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OCCUPATION CENTRES FOR MENTALLY DEFECTIVE CHILDREN.
29 In order to obviate this unwelcome result, should the operation be performed in adults for other stomach conditions, Pannett suggests an oblique division of the sphincter or the interposition of a large pad of omentum between its severed ends. Miller, Bowing, and Stepp were able to show that there was no weakening of the wall of the pyloric canal at the site of the operation, when tested by hydraulic pressure. The strength of the wall of the alimentary canal depends apparently upon the fibrous submucous coat. Nevertheless it must be remembered that fibrous continued tension without to tissue subjected support from muscular tissue will always stretch and a diverticulum will be likely to form with the passage of time. Whether it will give rise to symptoms is extremely doubtful, and this consideration need not necessarily be a contra-indication to the performance of the operation. Finality has not yet been reached in the surgical treatment of gastric ulcer, but present measures on the whole give commendable results. Before we can consent to change them the new procedure must be proved to be more effective or more physiological, or to entail a smaller risk to the patient and less mutilation of the stomach.
REFORMS
IN
THE TREATMENT OF
GALL-STONES. IN a recent paper on the subject of gall-stones, Dr. Svend Hansen,1 of Copenhagen, has published some statistics and comments thereon which are calculated to provoke a spirit of reform rather than of selfcomplacency. During a period of 21 months he has systematically examined the biliary system for gallstones in every case coming to necropsy at his hospital. Among 1191 consecutive necropsies in persons over the age of 20 he found 293-i.e., 25 per cent. of the totalto harbour gall-stones. This was the case among 19 per cent. of the men and 31 per cent. of the This ratio of 2 to 3 differs considerably women. from the operation ratio, the proportion of men to women operated on for gall-stones being approximately 1 to 9. The divergence obviously depends on the fact that gall-stones cause inflammatory changes in their surroundings far more frequently in women than in men. Dr. Hansen found that when the biliary system was unaffected by the presence of gall-stones, there was no divergence in the sex incidence, but among the cases showing morbid changes as the result of gall-stones, the ratio of men to women was as 1 to 2. In as great a proportion as 23 per cent. of all the cases of gall-stones they were found in other parts of the biliary system than the gall-bladder, and Dr. Hansen emphasises this finding for the benefit of surgeons who are apt to neglect a thorough search of the whole biliary system for gall-stones. They are elusive things, and their presence is apt to be overlooked by the surgeon even when he probes and palpates most conscientiously ;not infrequently gallstones escape detection till every biliary passage is slit open by the pathologist. Even pathologists may err, and Dr. Hansen notes that the frequency with which gall-stones have been found post mortem has ranged from 1 to 18 per cent. These astonishing discrepancies do not, in his opinion, indicate differences in the actual incidence of gall-stones determined by racial, dietetic, and other factors, but they depend on the skill and diligence with which pathologists have sought gall-stones. In the period under review necropsies were made on 40 persons who had died of cholelithiasis and its sequels. Nine of these persons died in medical wards. In the same period necropsies were made on only 26 persons dying from appendicitis. These figures are in themselves illuminating. They are also deplorable, and Dr. Hansen, writing with the impartiality of the pathologist, suggests that the physician’s attitude towards gall-stones at the present time is what it was a short time ago to appendicitis. Only when the great frequency of gall-stones becomes 1
Ugeskrift for Læger, April 27th, 1922.
general knowledge, and the necessity for cases of this kind to be under the unhampered observation of the surgeon becomes recognised, will the treatment of gall-stones emerge from the most unsatisfactory position in which it stands to-day. To wait for biliary colic and jaundice before diagnosing gall-stones h, often to wait until disaster has overtaken the patient. Test the urine for urobilin is Dr. Hansen’s hint in this connexion.
____
OCCUPATION CENTRES FOR MENTALLY DEFECTIVE CHILDREN. OCCUPATION centres are,
so
far
as
this
country is
concerned, the most recent development in the training of defectives. The definitely educable type is already provided for in many areas by the special schools of local education authorities, and institutional treatment is now to some extent available for the " permanent care " cases, but both are far short of requirements, and in addition there are intermediate cases-chiefly low-grade feeble-minded and high-grade imbeciles-some of whom can, with a degree of security, be kept at home under supervision. Home training is in most cases hopelessly inadequate, and the children tend to become more and more a burden on account of their bad habits. It is for these especially that the occupation centre is designed, so as to provide " opportunities for learning muscular control, cleanliness, obedience, and simple manual work." The Central Association for Mental Welfare has just issued a pamphlet for the guidance of local voluntary associations in organising such centres. Useful advice is given in regard to staffing, work, and apparatus. The Association is prepared to assist practically with the initial steps and to provide training for teachers. A list is given of 16 centres already in existence, and the number is gradually increasing ; in a few areas a further development is the formation of special classes for defectives over school age who are unemployed or unemployable. The Association is, we think, to be commended for its support of this new movement. It may appear to some a mistaken departure from the ideal of permanent institutional care which the Mental Deficiency Act embodied. But the Association is merely recognising an existing situation-insufficient provision of institutions through post-war economies-and providing a useful temporary stop-gap on the well-tried principle that half a loaf is better than no bread. ____
THE THERAPEUTIC ADMINISTRATION OF GASES. THE description by Mr. Stanley Rowbotham on page 24 of a new and convenient form of apparatus for administering nitrous oxide and oxygen with or without admixture of ether vapour reminds us that, in order to obtain a fair test of any method of anaesthesia the materials must be easily available. This is a matter of much more difficulty in the case of gases than of liquids. It appears that, for some time past, cylinders of compressed oxygen are kept in
stock at nursing homes and other places where operations are frequently carried out, but that hitherto the anaesthetist who wishes to administer nitrous oxide has often been in the position of having to bring his gas cylinders with him. This inconvenience can hardly result otherwise than in condemning the patient, should the supply of nitrous oxide fail, to the administration of some other more portable anaesthetic which had been considered less suitable for his individual needs. All those who had during the war practical experience of the use of nitrous oxide and oxygen as an anaesthetic in cases of injury associated with severe shock were confident that the extended use of these gases in cases of similar nature in civil practice would be a boon to the patient. The time seems to have come for nitrous oxide to be available in quantity at any place where emergency surgery is likely to be practised. With oxygen, on the other hand, the supply as a rule is there, or, if not
REFORMS
IN
THE TREATMENT OF
GALL-STONES. IN a recent paper on the subject of gall-stones, Dr. Svend Hansen,1 of Copenhagen, has published some statistics and comments thereon which are calculated to provoke a spirit of reform rather than of selfcomplacency. During a period of 21 months he has systematically examined the biliary system for gallstones in every case coming to necropsy at his hospital. Among 1191 consecutive necropsies in persons over the age of 20 he found 293-i.e., 25 per cent. of the totalto harbour gall-stones. This was the case among 19 per cent. of the men and 31 per cent. of the This ratio of 2 to 3 differs considerably women. from the operation ratio, the proportion of men to women operated on for gall-stones being approximately 1 to 9. The divergence obviously depends on the fact that gall-stones cause inflammatory changes in their surroundings far more frequently in women than in men. Dr. Hansen found that when the biliary system was unaffected by the presence of gall-stones, there was no divergence in the sex incidence, but among the cases showing morbid changes as the result of gall-stones, the ratio of men to women was as 1 to 2. In as great a proportion as 23 per cent. of all the cases of gall-stones they were found in other parts of the biliary system than the gall-bladder, and Dr. Hansen emphasises this finding for the benefit of surgeons who are apt to neglect a thorough search of the whole biliary system for gall-stones. They are elusive things, and their presence is apt to be overlooked by the surgeon even when he probes and palpates most conscientiously ;not infrequently gallstones escape detection till every biliary passage is slit open by the pathologist. Even pathologists may err, and Dr. Hansen notes that the frequency with which gall-stones have been found post mortem has ranged from 1 to 18 per cent. These astonishing discrepancies do not, in his opinion, indicate differences in the actual incidence of gall-stones determined by racial, dietetic, and other factors, but they depend on the skill and diligence with which pathologists have sought gall-stones. In the period under review necropsies were made on 40 persons who had died of cholelithiasis and its sequels. Nine of these persons died in medical wards. In the same period necropsies were made on only 26 persons dying from appendicitis. These figures are in themselves illuminating. They are also deplorable, and Dr. Hansen, writing with the impartiality of the pathologist, suggests that the physician’s attitude towards gall-stones at the present time is what it was a short time ago to appendicitis. Only when the great frequency of gall-stones becomes 1
Ugeskrift for Læger, April 27th, 1922.
general knowledge, and the necessity for cases of this kind to be under the unhampered observation of the surgeon becomes recognised, will the treatment of gall-stones emerge from the most unsatisfactory position in which it stands to-day. To wait for biliary colic and jaundice before diagnosing gall-stones h, often to wait until disaster has overtaken the patient. Test the urine for urobilin is Dr. Hansen’s hint in this connexion.
____
OCCUPATION CENTRES FOR MENTALLY DEFECTIVE CHILDREN. OCCUPATION centres are,
so
far
as
this
country is
concerned, the most recent development in the training of defectives. The definitely educable type is already provided for in many areas by the special schools of local education authorities, and institutional treatment is now to some extent available for the " permanent care " cases, but both are far short of requirements, and in addition there are intermediate cases-chiefly low-grade feeble-minded and high-grade imbeciles-some of whom can, with a degree of security, be kept at home under supervision. Home training is in most cases hopelessly inadequate, and the children tend to become more and more a burden on account of their bad habits. It is for these especially that the occupation centre is designed, so as to provide " opportunities for learning muscular control, cleanliness, obedience, and simple manual work." The Central Association for Mental Welfare has just issued a pamphlet for the guidance of local voluntary associations in organising such centres. Useful advice is given in regard to staffing, work, and apparatus. The Association is prepared to assist practically with the initial steps and to provide training for teachers. A list is given of 16 centres already in existence, and the number is gradually increasing ; in a few areas a further development is the formation of special classes for defectives over school age who are unemployed or unemployable. The Association is, we think, to be commended for its support of this new movement. It may appear to some a mistaken departure from the ideal of permanent institutional care which the Mental Deficiency Act embodied. But the Association is merely recognising an existing situation-insufficient provision of institutions through post-war economies-and providing a useful temporary stop-gap on the well-tried principle that half a loaf is better than no bread. ____
THE THERAPEUTIC ADMINISTRATION OF GASES. THE description by Mr. Stanley Rowbotham on page 24 of a new and convenient form of apparatus for administering nitrous oxide and oxygen with or without admixture of ether vapour reminds us that, in order to obtain a fair test of any method of anaesthesia the materials must be easily available. This is a matter of much more difficulty in the case of gases than of liquids. It appears that, for some time past, cylinders of compressed oxygen are kept in
stock at nursing homes and other places where operations are frequently carried out, but that hitherto the anaesthetist who wishes to administer nitrous oxide has often been in the position of having to bring his gas cylinders with him. This inconvenience can hardly result otherwise than in condemning the patient, should the supply of nitrous oxide fail, to the administration of some other more portable anaesthetic which had been considered less suitable for his individual needs. All those who had during the war practical experience of the use of nitrous oxide and oxygen as an anaesthetic in cases of injury associated with severe shock were confident that the extended use of these gases in cases of similar nature in civil practice would be a boon to the patient. The time seems to have come for nitrous oxide to be available in quantity at any place where emergency surgery is likely to be practised. With oxygen, on the other hand, the supply as a rule is there, or, if not