AN EAST AFRICAN MEDICAL RESEARCH FUND.

AN EAST AFRICAN MEDICAL RESEARCH FUND.

88

published,l he had to determine where a beginning should be made. Was the economic state of these certified. The Master then asked that Dr. RUSSELL people to be bettered, so that their health should be should make an affidavit as to the necessity of a improved, or was the attack to be begun in the other physical examination in Mrs. EASTON’S case. Dr. direction ? He makes clear once again that there is RussELL thus came to assert the series of physical no royal road to malaria control, but that the best examinations which he said should have been made. means of effecting this must be discovered afresh for The pupil of the eye should have been examined-an all localities, for they vary with different conditions ophthalmoscope employed to detect pressure on the of climate and population. In the great area under brain-search made for tremor of the face, tongue, discussion the measures needful for a direct attack on and hands-knee-jerks tested, and so on. What the the malaria parasites in man and anopheles would be Court of Appeal thought of these assertions we know. difficult and expensive, and their application would Lord Justice GREER said that, if it were literally true be beyond all available resources. Merely to envisage that there must be no certification without physical the task of screening the rough shelters of these examination, then, even when an alleged lunatic people, of inducing the general use of mosquito nets, came into a room with an open knife and attacked the mosquito boots and quinine, and of applying antitwo doctors and afterwards tried to kill himself, larval measures generally, is to be convinced of its it would still be necessary, according to Dr. futility. Economic progress must be made, and the RUSSELL, that they should test his physical jerks native must be educated to realise the advantages he before certifying him. Lord Justice SCRUTTON, as can get from the applications of medicine and hygiene reported in our columns a fortnight ago, said that a before any real beginning can be made in the effort doctor who comes to examine an alleged lunatic is not ’, to stamp out malaria from the native reserves, and employed by the patient and has no authority to thus to eliminate a reservoir from which malaria is apply all these tests to which the patient would being widely diffused through Kenya.2 This will be probably object strenuously. He mentioned the a long process, and no dramatic results can be looked case (which he had once tried at Exeter) of a lunatic for to cheer those who spend their lives in propaganda who believed himself to e e a member of the Royal which will take generations to soak in. of punishing anybody Family, with special rig Fortunately an indirect attack-or, in other words, with whom he disagreed. If the patient expressed the application of well-tried measures directed to prosuch delusions, a careful octor (provided that he tect from malaria farms, railways, roads, and towns-is were satisfied that the patient was not playing him feasible and promising, but here again Colonel JAMES a joke) would be entitled to deem him of unsound insists that there is no short cut: even now much mind without further examination. investigation in field and laboratory is needed before The upshot of the Court of Appeal’s decision is to local antimalarial work can be used to the greatest furnish valuable first aid towards the relief of a certify- advantage. The small technical staff required for ing doctor from legal liability. But everything will this work, who might receive part of their training in depend upon the evidence which the doctor will be India, includes a medical entomologist and an antiable to produce on an application under Section 330 (2), malarial engineer; this team should, it is advised, when he asks the Court to stop the plaintiff’s action. continue and extend the work initiated by Colonel He should put himself in a position to prove, for JAMEs-work which implicated Anopheles funestus and example, so small a matter as the length of his examin- A. costalis as two of the local carriers; and should keep ation ; by noting down the time taken he may be in touch with the world’s malaria literature and with the able afterwards to refute the usual allegation by the technical experts of all the Government’s departments, patient that the examination was casual and per- whose activities may influence malarial incidence. functory and that " he only looked at me for a couple Sound measures are advised to meet the special needs of minutes." And the doctor should bear in mind of certain sections of the community, but Colonel the value of corroboration. All this precaution adds JAMES refuses to minimise the considerable difficulties new worries to the never very welcome duty of involved. For instance, Colonel JAMES found that in Uganda and parts of Rhodesia everycertifying. But it may save trouble in the end with the law as it is. one who could afford it had a screened house, in Kenya hardly anyone seemed prepared to pay for this protection; and he cites a case where, in spite AN EAST AFRICAN MEDICAL RESEARCH of nine attacks of blackwater fever between them, a farmer and his wife had been content to live for FUND. sixteen years in the same necessarily unscreened IN the 200,000 square miles over which are scattered wattle and daub house. Not that screening can be the native reserves of Kenya there live 2,500,000 firmly trusted ; inside all the screened houses of Africans, poor, illiterate, destitute even of such Government officials with whom he stayed Colonel household furniture as a bed, and usually without JAMES caught mosquitoes, and it is specially significant clothing. Not less than 1,000,000 of them are con- that medical officers living in these same screened stantly suffering from malaria, and probably not more ! houses saw to it that they and their families wore than a score are within reach of a medical man. TheirI mosquito boots after dark, and slept under curtains. malarial index is, in places, as high as 80 per cent., Since then, whether from faulty workmanship or and certain of them pass from their reserves to work from the carelessness or laziness of servants, screened on farms, roads, railways, and in towns, where they houses are not in practice mosquito-proof, it is only and to their infection spread European generously by incessant watchfulness that even Europeans can Asiatic non-immune immigrants. These Africans escape malaria until such time as steady, sanitary formed the core of the problem which confronted 1 Report on a visit to Kenya and Uganda to advise on antiColonel S. P. JAMES, the advisor on Tropical Diseases malarial measures. By S. P. James, I.M.S. (retd.), Advisor Diseases to the Ministry of Health. Published by on to the Ministry of Health, when he was deputed to the Tropical Crown Agents for the Colonies, 4, Millbank, London, S.W. 1s. tour East Africa and report on the malaria position 2 A Government report on the public health of Kenva for 1928 just been published, and is reviewed on p. 113 of this issue. there, and the measures which could be taken to has It provides some pertinent intelligence as to the malarial position of in a First out as it. he all, report existing during the year. points mitigate Hume

Spry case to the effect that it was not essential a physical examination of the person to be

now

to have

ts

while

89

DEPRESSION.

the case calls for a tonic, a digestive, a search for focal races has done its slow work. Regarding towns, Colonel JAMES writes " no anti- sepsis, a cheery reassurance, a pathological examinamalarial scheme, based on measures to reduce mos- tion, a psychological analysis, a rest, or a certificate quitoes has ever been successful which did not include under the Lunacy Acts. He has also to struggle legislation to enforce the necessary measures.’’ against the almost overwhelming temptation to Research and education working hand in hand hold make a meaningless diagnosis of " a bit liverish " promise for the future, but discipline must also play or, as Sir FARQUHAR BUZZARD suggests, " neurasthenia "-a diagnosis which will very likely satisfy the a part. For the furtherance of research the pattern advised patient but can never satisfy the professional conis the Indian Research Fund Association, with its science. He owes a real debt of gratitude to those record of valuable work, its annual Government leaders who, like Sir FARQUHAR, try to differentiate contribution of 33,000, and the aid given to it by for him the different types of mental case in language From the " dump " of donors from the general public, who thereby obtain free from technicalities. the privilege of suggesting lines of investigation. The neurasthenia Sir FARQUHAR draws out two distinct report advises the initiation of an " East African groups, the anxiety state and the manic-depressive Medical Research Fund," with a yearly grant of state. Some of his readers may be troubled by a 95000 from each of the Governments of Kenya, suspicion that the problem is not quite so simple as Uganda, and Tanganyika. The aggregate amount they are here led to believe, but most will be more than would suffice to maintain workers set apart for the grateful for guidance in the distinction of types of sole study of malaria, and would thus provide for depression which require fundamentally different that intensive scientific campaign for which the PRINCE treatment. An important fact not taught in the OF WALES asked so earnestly in a speech delivered in medical schools until quite recent times is that there Nairobi on Armistice Day, 1928. This speech made a are far more manic-depressives outside than inside profound impression in East Africa, and was clearly mental hospitals. It may not be wise to admit to the responsible for initiating the investigation from which patient that his depression, though it may have been Colonel JAMES’S admirable report has emerged. Some precipitated by some external cause, is really only local disappointment may be caused that no more the reverse picture of his own buoyant self-confidence concrete suggestions could be made. The lay public and that in time the cycle will be re-established. wearies of exhortations to spend money on research, But it can do no harm to dissuade his friends from when it would welcome a demand for a greater sum attempts to brace and activate a mind whose for a well-defined, simple scheme of engineering. But depression increases after effort and whose chief A Colonel JAMES has spoken bravely and honestly, and symptom may be an abnormal fatiguability. no one who knows anything of endemic diseases will practitioner who has grasped the distinction insisted disagree that while our tropical lands can exchange on by Sir FARQUHAR has at least his mind open to experiences with advantage, each one has to work out the study of one of the commonest and most for itself, in its own place, its own malarial problem. distressing maladies he will meet, and has put himself in a position to help both the patient and his friends. Dr. R. D. GILLESPIE from his experience at the Cassel Hospital has also been trying to differentiate DEPRESSION. various types of depression,’- and distinguishes three THE comparison between DARWIN and FREUD has classes : the reactive, the autonomous, and the recently been drawn afresh. In many respects the involutional. In the first group he puts those who troubles of psychiatrists to-day do indeed resemble are susceptible to environmental influences, both those of zoologists when DARWIN had convinced them internal and external, and whose illness seems to have that their systematic zoology must be reconciled with been precipitated by some obvious external cause, such the process of evolution. Great geniuses like as sickness, bereavement, or business difficulties. The KRAEPELIN had studied the end-products and autonomous group is a mixed one, including depresdescribed outstanding groups of mental symptoms, sions which appear as part of the splitting-up of a cutting, so to speak, transverse sections of mental personality (schizophrenic), those which are part of the Then came FREUD, insisting, as Sir direct development of a personality, and those which disorder. FARQUHAR BuzzARD pointed out in the Purvis appear as a phase in a mood-cycle (manic-depressive). Oration which we published last week, on a longi- In this last group the condition varies little if at all tudinal section, wherein the evolution of these in response to intercurrent stimuli, and a tendency

education of all

’

disorders could be traced from earliest childhood and This inevitably meant some confusion; before. apparently related species were found to have very different origins, while offspring of one kind of psychological trauma might diverge to produce very different-looking diseases. Systematic psychiatrists are still struggling with the reorganisation of their classification, and the general practitioner may well feel helpless and bewildered when he is called upon to deal, practically and promptly, with the endproducts. Suitable treatment for one kind of mental disorder may be the worst thing in the world for another kind which closely resembles it, and two, apparently similar cases call for widely differing prognoses. Commonest of all symptomatic groups is that whichl may be vaguely called " depression." Hardly a day passes but the practitioner meets a patient who} complains of lack of enthusiasm and vitality. The doctor has to decide, perhaps quite promptly, whether ,

.

-

r

more often found here than in the reactive group, whose victims generally blame their environment. Dr. GILLESPIE thinks that the presence or absence of reactivity is likely to be the most useful sign in indicating prognosis and treatment, although he admits that no one sign can ever be a touchstone. The prognosis is much better for the reactive than for the autonomous, and only the reactive are at all accessible to psychotherapy. Another effort in the same direction is that of Dr. MARJORIE FRANKLIN2 who distinguishes psychoses, She psychoneuroses, and character-formations. approaches them from the evolutionary point of view and characterises the psychoses as those conditions in which the fixation is at a low-first and second oral or first anal-stage, the object relationship auto-erotic or narcissistic, destructive impulses strong and ego changes predominant. In other words, the psychotic

to self-accusation is much

1 2

Guy’s Hospital Reports, 1929, lxxix., 306.

Journal of Mental Science

1929, lxxv., 671.