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THE THREE R’s

Julian Huxley, in his foreword to a UNESCO reporton fundamental education,! quotes Lincoln’s words aboutthe nation half slave and half free being unable to stand,and emphasises that the same applies to a world inwhich half the people lack the elementary freedom of theability to read and write. Statistics show that illiteracyreaches vanishing-point in the countries of northernEurope (less than 1%), but in the British Army 20% ofrecruits during the war were found to be semi-literate ;Italy, Spain, Portugal, and Bulgaria have illiteracy-ratesranging from 27% to 55% ; Asia is fairly constant at80-90% (except for Japan) ; and Africa has the highestilliteracy-rate of all, from 90% to 98% among thecoloured people. As one might expect, the main featuresassociated with a high rate of illiteracy are mountains andother obstacles, poverty, and over-population.

Various attempts have been made by countries allover the world to increase the numbers of those who canread and write. France, for example, uses the Frenchlanguage as a political tool in helping to grant freedom tothe native people she rules. In the Union of South Africa,however, the technically trained coloured youth is up againstthe difficulty that only 1 in 100 stands much chance of

getting a skilled job. The fine plans of the Chinese govern-ment since 1927 to reduce illiteracy have been upset bythe eight years’ war against Japan ; but even so, the

expenditure of some of the district governments on

education has been as much as a third of the total budget.In India the chief physical difficulty is that only 15%of people live in towns or cities, compared with 79% inEngland and 51% in the U.S.A. Lenin’s words applyaptly to India : "An illiterate man is outside politicsand before he can be brought in he must be taught thealphabet. Without this there can be no politics-onlyrumours, gossip, tales, superstitions." Often the Indianasks : " Is it worth while for my children to beeducated ? " and decides in the negative. " Few Indiansthink education good in itself." Perhaps the most interest-ing section of the report is that dealing with the attemptsof the U.S.S.R. to educate its people ; some tribes hadnot yet emerged from primitive devil-worship and thevast mass were illiterate, though at the other extremethere were small groups of highly educated people.Russian is compulsory in all schools, but education iscarried out in ninety different languages throughout theSoviet Union-a remarkable attempt to keep alive thedifferent cultures of a vast land.The report points out that even in illiterate areas

ancient religions such as Islam, Confucianism, andBuddhism have preserved certain forms of education ;but these will not serve for today, despite the dangersof uprooting the old ways of life : history provides manyexamples of civilisations which have snapped from suddenchange in their culture. Writing from the standpoint ofthe anthropologist, Dr. Margaret Mead agrees that suchnativistic movements as the American Indian ghostdance and the revival of Celtic languages may be regardedas expensive drags on the progress of human culture;but she herself seems to disapprove of this view. Onthe major problem of language the report favours

simplification to ease translation from one to another.Sense aids such as films, records, radio, and maps shouldbe used where possible ; and emphasis is laid on offeringnot only the bare bones of literacy in a knowledge ofhow to read ; people should be taught also why theyread, and should be helped in deciding what toread.How far can the West, with its greater power, afford

to influence the Orient in fundamental education ? z?Did Britain keep India from sinking through apathy1. Fundamental Education : Common Ground for All Peoples.

UNESCO. H.M. Stationery Office. 1947. 7s. 6d.

and internecine strife, or will India, with the removalof Britain’s inhibiting influence, raise its standard of

living ? ’1 The report quotes an old African woman assaying : " You Europeans think you have everythingto teach us. If, as you say, we have been eating the wrongfood all this time, cultivating our fields and rearing ourbabies the wrong way-why, we’d all be dead. But yousee we are not."

EPIDEMIOLOGY OF CHOLERA

IN India upwards of 200,000 die of cholera each year ;and in China the figure is probably larger. This estimatewas made by Sir John Taylor at last Monday’s meetingof the epidemiology section of the Royal Society ofMedicine. Basically, he said, the problem of cholerais the problem of two endemic areas-Lower Bengaland the Yangtse valley. There may, however, be otherminor areas of endemicity. From India cholera isdisseminated by three principal routes. It may spreadvia Afghanistan to Persia and south-east Russia; butthis route has not beenfollowed for many yearsand it does not appear tobe now a major danger.Secondly, it may spreadvia Iraq and Syria ; and

Iraq has been infected

eight times in the presentcentury. Thirdly, it may CI)spread by the Red Sea to Egypt. The common

Q

source of infection inEgypt used to be the p rannual pilgrimage ; thiswas the cause of the1902 epidemic when

34,000 died. The pil-grimage was again in-fected in 1907, 1908, 1911,and 1912. Since then,however, it has not beeninfected owing to theeffectiveness of quaran-tine measures. Infection Cases and deaths in Egypt from... - , , Sept. 22. Afailing incidence wasis maintained by cases, reported last week (Times, Nov.4).convalescents, and close

contacts ; and steps to prevent spread must be relatedto the infectivity of each of these groups. The incubationperiod may be taken as about five days, so by the searoute a case infected in India will manifest itself before

reaching Suez. Patients excrete the cholera vibriofor about five days, though occasionally excretion maycontinue up to thirteen days ; close household contactsexcrete the organism usually for about five days, butoccasionally up to nine days. Convalescents and contactswill thus be clear by the time that Suez is reached;it is unlikely, moreover, that recent convalescents wouldpass the routine examination at the embarkation point.There remains, however, the risk of the missed case onshipboard. With normal air traffic there is no greatrisk of infection being introduced ; there have been sus-pected but no proved cases. Positive contacts might,however, arrive by air, and the present refugee trafficmay increase the risk. Even so there is little dangerthat infection introduced into this country wouldspread.

’

Sir Leonard Rogers, F.R.S., prophesied that the

Egyptian outbreak would now die down though it mightcome to life again next year. The real danger, he con-cluded, lies in the Punjab epidemic ; for there is graverisk that next year it may spread to Russia.

Public-health measures were discussed by Dr. MelvilleMackenzie, who said that surveillance was to be imposedon air passengers who had spent nights in Egypt. The

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sea passage took about two weeks, so imported food wasno problem. Some countries, he noted, were placingunreserved confidence in vaccination. For Egypt massvaccination, with material made in different countries

by differing standards, was a difficult undertaking;a universal standard was required.Mr. P. Bruce White described the work leading up to

the identification of the three types of cholera vibrio-original, intermediate, and variant. These types were,he said, variants of a single species ; but though theywere transmutable, mixed infections were not found.It was not absolutely certain that the vibrio was thecause of cholera : in some epidemics only non-agglutin-able vibrios were isolated in about 30% of cases. Hehad been impressed by the consistent absence of labora-tory infection. Did the vibrio lose some virulent factorin culture ?

"CORRECTIVE EXPERIENCE"

VERY few doctors now deny that more or less expertpsychological treatment is necessary for some patients :controversy has shifted to the choice of method and theright solution to the problem created by the cost andlengthiness of psychotherapy. Psycho-analysis, to takethe salient instance, could never be afforded to the

majority of neurotic children and adults (even if it wereof proved efficacy in making them healthy) unlesswe came to regard it much as we regard education orthe water-supply. Recognition of this dilemma hasled on the one hand to energetic experiments in grouptreatment-taking a leaf out of education’s book-andon the other hand to efforts to shorten ’psychotherapywithout emasculating it. Among psycho-analysts, abbre-viated or simplified treatment has had short shrift sincethe defection of Adler and Stekel, the ill-starred attemptof Ferenczi, and similar misadventures caused anythingbut " full " analysis to be classified with hypnosis,persuasion, and other-more or less despised-alterna-tives to the rigorous analytic procedure. An enterprisingschool of analysts at Chicago led by Dr. Alexander haveof late years had the courage to challenge this, and theirstandpoint and achievements are clearly stated in a

collective report,! Its keyword is "

flexibility " : so

much so, that at the end of his introduction Dr. Alexander

says roundly that few if any cases require strict adherenceto standard psycho-analytic technique throughout theircourse of treatment. He attacks as doctrinaire andharmful the standard assumptions about the importanceof infantile happenings in determining later neurosis,and the orthodox refusal of analysts to advise the patientabout his daily life. Psycho-analytic treatment hassometimes been unjustifiably prolonged, he holds, andinterviews have been too frequent; too much emphasishas been laid on recovery of forgotten memories, whichis not essential to recovery-" merely remembering anintimidating or demoralising event does not change theeffect of such an experience, only a corrective experiencecan undo the effect of the old. This new corrective

experience may be supplied by the transference relation-ship, by new experiences of life, or by both."Such challenges to widespread psycho-analytic practice

and theory would have little weight with orthodoxanalysts unless supported, as they are here, by case-records and respectable analytic experience. Dr.Alexander and Dr. French hold, with some justification,that their methods are a logical continuation of thoseinitiated by Freud’s discovery that the " transference "is the dynamic agent of the curative process. The testof good treatment, however, does not lie in historicalcontinuity or doctrinal soundness, but in the number ofpatients who are made well ; and on the information

1. Psychoanalytic Therapy : Principles and Application. ByFRANK ALEXANDER, M.D., and THOMAS MORTON FRENCH,M.D., with staff members of the Institute for Psychoanalysis,Chicago. New York : Ronald Press. 1946. Pp. 353. $5.

given the Chicago psychotherapeutic methods seem tostand this test. The work described is important notonly to psycho-analysts but to psychiatrists generally,and especially to those concerned with deciding howthe people who need. psychotherapy may get it in aNational Health Service.

CHEMOTHERAPY OF CANCER

To anyone with experience of malignant disease, itis astonishing to see the melting away and total disap-pearance of a tumour as the result of X-ray treatment.The figures for cure by radiotherapy of cancer of thebreast, cervix, and anterior portion of the tongue,which equal those achieved by surgery, have inspiredradiologists and surgeons to investigate the laws governingthis destructive capacity and to adapt the physicalmeans to these laws.

That the treatment of cancer by chemical methods isequally worthy of further’ study was shown by lastweek’s meeting of the Royal Society of Medicine’ssection of medicine. Prof. Alexander Haddow remindedhis listeners that to sceptics attempts at chemotherapymight seem absurd, since the cancer cell was only amodified form of the normal ; the malignant cell wasstable and there was no real evidence of reversibility.The real difficulty was to overcome the energy barrierbetween the two states ; the difference was not struc-tural. By oestrogens, urethane, and P-chlorethylaminecancer might be controlled or modified, though not cured.It was noteworthy, Professor Haddow said, that the valueof these drugs had been appreciated thanks to observa-tion for its own sake in man ; their effectiveness wouldnot have been guessed from animal experiment alone.

Mr. E. W. Riches reported that 90% of his cases ofprostatic cancer treated with oestrogens showed signsof response : 87% were alive at the end of one year,29% at the end of two, 19% at the end of three, and 5%at the end of four years. If metastases appeared duringtreatment, the dose should be increased ; side-effectswere not an indication for stopping treatment. Dr.Edith Paterson referred to the use of urethane inleukaemia. Its effect, she said, is similar to that ofX rays. In myeloid leukxmia the cell-count is reducedand the haemoglobin increased ; and in both myeloidand lymphatic leukaemia cell differentiation appears tobe increased. Mr. Eric Boyland, D.sc., urged the need forfurther trial to establish the dosage of chemotherapeuticagents ; it would be wrong to follow blindly the dosageadopted in the original trials. Using (3-chlorethylaminefor the treatment of the reticuloses, Dr. Jean Watkinsonhad observed symptomatic improvement only in Hodg-kin’s disease. Dr. 0. H. Warwick spoke of the sympto:matic relief obtained by the treatment of bronchogeniccarcinoma with nitrogen mustards.

That the interests of the patient must be the firstconsideration in the choice -of treatment-whether bysurgery, X rays, medical care alone, or one of the newerdrugs-was apparent from each speaker’s testimony.One expressed the view that the price, in suffering,for mere palliation may well be too great. ProfessorHaddow deprecated any attempt at assessment of thevalue of chemical treatment at this stage, claiming thatthe observations ought to be pursued for their ownsake. It is clear, however, that the eestrogen treatmentof prostatic cancer has already justified itself, if onlyby reducing (as Mr. Riches demonstrated) the alarminglyhigh mortality in the first year of disease.

B.M.A. NUTRITION INQUIRYTHE council of the British Medical Association has

decided to appoint a committee to consider ° problemsof nutrition in this country, including current nutri-tional standards." The membership will be announcedshortly.