782

is relatively acid, is less likely to support bacterial growththan normal saline or Hartmann’s fluid with 5% glucose ;but their finding is none the less important.On page 775 Dr. Bull and Mr. Hurst report that they

investigated cases of unexplained pyrexia after trans-fusion, and they give evidence that accidental infectionis a possible hazard of transfusions assisted by air-

pressure. Apparently the bellows of a pressure-trans-fusion apparatus regularly become contaminated withsmall quantities of transfusion fluid, and this permits thegrowth of a variety of bacterial species including Pseudo-monas pyocyanea. Bull and Hurst describe a simpledevice which prevents infection from this source

by filtering the air from the bellows through a

U-tube containing a wad of dry cotton-wool in eacharm.

These different reports clearly emphasise that variousforms of treatment as now administered in the wards of

hospitals need to be carefully overhauled, because thereis little doubt that some of them constitute potentiallydangerous sources of infection. The first requirement ofany treatment is that it should not do harm, and it isa grave reflection on all concerned when accidentalinfections in hospital cause avoidable suffering and evenloss of life. Because of our increased control over manycommon infections there is a possible risk that we maygrow forgetful and perhaps even contemptuous ofbacteria.

DOCTOR AND CAMERA

PHOTOGRAPHY has been used in medicine for morethan a century ; but only in recent years have we

begun to appreciate how much the camera can help us.An exhibition this month at the Royal PhotographicSociety’s house in Kensington surveys the century’sprogress and makes it clear that this has been most

rapid in the past fifteen years. For instance, close-uppictures of the eye, and colour photography of the livingretina with snapshot exposures, have only been satis-

factorily achieved since 1939. Techniques for endo-vesical and intraperitoneal photography are post-wardevelopments, exemplified in a fine colour-print of a

nodule of regenerating tissue on the surface of a livingsyphilitic liver.The main function of photography is simply to record-

for example, the changing pattern of skin lesions, therepair of defects by plastic surgery, and the follow-

up of a case. The exhibition includes a series of picturesshowing a patient in 1905 before removal of his cerebellartuberculoma, and as he is today, together with picturesof the pathological specimen and its histological section.There is also a panel of smallpox cases with views ofthe floating hulks on the Thames off Deptford whichused to be an isolation hospital, which teaches a good dealof value in public health as well as illustrating a diseasethat is now uncommcn. But photography is also an

important research technique. Infra-red pictures will

display the invisible subcutaneous venous network ;and photogrammetry will record growth and physicaltype for somatotyping and other anthropometricstudies.As the techniques have grown so have the numbers of

specialists, and now over 300 medical photographersbelong to the Royal Photographic Society’s medical

group, which was founded in 1946. There are, however,still many hospitals and many doctors, even in researchdepartments, who have no inkling of what the medicalphotographer can do to help them. The present excellentlittle exhibition is composed largely of portable panels,and could go on tour to medical schools. Perhaps theorganisers will consider how they can circulate their

show, if only in part. Photography is a part of thescience of Light, and should not be hidden under abushel.

DESERTED CHILDREN IN FRANCE

IN France the task of saving and rearing childrendeserted by their parents, begun in the 17th century bySt. Vincent de Paul, has been faithfully pursued by latergenerations. His plan of placing the newly born withcountry foster-parents is still sound ; and, though theinfant mortality among these foundlings was at firstvery high, the centuries have seen a steady improvement.Marcel Lelong 1 notes that of 55,000 newborn childrensaved between 1790 and 1802, some 31,000 died. Up to1862, when receiving centres were set up, children werestill being left on the turntables set in monastery doorsfor the purpose. In 1874 medical supervision of foster.children was started and in 1926, in the Departement dela Seine, the Pouponniere d’adoption-giving the newlyborn residential care in a crêche—was established,working in conjunction with the centres for approvedwet-nurses. In this department the neonatal mortalityamong children in the care of the Assistance Publique(A.P.) is now lower than the average for the country as awhole.

The numbers of deserted children coming under thecare of the Seine A.P. have fallen considerably in thecourse of time (from 7676 in 1772, to 5026 in 1900, 3477in 1920, and 758 in 1946) ; but a change-presentingserious problems-has taken place in the age-range ofchildren deserted. In 1900 more than half the childrenwere under the age of 3 months, and two-thirds of themunder the age of 2 years ; in 1949 only about 5% wereunder 3 months, nearly half were over the age of 6 years,and some 15% over 14. Concurrently, the numbers ofchildren confided temporarily to the care of the A.P.have risen steeply-from 3307 in 1880 to nearly 12,000in 1952. This has been partly due to a humane inter-pretation of regulations : the A.P. will accept childrenbrought in at any hour of the day or night. Not all ofthem come from the Seine area-some are from overseas,from distant or neighbouring departments, or from otherEuropean countries, and many of them are children ofrefugees or displaced persons passing through Paris.About 70% belong to normal families temporarily indifficulties and unable to look after them, and thesechildren usually rejoin their parents within threeweeks.The decline in the numbers of babies under 3 months is

said to be leading to a gradual disappearance of would-beadopters. Many of the older children have been pro-foundly affected by their experiences, which often includea broken home, immoral or delinquent parents, andsometimes a personal experience of sexual assault or

incest. Small wonder that they are often abnormal-vagabonds, potential delinquents, or at the very leastsocially maladjusted. Children with such a background,as we know from our own experience, are not reclaimedin a moment ; but many of them do respond to sym-pathetic handling in secure surroundings. But Frenchchildren of this kind suffer a further devastating blow.As soon as the A.P. undertakes their permanent care, aprocess is started to secure their legal separation fromtheir parents. Months pass before the judgment is given,and even when it has been passed the parents retain theright for three years to ask that it shall be reconsidered.The whole process is extremely painful and damaging toany child who is old enough to know he is being cast oft,or-as he more often imagines it-cut off by tyrannicalauthorities from parents who want to keep him. More-over, he is thus artificially made into an orphan at anage when adoption can no longer be expected, and whenreadjustment is at best difficult to achieve. The olderchildren rebel against the judgment, and resent all

attempts to place them with foster-parents. Theyremain a charge on society and ultimately a danger to

1. Bull. Acad. Méd. Paris, 1953, 137, 40.

783

it, for they refuse to adjust to anything but their originalmilieu, to which they are always seeking to return. The

younger ones form fantasies about their lost parents, andsooner or later develop such signs of instability as

anxiety, truancy, aggressiveness, or antisocial behaviourof various kinds. On Jan. 1, 1951, there were 27,263children in the care of the Seine A.P., of whom 12,591were under tutelage and 14,772 under protection or

confided to care-that is, still having a real or fictitiouslink with their parents.

It is interesting that in his proposals for relieving thisgeneral situation Lelong does not suggest any changein the law which requires this damaging severance of theparental tie. On the contrary, he favours the separation,though at a much earlier age. A child, he says, certainlyneeds a mother, but it does not particularly matter whatmother he has ; and to force a mother to take back achild whom she has abandoned, when she has neither thematerial goods nor the moral qualities to bring him upproperly, is not a sound solution. - He deprecates thosesocial services which enable a French mother to retainher child while he is an infant, only to discard him whenhe is older. " Material aid to a mother is illusory whenthat mother is unfit to fulfil her role." This runs counterto current opinion in this country, where we are findingthat even a feckless mother may contribute something toher child’s development which a deputy, unless highlydevoted, finds it hard to supply. Lelong’s solution to theproblem is an extension of the idea of family placement.He would have the children boarded out with foster-parents or in residential homes where family groups ofchildren of various ages can live under the care of a house-mother. Children would be placed from disposal centres,and would attend clinics for medical supervision and(if necessary) child guidance ; social workers would alsovisit the homes. The older children, he suggests, shouldlive in a " children’s village," specially built in thesuburbs and consisting of a cluster of

"

family-group "

residential homes, and equipped with its own school andschool-teachers. This again runs counter to Englishexperience : we find that children in such homes do bestwhen their house is one of an ordinary row, and they goto the local school and join in the life of the neighbour-hood. Separation from parents and segregation fromordinary families are ostracising techniques, designed-it almost seems-to make these deprived children feelacutely, and resent, their difference from ordinarychildren.

1. Yap, P. M. J. ment. Sci. 1952, 98, 515.

LATAH

THE study of such exotic mental abnormalities as

latah and amok has hitherto been left mainly to

physicians interested in tropical medicine, to generalpractitioners working in Eastern countries, and to anthro-pologists and other non-medical observers. Now a psychi-atrist, Dr. P. M. Yap, lecturer in mental diseases atHong-Kong University, has surveyed latah and relatedtonditions.1

Yap regards latah as a psychogenic reaction to a

sudden stimulus, mainly to fright, with some hysteriformfeatures, yet distinct from hysteria. The patients,usually middle-aged women, are strongly influenced intheir behaviour by their low level of civilisation ; latahis a kind of primitive response of the rural illiterate and,perhaps, senile persons with little power of adaptation.The first symptom is a sudden start sometimes followedby a short stupor, echolalia, echopraxia, automaticobedience, uttering of obscenities, and possibly " decom-position of speech." Some patients seem to enjoydemonstrating their symptoms, and others seem to

provoke stimulation by inviting to be tickled, whichleads to the peculiar behaviour. The patient may be abutt or joke of the village, and in its milder forms the

condition is not regarded by the natives as grosslyabnormal or morbid. In the more severe cases the patientmay struggle against the paroxysms, which fill her withanxiety or anger.

All this is very difficult to place in any one psychiatriccategory. Yap attempts to group the obvious psycho-logical release of the syndrome with the echo-symptomsand the shameless and coprolalic behaviour occasionallyarising in women, apparently caused by organic deteriora-tion. He seeks to relate latah to the culturally simplesociety in which the patients live ; and he compares itwith reflex-like fright reactions observed in Germansoldiers in the first world war. This is by far the mostcomprehensive account of latah, which, though a rela-tively harmless peculiarity of elderly women in remotesocieties, should arouse special interest since it seems tobecome rare with the intrusion of the Western mode oflife.

1. Chaves, A. D., Abeles, H. Amer. Rev. Tuberc. 1953, 67, 45.

ENLARGED HILAR GLANDS

WITH the introduction of mass miniature radiography,more cases of asymptomatic enlargement of the hilar

glands are being discovered. The people affected arecommonly young adults, and students and nurses areoften among them. Enlarged hilar glands can usually beidentified as smoothly rounded shadows projecting intothe lung fields, causing enlargement of the normal hilarroots. Occasionally enlarged glands in the carina cause abackward displacement of the barium-filled oesophagus atthis level. But it is sometimes hard to decide whether

enlarged hilar shadows are due to dilatation of the

pulmonary artery or to glandular enlargement. In thesecases a single tomographic cut through the plane of thecarina may show the glands situated in the bifurcationof the main bronchi and distinct from the pulmonary-artery shadows.

In generalised diseases of the lymphatic system, suchas the leukaemias and Hodgkin’s disease, the intrathoracicglands are sooner or later involved ; indeed, the first

symptoms may be caused by pressure of the glands onthe bronchi. In Hodgkin’s disease the mediastinal groupsare not infrequently the first to be involved. As well asthe part they play in the primary complex of tubercu-losis, enlarged glands also appear in sarcoidosis and thepneumoconioses, and sometimes in atypical pneumoniaand in lobar pneumonia in young children. And of coursethe segmental glands draining a peripheral carcinoma ofthe lung become enlarged by lymphatic spread. Involve-ment of the mediastinal glands may be seen in acuteinfections, such as glandular fever, german measles, andwhooping-cough, and it can also occur in scarlet feverand systemic fungus infection. It is important.to remem-ber that the enlargement of the glands may persist for aconsiderable time after the infection has subsided.

When enlarged hilar glands are found by routineexamination of a patient who has no symptoms, a

thorough search may in the end show no definite evidenceof the cause. Biopsy of suspicious superficial glands,however, may identify the disease ; and blood-counts,the Wassermann and Mantoux reactions, and the histo-plasmin and Kveim tests may also help. Broncho-scopy is often necessary to exclude carcinoma of the

lung.Chaves and Abeles have now followed up for periods

of from 1 to 9½ years twenty patients with asymptomaticenlargement of hilar glands for which no cause could befound. The enlargement subsided in every case, and thetime it took to do so varied from 4 to 16 months. Onlyfour of the patients had a positive Mantoux reaction, andin this group the glands took longer to subside than inother patients. The two patients with the greatestglandular enlargement had negative Mantoux reactions.Examination of the blood showed no abnormality, and