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EVACUATION PROBLEMS GETTING SOLVED

ivLANY or tne scnool reports mat are coming in tnrowlight on the evacuation problem and demonstrate the

capacity of the medical service to cope with all matterswhich lie within its province. Of the children evacuatedfrom the London area to Northampton county Dr. C. M.Smith tells us that 10 per cent. were unclean. In thethree years 1936-38 the uncleanliness percentage of thenative children was 5.2, 6.1 and 5-7 respectively. Thedifference expressed in rates does not appear to be greatbut in practice it is formidable. Dr. Smith remarks thatthe fault is mainly carelessness, indifference or negligence,and in some few cases sheer incapacity, on the part of theparents. The school service soon learned that these four" causes " not only required different treatment butvaried according to the level of cleanliness locally.Incapable parents may have been prevented by hardluck, severe poverty and the like from giving theirchildren the attention they require, or their lack ofmental ability may make them incapable in any circum-stances. The incapable who have shown themselveshopeless should be obliged, Dr. Smith feels, to hand overtheir children to the state, for nothing short of that willgive them an opportunity of reasonable upbringing.This is arguable, but it serves to show that the onlyobstruction which the school medical service cannotovercome is lack of mental capacity on the part of

parents. It can see its way through all other difficultiesif backed by a strong public conscience. Bedwettingcame as a complete surprise to receptionists, but Dr.Smith soon found his way through this difficulty, as hedid through those connected with contagious skin con-ditions. Repeated application to governmental de-

partments and tQ evacuation authorities for extra helpwere in general fruitless, but metropolitan medicalofficers were helpful (he mentions Willesden and Waltham-stow). He appreciated the arrangements made by theCentral Midwives Board for drafting staff to the districtswhere it was required, but as the C.M.B. has nothing todo with the school service the appreciation is a covertrebuke to the Board of Education and Ministry of Healthfor not having done likewise. Dr. Smith insists that it wouldbe entirely wrong if the impression were gained that theimmigrant children had given rise to endless trouble andanxiety. They gave work, hard work, and in some caseswork which was not expected, but (says he) a well-organised school medical service is not easily put out.Epidemiologists will learn with interest that the childrenfrom London suffered less than the native childrenfrom influenza, rubella and measles, which were highlyprevalent in Northants during the spring of 1940.

PANTOTHENIC ACID AND ADRENAL LESIONS

NEw discoveries of the essential constituents ofanimal diets are made yearly, and it should soon bepossible to feed animals completely on synthetic materials.Where yeast or wheat germ or their fractions used tobe given as sources of the vitamin-B complex, it is nowalmost possible to substitute the individual substancesof the complex. The synthesis of pantothenic acid,announced earlier in the year, is another step in thisdirection. The substance has been shown to be essentialfor the growth of rats, and to prevent dermatitis inchicks. As further essential substances are identified itbecomes easier to study the symptoms produced by adeficiency of any one of them. Daft and his co-workers1have fed rats a diet consisting of casein, cod-liver oil,Wesson oil (as an additional source of fats) a salt

mixture, and sucrose, with supplements of choline,thiamin chloride (aneurin B1), riboflavin (B2), pyridoxinhydrochloride (adermin B6)’ and nicotinic acid (B7).The absence of vitamin C is not i evelant, since rats do not

1. Publ. Hlth Rep., Wash. July 26, 1940, p. 1333.

use this vitamin. More than half these rats developedepistaxis, ocular exudate, spectacled eyes, depilation anddegeneration in the adrenal glands. Ashburn reports2that their adrenals showed congestion, haemorrhage,atrophy, necrosis, fibrosis, hxmosiderin deposition andcortical fat depletion. The spleen and pancreas werehealthy, but testicular function was abnormal and theupper epiphyseal cartilage showed hypoplasia.The diet was deficient ’in only one fully identified

essential factor-pantothenic acid. After 10 weeks onthe diet the rats were divided into different groups. One

group continued on the old menu ; the others received,in addition, doses of pantothenic acid, ranging from 100-200 iig., for periods of 6-14 days. In all the treatedrats, the symptoms disappeared entirely or decreased inseverity, while the symptoms of those receiving nosupplement were exacerbated. In the rats in all groupsthe adrenals showed congestion, fibrosis, scarring andhaemosiderin deposition ; but’in 10 out of 16 rats on thedeficient diet the adrenals also showed haemorrhage,atrophy, and necrosis ; only 1 of the 28 rats in the othergroups showed active lesions (and Ashburn suggests thatthis one was mislabelled). The fat content of theadrenals of the different groups varied strikingly : 14 ofthe 16 untreated animals showed considerable depletionin the fascicular zone ; in the 28 treated animals this zonewas normal in 6 and slightly depleted in 18 others ; theremaining 4 showed moderate depletion in patchy areas.The functional state of the gland is thought to be relatedto its fat content, so that pantothenic acid may beconcerned with the ability of the gland to producecortical hormone. In this experiment the testes failedto recover normal appearance or function as a result of

pantothenic acid, but in another experiment, where thesupplement was given for 5 weeks, the testes at the end oftreatment showed no abnormal cells and spermatozoawere numerous. Evidently function does improve butthe change is gradual and takes some time to becomedemonstrable. In the treated animals, the tibial

epiphyseal cartilages become hyperactive, and skeletalgrowth, which is glower than usual in the untreatedanimals, is accelerated. Daft and his co-workersattributed the pathological findings in rats on a dietdeficient in pantothenic acid to adrenal cortical

insufficiency.

MONKEY TRICKS IN THE NURSERY

NEARLY 50 years ago attention was first drawn to thecurious ability of the newborn infant to suspend theweight of his body in mid-air by the strength of his owngrip. Why this should happen is still not clear and

speculation does not offer much of scientific value. Buta study of the performance in the developing infant andthe relationship of changes to the maturation of thecentral nervous system present some scope for the

investigator. Myrtle B. McGraw,3 working in the de-partment of pediatrics of Columbia University and atthe Babies’ Hospital, New York, devised a standardmethod of observing the length of time that infantswould remain suspended from a rod by both hands or byright hand or left hand alone. Measurements of this"

suspension time " were obtained at intervals on a groupof 91 children over several years. The total number ofmeasurements for two-hand suspension was 3121, forright-hand suspension 2017 and for left-hand suspension1827. It was found that starting from a relatively lowlevel immediately after birth both single-hand anddouble-hand suspension reach a maximum at about theend of the first month. About the end of the third orfourth month single-hand suspension becomes almostextinct and suspension by both hands fluctuates about alow level. Then, somewhat surprisingly, this suspension

2. Ibid, p. 1337.3. Amer. J. Dis. Child. October, 1940, p. 799.

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phenomenon reappears and from the end of the first yearin the case of two-handed suspension and somewhat later-even as late as the third year-in the case of single-hand suspension the measured time increases. Thereare, however, qualitative differences in the performance.of older children which suggest that the later achieve-ments are deliberate or voluntary. There is a differencein postme also in these older children. The infant

hanging by both hands lets the head drop back towardsthe interscapular region and flexes the lower extremitieson the abdomen. The older child tends to hold the headerect and extend the legs, until fatigue causes a reversionto the infantile position. The method of grasp also

varies ; the young infant localises his grip in the distalphalanges, leaving the thumb passively adducted on thepalm ; as the child grows older there is an increasingtendency for him to hold the rod in the palm of the handwith the thumb actively engaged in the grip. It is

suggested that the suspension phenomenon in thenewborn infant is controlled at a subcortical or lowerlevel in the central nervous system. Indeed McGrawhas observed the phenomenon in 3 anencephalic infants.The reduction in suspension-time after the first monthsuggests that the inhibiting influence of the cortex isbeginning to assert itself and during the next 3 monthscortical inhibition becomes completely dominant, so thatsuspension behaviour is either extinct or nearly so. Thelater re-establishment of the phenomenon suggests a largedegree of voluntary cooperation. This is regarded asevidence of the maturation of those cortical cells whichactivate or control neuromuscular movements and fitsin with other studies of neuromuscular development.Although McGraw’s studies are solely concerned with thesuspension phenomenon in normal infants, failure or

delay in the appearance of the third phase, when abilityto hang by the hands returns, might serve as a warningof serious mental defect.

CARDIOVASCULAR SYPHILIS

THE early diagnosis of syphilitic aortitis is as difficultas any in clinical medicine, and, as O’FarrelP says,involvement of the aorta is so constantly present incardiovascular syphilis that other forms may be dis-

regarded with few exceptions.2 Most pathologists nowagree that syphilitic involvement of the myocardium isexceedingly rare. Among recent attempts to make thediagnosis of early specific aortitis easier is that of

Maynard,3 who gives the following six criteria to lookfor : (1) a definite history of syphilitic infection ; (2) theabsence of any evidence of other disease that might dilatethe aorta ; (3) a patient aged 40 or less ; (4) radiologicalevidence of dilatation of the aorta ; (5) a hollow, accen-tuated aortic second sound ; (6) a systolic murmur in theaortic area. O’Farrell rightly points out that the secondof these criteria is often the most important, and the maindifficulty here is the exclusion of the dilated, tortuousaorta of " arteriosclerosis." An enlarged left ventriclewithout aortic incompetence makes aortitis unlikely, butsince an appreciable number of cases of specific aortitisare complicated by hypertension the final decision maynot be easy. A valuable point which O’Farrell does notmention is the increased density of the aorta detectable onscreening in many syphilitic cases. The late stage ofaortitis-aneurysm of the aorta-is as a rule easier todiagnose, especially if radiology is employed in all casesof suspected heart disease or pain in the chest, thoughthe time-honoured classification of aneurysms into thoseof signs and those of symptoms has now had a thirdcategory added to it-those with neither signs nor

symptoms. O’Farrell suggests that aneurysm of thefirst part of the aorta is particularly difficult to diagnose,

1. O’Farrell, P. T. Irish J. med. Sci. November, 1940, p. 731.2. Burke, E. T. Venereal Diseases, London, 1940.3. Maynard, E. P. Brooklyn Hosp. J. 1940, 2, 69.

but actually these are the cases in which the aortic valveis most likely to be involved and it is usually not longbefore an aneurysm in this area shows itself by pulsationin the chest wall. A commoner difficulty lies in mistak-ing pulsation to the right of the upper part of the sternumdue to aortic incompetence for an aneurysm. It is

regrettable that O’Farrell supports the old teaching thatit is possible to differentiate between the murmurs ofrheumatic and syphilitic aortic incompetence by theirsite, the former being supposed to be maximal to the leftof the sternum and the latter to the right. The relation-ship of syphilis to coronary disease deserves further

investigation, especially in these days when doctors arebecoming so coronary-conscious. In the past we mayhave been too apt to attribute symptoms and signs tosyphilis, but so far as coronary disease is concerned weare now swinging too far in the opposite direction.

Consideration of cardiovascular syphilis leads to onecertain conclusion-that prevention is easier than cure,and that the first essential is to treat every syphiliticefficiently at the time of primary infection. As a further

precaution all people who have had such an infectionshould have their heart examined, clinically and radio-logically, once or twice every year.

ENDOCRINES AND INVOLUTIONAL MELANCHOLIA

THAT endocrine therapy should fail to influence

depression at the menopause has always seemed like amuffed conjuring trick. The state of the patient stronglysuggests some degree of endocrine imbalance, and bearingthis cardinal fact in mind R. E. Hemphill and Max Reisshave attackedl the problem again. The imbalance, theybelieve, is more likely to be complex than simple, so theyhave attempted to classify the types of endocrineabnormalities found in a series of 30 women admittedto hospital with depression associated with the meno-pause ; only 4 of them had a history of previous attacksof depression.They were grouped tentatively as follows : type 1,

hypo-ovarian secretion (11 cases), patients with men-strual cessation or irregularity, fat deposition round thelower abdomen and thighs, and symptoms of flushingand giddiness ; type 2, hypo-ovarian and hypothyroidsecretion (4 cases), patients with menstrual irregularity,few somatic symptoms, dry skin, falling hair, and a smallimpalpable thyroid ; type 3, hypo-ovarian and hyper-thyroid secretion (7 cases), patients with menstrual

irregularity, somatic symptoms, moist sweating skin,increased pulse-rate, full thyroid and in 2 cases exoph-thalmos ; type 4, hypo-ovarian and hypo-adrenalsecretion (8 cases), patients with acute loss of weight,sallow complexion, flabby muscles and skin and animpalpable thyroid. Patients of type 1 were depressedand quiet ; patients of types 2 and 4 showed motoragitation ; the type-3 patients reacted more acutely tochanges in their environment than the others, and 4 ofthem were suspicious, almost paranoid. It may ormay not be significant that 9 of the type-1 patients hadnever borne children. Gonadotrophic hormone is said tobe increased in the urine of women after the menopause ;. oin this series it was not a constant finding but wascommon in types 1 and 3. Since folliculin inhibits the

production of gonadotrophic hormone, follicular hormonewas given to 19 patients in the series in large doses, bothby mouth and parenterally. Of 7 type-1 patients treatedin this way, 3 made complete and 2 partial recoveries ;the other 2, who had had symptoms for more than twoyears, showed no change. Of the 4 untreated patientsin this group, 2 recovered and 2 showed no change.Type-2 and type-4 patients treated with follicular hor-mone were not improved. Of 5 type-3 patients treated3 improved sufficiently to go out and the other 2 weresymptom-free at the time of publication of the report ;

1. J. ment. Sci. November, 1940, p. 1065.