THE RESPONSIBILITIES OF THE M.A.B.

618 I

patient’s own spinal not be forgotten that the abdominal spasms which cause such acute pain when they first appear usually cease to be so painful after a few days, and that gradually the spasms may occur almost painlessly. For the attacks of disordered breathing (polypnoea, dyspnoea, &c.), which often cause considerable alarm when they first occur, oxygen may be administered with good effect. In most cases a confident assurance to the patient and his friends that they are not dangerous and a simple sedative will suffice. In the acute stage troublesome constipation often requires attention ; frequent soap-and-water enemata

injections of 10 fluid, but it must

c.cm.

of the

Special Articles. THE RESPONSIBILITIES OF THE M.A.B.

may be useful. The tongue may remain foul and coated for longer than the general condition appears to warrant, when ordinary methods of local cleansing

should be

employed.

-4fter- Treatment. After-treatment may demand great patience and

endurance. When once the acute stage is over, say in two to four weeks, there does not seem to be any necessity for complete rest in bed. Many cases remain weak both mentally and physically for very long periods, and require a long rest before returning to work. A sea voyage, a holiday abroad, a quiet retreat in the country, at the sea, or even at whatever course is decided on, must be designed as a real rest for the mind, and must therefore be congenial to the patient. In some cases motoring has

-

home,I

proved effective.

The Parkinsonian syndrome as a sequela presents great difficulty in treatment. Massage, hydrotherapy, and passive movements have been advocated, and in some cases give a certain amount of relief. Electrical applications appear to give no benefit, and in some cases to do harm. Various drugs have been recommended, including arsenic, luminal, belladonna, and tincture of arnica. Scopolamine undoubtedly relieves the tremor and rigidity for a time, but has no permanent effect. Its use cannot be continued for long periods. After choreiform attacks recovery may be considerably hastened by the judicious employment of regulated exercises. For this purpose simple callisthenic arm exercises may be carried out, or, in small children, building with toy bricks. At the City Fever Hospital, Sheffield, Dr. Egerton Williams has obtained rapid improvement in older children by getting them to knit. The most disturbing sequela is perhaps the peculiar nocturnal excitement and insomnia, which, though not limited to children, reaches its highest grade in them. In most cases much may be done by judicious control and " good mothering." Even then sedatives are often required as well. Of these, bromide and chloral hydrate, or chloretone seem to be the most generally useful. The method of injecting small quantities of milk intramuscularly, which was first suggested by ’, Lust of Karlsruhe, has proved effective in many of our cases ; 2 c.cm. of boiled milk are thus given at bedtime, and the child usually goes to sleep in an hour or two, and sleeps soundly for six or seven

I I

hours or more. Nor is its action limited to children. In the case of a man who had not been able to sleep until 3 or 4 o’clock in the morning since his acute attack five months ago, intramuscular injections - of milk given at 9 o’clock each night for a week produced sound sleep from 10 till 5 next morning. Preliminary injections of distilled water in similar quantity at the same hour had failed to have any effect. It does not always succeed, but should be tried in any obstinate case. In some cases a change to the seaside or country, with plenty of exercise in the fresh air, will give temporary relief, but a relapse on returning to home conditions is not uncommon.

ARTHUR J. HALL, M.D. Camb.,

F.R.C.P.

Lond.,

Professor of Medicine, University of Sheffield; Senior Physician, Sheffield Royal Hospital.

THE annual report’ of the Metropolitan Asylums Board contains, as usual, a historical summary of the evolution of this great organisation and a clear accoimt of the manifold duties it performs for the 28 parishes and unions which make up the Metropolitan Asylums district. To maintain this service, ratepayers at Hampstead combine with residents in unfashionable Wandsworth; Kensington in the West gets as efficient but no better service than does Limehouse in the East. The Board is composed of 73 members, 55 being elected by the metropolitan boards of guardians and 18 being nominated by the Ministry of Health. Their duties include the provision and management of hospitals and other institutions for infectious diseases, tuberculosis, children suffering from specified contagious diseases and those requiring special treatment in general hospitals or convalescent homes, mental defectives and epileptics, training boys for sea service, and for casual poor; they also provide ambulance and transport services. Of these activities the fever hospitals and the ambulance and transport service are best known to practitione s as being available for use by the public apart from Poor-law cases, but it is not generally realised how numerous are the contingencies affecting the public which the Board now has to meet. A list given in Appendix III. of the report divides the several classes of persons for whom the Board is now required to provide accommodation into (a) the mentally afflicted and epileptics, (b) the physically afflicted, (c) healthy classes, and this method of classification shows how wide are their responsibilities. The Mentally Afflicted. Harmless Poor-law imbeciles of any age,-whether regarded as capable or incapable of improvement, have had to be provided for since the inception of the Since this date also suitable cases Board in 1867. certified under the Lunacy Acts transferred from the London County mental hospitals have been received. In 1897 the Board assumed charge of feeble-minded Poor-law children (uncertified), and in 1916 of sane epileptics (Poor-law). From 1917 cases certified under the Mental Deficiency Act, 1913, have been accepted. It -will be seen that during the last 50 years, by formal addition of new classes of persons and, perhaps, still more through freedom in the interpretation of the terms in which the original classes were defined, it has come about that the Board’s purview of mental iniirmity has extended so as to embrace a wide range of persons. N0 attempt is made to define the type of lunatic who may properly be detained in the mental

hospitals provided by the Metropolitan Asylums Board, which by the Lunacy Act, 189U, are included under the definition of a workhouse. In practice the Metropolitan Asylums Board now provides in its mental hospitals for : (a) Chronic and harmless cases of all forms of insanity ; (b) idiots and imbeciles who come within the terms of the Lunacy Acts ; (c) feeble-minded persons as approved by the Local Government Board in 1897 and 1911 ; (d) cases covered by the Mental Deficiency Act, 1913, with certain restrictions. The distribution of the 9077 beds provided is as follows : Caterham Mental Hospital, 2109 ; Fountain Mental Hospital, 658 ; Leavesden Mental Hospital, 3309 ; Tooting Bee Mental Hospital, 1098 ; Darenth Training Colony, 2298 ; Edmonton Epileptic Colony, 355 ; Brentwood Institution, 350. At the present time a scheme exists which aims at ensuring the classification of the different types of cases in suitable institutions and the regular movement through the institutions of patients according to changes in age and mental or physical condition. 1 Office of the Board, Victoria Embankment, London, E.C.4. Price 5s.

619

Thus, at the Fountain Mental Hospital are received report, taking up 81 pages, is edited by Dr. F. Foord all children under 7, unimprovable boys up to 9 years Caiger, chief medical officer of the infectious hospitals of age, and girls up to 16. The children under 7 are service, who besides contributing a note on the prowatched and classified so that when the time comes tective inoculation by the Schick test and, active those who are thought to be trainable can be sent on immunisation against diphtheria of _the boys on the to Darenth Training Colony. A few adult female training ship Exmouth, makes observations on certain working patients are maintained at the Fountain of the statistical tables. He calls attention to the Mental Hospital. Tooting Bee Mental Hospital is the lower incidence of scarlet fever and of diphtheria in receiving home for all adult Lunacy Act cases sent by London, and to the diminution of the death-rate metropolitan boards of guardians, but no cases under of these diseases from 1-8 per cent. and 8-7 per cent. the Mental Deficiency Act are received there. Aged respectively in 1922 to1 -2, per cent. (scarlet fever) patients are retained at Tooting Bee Mental Hospital, and 6-8 per cent. (diphtheria) in 1923. The lastbut younger ones, after observation, are transferred to named figure is still considered too high and could the institutions for which they are suitable. Caterham be materially reduced by the earlier administration Mental Hospital receives healthy unimprovable adults of antitoxin. Incidentally in a note on the deathof both sexes and a certain number of low-grade rate in diphtheria as influenced by the dosage of trainable cases not up to standard for Darenth antitoxin, which forms one of 16 noteworthy contriTraining Colony. Caterham also has a large number butions by medical officers to this section of the of children’s beds for unimprovable and low-grade report, Dr.Margaret Bjorkegren observes that in so trainable children, receiving the untrainable boys over far as inference can be drawn from statistics in so 9 as they leave the Fountain Mental Hospital. complex a subject, the average optimum dose would Leavesden Mental Hospital may be regarded as an seem to be about 20,000 units per patient. Dr. Caiger infirmary institution. It accommodates unimprovable points out that the incidence of enteric fever is now so adults of both sexes, chiefly those suffering from small that the disease has been omitted from the charts. chronic infirmity not primarily due to old age. Owing to the low prevalence of scarlet fever it has The full statistical tables given of the work done in been possible to devote more beds to the reception of the mental hospitals present no featut-es of special measles and whooping-cough. 1767 cases of measles importance. Dr. G. B. Sherlock, chief medical were admitted during the year with the very low officer of the Mental Hospitals Service, draws attention case mortality of 7-7. The whooping-cough mortality, to the curious fact that among the 423 deaths recorded on the other hand, was high-14-6 per cent. of 528 cases in patients who died at the ages of 45 and upwards admitted. The puerperal fever admissions during the during 1923, there were only 15 deaths attributed to year numbered 78, of whom 15 died. Sir Almroth cancer-i.e., 3-54 per cent. This is not a new feature, Wright and his assistants are making trial of the since the corresponding figures for the previous four immuno-transfusion2 treatment on certain of the more years were 9, 7, 16, and 21 deaths from cancer, the severe cases of septic infections in three of the fever total deaths being respectively 629, 472, 536, and 557. hospitals in cooperation with the medical officers, but Dr. Sherlock points out that since most of the patients the number of cases so treated is not yet sufficiently belong to London, a comparison with the Registrar- large to pronounce on its value. Cases of mistaken diagnosis, that is to say, cases of General’s returns for that area is permissible. For 1923 the numbers were : Deaths from cancer (45 diseases properly admissible into the fever hospitals years and upwards), 5535 ; total deaths (45 years and in which, either at the time of their reception at the upwards), 33,056, or 16-74 per cent. The reason for this hospital, or as the result of subsequent observation, marked difference between the figures for London and the diagnosis of the certifying practitioner was not those for the Board’s mental hospitals is not obvious. confirmed, numbered 3527. The disease in respect of which a mistake in the diagnosis was most common 7 Ae l’hYS1Cally 13,t2cte.cL. was, as usual, enteric fever. The diagnosis of enteric Infecliozca and Confagiow5 Diseases.-The Board fever was negatived in no less than 37-9 per cent. of have 14 hospital for infectious diseases, where they cases so the diseases most often mistaken for certified, provide accommodation for cases of scarlet, enteric, enteric fever being pyrexia of unknown origin, or typhus fever, diphtheria, measles, whoopingenteritis, influenza, and meningitis. cough, puerperal fever, cerebro-spinal fever, oph- pneumonia, comes next with 20-9 per cent. (the figure Diphtheria thalmia neonatorum, trench fever, malaria, and for 1922 was 14-1), mistakes being most frequent in dysentery. All patients suffering from these maladies, respect of tonsillitis, laryngitis, and Vincent’s angina. whatever their status, are now receivable. Poor-law Research into problems connected with scarlet children suffering from ophthalmia, or other con- fever is being actively pursued in the Belmont tagious diseases of the eye are treated. in an institu- Laboratories by the research pathologist to the Board, tion (White Oak, Swanley) which is a collection of Dr. W. Mair, who contributes to this report an groups of similar cottages, and serves the double article on the aetiology of scarlet fever. purpose of hospital and school. There is room for Tuberculosis.-The section of the report devoted to 36U children, and Mr. E. Treacher Collins acts as tuberculosis deals with the arrangements made for visiting ophthalmic surgeon. During 1923 271 cases (a) of pulmonary tuberculosis, (b) of nonchildren were discharged cured, 240 were admitted, tuberculosis. The Board has entered into 101 from metropolitan and 22 from extra-nletro- pulmonary with the London County Council under arrangements politan Poor-law schools, and 117 from London which they provide residential treatment for tuberCounty Council schools. Apparently these are the culous patients in the County of London. The only sources of admission, and since the reduction institutions for adult patients under their control in the number of cases leaves vacant accommoda- include two sanatoriums for early cases of pulmonary tion at this hospital, now partially used as a con. three hospitals for advanced cases, and tuberculosis, valescent home, we suggest that the admission of one hospital for surgical tuberculosis. For children patients from middle-class homes who attend private suffering from tuberculosis three institutions have schools might be worth consideration by the Board, been provided-two at the seaside and one in the on the analogy of the reception of patients of this Provision has been made in all for 1000 country. class into fever hospitals. Diseases of the skin or adults and about 1200 children. scalp in Poor-law children are treated at Gtoldie Dr. James Watt, the chief medical officer of the Leigh Homes, Abbey Wood ; during the year 591 Medical Tuberculosis Service, commenting on the children were dealt with, the large majority suffering statistics for pulmonary tuberculosis, pleads for more from ringworm, and here also the admission of the beds for advanced cases, since continued voluntary public other than those coming Under the Poor-law segregation would, in his opinion, do much to prevent might he greatly appreciated. A detailed account of the spread of infection. With regard to the ultimate the methods used at this home, giving a proportion result of treatment, as measured by the proportion of of 487 cures out of 513 cases of ringworm, would be 2 of interest. The Infectious Diseases section of the See THE LANCET, 1923, ii., 1341. -

f

620 cases surviving four to five years after discharge from and the introduction of greater variety in farinaceous the sanatorium, Dr. Watt states that a misleading foods and dried fruits. The question of a further impression has been fostered that in general all the revision of the scale is under consideration. As to the

negativecases do well and all the positive cases do casual wards, one of the seven in use during 1923 has badly. The statistics of the London County Council been closed and used as a hostel for men, carefully show that only about 30 per cent. of the positive cases selected from the casual wards or from the night office, survive for four to five years, while about 70 per cent. who are likely to find work. of the negative class are alive at the end of that period. The length of stay in the hostel is ordinarily limited But it is clear from the figures given that although to 14 days. The inmates are given a more liberal diet the prognosis is good where the lung lesion is slight, than is provided in the casual ward ; are subject only and there is not much deterioration of the general to such regulations as are necessary for the proper health, yet even in the negative class, where the lesion conduct of the institution ; and are allowed complete is extensive and the general health considerably liberty to seek work, with the result that many affected, the issue hangs in the balance. There is a situations have been found by the men. The likelihood good case therefore for giving as thorough and as of response to the assistance which they would be prolonged treatment to patients of the negative as of given was the sole factor in the selection of the cases, the positive class. A certain proportion of the former as is illustrated by the fact that the men were drawn are so little deranged in health that a short period of from over 70 trades. Of the 471 cases admitted to treatment and education may suffice ; but on the the hostel during the first six months, 130 were other hand a considerable proportion of the positive known to have found employment, of whom only class have so little prospect of recovery, even with 15 subsequently returned to the casual wards. The Board has approved the continuation of this prolonged sanatorium treatment, that the latter is wasted on them, and could be replaced by less expensive apparently excellent scheme for the full period of one methods of teaching the rules of healthy living. year for which it has been sanctioned by the Ministry The section of the report devoted to non-pulmonary of Health. tuberculosis, which service is under the general direction of Dr. W. T. Gordon Pugh, includes a THE MILK PROBLEM AND THE description of Princess Mary’s Hospital for Children MINISTRY OF HEALTH.* at Margate, which has 271 beds and excellent educational facilities. Six signed articles on special points by medical officers of the tuberculosis service of the THE fresh milk consumed in this country is for all Board are appended. purposes entirely home produced, in this practical children Other Diseases.-Poor-law requiring seaside air or special treatment in a hospital or convalescent respect differing from all our other food-supplies. are over 2t million dairy cattle in the country, home are well served. Queen Mary’s Hospital, There and of these nearly 2 million are actually producing Carshalton (900 beds), and The Downs Hospital, Sutton (360 beds), take all sorts of cases. St. Anne’s milk. The yield of milk during 1923 was 1150 million gallons, and of this the amount consumed as fresh Home, Herne Bay, provides 15 beds at a seaside milk was 730 million gallons. When it is remembered convalescent home, supplemented by beds at White that some 2 per cent. of the milking cows are yielding Oak, Swanley. The section of the report dealing with children milk containing tubercle bacilli ; that much of the includes a lengthy and copiously illustrated mono- milk distributed for consumption as such is produced under extremely unhygienic conditions and is liable graph on the Conservative Mastoid Operation and its in course of production, handling, and distribution to aural J. Mr. Charles Heath, consulting Objects, by contamination gross by dirt derived from varied surgeon to the Downs Hospital for Children. Venereal Diseases.-The treatment of venereal sources ; that such milk may be consumed by young diseases at the Sheffield-street Hospital has been infants, delicate children, and invalids; and that even continued during the year ; 121 women, 7 of whom where milk is treated by heat the process employed had babies with them, were admitted to the hospital, is rarely capable of destroying disease-producing a while 21 babies were born in hospital. At the organisms, it is abundantly clear that there exists Thavies Inn Institution for parturient women suffering formidable milk problem bearing directly on the from venereal diseases, Mr. John Adams records a health of the community. diminution in the number of cases of syphilis and Importance of 1Jlfilk as a Food. believes that this decrease is likely to continue. In view of the great value of milk as a staple article During the year under review 12 mothers were admitted of food, especially for the young, Sir George Newman with syphilis, 10 infants were born alive, 6 with unhesitatingly lays down that the consumption of positive and 4 with negative W.R. As to the two milk ought to be much greater than it is at present. stillborn foetuses, one mother was admitted in labour It has been estimated that the average consumption and the other was confined seven days after admission, per head of our population per day amounts to no neither having had previous treatment. At St. more than a quarter of a pint. This is less than half Margaret’s Hospital for ophthalmia neonatorum, where the quantity consumed in most other countries, mothers may be admitted with infants, 164 women notably in America, and it indicates that there must and 225 infants were admitted during the year. Dr. be a grave deficiency in the amount of milk at present Doris M. Howard records that 203 infants were consumed during the early years of their lives by the discharged with sight unimpaired, 19 with sight bulk of the children in this country. impaired in one or both eyes, and 3 blind in one eye. The milk problem as it stands to-day presents two The hospital now undertakes the treatment of venereal aspects. First, the consumer must be protected as far disease in the mothers admitted with their babies, as possible from risk of infection by disease, especially with good results. This hospital is not confined to tuberculosis, and his milk must have a satisfactory, Poor-law cases. unadulterated, nutritive value ; and second, in order Healthy Classes. to increase consumption, it is necessary that milk Since 1875 the Board have received Poor-law should be attractive and appetising, of good keeping boys for training for sea service (including many qualities, and of recognised economic value. The received from extra-metropolitan parishes and unions), question of protecting the consumer resolves itself and since 1911 they have had to deal with the " casual into eliminating tuberculosis from the milking herd poor." The number of boys admitted to the training and in protecting the milk from contamination by ship Exmouth during the year was 290. Of the boys human and other infections, and to this end the discharged, 45 entered the Royal Navy, 153 the Milk and Dairies (Consolidation) Act is designed, in Mercantile Marine, and 21 were drafted into the Army conjunction with the Tuberculosis Order. As a second as musicians. With a view to increasing the physical Abridged from a section of the Annual Report of the Chief standards of the boys, the dietary scale on the ship Medical Officer of the of Health for 1923. London: has been improved by the addition of more milk H.M. Stationery Office. Ministry *