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of the voluntary hospitals is entirely due to thecontributory schemes up and down the country,for though hospitals in almost every district canget capital sums for enlargements the great diffi-culty is to provide for annual maintenance. Mr.R. H. P. ORDE pointed out the dangers of lookingupon the contributory schemes merely as banksinto which the voluntary hospitals can dip whenthey want to pay their bills. It is not fusion buta system of cross representation that is urgentlywanted between those who administer the fundsand those who foot a large section of the bill-the contributory schemes are said to pay to thehospitals some 2,000,000 a year. A start hasbeen made with cross representation in the bigassociations, but it depends on the response ofthose running the individual contributory schemesin the various districts and of the boards of manage-ment of the local hospitals whether cooperation isreally secured.

Incidentally there is a third group of persons(quite apart from the patients) whose interestsare vitally concerned-the general practitionersin the area covered by each contributory scheme.We have heard complaints lately of the sad dif-ference their spread has made to the type of

professional work as well as to the emolumentsarising from general practice. The middle-class

patient near the higher income limit of theseschemes naturally proposes to get value for hiscontribution, and, though he may still send forhis family doctor when he falls ill, it is often toinform him that if bed treatment is required thepatient is entitled to go into one of the local hospitalsand to ask that arrangements may be made forhis admission. The doctors thus stand to lose not

only the fees for attendance during the illness

but, what is of even more concern to most of

them, the opportunity of exercising professionalskill. The voluntary system of hospital provisionis bound up, in the eyes of most of its supporters,with the ideal of maintaining the voluntary choiceof a doctor on whose continued personal interestin their welfare patients feel they can rely, if forno other reason than that his livelihood dependson their recognition of his zeal and competence.It would be a hollow and short-lived triumph forthe voluntary system of hospital management ifit survived only through the development of

contributory schemes on lines which left no scopefor the family practitioner. This danger can, webelieve, be avoided, but only if the practitionersas such, and not only those who may be membersof the hospital staff, are also given representationas a third party whose risk is as great as that ofthe two principals.

There is another function the family doctorcould usefully perform on a hospital board-hecould act as interpreter for the patient. There isevidence enough that while the present institu-tional atmosphere is not ill adapted to the needsof the patients of what used to be termed the

hospital class, there are still adjustments, mostlypsychological, to be made in most hospitals beforethe patient who belongs to a family with an income

of 1200 or 300 a year is conscious of receivingthe same measure of consideration for his personaltastes as he would get at home. In the matterof choice of food, light, visits from friends, abilityto send for the doctor in charge of his case andto speak with him alone, and other matters he isat a disadvantage which he may resent but cannotremedy. Some of these restrictions are inevitablein any institution ; others, such as the absenceof a bedside lamp with a beam circumscribedenough not to disturb other patients, or the dailyprovision of fresh fruit and salads where per-mitted, are matters of adjustment. Among sometrenchant criticisms of hospital administration ina book reviewed on another page the authorshows how many and various are the discomfortsthat may be experienced by a sensitive patient-from that induced by the routine use of a mackin.tosh sheet to the loss of dignity when " othersrule you and think for you and lie to you ; and allyour established habits of life are taken from youand a new set of unaccustomed habits thrust on

you." It is a matter of pride in many hospitalsthat in general patients soon settle down andsubmit to a routine which time has shown to bethe most convenient. It would be a more legiti-mate source of pride if the routine was made asflexible as possible, and if the staff were largeenough to exploit the psycho-therapeutic valueof giving personal and unhurried attention toeach patient. In this way we should have insti-tutions of which the patent and not only thelatent object is the comfort and welfare of thesick people within its walls, and the voluntaryhospital system would be secure in the affectionand support of the country.

ROCHDALE AND AFTER

A CIRCULAR addressed last Friday to localsupervising authorities by the Minister of Healthdescribes the Midwives Act, which came into opera-tion at the beginning of August, as an importantstep in the campaign for reducing maternalmortality and urges these authorities to get onwith the scheme for a complete domiciliary serviceof salaried midwives.Two professorial pronouncements in our last

issue will have added another twinge to a growingdiscomfort about the mortality of childbirth.

Addressing a Scottish congress Colonel P. S.LELEAN, who occupies the chair of public healthat Edinburgh, gave many figures to illustrate thepresent state of national fitness in Scotland andremarked that maternal mortality had risen therelast year to 6 per 1000 births, as against 4 per1000 in England. That is indeed regrettableeven if we frankly admit certain factors whichmake deduction from any such figures hazardous.The maternal mortality-rate as at present calculatedis recognised to be statistically unsound. It isbased on the proportion of deaths in pregnantwomen to 1000 live births, the number at risk

being very much higher than the number to whichit is related, as the prevalence of abortion has

definitely increased. In comparing the rate with

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that 20 years ago it must not be forgotten thatthe decrease in the number of children per marriageand the age of the first parity operate in the direc-tion of increasing the rate. As a matter of factthe number of mothers who die as a result of theactual process of childbirth is lower than at anyprevious period. The rate is not calculated on thesame basis throughout the world ; were it so, itwould probably be found that there is only onecountry, Holland, which can claim better resultsthan ours. Nevertheless the Commission on

Maternal Mortality asserted that in half the deathsthere was a preventable factor and then wenton to allocate responsibility among the partiesconcerned-the mother, the midwife, the doctor,the hospital, the local authority. Fifty per cent.may well be too high a figure except under condi-tions unattainable in a workaday world; howmuch, one may ask, would the death-rate fromdiphtheria or the acute abdomen be reduced wereperfect treatment available and applied in everycase ? We can, however, all agree that there aremany unnecessary deaths in pregnancy and child-birth, the proportion being at least 50 per cent.in some areas where the rate has been persistentlyhigh, and probably much less in others where

something approaching the irreducible minimumhas already been reached. We must at presentbe prepared to accept an occasional fatal termina-tion in a condition where there is so much psychical,vascular, and endocrine disturbance.The problem which doctors, midwives, and the

community in general have to face is how best toorganise the maternity services so that theincidence of the avoidable deaths will be reducedto a minimum. But consider now the second

pronouncement. Dr. G. I. STRACHAN, writingon antenatal supervision from the chair of obstetricsat Cardiff, remarked that maternal mortality hasappeared to increase rather than to decrease sincethe introduction of such supervision. To makethis supervision effective and preventive was notthe simple matter it was once supposed to be ;some women, he thought, might even have beenbetter off without it. Reading these statementsin the light of the Rochdale experiment one canhardly avoid being perplexed, for it seems quiteclear that for the four years before 1931 the

average mortality-rate among Rochdale motherswas 9 per 1000 births and for the four years afterthis date 3 per 1000, and that the turning pointwas an intense campaign of propaganda throughall classes of the community. It must then be thefailure of one or more links in the organisationof a maternity service that invalidates the wholeeffort and robs it of success. There are severalrespects in which each may be blameworthy andan ostrich-like attitude on the part of any oneof them is a hindrance to improvement. It isfor instance a short-sighted policy for the medicalprofession to refuse to admit that, as a result ofinadequate training, coupled in many cases withlack of interest in the subject, a proportion of itsmembers are not qualified to conduct a case inwhich there is any serious abnormality; it is

equally futile to deny that the doctor courtstrouble when he is too ready to interfere wherethere is no medical indication for him to do so.The standard of midwives has improved and whilethey are, as a body, competent and conscientious,the financial insecurity under which they have towork-and which the new Act is designed to

prevent-must incline some of them to takeunjustifiable risks or to shelve responsibility.The expectant mother and her relatives are

primarily responsible for many of the fatalities ;they will not avail themselves of the facilitiesoffered, will not act on the advice given them andinsist on interference merely to expedite whatmust, from its very nature, be a harassing experiencefor all concerned. And finally there is the localauthority which does not supply good facilities,properly qualified staff, and reasonable hospitalprovision, or which may carry out the various recom-mendations of the Ministry in the letter and notin the spirit.

There is then no royal road to the attainment ofa minimal maternal mortality-rate, but there areseveral essentials which must be present. Judgingby the experience of Rochdale one of the mostimportant is that the true facts about the causesand prevention of death in pregnancy and child-birth should be openly stated and discussed. Noone will deny that the spectacular drop in infantilemortality is due to the dissemination of knowledge.Even in the meanest homes the feeding and generalcare of the infant is immeasurably more sensiblethan it was 20 years ago ; the people themselvesknow the folly of overfeeding and overclothingtheir babies ; they know the absolute necessityof bowel regulation, fresh air, and sleep as theirparents did not. Exactly the same improvementis to be expected if the elementary facts aboutpregnancy, the need for antenatal examinationand supervision, the danger signals to look for, andthe futility of trying to expedite nature’s processeswere appreciated by the public. Knowledge offacts and the reasons underlying medical advicewould be followed by a willingness to conform.It is only where the public do not know what isconnoted by proper antenatal supervision and

by correct labour technique that carelessness or

incompetence on the part of doctor or midwife,or failure on the part of hospital or local authorityto provide facilities up to modern requirements,would be tolerated. Unity of medical supervisionthroughout pregnancy and at the confinementis probably the ideal ; it can be achieved by thewoman who is to be confined at home being sentfor antenatal care to the doctor whom she wishesto call in when necessity arises. Obviouslyher choice should be limited to practitioners of

adequate experience. It can be achieved by givingthe doctor employed at the antenatal centre anappointment at the parent lying-in hospital or

alternatively by employing the staff of the hospitalon clinic duties outside the hospital. Whereneither of these is feasible the private doctor ormidwife of a patient attending the clinic should bekept fully informed of the findings there and should

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be invited to attend with the patients if they sodesire. Where there is a maternity hospitalconveniently situated the best possible examina-tion and supervision can be given as an out-

patient service to prospective in-patients : if nodistrict service is run by the hospital, privatemidwives and doctors should be notified ofthe findings as in the case of non-hospitalclinics.Good results have been obtained by each of these

systems in different areas, and it is not feasible,even if it were desirable, to get uniformity. Buthowever good the system it will break down unlessgoodwill, cooperation, and frankness are in evidence.

In the Rhondda Valley and in Rochdale the out-standing feature has been the enthusiasm withwhich all parties have worked together. It would

appear that antenatal clinics, hospital beds, highertraining of midwives and doctors, provision ofconsultants, extra nourishment, and the like,depend for their ultimate success on the spiritunderlying the work. The Rochdale experimentowed its success to all the people doing all the timewhat elsewhere some of the people are doing someof the time. Without knowledge on the part ofthe public and cordial cooperation among all theother agencies a permanent fall in the maternalmortality-rate cannot be hoped for.

ANNOTATIONS

INSULIN IN SCHIZOPHRENIA

THE treatment of schizophrenia by severe hypo-glycsemic shock has already been the subject ofreference in these columns.1 It is now possible forEnglish psychiatrists who have no access to the

original German papers to become familiar with thetechnique and the results, as seen by a detached butbenevolent observer. In a report summarised onanother page Dr. Isabel Wilson has combined herown observations in Vienna and Munsingen with afair and full account of the literature of the subject.It is clear from her balanced statement that no

opinion can yet be ventured as to the curativeinfluence of the treatment ; a case recorded as in acomplete remission after the treatment has relapsed,and all the customary difficulties in assessing theefficacy of therapy in schizophrenia have arisen.But what is striking is the prompt change in themental state of patients following the daily hypo-glycaemia, and the rapidity with which in some casesthe schizophrenic attack has been curtailed. Thefirst point has made a strong impression on Dr. Wilson,who writes : " I do not feel that we can yet be surethat any other combination of severe therapy withclose individual nursing and attention, medical

energy and genuine hope, and with discharge in anatmosphere of optimism at an early stage, would notlikewise produce excellent results. The strongestpoint against such a view is to my mind the lucidityin relation to the after-injection period, when it

occurs, it makes on the observer and sometimes onthe patient a very strong impression that there is

something in the nature of a direct attack on thebasis of the psychosis going on." It must be

remembered, however, that similar observationshave been made with a number of drugs in thelast decade. The second point-the curtailmentof the attack-is of importance and should be easyto test.

Dr. Wilson’s plea for clinical trial of a methodwhich she thinks promising is certain to be taken upand carried into effect along the lines she recom-mends. We would suggest that this trial be supple-mented by others, for the efficacy of the method isadmittedly hard to gauge. However well-foundedher warnings against allowing scientific scepticismto pervade the atmosphere of the insulin ward, it isnecessary to remember that if the claims now madefor the method are exaggerated, as has happenedwith others equally promising on their first appear-ance, our hopes must not be allowed to mislead our

1 THE LANCET, 1936, i., 1418.

judgment. In our view the trial should not belimited to one hospital, and somewhere it should beobserved by sceptical, or at any rate dispassionate,psychiatrists. It is difficult to approach this topicwithout a feeling that the method is efficacious orthat it is inept. If Dr. Wilson’s conclusions suggestto readers that her personal bias is towards theformer assumption, all will admit that she isscrupulously impartial in her account of the presentposition. For example, she says : "Another pointof view, with which many experienced psychiatristsare in agreement, is that of Hofrat Prof. Dr. Wagner-Jauregg, who said that he had no personal experienceof the method and could therefore only speak withreserve ; that he had not been convinced of its valueby what he had heard and read, and awaited withinterest further publications on the subject. As tothe possibilities for the future, he believed we couldnot do more than await developments.... No

purpose would be served by quoting more of themany other views I heard for or against the treat-ment. Enough has been said to show that agreementis still far off." We would commend to the attentionof those proposing to undertake a clinical trial of this(or any other) new remedy in a disease of variedsymptomatology subject to remissions the admirablecritique of therapy in multiple sclerosis published afew months ago by Dr. R. M. Brickner.2

THE MOOSE RIVER MINE ACCIDENT

THE doctors who attended the unfortunate victimswho were trapped in a Nova Scotia gold-mine lastApril have written an account of the rescue, con-

dition, and treatment of the prisoners.3 The minewas cold and damp, but contained plenty of waterfit for drinking, and from the sixth to the tenth dayof their confinement the men had a little food passedto them through a diamond drill-hole. The con-ditions were therefore those of exposure, with firstcomplete and then partial starvation. Resistance tothese conditions seems to have been a matter ofindividual stamina, for Mr. Magill, the youngest ofthe three, died before the rescue, Mr. Scadding wasseriously ill, while Dr. Robertson was able to walkto the ambulance and made an uncomplicatedrecovery. He was older than the others, somewhatfatter, and a physician, but it is impossible to saywhich of these was the most important factor. Bothsurvivors testified to the absence of hunger while

2 Bull. Neurol. Inst., N.Y., 1936, iv., 667.3 McDonald, H. K., and Rankin, W. D. : Canad. Med. Assoc.

Jour., August, 1936, p. 143; McDonald, I.: Ibid., August,1936, p. 149.