393

anatters of congratulation are the reorganisation by Dr.J. E. McCARTNEY, appointed director last year, of thepathological services of the various hospitals which arenow to be grouped into two central laboratories, thatof the Northern Group being completed two monthsago. At the Queen Mary’s Hospital for Children anexperimental unit has been started to deal with36 girls and 24 boys suffering from rheumatic fever,acute endocarditis, or chorea, research work being now.in progress. At the Downs Hospital for Children an,artificial sunlight room has been fitted up for thetreatment of children suffering from ear disease,rickets, and debility. A veranda has been added tothe infirmary at White Oak for the use of childrensuffering from interstitial keratitis. The revised

dietary scale for children, which substituted butterfor part of the margarine allowance, has been in

operation for a year and is confirmed. These are asample of the ever progressive activities of theBoard’s medical staff, of which examples will be

given later at greater length.

MENORRHAGIA.EXCESSIVE bleeding at the menstrual periods is a

very common symptom, yet it is one for which, asoften as not, no really satisfactory explanation canbe found. Even the recognition of abnormal menstrualloss has its difficulties, for what is harmless and naturalin one woman may give rise to general ill-health inanother. Often, of course, an excessive flow isassociated with gross organic lesions of the generativeorgans, such as fibromyomata of the uterus, andhere the accepted mechanical explanation appearsadequate. There remains, however, a large majorityof cases in which no gross physical change can bedetected, and it was these especially that came upfor discussion at the Meeting of the Section of Obstetricsof the British Medical Association which we reporton page 378. Amongst them perhaps the most

interesting are the two forms of menorrhagia whichoccur, respectively, at puberty and in the second halfof the child-bearing period. In the last few yearsevidence has gradually accumulated that menorrhagiaof this kind is not due to abnormality of the uterusitself or of its lining mucous membrane, but rather toan excessive stimulus to menstruation which acts

upon them. Unfortunately, the nature of the normalphysiological stimulus to menstruation is not yet fullyunderstood. Presumably a chemical hormone is theimmediate agent, and the balance of evidence favoursthe view that this hormone is formed in the Graafianfollicle, though the corpus luteum and the interstitialcells of the ovary are both possible sources ; it seemsclear, too, that the other ductless glands, particularlythe thyroid and pituitary, have an important relationto the process.

Soon after puberty there appear examples of hypo-and hyper-secretion, recognised clinically as primary.amenorrhoea and menorrhagia of puberty, which arecomparable to the cretinism and hyperthyroidism dueto abnormal function of the thyroid gland. On thisanalogy very severe puberal menorrhagia might betreated by removing part of the ovary, though it isquestionable whether the results would be better thanthose of partial thyroidectomy for hyperthyroidism ;but, fortunately, nearly all cases of menorrhagia inyoung girls get better spontaneously, their cure oftenbeing hastened if calcium is administered, apparentlybecause the metabolism of calcium is rather intimatelyrelated to menstruation. Primary amenorrhcea is ofspecial interest because its treatment may throw lighton the mechanism of normal menstruation. It is

by no means a rare condition, but the published resultsof particular forms of treatment are very variable.Sometimes the administration of thyroid and anteriorpituitary extracts seems to have established menstrua-tion-cases were recently reported in our columns byDr. H. GARDINER-HILL and Dr. J. FOREST SMITH 1-but usually it has failed. An occasional success hasalso been recorded with various ovarian extracts. Itseems possible that in some patients the ovary onlyneeds a slight stimulus from the thyroid or pituitaryto establish its secretory function, but where thisfunction is wholly wanting the only hope lies in regularinjection of the appropriate ovarian extract. Unfor-

tunately, no satisfactory ovarian extract is at presentavailable ; doubtless the ovary supplies more thanone substance, and possibly these are mutuallyantagonistic.The other and larger group of cases of menorrhagia

-those which occur in the later part of the child-bearing period-is not so interesting from the physio-logical point of view, but clinically is of considerableimportance. In these women curettage often revealsa degree of hypertrophy of the endometrium whichmost pathologists consider to be definitely in excessof that found at any stage of the normal menstrualcycle ; but at the age when this condition is foundso many diseases may have left their mark on the

genital organs that the problem is greatly complicatedand probably no one explanation applies to all thecases. So far as investigation is concerned, it seemsto be most useful to assume that the ovary is at fault.It is conceivable that anything which causes a

thickening of its tunic may, by preventing ruptureof the follicles, prolong the period during whichovarian secretion is absorbed, and a few interestingcases are recorded in which ovarian grafts becamecystic and gave rise to severe menorrhagia becausethey were in a position where the follicles could noteasily rupture. Whatever the cause of the condition

curettage is usually only of temporary benefit-at theNottingham meeting Mr. COMYNS BERKELEY describedit as the commonest and most hopeless operation forhæmorrhage—and in the last few years radium andX rays have been more and more employed as remedies.The results, though variable, have on the whole beengood in so far as the menorrhagia is concerned, butmost patients are only cured by a dose so big as tocause sterility, and this risk should certainly not berun without profound consideration. Radium is

generally effective at first, but when it is used there isa tendency for bleeding to recur after an interval ofmonths, though this is by no means common ; X rays,on the other hand, may be some time in acting, buta successful result is likely to be permanent. This

suggests that radium has an effect on both endo-metrium and ovaries, whereas X rays act on theovaries alone. These methods are simple-perhapstoo simple ; they are relatively safe and their adminis-tration causes the patient very little inconvenience,but they cannot be considered altogether satisfactory,for the ideal of cure must always be the re-establishmentof normal function. In this they fail, for sterility isthe rule, and too often the symptom treated is replacedby the complex of the menopause. Improvement intechnique may lead to better results, but the veryway in which X rays and radium act suggests diffi-culties, and a far more useful therapeutic agent wouldbe the chemical inhibitor of menstruation. Thecorpus luteum appears to produce such a substance,but efforts to extract it have so far failed.2 At

1 THE LANCET, July 31st, p. 219.2 A. S. Parkes and C. W. Bellerby: Journal of Physiology,

August 6th, 1926.

394

all discussions of uterine haemorrhage the needfor a standard nomenclature becomes evident. Theterms proposed by Prof. BECKWiTH WHITEHOUSE weregenerally approved at the Nottingham meeting,and we take this opportunity of drawing attentionto them.

Annotations.

THE CINEMA AND THE CHILD.

" Ne quid nimis."

IN his annual report to the County Borough ofCroydon Dr. H. P. Newsholme makes some importantsuggestions concerning the influence of the cinemaupon character formation in the child. Hitherto thisinfluence has been considered as affecting the consciousmind of the child, but Dr. Newsholme believes thatthe circumstances in which the film is seen-thedarkness ; the quiet ; the sense of expectancy amonga crowd intent on the same object; the concentrationof the one active sense, sight, on a very bright clearlydefined patch of flickering light-all favour an actualhypnotic condition, particularly in the introspectivetype of child. The emotional content of the filmmessage may thus become sunk in the subconsciousmind, to affect the reactions of the child in the manyways that such buried material is known to do. Asan illustration he notes the case of a girl, alreadysensitive, introspective and backward, who saw afilm of high " artistic " merit depicting scenes ofwar and desolation ; from the moment of seeing thefilm she presented a fundamental alteration ofcharacter involving periods of extreme mental con-fusion amounting almost to stupor. She is now undertreatment, and it may be noted that modern methodsof treating a patient of this kind, if she is accessibleto mental exploration, should establish and accountfor the connexion between the picture story and themental state that ensued upon seeing it. It is, infact, the function of psychopathologists to bring sucha hypothesis as Dr. Newsholme’s to the test of

experience. The effect of the cinema has not escapedthem, for it has been noted that the cinema has apossibility of stimulating so many unpleasing emotionsthat it serves as a touchstone to morbid anxiety. Thedarkness, the crowd, the confinement, and theemotional stimulus of the pictures themselves rarelyfail to find a weak spot in the anxiety patient, whotherefore usually avoids them. If an individual childis an actual or potential sufferer from morbid anxietyit does not require a hypnotic condition to produceresults which the adult sufferer , wise in his generation,has learnt to avoid.

It is probable that whatever harm is done by thecinema is on the unconscious rather than the consciousplane. Suggestions which are recognised are satis-factorily dealt with in consciousness-one may doubtwhether the portrayal of crime does more than deter-mine the manner of its performance by a personalready disposed to it. But the ill-effect of ’’

sugges-tive " films, perhaps allowed in the trustful beliefthat the child will not understand, can arise in thevery lack of understanding, for they may stir up thatcompound of shame, fear, and curiosity which sooften exists in the childish mind. At a deeper levellie unconscious tendencies that are beyond thepurview of those who recognise only the world ofconsciousness, and if the censoring of films wereentrusted to someone with psycho-analytical know-ledge it is probable that a good deal would be excludedwhich now escapes question. Themes of cruelty, forexample, or of dominance or submission, would besuspect through the danger, by a blend of fear andfascination, of stirring up sleeping dogs that mightnever give trouble if left undisturbed. The popularityof the film depends upon the ease of its emotionalappeal as compared with the appeal of the written or

spoken word, and it is a sound principle in child-training to allow adequate and useful expression toemotion whilst avoiding unnecessary or excessivestimulation. The problem of the nervous child involvesas much unhappiness and inefficiency as does thatof the delinquent child, and the dangers of the cinemalie more in the nervous results of excessive stimulationthan in any incentive to delinquency. Dr. Newsholme’sessay upon the psychopathology of the films, whichhe feared might be regarded as remote from the matterproper to a school medical report, thus has a practicaland immediate bearing upon the well-being of the child.

OPHTHALMIA NEONATORUM.

THOSE who study the Registrar-General’s returnsfrom week to week will have seen that hardly a,

week passes without 100 or more cases of ophthalmianeonatorum being brought to the notice of sanitaryauthorities in England and Wales, and hardly anyannual report of a county health officer fails to recordpermanent impairment of vision in one or both -eyesof some of the children thus notified. During lastyear 186 new-born babies suffering from ophthalmiawere admitted to St. Margaret’s Hospital from themetropolitan area, of whom 10 died, 4 becamecompletely blind in one eye, and 20 others were left withimpaired sight, and this in spite of every advantageof skilled medical attention and nursing. TheScottish Board of Health two years ago, in callingattention to the serious amount of blindness stillbeing caused by this disease, stated that in theiropinion few if any cases could be treated at homewith safety. The Scottish health officer was advisedto ascertain through his health visitors or visitingnurses the progress of these babies from day to day,in order that hospital treatment should be commencedas soon as the disease showed any tendency to becomeserious. In London only about one-third of thecases notified reach St. Margaret’s Hospital, and on theaverage not until the ninth day of the disease whencorneal ulceration may already have developed. Ata representative conference held in London four yearsago it was agreed that one of the factors leading todelay in treatment was the dual control of midwiveswho are at present required to notify the case to theborough medical officer of health (when they believethat this has not been done by a medical practitioner),and also to inform their own supervising authority.The circular1 issued last week by the Ministry ofHealth states the decision of the Ministry to placethe duty of notification solely upon the medicalpractitioner in charge of the case. Under the newarrangement the midwife will only have two duties ;on observing any inflammation of or discharge from theeyes she will, first, call in a medical practitioner and,secondly, will send word to her immediate supervisorin the midwife service-namely, the county medicalofficer. Here her statutory responsibilities end. Onbeing summoned to see the child it is the duty of themedical practitioner to consider whether the case isor is not one of ophthalmia neonatorum. If hisdiagnosis is negative he need not notify anyone, butthe public authorities will nevertheless be aware ofthe case because the midwife has informed the countymedical officer (in the capacity of her supervisor)that the eyes were sore and that she called in adoctor to see them. On receiving this informationthe county medical officer, besides taking steps tofind out whether the midwife ought to continue herwork, will also arrange-either directly or through thelocal medical officer of health-that the resources ofthe child welfare service shall be available in case ofneed. The officer in charge of child welfare will send

: a health visitor to visit the home and ascertain the.

conditions there, and will communicate with themedical practitioner so as to find out whether nursing

. or other assistance may be wanted. This somewhat: complicated circle thus comes back to the practitioner,

1 Ministry of Health, Circular 617 (London), 617 A (OutsideLondon). H.M. Stationery Office. 2d.