643

supports this type of treatment in a recent accountof fresh air as employed at the University Children’sClinic, Hamburg. Broadly speaking, he claims thatwith strictly comparable treatment in all other

respects young children kept freely in the open airduring their pneumonia had a mortality-rate onlyone-third of that when this benefit was not employed.In the Hamburg series a particular point was thatthe children were carried about by nurses in thefresh air for so many hours a day, a method whichis said to combine the value of fresh air, change ofposition, and a certain amount of " mothering."Enthusiasts, therefore, for oxygen therapy mightbe reminded of these cheaper measures, and themedical man who likes to combine instruction with

pleasure might well read or re-read the descriptionof an adult case of pneumonia treated in the openair with success in " Cupid Goes North " from the penof a member of the profession under the pseudonymM. Swayne, now unfortunately out of print.

THE ADMINISTRATIVE SIDE OF PSYCHIATRY

THE socialisation of medicine has in most countriesgone to its furthest lengths in the fields of publichealth and mental disorder. The provision of treat-ment, not only for the certified insane, but also forthose neurotic and other psychiatric patients whosedisorder is not of a kind that calls for institutionalcare, has come more and more to be a responsibilityof the State, as openly recognised and fully borne asthe prevention of epidemics. The extent of this

development in the field of psychiatry is not to bejudged solely by mental hospitals, though they arestill the main medium and concern of public mentalhygiene. The administration of a modern mental

hospital demands some things that would not haveentered the head, much less furthered the success,of an " asylum superintendent " of the past. Manyof the essentials for running a mental hospital are, ofcourse, the same now as formerly, but with the

development of social psychiatry and of a wider

conception of mental disorder, the outlook and thefunctions of the medical superintendent have beenenlarged. With this growth have come complexitieswhich differ from place to place, and certainly fromcountry to country; yet the basic problems are every-where much the same and the recorded experienceof a skilled and distinguished administrator in

any country can be a most profitable stimulus tocolleagues abroad. Dr. W. A. Bryan, in a bookreviewed on another page, shows that mental hospitaladministration is by no means the soulless steward-ship often denounced by enthusiastic workers in otherbranches of psychiatry. The combination of qualitieswhich it demands is rare. In Dr. Bryan’s view thefunctions of the mental hospital are sound clinicalpractice, research, teaching, and prevention. It hasbeen possible at the Worcester State Hospital,Massachusetts, of which he is superintendent, to seeall these functions working. In research especially,the hospital has, through exceptional circumstances,acquired international renown for the unusuallyambitious and thorough plan of investigation into

schizophrenia carried out there. It is not to be

expected that in teaching and the prevention ofmental illness the achievement could be as notable.Many factors conspire to make this, like research,more the work of the university clinic and psycho-pathic hospital, where a wider range of materialoffers and a closer contact with the rest of medicineand the public can be maintained. Nevertheless, evenin teaching and prevention the mental hospital has

much to do. With what most of us would regardas excess of zeal, Dr. Bryan sees the mental hospitalof the future as the coordinating agency which willlink up " all activities dealing with human beings."Such ambitions overleap themselves. More sober

prophets will be satisfied if it becomes, more conspicu-ously than at present, a progressive, as well as

indispensable, part of every organised scheme ofpublic mental hygiene and research.

CIRCULATORY FUNCTION IN LIMBS

THE last few years have seen an intensive study ofthe obliterative arterial diseases, especially thrombo-angiitis obliterans. In dealing with these disordersthe surgeon is confronted with the difficulty of esti-mating the circulatory value of the limb-an accurateestimate being important both in choice of treatmentand in judging results. The symptoms and theordinary clinical examination will reveal only thegrosser changes, and this is true also of oscillometricmethods. Hence a simple mechanical method thatwould give a numerical result would be extremelyvaluable. Early last year, in our own columns,lSimmons of Manchester described such a method,making use of a simple ergometer, and Ratschow 2now gives an account of an almost identical apparatuswith which he employs similar weights and time-intervals. The findings closely agree, except that theManchester clinic used the more powerful group offlexors instead of the extensors, and so their numericalresults are higher. The flexors appear to be the moresuitable muscle-group for testing purposes, for it is

nearly always these muscles that are affected inintermittent claudication. Ratschow repeats an

observation, often made, that this method is of

great value in differential diagnosis from neuritis,rheumatism, and other conditions, and he points outthat the work is more easily performed when the limbis dependent. This latter observation supportsTelford’s teaching that the limbs must not beelevated on pillows, but must be as dependent aspossible. Unfortunately the medical text-book andcurrent nursing practice do not as yet, in this respect,differentiate between an arterial and venous

thrombosis.The German school also claims that graduated

exercise by means of an ergometer is an importanttherapeutic agent; but it is doubtful on whatgrounds this claim is made and it will be interestinglater to hear whether it is being maintained.

TEETH IN TRISTAN DA CUNHA

FivE years ago H.M.S. Carlisle paid an officialvisit to this isolated group of small islands in thesouthern Atlantic, and the opportunity was takenof making a dental survey of the inhabitants. Atthat time these were found to show a remarkableabsence of caries. When the ship visited the islandagain in February of this year the survey wasrepeated, and Surgeon Lieutenant-Commander (D)W. E. A. Sampson, who carried out the work with thehelp of Mr. J. R. Moore of Capetown (the nearesttown), has recently published his results.3 In the

five-year period the population has increased from162 to 183 and, mainly owing to the efforts of thechaplain, education has been greatly improved, allchildren under 10 years now attending school. Ten

ships have visited the islands in the last 3t years, aconsiderable increase over previous years, and these

1 Simmons, H. T., Lancet, 1936, 1, 73.2 Ratschow, M., Münch. med. Wschr. July 16th, 1937 p. 1128.

3 Brit. dent. J. July 15th, 1937, p. 86.