437

Dr. A. MEYER gave an account of the present state ofhis anatomical studies based on the brains of patientswho have died after prefrontal leucotomy. He stressedthe absolute obligation to make full use of this uniquematerial for this purpose.

Dr. R. MESSiMY (France) has been working for manyyears on the effect of ablation of the prefrontal cortex inmonkeys. He emphasised particularly the resulting over-sensitivity, which he attributes to loss of an inhibitingeffect on the thalamus.

SOCIAL SURVEYS

Dr. BERNARD HART presided at a meeting on Sept. 11of the sections of psychiatry and social medicine.

Dr. C. P. BLACKER said that the earliest surveys were

delayed expressions of a growing awareness of the evilsof urbanisation. Most local surveys are concerned withhealth. Centrally initiated surveys may be single ; or

periodical, like a decennial census ; or continuous, likethe notification of diseases. In most surveys of territorycommon to social medicine and psychiatry the threemain objectives are to ascertain the incidence, differentialincidence, and trend of the condition studied, its causeor causes, and its possible remedies ; and if surveys in

. different countries are to be comparable, terms must becomparable. The International Statistical Classificationof Diseases, Injuries, and Causes of Death, which is nowbeing prepared, will be specially welcome to psychiatrists,he thinks, because of the confusion of diagnostic nomen-clature in this3specialty.

’

’Dr. E. 0. LEWIS described the survey he and his

colleagues made some years ago of mental deficiency inEngland and’Wales.The incidence was found to be about 8 per 1000 population,

and the total number of mental defectives in the countryabout 300,000. The incidence was by no means uniform,that of rural areas being 60 % higher than that of urban areas.Since many of the more intelligent and enterprising haveflocked to the towns in the past hundred years, rural areashave lost much of their best human stock and have been leftwith those of lower intelligence who have in1;>red. This

biological selective process has proved more dysgenic than thepoor conditions of life in large towns. Lower-grade defectives- imbPCiles and idiots-are evenly distributed throughout thesocial classes, but the higher-grade type of defectives-thefeeble-minded-are largely found in the poorer classes. Morethan 62% of feeble-minded children in the survey came frominferior homes ; only 27% came from average homes and11% from superior homes. ’

Feeble-minded families, said Dr. Lewis, are most oftenfound in the poorest social class. They show a highincidence of diseases arising from chronic poverty andunhealthy home and industrial conditions. When theseenvironmental factors have been remedied social medicinemust turn its attention to the hard core of the problem-the nature and quality of the human material.

Dr. ERIK STROMGREN (Denmark) described his survey,completed in 1936, of the island of Bornholm.

This island, belonging to Denmark, is south of Sweden,and its population was drawn originally from both countries.The people are largely isolated and speak with a distinctiveaccent which makes them easy to trace. The 46,000 inhabi-tants know each other fairly well, and it is easy to getinformation about any Bornholmian. Many families ’keeprecords of their ancestors. The island has its own generalhospital, but for the last 100 years psychotic patientshave always been sent to the same mental hospital onSeeland.

Dr. Stromgren began by making three studies of the mentalhealth of the general population. In each case the mentalhealth of about 150 people and of their parents and siblingswas investigated-some 427 people and 1927 siblings in all.Mental abnormality was found in 12.4% of the 427, psychosisin 28°,0, and mental defect in 3-1%. In siblings the incidenceof mental abnormality was 5 %, while 2% were or had beenpsychotic, and 0-7% were feeble-minded. If all the psychoticsin the parental generation had been sterilised, the incidence

of insanity in the following generation would have been 1-5%instead of 1-9%. Most of the children, however, had been born .before the parental psychosis developed.

In a fourth study a census was taken of a small district .with about 1000 inhabitants ; and again the incidence ofabnormality was 12% in all people over 20.

In a fifth investigation an attempt was made to ascertainall the inhabitants who were, or had been; psychotic. Amongthe 46,000 population, 525 such people-or 1-15%-werefound ; 0.31% were in hospital, 0-40% were still psychoticbut not in hospital, and 0-44% had recovered. If Bornholmis representative, there should have been 11,500 people in allDanish mental hospitals at the time ; and there were in fact11,000. Presumably, then, there were 14,000 psychotics inDenmark who were not in hospital and 1600 who hadrecovered.-

In the sixth and final investigation he ascertained that,since 1890, there had been 900 cases of psychosis on Bornholm,20-30% of them being schizophrenics and 20% manic-

depressives.Dr. Stromgren went on to discuss investigations carriedout later by Dr. Fremming, and by the Danish Social

Ministry.Dr. J., A. FRASER ROBERTS emphasised the importance,

in social surveys, of a suitable area, sound samplingmethods, and exact execution. He hoped that psychi-atric classification will soon become uniform : it is the

despair of statisticians.Dr. W. MAYER-GROSS (Dumfries), on the contrary,

felt that a definition is often a bandage covering an openwound ; and he feared that an international terminologymight have this obscuring effect. He is at presentcarrying out a survey, in a rural area of Scotland, of- .borderline cases-psychopaths and neurotics not recog-nised as such by the authorities, the family doctors, oreven by themselves-who form such -a large proportionof the unemployable and petty criminals.

.

Prof. JOHN RYLE (Oxford) thought the time has cometo have done with the historic type of survey and toconcentrate on scientific studies of a quantitative kind.In his department at Oxford they have gone to school,he said, to teach themselves methods. They havestudied survey techniques with small groups, recordcards, methods used in pilot surveys, ways of collabora-ting within the research unit, and descriptive methods.

Dr. J. D. KERSHAW (Colchester) said that, as a pro-vincial medical officer of health, he found that social

surveys tend to be centrally organised. While thismeans that they can be detached and scientific and canafford expert services,.it also means they often fail toappreciate sharp social differences within the area studied.Thus in part of Lancashire cotton-weaving in one smalltown is traditionally a woman’s job, in another a man’s;one town is inward-looking and stationary, another

outward-looking and progressive ; while the culturalactivities of the area are mainly centred in one of thesmaller towns. Often the field worker of the centralorganisation is not able to make the right sort of contactwith the people. The local health department couldsometimes say that a given area is not suitable for a

given survey, or that a given technique is not suitablefor the people. Local field workers, though they are nottrained in special techniques and would need guidance,are in touch with the people, and should be used ; and alarge-’mass of data available in reports and records couldalways be dug out. He suggested that the first functionof social-survey organisations should be to establish

two-way contact with local public-health bodies, andthat these bodies should be able to ask the help of suchorganisations in answering special local problems.

Mr. PATRICK SLATER discussed some aspects of" Social Survey," the organisation now attached to theCentral Office of Information. In the course of routinesurveys, he said, it is found that 20-30% of people com-plain of " nerves," but suffer little incapacity ; theyhave four consultations with their doctor for every

438

one day’s incapacity ; while those who do not suffer from" nerves " have one consultation for every three days’incapacity. Statistics of this kind, he said, raise broadquestions which might be studied further.

B.C.G. VACCINATION

_ On Sept. 12 the sections of chest disease, paediatrics,

and social medicine held a joint discussion under thechairmanship of Sir WILSON JAMESON.

Prof. W. H. TYTLER (Cardiff) remarked that GreatBritain has the questionable distinction of being the onlyone of the major countries which has contributed littleor nothing to B.C.G. vaccination. Perhaps our nationalscepticism has been to blame, especially in view of thelack of statistical analyses everywhere on the subject.The B.C.G. vaccine varies in its applicability to differentgroups ; the results in the North American and CanadianIndians have been striking, whereas those in childrenin New York have been less spectacular. It seems thatwhere the incidence of tuberculosis is low, B.C.G. isless effective ; for low incidence represents the residueof an immunised population. In Britain, though we mightexpect some advantage from the introduction of B.C.G.vaccination in childhood, it would not be dramatic ;and local abscess formation might give rise to prejudice.The plea for use in special cases is striking ; but here thefield is smaller and the situation has changed lately.The incidence of the tuberculin-negative nurse is perhapslower in Great Britain than in other countries and so isthe incidence of active tuberculosis in nurses ; never-

theless, B.C.G. vaccination is well worth trying even ifthe results will not be spectacular.

Prof. ARvID WALLGREN (Stockholm) said that thoughearly work on B,C.G. was unreliable, the vaccine is nowsafe and non-virulent and the new methods of injectionare free from unpleasant consequences. The multiple-puncture route confers a shorter period of immunisationthan the intradermal. Control by tuberculin tests isessential ; ’there is no point in vaccinating a tuberculin-positive reactor. Tuberculin sensitivity disappearsmore quickly after B.C.G. than after natural infection,but there is no reliable method of distinguishing betweenthe two-The criteria for estimating the value of vaccination,

continued Professor Wallgren, are that the dose mustbe adequate, that there must be a control group, thatthe risk of infection must be equal in the vaccinatedand the controls, and that the numbers should besufficient. He believed that B.C.G. vaccination is mostvaluable in conquering primary infection in childhood.It should prevent primary and postprimary infections,and until we possess something more effective, it is

likely to retain its place for this purpose. His adviceto Great Britain was " give it a fair trial."

Dr. J. HEIMBECK (Norway) said that the real questionis whether the immunising effect of a natural primaryinfection can be improved on by B.C.G. The old Germanand Austrian figures showing almost universal child-hood infection are not true for Norway. He showedstatistical tables of the Ullevaal nurse entrants whohave been vaccinated, group by group, since 1927.

They were all healthy women, aged about 20, living andworking under the same conditions, and the incidence oftuberculosis was greatest during the first year in hospital.Up to 1936 he has records of 1453 probationers, and themorbidity-rate per 1000 observation years for these was12.4 for tuberculin-positive nurses, 141-2 for the tuberculin-negative who had not been vaccinated, and 24-1 for

tuberculin-negative nurses vaccinated with B.c.G.Prof. G. S. WILSON, in the role of devil’s advocate,

found it impossible to compare results from one countrywith another : B.c.G. might be successful in non-immunisedpeople and not so successful in Great Britain. Despite

22 years’ experience of the vaccine, very few workershave recorded carefully controlled tests. He cited four

interesting sets of figures : (1) those of Rosenthal andhis colleagues on infants in Chicago ; (2) those of Levineand others on infants in New York ; (3) Heimbeck’sown statistics; and (4) Aronson and Palmer’s work onNorth American Indian children and adults. None of

these, however, provides conclusive statistical proofof the efficacy of B.C.G. Conditions of successful testare that the culture should be used within a week;that the strain should as far as possible be of fixedvirulence ; that local inconveniences of inoculation

(e.g., abscesses)- should be eliminated ; and that thevaccinated should be segregated for 6 weeks beforeand for 2-3 months after vaccination. This last criterionmakes B.c.G. vaccination essentially different practicefrom all other forms of immunisation. None of theseconditions is impracticable, but together they constitutea formidable problem. Nevertheless an adequate con-trolled experiment is the first essential.

Furthermore the chance of an infant dying of tuber-culosis in this country, added Professor Wilson, is

something like 1740 to 1 against, and if vaccinationis to be carried out, he would be in favour of delaying ituntil the age of 6 months at least. For the vaccination ofmedical students and nurses, the gains must be commen- ’surate with the disadvantages. During the Prophitsurvey of nurses in this country there were only2 deaths, while there are 4000 tuberculin-negativestudent nurse entrants per annum. g

.

Dr. J. HOLM (Denmark) spoke of the work of the Copen-hagen Serum Institute in the control of tuberculosiswith B.C.G. Infant vaccination is carried out only underexceptional circumstances, and for the most part - theinoculations are made during the school years andin early adult life. Vaccination, which is voluntary,has, he thinks, reduced tuberculosis morbidity to one-fourth. Generally the percentage of reactors from 6-8weeks afterwards is 97%, while 95% are still positive4 years afterwards. The great majority of the inocula-tions are carried out by the dispensary physicians:it has been found inadvisable to leave them in the handsof inexperienced general practitioners. The tuberculosismortality in Denmark is now 32 per 100,000 population,which he believes is the lowest in the world. Teams ofvaccinators are now being sent out from Denmark toPoland, Hungary, and other parts of the Continent,and short courses of training are being given. Freshlyprepared vaccine could be sent from Denmark to GreatBritain by air.

Dr. W. R. F. COLLIS (Dublin) related his experienceswith the vaccination of newborn babies at the Rotunda.

Hospital. He has come to the conclusion that the infantshould be isolated and tuberculin-tested twice. Afterthat an interval of 6 weeks should be allowed before

using B.C.G. The test question is, will the vaccine pre-vent fatal acute generalised tuberculosis? He believesthat it may.

Dr. PHILIP ELLMAN agreed that tuberculosis tends toassume a different pattern in different countries andthat this may account for the varying results withB.c.G. In his opinion, however, the Scandinavian workershave made out a good case for B.C.G. trials. Some con-sideration should also be given to the vole bacillus.The vaccine prepared from this organism is more stable-and more potent than B.c.G. It is essential that oneperson should be responsible for preparation of thevaccines, and the statistical records should be abovereproach. The vaccination must be truly intradermal,and he has found no enthusiasm in Scandinavia for thescarification method.

Dr. DAVID NABARRO, who in the early days of B.c.G.made some preliminary investigations at the Hospitalfor Sick Children, Great Ormond Street, did not agree-