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ANOREXIA AND MALNUTRITION IN CHILDREN.
THE LONGEVITY OF CRICKETERS.
is made that " cases of bronchial gland tuberculosis have done very well, and the X ray evidence tends to support the view that the light has had a favourable effect, although one is naturally cautious in drawing any definite conclusions, as it is possible the improvement might have taken place without the light." Now it is notorious that the diagnosis of tuberculous infection of the tracheo-bronchial glands can seldom be made with any degree of certainty. To determine by means of X rays or physical examination that an active lesion in this situation has become quiescent is in the present It is, therefore, state of knowledge impossible. undesirable to include statistics for a disease which can only be suspected, in tables devoted mainly to surgical tuberculosis of which the diagnosis is usually patent. A further assertion to the effect that "tuberculous eye conditions seem to respond very well to general treatment " is unsupported by evidence. Although one case of phlyctenular conjunctivitis is reported as cured, the assumption that this condition is tuberculous is not warranted. We recommend all those whose work brings them into contact with the tuberculosis service to read Dr. Cox’s report on the results obtained in the course of an interesting and very hopeful experiment. THE LONGEVITY OF CRICKETERS. IT is a deep-rooted belief that first-class athletes tend to die relatively young, but Mr. A. Bradford Hill, D.Sc., in a study from the National Institute for Medical Research (which appears on p. 919) shows that this belief is not well founded as far as cricket is concerned ; a strict analysis based upon data in Wisden’s " Cricketers’ Almanac " makes it clear that cricketers are long-lived in comparison with the general population. Dr. Hill is here dealing only with cricketers of British nationality born since 1888, and his analysis terminates in 1913 in order to avoid the disturbing influence of the years of war. Taking his analysis a little further Dr. Hill finds that amateurs have a slight advantage over professional players in regard to longevity, the explanation no doubt being that while the amateur shares with the professional the advantage of physical selection he has in addition the benefit, as regards length of life, of social selection. The statistical analysis on which Dr. Hill’s conclusions are based, although far more complete than any which has hitherto been made, was foreshadowed by figures given by a cricket enthusiast, Mr. Frederick Gale, Mr. Gale followed up the lifesome 45 years ago. history of the so-called " B eleven chosen by Lord Frederick Beauclerk to play against All-England. Of these 11 men the youngest died at the age of 69, while the others lived to various ages up to 95. In commenting on these figures Mr. Gale remarked that insurance offices would grow rich if no lives but those of cricketers were taken. It is not without interest that at the lecture in which Mr. Gale conveyed his observations, which were published at the time in our columns, the chair was occupied by Mr. Ruskin, then Slade Professor at Oxford.
929
producing State examines the water, prohibits shellfish being taken from unsafe water, gives licences for taking the shell-fish, inspects the marketing, packing, and shipping arrangements, and issues certificates to shippers who have complied with The State certificates are the State regulations.
submitted to the Federal service, which, if satisfied, adds the name of the certified shipper to a list which is sent out twice a month to the health authorities in the various States. The success of the scheme depends upon the effectiveness with which the health authorities of the shellfish-consuming States admit to their markets only shell-fish which come from properly certified shippers. Mr. Fisher’s article deals with other matters affecting the industry. Oysters thrive in a mixture of fresh and salt water, and the importance of the industry has in some cases led to the protection of estuaries from sewage pollution. The transfer of " seed " oysters from polluted waters to clean areas for development and maturity is mentioned as a danger, and the similar transfer of mature oysters as a still greater danger. In order that the oyster may free itself from impurity the temperature of the water must not be below 60’F., as a lower temperature interferes with the activity of the oyster, and prevents it cleaning itself. The examination of the water of the beds at frequent intervals is possibly a more reliable guide to safety than the examination of a certain number of the oysters. The practice of " fattening " oysters by removing them for short periods to fresher water and thus promoting osmosis brings added risk and has been prohibited by most of the oyster-producing States. The experiments which have been made to clean oysters by the use of chlorinated water have not so far met with approval and are compared to the " practice of pasteurising dirty milk." Mr. Fisher points out that there is a tendency amongst some of those engaged in the industry to make too much of the certification scheme as if it were an absolute guarantee given by the State and Federal governments, whereas the certificates refer only to the source of the oysters and the manner of packing at the point of origin. No responsibility is assumed for what happens to the oyster in its passage from the original shipper to the consumer. The progress of the scheme will be watched with much interest. In the past the careful conscientious oyster man has suffered from the doings of the less scrupulous producer. It is obviously of the utmost importance to the industry that the confidence of the public should be won.
"
SANITATION. THE outbreaks of enteric fever and other gastrointestinal complaints which have been traced from time to time to the consumption of shell-fish have seriously affected the prosperity of this industry in A conference held in Washington in America. February, 1925, led to the formulation of a scheme, described1 by Mr. L. M. Fisher, a sanitary engineer in the U.S. Public Health Service ; this scheme is promoted alike by the representatives of the health and commercial interests. The chief responsibility is thrown on the individual States, coordination and uniformity being secured by mutual agreements between the States with the help and advice of the Federal service. Under the scheme the shellfishSHELL-FISH
1 Public Health Reports, Sept. 16th, 1927.
ANOREXIA AND MALNUTRITION THE
views
expressed
at
a
IN CHILDREN.
recent
meeting
of
in Washingtonsuggested considerable of opinion on the best way of combating anorexia and malnutrition in children. Dr. C. A. Aldrich, giving an account of his method of avoiding anorexia, and the theory on which it is based, laid stress on the distinction between hunger (a purely physiological function) and appetite, " a much more complex mental process dependant on pleasant memories of feelings, tastes, odours, and sights." The former, he said, merely initiates the taking of food ; the latter controls the amount eaten. Transitory anorexia being usually the first symptom of an infection, whilst chronic anorexia results from the displeasurable feelings aroused by attempts to force the child to take food, Dr. Aldrich’s invariable rule is to allow the child-even during infancy-to regulate the quantity of its feeds " with appetite as a guide." The success of this practice was shown by answers to a questionaire circulated to the parents, for it was found that on the average the children so treated were 3-6 lb. heavier than the normal for their age. In those who were under weight a definite physical cause for malnutrition was usually present. That there is much to be said, on empirical grounds, for Dr. Aldrich’s line of treatment will be readily conceded
psediatrists divergence
1 Jour. Amer. Med. Assoc., Sept. I7th.
930
HOSPITALS AND MOTOR ACCIDENTS.
by many observers, though not all will admit the validity of the hypothesis on whichit is based. His remarks seem to apply to children of all ages, expressly including infants on the bottle ; and that so complex ’a mechanism as appetite," according to his definition, should govern the quantity of food taken in infancy is an idea that wilt be accepted by few psychologists at the present day. Dr. L. W. Sauer described a routine treatment of underweight children of various types (excluding sufferers from diabetes and some special diseases) which is based on lines diametrically opposed to those advocated by Dr. Aldrich, and consists of a course of forced feeding lasting for three months and combined with ’ periods of rest in bed. A five-meal diet is prescribed ;
sort of representation ought to be made to the Home Secretary to remove the stigma of his having been made a criminal." When Parliament reassembles some Member will doubtless inquire of the Home Secretary what has been, or is proposed to be, done: The case looks like one of those which divide medical and legal opinion. The medical profession detects a series of symptoms which culminate in the climax of legal insanity ; the symptoms and the climax are all stages of one disease ; looking back upon the history of the case the supposedly criminal act is seen to have been the act of an insane man. On the other hand, the law courts and the Home Office will not admit that the earlier stages of mental disease can be accepted as lessening the criminal responsibility afebrile children are started on an allowance of of the accused. The guardians of our penal system 40 calories pl-r lb. of actual weight, which is raised will not surrender the deterrent value of the hangman until it approximates 40 calories per lb. of the or the prison cell so long as the accused person has theoretical weight for the height and age. Even a lucid moment in which he can thereby be deterred. vomiting is not regarded as a contra-indication. A kind of rough-and-ready give-and-take between The results tabulated by Dr. Sauer show a gain the medical and the legal views is accepted by the of weight which is as striking as the rise in Dr. public because it is believed that the legal view is Aldrich’s cases. His patients were of ages ranging applied with the utmost humanity and with full from 5 to 12, and the psychological aspect of and enlightened use of the best medical information. " appetite " might have been expected to play a more If cases occur in which humanity is offended and important part in their nutrition than in that of the medical information is ignored, the public may series first described. be roused to a sense of the limitations of the legal view. some
"
ENOUGH
’
I
____
SANE
,
FOR SENTENCE.
COLOUR VISION. AT the recent Bedfordshire Assizes an inmate of A COMMITTEE of the British Association, consisting the Three Counties Me’atal Hospital at Arlesey was convicted and sentenced for assaulting one member of Sir Charles Sherrington, Prof. H. E. Roaf, Dr. In Mary Collins, and Dr. F. W. Edridge-Green, have of the hospital staff and threatening another. issued a report on colour vision, with particular the passing a sentence of two months’ imprisonment to the classification of colour - blindness. judge announced that he should assume that the reference accused man was sane. Possibly on this occasion Any reference, implicit or explicit, to any theory of the law was tempering justice with mercy ; two colour - blindness is carefully excluded, and it is months’ detention in a normal prison is regarded as recommended that the terms protanopia, deuteranopia, and tritanopia be abolished. Colour-blindness a lesser penalty than confinement for an indefinite is defined as any marked decrease in sensitivity to a at Broadmoor as a criminal lunatic. Neverperiod special region of the spectrum-e.g., to red-and it is theless, it certainly suggests that there must be recommended that if possible the precise wave-lengths the an with law when something wrong asylum involved should be specified. Fa lure to discriminate inmate is sentenced as a sane man. This and other incidents raise the od disquieting doubts whether colours should be described not as colour-blindness, but the law courts do not sometimes deliberately ignore as colour confusion-the number of distinct colours the medical history of accused persons instead of which are recognised in the spectrum being a rough of the degree of colour discrimination. All obtaining the utmost possible information before measure those persons who recognise only two colours in the The annual of sentence. latest the passing report Prison Commissioners contained some remarkable spectrum possess a neutral region in which no sensation revelations of the tendency of certain magistrates ’, of colour exists. Its position and extent should be to sentence a man first and to inquire into his mental determined. condition afterwards. Persons, it appears, are not HOSPITALS AND MOTOR ACCIDENTS. infrequently convicted and sentenced who are certified insane on their arrival in prison. A few months ago ALMOST every hospital in the country is faced by the Court of Criminal Appeal reaffirmed its rule of more or less serious difficulties as the result of the refusing to hear any fresh medical evidence in cases steadily increasing number of accidents caused by where the state of the accused’s mind is a ground motor traffic. Sometimes it is the occupants of the of appeal. The case of George Jordan, to which a cars who are injured, often seriously ; sometimes it correspondent draws attention in another column, is the unlucky pedestrian who suffers. Whichever it seems to suggest the same attitude of judicial indifferis, the result is the same for the nearest hospital. ence to matters which, after all, may be as relevant However acute the difficulty of finding room, the " " " " to the issue of guilty or not guilty as any sufferer has to be taken in and tended ; the general matters can be. experience is that, on the average, he occupies a bed If the facts in Jordan’s case are correctly stated, for a longer period than the ordinary patient ; and his he was sentenced to 18 months’ imprisonment by presence may delay the reception of a patient who has a court which did not adequately inform itself of his been waiting for admission, perhaps for months. This medical history and condition, and he was certified is the human side of the problem, but there is also insane soon after he began to serve his sentence. a serious financial side. More often than not these If so, he was stigmatised as a criminal without sufferers from motor casualties make no offering to sufficient consideration of his right to have the the institution that has put them on their legs again, defence of insanity raised on his behalf. He recently and the companies in which they are insured refuse committed suicide, and the coroner (Mr. Arthur H. to pay anything on the ground that hospitals are Emanuel, of Southampton), having apparently access voluntary institutions and are therefore unable to to medical evidence which must have made all the sustain a claim at law. Obviously the situation cannot difference if it had been available in the criminal be left there, and the hospitals, in self-defence and in court by which Jordan was sentenced, observed that the interest of those who have what may fairly be the case was one of the hardest and saddest in his described as the first claim upon them, will be comexperience. " By reason of his war service this man pelled to find some means of self-protection. The underwent injuries which made him assume the Norfolk and Norwich Hospital, the waiting-list of attributes of a criminal, whereas he was a splendid, which is being heavily encumbered by the results of honest man ; for the sake of his wife and children motor accidents, seems to have found an ingenious .
_____
.
is made that " cases of bronchial gland tuberculosis have done very well, and the X ray evidence tends to support the view that the light has had a favourable effect, although one is naturally cautious in drawing any definite conclusions, as it is possible the improvement might have taken place without the light." Now it is notorious that the diagnosis of tuberculous infection of the tracheo-bronchial glands can seldom be made with any degree of certainty. To determine by means of X rays or physical examination that an active lesion in this situation has become quiescent is in the present It is, therefore, state of knowledge impossible. undesirable to include statistics for a disease which can only be suspected, in tables devoted mainly to surgical tuberculosis of which the diagnosis is usually patent. A further assertion to the effect that "tuberculous eye conditions seem to respond very well to general treatment " is unsupported by evidence. Although one case of phlyctenular conjunctivitis is reported as cured, the assumption that this condition is tuberculous is not warranted. We recommend all those whose work brings them into contact with the tuberculosis service to read Dr. Cox’s report on the results obtained in the course of an interesting and very hopeful experiment. THE LONGEVITY OF CRICKETERS. IT is a deep-rooted belief that first-class athletes tend to die relatively young, but Mr. A. Bradford Hill, D.Sc., in a study from the National Institute for Medical Research (which appears on p. 919) shows that this belief is not well founded as far as cricket is concerned ; a strict analysis based upon data in Wisden’s " Cricketers’ Almanac " makes it clear that cricketers are long-lived in comparison with the general population. Dr. Hill is here dealing only with cricketers of British nationality born since 1888, and his analysis terminates in 1913 in order to avoid the disturbing influence of the years of war. Taking his analysis a little further Dr. Hill finds that amateurs have a slight advantage over professional players in regard to longevity, the explanation no doubt being that while the amateur shares with the professional the advantage of physical selection he has in addition the benefit, as regards length of life, of social selection. The statistical analysis on which Dr. Hill’s conclusions are based, although far more complete than any which has hitherto been made, was foreshadowed by figures given by a cricket enthusiast, Mr. Frederick Gale, Mr. Gale followed up the lifesome 45 years ago. history of the so-called " B eleven chosen by Lord Frederick Beauclerk to play against All-England. Of these 11 men the youngest died at the age of 69, while the others lived to various ages up to 95. In commenting on these figures Mr. Gale remarked that insurance offices would grow rich if no lives but those of cricketers were taken. It is not without interest that at the lecture in which Mr. Gale conveyed his observations, which were published at the time in our columns, the chair was occupied by Mr. Ruskin, then Slade Professor at Oxford.
929
producing State examines the water, prohibits shellfish being taken from unsafe water, gives licences for taking the shell-fish, inspects the marketing, packing, and shipping arrangements, and issues certificates to shippers who have complied with The State certificates are the State regulations.
submitted to the Federal service, which, if satisfied, adds the name of the certified shipper to a list which is sent out twice a month to the health authorities in the various States. The success of the scheme depends upon the effectiveness with which the health authorities of the shellfish-consuming States admit to their markets only shell-fish which come from properly certified shippers. Mr. Fisher’s article deals with other matters affecting the industry. Oysters thrive in a mixture of fresh and salt water, and the importance of the industry has in some cases led to the protection of estuaries from sewage pollution. The transfer of " seed " oysters from polluted waters to clean areas for development and maturity is mentioned as a danger, and the similar transfer of mature oysters as a still greater danger. In order that the oyster may free itself from impurity the temperature of the water must not be below 60’F., as a lower temperature interferes with the activity of the oyster, and prevents it cleaning itself. The examination of the water of the beds at frequent intervals is possibly a more reliable guide to safety than the examination of a certain number of the oysters. The practice of " fattening " oysters by removing them for short periods to fresher water and thus promoting osmosis brings added risk and has been prohibited by most of the oyster-producing States. The experiments which have been made to clean oysters by the use of chlorinated water have not so far met with approval and are compared to the " practice of pasteurising dirty milk." Mr. Fisher points out that there is a tendency amongst some of those engaged in the industry to make too much of the certification scheme as if it were an absolute guarantee given by the State and Federal governments, whereas the certificates refer only to the source of the oysters and the manner of packing at the point of origin. No responsibility is assumed for what happens to the oyster in its passage from the original shipper to the consumer. The progress of the scheme will be watched with much interest. In the past the careful conscientious oyster man has suffered from the doings of the less scrupulous producer. It is obviously of the utmost importance to the industry that the confidence of the public should be won.
"
SANITATION. THE outbreaks of enteric fever and other gastrointestinal complaints which have been traced from time to time to the consumption of shell-fish have seriously affected the prosperity of this industry in A conference held in Washington in America. February, 1925, led to the formulation of a scheme, described1 by Mr. L. M. Fisher, a sanitary engineer in the U.S. Public Health Service ; this scheme is promoted alike by the representatives of the health and commercial interests. The chief responsibility is thrown on the individual States, coordination and uniformity being secured by mutual agreements between the States with the help and advice of the Federal service. Under the scheme the shellfishSHELL-FISH
1 Public Health Reports, Sept. 16th, 1927.
ANOREXIA AND MALNUTRITION THE
views
expressed
at
a
IN CHILDREN.
recent
meeting
of
in Washingtonsuggested considerable of opinion on the best way of combating anorexia and malnutrition in children. Dr. C. A. Aldrich, giving an account of his method of avoiding anorexia, and the theory on which it is based, laid stress on the distinction between hunger (a purely physiological function) and appetite, " a much more complex mental process dependant on pleasant memories of feelings, tastes, odours, and sights." The former, he said, merely initiates the taking of food ; the latter controls the amount eaten. Transitory anorexia being usually the first symptom of an infection, whilst chronic anorexia results from the displeasurable feelings aroused by attempts to force the child to take food, Dr. Aldrich’s invariable rule is to allow the child-even during infancy-to regulate the quantity of its feeds " with appetite as a guide." The success of this practice was shown by answers to a questionaire circulated to the parents, for it was found that on the average the children so treated were 3-6 lb. heavier than the normal for their age. In those who were under weight a definite physical cause for malnutrition was usually present. That there is much to be said, on empirical grounds, for Dr. Aldrich’s line of treatment will be readily conceded
psediatrists divergence
1 Jour. Amer. Med. Assoc., Sept. I7th.
930
HOSPITALS AND MOTOR ACCIDENTS.
by many observers, though not all will admit the validity of the hypothesis on whichit is based. His remarks seem to apply to children of all ages, expressly including infants on the bottle ; and that so complex ’a mechanism as appetite," according to his definition, should govern the quantity of food taken in infancy is an idea that wilt be accepted by few psychologists at the present day. Dr. L. W. Sauer described a routine treatment of underweight children of various types (excluding sufferers from diabetes and some special diseases) which is based on lines diametrically opposed to those advocated by Dr. Aldrich, and consists of a course of forced feeding lasting for three months and combined with ’ periods of rest in bed. A five-meal diet is prescribed ;
sort of representation ought to be made to the Home Secretary to remove the stigma of his having been made a criminal." When Parliament reassembles some Member will doubtless inquire of the Home Secretary what has been, or is proposed to be, done: The case looks like one of those which divide medical and legal opinion. The medical profession detects a series of symptoms which culminate in the climax of legal insanity ; the symptoms and the climax are all stages of one disease ; looking back upon the history of the case the supposedly criminal act is seen to have been the act of an insane man. On the other hand, the law courts and the Home Office will not admit that the earlier stages of mental disease can be accepted as lessening the criminal responsibility afebrile children are started on an allowance of of the accused. The guardians of our penal system 40 calories pl-r lb. of actual weight, which is raised will not surrender the deterrent value of the hangman until it approximates 40 calories per lb. of the or the prison cell so long as the accused person has theoretical weight for the height and age. Even a lucid moment in which he can thereby be deterred. vomiting is not regarded as a contra-indication. A kind of rough-and-ready give-and-take between The results tabulated by Dr. Sauer show a gain the medical and the legal views is accepted by the of weight which is as striking as the rise in Dr. public because it is believed that the legal view is Aldrich’s cases. His patients were of ages ranging applied with the utmost humanity and with full from 5 to 12, and the psychological aspect of and enlightened use of the best medical information. " appetite " might have been expected to play a more If cases occur in which humanity is offended and important part in their nutrition than in that of the medical information is ignored, the public may series first described. be roused to a sense of the limitations of the legal view. some
"
ENOUGH
’
I
____
SANE
,
FOR SENTENCE.
COLOUR VISION. AT the recent Bedfordshire Assizes an inmate of A COMMITTEE of the British Association, consisting the Three Counties Me’atal Hospital at Arlesey was convicted and sentenced for assaulting one member of Sir Charles Sherrington, Prof. H. E. Roaf, Dr. In Mary Collins, and Dr. F. W. Edridge-Green, have of the hospital staff and threatening another. issued a report on colour vision, with particular the passing a sentence of two months’ imprisonment to the classification of colour - blindness. judge announced that he should assume that the reference accused man was sane. Possibly on this occasion Any reference, implicit or explicit, to any theory of the law was tempering justice with mercy ; two colour - blindness is carefully excluded, and it is months’ detention in a normal prison is regarded as recommended that the terms protanopia, deuteranopia, and tritanopia be abolished. Colour-blindness a lesser penalty than confinement for an indefinite is defined as any marked decrease in sensitivity to a at Broadmoor as a criminal lunatic. Neverperiod special region of the spectrum-e.g., to red-and it is theless, it certainly suggests that there must be recommended that if possible the precise wave-lengths the an with law when something wrong asylum involved should be specified. Fa lure to discriminate inmate is sentenced as a sane man. This and other incidents raise the od disquieting doubts whether colours should be described not as colour-blindness, but the law courts do not sometimes deliberately ignore as colour confusion-the number of distinct colours the medical history of accused persons instead of which are recognised in the spectrum being a rough of the degree of colour discrimination. All obtaining the utmost possible information before measure those persons who recognise only two colours in the The annual of sentence. latest the passing report Prison Commissioners contained some remarkable spectrum possess a neutral region in which no sensation revelations of the tendency of certain magistrates ’, of colour exists. Its position and extent should be to sentence a man first and to inquire into his mental determined. condition afterwards. Persons, it appears, are not HOSPITALS AND MOTOR ACCIDENTS. infrequently convicted and sentenced who are certified insane on their arrival in prison. A few months ago ALMOST every hospital in the country is faced by the Court of Criminal Appeal reaffirmed its rule of more or less serious difficulties as the result of the refusing to hear any fresh medical evidence in cases steadily increasing number of accidents caused by where the state of the accused’s mind is a ground motor traffic. Sometimes it is the occupants of the of appeal. The case of George Jordan, to which a cars who are injured, often seriously ; sometimes it correspondent draws attention in another column, is the unlucky pedestrian who suffers. Whichever it seems to suggest the same attitude of judicial indifferis, the result is the same for the nearest hospital. ence to matters which, after all, may be as relevant However acute the difficulty of finding room, the " " " " to the issue of guilty or not guilty as any sufferer has to be taken in and tended ; the general matters can be. experience is that, on the average, he occupies a bed If the facts in Jordan’s case are correctly stated, for a longer period than the ordinary patient ; and his he was sentenced to 18 months’ imprisonment by presence may delay the reception of a patient who has a court which did not adequately inform itself of his been waiting for admission, perhaps for months. This medical history and condition, and he was certified is the human side of the problem, but there is also insane soon after he began to serve his sentence. a serious financial side. More often than not these If so, he was stigmatised as a criminal without sufferers from motor casualties make no offering to sufficient consideration of his right to have the the institution that has put them on their legs again, defence of insanity raised on his behalf. He recently and the companies in which they are insured refuse committed suicide, and the coroner (Mr. Arthur H. to pay anything on the ground that hospitals are Emanuel, of Southampton), having apparently access voluntary institutions and are therefore unable to to medical evidence which must have made all the sustain a claim at law. Obviously the situation cannot difference if it had been available in the criminal be left there, and the hospitals, in self-defence and in court by which Jordan was sentenced, observed that the interest of those who have what may fairly be the case was one of the hardest and saddest in his described as the first claim upon them, will be comexperience. " By reason of his war service this man pelled to find some means of self-protection. The underwent injuries which made him assume the Norfolk and Norwich Hospital, the waiting-list of attributes of a criminal, whereas he was a splendid, which is being heavily encumbered by the results of honest man ; for the sake of his wife and children motor accidents, seems to have found an ingenious .
_____
.