1356

the symptom is recognised by the patient as absurdand irrational and is therefore to be hidden from theworld. The frequent association of the disorder withhigh intellectual ability and devotion to work suggeststhat some puzzling cases of suicide, in which thevictim is described as having possessed those qualities,may have their explanation in an unsuspectedobsessional state, or, as Vurpas would express it, ina constitutional psychasthenia. He believes that inthe true psychasthenic there are minor indicationswhich, apart from the obsessions, reveal the psychicalconstitution ; when these indications are absent thecase belongs to some other group, commonly themanic-depressive, and this observation may helpin the recognition of certain cases which, beginningapparently as obsessional states, falsify the resultantprognosis and become certifiable as frank melancholia.Obsessions may also, he thinks, mark an early stageof dementia praecox or general paralysis, may appearas fugitive symptoms in senile or arterio-scleroticpsychoses, or evolve parallel with another psychosis.Thus the obsessional symptom occurs in a larval formcompatible with ordinary social life, being thencontrolled or even dissimulated ; it often leads to atemporary breakdown or permanent incapacity ; itis sometimes a part of a psychosis belonging to a well-defined clinical group. Although Vurpas follows Janetin regarding psychasthenia as a constitutional disorderfor which only palliation is possible, yet more hopefulviews are held as to the accessibility of these patientsto analysis. His discussion of clinical possibilitiesis, therefore, of interest to the general practitionerwho might overlook an important group of troubles,to the psychotherapist who must carefully select hiscases for treatment, and to the psychiatrist who hasthe opportunity of watching the evolution of thepsychoses.

DISCIPLINE IN MUNICIPAL HOSPITALS.

IN the army, the navy, the police force and otherpublic services it is well understood that a clearlydefined channel must be provided for the making ofcomplaints. It is certain that there will always begrumblers, but it is equally certain that some grumbleswill be justified. The sense of unfairness and injusticeis not so bitter if the supposed grievance can be

’’

reported, investigated and dealt with by a knownsuperior officer under some open and well-recognisedsystem. The same principle applies to service in thenursing staff of a hospital. Prevention being betterthan cure, disciplinary difficulties may often be avertedif the persons concerned are clearly instructed intheir rights and duties. The public assistancecommittee of the Birkenhead Corporation recentlyhad occasion to consider this question in connexionwith the administration of a poor-law infirmarywhich the corporation had taken over under theLocal Government Act of last year. The incidentswhich led to the inquiry are of no public concern ;the recommendations which resulted are of more thanlocal interest. Those who have any share in theorganisation of a municipal hospital may usefullyexamine their own disciplinary conditions ; if they havemade no provision for the ventilation of grievancesthey should study the admirable report drawn up by Dr.D. Morley Mathieson for the public assistance com-mittee at Birkenhead as the result of the recent inquiryand published in the Medical Officer for June 7th(p.257). Discipline, as he observes, must be maintained.Discipline does not mean oppression; it means efficiency,precision, balance, fairness, self-control and harmony ;the alternative to discipline is disorder. The hospitalcommittee must support the medical superintendentand matron ; the matron must support the sisters,who are her lieutenants. A matron cannot discussa sister with a probationer; a member of the com-mittee cannot discuss a matron with a sister, or asister with a probationer. The nursing staff cannot Iapproach individual members of the committee to Ivoice grievances or discuss their conditions of work. I

Members of the nursing staff must be instructed that i

they are never to discuss hospital matters outsidethe hospital. Gossip about the patients or the staffis unprofessional and a serious breach of hospitaldiscipline.

Dr. Mathieson’s recommendations for the improve-ment of hospital discipline may be briefly summarised.He suggests that a log-book be provided for eachsister wherein all reprimands and complaints are

to be recorded. Minor corrections and admonitionssuch as normally occur in a probationer’s trainingare not to be reckoned as reprimands for this purpose.But if a sister has occasion to reprimand a probationerfor neglect of duty, disobedience, insolence, breachof rules or gross breach of nursing practice or for anyother reason of like gravity, the sister will enter thefull facts in her log-book. A complaint by a

probationer is similarly to be entered. In eithercase both sister and probationer will sign the entry.If the probationer declines to sign on the ground thatthe entry incorrectly records the matter, there is tobe an immediate reference to the matron, who willinvestigate. forthwith and, if necessary, consult the-medical superintendent. In certain events there is.to be an appeal to the sub-committee. Where the-reprimand concerns a sister, or where a sister makes-a complaint, similar records will be made by the matronThe purpose of this machinery is to ensure the-prompt and regular disposal of matters of complaint,and thus to prevent the nursing of grievances andthe demoralising effects of cavilling and other formsof disloyalty. The machinery should be as simpleas possible. Recourse to it will not be frequent ifthose in charge of subordinate staff avoid ill-temper,undue, severity and unfairness. " A good disci-plinarian," says Dr. Mathieson, "has no need toemploy despotic or spectacular methods, and iskindly, impartial and even-tempered when dealingwith subordinates ; this is especially so when anyreproof or correction is called for."

SO-CALLED SCIATICA.

THAT man’s assumption of the erect attitude has-much to do with many cases of sciatica is becomingincreasingly evident, and A. P. MacKinnon says thathe regards most cases of sciatic pain as due to som&disturbance in the fundamentally unstable sacro-iliacor lumbo-sacral joints. Goldthwait, Smith-Petersen,.and Danford and Wilson in America, and Sicard andPutti in Europe, have drawn attention to the part,which strains, injuries, and disease of the lower partof the spine may play in producing pain along thecourse of the sciatic nerve. C. W. Buckley 2 in thiscountry found that in 108 patients complaining ofsciatic pain the main underlying conditions were-

osteo-arthritis of the hip (30 cases), lumbar andsacro-iliac strain (26), neuritis of the sciatic nerve (20),and sacralisation of the last lumbar vertebra (9)-or, to put it another way, only 20 of his cases had aneuritis of the sciatic nerve. MacKinnon looks onlumbo-sacral arthritis as the main cause, and thinksthat other pathological conditions, especially sacro-iliac disease, are of minor importance. It is true thatthe anterior ramus of the fifth lumbar root, whichplays such an important part in the formation of thesciatic nerve, is the largest of the emerging nerves,passes through the smallest intervertebral foramen,..and has the longest bony canal to traverse before itreaches the cavity of the pelvis. On the other hand,our methods of differentiating lumbar arthritis andstrains, sacro-iliac and lumbo-sacral disease are still’so unsatisfactory that it is hard to accept his claimthat the large group of cases previously classed asidiopathic sciatica should be regarded as symptomaticsciatica due to lumbo-sacral arthritis. If this weretrue the good results reported from local treatmentof the nerve trunk itself would be difficult to explain-The nomenclature of sciatica will remain somewhat

1 Canad. Med. Assoc. Jour, April, 1930, p. 492.2 Buckley: Practitioner, June, 1930, p. 653.

1357

.chaotic till more is known of the cause or causes. It Iis fairly certain that patients will stick to the familiar Iword, and practitioners will know exactly what they ’,

mean, especially if they too have suffered. Thereare few terms in medicine which are so definitive inthe mouth of a patient, and at the same time so aptto mislead writers and readers of medical literature.’There is much to be said for Sicard’s classificationof sciatic pain into high, middle, and low, accordingas to whether the mischief arises in spine, pelvis, or I,buttock and thigh. As Buckley points out, this is auseful differentiation for purposes of diagnosis. I

I

HOSPITAL LIBRARIES.. THE address given by Dr. C. Hagberg Wright atSt. James’s Palace during the recent British EmpireRed Cross Conference was a timely reminder of anundertaking which has a great future as well as avery creditable past. The hospital library scheme,started by Mrs. Gaskell early in the war, .was run ona vast scale by the British Red Cross and the Orderof St. John. The war over, the marvellous stream ofbooks to hospitals began to wane, but so urgent wasthe demand for books, and more books, by those whohad known their stimulus and cheer that the JointRed Cross Council gave a fund for the continuationof the scheme ; and to-day the library is housed atLancaster Gate, and carried on, in over 2000 hospitals,by a very small staff. Appeal is constantly beingmade to the public for books and magazines, whichare distributed to hospitals that ask for them ; whenrequired and whenever possible, special technicalbooks in addition are bought and supplied. Butalthough the work has’ been unobtrusive, therealisation that libraries in hospitals should meansomething more fundamental than a mere collectionof books has begun to take root and to growtowards not only a national but an internationalideal. America has an extensive and highly developedsystem of hospital libraries ; Germany is giving closestudy to it, and efforts are being made in othercountries. Public opinion is awakening to thenecessity of a well-stocked library as part of thecurative equipment of every hospital. But thewell selected library is only the first stage of the work.It is of little value unless the books are distributedaccording to the tastes and the physical conditionof individual patients. This means a system oflibrarians with knowledge of psychology as well asof literature. Sometimes a member of the hospitalstaff combines these duties, but more often a volunteerfrom outside has to be found. Methods vary incertain countries and their comparative merits awaitfurther study. In the stage that has been reachedcertain facts stand out clearly. First, hospitallibraries depend for their success on wide studyand above all on public opinion. The HospitalOfficers’ Association is taking a keen interest in themovement, and the February issue of the Hospitaloutlines a scheme for running a library in a largeLondon hospital. In the Manchester Royal Infirmary.a rota of Toc H members in conjunction with theirleague of women helpers distribute books to patientsfive nights in the week. Such libraries need thebacking of the great body of doctors, nurses, hospitalauthorities, and welfare workers. It is easy enoughto send a parcel of books to a hospital; it is lesseasy to fit the reading to the state of the patients,and to select books so that they may alleviate, amuse,or stimulate, as the need may be. In countlessinstances the mind of a patient can be relieved by theright book at the right moment; this is especially thecase with interrupted studies. There are manyincidentals of the work, such as unpacking, rebinding,cleaning, mending, listing, and packing, all importantto the successful working of the scheme. Those whoare doing this hospital library work would welcomeinquiries and constructive criticism. Correspondencemay be addressed to the secretary at 48, Queen’s-gardens, Lancaster Gate, W. 3,

REDUCTION OF FRACTURES.

THE first essential in the treatment of a fractureis its reduction, and this will often test the skill ofthe most experienced. Some form of traction isnecessary, and during the last few years manysurgeons have been considering what is the best wayof applying it. Lorenz Bohler, of Vienna, has drawnattention to the value of pin-traction as a means ofreducing, and maintaining the reduction of, fracturesof a; long bone. In fractured femur, for instance,a steel pin is passed in and out of the limb, throughtwo skin punctures, and transfixes either the shaftof the femur below the fracture or the tibia belowthe anterior tuberosity ; to the ends of the pin asteel stirrup is attached, and from this last a tractioncord passes to a pulley and weight. The use ofKirschner’s wire is lending this method a remark-able simplicity and precision. Recently a valu-able contribution to the technique of fracturereduction has been made to the Journal of theAmerican Medical Association (May 17th, p. 1547)by Robert Soutter, of Boston. The method is toincrease traction gradually, under an anaesthetic, toan amount that will in 15-30 minutes relax themuscles enough to make reduction fairly easy. Thetraction is facilitated by an apparatus consisting ofa rod 80 inches long bent at right angles at one end.The figure which we reproduce from the Journalshows the method of reducing fractures of thehumerus and elbow.

" At the end of this right angle is a hook and at the otherend of the rod is a hook. The rod is made up of severalpieces, so that it may be taken apart and put in a smallcase. Each section is about 20 inches long. It is made oftubular steel and not of iron piping, as the latter does notstand the strain. Each tube is fastened to the next by asteel rod which is inserted in the tube. The steel rod shouldnot bend and should be very strong. There are two webbingstraps 46 inches long and 3! inches wide with a heavy steelring in each end. The webbing should be strong anddouble, and the ring should be stitched solidly so that thestitching will not rip. There is a spring balance that willmeasure 100 pounds, and there are two double block pulleys

with heavy cord. These block pulleys are 3 inches longand I inches broad, and there are rings for hooks at eachend." "

Unbleached calico is used for making a Delbet knot fortraction at the wrist or ankle in fractures of the upper orlower limb respectively ; or at the ankle, instead of thisknot, loops may be employed of heavy webbing 1 inchbroad and 5 feet long made of three thicknesses stitchedfirmly together. The ankle and foot are encased in thickfelt and the webbing is applied over it in the form of afigure of eight.On the average traction begins with 10 lb., increas-

ing at three-minute intervals to 20 or 25 lb., at whichit remains for 15 to 30 minutes. The maximaltraction in some cases is 15 lb., while in others,especially fractures of the femur, it may be 50 lb. ormore ; the amount is measured by a spring balance.At the end of the indicated time there is musclerelaxation lasting five to seven minutes, and duringthis period the fragments are manipulated intoposition with or without the maintenance of traction.If reduction is unsuccessful then the maximal

traction is applied again for five or ten minutes moreand another attempt made. When reduction is! effected full traction is applied until the controllingsplint is fixed ; after this the traction is diminished-for example, when Thomas and sheet metal splints