949

no antidiuretic effect. From all this VERNEY postulatesthat there are in the brain " osmoreceptors

" which are

closely connected by nerve-paths with the pituitary,and, according to tonicity of the blood supplyingthem, are continually regulating the secretion ofthe antidiuretic hormone and hence of the urineflow. The exact site of these osmoreceptors is stilluncertain.The renal mechanism through which the posterior

pituitary acts has not yet been revealed by VERNEY’sexperiments. It has been generally assumed that theaction of the posterior-pituitary secretion is mainlyon tubular reabsorption, but it remains to be seenwhether in addition there is not some alteration ofrenal circulation like that demonstrated by TRUETAand his colleagues after various types of nervestimulation. One obvious difference is that the Truetaphenomenon disappears after physiological denervation of the kidney by splanchnic block, whereas

posterior-pituitary extract continues to act on thedenervated kidney.

Annotations

GUIDE TO BOARDING OUT

RULES always need explanations if they are to beobeyed willingly and intelligently. On paper, the

regulations for the boarding out of children should havesufficed at least to prevent tragedies in practice, butthey were such dull official reading that they failed totouch the imagination, or to bring home their responsi-bilities to some authorities. As a result of Sir Walter.Monckton’s report, in 1945, on the death of DennisO’Neill, the Home Office and the Ministry of Healthhave revised the boarding-out rules, and the work ofmany local authorities has been reviewed. The newrules have been incorporated in an explanatory memo-randum 1 which includes such of the Curtis Committee’srecommendations 2 as can be applied without legislativechanges. Thus the hoped-for " children’s officer " doesnot yet appear, though the boarding-out visitor is chargedwith many of her duties. While the child is in a receptionhome the visitor who will later supervise him is instructedto get to know him " as a new friend," and to tell himabout the plans being made for him, describe the foster-home when it is found, and encourage him to look forwardto being received into it. She must also get to knowthe foster-parents as a friend, and must make it clear tothem that they share the responsibility for the childwith the local authority, and help them to fulfil theirundertakings. The child must be examined by a doctorbefore being boarded out, and a doctor-who may be themedical officer of the local authority or the family doctorof the foster-parent-must be appointed to attend himwhen ill, and to examine him yearly. The local authorityis responsible for all medical and dental care, and must benotified if the child is seriously ill or hurt ; the visitormust make sure that the foster-parents can get intotouch with her quickly in case of need. Her attitudeto the child is carefully outlined ; she must-

"... attempt to find for each child the environmentmost suited to his temperament and aptitudes, endeavouringto make the first placing a successful and lasting one.She will consider, for example, whether the child in questionneeds a careful and orderly home, or will be happier wherestandards are not too rigid; whether he has a stronger

1. Trueta, J., Barclay, A. E., Daniel, P., Franklin, K. J., Prichard,M. M. L. Lancet, 1946, ii, 237.

1. Home Office and Ministry of Health. Memorandum on BoardingOut of Children and Young Persons. H.M, Stationery Office.Pp. 18. 4d.

2. See Lancet, Nov. 2, p. 648.

preference for town or country life, and whether he isaccustomed to, and would miss, the company of otherchildren of his own age. For a dull child she will try tofind a foster-home where he will not suffer by comparisonwith more intelligent children, while for a child of highintelligence or with some special ability she will seek anenvironment in which his interests and potentialities willbe understood and encouraged. Some foster-parents willbe at their best with a delicate, nervous, or physicallyneglected child, while others will be able to understandand manage the active undisciplined boy or the precociousadolescent girl."This is the sort of guidance which will help boarding-

out visitors to recognise their opportunities ; but it

implies, of course, that they have a wide choice of foster-homes at their disposal. This is not always so, and it isperhaps a pity that the memorandum does not drawattention to another suggestion of the Curtis Committee-that opportunities for boarding out in comfortablemiddle-class homes should be more fully explored.The child’s needs and wishes are well considered

throughout the memorandum. Two pieces of adviceserve to show that these are assessed by contemporarystandards : the child is to have regular pocket-moneyand is to be encouraged to learn how to spend it as wellas how to save it ; and the foster-parent is to let thevisitor know when extra financial help is needed " for

holidays and for festive occasions, for a bicycle, or forspecial clothing for games or other purposes."

INFECTIOUS LYMPHOCYTOSIS

IN 1941 Smith in America drew attention to a benignand probably infectious lymphocytosis appearing as anacute or chronic disease in children. The acute caseshad a vague and varied symptomatology, but a sharplymphocytosis was always present. The chronic cases

usually followed an infection of the upper respiratorytract ; there was a low, persistent pyrexia, vaguemalaise and anorexia, and often spasms of peri-umbilicalpain ; a persistent lymphocytosis lasted a month ormore ; eventually the whole disturbance settled down,and there were no complications. Duncan describedan acute case in a girl of 5 years, beginning with acuteabdominal pain and rigidity ; there was no enlarge-ment of lymphatic glands, liver, or spleen ; there were29,600 lymphocytes per c.mm., sternal puncture showedincreased cellularity with 86% lymphocytes, plateletswere rather low, but red cells and haemoglobin werenormal ; the Paul-Bunnell (heterophile antibody) reactionwas not significant. The acute symptoms subsided ina few days, but the pyrexia and the lymphocytosispersisted for a month. Later Duncan 3 reported 2 casesin young adults, and added a morbilliform rash to theclinical picture. Another acute case in an adult-thistime a U.S. naval recruit of twenty-nine-is reportedby Yuskis,4 and here again there was a morbilliformrash, mainly on hips, thighs, and legs, and lasting threeweeks.

Lorenz and colleagues 5 report 2 more cases in children’with peak counts of 47,500 and 58,000 lymphocytes perc.mm., and clinically only mild respiratory affection ;sternal marrow was normal in these patients, with nolymphocytosis ; the Paul-Bunnell reaction was positiveup to a titre of 1 in 80, but this is too low for a diagnosisof infectious mononucleosis. In this issue Steigmanreports a small outbreak involving 6 children in one

village in southern England ; here cervical lymph-glands were notably enlarged and there was pro-tracted lymphocytosis, but all recovered withoutincident. According to Smith 6 the disease is con-

1. Smith, C. H. Amer. J. Dis. Child. 1941, 62, 231.2. Duncan, P. A. Ibid, 1943, 66, 267.3. Duncan, P. A. New Engl. J. Med. 1945, 233, 177.4. Yuskis, A. S. J. Amer. med. Ass. 1946, 132, 638.5. Lorenz, M., Hardy, L. M., Alt, H. L. Ibid, 1946, 131, 882.6. Smith, C. H. Ibid, 1944, 125, 342.

950

tagious and infectious, with an incubation period of12-21 days.

There are already several known causes of lympho-cytosis in children. Kato pointed out that from threemonths to four years of age lymphocytes are normallymore numerous than polymorphs. A well-markedlymphocytosis has been recorded in whooping-cough,rubella, and mumps after the initial stage. Infectiousmononucleosis is common in children, and it is likelythat several cases of infectious lymphocytosis have beenclassified with this disease-for example, Thelanderand Shaw’s 7 cases of infectious mononucleosis with signsof meningeal irritation, which had a lymphocytosis andnegative Paul-Bunnell tests.

Here, then, is a benign almost certainly infectiouscondition, mainly affecting children, with a very variableclinical picture, sometimes simulating acute abdominalor nervous disease at onset, and sometimes only a mildrespiratory tract affection ; pyrexia may be protracted,and the blood shows a pronounced lymphocytosis.The Paul-Bunnell reaction is not significant. Thedifferential diagnosis from infectious mononucleosis

(glandular fever) may turn on the Paul-Bunnell reaction-not an entirely reliable sign-but the blood picture ininfectious lymphocytosis shows only small lymphocytes,with no glandular fever cells or excess of mono-

cytes. In lymphatic leukaemia the patient is muchmore ill and has a rapidly increasing anaemia, andsternal puncture always shows a massive lymphocyticinfiltration.The prognosis in infectious lymphocytosis is excellent,

even if the course is long ; no specific treatment has beenproposed. The cause has not been identified ; it has, asusual, been ascribed to a virus, but no supporting evidencehas appeared yet.

NUTRITION IN CEYLON

THE peasants of the Middle East, we are told,! " con-stitute the bulk of the population and ... produce mostof the basic wealth, have few schools, almost no medicalfacilities, till soil that is not their own, have little pur-chasing power, and exist under standards that are

tragically low." This dismal statement applies also toCeylon, as is shown in a publication of the departmentof medical and sanitary services.2 The basic wealthof the country is derived from the chief exports-tea,rubber, and coconuts. The food that is grown in Ceyloncan support barely a third of the population. For herrice Ceylon depends on Burma and for other food-stuffs on India. During the late war, when Burma wasoccupied and India was facing a famine, Ceylon had toturn to Australia for wheat and other foodstuffs. Shehas few or no cottage industries to help the peasantpopulation and occupy their time when idle. That thediet is bad there can be no doubt. The state of nourish-ment is so poor that it is impracticable to use modernEuropean and American standards. Any standards

accepted must -be based on those ensuring reasonable(not " abounding ") health, and often these low standardsare not achieved. In 1944,40% of the families examinedwere obtaining too few calories (standard, 2000 a day !),65% too little protein, and 54% too little calcium.Toad-skin and -Bitot’s spots in the children examinedpointed to gross deficiency of vitamin A, and there wasevidence of a lack of the B vitamins. The average costof the diet before the war was 15 cents a day. It hadrisen to 38 cents in 1944, and nearly two-thirds of thepeople spent less than this amount. The death-rate is20 per 1000 and the infantile mortality close on 140 per7. Thelander, H. E., Shaw, E. B. Amer. J. Dis. Child. 1941, 61,

1131.

1. Allen, H. B. Rural Education and Welfare in the Middle East.H.M. Stationery Office. 1946. 1s. 6d.

2. Ceylon Health News, 1945, 12, no. 2.

1000 live births. Despite these figures the populationhas risen and is still rising. In no direction are thereany grounds for complacency, though there is a littlecomfort in the fact that things are not as bad as theywere in 1937. That the prospects are so unpleasing isnot because man is vile but because man, the entre-preneur, has exploited the land and its resources andpaid no real attention to the welfare of those whoproduce most of the basic wealth of the island. It willneed a long-term plan of primary, secondary, and adulteducation, agricultural improvement, supply of medicalservices, and improvement of the standard of living,with or without a short-term policy of world agricultureorganisation, to remedy the deplorable state of the publichealth in Ceylon.

DOCTORS DIFFER

A BOOK with this title seems in tune with the times;and though Dr. Harley Williams 1 deals with historicrather than current differences-and not merely differ-ences of opinion but of quality and character-hisargument is opportune, for he shows that through thedifferences of doctors medicine grows. There is nothingnew about this : the energy generated by oppositesmoves many things in nature, as British party politicsshow. But he sets about it with enthusiasm, and’hisrattling pen and vivid fancy get the circulation going inhis ten subjects and put them before us as live men-though not necessarily quite the men who walked theearth under those ten names. He is deeply read in thedebates of Elliotson and Wakley over mesmerism, inthe lives of old Hugh Owen Thomas and young RobertJones, of plodding Mackenzie and quicksilver Osler, ofMacewen and Victor Horsley, and urbane Robert WilliamPhilip and country-loving Trudeau. His portraits arein the main kindly, even flattering. Sometimes indeed hemust have shared the perplexity of Mrs. Gaskell facedwith the task of writing acceptably of the Brontes :the great can be so awkward. Is it true, for example,as Dr. Williams puts it, that " some admiring nursessubscribed secretly and bought a’fish-kettle for Macewento boil his forceps " ? Or did the sister exclaim, one day," He’s been on about that fish-kettle for weeks. Forheaven’s sake let’s buy him one " ? °? If this kind of doubtafflicts the reader from time to time it will not impairhis enjoyment of stories which revive the times as wellas the men. He does less than justice perhaps to ThomasWakley, founder of this journal; and in his relish of thepomposities of Philip he seems for a moment to shed someof his own years and to become one with the irreverentstudents who enjoyed them.

CONTROL OF RATS AND MICE

THE immense importance of rats and mice as carriersof disease and destroyers of food is perhaps not sufficientlyrealised in this country. Rattus rattus, the " black " or"

ship " rat, was the earliest invader of Europe, comingfrom the East shortly after the Crusades, probably byship. This settler spread rapidly, but was eventuallyalmost entirely replaced by Rattus norvegicus, the larger,short-nosed, short-tailed common brown rat, as a resultof a strange revolution in the rat world which took placetowards the end of the seventeenth century. Prof. G. M.

Trevelyan 1 claims this change-over as the chief causeof the decline of the plague of 1665, because the brownrat did not carry the plague-flea to nearly the sameextent as its predecessor. It is certain that betweenthem they have been responsible for an incalculablenumber of deaths from plague and typhus, and also forthe spread of such infections as rat-bite fever and Weil’sdisease. The 40,000,000 rats in England at present are1. Doctors Differ. By Harley Williams. London: J. Cape. Pp. 253.

12s. 6d.

1. English Social History, London, 1944, p. 290.