1935, and intrinsic stimuli. It was found, for example, which was completed with the issue of Dec. 28th, that the sudden application of pain or cold to any is now ready. A copy will be sent gratis to subpart of the skin, or the occurrence of a sudden noise, scribers on of a post card addressed to the receipt produces an almost immediate fall in the volume of the digits in all limbs. This effect is also produced Manager of THE LANCET, 7, Adam-street, Adelphi, Subscribers who have not already indicated by voluntary deep breathing, by mental activity, W.C.2. their desire to receive Indexes regularly as published and by visceral pain. It was shown that this effect do so now. should still occurs when the normal blood-supply of the limb is entirely cut off by a tourniquet. In subjects from whom the sympathetic control to one limb has PORT REGIS PREPARATORY SCHOOL.-At this been either removed by operation or destroyed by school two scholarships of :flOO each are preparatory injury this vasoconstrictor action fails to occur in annually awarded to the sons of medical men. The the affected limb. Further, the stimulus is only school is at Broadstairs, Kent, and the scholarships effective if applied to a part of the body from which were recently founded by Sir Milsom Rees. The next normal sensory nerve conduction is intact. When examination will be held on March 3rd, 1936. Candidates must be under 9 years of age at the time of competing, a painful stimulus is repeated the initial vasoconstrictor effect gradually passes off, even though and the scholarships are normally tenable till the holder leaves the school. The holders will be selected at an the last stimuli are as painful as the first. The interview in London from among those boys who have 23 patients suffering from lesions of the cerebral done best in some examination conducted in or
simple
their houses. Applications for the scholarships must be addressed to the headmaster, Port Regis School. Broadstairs, from whom full particulars may be obtained. The applications must be made not later than Feb. 20th.
near 1
Uprus, V., Gaylor, J. B., Williams, D. J., and Carmichael, 1935, Iviii., 448. 2 Sturup, G., Bolton, B., Williams, and Carmichael: Ibid.,
.
E. A.: Brain,
’
p. 456.