Under Tension

UNDER TENSION

THE LANCET WNDON:SATURDAY, OCT. 9, 1948

Under Tension THE cause of the present international crisis, we aretold, is the antagonism of democratic and totalitarian conceptions of government. Psychologically, the democratic and the totalitarian regimes represent two different types of adjustment to gregarious life; and each has a long history. What

is the essential difference between them ? The two types of adjustment may be contrasted by reference to the old saying " It takes all sorts to make a world." Those who can accept this exacting notion are prepared to find satisfaction in the thought that others may be very unlike themselves and yet be worthy of respect and - even affection. People with such an attitude of mind can tolerate, without undue strain, profound divergences of outlook in the world in which they live ; indeed they may even experience a relief when there is not too much uniformity in the cultural pattern. To take an instance from the political field, His Majesty’s Opposition is accorded almost as much respect as His Majesty’s Government, for both are loyal to the Throne and both are made up of persons who represent the people; and when they are of almost equal power we have a feeling that our constitution is safe, since changes will not come at a speed we cannot check. Other instances in this country include the unembittered rivalry of religious groups, the general tolerance of agnosticism, the easy mixing of agegroups in the community, and, above all, the way in which ancient institutions are adapted to present purposes instead of being destroyed. The ideal democracy is based on a conviction that the fullest life is- only to be found in a diversely constituted society. The totalitarian, on the other hand, holds that conflict of ideas within his nation or group is dangerous, and his remedy for internal tension is to induce everyone to think alike and behave alike. This attitude long antedates the Soviet and Nazi totalitarian states. In pre-revolutionary Russia it found expression in the oneness-of-mind which characterised the decisions of the-village mir, in the religious notion of sobornost (a sort of pentecostal unifying inspiration of the whole congregation), and in political and religious self-abnegation. The readiness of Russian communities to accept vast changes of policy was established long before Marxian dialectic was thought of. These two modes of adaptation to tension may -be alternative cultural responses to a situation that every individual has to deal with in his own development. Mental growth results from a complex of contrasting impulses of love and hate, and our picture of ourselves and the social world in which we live is

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at first permeated with images of fantastically good and fantastically bad people. It is commonly reckoned an advance towards maturity when we can recognise the good-and-bad in ourselves as well as the good-and-bad in those around us : we achieve an accommodating, not over-demanding, attitude to ourselves and to others. In some societies this flexible and tolerant way of social life is transferred to the community, and to those who are its symbol and executive. The State is not divine, nor yet is it abhorrent. In the individual’s relation to the State there is again a contrast between the democratic and the totalitarian societies ; for the former have evolved a sociopolitical device by which the people, without disloyalty or disruption, can express hostility to authority. In England and the United States interest in politics is split into two.. One portion is reserved for the Crown (in America for the Constitution and the Supreme Court), and discontent, however active, does not disturb it : the other portion is focused on the Cabinet, which discontent can remove from office without upsetting the fundamental relation to the central authority. But totalitarian nations have no comparable device. HITLER made himself a god to his people, and had no

cabinet worth attacking. The leading one-party State of the present time, Soviet Russia, has likewise exploited the notion of an omnipotent ruler., and provides hardly any means by which peoplecan legitimately express discontent with the policy of their government on major issues. Instead, the hostility that the rulers might incur by their shortcomings is often diverted to some external agencya custom that menaces international harmony, by producing uncontrollable suspiciousness and a paranoid attitude to neighbours. Another and different factor which makes the present situation dangerous is that the acquisition of great military force excites latent ambition which would otherwise lie dormant. We cannot ignore the fact that the invention and virtual monopoly of atomic weapons puts a strain on American statesmanship, and that possession of these, instruments places excessive power in the hands of a minority of citizens. A nation which is by tradition democratic is thus labouring under some temptation to behave like an ambitious oligarchy-a temptation to which in the past we ourselves have sometimes succumbed, but to which at the moment we are not

exposed. England

today stands between.:-two great Powers who do not understand each other, and who might each be irritated into supposing that war would bring- advantage to the world. If in such risky circumstances we are to justify our reputation for political common sense we should perhaps pause before committing ourselves emotionally to either side ; for in so doing we should lose any remaining chance of serving as mediators. Moreover, we might run a risk of denying a principle for which our ancestors fought and died, and towards which we strive in our slow growth as individuals. Nothing’ is harder to remember in a time of crisis, but at no time is it more necessary to recall that it takes all sorts to make a world.

AMERICAN PLAN

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of case grouped under the same heading, even after all the other causes of symptomatic vomiting IT has been and diarrhoea have been excluded. The cases with mouth is neither much absorbed from the gut nor Proteus vulgaris in the stools have responded uniformly inactivated by intestinal organisms, and that in well to this treatment, and those in which no eetiologipracticable concentrations it is bacteriostatic against cal agent has been found may give equally good Bact. coli and Proteus vulgaris, though the anaerobic results. On the other hand, there is a third group flora and faecal streptococci are not appreciably of cases in which no response can be obtained, and affected by it. There therefore seemed reason to these may well turn out to be due to a virus. This hope that this antibiotic would be useful in some last group of cases commonly have blood in the stools, intestinal infections as well as in the preparation of and at necropsy they show a totally different picture In his summary from the customary findings, in that sanguineous cases for large-bowel surgery.l report on the Medical Research Council trials of2 discharges are present in the serous cavities, with streptomycin in non-tuberculous infections, WiLSON engorgement and ulceration of the intestines. A further noted that the results obtained in infantile diarrhoea reason for hospital rather than home treatment is that a small amount of streptomycin (about 5%) is so far have been variable : some centres have reported benefit from 2-4 g. spread over a week, but others absorbed and when carried round by the blood-stream it may be sufficient to render pathogens elsewhere are not satisfied that their results have been significant. He remarked that in further trials streptomycin is streptomycin-resistant. Not only may the organism to is a of a coincident urinary infection be so affected, as alternate cases. This being given obviously sound method to adopt in any therapeutic trial, JAMES and KRAMER mention, but the organisms but its application to babies presents difficulties, in a latent or unrecognised mastoiditis may acquire not only on humanitarian grounds. A retrospective similar undesirable properties. It is true that such of admissions to with the survey diagnosis incidental infections would probably respond to hospital of gastro-enteritis will quickly demonstrate that this penicillin or salphonaxnides, but even so it will be symptom complex is easily confused with a wide less worrying for all concerned if these complications range of other conditions which can only be excluded arise in a baby already under observation and by the most rigorous clinical and bacteriological treatment in hospital. examinations. Added to this, there is the overAmerican Plan whelmirg difficulty in avoiding cross-infection of the its had bowel sterilised with LAST January President TRUMAN asked Mr. OseAR baby who, having streptomycin, is in the same ward as another baby receiving R. EwiNG, Federal Security Administrator, to report, controlled treatment. Where this problem has been on the state of the nation’s health, and on plans recognised, only by setting up a special unit for the ’ to raise the national level of health during the purpose, and by employing two separate staffs to next decade." After consulting a body of some 800 treat the infants before and after sterilisation distinguished American citizens-professional and of the bowel, has cross-infection been completely community leaders, organised into 14 advisory panels overcome. - Mr. EwiNG prepared his report,l which has now What the doctor will want to know is, first, does been published with a covering statement by the the evidence so far obtained justify the use of strepto- President. It is an important document. Written mycin by mouth in these cases ; and secondly, in clear and vigorous English, it presents in 186 pages should these babies be treated at home or in hospital ? a remarkable fund of information on American health In this issue JAMES and KRAMER report on 30 cases conditions, and it will be widely discussed. of infantile diarrhoea treated with streptomycin by Mr. Ewi-NG refers to the great reductions in mormouth; and ARMrrAGE’s independent statistical tality and sickness that have already been achieved analysis leads to the conclusion that " the results in the United States, but points to certain conditions indicate a real improvement in the treated groups." showing that much remains to be done. For example, A brief scrutiny of the weight charts can scarcely every year 325,000 persons die from conditions that fail to impress the clinician favourably. The treat- could have been prevented, 4,300,000 man-years of ment had the remarkable effect of checking vomiting work are lost through bad health, and the consequent immediately ; otherwise, indeed, it would have been loss to the national wealth is some$27,000 million. useless to continue with medication bv mouth. This Careful inquiries have revealed a serious lack of put an abrupt end to the loss of fluid, the exhaustion, medical, dental, and ancillary personnel, and of hosand the tendency to alkalosis which accompany pital and teaching facilities. The number of pracpersistent vomiting. As a result, the treated children tising doctors (190,000) is only 80% of the number could leave hospital within a fortnight of starting needed ; at the present rate of recruitment the treatment, so that the risk of cross-infection was much deficiency of doctors in 1960 will be 42,000. In some reduced. The Finns,3 who gave streptomycin mainly special branches of medical practice there are greater by intramuscular injection, have had similar successes ; shortages ; it is estimated that the nation needs at but giving the drug by mouth is certainly simpler and least three times the present numbers of psychiatrists kinder than injecting babies eight times a day. and paediatricians. The lack of enough doctors is Admission of these infants to hospital seems to be felt particularly now that the effective demand for essential, because there are at least three types medical. services has risen. The American national 1. Kane, L. W., Foley, G. E. Proc. Soc. exp. Biol., N.Y. 1947, income, the report says, is now at the highest level

in Infantile Enteritis shown that streptomycin given by

Streptomycin

"

66, 201. 2. Wilson, C. Lancet, Sept. 18, p. 445. 3. Leisti, P. Ann. med. intern. fenn. 1947,

a Report to the President. U.S. Government Printing Office, Washington, D.C. $1.

1. The Nation’s Health:

36, 575.