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REFORM OF THE POOR-LAW.
83 a painful experience, why some save comfort his patient. Vaginal examinations he strong and others weak, and why the strongly deprecates. His views on the use of pituitary process of expulsion in a normal pelvis sometimes extract, ergot, and quinine correspond with those encounters overwhelming resistance and sometimes commonly held in this country. Quinine is mild and none at all. " Lieferung XX." of the new German hardly ever causes cramp or other bad results, but its text-book on gynaecologyl contains 200 pages on uncertainty restricts its use to the second stage, when the expulsive forces alone, contributed by Prof. pains are weak, and to abortions. Ergot he thinks HANS GuGGISBERG, of Berne, who expatiates on chiefly valuable during the period immediately
should be such
pains
are
of uterine activity, results of artificial stimulation, the clinical aspect of pains, the various theories of the exciting agency of labour, weak and strong pains and their therapeutic control, and his treatise may be confidently referred to as an exhaustive and up-to-date study of the subject. But the student who hopes to extend his knowledge of the essential physiology of birth will find in it little to satisfy him, for whenever the scent freshens he comes up against a baffling wall in the author’s conclusion that "in the present state of our knowledge we are unable to answer this the the
experimental investigation
"
question." In discussing
the reason for the painfulness of labour, Prof. GUGGISBERG compares the process to peristalsis, which becomes painful if it is resisted, and points out that the uterine muscle meets with more resistance in the performance of its function than any other muscle of the body. The pain varies largely with the state of the soft parts, and elderly primiparae are on this account liable to severe labour, while patients with placenta praevia, whose soft parts are slack, may undergo several hours of labour before they feel pain. Other causes of pain are the pressure to which the pelvic organs are subjected and the stretching of the peritoneum incident to the uterine
following expulsion, especially when the muscular tone is bad, and prefers it to pituitary extract
because it is milder. Combined with this extract it reduces bleeding in Cæsarean section to a minimum, Pituitary extract has the advantage of being a natural substance produced by the body itself and not a foreign introduction, and on the whole he does not
regard it
as
dangerous.
All this, however, has been said before, and the fact that a text-book of this magnitude has to confess ignorance on almost every page should act as a strong spur to investigators. Obstetricians are tending more and more nowadays to " leave everything to Nature," and if this clinical attitude is to be justified it would be as well to know a little more clearly the processes by which Nature works.
Annotations. "Ne
quid nimis."
THE NEW YEAR HONOURS. THE list of New Year Honours, though short, contains a number of names representing various branches of the medical profession. Sir Robert Jones, who has become a baronet, is identified with recent progress in orthopaedic surgery. Surgeon ViceAdmiral Joseph Chambers, who has been promoted to K.C.B., is the head of the Medical Department of the Navy. Dr. Robert Bolam, one of the new knights, is Chairman of Council of the British Medical Association. Lieut.-Colonel Frank Powell Connor, D.S.O., I.M.S., professor of surgery and surgeon to the Bengal College of Medicine, Calcutta, and Dr. Henry Alfred Alford Nicholls, lately P.M.O. to Dominica, Leeward Islands, have also received the honour of knighthood, while the C.LE. has been conferred upon Lieut.-Colonel John Wallace Dick Megaw, I.M.S., Director of the School of Tropical Medicine and Hygiene, Calcutta, and upon Major Robert Henry Bott, I.M.S. Dr. Frederic Jeune Willans, Surgeon Apothecary to H.M. Household at Sandringham and to the late Queen Alexandra, has been promoted to C.V.O. Dr. Jessie Carleton, of the American Presbyterian Mission, Ambala; Dr. Matilda Allyn, of the Canadian Baptist Telugu Mission, Pithapuram, Madras; and Dr. Charlotte Leighton Houlton, medical officer in charge of the Lady Reading Hospital for Women and Children at Simla, have received the Kaisar-i-Hind medal of the first class for public services in India. To all these recipients of well-merited honours we tender hearty congratulation in the name of the medical profession.
contractions. He contrasts human labour with that of animals, noting that in the former the cervix and vagina are passive, while in the latter the vagina playss an expulsive role. The chief function of the human vagina seems to be to expel the placenta. Animal experiments have thrown little light on the part played by the various nervous connexions ; the uterus appears to have its own controlling ganglia and will function perfectly well even if its connexions with the cerebral, spinal, and sympathetic systems have been severed. The experiments give widely differing results not only in different animals of a species, but also in the same animal at different stages in the reproductive process. There seems no doubt that the contractions can be affected through the motor centres of the central nervous system, and anaemia of the brain can act as a stimulant, but this aspect has been very little investigated and has at present no therapeutic significance. Reflex stimulation-that, for instance, of a loaded alimentary tract or bladderis well known to inhibit pains," which can be also GOTTLIEB showed that excited from the skin. irritation of the intestine led to heightened blood pressure in the pelvis and reflex excitation of the uterus. It is this autonomy of the uterus that has limited obstetric drugs to those which act directly on the uterine musculature, such as pituitary extract and quinine, but stimulation via the sympathetic and autonomic nerves may be of value under certain circumstances. SCHÄFFER and KURDINowsKi have demonstrated the rapid and efficacious action of REFORM OF THE POOR-LAW. adrenalin on the contractions, and the former has SINCE an Act of Queen Elizabeth directed that recommended its use therapeutically in conditions of haemorrhage. Prof. GUGGISBERG thinks that it is three or four substantial householders should act as indicated in atony with post-partum haemorrhage and overseers of the poor in every parish, the ultimate in Caesarean section, in doses of 0’1 to 0’3 mg. directly responsibility for the relief of the destitute has injected into the body of the uterus. NEU observed gradually passed, by way of Poor-law Commissioners a tonic contraction of the os after its administration, and the Local Government Board, to rest at last in and for this reason and on account of the idiosyncrasy the Ministry of Health. Yet the local guardians of some women to the drug it must be used with elected to deal with their own parishes have survived considerable caution. Prof. GUGGISBERG lays stress the changes of 325 years. They have carried out their duties with more or less success, and it is only the on the value of reassurance in primary inertia and urges the practitioner to be content to do nothing growth of other machinery of loca,l government, whose sphere of influence and work often overlaps that of 1 Biologie und Pathologie des Weibes. Ein Handbuch der the guardians, which has convinced most political Frauenheilkunde und Geburtshilfe. Josef Halban and Ludwig Seitz. Urban and Schwarzenberg. Berlin and Vienna. 1925. leaders that the guardians themselves are obsolete. It is to be hoped that a measure of Poor-law reform Pp. 1059. Die Wehen. "
Jessie
84 will never be the subject of party bickering, and it is well that the Minister of Health should allow plenty of time for consideration of his new proposals by those concerned before pressing a Bill upon Parliament. These proposals will probably meet with the approval of theorists (who are often right), but they have already raised something of a storm in the parishes. The Minister’s circular sums up his proposals in the following words :-
the facilities for treatment are excellent, and it is very desirable that they should no longer remain out of the reach of many sections of the community who either cannot or will not bring themselves within the scope of the Poor-law. PUBLIC TREATMENT OF TUBERCULOSIS.
WITH the New Year there came into operation an instruction of the Ministry of Health (Mem. 37/T) to all local authorities responsible for the treatment of cases of tuberculosis, by which it prescribes uniformity of records and statistical returns. As and sickness, accident, infirmity. 2. The coordination of all forms of public assistance, the Ministry pays half the expenditure of local and especially an improved correlation between Poor-law authorities in treating cases of tuberculosis, it has relief and unemployment benefit. some right to call the tune and to see that the public 3. The decentralisation of the responsibility at present’ gets full value for the money it spends. The Ministry falling on the Minister. desires to know what progress tuberculosis schemes 4. The simplification of the financial relations between the Ministry and the local authorities and the freeing of the are making, what is the volume and character of the local authorities from the financial restrictions in matters of; work being done, and what are the immediate and comparative detail which are a necessary concomitant of; ultimate results of treatment under each scheme. the present system. With this end in view it requires the keeping of 5. The correction of certain anomalies of historic origin, uniform records and the presentation annually of such as the association of the registration service (births, certain uniform statistical information. Such adminisdeaths, and marriages), with the provision for the relief of the trative control is no doubt inevitable, but the duty poor. of furnishing the information which the Ministry The two main suggestions are that boards of although the latter is stated to be reduced guardians should be entirely abolished and that theirrequires, to a minimum, undoubtedly entails a considerable functions should be transferred to the county councils amount of extra clerical work for those in charge of and county borough councils. The county councils: tuberculosis dispensaries. The demand for uniformity are to be the administrative units and are to be freed in work may be expected to produce here, as it does from central government control, as far as their in similar some raising of the standard of work health services are concerned, by receiving block grants in the lesscases, efficient dispensaries and institutions, but of money which will supply their needs over a period it may at the same time hamper and discourage of years and will enable them to deal with their own those who set up high standards of performance. problems without frequent application to the Ministry The memorandum has been incubating at the for sanction of details. will be councils County for several years and has been the subject entitled to delegate their new duties to borough and Ministry of consultation between the Ministry’s officers and district councils, who will be expected to bear the tuberculosis workers of all branches. Though regarded cost of their own work but may receive additional by the latter as a disagreeable necessity, it has been grants from the counties. The assigned revenue moulded to reconcile as far as possible many divergent system will be abolished, but local taxation licence points of view. The basis of the uniformity aimed at duties at present levied by county councils and county is the new of classifying patients suffering system councils be levied will still borough by them. from tuberculosis which the Ministry imposes. This Critics of the proposals feel strongly that the county though stated to be purely tentative, pending councils, whilst giving uniformity to the administra- system, agreement among clinicians on a better system, cuts tion of relief in their areas, will lack the local and across all existing systems of classification, and right personal knowledge which boards of guardians have renders statistical comparisons with previous years possessed. The councils, it is suggested, have already and other countries almost impossible. It is, therefore, a vast amount of work to do, and the Minister’s all the more to be regretted that a new system should that their should be proposal membership enlarged forward which itself shows defects so far as it to include ex-guardians who have special knowledge be put In several does not altogether meet the objection that the applies to cases of pulmonary tuberculosis. a considerable advance, notably in it marks respects service of poor relief will lose a good deal of that putting in two different classes cases in whose sputum voluntary work which is so valuable. It is feared tubercle bacilli have at some time or other been that it will tend, unless checked, to fall largely into and those in whose sputum they have demonstrated the hands of paid officials. The paid official is a never been found. Thus are separated the cases of but tradition necessary part any scheme, English can be no doubt of the accuracy of the where there always-and rightly-prefers him as the servant of diagnosis from those in which there must always remain an elected and executive body which takes a condoubt. The some done well also in has Ministry and interest in his work. It is tinuous unremitting the failure of a few elected bodies to do their work laying emphasis on the degree of constitutional disturbance present, since this has more value in properly and with responsibility that has finally assessing a patient’s prospect of recovery than the forced reform upon us after many years of vague discussion. The extension of the municipal franchise mere extent of lung involved. The " T.B. plus " cases has placed power in the hands of the wage-earner are sorted into three groups, the first of which must rather than in those of the ratepayer, and it is have physical signs and symptoms of such limited degree that probably no more than 10 or 15 per cent. intolerable, as the Minister implies, that the election of the cases ordinarily treated in a sanatorium would of guardians should depend on how much they will offer to pay to the unemployed. The Minister evidently satisfy the criteria. At the other end of the scale is believes that by making poor relief a part of the Group 3, equally limited in numbers and defined as functions of a larger body-the county council-he follows :Cases with profound systemic disturbance or constitucan abolish this abuse. His critics fear that the abuse will be transferred to the councils themselves, tional deterioration ; with marked impairment of function, and that popular clamour for relief will rule these either local or general, and with little or no prospect of All cases with grave complications, whether recovery. elections also. tuberculous or not, should be classified in this group-e.g., Mr. Neville Chamberlain’s plans for the future of diabetes, tuberculosis of larynx or intestine, &c." the hospitals can conveniently be discussed at another time, but it may be mentioned that his memorandum These criteria seem to be not alternative but cumusuggests that the reforms ought to make the amenities lative, and it is unlikely that a definition, to which of Poor-law medical institutions available and accept- in practice widely varying interpretations will be able to all classes of the population. In many of them given, and which is so illogical as to make the 1. The coordination and improvement of the provision made for the prevention and treatment of ill-health, both institutionally and otherwise, and the inclusion in this) provision of all public assistance required as the result of .
, ,
, ,
,
,
,
"
should be such
pains
are
of uterine activity, results of artificial stimulation, the clinical aspect of pains, the various theories of the exciting agency of labour, weak and strong pains and their therapeutic control, and his treatise may be confidently referred to as an exhaustive and up-to-date study of the subject. But the student who hopes to extend his knowledge of the essential physiology of birth will find in it little to satisfy him, for whenever the scent freshens he comes up against a baffling wall in the author’s conclusion that "in the present state of our knowledge we are unable to answer this the the
experimental investigation
"
question." In discussing
the reason for the painfulness of labour, Prof. GUGGISBERG compares the process to peristalsis, which becomes painful if it is resisted, and points out that the uterine muscle meets with more resistance in the performance of its function than any other muscle of the body. The pain varies largely with the state of the soft parts, and elderly primiparae are on this account liable to severe labour, while patients with placenta praevia, whose soft parts are slack, may undergo several hours of labour before they feel pain. Other causes of pain are the pressure to which the pelvic organs are subjected and the stretching of the peritoneum incident to the uterine
following expulsion, especially when the muscular tone is bad, and prefers it to pituitary extract
because it is milder. Combined with this extract it reduces bleeding in Cæsarean section to a minimum, Pituitary extract has the advantage of being a natural substance produced by the body itself and not a foreign introduction, and on the whole he does not
regard it
as
dangerous.
All this, however, has been said before, and the fact that a text-book of this magnitude has to confess ignorance on almost every page should act as a strong spur to investigators. Obstetricians are tending more and more nowadays to " leave everything to Nature," and if this clinical attitude is to be justified it would be as well to know a little more clearly the processes by which Nature works.
Annotations. "Ne
quid nimis."
THE NEW YEAR HONOURS. THE list of New Year Honours, though short, contains a number of names representing various branches of the medical profession. Sir Robert Jones, who has become a baronet, is identified with recent progress in orthopaedic surgery. Surgeon ViceAdmiral Joseph Chambers, who has been promoted to K.C.B., is the head of the Medical Department of the Navy. Dr. Robert Bolam, one of the new knights, is Chairman of Council of the British Medical Association. Lieut.-Colonel Frank Powell Connor, D.S.O., I.M.S., professor of surgery and surgeon to the Bengal College of Medicine, Calcutta, and Dr. Henry Alfred Alford Nicholls, lately P.M.O. to Dominica, Leeward Islands, have also received the honour of knighthood, while the C.LE. has been conferred upon Lieut.-Colonel John Wallace Dick Megaw, I.M.S., Director of the School of Tropical Medicine and Hygiene, Calcutta, and upon Major Robert Henry Bott, I.M.S. Dr. Frederic Jeune Willans, Surgeon Apothecary to H.M. Household at Sandringham and to the late Queen Alexandra, has been promoted to C.V.O. Dr. Jessie Carleton, of the American Presbyterian Mission, Ambala; Dr. Matilda Allyn, of the Canadian Baptist Telugu Mission, Pithapuram, Madras; and Dr. Charlotte Leighton Houlton, medical officer in charge of the Lady Reading Hospital for Women and Children at Simla, have received the Kaisar-i-Hind medal of the first class for public services in India. To all these recipients of well-merited honours we tender hearty congratulation in the name of the medical profession.
contractions. He contrasts human labour with that of animals, noting that in the former the cervix and vagina are passive, while in the latter the vagina playss an expulsive role. The chief function of the human vagina seems to be to expel the placenta. Animal experiments have thrown little light on the part played by the various nervous connexions ; the uterus appears to have its own controlling ganglia and will function perfectly well even if its connexions with the cerebral, spinal, and sympathetic systems have been severed. The experiments give widely differing results not only in different animals of a species, but also in the same animal at different stages in the reproductive process. There seems no doubt that the contractions can be affected through the motor centres of the central nervous system, and anaemia of the brain can act as a stimulant, but this aspect has been very little investigated and has at present no therapeutic significance. Reflex stimulation-that, for instance, of a loaded alimentary tract or bladderis well known to inhibit pains," which can be also GOTTLIEB showed that excited from the skin. irritation of the intestine led to heightened blood pressure in the pelvis and reflex excitation of the uterus. It is this autonomy of the uterus that has limited obstetric drugs to those which act directly on the uterine musculature, such as pituitary extract and quinine, but stimulation via the sympathetic and autonomic nerves may be of value under certain circumstances. SCHÄFFER and KURDINowsKi have demonstrated the rapid and efficacious action of REFORM OF THE POOR-LAW. adrenalin on the contractions, and the former has SINCE an Act of Queen Elizabeth directed that recommended its use therapeutically in conditions of haemorrhage. Prof. GUGGISBERG thinks that it is three or four substantial householders should act as indicated in atony with post-partum haemorrhage and overseers of the poor in every parish, the ultimate in Caesarean section, in doses of 0’1 to 0’3 mg. directly responsibility for the relief of the destitute has injected into the body of the uterus. NEU observed gradually passed, by way of Poor-law Commissioners a tonic contraction of the os after its administration, and the Local Government Board, to rest at last in and for this reason and on account of the idiosyncrasy the Ministry of Health. Yet the local guardians of some women to the drug it must be used with elected to deal with their own parishes have survived considerable caution. Prof. GUGGISBERG lays stress the changes of 325 years. They have carried out their duties with more or less success, and it is only the on the value of reassurance in primary inertia and urges the practitioner to be content to do nothing growth of other machinery of loca,l government, whose sphere of influence and work often overlaps that of 1 Biologie und Pathologie des Weibes. Ein Handbuch der the guardians, which has convinced most political Frauenheilkunde und Geburtshilfe. Josef Halban and Ludwig Seitz. Urban and Schwarzenberg. Berlin and Vienna. 1925. leaders that the guardians themselves are obsolete. It is to be hoped that a measure of Poor-law reform Pp. 1059. Die Wehen. "
Jessie
84 will never be the subject of party bickering, and it is well that the Minister of Health should allow plenty of time for consideration of his new proposals by those concerned before pressing a Bill upon Parliament. These proposals will probably meet with the approval of theorists (who are often right), but they have already raised something of a storm in the parishes. The Minister’s circular sums up his proposals in the following words :-
the facilities for treatment are excellent, and it is very desirable that they should no longer remain out of the reach of many sections of the community who either cannot or will not bring themselves within the scope of the Poor-law. PUBLIC TREATMENT OF TUBERCULOSIS.
WITH the New Year there came into operation an instruction of the Ministry of Health (Mem. 37/T) to all local authorities responsible for the treatment of cases of tuberculosis, by which it prescribes uniformity of records and statistical returns. As and sickness, accident, infirmity. 2. The coordination of all forms of public assistance, the Ministry pays half the expenditure of local and especially an improved correlation between Poor-law authorities in treating cases of tuberculosis, it has relief and unemployment benefit. some right to call the tune and to see that the public 3. The decentralisation of the responsibility at present’ gets full value for the money it spends. The Ministry falling on the Minister. desires to know what progress tuberculosis schemes 4. The simplification of the financial relations between the Ministry and the local authorities and the freeing of the are making, what is the volume and character of the local authorities from the financial restrictions in matters of; work being done, and what are the immediate and comparative detail which are a necessary concomitant of; ultimate results of treatment under each scheme. the present system. With this end in view it requires the keeping of 5. The correction of certain anomalies of historic origin, uniform records and the presentation annually of such as the association of the registration service (births, certain uniform statistical information. Such adminisdeaths, and marriages), with the provision for the relief of the trative control is no doubt inevitable, but the duty poor. of furnishing the information which the Ministry The two main suggestions are that boards of although the latter is stated to be reduced guardians should be entirely abolished and that theirrequires, to a minimum, undoubtedly entails a considerable functions should be transferred to the county councils amount of extra clerical work for those in charge of and county borough councils. The county councils: tuberculosis dispensaries. The demand for uniformity are to be the administrative units and are to be freed in work may be expected to produce here, as it does from central government control, as far as their in similar some raising of the standard of work health services are concerned, by receiving block grants in the lesscases, efficient dispensaries and institutions, but of money which will supply their needs over a period it may at the same time hamper and discourage of years and will enable them to deal with their own those who set up high standards of performance. problems without frequent application to the Ministry The memorandum has been incubating at the for sanction of details. will be councils County for several years and has been the subject entitled to delegate their new duties to borough and Ministry of consultation between the Ministry’s officers and district councils, who will be expected to bear the tuberculosis workers of all branches. Though regarded cost of their own work but may receive additional by the latter as a disagreeable necessity, it has been grants from the counties. The assigned revenue moulded to reconcile as far as possible many divergent system will be abolished, but local taxation licence points of view. The basis of the uniformity aimed at duties at present levied by county councils and county is the new of classifying patients suffering system councils be levied will still borough by them. from tuberculosis which the Ministry imposes. This Critics of the proposals feel strongly that the county though stated to be purely tentative, pending councils, whilst giving uniformity to the administra- system, agreement among clinicians on a better system, cuts tion of relief in their areas, will lack the local and across all existing systems of classification, and right personal knowledge which boards of guardians have renders statistical comparisons with previous years possessed. The councils, it is suggested, have already and other countries almost impossible. It is, therefore, a vast amount of work to do, and the Minister’s all the more to be regretted that a new system should that their should be proposal membership enlarged forward which itself shows defects so far as it to include ex-guardians who have special knowledge be put In several does not altogether meet the objection that the applies to cases of pulmonary tuberculosis. a considerable advance, notably in it marks respects service of poor relief will lose a good deal of that putting in two different classes cases in whose sputum voluntary work which is so valuable. It is feared tubercle bacilli have at some time or other been that it will tend, unless checked, to fall largely into and those in whose sputum they have demonstrated the hands of paid officials. The paid official is a never been found. Thus are separated the cases of but tradition necessary part any scheme, English can be no doubt of the accuracy of the where there always-and rightly-prefers him as the servant of diagnosis from those in which there must always remain an elected and executive body which takes a condoubt. The some done well also in has Ministry and interest in his work. It is tinuous unremitting the failure of a few elected bodies to do their work laying emphasis on the degree of constitutional disturbance present, since this has more value in properly and with responsibility that has finally assessing a patient’s prospect of recovery than the forced reform upon us after many years of vague discussion. The extension of the municipal franchise mere extent of lung involved. The " T.B. plus " cases has placed power in the hands of the wage-earner are sorted into three groups, the first of which must rather than in those of the ratepayer, and it is have physical signs and symptoms of such limited degree that probably no more than 10 or 15 per cent. intolerable, as the Minister implies, that the election of the cases ordinarily treated in a sanatorium would of guardians should depend on how much they will offer to pay to the unemployed. The Minister evidently satisfy the criteria. At the other end of the scale is believes that by making poor relief a part of the Group 3, equally limited in numbers and defined as functions of a larger body-the county council-he follows :Cases with profound systemic disturbance or constitucan abolish this abuse. His critics fear that the abuse will be transferred to the councils themselves, tional deterioration ; with marked impairment of function, and that popular clamour for relief will rule these either local or general, and with little or no prospect of All cases with grave complications, whether recovery. elections also. tuberculous or not, should be classified in this group-e.g., Mr. Neville Chamberlain’s plans for the future of diabetes, tuberculosis of larynx or intestine, &c." the hospitals can conveniently be discussed at another time, but it may be mentioned that his memorandum These criteria seem to be not alternative but cumusuggests that the reforms ought to make the amenities lative, and it is unlikely that a definition, to which of Poor-law medical institutions available and accept- in practice widely varying interpretations will be able to all classes of the population. In many of them given, and which is so illogical as to make the 1. The coordination and improvement of the provision made for the prevention and treatment of ill-health, both institutionally and otherwise, and the inclusion in this) provision of all public assistance required as the result of .
, ,
, ,
,
,
,
"