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itself. Two other drugs tried are Ethizone ’ (TB3) 6 andiliisoamyloxythiocar: bani1iÇle.

Care of Hands and Feet , ,

As most of the patients have some degree of peripheralnerve damage, minor injuries are slow to heal and areliable to lead to trophic ulceration. , New shoes are

dangerous unless they are made to measure by an expert.Analgesia of the hands maizes, it difficult to guard againstburns, especially when cooking, and hot-water bottleshave had to be strictly forbidden -because they are liableto burn the feet or legs. If peripheral-nerve damagehas advanced sufficiently to cause weakness of themuscles of hands or feet, daily physiotherapy is necessaryto prevent contractures,. Paralysed muscles call fortendon transplantations.

Intercurrent Diseases .

Though the number of beds is small, a wide varietyof intercurrent disorders have had to be treated duringthe three and a half years of the hospital’s existence.

Surgical operations (performed by Mr. H. R. I. Wolfe atthe Hospital for Tropical Diseases or by the surgeons at

University College Hospital) have included bilateral oophorec-tomy for chocolate cysts, osteotomy of the femur for chronicarthratis- of the hip, lobectomy for bronchial carcinoma,haHHorrhoidectomy, radical antrostomy, and extensive skin-grafting for severe burns contracted before admission. Medicalproblems have included paranoid schizophrenia, hysteria,diabetes : mellitus, idiopathic epilepsy, renal amyloidosis,pyelitis, and various helminthic diseases and acute infections.

.

. PERSONAL PROBLEMS

Perhaps in no other disease is the doctor-patientrelationship so important as it is in leprosy ; for not

only is progress slow and treatment prolonged but thesufferer is liable to periods of frustration and despair,and to periods of prolonged physical suffering. The

patients who despair have to be given courage to go on ;those who are worried by domestic or other difficultiesneed advice ; those who quarrel have to be reconciledto each other ; those who ’break regulations have tobe gently yet firmly reproved ; those who are in painneed relief-and this is especially difficult in a long-standing disease like leprosy because the best analgesicsare habit-forming and therefore must be avoided if

possible. For severe nerve pain I have found smallintraneural injections of procaine valuable. All thesetroubles make great demands on the nurses and call formuch patience and understanding on their part.The regulations regarding notification differ from those

in South Africa and Australia in that they contain nostatutory powers whereby a patient can be removed to,or detained in, hospital against his will. This meansthat our patients can discharge themselves from hospitalwhen they so desire, and much time has to be spentpersuading those who want to leave hospital that it isto their advantage (and to that of their families) toremain as long as their disease is active. Not only maydangerous ophthalmic or neuritic reactions appear sud-.denly and cause permanent damage if not reported earlyor if not handled expertly, but, in spite of warnings,patients living at home repeatedly burn their hands orinjure their feet. Mothers of young children find separa-tion hard to tolerate, but have to be persuaded to remainin hospital for their children’s sake. An additionalreason for such a patient not returning home before sheis cured is the fact that pregnancy must be avoided atall costs ; not only does it seriously aggravate the diseasebut it involves all the emotional strain of having thebaby sent away immediately after birth. Finally,experience in handling’ outpatients has shown that some

6. Jopling, W. H., Kirwan, E. W. O’G. Trans. R. Soc. trap. Med.Hyg. 1952, 46, 656.

fail ,to, report regularly for examination and laboratorytests, and a few cannot even be relied upon to carry outtreatment. In an extreme case the patient deliberatelydiscontinued treatment for six years, with disastrousresults to. herself. 7 Fortunately such an occurrence isless likely now that leprosy is notifiable and the Ministry’sadviser,keeps.,, the notified cases, together with ;theirfamilies,, under, review.

J THE OUTLOOK

Until such time as research-workers discover how tocultivate the leprosy bacillus, either in vitro or in vivo,the clinician must make use of drugs which have atuberculostatic activity ; or he may. turn to the patho-logist for guidance as to how immunity manifests ’itselfin leprosy and asj to how the body’s defence mechanismcan be stimulated so that the macrophage cells no longerprotect the bacilli which multiply within them. Research-workers in many, parts of the world are opening up newavenues of thought and endeavour-Hanks and Gray 8with their work on the rat-leprosy bacillus, Suter 9 withhis studies on the intracellular parasitism of tuberclebacilli, Campos 10 with his work on B.C.G. vaccinationin the prophylaxis of leprosy, Lowe and McNulty 11 withtheir observations on immunology, Ridley 12’ with hisinvestigations on the significance of antibody, and otherstoo numerous to name.

‘

The Jordan Hospital, because it can combine detailedclinical observation with the fullest possible pathologicalcontrol, is in an unrivalled position to develop and perfectnew methods of treating this challenging disease.

I would like to thank Sir Neil Hamilton Fairley, Sir GeorgeMeRobert, and Prof. A. W. Woodruff for permission to publishdetails of some of their patients.

7. Brit. med. J. 1953, i, 1053.8. Hanks, J. H., Gray, C. T. Int. J: Leprosy, 1954, 22, 147.9. Suter, E. Ibid, 1954, 22, 1.

10. Campos, N. de S. Ibid, 1953, 21, 307.11. Lowe, J., McNulty, F. Brit. med. J. 1953, ii. 579.12. Ridley, D. S. Trans. R. Soc. trop. Med. Hyg. 1954, 48, 400.13. New York Times, April 14, 1955.

POLIOMYELITIS VACCINE

MEDICAL RESEARCH COUNCIL PLANS

THE Medical Research Council have announced thata limited amount of poliomyelitis vaccine, of the kindused in the United States, will be available to them thisyear. Sufficient will be allocated for the vaccination ofsmall groups of children in a few centres in Great Britainand Northern Ireland in which there are laboratories

studying the poliomyelitis virus. The arrangements willbe made locally. The response to the vaccine will be

judged serologically and compared with other informationobtained from laboratory tests. This course, the counciladd, is necessary for planning the most effective use ofthe larger quantities of vaccine which are likely to becomeavailable in this country in 1956. They emphasise thatthe vaccine is at present available only for these limitedpurposes and that applications for inoculation cannotbe entertained.

SUPPLIES IN THE UNITED STATES

It is expected that there will not be enough vaccineto meet the first big demands in the United States, butby the end of the summer supplies will probably beadequate.l3 President Eisenhower has directed hisSecretary of Health, Education, and Welfare to organisea voluntary system of allocating the vaccine. It hasbeen suggested that Congress should take steps to preventa black market in the vaccine. The manufacturers haveundertaken to supply the National Foundation forInfantile Paralysis with sufficient vaccine to immuniseall school-children in the first and second grades through-out the United States and its territories. A -booster

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dose will be offered to the 500,000 children vaccinatedin last year’s trial.

REACTIONS IN OTHER COUNTRIES

Dr. Herdis von Magnus, of the State Serum Institutein Copenhagen, is reported 14 as saying she had heardfrom Dr. Salk that the results of further investigationswere even more favourable than those already published.She found it difficult to understand objections raised inBritain, France, and Norway that the vaccine would notbe as successful in Europe as in the United States. InGeneva Dr. A. M. Payne, of the World Health Organisa-tion’s division of communicable diseases, pointed to the asyet little-known properties of the vaccine, and said hethought that poliomyelitis was not yet beaten. In Paris,the French Minister of Health said that France wouldmass-produce a similar vaccine developed by Prof. PierreLepine .15 The Swedish board of medicine have orderedenough American vaccine for 100,000 people. A Swedishvaccine, using human and not monkey tissue, will alsobe given.

14. Scotsman, April 14, 1955.15. Newcastle Journal, April 13, 1955.16. The Incidence of Neurosis among Factory Workers. Medical

Research Council: Industrial Health Research Board, reportno. 90. London : H.M. Stationery Office, 1947. See Lancet,1947, ii, 254.

17. Lancet, Jan. 15, 1955, p. 135; Ibid, April 2, 1955, p. 716.

A COURSE IN FAMILY PSYCHIATRYPSYCHOSIS is found in about 0-5% of the population,

mental deficiency in about 1%. What fraction theseconditions represent of the total mental illness in thecountry is hard to estimate, but neuroses of varyingdegrees of severity are so common that it cannot be alarge one. Patients with psychosis and mental defectfill nearly half our hospital beds, and in industry neurosisis responsible for about a third of all absences from workdue to illness.16

It is now generally held that the public-health serviceshould begin to develop a formal mental-health pro-gramme 17; and there are signs of a growing interest inthis subject among school medical officers. This wasillustrated at a refresher course in child psychiatryarranged by Dr. J. G. Howells, and held at the end ofMarch by the child-psycthiary department of the Ipswichgroup hospitals. In this, the second year of the course,those taking it included 13 school medical officers, 9

general practitioners, 3 psychiatrists, and 2 paediatricians.The general practitioners came mostly from the area ofthe East Anglian Regional Hospital Board, but theschool doctors came from all parts of the country,including Scotland. Last year only 16 people attendedthe entire course, and 10 came for parts of it ; this year27 members were attending full-time, and only 2 or 3part-time. The growth of interest among general practi-tioners in the psychiatry of childhood is shown by thefact that in 1947 only 3% of the children attending thedepartment’s clinic were referred by their family doctors :now nearly 70% of them are referred from this source.Dr. Howells estimates that if about 5 general practi-tioners attend the course every year, by the end of tenyears most of the partnerships in the area will have beenrepresented. (More still would attend, he thinks, if theywere able to claim expenses for putting in a locumduring their absence ; but at present the Ministry ofHealth is not willing to meet this expense for doctorsattending courses arranged by " other persons " thanuniversities and medical schools, although the 1946 Actpermits such payments to be made.)The course lasts four days, the first three sessions being

concerned with the three main reactions-neurotic,delinquent, and psychosomatic-of children to emotionalstress. The fourth session dealt with adolescent reactions,and in a fifth session all these subjects were brought

together in a consideration of the family as a whole. Thelast three sessions covered speech difficulties, epilepsy,and the emotional aspects of mental deficiency, cerebralpalsy, and psychosis. At these sessions, Dr. Howells, astutor, demonstrated a long case, and after a pause forquestions and discussion, summed up. He then showedshort cases relative to the same general theme, and againallowed a short period for questions. These lecturesessions alternated with demonstrations, conducted bymembers of the psychiatric team of the department, onpsychometry, play therapy, bibliotherapy, and record-keeping.

"

Bibliotherapy " in this context means the use of readingmatter for therapeutic purposes, and books and papers usedin this way were shown at the demonstration. The departmentlends parents articles and books on childhood problems, andalso keeps a small lending library of children’s books. Atthe end of the play session each child can borrow a book,which he brings back to exchange for another at the nextsession. The stories help to keep the child in touch with theclinic between sessions and make good topics of conversation.All members of the course had been supplied with a list ofbooks recommended for their own reading, and these too wereshown at the demonstration.

Finally, a demonstration had been arranged, at oneof the hospitals of the group, of the electro-encephalo-graphic examination of a child. Attendance at demon-strations was kept small and wieldy by splitting themembers of the course into four groups, and repeatingthe demonstrations for each group in turn. From theinterest taken and the questions asked it was clear thatthe course was proving useful even to those alreadyengaged in psychiatry. The lectures were well foundedin experimental work, and the point was repeatedly madethat the child cannot be treated apart from his family :as Dr. Howells put it, " the neurotic reaction of thechild is a reaction to an emotional battering from theneurotic or disturbed adult."

This seems at present to be the only course of its kindin the country.

1. Western Daily Press, April 5, 1955. Birmingham Post, April 5,1955.

Medicine and the Law

Bogus Doctor FinedA FORMER medical student has been fined £ 100 for

forging a letter purporting to show that he was a qualifieddoctor .1

Reginald Morgan Ford, aged 35, pleaded guilty to forginga letter from the chief clerk of the General Medical Council

purporting to show that he was a graduate in medicine andsurgery of the University of Bristol, held the degrees of )!.B.and cH.B., and was registered in the Medical Register.Ford had been accepted as an assistant and subsequently

produced the forged letter to support his claim to be a doctor.He never purchased dangerous drugs. He had entered BristolUniversity in 1947 but was later expelled for a breach ofdiscipline. On Ford’s behalf it was stated that he had offeredto repay money paid for his services while posing as a doctor,but the principal had declined the offer because he wassatisfied with his work whether practised under deception orotherwise.

The Recorder, in passing sentence, said that until heheard the mitigating circumstances he had thought itwould be a case for a prison sentence, but he felt afterhearing them that no good purpose would be done bysending him to prison. "There is no doubt," theRecorder told Ford, " that you were in possession ofsufficient skill to satisfy those who became your patients,and you appear to have been very careful not in any wayto abuse the professional position you wrongly assumed.Apart from being a bad example you have really doneno harm."