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ROBINSON'S TRAVELS
646
though infection is not constantly associated with emphysema. Shaw and Simpson1 have now elucidated this problem. They began their study by considering only patients in whom arterial oxygen saturation was persistently low over a period of at least a year, since it seemed possible that intermittent lack of oxygen might not stimulate red-cell formation.2 These workers used radioactive iron to study erythropoiesis, and radioactive chromium to measure plasma-volume. They found that the pattern of iron-binding capacity and the increases in the plasma-iron after their patients had been given an oral dose were typical of iron deficiency but quite unlike those reported in the anaemia of infection. At the same time they found that the patients’ plasma-volume was nearly 50% higher than in the controls, the greatest values being in those with a past history of heart-failure. There was no evidence of increased red-cell destruction, and the patients did have a substantial increase in red cells expressed as a fraction of body-weight but not expressed as a fraction of blood-volume. In other words the patients had a true plethora of red cells but were not polycythEemic according to the customary restricted definition. Quantitative studies showed that the redcell volume (in ml. per kg. body-weight) bore the same linear relationship to the percentage saturation of the arterial blood both in the group of patients and in dwellers at high altitudes. In answering the question Why does the red-cell count rise in hypoxic emphysema ? Shaw and Simpson have posed another: Why does the plasma-volume rise at the same rate as the red-cell volume ? Clearly the answer lies in the interrelation between pulmonary and hxmodynamic function and not, as has hitherto been thought, in that between pulmonary and hsemopoietic function.
not
ROBINSON’S TRAVELS
WORLD Mental Health year, which ends this month with the congress of the World Federation for Mental Health in Paris, was chosen by the National Association for Mental Health as the appropriate time for a selective global review of other countries’ mental-health services. With the help of the Bruern Foundation, they offered Mr. Kenneth Robinson, M.P., a travelling fellowship which has enabled him to visit Holland, France, the United States, and the Soviet Union. In his reporton his comparative study tour he admits that he was somewhat surprised everywhere to meet so many familiar anxieties, difficulties, and pressures. He was heartened to find that everyone was moving in the same therapeutic direction" towards community care, towards more dynamic treatment, towards a more liberal hospital atmosphere, and towards public enlightenment about the nature of mental disorder ". But progress is uneven, though in each country he visited he was impressed by promising spearheads. Mr. Robinson is clearly a fair-minded assessor and it is reassuring that he thinks that on the broad front no country has proceeded so far as Britain. At some points, indeed, he holds that we have a lead-notably in the introduction of the open-door policy, in the reablement of the long-stay patient, and in the use of non-medical therapy, such as factory projects. Many other countries 1. Shaw, D. B., Simpson, T. Quart. J. Med. 1961, 118, 135. 2. Simpson, T. Lancet, 1957, ii, 105. 3. Patterns of Care. 1961; pp. 42. (Obtainable from the National Association for Mental Health, 39, Queen Anne Street, London, W.1. 2s. 6d.)
and the proof foreign psychiatrists. Most important of all, he considers, is the fact that the actual care and treatment offered to patients in our progressive hospitals are unequalled. Nowhere did he find a more " liberal, permissive, therapeutic atmosphere ". One reason for this, he suggests, is that our hospitals are more generously staffed with trained The shortage of trained nurses everywhere, nurses. except in the Soviet Union, is apparently acute, and by the end of his tour he was startled to find that he had begun to think that Britain was " relatively fortunate ". are
handicapped by outmoded legislation,
visions of
our new
Mental Health Act
are the envy
But there are points where we lag behind other In the United States and in France Mr. countries. Robinson saw new mental hospital buildings which were incomparably better than anything we have yet to show. For instance, Dr. Sivadon, one of the authors of the W.H.O. report on the design of psychiatric hospitals,4 is building a 300-bed hospital at Chateau de la Valliere, at a cost of E7000 a bed, which will provide a flexible therapeutic background of comparative isolation, a small group, a larger group, or contact with the community, according to the patient’s needs. Mr. Robinson has often urged, at Westminster and elsewhere, that psychiatry should be given a larger place in the medical curriculum, and this opinion has been reinforced by what he saw. He comments on the " remarkable break-through " made by psychiatrists in the United States during the last five years. The teaching of psychological medicine there now receives much more emphasis, and in the University of California, for instance, it has been increased to over 10% of the students’ study hours. A compulsory paper in psychological medicine is to be introduced into the National Board’s final examination. Only in the United States did Mr. Robinson find that enough money and people were being allocated to research. The National Institute of Mental Health at Bethesda has a budget of 101 million dollars of which 39 million goes to research, while 75 beds are set aside for mental health at the 500-bed clinical research centre The institute also sponsors research proat Bethesda. in other parts of the States. One that interested jects Mr. Robinson was the clinical neuropharmacology centre in Saint Elizabeth’s Hospital, Washington, run by Dr. Joel Elkes, who formerly held the chair of experimental psychiatry at Birmingham. At the centre, which has 350 beds, new research techniques applicable to a mental-hospital population are being studied. Ultimately, progress in the care of the mentally ill depends on public opinion, and Mr. Robinson admits that this is hard to assess. In his view, though public interest is most intense in the United States it may have " some element of morbidity ". But acceptance is important as well as awareness, and he was impressed by the tolerance and sympathy shown to these patients in the Soviet Union, though he fancied that there seemed to be a tendency to regard subnormality (as opposed to mental illness) as a slur on their form of society. In this country he feels that the acceptance of the Mental Health Act by the public and the Press shows that we are shedding old prejudices and fears. But we have still many shortcomings and gaps, and we clearly have much to learn from Mr. Robinson’s candid account of his travels. 4. Baker, A., Llewelyn Davies, R., Sivadon, P. paper no. 1. Geneva; 1959. See Lancet, 1960
W.H.O.
i, 965.
public health
though infection is not constantly associated with emphysema. Shaw and Simpson1 have now elucidated this problem. They began their study by considering only patients in whom arterial oxygen saturation was persistently low over a period of at least a year, since it seemed possible that intermittent lack of oxygen might not stimulate red-cell formation.2 These workers used radioactive iron to study erythropoiesis, and radioactive chromium to measure plasma-volume. They found that the pattern of iron-binding capacity and the increases in the plasma-iron after their patients had been given an oral dose were typical of iron deficiency but quite unlike those reported in the anaemia of infection. At the same time they found that the patients’ plasma-volume was nearly 50% higher than in the controls, the greatest values being in those with a past history of heart-failure. There was no evidence of increased red-cell destruction, and the patients did have a substantial increase in red cells expressed as a fraction of body-weight but not expressed as a fraction of blood-volume. In other words the patients had a true plethora of red cells but were not polycythEemic according to the customary restricted definition. Quantitative studies showed that the redcell volume (in ml. per kg. body-weight) bore the same linear relationship to the percentage saturation of the arterial blood both in the group of patients and in dwellers at high altitudes. In answering the question Why does the red-cell count rise in hypoxic emphysema ? Shaw and Simpson have posed another: Why does the plasma-volume rise at the same rate as the red-cell volume ? Clearly the answer lies in the interrelation between pulmonary and hxmodynamic function and not, as has hitherto been thought, in that between pulmonary and hsemopoietic function.
not
ROBINSON’S TRAVELS
WORLD Mental Health year, which ends this month with the congress of the World Federation for Mental Health in Paris, was chosen by the National Association for Mental Health as the appropriate time for a selective global review of other countries’ mental-health services. With the help of the Bruern Foundation, they offered Mr. Kenneth Robinson, M.P., a travelling fellowship which has enabled him to visit Holland, France, the United States, and the Soviet Union. In his reporton his comparative study tour he admits that he was somewhat surprised everywhere to meet so many familiar anxieties, difficulties, and pressures. He was heartened to find that everyone was moving in the same therapeutic direction" towards community care, towards more dynamic treatment, towards a more liberal hospital atmosphere, and towards public enlightenment about the nature of mental disorder ". But progress is uneven, though in each country he visited he was impressed by promising spearheads. Mr. Robinson is clearly a fair-minded assessor and it is reassuring that he thinks that on the broad front no country has proceeded so far as Britain. At some points, indeed, he holds that we have a lead-notably in the introduction of the open-door policy, in the reablement of the long-stay patient, and in the use of non-medical therapy, such as factory projects. Many other countries 1. Shaw, D. B., Simpson, T. Quart. J. Med. 1961, 118, 135. 2. Simpson, T. Lancet, 1957, ii, 105. 3. Patterns of Care. 1961; pp. 42. (Obtainable from the National Association for Mental Health, 39, Queen Anne Street, London, W.1. 2s. 6d.)
and the proof foreign psychiatrists. Most important of all, he considers, is the fact that the actual care and treatment offered to patients in our progressive hospitals are unequalled. Nowhere did he find a more " liberal, permissive, therapeutic atmosphere ". One reason for this, he suggests, is that our hospitals are more generously staffed with trained The shortage of trained nurses everywhere, nurses. except in the Soviet Union, is apparently acute, and by the end of his tour he was startled to find that he had begun to think that Britain was " relatively fortunate ". are
handicapped by outmoded legislation,
visions of
our new
Mental Health Act
are the envy
But there are points where we lag behind other In the United States and in France Mr. countries. Robinson saw new mental hospital buildings which were incomparably better than anything we have yet to show. For instance, Dr. Sivadon, one of the authors of the W.H.O. report on the design of psychiatric hospitals,4 is building a 300-bed hospital at Chateau de la Valliere, at a cost of E7000 a bed, which will provide a flexible therapeutic background of comparative isolation, a small group, a larger group, or contact with the community, according to the patient’s needs. Mr. Robinson has often urged, at Westminster and elsewhere, that psychiatry should be given a larger place in the medical curriculum, and this opinion has been reinforced by what he saw. He comments on the " remarkable break-through " made by psychiatrists in the United States during the last five years. The teaching of psychological medicine there now receives much more emphasis, and in the University of California, for instance, it has been increased to over 10% of the students’ study hours. A compulsory paper in psychological medicine is to be introduced into the National Board’s final examination. Only in the United States did Mr. Robinson find that enough money and people were being allocated to research. The National Institute of Mental Health at Bethesda has a budget of 101 million dollars of which 39 million goes to research, while 75 beds are set aside for mental health at the 500-bed clinical research centre The institute also sponsors research proat Bethesda. in other parts of the States. One that interested jects Mr. Robinson was the clinical neuropharmacology centre in Saint Elizabeth’s Hospital, Washington, run by Dr. Joel Elkes, who formerly held the chair of experimental psychiatry at Birmingham. At the centre, which has 350 beds, new research techniques applicable to a mental-hospital population are being studied. Ultimately, progress in the care of the mentally ill depends on public opinion, and Mr. Robinson admits that this is hard to assess. In his view, though public interest is most intense in the United States it may have " some element of morbidity ". But acceptance is important as well as awareness, and he was impressed by the tolerance and sympathy shown to these patients in the Soviet Union, though he fancied that there seemed to be a tendency to regard subnormality (as opposed to mental illness) as a slur on their form of society. In this country he feels that the acceptance of the Mental Health Act by the public and the Press shows that we are shedding old prejudices and fears. But we have still many shortcomings and gaps, and we clearly have much to learn from Mr. Robinson’s candid account of his travels. 4. Baker, A., Llewelyn Davies, R., Sivadon, P. paper no. 1. Geneva; 1959. See Lancet, 1960
W.H.O.
i, 965.
public health