177

weakness and skin eruptions, and has been known toevoke nausea and vomiting and psychosis, and evenoccasionally collapse and exfoliative dermatitis is not

likely to commend itself to British clinicians, who preferto feel comfortable about the drugs they use, and if

possible to know that their patients are feeling comfort-able too. Moreover, individual response to the drug isuneven, the optimum concentration in the blood beingproduced by very variable dosage, and there seems to beno means of detecting the susceptible individual exceptby repeated estimations of the blood thiocyanate.

INFANTILE DIARRHOEA AND VOMITING

IN the closing years of last century the death-rate frominfantile diarrhoea in England and Wales was about 0-7per 1000 of the population. Before the present war ithad dropped to about a tenth (0-08 in 1937, for example).For this amazing fall various factors are given credit,ranging from the advent of the motor-car, which led to

’the disappearance of manure-laden streets in cities, tothe spread of education in mothercraft by the welfare-clinic movement and the vastly increased use of driedmilk. But acute gastro-enteritis still remains af menaceto infant life and health, especially during the firsttwelve months of life and there is much that is still

mysterious about this malady. In his Bradshaw lecturelast year J. C. Spence pleaded for a better organisedstudy of the infantile infections, and G. L. Ormiston’s 2work for the Medical Research Council on epidemicneonatal diarrhoea was a good example of the " field

survey " which is needed. Now R. M. Campbell andA. A. Cunningham 3 have reported on 574 infants withgastro-enteritis admitted to the Park Hospital, insouth-east London, between January, 1937, and August,1939. They use the term " alimentary-infectious com-plex " (or AIC) for their cases, for the series studiedwas a mixed one, being those infants with diarrhoeawhich remained after the exclusion of specific gastro-intestinal infections (including dysentery), local causes ofdiarrhoea, digestive disorders and the parenteral infec-tions or infectious diseases in which diarrhoea was aninsignificant symptom. There has been an attempt inrecent years to establish the doctrine that infantilediarrhoea is either an infection, usually acquired in hos-pital or some other institution, or else secondary to afocus of infection such as otitis media. Campbell andCunningham exclude the first by definition, so to speak,and show that only 30-5% of their 574 infants had any.evidence of parenteral infection on admission and clearlysuch infection was not playing a dominant part in causingdiarrhoea and vomiting in every one of these cases. Thus s

they were studying the ordinary " d and v " of the

hospital receiving-room. Nearly 80% of their infantshad developed the disease in their own homes, nearly70% were under nine months of age and more than halfthe cases began in the five months, June-October.

Only 18 infants, or 4-5% of those under nine months,were breast-fed at the onset of the illness and only 3 ofthese died. Anyone who advises the weaning of a baby onto a bottle-be he medical practitioner, chemist, nurse orlay relative-should realise that he is transferring it froma group in which the mortality from d and v is negligibleto one in which it is high. The fatality in the wholeof the Park Hospital series was 27-7%, but under ninemonths it was considerably higher-for the first three-monthly periods of life the rates were 52-2, 58.1 and62’7%. Age, in fact, seemed to be the most importantfeature in prognosis, but another emerging from thisseries is the degree of dehydration, for the death-rate in283 dehydrated cases was 53%, compared with only2’7% for the 291 non-dehydrated cases. In the words ofour forefathers the inelastic skin is 11 malum signum."This l>1Jd; 0 h>:p.l’v>I,tlon noint", +1io a-n- tin Trhot ia tpl"lY1Ml

1. Lancet, 1941, i, 777. 2. Ibid, 1941, ii, 588.3. Arch. Dis. Childh. 1941, 16, 211.

" the most important single factor in treatment "-therelief of dehydration. Campbell and Cunningham advisea starvation period, during which water should frequently.be given by mouth in small amounts and if parenteralfluid is not being given concurrently half-normal salineshould also be given by mouth. Glucose is later addedto alternate feeds and next a careful change is made to aseparated dried milk using small feeds at regular inter-vals. Parenteral fluid is best given, they say, by thecontinuous subcutaneous route, ringing the changesbetween normal saline, Ringer’s solution and 3% glucosein 0-25% saline. In severely ill patients this should besupplemented in the first twenty-four hours by intra-peritoneal or intravenous therapy. Great attention was

naturally paid at the Park Hospital-one of the London’County Council infectious diseases hospitals-to the

general ward management of these infants with diarrhoea.An open ward can only be used with a high risk of com-plications. Bed isolation is important, with free ventila-tion, damp or vacuum cleaning, and careful disposal ofsoiled linen. These measures have a, familiar ring inconnexion with the modern work on the prevention ofwound infection in hospital wards. Campbell and

Cunningham recommend " dilution " of acute cases byolder infants and convalescent cases, and also a systemof " feeders " and "

changers " which increases the

requirement of nurses but ensures that those responsiblefor the feeds are not also concerned with the toilet arrange-ments. Destructable squares are valuable for the acute.period of the disease and details are given of a system ofmovable bins and a general team for changing the babieswhich again has a familiar ring. ’ So also are the remarkson the possibility of infection .being conveyed by bathwater. Individual isolation accommodation is the idealmethod of dealing with these infants. Authorities are

apt to regard this as expensive, but until preventivemeasures, including a campaign for breast-feeding, areundertaken, the mortality from infantile diarrhoea is toohigh to allow expense to be used as an excuse for inade- ’ouate treatment.

DIRECT PHOTOGRAPHY OF ANTIGENS AND

ANTIBODIES

THE electron microscope, by extending resolvingpower to a practical limit of 50 Angstrom units, hassolved several of the structural mysteries of bacteriaand other minute bodies. It was obvious that the sameinstrument would sooner or later throw direct light notonly on structure but on ,mechanisms which hithertohad to be explained mainly by deduction and circum-stantial evidence. The lysis of bacteria by phage, theinteraction of colloidal gold particles with virus moleculesand the combination of virus with antivirus moleculesare a few of the biological processes which’ Americanworkers have already photographed. The electronmicroscope has now been used to demonstrate thecombination of antibodies with flagellar and somaticantigens.1 A good deal is already known about altera-tions in cell-walls and in flagella during agglutination ofsensitised bacteria and about the combination of anti-bodies with antigens at bacterial surfaces, but now thesechanges can be seen in electron pictures. From a

hundred measurements of prints of Bacillus subtilis,Mudd and Anderson compute that the mean diameterof the flagella of this organism is 186 ...:... 4 A, but so farthey have been unable to produce accurate values forthe flagella of Bacterium typhosum or Bact. pai-aty_phosu2)z.A, the other organisms studied. Their next step was tomake suspensions of B. subtilis, add specific antiseradiluted ten times with distilled water (saline producesundesirable crystals in this technique), staiid the mixturefor half an hour, and finally dilute it with 100 parts ofdistilled water before mounting. When the flagella

1. Mudd, S. and Anderson. T. F. J. Immunol. 1941, 42, 25.

178

were then examined they were irregularly thickenedwith many granules attached and the maximal thicknesswas 167 A greater than the original mean diameter.The interpretation of these findings is that there has.been a deposition of homologous antibodies on the

flagella which takes place unevenly and does not form acomplete film. Similar results were obtained whenmixtures of specific sera with Bact. typhosum and Bact.pa1’atyphosum A were examined. When, however, a

suspension of Bact. typhosum was mixed with a heterolo-gous serum the flagella were only faintly visible and thebacterial cells had sharply defined walls, whereas in

typhoid-antityphoid serum mixtures the cell-walls arefuzzy and appear to be surrounded by fine streamers.The loss of definition in cell-wall outline is explained bya deposition of antibody molecules along its margin.’Since the size of certain antibody-globulin molecules isalready known 2 it would appear that accurate measure-ments could show definitely whether the thickness ofdeposited antibody on an antigen surface was related tothe size of the antibody molecule. Something of thissort has indeed been shown with tobaeco mosaic virusmolecules and homologous rabbit antiserum.3 Thereare difficulties, because the antibody-globulin moleculesof rabbit antiserum are elongated and may arrangethemselves radially to the antigen molecules or they maylie flat against an antigen surface, the arrangementdepending among other things on the concentration ofserum. These observations are still at an early stage,but it seems probable that a systematic study of depositsand of the orientation and distribution of antibodymolecules on fine antigenic surfaces may yet explainsome of the puzzles of antigen-antibody reactions.

POSTURE AND SLEEP

MEN and animals have been so long at sleeping that weshould by now have recorded anyuniversalrulesgoverningthe attitudes of sleepers. Yet there is still disagreement

about the facts, as our correspondence columns haverecently shown. Dr. F. Schütz4 4 finds that different

sleepers take up characteristic postures, and seldom varythem. He notes the preference of patients with anginafor the left side, and has observed further that patientswith affections of the liver or gall-bladder include aremarkable proportion of people who habitually sleep ontheir abdomen. Dr. W. N. Leak 5 mentions that a

preference for sleeping on the left side, associated withnocturnal polyuria, may be a sign of mild cardiac

inefficiency ; but Dr. F. B. Parsons will have none of it,6and quotes the work of Johnson, Swan and Weigand asevidence that we have no fixed postures in sleep but tossabout far more than we think. Today Dr. Joah Batesweighs in (p.186) with a few brisk assertions from Adler.Johnson and his colleagues in America attached a pen tothe part of the bed which yields to the sleeper’s move-ments ; the pen wrote on a strip of moving paper and everygross movement of the sleeper produced a spike. Children,university students, 112 healthy people and 70 patientsin hospital were investigated by this tell-tale device,which showed that the average sleeper moved between20 and 45 times a night, the movements ranging betweensingle limb movements and complete changes of posture.Nevertheless 20 or 45 movements a night seem a lotto those of us who fancy we hardly stir, and the value ofthe experiment perhaps depends on whether the victimsknew the record was being made or not. The sleepingmind, if all they say of it is true, would not have beenabove tinkering with the record by spurring the dreamerto unwonted aetivitv. The American workers also took

2. Neurath, H. J. Amer. chem. Soc. 1939, 61, 1841.3. Anderson, T. F. and Stanley, W. M. J. biol. Chem. 1941, 139, 339.4. Lancet, 1941, ii, 774.5. Ibid, 1942, i, 26.6. Ibid, p. 91.7. Johnson, H. M., Swan, T. H. and Weigand, G. E. J. Amer. med.

Ass. 1930, 94, 2058 ; and see Lancet, 1930, ii, 198.

moving pictures of some of their moving sleepers, but astheir method entailed a 100 watt lamp over the bed, ataffeta bandage over the eyes and no blankets the sleepershad some excuse for kicking. Something may perhapsbe allowed for the temperament of sleepers, and heredomestic animals offer a fair field for experimentalobservation. Most cats are still sleepers, resting hourafter hour with limbs tucked away in flexion, and nothingbut the rhythmic bellows’ action to show the watcherthat the creature lives. Many dogs on the other hand arerestless hair-trigger sleepers, always on the brink ofwaking, haunted by strenuous dreams. If there is any-thing in the idea of physiological types humans maydiffer as much. A matron of a London hospital, askedto inquire into sleep and posture, set her night nurses towatch the patients. Those who had taken drugs, whohad raised temperatures, or who were immobilised byany surgical appliance were ignored and convalescentsonly were watched. The nurses found that sleepingpatients rarely made gross movements ; they actuallyturned over only two or three times in a night and theyhalf wakened to do that. It thus seems doubtfulwhether. Johnson and his colleagues have said the lastword about sleepers, at any rate about those on this sideof the Atlantic.

MENINGOCOCCAL OPHTHALMIA

OPHTHALMIA neonatorum with its purulent reactionwas at one time regarded as being exclusively due to thegonococcus ; but it is now known to be caused by variousorganisms, the staphylococcus being at least as significantas the gonococcus. Similarly, purulent conjunctivitisin children and adults also has a multiple 2etiology ; andin this the meningococcus plays a little-recognised part.Metastatic conjunctivitis, serous or purulent, may ofcourse develop in a patient with meningococcalmeningitis ; but the meningococcus may also be foundoccasionally in the conjunctival sacs of apparentlyhealthy people, and may sometimes give rise to a

primary meningococcal conjunctivitis. The infection mayproduce a serous or a mucopurulent response, or even apurulent conjunctivitis resembling that caused by thegonococcus. This happens seldom, judging by the

scanty-usually single-cases reported ; but it is prob-ably commoner than is generally believed, since on

superficial examination the gonococcus and the

meningococcus-both gram-negative diploeocei-areeasily confused. Acute purulent conjunctivitis due toeither responds well to sulphapyridine, but the differential.diagnosis is not altogether an academic exercise.F. Clifton and S. M. Laird have given a useful remiuder 1that purulent ophthalmia is an epidemiological as well asa therapeutic problem. The danger of an epidemic ofmeningitis originating from a purulent conjunctivitis,particularly under Army conditions, cannot be ignored.

MANY hospitals will remember the generosity of SirEDWARD MEYERSTEIN, a member of the Stock Exchange,who died last Sunday, for his gifts had a discerningquality. At one time it might be a radiological depart-ment, at another an athletic ground for the students, or a,swimming-bath for the nurses. To the Middlesex .

Hospital it meant the completion of a cherished buildingscheme.

1. Jour. R. Army Med. Cps, 1941, 77, 318.

MEDICAL HoNorrRS.—The Royal Naval Volunteer Reserveofficer’s decoration has been awarded to Surgeon CommanderJ. A. Kerr, M.D. Glasg., who in civilian life is MOH forGrimsby. The King has given permission to Dr. H. C.Sinderson to wear the insignia of the second-class (civildivision) of the order of Al Rafidain, conferred on him by theKing of Iraq. Dr. Sinderson is dean of the Royal MedicalCollege of Iraq.