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GRAINS AND SCRUPLES

Under this heading appear week by week the unfettered thoughts of doctors invarious occupations. Each contributor is responsible for the section for a mouth ;

his name can be seen later in the half-yearly index.

FROM A PUBLIC HEALTH CLINICIANT

OF all hobbies natural history best befits the train-’

ing and daily life of a doctor. And of all branchesof natural history ornithology is the best suited.Observation in this field must be swift and accurate ;with use it becomes more detailed. And there is

nothing more helpful to our daily work than thepower of swift, accurate, and detailed observation.It is not enough to note the passage of a large orsmall bird with bright or sombre plumage, we mustnote the details of the colouring, the colour of wings,legs, and rump. There are also other points such asthe manner of perching and the mode of flight orthe habits of feeding. The habits and idiosyncrasieseven of common species provide a constant field ofchanging interest and training. It is not only theeye that is trained but equally the ear. The recogni-tion of special notes and songs makes the wholecountryside seem more friendly and however longwe may have been watching or listening, each daymay produce some new sound or display some

unfamiliar feature.* * ...

The drawback to a prolonged study of ornithologyis the limited number of British birds, so that, aftera few years, the thrills of new discoveries becomefewer; but there is always the excitement of seeingsome new antic and it is here that other branches ofnatural history may fill the gaps. The observer mayturn to entomology or to the more leisurely contempla-tion of botanical, mycological, or bryological finds.Fortunately no doctor who has to earn a living willever become a really expert ornithologist, or indeedexpert in any branch of natural history; he mustremain a dilettante naturalist. The more dilettantethe student the more relaxation is he likely to achieve;discoveries which to the expert would be mere drossare to him golden. A lifetime can be spent learningin this domain and much will still remain undisclosed

or undiscovered. Medicine, in the broadest sense,is similar: for forty years we may continue observingand note-taking, yet the very next day we may detecta clinical entity, or a syndrome, which we have neverbefore noticed, read about, or even heard tell of.

* * *

Accuracy of observation by ear or eye is a comparatively rare gift, and experience of the examinationof girl guides and boy scouts tends to confirm thisimpression. How often one reads in their reportsthat the birds " sang sweetly " or that the observersaw " several beautiful birds " ; how seldom is an

attempt made to describe correctly the sounds heardor to give the exact plumage of any one bird, even of arobin or house sparrow. Small blame to the scouts,for they are novates and we doctors are trainedobservers, yet when stories of cases are narratedto us by colleagues we hear of " influenza,""rheumatism," or "neuritis" when what wouldinterest us more would be the exact symptoms ofwhich the patient complained in chronological orderand in plain English.

Plain English of course may have its limitations,and taste in the selection of words is a little uncertain.

One doctor always employs the word " belly " whenspeaking or writing of what we usually call theabdomen. " She had a pain in the belly," says he,or perhaps, " Two days later I opened the belly,"or again, when questioning a patient, he may ask," have you had any pain or discomfort in the belly "He does it so nicely, and with such a gentle andcultured air, that I am almost persuaded that theword should be more freely used, and that it is moreapt when speaking to a patient than "stomach"or

"

tummy " ; but there prejudice, whether inbornor acquired, steps in. I fall and find myself preferringinstinctively

" abdomen " or " stomach."

* * *

Those who manufacture chemicals and other articlesof commerce deluge us with samples of their wares,and it is difficult to decide how best to utilise or disposeof these. Put them in a cupboard to await an

appropriate patient, there they are discovered dusty,desiccated, or mildewed some twenty years later;dispense them to a patient and the result may bedisappointing or on the other hand more and moremay be asked for ; our samples become exhaustedand we have to buy further supplies at exorbitantprices of something in which we perhaps have littlefaith. If we decide to take them ourselves we mayhave to wait long for the right illness ; or a false

parsimony may induce us to take them withoutdelay and so maybe spoil the digestion of an

otherwise enjoyable dinner.

* * *

It is fortunate that I have made the acquaintanceof a Scottish spinster of uncertain age who enjoysswallowing any and every sample that I am preparedto hand over. Lactic acid bacilli in legion have foundtheir way to her and scores of aperients dispensedas liquid, pills, or powder. Tonics too please her,and many familiar green bottles have passed thatway as well as cough syrups and the like. Highlyor less highly concentrated hormones and vitaminsdelight her, be they from corn husk, testis, ovary,or pituitary. But best of all did she like a smallyellow bottle of concentrated vitamins, or hormones,and so great was her affection for this tonic thatshe wished to obtain it privately. The chemistoffered to supply it at 10s. 6d. a bottle ; this did notplease her. I wrote the firm, and they would letme have it at a professional price of 6s. 6d. ; thatstill did not appeal to her. Then I read the bottleand noticed that the specimen contained 20 per cent.of alcohol and explained to her that it was that

ingredient, perhaps, which made the remedy agree-able. If she spent her money, I suggested, on cookingsherry, or even upon beer, her outlay would bebetter repaid. I cannot yet say whether my advicewas taken.

Fortunately some years have passed since weceased to receive packets of handkerchiefs or

fountain pens for purchase or return. Handker-chiefs were bought and the price was not unreason-able, but a fountain pen I once retained withoutpayment to see what happened. After a series ofletters, which remained unanswered, the pen stayedwith me, to be rediscovered many years later. I

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could not make it serve the purpose which its designerhad intended, and so after all it died unused. Perhapssimilar pens shared a similar fate, and so this methodof salesmanship became unprofitable.

* * *

Students are led to believe that the general practi-tioner is a dangerous necessity, seldom other thanignorant and incompetent. In practice later, on

the other hand, we are told, when consultants addressus, that we are the backbone of the profession, up todate, eager, wise, and conscientious. It would beserious for our moral welfare if we did not encounteroccasional fractious patients who frankly criticiseour methods. Most of us would acknowledge onreflection that the majority of doctors of consultantrank are more intelligent and better informed than themajority of general practitioners. The chief mentaldifficulty of the general practitioner is isolation.He is conversing with and treating those who knownothing about medicine and who accept his dictaand explanations almost without question. Graduallythe isolated doctor, and in this respect he may be asmuch isolated in town as country, becomes to believefervently in himself and in his own dicta, and observa-tion of one or two lucky cases may lead him to believethat his therapeutic methods are superior to thoseof others. The conceit occasionally revealed by suchdoctors is surprising; yet such a doctor may not beuseless to the community. A man who believes

sincerely in his own powers and his own remedieswill have a better and more useful influence over hispatients than one who is diffident and hesitant.

* * *

The remedy for isolation is within reach of everyone ;it is to attend meetings, encounter others, and exchangeviews. These opportunities are provided by localmedical societies and the B.M.A. But there willalways be a large number who never attend meetingsand who deteriorate unconsciously but continuously.The best doctors in any locality are those who attendmeetings. The most dangerous period is the begin-ning ; once the habit of meetings and post-graduatestudy is formed all goes well, but these habits shouldbe cultivated in the first year of practice or it maybe too late.

* * *

It is curious how often doctors continue to believein, and to practise, methods which were foremostin their student days but which have now been largelyabandoned. It is almost possible to date a man byhis methods. There will be the vaccine fan turnedout in the opsonin days ; the country surgeon ofa little later date who fixes the abdominal viscera ;the man who circumcises all the babies, or blocks upsinuses with gauze, or the one who has one or other

special drug for curing pneumonia. Yet all these

happenings increase the varied interest which medicalpractice and life provide.

PARLIAMENTARY INTELLIGENCE

INSANITY AND DIVORCE

BEFORE the House of Commons rose the MarriageBill was further considered by Standing Committee A,when Lieut.-Commander AGNEW moved an amend-ment to delete the paragraph which providesthat incurable insanity after the respondent hasbeen certified a lunatic for at least five yearsshall form a ground for divorce. He said thatthe proposals of the promoters of the Billdiffered very widely from the recommendationsof the majority report of the Royal Commission of1912. The Mental Deficiency Act of 1930 mighthave altered the situation, but through the majorityreport very great power resided in the Lunacy Com-missioners. He regarded the proposals of the Billas a weakening of that position, and the essentialsafeguards which the Commission sought to recom-mend would be entirely lacking. Before a petitionercould go to the court under the five-years rule andsue for a divorce, the spouse might leave the mentalhospital from time to time and there was nothing inthe Bill to stop what they all wanted to avoid, thethe procreation of children who themselves might bementally afflicted. This social evil would thereforego on exactly as before. Were those that mightsubsequently recover their sanity to come out andfind that a new marriage had been contracted ?The very knowledge that this might occur would havea detrimental effect on their recovery while they werein the asylum. He thought it would be wiser tokeep the insanity in the same position as totalbodily paralysis or epilepsy, grave calamities thatdeprived one partner of all that marriage meant.-Mr. HERBERT, who was in charge of the Bill,replied that the promoters of the Bill intended thatproceedings should be served on the King’s Proctor,who should refer to the Board of Control. They werenow inserting a new ground for divorce, and thepresent feeling was that the subsidiary effects andresults could be dealt with under Rules of Courtwhich had to be laid before Parliament so thatcontrol would be effective.

Sir ARNOLD WILSON, who opposed the amend-ment, said that there were something like 50,000married persons of unsound mind who were nowin institutions in’this country and the majorityhad been there for more than five years. Since theRoyal Commission sat in 1912 one of the aspects ofinsanity that had been best established was that asa rule it was not a catastrophic accident comparativelylate in life ; it was more often inherent, usuallycoming out long after the marriage took place.There was not much ground for believing that therehad been any very serious eugenic consequences fromthe liberation of persons during temporary periodsof sanity.

Mr. LYONS asked why they should take only onekind of disease disease of the mind-and use that asa ground of divorce ? The proposal required thevery gravest scrutiny. He believed that publicopinion was in favour of maintaining the obligationof the marriage tie and not of whittling it awayat the will of some new statute designer. Suchexperiments were fraught with danger.-Mr. RAIKESsaid that if there were to be any extended grounds fordivorce at all insanity had a stronger case thananything else. There were thousands of peoplewho had been driven by the present laws into irregularunions.

Mr. G. GRIFFITHS said that there had been more

working-class married women pronounced insanesince 1926 than ever before. That was because ofthe domestic difficulties from not having the moneyto carry on the home. If a working man’s wife wassent to an institution this Bill might be taken advan-tage of to obtain a divorce after she had been there5 years. She might come out completely cured andfind that her husband had remarried. He suggestedthat the period should be increased from 5 to 10

years.This amendment was defeated by 16 votes to 5.Sir A. WILSON moved an amendment, first, to

substitute for the word " insane " the words " ofunsound mind," in order to bring the Bill into linewith the wording of the Mental Treatment Act, 1930.