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THE BIRTH-STRUGGLES OF PSYCHOPATHOLOGY
V1TA7. STATISTICS FOR
must
from the sargeon, who in turn must
come
and
1934
frequent
279 attention to the valves ;
it also
understand the principles upon which the manu- depends materially upon the nature of the materials facturer is working. These consiclerations apply to be sterilised and the way they are packed and with especial force to the methods of attaining arranged in the sterilising chamber. Air is heavier than steam and the movement of both gases in an asepsis, the basis of modern surgery. This question of surgical asepsis is raised by a autoclave is from the top to the bottom, where series of papers dealing with the sterilisation of the air escapes. Steam must be allowed access surgical dressings, contributed to the December not only between individual packages, but to the Bulletin of the American College of Surgeons by interstices of the materials themselves. It has technical experts and representatives of hospital been proved that the usual package of towels or administration. The surgeon usually takes the surgical dressings will require from two to three modern autoclave for granted, and relies implicitly times as long for permeation with steam if laid upon its efficacy. He will therefore be surprised horizontally as if placed on edge. Tight packing to learn what complicated mechanism goes to its will hinder, loose arrangement favour, the sterilising construction and what constant care and supcr- process. It is shown in these papers that the vision is needed to keep it in perfect order ; he presence of a residuum of air in an autoclave will may be a little disturbed to realise how many vitiate its efficiency in many ways. The pressure loopholes there are for error. Bacteria, like all gauge indicates the temperature of the chamber living matter, contain about 15 per cent. of protein only when it contains pure steam. When air and 85 per cent. of water. They may be destroyed remains, the temperature varies greatly in different either by dehydration, or by coagulation of their parts of the sterilising box, the ultimate temperaprotein content. Dehydration requires a degree ture that can be secured is reduced, the time of heat that will also scorch any animal or vege- required for securing a uniform temperature is table fibre and impair its structure ; while the greatly increased, and the permeating properties method may be used to sterilise metal or earthen- of the sterilising medium are seriously reduced. An autoclave containing air is not of necessity a ware, it is for this reason useless for the preparation of dressings. The coagulation of protein, on steriliser. the other hand, can be assured at comparatively Post-operative wound infections are uncommon low temperatures by a combination of heat and at the present day, but not unknown. Some are moisture. For practical purposes it may be undoubtedly the fault of members of the team ; that accepted pure steam at a temperature of others may be traced to catgut, but this source F. will kill all bacteria and their spores in is often unjustly blamed. 250° Contamination by half an hour ; this temperature is attained at a dressings imperfectly sterilised should however pressure of 15 lb. An autoclavetherefore depends be impossible in a modern hospital, and on these upon the employment of steam under pressure grounds it would be well if the principles and and the complete replacement of air by steam is precautions outlined in these articles could be essential to its action. The efficient evacuation brought from time to time before the personnel in of air requires not only well-designed apparatus charge of the sterilising apparatus in all institutions.
ANNOTATIONS is 5 per 1000 below that for 1933 and is the lowest recorded, the previous lowest being that for 1930 (60). The rates are provisional and are issued for the information of medical officers of health, but they are not likely to require substantial modification.
mortality-rate
VITAL STATISTICS FOR 1934
THE Registrar-General has issued a provisional statement of the figures for birth-rate, death-rate, and infant mortality during the year 1934. --
THE BIRTH-STRUGGLES OF PSYCHO-
PATHOLOGY THE outcome of a personal stocktaking on the a physician who has had some years of practice in psychopathology is printed on another page. Dr. Emanuel Miller explained to the members of the medical section of the British Psychological Society that it was in the belief that others, like himself, are dissatisfied with the authoritarian attitude of certain schools, as well as with the indeterminate doctrines of others, that he had chosen his subject. If one surveyed the wide field of psychopathology from a distance, he added, one saw a very luxuriant growth. But when walking down the furrowed ranks one perceived many tares and weeds mingled with the healthy wheat, and it seemed likely that the harvest would yield to the psychopathologist bread so contaminated with alien substances that only gargantuan digestion could handle it. He himself had come to the harassing problems of neurosis and psychosis
part of The smaller towns are those with estimated resident of 25,000-50,000 at the 1931 census. The birth- and death-rates for England and Wales as a whole are calculated on the estimated mid-193-1 population, the remaining rates on the estimated mid-1933 populations. The birth-rate is based on live births, the death-rate on crude deaths.
populations
The birth-rate for England and Wales shows an increase of 0.4 per thousand abovethe low record of 1933, and is noteworthy, the Registrar-General remarks, as being the only increase recorded since 1920, except in 1928 when there was a very slight improvement of 0.1 following an exceptional fall in the previous year. The (crude) death-rate is 0-5 below that for 1933, and only 0-4 above that for 1930, which is the lowest recorded. The infant
280
ROYAL FREE HOSPITAL: ANNUAL DINNER
after having studied in the calm groves of the academic mental sciences, sitting at the feet of McTaggart, Ward, Russell, and Moore. This approach might have disadvantages but it implied the possession of instruments designed not only to dissect phenomena but sharp enough to make clean logical cuts in the material with which one had to deal. At first such cuts tend to be too severe ; the attempt to expose a clean academic skeleton results only in the removal of the very living tissue of the mental life. But the period of scepticism passes, to be succeeded by the sensible conclusion that after all there is a lot to be said for the theories of the many warring schools. Dr. Miller himself emerged with the belief that on the whole the greatest security is to be found in the fundamental doctrine enunciated by Freud, realising, however, that conviction of the overwhelming truth of one or two items of a doctrine may only too easily make us accept all the others in the same canon. He holds that the student of Freud finds himself in a region which is more intelligible than is that on which the schools of Jung and Adler are built, but that even here concept has been piled upon concept, and a veritable baroque architecture has been constructed, imposing and attractive, of which the foundations are not always secure. It is one of the canons of modern architecture that buildings should not merely please the eye but that they should be functional and definitely related to the ground upon which they stand. Dr. Miller, in the presidential address which followed these introductory remarks, has certainly contributed towards the establishment of psychological structure on a sounder biological
foundation. ROYAL FREE HOSPITAL: ANNUAL DINNER
MANY generations of students, in more than one London hospital, have had reason to be grateful to Mr. G. P. Mudge for tuition in biology which exactly fits their needs. The clear coloured diagrams on the board, so easily reproduced in note books, and the pithy summary of the ground covered which concluded each lecture are long remembered, while by his concise exposition of complex biological concepts, such as theories of evolution or heredity, Mr. Mudge stimulated some at least of his pupils to further productive study. The graceful tributes paid him by Miss E. H. Jebens, F.R.C.S., when proposing his health, were received with enthusiasm by the large company assembled at the Savoy for the Royal Free Hospital dinner, over which he presided on Jan. 24th. It emerged that he had served the London School of Medicine for Women for 30 years, and he confessed to have derived so much pleasure from this service that he could wish his term of office to be extended for at least as long again. Speakers at this dinner included Dame Louise McIlroy, M.D., Dr. Frank Howitt, Sir Thomas Carey Evans, F.R.C.S., and Miss Addison Phillips. Dame Louise, who has recently resigned from the chair of obstetrics and gynaecology at the school, spoke warmly of its fine traditions and wished it in the future even greater and more prosperous days. The chairman, in reply, spoke of the progress achieved during the year, and of the losses sustained by the school through death or retirement, making specially sympathetic reference to the life and work of Lord Riddell and of Lady Berry. Dr. Howitt found terms of appreciation nicely appropriate to each of the principal guests, and conveyed by his friendly manner Sir a cordial welcome to the many unnamed ones. Thomas Carey Evans, in response, told of the valuable work done by medical women in India, where of 20 medical colleges five catered for women, whose services
not only needed but welcomed by the Indians. spoke in optimistic vein about the progress of tropical medicine. For example, whereas formerly were
He
99 per cent. of the victims of kala-azar died, now the case-mortality rate was less than 5 per cent. ; similarly of those afflicted with amoebic dysentery, twenty years ago 80 per cent. died, and now less than 1 per cent. of the cases proved fatal. Miss Addison Phillips also responded, with many wise quips equally applicable to practitioners of either sex. Doctoring, as she said, is an uphill job from start to finish. The public’s efforts at " doing without a doctor" robs the profession of fees temporarily and adds to their difficulties at a later stage of the illness ; no one attempts, she added, to do without a dentist, knowing that the result could only be one great holocaust. She confessed to appreciation of a good bedside manner, having little use for the brusqueness which is said to veil a good heart, and concluded with som& friendly advice to doctors-e.g., (1) don’t treat patient as if he were a fool, he may not be ; (2) don’t let your manner be either too enigmatic or aggressively cheerful; (3) remember that the patient’s anxious face may be a reflection of that of the young doctor who is taking the notes ; (4) don’t talk to the nurse across the temporarily dead body of the patient ; and don’t keep relatives anxious while you gossip with consultants. Finally, she said, don’t neglect minor ills ; one who could cure chronic indigestion would change clouds of depression into clouds of incense.
PRE-OPERATIVE MEDICATION AND THE SMALL INTESTINE DISTENSION of the bowel after abdominal operations remains one of the most formidable obstacles to recovery with which surgeons have to contend. Mr. Victor Bonney, in his recent Bradshaw lecturer showed that distension is due to " a breakdown of the gas-balancing mechanism, either in the direction of increased production, or diminished removal, or of the two together." Opening the peritoneal cavity causes cessation of peristalsis, thus withdrawing one factor in the mechanism for removing gas. "The cessation in the first instance is the result of antsthesia " said Mr. Bonney. He also showed that interference with the intestinal blood-supply, which in its turn interferes with the gas-absorption mechanism, is the essential element in producing distension, and he believes that this is brought about by some toxic factor arising in the damaged tissues. Some authorities attribute continued distension, when it occurs, entirely to the action of the general anaesthetic which has been used ; others believe that the surgical interference-handling of gut, &c.is the chief cause of the trouble. Finsterer, of Vienna, claims to have shown by his results with splanchnic analgesia that it is the general anaesthetic which is solely to be blamed. In an experimental study H. G. Carlson2 has endeavoured to show the part played by pre-operative medication and by anaesthesia in influencing movements of the small intestine. His conclusions are in one important particular opposed to the opinion generally held as the result of clinical experience. He finds that morphine increases intestinal tone and intestinal contractions in its usual doses, and that its use as preand post-operative medication is to be recommended. His description of the action of ether, on the other hand, is in accordance with the usually accepted view-that it tends to encourage abdominal distension 1 THE LANCET, 1934, ii., 1326. 2 Anæsth. and Analges., Nov.-Dec., 1934, p. 22.
must
from the sargeon, who in turn must
come
and
1934
frequent
279 attention to the valves ;
it also
understand the principles upon which the manu- depends materially upon the nature of the materials facturer is working. These consiclerations apply to be sterilised and the way they are packed and with especial force to the methods of attaining arranged in the sterilising chamber. Air is heavier than steam and the movement of both gases in an asepsis, the basis of modern surgery. This question of surgical asepsis is raised by a autoclave is from the top to the bottom, where series of papers dealing with the sterilisation of the air escapes. Steam must be allowed access surgical dressings, contributed to the December not only between individual packages, but to the Bulletin of the American College of Surgeons by interstices of the materials themselves. It has technical experts and representatives of hospital been proved that the usual package of towels or administration. The surgeon usually takes the surgical dressings will require from two to three modern autoclave for granted, and relies implicitly times as long for permeation with steam if laid upon its efficacy. He will therefore be surprised horizontally as if placed on edge. Tight packing to learn what complicated mechanism goes to its will hinder, loose arrangement favour, the sterilising construction and what constant care and supcr- process. It is shown in these papers that the vision is needed to keep it in perfect order ; he presence of a residuum of air in an autoclave will may be a little disturbed to realise how many vitiate its efficiency in many ways. The pressure loopholes there are for error. Bacteria, like all gauge indicates the temperature of the chamber living matter, contain about 15 per cent. of protein only when it contains pure steam. When air and 85 per cent. of water. They may be destroyed remains, the temperature varies greatly in different either by dehydration, or by coagulation of their parts of the sterilising box, the ultimate temperaprotein content. Dehydration requires a degree ture that can be secured is reduced, the time of heat that will also scorch any animal or vege- required for securing a uniform temperature is table fibre and impair its structure ; while the greatly increased, and the permeating properties method may be used to sterilise metal or earthen- of the sterilising medium are seriously reduced. An autoclave containing air is not of necessity a ware, it is for this reason useless for the preparation of dressings. The coagulation of protein, on steriliser. the other hand, can be assured at comparatively Post-operative wound infections are uncommon low temperatures by a combination of heat and at the present day, but not unknown. Some are moisture. For practical purposes it may be undoubtedly the fault of members of the team ; that accepted pure steam at a temperature of others may be traced to catgut, but this source F. will kill all bacteria and their spores in is often unjustly blamed. 250° Contamination by half an hour ; this temperature is attained at a dressings imperfectly sterilised should however pressure of 15 lb. An autoclavetherefore depends be impossible in a modern hospital, and on these upon the employment of steam under pressure grounds it would be well if the principles and and the complete replacement of air by steam is precautions outlined in these articles could be essential to its action. The efficient evacuation brought from time to time before the personnel in of air requires not only well-designed apparatus charge of the sterilising apparatus in all institutions.
ANNOTATIONS is 5 per 1000 below that for 1933 and is the lowest recorded, the previous lowest being that for 1930 (60). The rates are provisional and are issued for the information of medical officers of health, but they are not likely to require substantial modification.
mortality-rate
VITAL STATISTICS FOR 1934
THE Registrar-General has issued a provisional statement of the figures for birth-rate, death-rate, and infant mortality during the year 1934. --
THE BIRTH-STRUGGLES OF PSYCHO-
PATHOLOGY THE outcome of a personal stocktaking on the a physician who has had some years of practice in psychopathology is printed on another page. Dr. Emanuel Miller explained to the members of the medical section of the British Psychological Society that it was in the belief that others, like himself, are dissatisfied with the authoritarian attitude of certain schools, as well as with the indeterminate doctrines of others, that he had chosen his subject. If one surveyed the wide field of psychopathology from a distance, he added, one saw a very luxuriant growth. But when walking down the furrowed ranks one perceived many tares and weeds mingled with the healthy wheat, and it seemed likely that the harvest would yield to the psychopathologist bread so contaminated with alien substances that only gargantuan digestion could handle it. He himself had come to the harassing problems of neurosis and psychosis
part of The smaller towns are those with estimated resident of 25,000-50,000 at the 1931 census. The birth- and death-rates for England and Wales as a whole are calculated on the estimated mid-193-1 population, the remaining rates on the estimated mid-1933 populations. The birth-rate is based on live births, the death-rate on crude deaths.
populations
The birth-rate for England and Wales shows an increase of 0.4 per thousand abovethe low record of 1933, and is noteworthy, the Registrar-General remarks, as being the only increase recorded since 1920, except in 1928 when there was a very slight improvement of 0.1 following an exceptional fall in the previous year. The (crude) death-rate is 0-5 below that for 1933, and only 0-4 above that for 1930, which is the lowest recorded. The infant
280
ROYAL FREE HOSPITAL: ANNUAL DINNER
after having studied in the calm groves of the academic mental sciences, sitting at the feet of McTaggart, Ward, Russell, and Moore. This approach might have disadvantages but it implied the possession of instruments designed not only to dissect phenomena but sharp enough to make clean logical cuts in the material with which one had to deal. At first such cuts tend to be too severe ; the attempt to expose a clean academic skeleton results only in the removal of the very living tissue of the mental life. But the period of scepticism passes, to be succeeded by the sensible conclusion that after all there is a lot to be said for the theories of the many warring schools. Dr. Miller himself emerged with the belief that on the whole the greatest security is to be found in the fundamental doctrine enunciated by Freud, realising, however, that conviction of the overwhelming truth of one or two items of a doctrine may only too easily make us accept all the others in the same canon. He holds that the student of Freud finds himself in a region which is more intelligible than is that on which the schools of Jung and Adler are built, but that even here concept has been piled upon concept, and a veritable baroque architecture has been constructed, imposing and attractive, of which the foundations are not always secure. It is one of the canons of modern architecture that buildings should not merely please the eye but that they should be functional and definitely related to the ground upon which they stand. Dr. Miller, in the presidential address which followed these introductory remarks, has certainly contributed towards the establishment of psychological structure on a sounder biological
foundation. ROYAL FREE HOSPITAL: ANNUAL DINNER
MANY generations of students, in more than one London hospital, have had reason to be grateful to Mr. G. P. Mudge for tuition in biology which exactly fits their needs. The clear coloured diagrams on the board, so easily reproduced in note books, and the pithy summary of the ground covered which concluded each lecture are long remembered, while by his concise exposition of complex biological concepts, such as theories of evolution or heredity, Mr. Mudge stimulated some at least of his pupils to further productive study. The graceful tributes paid him by Miss E. H. Jebens, F.R.C.S., when proposing his health, were received with enthusiasm by the large company assembled at the Savoy for the Royal Free Hospital dinner, over which he presided on Jan. 24th. It emerged that he had served the London School of Medicine for Women for 30 years, and he confessed to have derived so much pleasure from this service that he could wish his term of office to be extended for at least as long again. Speakers at this dinner included Dame Louise McIlroy, M.D., Dr. Frank Howitt, Sir Thomas Carey Evans, F.R.C.S., and Miss Addison Phillips. Dame Louise, who has recently resigned from the chair of obstetrics and gynaecology at the school, spoke warmly of its fine traditions and wished it in the future even greater and more prosperous days. The chairman, in reply, spoke of the progress achieved during the year, and of the losses sustained by the school through death or retirement, making specially sympathetic reference to the life and work of Lord Riddell and of Lady Berry. Dr. Howitt found terms of appreciation nicely appropriate to each of the principal guests, and conveyed by his friendly manner Sir a cordial welcome to the many unnamed ones. Thomas Carey Evans, in response, told of the valuable work done by medical women in India, where of 20 medical colleges five catered for women, whose services
not only needed but welcomed by the Indians. spoke in optimistic vein about the progress of tropical medicine. For example, whereas formerly were
He
99 per cent. of the victims of kala-azar died, now the case-mortality rate was less than 5 per cent. ; similarly of those afflicted with amoebic dysentery, twenty years ago 80 per cent. died, and now less than 1 per cent. of the cases proved fatal. Miss Addison Phillips also responded, with many wise quips equally applicable to practitioners of either sex. Doctoring, as she said, is an uphill job from start to finish. The public’s efforts at " doing without a doctor" robs the profession of fees temporarily and adds to their difficulties at a later stage of the illness ; no one attempts, she added, to do without a dentist, knowing that the result could only be one great holocaust. She confessed to appreciation of a good bedside manner, having little use for the brusqueness which is said to veil a good heart, and concluded with som& friendly advice to doctors-e.g., (1) don’t treat patient as if he were a fool, he may not be ; (2) don’t let your manner be either too enigmatic or aggressively cheerful; (3) remember that the patient’s anxious face may be a reflection of that of the young doctor who is taking the notes ; (4) don’t talk to the nurse across the temporarily dead body of the patient ; and don’t keep relatives anxious while you gossip with consultants. Finally, she said, don’t neglect minor ills ; one who could cure chronic indigestion would change clouds of depression into clouds of incense.
PRE-OPERATIVE MEDICATION AND THE SMALL INTESTINE DISTENSION of the bowel after abdominal operations remains one of the most formidable obstacles to recovery with which surgeons have to contend. Mr. Victor Bonney, in his recent Bradshaw lecturer showed that distension is due to " a breakdown of the gas-balancing mechanism, either in the direction of increased production, or diminished removal, or of the two together." Opening the peritoneal cavity causes cessation of peristalsis, thus withdrawing one factor in the mechanism for removing gas. "The cessation in the first instance is the result of antsthesia " said Mr. Bonney. He also showed that interference with the intestinal blood-supply, which in its turn interferes with the gas-absorption mechanism, is the essential element in producing distension, and he believes that this is brought about by some toxic factor arising in the damaged tissues. Some authorities attribute continued distension, when it occurs, entirely to the action of the general anaesthetic which has been used ; others believe that the surgical interference-handling of gut, &c.is the chief cause of the trouble. Finsterer, of Vienna, claims to have shown by his results with splanchnic analgesia that it is the general anaesthetic which is solely to be blamed. In an experimental study H. G. Carlson2 has endeavoured to show the part played by pre-operative medication and by anaesthesia in influencing movements of the small intestine. His conclusions are in one important particular opposed to the opinion generally held as the result of clinical experience. He finds that morphine increases intestinal tone and intestinal contractions in its usual doses, and that its use as preand post-operative medication is to be recommended. His description of the action of ether, on the other hand, is in accordance with the usually accepted view-that it tends to encourage abdominal distension 1 THE LANCET, 1934, ii., 1326. 2 Anæsth. and Analges., Nov.-Dec., 1934, p. 22.