2
624 whether folinic, rather than folic, acid is the important factor in the treatment of these diseases, and whether folic acid really acts only when converted to folinic acid. It should not be hard to get the facts, but we hope that a sufficiency of reliable clinical tests will be assembled before any new theories about the ætiology of megaloblastic ansemias are proposed. Annotations SYMPTOMS OF PUBERTY " JuvENiLE delinquency is what the law says it is " ; and the law draws the line in different places in different countries. Dr. Lucien Bovet, who quotes this saying in a new W.H.O. monograph.! notes that in many European countries a minor is a delinquent only if his behaviour is an offence to the whole population, whereas in parts of the United States he may be brought into court for a number of other things, including truancy from school, consistent disobedience to parents, con- sumption of alcohol, and smoking in public. In England a boy is legally incapable of sexual intercourse before the age of 14 ; and though he may have raped another child and caused her death, if he is less than 14 he must be declared " not guilty." A country with an efficient police force has a higher delinquency-rate than a country where the police are slack ; and in any country the social position and influence of the parents may decide whether a child is charged or not. Even the severity with which an offence is punished varies from one magistrate or judge to another. Indeed, our response to the whole idea of juvenile delinquency is illogical. We can never outgrow, it seems, our astonishment that those so young should be so bad ; yet statistics make it quite clear that the peak age for crime is in the teens and early twenties. In other words, if criminal behaviour is ever to be expected, it is to be expected then, along with neurotic or schizoid episodes, erotic fantasies, physical ebullience, a taste for brilliant garments, and all the other signs of adolescent instability and stress. Moral indignation is no more relevant to the aberrant conduct of the adolescent than it would be to the depres- sion, hot flushes, and giddiness of the menopausal woman : both are expressions of hormonal disequili- brium of which the subject is only obscurely conscious. The social difficulty is that in the adolescent such expres- sion may range from giggling inconsequence to seemingly wanton destructiveness or brutal outrage. What decides the form it takes ? That is for research to discover, as Dr. Bovet insists. Mr. Joyce Carey, in Charley is my Darling. gives an intuitive answer as far as destructiveness goes. The need to boast, the need to make the boast good, the need to get excited and break things, are not forces the boy can reason about ; they befall him, and so do the consequences. Probably no living adult has made the curious and difficult adjustment perfectly at every step ; who, then, is qualified to advise the growing child ? Dr. Bovet’s monograph is studded with reports of our ignorance, but he outlines the growing body of knowledge and opinion and directs attention to whatever is sure. Treatment may vary-and indeed it should vary, if it is to be adapted to the needs of individual children -but the aim of even the most diverse methods is the same : to help the child to build up safe and stable relationships with the people round him, and to achieve that inner security on which are founded his own moral independence and that consideration for others which lies behind good social behaviour. In time we shall know better how to do this difficult thing. 1. Psychiatric Aspects of Juvenile Delinquence. World Health Organisation, Palais des Nations, Geneva, 1951. Pp. 90. 5s. SWEDISH HOSPITALS SWEDEN, with its lakes and forests, clean air, and bracing climate, is a fine place for hospitals ; and indeed it has some of the most up-to-date hospitals in the world. Nevertheless, the members of the International Hospital Federation 1 who made a study tour of Swedish hospitals last September were more taken with the older, smaller, more homely, hospitals than with the great Sodersjukhus at Stockholm,2 with its 9 floors, 40 wards, 50 lifts, and vast central kitchen, perched at the top of the main block and connected to its 11 branch kitchens by a 400 ft. corridor, along which the staff dash to and fro on scooters. Scooters, indeed, are a good idea, and might well be introduced into some of our own long hutted hospitals (Stoke Mandeville, for instance). But the mere notion of anything so large as the Sodersjukhus shocks our new British thrift, concerned as never before with the cost of upkeep. The expense of maintaining the great place is, in fact, already beginning to weigh heavily on the authorities of this hospital. We have plenty to learn, however, from other aspects of the Swedish hospitals. They seem to pay more attention to the comfort of the patient and his relatives than is usual here. These hospitals are quieter than ours, for instance : walls and ceilings are made of sound- absorbing material, and lift-doors of wood with no clanging inner gates ; trolleys are often electric and are all well made and easy to move ; doors are fitted with door-checks, and many of them are designed to push open so that noisy handles are unnecessary. Relatives are received in a large and pleasant entrance hall which usually contains a florist’s shop, a tobacco and news- paper stall, a cafeteria, and sometimes a post-office, and a hairdressing salon for the use of ambulant patients. There is nearly always an information bureau as well, and a large model of the hospital on which a visitor can learn his way about. The beds, it is true, were thought to fall short of British models. They measure 2 ft. 6 in. across, and have their bottom legs set back some way from the foot, which gives them rather a makeshift look. Actually they are rather ingenious, for they are fitted with a wheeling device, and when the foot is lifted they can be pushed easily about like a wheelbarrow. Screens are not used in the wards, since treatments, dressings, and blanket-baths are given in a separate annexe and patients are usually wheeled to the water-closet either in their beds or in a lavatory chair. This must reduce greatly the traffic in bedpans, though these are of course provided. The pans are all made of stainless steel, and are well maintained, though the cleaning equipment is not of that latest type which cleans and sterilises. They are washed in a deep metal sink, usually in cold water, sometimes under pres- sure; but they are only sterilised in maternity and gynaecological wards. The pans are numbered, however, and each patient retains his own throughout his stay in hospital. The medical equipment is of a very high standard indeed, and extremely lavish and well cared for. Theatres in the newer hospitals are spacious and well planned, and many operations are done by daylight-another advantage of clean bright air. In the wards lights are conveniently placed over the beds, and are -often fitted with a revolving shutter which allows the patient to adjust the amount of light given out. The night light is never overhead, but usually placed in a recess in the wall, near the door, about a foot from the floor. In one hospital the night light was sunk flush in the centre of the floor of the ward, which must give a specially restful effect. 1. Report of Study Tour of Hospitals in Sweden. International Hospital Federation, at King Edward’s Hospital Fund for London, 10, Old Jewry, London, E.C.2. 1951. Pp. 60. 7s. 6d. 2. See Lancet, 1945, ii, 571.

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Page 1: SWEDISH HOSPITALS

624

whether folinic, rather than folic, acid is the importantfactor in the treatment of these diseases, and whetherfolic acid really acts only when converted to folinicacid. It should not be hard to get the facts, but wehope that a sufficiency of reliable clinical tests willbe assembled before any new theories about the

ætiology of megaloblastic ansemias are proposed.

Annotations

SYMPTOMS OF PUBERTY" JuvENiLE delinquency is what the law says it is " ;

and the law draws the line in different places in differentcountries. Dr. Lucien Bovet, who quotes this sayingin a new W.H.O. monograph.! notes that in manyEuropean countries a minor is a delinquent only if hisbehaviour is an offence to the whole population, whereasin parts of the United States he may be brought intocourt for a number of other things, including truancyfrom school, consistent disobedience to parents, con-

sumption of alcohol, and smoking in public. In Englanda boy is legally incapable of sexual intercourse beforethe age of 14 ; and though he may have raped anotherchild and caused her death, if he is less than 14 he mustbe declared " not guilty." A country with an efficientpolice force has a higher delinquency-rate than a countrywhere the police are slack ; and in any country thesocial position and influence of the parents may decidewhether a child is charged or not. Even the severitywith which an offence is punished varies from one

magistrate or judge to another. Indeed, our responseto the whole idea of juvenile delinquency is illogical.We can never outgrow, it seems, our astonishment thatthose so young should be so bad ; yet statistics make itquite clear that the peak age for crime is in the teensand early twenties. In other words, if criminal behaviouris ever to be expected, it is to be expected then, alongwith neurotic or schizoid episodes, erotic fantasies,physical ebullience, a taste for brilliant garments, andall the other signs of adolescent instability andstress.Moral indignation is no more relevant to the aberrant

conduct of the adolescent than it would be to the depres-sion, hot flushes, and giddiness of the menopausalwoman : both are expressions of hormonal disequili-brium of which the subject is only obscurely conscious.The social difficulty is that in the adolescent such expres-sion may range from giggling inconsequence to seeminglywanton destructiveness or brutal outrage. What decidesthe form it takes ? That is for research to discover, asDr. Bovet insists. Mr. Joyce Carey, in Charley is myDarling. gives an intuitive answer as far as destructivenessgoes. The need to boast, the need to make the boastgood, the need to get excited and break things, are notforces the boy can reason about ; they befall him, andso do the consequences. Probably no living adult hasmade the curious and difficult adjustment perfectlyat every step ; who, then, is qualified to advise thegrowing child ? Dr. Bovet’s monograph is studded withreports of our ignorance, but he outlines the growingbody of knowledge and opinion and directs attention towhatever is sure.Treatment may vary-and indeed it should vary,

if it is to be adapted to the needs of individual children-but the aim of even the most diverse methods is thesame : to help the child to build up safe and stable

relationships with the people round him, and to achievethat inner security on which are founded his own moralindependence and that consideration for others whichlies behind good social behaviour. In time we shallknow better how to do this difficult thing.1. Psychiatric Aspects of Juvenile Delinquence. World Health

Organisation, Palais des Nations, Geneva, 1951. Pp. 90. 5s.

SWEDISH HOSPITALS

SWEDEN, with its lakes and forests, clean air, andbracing climate, is a fine place for hospitals ; and indeedit has some of the most up-to-date hospitals in the world.Nevertheless, the members of the International HospitalFederation 1 who made a study tour of Swedish hospitalslast September were more taken with the older, smaller,more homely, hospitals than with the great Sodersjukhusat Stockholm,2 with its 9 floors, 40 wards, 50 lifts, andvast central kitchen, perched at the top of the mainblock and connected to its 11 branch kitchens by a 400 ft.corridor, along which the staff dash to and fro on scooters.Scooters, indeed, are a good idea, and might well beintroduced into some of our own long hutted hospitals(Stoke Mandeville, for instance). But the mere notionof anything so large as the Sodersjukhus shocks our newBritish thrift, concerned as never before with the costof upkeep. The expense of maintaining the great placeis, in fact, already beginning to weigh heavily on theauthorities of this hospital.We have plenty to learn, however, from other aspects

of the Swedish hospitals. They seem to pay moreattention to the comfort of the patient and his relativesthan is usual here. These hospitals are quieter thanours, for instance : walls and ceilings are made of sound-absorbing material, and lift-doors of wood with no

clanging inner gates ; trolleys are often electric andare all well made and easy to move ; doors are fitted withdoor-checks, and many of them are designed to pushopen so that noisy handles are unnecessary. Relativesare received in a large and pleasant entrance hall whichusually contains a florist’s shop, a tobacco and news-paper stall, a cafeteria, and sometimes a post-office,and a hairdressing salon for the use of ambulant patients.There is nearly always an information bureau as well,and a large model of the hospital on which a visitorcan learn his way about. The beds, it is true, werethought to fall short of British models. They measure2 ft. 6 in. across, and have their bottom legs set backsome way from the foot, which gives them rather amakeshift look. Actually they are rather ingenious,for they are fitted with a wheeling device, and whenthe foot is lifted they can be pushed easily about like awheelbarrow. Screens are not used in the wards,since treatments, dressings, and blanket-baths are givenin a separate annexe and patients are usually wheeledto the water-closet either in their beds or in a lavatorychair. This must reduce greatly the traffic in bedpans,though these are of course provided. The pans are allmade of stainless steel, and are well maintained, thoughthe cleaning equipment is not of that latest type whichcleans and sterilises. They are washed in a deep metalsink, usually in cold water, sometimes under pres-sure; but they are only sterilised in maternity andgynaecological wards. The pans are numbered, however,and each patient retains his own throughout his stay inhospital.The medical equipment is of a very high standard

indeed, and extremely lavish and well cared for. Theatresin the newer hospitals are spacious and well planned,and many operations are done by daylight-anotheradvantage of clean bright air. In the wards lights areconveniently placed over the beds, and are -often fittedwith a revolving shutter which allows the patient toadjust the amount of light given out. The night light is never overhead, but usually placed in a recess in thewall, near the door, about a foot from the floor. Inone hospital the night light was sunk flush in the centreof the floor of the ward, which must give a speciallyrestful effect.

1. Report of Study Tour of Hospitals in Sweden. InternationalHospital Federation, at King Edward’s Hospital Fund forLondon, 10, Old Jewry, London, E.C.2. 1951. Pp. 60.7s. 6d.

2. See Lancet, 1945, ii, 571.

Page 2: SWEDISH HOSPITALS

625

Sweden has staffing difficulties like the rest of us.

Nurses are scarce, but, on the other hand, if they takeup the profession they seem to stick to it : wastage issaid to be only 3%. This may be partly because nearlyall the trained staff live outside the’ hospital, and

appreciate the opportunity ; but it may also be becausethe Swedish nurse has a very interesting training, withexperience, of laboratory work and radiology. Whenshe is qualified, moreover, she is entrusted with importanttechnical duties : for example, blood-transfusions are

almost everywhere given by nurses. The British visitorswere inclined to shake their heads over the time spentby Swedish nurses in the X-ray department and thevarious laboratories ; taking this into account, theythought 3 years and 5 months was not long enough totrain a nurse. Canadian experience, however, has shownthat an intelligent girl can become proficient in nursingin 2 years : are the Swedes perhaps right in using theremaining 17 months to stretch her mind ’? Evidentlygirls who are capable of managing responsible procedures,are entering the Swedish nursing service ; and a wastageof only 3% from such a class of entrants means that thetraining has captured their enthusiasm. We might wellaim to do as much ourselves.

CARDIAC ARREST UNDER ANÆSTHESIA

No more dramatic event takes place in an operating-theatre than cardiac arrest under general anæsthesia ;for everything may hang on early recognition of thiscomplication and on swift and decisive action. The factthat full recovery is possible even after the heart hasstopped for a considerable time is shown by a case

studied by Turner.! The patient was anæsthetised bythiopentone and cyclopropane, and after seven minutes’stoppage the heart was made to beat again by cardiacmassage through a subcostal incision. During the nexttwenty-four hours it stopped beating four times andbreathing stopped several times; but on the second daydeepening coma was replaced by gradual return of con-sciousness, and by the tenth day the patient was fullyorientated. He had a permanent retrograde amnesia oftwelve hours and a postoperative amnesia of about fourdays ; and a year after the accident he had symptomssuggestive of a mild frontal-lobe syndrome. But aftera further twelve months recovery seemed complete.Anderson and her colleagues 2 keep in the theatre a

" cardiac resuscitation kit " consisting of 2 small retrac-tors, 6- curved and 6 straight haemostats, 2 toothed for-ceps, and 2 scalpels, together with a syringe containing9-5 ml. of 1% procaine and 0-5 ml. of 1 in 1000 adrenaline.When warned of cardiac inhibition, the surgeon’s firstduty, if he is operating on the abdomen or chest, is toconfirm that the great vessels are pulseless ; and hisnext task is to reach the heart by whatever route seemsbest, not hesitating, if need be, to enter the left side ofthe chest through the fourth or fifth intercostal space.3" All surgical residents early in their training should beshown at the autopsy table how best to approach theheart for massage through the chest and through thediaphragm." With the anaesthetist maintaining artificialrespiration by intermittent compression of the breathing-bag, the surgeon compresses the heart at a rate of 60-80per minute (120 is the most efficient rate, but it is tootiring for a single surgeon). Further action, if sponta-neous rhythm is not soon resumed, depends on whetherthe heart is found to be fibrillating or at a standstill.If fibrillation is found, and if the electrical apparatus forserial defibrillation is not at hand, 40-60 mg. procaine ina 1% solution is injected intravenously. This mayrestore normal rhythm or bring the heart to a standstill ;1. Turner, H. J. Neurol. Neurosurg. Psychiat. 1950, 13, 153.2. Anderson, R. M., Schoch, W. G., Faxon, H. H. New Engl. J. Med.

1950, 243, 905.3. Lampson, R. S., Lincoln, J. R., Schaffer, W. C. J. Amer. med.

Ass. 1948, 137, 1575.

in the latter event (and when the heart is found in thefirst place at a standstill) manual massage will oftensuffice to bring about normal rhythm, but the heart-beatwill be strengthened by injecting up to 0-5 ml. of 1 in1000 adrenaline into a vein or into the right auricle orventricle. Anderson et al. defend their combination of

procaine and adrenaline in a single injection on theground that when circulatory arrest develops it is rarelypossible to be sure whether the cause is cardiac standstillor ventricular fibrillation.The mechanism of cardiac arrest under general anæs-

thesia has been studied by Johnstone. who concludes thatprobably the anæthetic stimulates sensory nerve-endingsin the lungs with resulting inhibition through the pulmo-cardiac reflexes. The arrhythmias to which the inhibitiongives rise include sinus bradycardia, auriculoventricularnodal rhythm, partial and complete auriculoventricularblock, ventricular standstill, and complete cardiac arrest.He judges that before operation atropine gr. 1/ ...intravenously probably protects against cardiac inhibi-tion for about thirty minutes, and gr. 1/5o intramuscularlyfor ninety minutes ; but special care to avoid highconcentrations of anaesthetic vapours should be takenwhere vagal tone is increased (as with jaundice, simplesinus bradycardia, and peptic ulceration). Johnstoneemphasises that simultaneous intravenous administrationof atropine and neostigmine to anæsthetised patients isdangerous, for in combination they may precipitate fatalventricular fibrillation ; and the only way to eliminatethis danger is to give minimal doses of curare, therebyeliminating the need for neostigmine. Johnstone main-tains that in cases of myocardial disease or where anms-thesia is protracted, electrocardiographic records shouldbe taken during the operation.

OUR ELDERS

VOLUNTARY and statutory bodies have formed manynotable alliances in the cause of social welfare. Inthe last few years their joint endeavours have madea remarkable difference to those old people whose lothas fallen to them in unpleasant places, and their projectshave owed much, both in counsel and cash, to theNational Corporation for the Care of Old People.5 Inthe past year the governors have had in mind the diffi-culties voluntary bodies nowadays meet in attemptingto raise money, and have therefore increased the averageamount of grants above the sums given in previousyears, especially to homes for the- infirm. A conditionis that the voluntary bodies applying for grants shouldapply to the appropriate local authority for help withthe maintenance costs- of individual residents ; and

nearly every authority approached has responded-without, moreover, attempting to make strict conditions.Two county boroughs, only, have refused. The governorspoint out that such refusals are shortsighted, for allthe homes that can be provided are needed urgently,and an authority can only benefit by having a homeprovided and run by a responsible organisation. Ifauthorities would go even further and agree to pay thewhole cost of maintaining old people in such homes,the voluntary bodies could, of course, do much more ;but so far only a few authorities have agreed to thiscourse.

Towards the end of the year the governors arrangedthat Mr. Howell E. James should visit the homes to whichgrants had been made, partly to see how the fundswere being used but mainly to help in planning futurepolicy. Some homes have solved problems with whichothers are still wrestling, and the governors hope topool such experience for the benefit of all. One problempresented by the old is that they grow older ; and

4. Johnstone, M. Brit. Heart J. 1951, 13, 47.5. Third Annual Report, for the year ended Sept. 30, 1950. Pp. 26.

The corporation’s address is 33, Doughty Street, London, W.C.1.