510

of internal secretions, Plenciz’s view that each typeof infectious disease is caused by a specific micro- iorganism, and Frank’s campaign for state public 1health departments made little impression. I

ALBUMINURIA OF EFFORT

THE mechanism of the production of so-called xbenign albuminuria, as opposed to the type associated Iwith renal disease, has given rise to much speculation. nVarious types of benign albuminuria have been

rdescribed as following severe exercise, mental strain, rexposure to cold, or a large intake of protein, or as vpreceding menstruation. Another type known as tessential (cyclic, postural, or orthostatic) albuminuria thas also received attention. Hellebrandt and his 1co-workers hold that the albuminuria of effort is con-

xnected with the fall in pulse-pressure which is always xfound after severe exercise. The postulate that exer- jcise is followed by a peripheral vasodilatation and jconsequent reduction in the renal circulation. This 1produces renal anoxaemia, with increased permeabilityof the capillary membranes of the kidneys. On the ’

other hand Wamisch and Mevler believe it is theacidity of the urine after exercise which causes the 1

albuminuria. Govaerts and Lanne have now made a "

careful study of the problem in students from a

military training school. Their investigation showsthat the amount of albumin appearing in the urineafter muscular effort is in proportion to the intensityof the work done. Albumin and tubular casts appearfor only a very short time after effort and duringthis period there is a fall in pulse-pressure. If enoughalkalis are taken beforehand to keep the urine alka-line after the exercise, the albumin and casts are

reduced and sometimes do not appear at all.

SEQUELÆ OF BRAIN INJURIESIN the last two decades there has been a change

of attitude towards head injuries. What was formerlyregarded as a purely surgical preserve is now beingopened up to the physician and the psychiatrist. No

longer is the fracture of the skull the main interest-the damage to the underlying brain tissue is both

immediately and ultimately more important. This

change was clearly brought out by Surgeon CaptainDanson 5 in his presidential address to the UnitedServices section of the Royal Society of Medicine.He summarised the present state of our knowledge ofconcussion, contusion and the postconcussional syn-drome, but he also discussed what are ultimately moreimportant and certainly less clearly understood, the

sequelae of cerebral injury. The question of attribut-ability will in the near future bulk large in the mindsof doctors who sit on service medical boards, and itwill be their task to see that the state is not called

upon to pay pensions for hysterical prolongations ofgenuine cerebral contusions. Apart altogether fromthe large sums of money which may be frittered awayon pensioning hysterics, there is a strong case formaking hysteria non-pensionable, both therapeuticallyand prophylactically. Should it become common

knowledge among the troops that prolonged headaches,for example, after head injury lead both to invalidingand a pension, one may look forward to a seriousincrease in hysterical hypochondriasis after trivialinjury. Equally, however, the non-psychogenicsequelae of head injuries deserve at least the sameconsideration as the sequelm of injuries to the limbs,eyes or other important organs. Captain Danson’spaper helps to show where the line should be drawn.

1. Hellebrandt, F. A. Amer. J. Physiol. 1932, 101, 357.2. Inaugural dissertation. Marburg. 1925.3. Meyler, L. Ned. Tijdschr., Geneesk. 1933, 77, 759.4. Govaerts, A. and de Lanne, R. Brux. méd. 1940. 21, 361.5. Danson, J. G. Proc. R. Soc. Med. 1939, 33, 51.

Trotter placed the major sequela; of head injuriesn this order of importance: residual infections, epi-epsy, cerebral neoplasms, and unresolved contusions.Captain Danson feels that the order must be radicallyevised. First he places persistent cerebral contusionproper. This has been termed by Mapother "trau-matic psychasthenia," a not altogether happy name.It is actually a traumatic organic confusion which

- nerges gradually into traumatic organic dementia. Itsmost significant sign is a retention defect of memory,which any competent psychiatrist can demonstrate toa medical board in a few moments. Unless this istested for, genuine cases where the man is organicallyincapable of work may be dismissed as hysterical.Next in importance Danson puts so-called neuroticreactions superimposed on cerebral injuries. In asmuch as these are almost all gainfully motivated, theymust be regarded as hysterical. They may take theform of a mass of hypochondriacal symptoms, a

bizarre headache, or a suspiciously prolonged retro-grade amnesia. Danson wisely says that these are theresult of pre-existing hysterical tendencies. In makingdecisions as to the attributability of such cases, afull and careful psychiatric history is of the greatestvalue. Other psychiatric manifestations which mayfollow head injury are affective upsets (usuallydepressive), schizophrenic episodes, and possibly therevelation of latent syphilitic organic states and alco-holic tendencies. Here the question of attributabilitypasses from a scientific and social to a moral andphilosophical plane. The trauma undoubtedly firesoff a pre-existing ’ constitutional potentiality. Hadthe trauma not occurred the mental illness would haveremained latent, perhaps for a time, perhaps for ever.Further, one’s feelings of pity are aroused acutely byschizophrenia brought on by a blow on the head. Onesuspects that the case is good enough to satisfy theaverage medical board, or even the average high-court judge, and the contused schizophrenic will prob-ably get his pension. Yet, apart from the feelingof pity, the situation is precisely the same for thepost-traumatic hysteric ; he too might never have exem-plified grossly his hysterical personality had not thetemptation been placed in his way. It benefits neitherthe hysteric nor the community that his illness shouldbe regarded as pensionable. Philosophically he is thevictim of an injustice. Pragmatically he is not. Andfortunately, most doctors are more pragmatic than

philosophical.CRAWFORD AND BALCARRES

Lord Crawford, who died on March 8, will be missedin many relations of life for his unassumed andunassuming competence whether as fellow of the RoyalSociety, trustee of the British Museum, Minister ofAgriculture or chancellor of Manchester University-or indeed as a corporal in the R.A.M.C. in the last war.Our own relationship was of a more personal characterwhen lie accepted the chairmanship of THE LANCETCommission on Nursing. While the commission wassitting Lord Crawford gave up much time to the workand was an unfailingly good-tempered chairman. Hisready sympathy allowed him to see both sides whenconfronted with the occasionally conflicting interestsof nurses and matrons or other hospital authorities;but his judgments were always human and practical.He was a most accomplished speaker; when the reportappeared his lucid presentment of its chief findingswon it the favour of several audiences. The othermembers of the commission found him a friendly, easycolleague: nothing ruffled him, not even an Australianpaper which described the commission as being underthe chairmanship of "the Earl of Crawford and an asso-ciate "-the associate, presumably, being Balcarres.