MYXOMATOSIS

104 " moral treatment " of insanity. This sentence reads : " The insane man is too often a sane man decivilised, and to him the various processes of civilisation have again to be applied."

ARTHUR BOWEN.

Bootham Park, Yor-k.

PULMONARY EMBOLISM

Sm,-In your leader of Dec. 31 there are statements which are at variance with experience in this hospital and which I fear may be misleading. You state " that most lethal emboli strike with dramatic suddenness, bringing vicious chest pain and haemoptysis before any diagnosis of limb thrombosis has been made." It is true that many fatal embolisms occur without recognised warning, but surely chest pain and haemoptysis are not signs of the rapidly fatal embolism but rather of the embolism which the patient survives, and depend on the development of local congestion and pleurisy. Although many embolisms, as you say, are almost instantaneously fatal, there are others in which death is delayed for a few hours and may be averted by treatment. If anything useful is to be done for these patients the diagnosis should be made and treatment In my experience neither pain nor started at once. haemoptysis is to be expected in the early stages after a large embolism. The important features of such a case are sudden collapse and signs of obstruction in the right side of the heart. Of more importance is your statement that there is statistical evidence for the view that " as it is the first embolism that kills, if the patient survives he has little to fear from later ones.". You do not give the source of this evidence, but in an investigation which was undertaken in this hospital and reported in your journal before the introduction of current methods of treatment,]- out of a total of 157 pulmonary embolisms only 34 were fatal in the first attack. Of the 123 survivors of an attack of embolism 10 died of subsequent attacks. A mortality-rate of 8% in the survivors of the first embolism can hardly be regarded with equanimity. University College Hospital, R. S. PILCHER. London, W.C.1.

and without a hall for a waiting-room or pram shelters -and working in excellent harmony with local-authority services without special rooms for antenatal and baby clinics. Let the Nuffield Trust carry on its wonderful work ; but it should not be thought that less costly ways are necessarily less efficient. C. E. MUNRO E. V. KUENSSBERG A. R. LAURENCE G. MACNAUGHTAN A. H. D. LARGE G. IRVINE. Edinburgh.

’

HEALTH CENTRE OR GROUP PRACTICE ?

SiR,-The main point we wish to make appears to have been missed by Dr. Stephen Taylor (Dec. 31). The provision of premises for group practices is being hindered by such persuasive statements on what constitutes the needs for " efficient general practice " as Dr. Stephen Taylor has put forward. He says that anything less costly than the Harlow centres can be got only by making real sacrifices in efficiency "-which implies that healthcentre practice on the Harlow scale is in fact the cheapest efficient way of conducting general practice. As a group of some years’ experience we beg to differ. "

MENTAL HEALTH SERVICES on a New Occupation Mentally Handicapped (Dec. 31),

Centre in Dr. Z. P. Fernandez, chairman of the Leeds mental health services subcommittee, is quoted as saying that Leeds spent more in the mental-health field than any other local authority in the country, averaging JS10S per 1000 of population, as against £7 or E8 in other areas. All credit to Leeds for its fine record in mental health-but the statement does scant justice to other local health authorities. The average annual expenditure on mental health services for county boroughs in -England and Wales is jE44 12s. per 1000 population, and the only authorities with an expenditure as low as f7or f8are a few Welsh counties and one Welsh county borough. Dr. Fernandez also states that Leeds has the highest ascertainment record in the country. Leeds has 3.8 known mental defectives per 1000 population, of whom 3-5 per 1000 are " ascertained " cases. In Bristol the figures are 4-15 per 1000 and 3-8 per 1000 respectively. Is mental deficiency really more prevalent in Bristol, or have we a higher ascertainment-rate’? I wonder !1

SIR,-In your note

Leeds for

H. TEMPLE PHILLIPS Department of Public Health, Tower Hill, Bristol, 2.

Chief assistant medical officer of health.

MYXOMATOSIS Sin,łYour annotation of Jan. 7 calls for certain criticism. It suggests that the immediate result of the deliberate spread of this plague is an increase in the yield in rabbit-free areas and that the eventual gains could be much more striking. But surely these figures are drawn from the returns last year when the weather conditions were abnormally favourable ; while certain farmers may have profited in this way, others, to whom the rabbit was their livestock, have lost heavily. When to the balance-sheet is added the price of inferior dead

rabbits imported for food at a very much enhanced price as a substitute for the good rabbits wantonly destroyed by disease, when our merchants are paying 22s. per dozen for foreign rabbit pelts which they formerly bought for 6s., when we We omitted to say in our first letter (Dec. 17) that about realise that the rabbit was a plentiful, cheap, and wholesome 60% of our finance was required for new building. The supply of meat for farm-workers and others throughout the remaining 40% comprised the purchase and the rebuilding land, competing with the high prices for other meat, surely and adaptation of an existing house. Had a suitable central we must think again before we put an undue assessment on the site been available for new building, our cost per patient at value of myxomatosis. risk would have come down further by three or four shillings. Recently a scientific farmer, the gist of whose paper is in favour of myxomatosis,l has stated that as the result of it we We have no intention of criticising the Harlow centres ; see farms, where the rabbits were the livestock and livelihood but Dr. Taylor’s arguments are liable to make general of the farmers, " now empty warrens, whose ill-fenced and practitioners and planners believe that nothing less will ill-watered lands are poorly adapted to sheep and inhospitable do, and that much which is inessential has received the to cattle-sheep and cattle which many of these farmers cannot afford to buy " ; while your annotation admits that " our stamp of approval and therefore must be essential. wild rabbit has qualities that will almost certainly ensure its In our earlier letter we showed that the widely myxomatosis and hordes of rabbits may be publicised de luxe standards in premises for general survival... both medical practice can be stripped down to basic and permanently with us." We then read that " To avoid this and to increase foodeconomically achievable proportions-to 13s. 3d. as supplies, the Minister of Agriculture is pressing on with the against £1per patient at risk. We know that just like designation of rabbit-clearance areas in which occupiers of the us, there are groups of doctors up and down the country land must destroy the rabbits or, if this is impossible, prevent working without sluice or specimen-examination rooms, their causing damage." The Ministry of Agriculture has .

1.

Pilcher, R. S. Lancet, 1939, ii, 629.

1. Birmingham

Post, Dec. 17,

1955.

105

unsuccessfully

used extermination

measures

for

fifty

DOMICILIARY CONSULTATION IN PSYCHIATRIC PRACTICE

years,

great cost in value of herds of cattle and flocks of poultry, to get rid of swine-fever, foot-and-mouth disease, and at very

but it has learnt little or nothing of cure of these though smallpox, cholera, typhoid, plague, and tuberculosis have largely been eradicated without the aid of

fowl-pest;

conditions

destruction of this type. While the spectacle of rabbits dying of the disease along every road horrified the public the spread of the disease was regarded as despicable and talks of punishment of the ill-doers even mentioned; now we learn from the press notices that the Government seek the result at vast expense.

unprofitable numerous

Since it is admitted by all good farmers that " rabbits are a sign of bad husbandry, bad estate management, and bad government," and that there is land which cannot be profitably used in any better way than for rabbits, why use such infectious measures, the ultimate effect of which Land will only yield a certain cannot be determined quantity of food for animals, and as long as farmers have not the means to use it profitably let us be thankful for the rabbit rather than seek a barren wilderness. JAMES F. BRAILSFORD. Birmingham. ABDUCTOR PARALYSIS AT THE SHOULDER

SIR,-May one offer a short congratulatory note to Mr. Sharrard and Dr. Knowelden on the clarity and usefulness of their paper last week. It became apparent many years ago that to splint the shoulder in abduction was somewhat of a negation of common sense. Paralysed or weak muscles need protection against the over-action of opponent muscles and " over-stretching." Neither of these deleterious factors apply to the shoulder abductors merely because the arm is kept in the natural position at the side of the trunk. Therefore, to abduct is not required. I have not splinted the shoulder in abduction for simple paralysis for some fifteen years, and have never regretted it. This paper, by the size of its sample359 cases-and its method of control, provides the proof of my beliefs which my small series could not supply. W. SAYLE-CREER. Manchester. ELECTRON-MICROSCOPY OF ATHEROMA

SiR,-The statement by Dr. Keech and Dr. Reed (Dec. 31) that the fibres I depicted (Dec. 10) are reticulin is, I think, a little far-fetched. They claim to see an accentuation of every third component in the banding, but a careful scrutiny of figs. 5 and 8 will show that such accentuations as are seen do not occur consistently at every third component, and can hardly therefore be regarded as significant. They make the arbitrary statement that the aortic intima consists

of, besides elastic tissue and amorphous material, fibres 300-900A in width ; but if they will look at my figures 5, 7, and 8 they will see fibres of no more than 100A in width. My so-called failure to mention elastic tissue was, of course, because I had carefully excluded from my preparations all but the superficial layers of the intima. My work was designed either to confirm or to refute Professor Duguid’s prediction that much of the substance of an atheromatous plaque would show the characters of fibrin, and I think I succeeded in confirming it ; but I carefully refrained in the main body of my paper from applying the term fibrin, and I think that Dr. Keech and Dr. Reed are bold in applying the term reticulin. It would be interesting to know by what reasoning they relate the material I obtained from a mass of very dense fibrous tissue to reticular tissue. Incidentally I would like to know how Dr. van den Hooff (Dec. 31) is able to identify as collagen, fibres which do not conform to the recognised electron-microscopic appearance of collagen. Department of Pathology, Royal Victoria Infirmary, Newcastle upon Tyne.

C. I. LEVENE.

SiR,-Dr. Philip Hopkins’s letter (Dec. 31) contains informative statistics on psychiatric patients in general practice. Do I understand correctly from the table that none of the five patients diagnosed as schizophrenic were admitted to hospital ? If so, further information about the clinical features and course of their illnesses, and of the action taken to help them, would be of interest. Warneford Hospital, Oxford.

**This letter has been reply follows.-ED. L.

IAN SKOTTOWE.

shown to Dr.

Hopkins,

whose

SxR,-Dr. Skottowe understands correctly that none of the five patients shown in the table accompanying my letter as diagnosed schizophrenic were admitted to hospital at the time of referral. They were all referred to a psychiatrist, with whom rested the final diagnosis and the decision whether or not to admit them to hospital. CASE I.-A 26-year-old man consulted me on June 25, 1951, "I was with a girl friend last night and I suddenly had a terrible desire to kill her." In addition to this there had been feelings of unreality over the previous few weeks. I had known him previously as a rather quiet withdrawn man. Referral to a psychiatrist resulted in the diagnosis of schizophrenia, but while arrangements were being made for his admission to hospital he was arrested on a charge of repeated thefts over the previous few months and ultimately he went to prison for three months. The magistrate was not influenced by the psychiatric report. CASE 2.-0n Sept. 26, 1951, a 30-year-old single woman came to me with a request to be referred to a plastic surgeon. She stated that her nose had been getting bigger for some years and was now interfering with her appearance so much that people were talking about her. She had, she said, had her nose in Cairo but the on plastic operations previously surgeon had made a terrible mistake. She was plainly suffering from delusions and had been unable to work for some time. I suggested that a psychiatrist could perhaps help her, and she agreed to go provided that she did not have to go into " an asylum." The psychiatrist’s diagnosis was schizophrenia ; and he suggested that she should be admitted to a hospital for nervous disorders. Neither the psychiatrist nor I have seen her since. CASE 3.-A 31-year-old single woman came asking to be referred back to a clinic she had attended eleven years earlier. At that time there had been delusions mainly associated with men in her bedroom at night ; a previous doctor had referred her to a gynaecologist to reassure her that she was still a virgin and was not pregnant-but despite the reassurance she still insisted she was pregnant. Following individual psychotherapy she had been able to continue with her work as a teacher, but her symptoms were worse when she consulted me on March 16, 1953. I referred her back to the clinic as she requested, but before she could resume treatment as suggested she took a job as a teacher abroad. I have recently been told by this patient’s mother that she is still working, but lives " a very secluded life." CASE 4.-On July 13, ] 953, a single man, aged 30, asked for a tonic "-but after a lengthy interview he agreed to go to a psychiatric clinic. I had been seeing him from time to time for the previous twelve months for " supportive " therapy, as he was clearly a, chronic schizophrenic : he had been brought up in a foundlings’ hospital, had never known his parents, and had no friends. At 141/2 years of age, he had been placed in the Regular Army as a band-boy ; after nine years he took his discharge, since when he had wandered from job to job. He had been afraid to mix with people as he thought they talked and laughed about him ; he always felt inferior and I referred him for had become completely withdrawn. psychiatric assessment, as a result of which it was agreed that I should continue to see him for " supportive " therapy. He managed fairly well by this means for some months, but eventually he left London, and I saw him no more. CASE 5.-On Dec. 12, 1953, a 25-year-old single man consulted me with a number of symptoms ; I had seen him many times during the previous three years on account of various symptoms, mostly associated with anxiety. He lived with his parents, with whom he had never on well; he had

stating :

got