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cough in 22 patients, measles in 11, and pneumoniain 22. In connexion with the last-named there is,of course, the fallacy that so-called pneumonia mayreally have been the first attack of asthma. Nasalcatarrh was present in 73 cases, enlarged tonsilsin 29, a tendency to run a temperature withoutobvious cause in 27, and " chills " preceding theasthmatic attack in 31. Climatic influences werealso considered, and in 29 patients it was thoughtthat the asthma was influenced by the weather.Psychical shock appeared to be responsible forprecipitating the asthmatic attack in one case. Asregards pathogenesis, Tuscherer sums up in favourof an unstable respiratory centre where stimuliboth from higher parts of the brain and from otherparts of the body may precipitate an attack.Prognosis can be summarised by saying that of the152 patients 35 had lost their asthma before puberty,and 39 became clear of attacks after puberty.

THE HOSPITAL PATIENT FROM HIS OWN

POINT OF VIEW.

THE charge is often levelled against hospitals thatthe patient is regarded as merely a case, while hispersonality is largely, if not entirely, neglected. Toa, certain extent this is inevitable, and for the mostpart those admitted are so appreciative of the medical.and nursing attention they receive that they do notgreatly resent the lack of that personal interestwhich forms a large part of the private practitioner’sbusiness. They are also marvellously tolerant oflong delays and complicated processes which are

never explained to them. Nevertheless therehas been a definite change of attitude since thehospital service has been extended to the middleclasses. Dr. W. S. Goodale who takes up thecudgels on behalf of the patient as an individual,urges the speeding-up and synchronising of suchpreliminaries as the admission history, the bath, the interview with the almoner, the students’ andhouse officer’s history and examination, and thedelayed and all-too-brief and uncommunicativevisit of the physician or surgeon. The patient’snext trouble is his food. The " house diet," saysDr. Goodale, " unalterable as the laws of the Medesand Persians, and garnished with a prune, apparentlyis planned for its calories and vitamins but withlittle regard, if any, for individual taste, much lessnational appeal." Why should not attractivealternatives be offered ? He next attacks hospitalsmells and sounds, and contrasts the filtered, washedand cooled air of the picture palace with the mixedodour of iodoform, carbolic, creosote, sweat, badteeth, and boiling vegetables that the hospital patientsometimes has to breathe. He also urges dailyvisiting for all convalescent patients ; since this isallowed in private wards it cannot be considerationfor the patient’s welfare that restricts visiting inthe public ward to four or five hours a week. He- criticises the inadequate supply of nurses, andremarks,

" If there is one nurse allotted to 10 or 12patients during the day-watch and one nurse to18 or 20 during the night-watch, the observingpatient is soon able to phrase a fairly good workingdefinition of ’ delayed service.’ ..... Why not a

patrol nurse whose sole duty is to visit all patientsvoluntarily and to inquire whether or not she can beof service ? " The tediousness of convalescence canbe greatly reduced by a good library service and aneducational occupation system. His proposed socialservice involves several revolutionary suggestions.The remark " no inquiries about patients can beanswered by telephone " is familiar enough in thetelephone directory and is certainly necessary as

long as one harassed porter has to attend two largeswitch-boards as well as perform the ordinary dutiesof a door-man. Dr. Goodale suggests that a specialsocial service should deal with all contacts with the

1 Jour. Amer. Med. Assoc., March 29th, p. 905.

public, providing a medium through which relativesand friends can blow off steam, whether by way ofanxious enquiry or complaint. This departmentwould also take over some of the duties now under-taken by the almoner, would see to the notification ofrelatives when a patient is on the danger-list, andmake sure that every patient on discharge had suitableclothing, hair-cut and shave, at least a shilling inmoney, a proper destination, and an escort. Itwould also see to the reception of mourners andundertakers if the patient died. The anxiety ofrelatives is often very seriously increased by theirinability to get any interview with a doctor, andDr. Goodale suggests that representatives of thehouse staff should be present in the lobby or a specialroom at certain fixed hours of the day, ready andwilling to meet the relatives of their patients. Weare hardly yet ready in this country for his finalcomparison of a hospital with a hotel, and his sugges-tion that hospital management has much to learnfrom successful inn-keeping. Hotel employees, hesays, have been trained to assume the attitude thatthe guest is always right and hotel managers haveaccumulated fortunes by astutely commercialisingthe Biblical aphorism " A soft answer turneth awaywrath." Hospital employees and managers haveboth these lessons to learn. They are seldom, headmits, positively cruel, but their ignorance ofpsychology and their lack of attention to the personalaspects of their patient result in a negative crueltyexpressed by a lack of that inexhaustible supplyof kindness, consideration, and forbearance that thesick guest needs so much more than the healthy.

Dr. A. T. Holbrook, in an article accompanyingDr. Goodale’s, maintains that hospitals are usedtoo much for cases which might be treated outsidethem if the general practitioner made more carefulexaminations and used comparatively simple labora-tory equipment in his own surgery. He also blamesthe practitioner for the state of affairs of which hecomplains so bitterly-i.e., that he is becoming amere directing-post to specialists. The generalpractitioner of the future, he says, must have twoqualifications-competence and honesty. He mustbe able to recognise and willing to call in help forconditions that are beyond him, but he must alsobe prepared to do conscientious and scientificdiagnostic work in a measure quite uncontemplatedby his predecessors.

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THE PATHOGENY OF ANGINA PECTORIS.

MANY hypotheses have been formulated to accountfor the pain of angina pectoris, but of them two onlyhave received much support. The one attributesthe condition to disease of the aorta, the other tocoronary arterio-sclerosis. Neither is completelysatisfying, for the accused organ has been foundhealthy at autopsy in unquestioned cases of angina,while gross lesions of the aorta or of the coronaryarteries may be present in patients who have neverexperienced anginal pain. The absence of pain inpatients with advanced coronary disease may possiblybe accounted for by a hyposensitive nervous

mechanism ; but the occurrence of angina in theabsence of any obvious anatomical lesion calls forfurther explanation. Probably it would be more

correct to speak of angina, not as a disease, but as asyndrome which may be attributable to various causeswhich all act in a similar way-namely, by produc-ing anoxaemia of the heart muscle. The whole subjectis critically reviewed by Dr. Douglas Hubble else-where in our present issue. Diagnosis cannot beregarded as satisfactory until it is possible to saywhich cause of pain is operative in any particularcase. Already one definite pathological entity hasbeen separated off from the group of lesions whichmay produce cardiac pain. That condition is cardiacinfarction following thrombosis or embolic occlusionof one of the larger branches of the coronary arteries.In addition to pain following the anginal distributioncardiac infarction is accompanied by dyspnoea,

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vomiting, shock, and other symptoms, which togetherwith the duration of the pain itself render itsrecognition possible during life. The diagnosis ofcoronary occlusion once infarction is completepresents but little difficulty, and the problem whichnow requires solution is how to differentiate the painassociated with the earlier phases of this processfrom that of ordinary angina. Dr. Hubble in hispaper describes a case which has an interestingbearing on this problem. In his patient the actualoccurrence of infarction was preceded during a periodof several weeks by prodromal anginal attacks ofincreasing severity. Dr. Hubble emphasises thefact that, in these attacks, the pain, so far as itscharacter and distribution was concerned, differedin no way from that of simple angina. The differencewas that the attacks occurred quite apart fromexertion or emotion and were not relieved by rest.They were often accompanied by dyspnoea. Thepain in this case was temporarily relieved by nitrites,but returned as soon as the effect of the drug hadworn off. Dr. Hubble suggests that the action ofnitrites in relieving the pain of angina is due partlyto a lowering of blood pressure and partly to acoronary dilatation which temporarily improve thecollateral circulation ; but, as he goes on to pointout, a lowering of the general blood pressure mayaccelerate thrombosis. For this reason alone

even during the prodromal phase, nitrites are contra-indicated in the treatment of coronary occlusion,and it is important that we should be able todifferentiate between these forerunners of myocardialinfarction and the ordinary attacks of simple angina.

MEDICAL ADVICE ON BIRTH CONTROL.

A COPY of certain correspondence which has takenplace between the Society for the Provision of BirthControl Clinics and the General Medical Council hasbeen sent to us, and although nothing will be servedby publishing the whole correspondence, the questionraised in it is an interesting one from the ethical side.At the beginning of March a letter was sent by thesecretary of the Society to certain practitioners,asking if patients seeking advice on birth controlquestions could be referred to them ; for the Societyreceives letters begging information from people notin touch with any of their clinics, and realises thatanswers can only be given adequately by a qualifiedmedical practitioner. The invitation to cooperationwas sent by one of its recipients to the GeneralMedical Council, with the result that a communicationwas received by the Society from the Registrarenclosing the Warning Notice of the Council in regardto advertising and canvassing, and going on to say" if an allegation were received that this (notice) wasbeing contravened together with adequate evidencethe matter would receive very careful consideration."The Society has replied to the Council expressing a- desire to keep the rules of the Council, but pointingout that the Warning Notice is not relevant, when theCouncil replied upholding the contrary view, and inso doing could justify its contention. Yet the matteris not quite so simple as either the secretary of theSociety for the Provision of Birth Control Clinics onthe one hand, or the Registrar of the General MedicalCouncil on the other, appears to consider. Fromthe point of view of the Council it must be pointedout that it is proposed through the instrumentalityof the Society to send women to consult doctors otherthan their own-that is to say, that the practice of onedoctor through the instrumentality of the Societymay be extended at the expense of that of anotherdoctor. But from the Society’s aspect of the case,it may be pointed out that before the instrumentalityof the Society is sought, the patient has, in most or allcases, already decided to obtain certain medicaladvice elsewhere than from her doctor-in otherwords, she is intending to exercise that free choice eof doctor which is associated with all modern relationsbetween the public and the medical profession.

Advice on the subject from the medical aspect cannotbe given by correspondence, while a patient mightdesire particular counsel from someone other than herown family practitioner. The Society should certainlypoint out to the medical practitioners who expressthemselves willing to help them the necessity, first,of keeping the patient’s own doctor informed of theadvice given, and, secondly, of impressing upon thepatient the fact that this advice is being given in aspecial manner, and not in the routine of practice.

THE CURRICULUM IN RUSSIA.

ACCORDING to the Moskauer Rundschau of April 13tha Russian national conference was recently held, atwhich proposals for the reform of medical educationwere discussed. A plan for the reorganisation ofmedical schools, as proposed by the authorities, wasconsidered and the conference suggested the lines onwhich the chief features of the plan should be embodiedin practice. It is proposed to have three different kindsof medical faculty at the universities, instead of oneuniform type as hitherto. The three types of facultywill be : (1) general medicine ; (2) public health andpreventive medicine ; and (3) maternity and childwelfare. The faculty of general medicine will includeseveral subdivisions, such as general treatment,surgery and internal medicine, and will also have amaternity and child welfare branch. The publichealth faculty will provide courses of studies intendedto produce experts in general sanitary science and itsbranches, such as epidemiologists, experts in thehygiene of housing, and specialists in industrial disease.The third type of faculty will educate specialists inmaternity and child welfare, and in children’s diseases.The length of a medical course in any one of the facultieswill be three and a half to four years. Some of themedical students will be evening students, and at thelargest medical schools complete evening medicalfaculties are to be opened. It is stated that this willenable the number of medical students to be increasedto 11,000 even in the current year ; there were 3300last year. The conference recommended that the useof Latin medical terms, " handed down from theMiddle Ages," is objectionable. Appropriate Russianwords are to be substituted for Latin terms in the studyof medicine, in all medical clinics and in prescriptions.

THE ANTI-INFECTIVE POWER OF CAROTENE.

Prof. Edward Mellanby and Mrs. May Mellanbyhave a flair for subjects in experimental dietetics whichhold great possibility of benefiting the public health.Apart from their well-known work on rickets andon dental caries, Prof. Mellanby has recently concernedhimself with the study of vitamin A as an anti-infective agent, and offers observations which mayprove of’much importance in preventive medicine.It has long been known that in rats whose diet isdeficient in vitamin A the mucous membranes through-out the body become especially liable to septicinfection. This is seen more particularly in the eye,the respiratory passages and adjoining glands, andthe bladder, and in drawing attention to thephenomenon Prof. Mellanby has pointed out thatthe septic foci of inflammation which occur in the ratare also found in man.1 Within the last two yearsthe whole question of the relation of carotene tovitamin A has come once more under consideration,and there is now no conflict of opinion that purifiedcarotene can act as an adequate source of vitamin A,although the nodal problem remains unsolved,whether carotene itself functions as vitamin A, orwhether it contains an impurity which defies allordinary means of separation. In their most recentcontribution, Green and Mellanby do not set them-selves to attack this problem, but seek to ascertainwhether, in vitamin A deficiency, carotene can supply

1 Green, H. N., and Mellanby, E.: Brit. Med. Jour., 1928ii., 691.

2 Green, H. N., and Mellanby, E.: Brit. Jour. Exp. Path.,1930, xi., 81.