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Annotations

MEDICINE IN THE ROYAL NAVY

FROM the first volume of the official history of the

Royal Naval Medical Service in the late war,l we learnsomething of this service’s vast administrative responsi-bilities. The book contains excellent accounts of theinter-war period ; of the problems of a sudden, extremeexpansion of medical, dental, and nursing personnel,establishments, supplies, and transport ; of the coincident

development of the Naval Air Arm ; of immense commit-ments in preventive medicine ; and of cooperation withthe other medical services, the new Ministries of Supplyand War Transport, the Central Medical War andMedical Personnel (Priority) Committees, and theMedical Research Council. Perhaps the most valuableaccount for future reference is the anonymous one onthe blood-transfusion service, with its comprehensiverecords. The book’s balance and perspective are thoseof a history, the medical picture being placed within thegeneral naval framework. It is not intended for detailedreference, and those who consult an individual sectionwill be disappointed.

The editor has given unity to the work by maintaininga cheerful, good-natured style throughout, and thereader is lulled into the pleasing belief that tout

compre-ridre, c’est tout pardonner. But the nation whichhas paid for this official history was entitled to a moreself-critical approach. Great changes are evidentlyneeded, yet this work does little to advocate them :it suffers from the limitations of an autobiography,with the added restraints of naval discipline, loyalty,and, as regards research, security. Happily the factsare recorded, and the reader who retains his criticalfaculty will be able to detect various mistakes of policybesides the few which are prefaced by " it is a matterfor regret," or summarised as

" some slight difficulty,"

or glossed over as " unfortunate but inevitable." It

is, however, easy to miss the brief statement on p. 184that " the casualties caused by preventable diseases farexceeded the casualties due to weapons." Their Lordshipsemployed medical personnel lavishly, but not alwayswisely. The nation may well ask the Board of Admiraltywhy only one out of eleven hospital ships acquired forthe war was selected in consultation with their medical

department (p. 113), and why this department waiteduntil after the war to assess the value of these shipsin which staff and stores were so often immobilised

during repeated adaptations. But this section closes

merely with the comment that it is more fitting to praisethe medical personnel than to condemn the organisation.

Careful scrutiny of this volume reveals frequentevidence of the need for the Board to consult andconfide in their medical department more completely, forthis department to be better integrated into the Service,and for its requirements to be given a higher priority.

1. History of the Second World War: The Royal Naval MedicalService. Vol. I.: Administration. Edited by Surgeon Com-mander J. L. S. COULTER, D.S.C., R.N. H.M. Stationery Office.1945. Pp. 512. 50s.

2. Evang, G. Eugen. Rev. 1953, 45, 247.

THE UNITED NATIONS AND WORLD POPULATION

IN a recent review 2 Dr. Evang, the director-general ofthe Norwegian Public Health Service, sketches a back-ground for the conference on world population which theUnited Nations is holding in Sweden next September.The secretary-general of the United Nations is inviting,in their individual capacity, experts nominated bygovernments, by various scientific organisations, and bythe specialised agencies W.H.O., F.A.O., UNESCO, andI.L.O. Topics for discussion will include mortality andfertility trends, with special attention to areas of lowerdeath-rates and of high death-rates ; international

migration ; population in relation to national resourcesand agricultural development, and in relation to capitalformation, investments, and employment; social aspectsof population changes ; and methods of demographicmeasurement.

Dr. Evang has been a leader in the demand that theincrease in world population should be considered bothas a medical problem and as one requiring internationalstudy. As head of the Norwegian delegation to theFifth Health Assembly last year he put forward a resolu.tion inviting the director-general of W.H.O. to " establishan expert committee to examine and report on the healthaspect of this problem." Though this gained some

support, a counter-proposal " that from the purely

medical standpoint population problems do not requireany particular attention on the part of W.H.O. at thepresent time " was strongly pressed by many countries-notably those with a large Roman Catholic population-and the matter was dropped. Clearly, with this divisionof opinion, any international conference must be limitedto individual experts and cannot contain governmentrepresentatives or delegates. Dr. Evang argues that thereis little sense in saving millions of lives through combatingdisease, if the survivors are to die from hunger or livethe miserable life of undernutrition and malnutrition." Death control must be balanced by birth control" isthe sum of his plea.

1. See Lancet, 1952, ii, 970.2. Hammon, W. M., Coriell, L. L., Stokes, J. jun. J. Amer. med.

Ass. 1952, 150, 739.3. New York Times, Feb. 23, 1954.

GAMMA-GLOBULIN IN POLIOMYELITIS

IT is little more than a year since we welcomed 1

the news that, in a carefully conducted trial by Hammonand his colleagues,2 gamma-globulin had shown a slightbut significant protective action in poliomyelitis. Buta recent report 3 suggests that things are not turningout as well as everyone hoped. A committee of theU.S. Public Health Service, meeting at Atlanta at theend of January, examined the effects of mass inoculationswith gamma-globulin in the summer of 1953, and theyconcluded that there was no evidence of any beneficialresults. In most of the cities where gamma-globulinwas used, the inoculations were performed after the

peak of the epidemic had passed, so there was littlechance of demonstrating any modification in the courseof the epidemic. Gamma-globulin was also given to"

family contacts " of recognised cases ; but the numberof subsequent paralyses in these households was not

significantly reduced, nor was there any measurableeffect on the severity of the paralyses. It was felt,therefore, that more experience and investigation wouldbe needed before the efficacy of gamma-globulin couldbe assessed. -

Why did the results of the 1952 and 1953 trials differin this way ? ’? For one thing, in the 1952 trial, controlswere injected with gelatin solution, whereas last summeruninjected people were used as controls. Hammonet awl. appreciated the possibility that inoculation ofgelatin, like that of many other substances, mightprovoke paralytic poliomyelitis in certain cases, and sogive gamma-globulin a false reputation for protectiveaction. Moreover, the conditions of the two trials werevery different, and it is possible that a small effect ina population under careful observation might not benoticeable in a larger and more heterogeneous populationin which the risk of exposure to virus was very variable.Whatever the explanation, the results are disappointingand they will strengthen the doubts of many people inthis country who already thought that the widespreaduse of gamma-globulin in poliomyelitis was impracticable.On the other hand, in the United States, plans are

going forward, and the president of the National Founda.tion for Infantile Paralysis has announced 3 that three

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million doses of gamma-globulin will be available formass inoculations this year, compared with one millionlast year; and an unusual position may conceivablyarise in which the supply of gamma-globulin exceedsthe demand. In view of these developments, the vac-cination trial 4 which the National Foundation is carryingout this year becomes more important than ever.

Approximately 500,000 children are being vaccinatedwith an inactivated tissue-culture vaccine to see whetherit will protect them against paralytic poliomyelitis.

4. See Lancet, 1953, ii, 872.5. January, 1954, p. 10.6. See Lancet, 1952, i, 651, 664.

THE MENTAL HEALTH RESEARCH FUND

MENTAL health has seldom been a warmly favouredchild of those who disburse research grants ; andthe demands on the Mental Health Research Fund,founded in 1949, are likely to be great and growingfor many years to come. What it has done already,and what it hopes to do, are set out in the current issueof the Journal of Mental, Science.5Careful thought has been given to the lines on which

it should develop. A conference held at Oxford inthe spring of 1952,6 to which were invited scientists fromall branches of research bearing on mind and brain,provided " a clear though complex picture " of whatis going on in territory which extends from the anatomyof the nervous system and the biochemical and electricalactivities of the brain on one hand to the work of thechild-guidance clinic, the mental hospital, and the specialschool on the other. The fund takes all this for its

province, its objects being :"To promote, finance, and encourage research on mental

health and disease, notably : (a) study of the factors c’on-ducive to the fullest development and maintenance of man’smental capacity ; (b) research on the causation, preventionand cure of nervous and mental illness ; (c) research onfundamental problems related to mental health, such as thephysiology of the nervous system ; (d) research on the forms ofsocial structure most likely to lead to the improvement of themental quality and stamina of the community and most likelyto reduce the incidence of addiction, delinquency and crime."Some of the ground has been further explored. The

Oxford conference led to one on the psychological develop-ment of the child, convened by the World Health

Organisation at Geneva- in 1953 ; and this was followed

by another on the same subject two months ago. A

meeting, in Bristol, of biochemists and others who hadattended the Oxford conference resulted in plans for asymposium on the development of the nervous system,to be held at Oxford next July ; and this will be organisedand sponsored by the fund. Then, research projectsare to be fostered by one or more fellowships carryingsalaries of nOOO-1500, and applications are soon to beinvited for the first of these, the only stipulation beingthat the applicant must be willing to undertake workwhich has some bearing on mental health.The fund has decided on some general rules as to the

ways in which it can best use its resources. As occasionoffers, it will finance conferences between research-workers-either small groups approaching a single topicfrom different aspects, or larger groups with a biggerrange. It will also make travel and subsistence grantsto workers who wish to confer with colleagues of similarinterests, to visit a different laboratory to learn a newtechnique, or take part in joint research at some othercentre. It will foster the projects of individuals eitherby means of fellowships, or by adding something to anexisting salary so as to enable the worker to continue,indefinitely or for a limited time, in research, or bypaying an alternative person so as to release the workerfrom part of his duties, or by means of grants for equip-ment and technical help. Prizes and awards will begiven, at two-yearly or other regular intervals, and these

will include awards, given without previous notification,to young research-workers, for advances which bearon mental health. The fund will also support efforts

(either its own or those of any other approved body)to raise the amount of public or other research fundsallocated to mental-health research : it will, for instance,advocate that the number of research professorships anddirectorships of clinical research in mental hospitals beincreased, and that the conditions of service of research-workers should be improved, and interest in this fieldstimulated. Finally, it will support any other projectbearing on mental health which does not fall into anyof the classes enumerated, but which the research com-mittee consider deserves approval. This committeewill also have the task of selecting projects to be givenfinancial help. It will base its decisions on the abilityof the man who is to undertake the work, on the situationin mental-health research at the time of his request,on the extent to which funds may be had from othersources, and on whether the men and material seemsufficient to get decisive results. Generally the preferencewill be given, as mentioned already, to projects whichcan be attacked in cooperation by workers trained indifferent disciplines and having different skills.

This programme, which is in the best tradition of

English grant-giving bodies, has a warmth and energyabout it appropriate to the spring season in which it isgrowing : it should set the sap rising in mental-healthresearch.

1. Gold, S. C., Gowing, N. F. C. Quart. J. Med. 1953, 22, 457.2. Rapaport, S. I., Meister, L., Steele, F. M., Caniglia, S. R.

Ann. rheum. Dis. 1953, 12, 268.3. Callender, S. T., Race, R. R., Paykoç, Z. V. Brit. med. J.

1945, ii, 83.

SYSTEMIC LUPUS ERYTHEMATOSUSCOLLAGEN disease is now fashionable, so it is liable to

be diagnosed whenever the signs and symptoms do notseem to fit together. Certainly the clinical picture ofsystemic lupus erythematosus is bizarre enough. Goldand Gowing note that this disorder occurs almostexclusively in young women between the ages of 20 and40. As regards the skin lesions, chronic discoid lupuserythematosus may progress sometimes to the systemicvariety ; in addition there may be

" a wide variety of

rashes occurring simultaneously or in succession."Purpura of thrombocytopenic type may be the presentingsign. Arthritic symptoms are prominent ; and usuallythey are relatively acute. The muscles may be swollenand tender, as in dermatomyositis. Renal symptomsare uncommon ; but progressive renal involvement, whenit does occur, is always a bad prognostic sign. Diarrhoeais often troublesome, and various other gastro-intestinalsymptoms have been recorded. Pleural effusion is

frequent and, when accompanied by pericardial effusionand ascites, may be wrongly ascribed to

" polyserositis."Widespread enlargement of lymph-glands is common,splenomegaly less so. Sometimes focal vascular lesionsin the central nervous system give rise to signs. This listis not exhaustive ; for instance, Rapaport et a1.2 havelately described 2 patients with presenting signs andsymptoms in the lungs.

In diagnosis clinical pathology gives much-needed help.The most important biochemical change, according toGold and Gowing, is hyperglobulinaemia; and " thediagnosis should be suspect if this is absent." This

hyperglobulinsemia is reflected in abnormal results ofother tests-for instance, increased erythrocyte-sedi-mentation rate (E.s.R.) and an occasional false positiveWassermann or Kahn reaction. The Coombs anti-

globulin reaction for red cells may also be positive : Goldand Gowing had 8 positives in their 26 cases. Further-more multiple antibodies may be formed after blood-transfusion ; for example, in a case described by Callenderet al.3 5 separate antibodies developed after multipletransfusions. Routine blood examination shows no