PSYCHOSES IN CHILDHOOD

602 should certainly be followed, of dosage of some drugs would make difficulties if the scheme was generally adopted. Thus the dose ofArtane’ ranges from 2-5 to 60 mg. If the official tablet contained 5 mg. (with a groove for division) some unfortunate patients would have to swallow twelve. An overdue reform is the deletion of useless or outmoded remedies and preparations from the B.P. and the B.P.C. Substances like bismuth carbonate, glycerophosphates, and creosote would gradually disappear from our prescriptions if they no longer received the official blessing. Coming even nearer home, the pharmacists spend many unprofitable minutes every day deciphering almost illegible scripts. Is it not rather a slur on the medical profession that the pharmaceutical qualifying examination still includes the puzzling out of unreadable prescriptions ? Now, when the patient may take his script to any convenient pharmacist--often one who has not met the calligraphy before-it seems reasonable to ask the doctor to spend the few more seconds on his prescriptions that will convey his requirements without doubt or to any dispenser in the land. We shall at least be saved such witticisms as : "Who wrote this ?’? Geoffrey of simplified dosages though the wide range

delay

Chaucer

SLOW AT STARTING DEANS pride themselves on spotting winners among the students who parade before them, in the course of the years ; but they know they are not infallible, and they usually err on the side of leniency when they are in doubt. Present regulations, however, sometimes force their hand to some extent, and lead them to weed out a young person who only needs freeing from entangling circumstances. Such a case has recently been reported to us. The student

of

with

creditable medical After a doctor. getting exemption, at a good scholastic level, from matriculation, he was accepted, while at school, for training in a London teaching hospital. He still had a year to spend at school, and the hospital dean-wisely, in our view-advised He therefore worked him against spending it on science. for, and took, his Higher Certificate in arts. He has since been told that this was inviting failure. He now came to London for the first time, and was pressed by his contemporaries to join every sort of society and to take part in every sport. None of his teachers seems to have A shown anything like the same interest in his doings. musical boy, he was now in reach, for the first time, of the best concerts in the country. He did what nine out of ten of us did in our first term at the university : he opened his mind to the new impressions crowding in on him, and made the most of the opportunity. At the end of that term, however, he realised how great was his handicap in not having spent He began to a preliminary year on science while at school. work hard, but with a sense of being at sea ; and soon, feeling that failure in the first M.B. was inevitable, he took some coaching. He failed, however, and so did 7 others out of 11 who had had no previous scientific grounding. He was rejected for further medical training by the school. He is now working at a crammer’s, and finding the work well within his scope ; but owing to his rejection, no hospital has so far been willing to take him on. comes

a

family

tradition, and has always intended

This seems to us student clearly has

a

a

to become

thoroughly

unfortunate

case.

The

ability, or he would not have passed his school examinations successfully ; moreover he seems to have an educable mind, not narrowly confined to his subject but widely interested-the kind of mind we need in medicine. If a year of humane studies at school is to prove a handicap instead of an asset, more and more students will specialise too soon, and enter their medical training lopsided and mentally narrowed, probably for life. It is right that on entry to their medical schools students should be warned by their deans that failure in two or more subjects in the first M.B. will be regarded But every as serious, and likely to lead to dismissal. case in which this happens should be carefully reviewed, and all young people with an arts rather than a scientific

training-provided they have worked reasonably wellshould be allowed a second chance. A student who has done two years’ science at school and then fails dismally in his first M.B. is a horse of a different colour: most likely he will go on failing in examinations, and become a burden on the school. As he can hardly be turned out after three or four years’ training he had better, for everybody’s sake, be rejected at the end of his first year. A rule is necessary, and it must be consistently applied if it is to have a properly bracing effect ; but there is no reason why it should be rigid, allowing no latitude for special circumstances. A boy accepted on a recommended training in arts should have been offered a system of tutoring in his first year which helped him, not only to adjust to a set of new subjects and terms, but to meet the freedom of university life steadily, and without too much excitement ; and since his school scholastic record was good he should have had some degree of licence over the first M.B. PSYCHOSES IN CHILDHOOD PSYCHOSIS in childhood is by no means as rare as an older generation of psychiatrists thought it. Twenty 1 years ago, Melanie Klein pointed out that many schizophrenic children, especially of the poorer classes, were not brought to psychiatrists, while others were classed as cases of arrested development, mental defi-

ciency,

or

some

psychopathic condition,

or

as

having

asocial tendencies. Because many of the characteristics and behaviour disturbances in these children differ only in degree from those seen during the development of the normal child, they are easily mistaken, in the early stages, for exaggerated examples of naughtiness, docility, or restlessness. Despert2 came to similar conclusions as a result of her work with American children. On March 11, at a meeting of the psychiatric section of the Royal Society of Medicine, Dr. Mildred Creak showed a film illustrating the distinctive appearance and behaviour of these children. At the onset of psychosis, the child shows an inability to form normal relations with people or objects around him. He may appear quite alert and intelligent, but his mental comes to a standstill, or begins to regress, speech reverting to infantile babbling or being given up entirely. Sphincter control and motor skills may be lost, and the child becomes clumsy, unable to manipulate feeding tools or toys. He may give up play, or his play may become aimless, or stereotyped and obsessional, or he may stay immobile for long periods. On the other hand he may be hyperkinetic, whirling and spinning about, or grimacing, pushing out his lips or his tongue, or moving and twisting his fingers. He may seem unaware of people about him, but if they withdraw he will often cling to them. If they approach he will reject them, however, and may have an outburst of aimless rage. Once the psychosis has become established these children fail to develop intellectually, and many of them—especially if they are noticeably odd and difficult to manage-get sent to mental-deficiency institutions. Dr. G. O’Gorman noted that this is not the result of mistaken diagnosis : schizophrenia interrupting normal mental development between birth and the age of sixteen or thereabouts may so retard a child’s progress that he does in fact become a mental defective. Indeed, adult demented schizophrenics can rightly be some classed as mental defectives, for their illness, in a quarter of the cases, begins before the age of 18. In all mental hospitals there are schizophrenics who could equally logically be in a mental-defective colony. About 10% of cases of mental defect in adolescents and adults, Dr. O’Gorman believes, are the end-result of childhood schizophrenia. On the other hand, ordinary mental defectives are not likely to develop schizophrenia; those

development

1. Klein, M. Int. J. Psycho-Anal. 2. Despert, J. L. Psychiat. Quart.

1930, 11. 1938, 12, 336.

603 who do

are

probably examples

of

relapse

of

an

initial

psychosis, after an intervening period of remission. Many of these psychotic defectives have higher intelligence quotients than ordinary defectives, but they are

less educable because they

less in touch with their Some of them have isolated areas of environment. intellectual preservation ; he mentioned a child who - though he could not read-after several years in a mental-defective colony could still play the piano, which he had learnt before the onset of his psychosis. Dr. D. W. Winnicott remarked that some phases in normal development can properly be termed psychotic. The young child lives in a mad world and only gradually learns to relate himself to reality : even in adults, he suggested, a retreat from the hard tasks of everyday reality-testing is allowed in the spheres of religion and art. The child analyst has to be able to enter a mad world where reality is dealt with by means of magical thinking. It may be questioned whether " psychotic " is the right term to use in discussing the phases of development ; being equated with " madness by parents and lay people, it is apt, as Dr. K. Cameron pointed out, to cause alarm and misapprehension. Speakers had very little to offer on the subject of treatment for these serious illnesses of childhood. Good results were claimed from loving and patient parental care of a difficult and apparently unrewarding child, psychotherapy (sometimes more efficacious after electroconvulsive therapy), and long-continued psycho-analysis ; but only in cases recognised early enough and treated with sufficient perseverance and intensity. Insulin, though it may improve the physical condition and so help the task of the psychotherapist, does not seem to have yielded results comparable to those seen in adult psychotics. All agreed that we must learn to recognise these cases earlier. are

"

-

VIRUS VARIATION

VIRUSES are well known to vary in virulence. At a meeting of the comparative medicine section of the Royal Society of Medicine on Feb. 20, Mr. J. R. Hudson pointed out that African natives recognise mild and severe forms of rinderpest, and in protecting their animals from the severe form by exposing them to the mild they practise something approaching Jennerian methods. Similarly, as Mr. I. A. Galloway, D.sc., pointed

out, the virulence of different strains of the foot-andmouth disease viruses varies widely, and many antigenic subtypes have been uncovered. Viruses may vary, as Mr. Hudson remarked, not only in antigenic characters and virulence but in host range, tissue affinities, and physical properties ; and with regard to the influenza viruses Professor Wilson Smith, F.R.S., made a plea for less preoccupation with the antigenic variations and greater attention to the other characters that might account for virulence. He described a variant of influenza virus which had been found in his laboratory, and which showed changes in its surface configuration without antigenic or other changes. Dr. D. J. Trevan and Mr. A. B. Maclntyre made it clear that the viruses of the dog distemper complex, though antigenically related, produce different clinical syndromes-notably the classical catarrhal distemper and the non-catarrhal "hard pad." The latter is essentially the distemper of recent times. This strain of virus gives rise to lesions in stratified squamous epithelium, and sometimes in the brain, which differ from those associated with the distemper virus as known to Laidlaw and Dunkin ; and typical catarrhal distemper does not follow injection of it into dogs. It is, of course, not easy to dissociate the virulence of a virus from the susceptibility of its host-; there are many well-known examples of a single virus strain causing mild disease in a partially immune population and extremely severe disease in a susceptible population

entering the area. When the behaviour of a virus changes on passage in a new-host, it is tempting to diagnose virus variation. Other possibilities, however,

One is that contamination taken strain has place ; a second is that by laboratory a mixture of two agents was originally present, one of which has been selected by the new host ; and a third is that inoculation with foreign material has activated a latent virus in the new host-workers with respiratory viruses and the virus of lymphocytic choriomeningitis are familiar with this difficulty. Very rigid criteria must be satisfied before altered behaviour of a virus can be ascribed to variation. At the meeting one further type of virus variation was mentioned : Mr. Hudson suggested that the three types of equine encephalomyelitis virus-Eastern, Western, and Venezuelan-may be variants derived originally from a common ancestor. But here we are leaving the virus world for the metaphysical. M. Jourdain was delighted to learn that he had been talking prose all his life ; perhaps the virologist will one day find that he has been talking metaphysics. must be taken into account. a

THE AUSTRALIAN RESIDENT THE qualified medical graduate in Australia often finds it impossible to get a resident hospital appointment. This difficulty is not confined to Australia, but a report1 by Mr. V. M. Coppleson, director of postgraduate studies in the University of Sydney, shows how acute it is in that realm. The number of doctors qualifying each year from the university is now double the pre-war figure, and the increase in internships has been quite insufficient to meet the demand. Moreover, Mr. Coppleson thinks that such vacancies as there are do not always measure up to the standard of training he would like to see in the vital first year after qualification. ’" No matter how good the couse he has attended, the type of hospital in which he trains after graduation will determine the standard of medicine a medical graduate will practise for the rest of his life." The report goes on to say that in Australia today " the young graduate who has not the ability and good fortune to obtain an internship at one of the larger teaching hospitals is likely to receive a poor and inadequate training in what is undoubtedly the most important year of his career." Newly qualified doctors, as yet too inexperienced to begin the practice of medicine, are left largely to their own resources. There is no compulsory intern year after qualification in New South Wales, though legislation to introduce one was passed as long ago as 1938 ; its enforcement was postponed first because of war and then because of shortage of jobs. Those who can, usually do four months each. Mr. Coppleson says of three appointments that internships should be more closely supervised and postgraduate teaching more widely planned by the Australian universities than at present. The standard that he would establish is undoubtedly a high one, compounded from the best that he has seen during a long tour last year of teaching centres in this country and the United States: The report is called Trends in Modern Medical Education, and it interprets the results of his investigationsinto every part of the subject in relation to,Australian conditions in general and those of Sydney and New South Wales in particular. But some judgments might find wider application. For instance : " In graduate medical education a false scent is being followed. The acquisition of diplomas has become the highest goal, and instead of through the hospital, the university and the research laboratory, the path of higher medical education is being blazed through the classroom and the examination hall." No system devised for the of yet specialised training physicians and surgeons can entirely escape this recurrent criticism, but undue emphasis on academic achievement can only be

newly

undergraduate

1. Bull. postgrad. Comm. Med., Unir.

Sydney, 1951, 7, 111.