- Email: [email protected]
THE TUBERCULOUS PATIENT
THE TUBERCULOUS PATII;NT
considerations relate to the past. are three other factors to be borne there Today in mind, of which the first is the speed of military Hitherto there has been an interval events. between the state of peace and the death-lock of battle-an interval of psychological preparation. But now there is no likelihood of such an interval, and up to the very moment of danger we shall be still trying to believe there will be no war. The fact that bombs might be dropped at once on our homes is reconciling us to much that we dislike, and conscription may be advocated as a means of stiffening the minds of Englishmen to meet the violent shock of war ; it would give some of the advantages of the obsolete interval between the official commencement of hostilities and their actual occurrence. The second new factor, which is also a derivative of science, is mainly economic. In primitive societies the men go to fight, the women and boys tend the fields. But in an industrial state a factory cannot be run at a moment’s notice by the women and boys left behind, and if it is true that an army marches on its belly it is equally true that a nation fights with its lathes. From this it might be thought that the simplest way to attain the maximum effort for the prosecution of a war would be to conscript the lathe-workers ; but this is not so simple as it sounds ; for the very monotony of factory toil has given birth to a new set of loyalties and rules-loyalties to fellow workmen, and rules
The
foregoing
831
bit by bit upon employers. Tradeunionism creates a state within the state, a minority as strong as the national minorities that trouble our continental neighbours, and this inner state influences home policy and foreign relations. Its attitude towards the conscription of workers (and of wealth) depends on the third factor in the situationnamely, the orientation of the aggressive impulse. The impulse towards aggression may find satisfaction directly in wars of conquest, and in domination over " inferior " races, or it may be turned against the forces of nature : the former activity raises the standard of national glory, the latter raises the standard of living. As workers come to recognise the social constructiveness of their toil, they gain a new basis for criticism of their own government, and they begin to demand that not only home but also foreign policy should be adapted to further their social projects. The ultimate " the conflict " in world ideological today is whether the man-power of the country shall be turned primarily to social productiveness or to deeds of national self-glorification. Those who care most about the betterment of society are not easily persuaded to turn their effort into military channels, and the control of the man-power of the country will not in England be put into any government’s keeping simply because it is the government in power. The question, it seems, is not " if and when to conscribe men " but on what programme the full force of the nation can be united.
imposed
ANNOTATIONS THE TUBERCULOUS PATIENT
THE Tuberculosis Association is essentially a clinical and practical body and many of the debates at its meetings centre round the treatment of the local lesion and the ingenious methods that have been devised for the closure of the tuberculous cavity. At the meeting of the association, held last week at Cambridge, there was a refreshing departure from these much discussed topics ; and the tuberculous patient himself would surely be relieved to learn that attention was diverted for a brief space from his lungs to his livelihood, which often causes him so much anxiety as to affect his progress. Dr. F. R. G. Heaf, who made it clear that his personal opinions must not be taken as those of his county council, asked if the tuberculous patient was getting a square deal and whether we were not trying to make the patient fit the scheme rather than the scheme fit the patient Without deprecating collapse therapy he did deprecate the tendency to regard the treatment of phthisis as beginning and ending with the closure of cavities ; relapse after an expensive course of treatment was often due to neglect of the economic position of the patient. To label a person a consumptive was apt to lead to his financial ruin through loss of employment. Industry could not be expected to absorb a substandard person, and moreover it was not in the patient’s best interests to enter into active competition with the fit and healthy. That is not to say that the tuberculous person after a course of treatment is not employable. Dr. Heaf showed a series of radiograms selected at random from patients in village settlements. These films, many of which revealed extensive disease, were all of men who had worked for from 3 to 10 years and earned from 300
to .S1500. Not only were they costing the nothing but they were actually earning a equivalent or more than equivalent to their
state sum own
maintenance. Dr. Heaf added that a number of the administrative difficulties of a tuberculosis scheme, such as persuading a patient to accept treatment, preventing the spread of infection by careless sputumpositive cases, and the caring for the chronic relapsing case would largely disappear if an adequate rehabilitation system was established, for then the distant future could safely be discussed with the patient and his relatives before active treatment was started. The best approach, in Dr. Heaf’s view, lay in the formation of a national board composed of tuberculosis specialists, industrial magnates and official representatives from the Ministries of Health and Labour. The functions of this board would be to found industrial settlements throughout the country and to encourage productive labour therein ; to act as a labour bureau for the tuberculous and invite firms to employ such persons on a sliding scale of subsidies; and finally to set up standards whereby patients could be graded as to their fitness for employment. It was suggested in the discussion
that followed Dr. Heaf’s paper that the trade-unions should certainly be represented on such a board ; and it is relevant that the unions have already recognised that the tuberculous patient is employable by allowing him to work at Papworth at trade-union rates. All this deserves thought. Is it as essential as believe to go all out for the closure of cavities and are the results of attempts to effect such closure so successful that it should be the prime consideration of treatment ? Those who saw and pondered over Dr. Heaf’s radiograms may be inclined to reserve some
832
BLOOD-TRANSFUSION IN INFANTS
judgment. In any case we ought to give more attention to improving the prospects of the consumptive. Last century he feared the disease because it meant death ; now he dreads the unemployment and loss of self-respect that follow in its wake. Dr. Heaf quoted Sir Clifford Allbutt’s observation that the first thing a physician had to give his patient was hope. It is impossible to give a patient hope until you have banished fear. CARDIAC INSUFFICIENCY AND ACUTE NEPHRITIS
THE observed frequency of cardiac insufficiency in acute nephritis varies with the criteria used for its recognition and the care with which it is sought. In different reported series its incidence has varied from 17 to 50 per cent. ; but in 138 cases of acute nephritis seen at the Johns Hopkins medical clinic1 evidence of cardiac insufficiency was found in 98 (71 per cent.). The nephritis in all the cases followed a streptococcal infection and it was mostly observed from the early stages. Symptoms of heart-failure appeared with the onset of the nephritis or a few days later. The main symptom was usually increasing breathlessness, which sometimes progressed to orthopnoea. Serial radiograms demonstrated enlargement of the heart, which regressed as the cardiac condition improved, and there were alterations in the heart sounds and rhythm. Systemic venous pressure was increased, and in some cases the liver was enlarged. In the presence of renal oedema it was difficult to state dogmatically that any increase in the oedema could be ascribed to the circulatory insufficiency, but it was significant that the onset of cerebral or pulmonary oedema coincided in some cases with the appearance of other signs of cardiac insufficiency. The Baltimore group divided their cases of nephritis into mild, moderately severe, and severe, according to their clinical features. Heart-failure was uncommon in the mild attacks, frequent in the moderately severe, and present in most of the severe cases. The authors point out the importance of recognising the condition, which, serious in itself, becomes doubly serious when the circulatory insufficiency further impairs the function of the damaged kidneys. Though the assessment of the value of treatment presents difficulties, digitalis in full doses seemed to benefit some of the patients with severe circulatory failure. BLOOD-TRANSFUSION IN INFANTS
number of conditions affecting the icterus gravis neonatorum, severe aneemia and the haemorrhagic diseases, in which the transfusion of blood may be desirable or even lifesaving, but the difficulties of intravenous administration in small babies are always great and sometimes seem insurmountable. For a satisfactory transfusion on an infant it is necessary to have three things. First, a vein which is constant in position and of reasonable size must be found; Ormiston2 recommends the superficial temporal vein or its tributaries ; Collins3 in Australia, however, uses the beginning of the great saphenous vein, where it passes upwards and backwards over the anterior surface of the medial malleolus of the tibia. Secondly, a method must be devised whereby the vein, however small, can be entered by the cannula with absolute certainty. In the apparatus described by Collins this is attained by using a gauge 18 hypoTHERE
are
newborn, such
a
as
1. Whitehill, M. R.. Longcope, W. T., and Williams,
Johns Hopk. Hosp. February, 1939, p. 83. 2. Ormiston, G., Lancet, 1938, 2, 82. 3. Collins, V. L., Med. J. Aust. 1938, 2, 1121.
R., Bull.
dermic needle, with the point cut off and the end left circular a,nd bevelled towards the lumen. Into this needle, or cannula as it has now become, is inserted a stilette with a rounded tip. Even the most minute vein can be entered by the stilette, and when that has been introduced it is a simple matter to insert the larger body of the needle. The third requisite for successful transfusion on the new. born is some means of exerting positive pressure so as to propel the fluid along the vein ; this is provided in Ceilings apparatus by a Record syringe and
three-way tap. Both recipient and donor must be grouped and their compatibility tested directly, for a reaction is more serious in a baby than in an adult. The blood is best collected by a closed method. The vein is found by a
small transverse incision carried down to the blunt dissection, and the cannula is then introduced and tied in. The amount of blood suggested by Collins is 66 c.cm. per kg. of bodyweight-rather more than most paediatricians advise. The speed of introduction must be very slow, not greater than 3 or 4 c.cm. per min. In larger infants, who need more blood, the continuous-drip method is a
periosteum by
more satisfactory ; this requires a slightly bigger needle and stilette. Ormiston’s method does not involve cutting down on a vein-an advantage where repeated transfusions are required-but needs a good deal of practice by the operator. Collins claims that with his apparatus blood or fluid can be given intravenously to any small or newborn baby, and that there is now no reason for withholding transfusion on the grounds of technical difficulty.
FACTOR ANALYSIS IN PSYCHOLOGY AND
MEDICINE
A REMARKABLY lucid and comprehensive survey of the aims and methods of factor analysis in psychology has been made by Prof. Godfrey Thomson.l He deals in turn with the analysis of mental tests, the assessment of factors for individual examinees, the errors and fluctuations produced by inadequate sampling or incomplete selection, and finally with the meaning of the factors themselves. In opposition to Spearman’s hypothesis of a general mental energy entering into every intellectual performance, but differing in amount from one individual to another, Prof. Thomson develops his theory that an intelligence test really samples the neurones in the examinee’s brain. In crude terms, this implies that the relative inefficiency of the mentally defective is due not to lack of mental energy but to lack of cortical neurones -to the fact that they have only about 7000 million neurones instead of 12,000 million : energy is taken to be the product rather of the emotional and instinctive Burt’s view that the mental and mechanisms. emotional types revealed by correlating persons are the same as those revealed by correlating traits is fully discussed ; though current methods of diagnosis tacitly im’ply its acceptance, it is held to raise several unsolved difficulties. In the main, however, the book is concerned with methods rather than with results-methods which could perhaps be applied quite as fruitfully to the wider problems of physiology and medicine as to those of the human mind or brain. The causes of physical disorder, like those of mental disorder, are nearly always multiple. The object of factor analysis Factorial Analysis of Human Ability. By Godfrey Thomson, D.Sc., Ph.D., professor of education in the of London : Edinburgh. University of London University Press. 1938. Pp. 326. 16s.
1. The
considerations relate to the past. are three other factors to be borne there Today in mind, of which the first is the speed of military Hitherto there has been an interval events. between the state of peace and the death-lock of battle-an interval of psychological preparation. But now there is no likelihood of such an interval, and up to the very moment of danger we shall be still trying to believe there will be no war. The fact that bombs might be dropped at once on our homes is reconciling us to much that we dislike, and conscription may be advocated as a means of stiffening the minds of Englishmen to meet the violent shock of war ; it would give some of the advantages of the obsolete interval between the official commencement of hostilities and their actual occurrence. The second new factor, which is also a derivative of science, is mainly economic. In primitive societies the men go to fight, the women and boys tend the fields. But in an industrial state a factory cannot be run at a moment’s notice by the women and boys left behind, and if it is true that an army marches on its belly it is equally true that a nation fights with its lathes. From this it might be thought that the simplest way to attain the maximum effort for the prosecution of a war would be to conscript the lathe-workers ; but this is not so simple as it sounds ; for the very monotony of factory toil has given birth to a new set of loyalties and rules-loyalties to fellow workmen, and rules
The
foregoing
831
bit by bit upon employers. Tradeunionism creates a state within the state, a minority as strong as the national minorities that trouble our continental neighbours, and this inner state influences home policy and foreign relations. Its attitude towards the conscription of workers (and of wealth) depends on the third factor in the situationnamely, the orientation of the aggressive impulse. The impulse towards aggression may find satisfaction directly in wars of conquest, and in domination over " inferior " races, or it may be turned against the forces of nature : the former activity raises the standard of national glory, the latter raises the standard of living. As workers come to recognise the social constructiveness of their toil, they gain a new basis for criticism of their own government, and they begin to demand that not only home but also foreign policy should be adapted to further their social projects. The ultimate " the conflict " in world ideological today is whether the man-power of the country shall be turned primarily to social productiveness or to deeds of national self-glorification. Those who care most about the betterment of society are not easily persuaded to turn their effort into military channels, and the control of the man-power of the country will not in England be put into any government’s keeping simply because it is the government in power. The question, it seems, is not " if and when to conscribe men " but on what programme the full force of the nation can be united.
imposed
ANNOTATIONS THE TUBERCULOUS PATIENT
THE Tuberculosis Association is essentially a clinical and practical body and many of the debates at its meetings centre round the treatment of the local lesion and the ingenious methods that have been devised for the closure of the tuberculous cavity. At the meeting of the association, held last week at Cambridge, there was a refreshing departure from these much discussed topics ; and the tuberculous patient himself would surely be relieved to learn that attention was diverted for a brief space from his lungs to his livelihood, which often causes him so much anxiety as to affect his progress. Dr. F. R. G. Heaf, who made it clear that his personal opinions must not be taken as those of his county council, asked if the tuberculous patient was getting a square deal and whether we were not trying to make the patient fit the scheme rather than the scheme fit the patient Without deprecating collapse therapy he did deprecate the tendency to regard the treatment of phthisis as beginning and ending with the closure of cavities ; relapse after an expensive course of treatment was often due to neglect of the economic position of the patient. To label a person a consumptive was apt to lead to his financial ruin through loss of employment. Industry could not be expected to absorb a substandard person, and moreover it was not in the patient’s best interests to enter into active competition with the fit and healthy. That is not to say that the tuberculous person after a course of treatment is not employable. Dr. Heaf showed a series of radiograms selected at random from patients in village settlements. These films, many of which revealed extensive disease, were all of men who had worked for from 3 to 10 years and earned from 300
to .S1500. Not only were they costing the nothing but they were actually earning a equivalent or more than equivalent to their
state sum own
maintenance. Dr. Heaf added that a number of the administrative difficulties of a tuberculosis scheme, such as persuading a patient to accept treatment, preventing the spread of infection by careless sputumpositive cases, and the caring for the chronic relapsing case would largely disappear if an adequate rehabilitation system was established, for then the distant future could safely be discussed with the patient and his relatives before active treatment was started. The best approach, in Dr. Heaf’s view, lay in the formation of a national board composed of tuberculosis specialists, industrial magnates and official representatives from the Ministries of Health and Labour. The functions of this board would be to found industrial settlements throughout the country and to encourage productive labour therein ; to act as a labour bureau for the tuberculous and invite firms to employ such persons on a sliding scale of subsidies; and finally to set up standards whereby patients could be graded as to their fitness for employment. It was suggested in the discussion
that followed Dr. Heaf’s paper that the trade-unions should certainly be represented on such a board ; and it is relevant that the unions have already recognised that the tuberculous patient is employable by allowing him to work at Papworth at trade-union rates. All this deserves thought. Is it as essential as believe to go all out for the closure of cavities and are the results of attempts to effect such closure so successful that it should be the prime consideration of treatment ? Those who saw and pondered over Dr. Heaf’s radiograms may be inclined to reserve some
832
BLOOD-TRANSFUSION IN INFANTS
judgment. In any case we ought to give more attention to improving the prospects of the consumptive. Last century he feared the disease because it meant death ; now he dreads the unemployment and loss of self-respect that follow in its wake. Dr. Heaf quoted Sir Clifford Allbutt’s observation that the first thing a physician had to give his patient was hope. It is impossible to give a patient hope until you have banished fear. CARDIAC INSUFFICIENCY AND ACUTE NEPHRITIS
THE observed frequency of cardiac insufficiency in acute nephritis varies with the criteria used for its recognition and the care with which it is sought. In different reported series its incidence has varied from 17 to 50 per cent. ; but in 138 cases of acute nephritis seen at the Johns Hopkins medical clinic1 evidence of cardiac insufficiency was found in 98 (71 per cent.). The nephritis in all the cases followed a streptococcal infection and it was mostly observed from the early stages. Symptoms of heart-failure appeared with the onset of the nephritis or a few days later. The main symptom was usually increasing breathlessness, which sometimes progressed to orthopnoea. Serial radiograms demonstrated enlargement of the heart, which regressed as the cardiac condition improved, and there were alterations in the heart sounds and rhythm. Systemic venous pressure was increased, and in some cases the liver was enlarged. In the presence of renal oedema it was difficult to state dogmatically that any increase in the oedema could be ascribed to the circulatory insufficiency, but it was significant that the onset of cerebral or pulmonary oedema coincided in some cases with the appearance of other signs of cardiac insufficiency. The Baltimore group divided their cases of nephritis into mild, moderately severe, and severe, according to their clinical features. Heart-failure was uncommon in the mild attacks, frequent in the moderately severe, and present in most of the severe cases. The authors point out the importance of recognising the condition, which, serious in itself, becomes doubly serious when the circulatory insufficiency further impairs the function of the damaged kidneys. Though the assessment of the value of treatment presents difficulties, digitalis in full doses seemed to benefit some of the patients with severe circulatory failure. BLOOD-TRANSFUSION IN INFANTS
number of conditions affecting the icterus gravis neonatorum, severe aneemia and the haemorrhagic diseases, in which the transfusion of blood may be desirable or even lifesaving, but the difficulties of intravenous administration in small babies are always great and sometimes seem insurmountable. For a satisfactory transfusion on an infant it is necessary to have three things. First, a vein which is constant in position and of reasonable size must be found; Ormiston2 recommends the superficial temporal vein or its tributaries ; Collins3 in Australia, however, uses the beginning of the great saphenous vein, where it passes upwards and backwards over the anterior surface of the medial malleolus of the tibia. Secondly, a method must be devised whereby the vein, however small, can be entered by the cannula with absolute certainty. In the apparatus described by Collins this is attained by using a gauge 18 hypoTHERE
are
newborn, such
a
as
1. Whitehill, M. R.. Longcope, W. T., and Williams,
Johns Hopk. Hosp. February, 1939, p. 83. 2. Ormiston, G., Lancet, 1938, 2, 82. 3. Collins, V. L., Med. J. Aust. 1938, 2, 1121.
R., Bull.
dermic needle, with the point cut off and the end left circular a,nd bevelled towards the lumen. Into this needle, or cannula as it has now become, is inserted a stilette with a rounded tip. Even the most minute vein can be entered by the stilette, and when that has been introduced it is a simple matter to insert the larger body of the needle. The third requisite for successful transfusion on the new. born is some means of exerting positive pressure so as to propel the fluid along the vein ; this is provided in Ceilings apparatus by a Record syringe and
three-way tap. Both recipient and donor must be grouped and their compatibility tested directly, for a reaction is more serious in a baby than in an adult. The blood is best collected by a closed method. The vein is found by a
small transverse incision carried down to the blunt dissection, and the cannula is then introduced and tied in. The amount of blood suggested by Collins is 66 c.cm. per kg. of bodyweight-rather more than most paediatricians advise. The speed of introduction must be very slow, not greater than 3 or 4 c.cm. per min. In larger infants, who need more blood, the continuous-drip method is a
periosteum by
more satisfactory ; this requires a slightly bigger needle and stilette. Ormiston’s method does not involve cutting down on a vein-an advantage where repeated transfusions are required-but needs a good deal of practice by the operator. Collins claims that with his apparatus blood or fluid can be given intravenously to any small or newborn baby, and that there is now no reason for withholding transfusion on the grounds of technical difficulty.
FACTOR ANALYSIS IN PSYCHOLOGY AND
MEDICINE
A REMARKABLY lucid and comprehensive survey of the aims and methods of factor analysis in psychology has been made by Prof. Godfrey Thomson.l He deals in turn with the analysis of mental tests, the assessment of factors for individual examinees, the errors and fluctuations produced by inadequate sampling or incomplete selection, and finally with the meaning of the factors themselves. In opposition to Spearman’s hypothesis of a general mental energy entering into every intellectual performance, but differing in amount from one individual to another, Prof. Thomson develops his theory that an intelligence test really samples the neurones in the examinee’s brain. In crude terms, this implies that the relative inefficiency of the mentally defective is due not to lack of mental energy but to lack of cortical neurones -to the fact that they have only about 7000 million neurones instead of 12,000 million : energy is taken to be the product rather of the emotional and instinctive Burt’s view that the mental and mechanisms. emotional types revealed by correlating persons are the same as those revealed by correlating traits is fully discussed ; though current methods of diagnosis tacitly im’ply its acceptance, it is held to raise several unsolved difficulties. In the main, however, the book is concerned with methods rather than with results-methods which could perhaps be applied quite as fruitfully to the wider problems of physiology and medicine as to those of the human mind or brain. The causes of physical disorder, like those of mental disorder, are nearly always multiple. The object of factor analysis Factorial Analysis of Human Ability. By Godfrey Thomson, D.Sc., Ph.D., professor of education in the of London : Edinburgh. University of London University Press. 1938. Pp. 326. 16s.
1. The