591

incisions with a reliable standard. Marsh et al.1 have

surveyed 1000 laparotomies in 500 of which theabdomen was closed by a standard method, while in theother 500 various different methods were used. As

regards dehiscence they concluded that there was

nothing much to choose between the transverse andvertical incisions, provided that the latter were closeto the midline ; but they found that dehiscence wasmuch rarer when a series of through-and-through sutureshad been added to the layer-closure.These findings are helpful, though they may be open

to some question since the 1000 cases reviewed wereselected from a series of 2000 cases. Subjects whichmight now be investigated include the comparativefrequency of wound dehiscence ill wounds sutured byabsorbable and by non-absorbable material ; the effect ofearly ambulation on the frequency of wound dehiscenceand later incisional hernia ; and the relative frequencyof incisional hernia after vertical and after transverseincisions. These would be difficult and lengthy researches,but definite conclusions would greatly aid the surgeon.

1. Marsh, R. L., Coxe, J. W., Ross, W. L., Stevens, G. A.J. Amer. med. Ass. 1954, 155, 1197.

2. Fortieth Annual Report of the Board of Control to the LordChancellor, for 1953. 1954. Pp. 9. 6d.

IN THE MENTAL HOSPITALS

OVERCROWDING in our mental hospitals grows steadilydenser-with great and growing detriment to patients.The Board of Control 2 report this week that, accordingto the standards prescribed by the Ministry of Health,these hospitals at the end of 1953 could properly take123,157 patients. They were, in fact, housing 139,135-which means that nearly 19,000 mentally ill people forwhom there were no places had somehow been squeezedinto them. It is greatly to the credit of the mental-hospital service that in such conditions, and with a quiteinadequate supply of trained and student nurses and

nursing assistants, they have achieved their best record,so far, of physical health among their patients ; theirlowest incidence of, and death-rate from, tuberculosisa decline of typhoid infections (once a scourge of mentalhospitals) to 22 cases, with 2 deaths ; and only 731 casesof dysentery, most of them mild. Thus can moderntreatment offset the ill eft-’ects on physical health of

overcrowding. Its ill effects on mental health can neitherbe so strikingly reduced nor so accurately measured.They must nevertheless be serious.The board, in their annual report, usually confine

themselves to a bare statement of figures (reserving theirfuller comments for the annual report of the Ministry ofHealth), but this time, impressed by the gravity of theposition, they have taken the opportunity to suggestremedies. The annual increase in resident patients duringthe past five years has averaged 1309 ; and attempts tocope with this increment have already led to a deteriora-tion in hospital conditions."There is need," the board say, "for more domiciliary

services, day hospitals, social clubs and beds both in the

Hospital Service and outside it. There is a widespread feelingthat certification and admission to mental hospitals could beavoided in many instances if suitable accommodation wereavailable elsewhere for old people who, though legallycertifiable, do not show such seriously disturbed behaviour asto make it essential."

They point out that old people often recover from mentalillnesses ; indeed, a survey of aged patients admitted tosix mental hospitals showed that well over a third weredischarged within a year. Some of those at presentadmitted to mental hospitals, the board suggest, mightwell respond to short-term treatment in special geriatricunits, and return home. ; -1 others might be admitted tochronic wards or to the lury-sta,y annexes of hospitalsadvocated by the Ministry of Health ; others might besuitable for " part-in accommodation " under the

National Assistance Act. " The aim," the board say," is to secure that everywhere certification shall be thelast resort." This is a humane enough principle ; and itis true that nearly 29% of the mental-hospital populationare over 65, so that any substantial reduction of theirnumbers would mean an easing of pressure in the over-crowded wards. On the other hand, before they arepacked off elsewhere it seems important to considerwhether they will be worse or better off. There are nowabout 1000 beds in long-stay annexes and a further 1000are likely to be available soon. These probably offerthe best and most appropriate way we have devised sofar of caring for the old person in frail health who is

likely to need a hospital bed at short notice and who hasno home to return to. Many chronic wards, too, arenowadays comfortable and kindly places ; but they stillvary. Some part-in accommodation is good ; but fromsome areas come reports of dark wards, high windows,steep stairs, inaccessible lavatories, and dining-roomsreached only after a long outdoor excursion in every kindof weather. Moreover, all these alternatives to themental hospital are themselves overcrowded. In this

desperate situation we shall not gain much by shiftingold people round, like pieces on a chess-board. Theservices needed for their reception and comfort mustdevelop and improve as-indeed, before-they are

transferred.

1. Naylor, P. F. D. 1’rans. St. John’s Ilosp. dei-m. Soc. 1952, 31, 29.2. Clarke, D. M. Med,. J. Aust. 1954" ii, 207.3. Goldblum, R. W., Pipor, W. N. J. invest. Derm 1954, 22, 405.

EFFECTS OF FRICTION ON THE SKIN

MANY people have an itchy skin ; but repeated scratch-ing does not always result in the peculiar leathery changecalled lichenification. On the other hand, some developlichenification rapidly, especially when the itch is causedby some manifest dermatosis such as eczema or ring-worm. " Lichen simplex " therefore belies its title.

In order to study objectively the effects of friction onthe skin, scratching machines have been devised by whichmeasurable amounts of pressure are applied at will.Naylor has used such a device to investigate the

strength of the epidermis ; and he has shown that aftera certain amount of friction has been applied the epidermisquite suddenly gives way. If the rubbing is stoppedjust before this point, a small flaccid blister may be seen.Histologically, the most superficial cells of the epidermisare mainly affected ; these become necrotic, and smallvesicles appear within the epidermis. From Naylor’sdescription the changes seem to differ from those- ofeczema, although Clarke 2 implies that friction alonecauses intra-epidermal vesicles of eczematous type andthat many cases regarded as eczema or neurodermatitisare primarily friction artefacts.

Friction alone has not yet been found to cause lichenifi-cation in healthy people. Goldblum and Piper 3 havesought to produce lichenification by means of a scratchingmachine, but so far they have succeeded only in patientswith skin disease-" neurodermatitis," eczema, and

pityriasis rubra pilaris. That lichenification is due to anunusual physical state is further suggested by their

experience with the case of pityriasis rubra pilaris. Whenthis patient was given large quantities of vitamin A, thepityriasis subsided notably and the area of inducedlichenification also improved despite continued scratch-ing ; but this returned to its former intensity when thevitamin was discontinued.

THE INDEX and title-page to Vol. I, 1954, which wascompleted with THE LANCET of June 26, is publishedwith our present issue. A copy will be sent gratis tosubscribers on receipt of a postcard addressed to theManager of THE LANCET, 7, Adarn Street, Adelphi, W.C.2.Subscribers who have not already indicated their desireto receive indexes reguhu’ly as published should do so now.