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ledge of anatomy to help her to decide the part ofthe body to which she should apply the treatmentwhich she had been specifically called in to give.This decision was necessarily followed in Macnaghtenv. Douglas in 1927. The plaintiff, a doctor of osteo-pathy of America, possessing no British medical

degree, sued for 30 guineas, including 3 guineas for a" consultation." The county court judge stopped thecase on the ground that the claim was barred bysection 32. On appeal Acton and Talbot, JJ., felt

obliged to send the case back to the county court in

the light of Hall v. Trotter. They seem to have hadtheir misgivings. Physicians and surgeons will

probably share them. How could Mr. JusticeHorridge say that " manipulative treatment of thetissues of the body " was not the performance of anoperation 7 Is there no operation without a knife ?Are we still in the age of the barber-surgeons ? Howcould he say further that the osteopath had not givenadvice 7 And how could Mr. Justice Shearman saythat the osteopath had not given "medical or surgicaladvice " or " attendance " ?

GRAINS AND SCRUPLES

Under this heading appear week by week the unfettered thoughts of doctors invarious occupations. Each contributor is responsible for the section for a month ; ;

his name can be seen later in the half-yearly index

FROM PETER QUINCEII

IN pulmonary tuberculosis it is well established thatpsychological distress prepares the soil for the tuber-culous seed : witness the incidence of this diseasein young adulthood, a time when the physical bodyis at its prime but when the emotional disturbancesare at their fiercest. The frequency with whichpulmonary tuberculosis follows hard on the heels ofa broken engagement, or develops during an engage-ment which ought never to have been entered, seemsto be more than mere coincidence would warrant.Equally commonplace is the tuberculous patientwho, faced with the prospect of returning to anintolerable home life, fails to respond to all forms oftreatment. Quite a few patients, too, admit to hav-ing received the diagnosis of their case with a bewilder-ing and almost impious feeling of relief. Taxedfurther, they will explain that it was not relief thatthe trouble was not more malignant, or that the

diagnosis marked the end of their uncertainty, butrather a feeling of

" Well, at any rate this is goingto make a difference," tinged with expectancy.Such a patient is well on the road to self-knowledgeand if he proceeds further and asks himself " Fromwhat circumstances am I glad to escape? " he maybe able to decide which must be altered for futureharmony-the circumstances or his attitude towardsthem.

* * *

Others have the greatest difficulty in accepting thediagnosis of their trouble. This seems particularlytrue of athletes and Tough Guys. To them theprodromal symptoms of malaise and lassitude con-veyed merely that they were " out of training,"and the athletes went on playing rugger and squashuntil they were literally blue in the face, while theTough Guys tried to snap out of it with more andmore alcohol, with much the same result-until ahaemoptysis red-flagged their Gadarene careers.

When diagnosed, the same compensatory mechanismwhich forced them to become athletes (and/or ToughGuys) often forces them to resist the whole significanceof the situation. (This can’t possibly happen to ME... I am different from other people....) It issometimes several weeks before the patient will

consciously acknowledge to himself that he hastuberculosis : indeed, he is nervous lest he catchit from other patients who visit him. And when hedoes grudgingly acknowledge it, it is not a seriousdisease for HIM: just a slight touch, to be thrownoff in no time. Such a patient will always be tryingto prove to his own satisfaction that he is not as ill

as all that, by breaking out into extravagant exertionsover and above those appropriate for his condition.When the athlete comes soberly to accept the situa-

tion he will do well : not, it is to be feared, because hisbodily organs are better than the next man’s, butbecause the habit of self-discipline which developswith athleticism is ingrained and will stand him ingood stead. The Tough Guy whose facade was butarmour-plating around childlike softness has not

got those inner resources and is apt to fare ill.* * *

Time is notoriously a Great Healer in cases ofemotional maladjustment. The period of retreat ina sanatorium brings about changes in both the innerand outer lives of many patients. The marriedman who was finding being engaged simultaneouslyto three different girls rather too wearing not onlyescapes a trying situation by developing tuberculosisbut he gains leisured detachment from which tosurvey his life and determine what he is really seeking :meanwhile with luck the situation will clear itselfup without his participation in some very disagreeablescenes being necessary. Such a patient, I remember,when his tuberculosis showed signs of resolvingbefore he was ready to face his world, proceeded tothrow classical " textbook " conversion-hysterias :it was they that gave the show away.

* * *

The most hopeless case is the one who exhibitswhat I call the " Dornford Yates syndrome." She

(and it’s nearly always a she) really believes thatsomewhere round the corner there exists such a worldas that gifted writer portrays in his delirious fan-tasies : a world where women are worshipped fromthe crowns of their heads to their glittering instepsby clean-limbed, leisured sportsmen with a tastefor witty philandering, where every lawn is centuriesold and every car a Rolls. It is a make-believeworld we create whenever we put on evening dressand smoke cigars and behave a little above ourselves ;but most of us accept the twopenny bus-ride backto reality with something like relief.The " D.Y.S." not only believes it exists, but that

it is her rightful kingdom from which she is exiledfor having been born to the wrong parents or havingmarried the wrong husband. Cinderella’s PrinceCharming does not live up to premarital sample.Disabling illness of any kind provides an escapefrom reality in to a world which matches her fantasy.On her admission to a nursing-home or sanatoriumshe enters her kingdom-or should I say Queendom 1Enthroned in bed she gains the power and the gloryabout which hitherto she has only been able to dream.

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Meticulous service she exacts from all who attend her,rewarding here with a gracious word, reprovingthere with queenly displeasure. Visitors, inquiries,gifts of flowers and exciting negligées all heightenthe illusion. Her rapid unpopularity among theother patients is, of course, rationalised. " Theother patients dislike me, my dear, simply becausethe doctors make rather a favourite of me," confideda Queen Me to a newcomer (who went to the trouble ofascertaining if it were true !)-" I have never beenso neglected in my life," she once snapped at a gogglingfloor-maid, and added, skilfully avoiding under-statement, " But then at home I had seven servants "-" Really, mum, would that be altogether or oneafter another ? " innocently asked the floor-maid ;and was reported for impertinence.

Reality has an uncomfortable way of breakingthrough the best fantasies, and when it does thetime has come to move to another establishment,bearing horrific tales of the shortcomings of the lastone which forced the patient to abdicate.Now the striking feature about cases of this kind

is not that the disease runs a sluggish and protractedcourse, but that all attempts at adjuvant treatmentseem doomed to meet with failure. Artificialpneumothoraces prove unselective ; section ofadhesions fail to close cavities ; sanocrysin therapyprovokes forbidding constitutional reactions. A

malign Fate seems at work. A dramatic improve-ment once occurred when a husband’s interest wasfound to be straying elsewhere.... But it mightequally well have caused a dramatic decline, so itis not to be advocated. She is after all the victimof a disorder more intractable even than her tuber-culosis, which is in comparison only a stage-property.She is perfectly adjusted to Being an Invalid, so whyshould she get well ? ’1

* * *

Happily there are other patients whose emotionaltroubles are not so deep-rooted and who do notrequire such a spiritual bouleversement for adjust-ment to reality as the " D.Y.S. " would. How can

they be helped Should the kind physician sit

tight on the bank and hope that Time alone willwork the miracle ? Or should he Rounder into the darkwaters with some sketchy notion of life-saving ?Some of us indifferent swimmers feel that we canonly prove a further embarrassment to those alreadyin difficulties. Most of us when we dive into thesedepths are apt to lose our sense of direction andemerge in panic, having stirred up more mud thanwe thought could possibly exist.

There are times when to run along the towpathuttering encouraging noises is good therapy, butthere are also times when we must lend a hand. Anddon’t we hate having to do it ! Hang it all, we argue,it is a job for a professional. However there is nofully trained psychotherapist at hand, and if therewere the patient couldn’t afford a series of interviewsat three guineas a crack ; there are no elderly, saintly,unshockable clergy in the neighbourhood, and thepatient doesn’t hold with this Oxford Group business.You have got to be the father-confessor and mediatorand you realise with a sinking heart that your relation-ship to that patient is going to change and getcompletely out of control and to lead you know notwhither: and further that you are definitely notqualified for the job.

* * *

The whole situation is fraught with difficulty.Your specialist in psychological disorders sees thepatient about his affairs in a certain place and at acertain time, and the patient can steel himself for

these interviews which are invested with an elementof ritual. The physician is Confessor, detached andsuperhuman. Such a relationship in matters spiritualis difficult enough between a patient and his generalpractitioner whom he may regularly beat at golf :with his Sanatorium Physician it is wellnighimpossible. They see too much of each other,running into each other as they do at every turn inthe day’s routine. Nobody wants to meet at break-fast-time the man to whom he confessed overnightthat he still masturbates. In fact it is embarrassingto both parties-unless they are both ardent OxfordGroupers who vied with each other in confession,in which case presumably they just go on wherethey left off....

Personally I would rather confess to a saint thanto a fellow sinner ; just as I would rather not competein a Hernia Show, but would prefer to take mymodest little affair (if I had one) to someone whounderstood it and could rid me of it. Finding thatother people were just as bad as I would reassure methat I wasn’t so worthless perhaps and might helpme to lift my head again ; but a saint who understoodmy evil could raise me to the stars.

* * *

That is the real trouble-we are not saints. " ThankGod," did I hear a gentleman with his feet on thewindow-sill murmur My dear Sir, are we agreedabout our definition of a saint ?A saint, I submit, is one who accepts evil as a

pathological process with no moral itch to heave abrick. Man’s blackest cruelties (from the verythought of which we recoil sickened) quicken in himthe same compassion, interest, and desire to healthat we feel when confronted with a filthy fungatingcarcinoma of the breast (from which the untrainedlayman would recoil with averted gaze).

So it looks as if " sainthood " might be merely amatter of training-self-training-and experience.And why not ? It is perfectly natural for a medicalstudent to find the theatre overwhelmingly stuffy athis first operation....

INFECTIOUS DISEASEIN ENGLAND AND WALES DURING THE WEEK ENDED

MAY 27, 1939Notifications.-The following cases of infectious

disease were notified during the week : Smallpox, 0 ;scarlet fever, 1694 ; diphtheria, 732 ; enteric fever,25 (38 " expected ") ; pneumonia (primary or influ-enzal), 794 ; puerperal pyrexia, 196 ; cerebrospinalfever, 31 ; acute poliomyelitis, 5 ; acute polio-encephalitis, 3 ; encephalitis lethargica, 1 ; relapsingfever, 1 (Newcastle-under-Lyme) ; dysentery, 33 ;ophthalmia neonatorum, 105. No case of cholera,plague or typhus fever was notified during the week.The number of cases in the Infectious Hospitals of the London

County Council on June 2 was 3001, which included : Scarletfever, 667 ; diphtheria, 579 (carriers, 20) ; measles, 5 :whooping-cough, 991 ; puerperal fever, 15 mothers (plus 9babies) ; encephalitis lethargica, 304 ; poliomyelitis, 4.At St. Margaret’s Hospital there were 27 babies (plus 14mothers) with ophthalmia neonatorum.Deaths.-In 126 great towns, including London,

there was no death from smallpox or enteric fever,2 (0) from measles, 3 (0) from scarlet fever, 21 (4)from whooping-cough, 18 (2) from diphtheria, 36 (8)from diarrhoea and enteritis under two years, and29 (4) from influenza. The figures in parenthesesare those for London itself.

Bradford, West Hartlepool, Birmingham and Bristol eachreported 2 deaths from whooping-cough. Fatal cases of diph-theria were scattered over 16 great towns, Liverpool reporting 2.Birmingham had 6 deaths from diarrhcea, Liverpool 3.The number of stillbirths notified during the weekwas 283 (corresponding to a rate of 42 per 1000 totalbirths), including 43 in London.