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RUBELLA IN PREGNANCY
495
the crop is pressed for oil, and the residue from the presses is destined for animal foodstuffs as meal or cake. Traces of aflatoxin can be found in the oil (which is one of the main constituents of margarine), but these are removed during the refining process. There were traces, too, in the milk of some cows fed experimentally on toxic meal ; but all tests of bulked milk from normal sources have been negative. No human disease attributable to this toxin has yet been detected; but inquiry is still in progress. An undertaking by the compounders of feeding stuffs to test all groundnut meal before use has reduced the risk to birds and beasts. Unfortunately, no method of detoxifying the affected meal has yet been devised. Groundnut growers hope that more careful harvesting and quicker drying will reduce fungal infection; but both the nuts and A. flavus flourish under similar atmospheric
conditions. The elucidation of this agricultural epidemic of hepatitis has been an elegant demonstration of epidemiological method, and that the working party1 has made its report within two years of the first signs of the illness is a credit to all who have taken part in the inquiry. We took a great deal longer to unravel the not dissimilar problem of
beriberi. NEUROGENIC BASIS OF RAYNAUD’S PHENOMENON
THE triphasic colour changes described by Raynaud are best regarded as a symptom complex common to many different disorders. Since the concept of a single " Raynaud’s disease " was abandoned, the underlying conditions with which white fingers may be associated have multiplied. In cold damp climates, many people have an inherited " local fault " first manifest around adolescence, which consists in an over-reaction of their digital vessels to cooling. Most of those so afflicted readily bear with the condition once they have been reassured that it is benign. Much more important is the group in which the colour changes in the fingers are an indication of general systemic disease-commonly, rheumatoid arthritis, scleroderma, or disseminated lupus erythematosus. In young men, thromboangiitis obliterans may well be responsible, whereas, in the elderly, the underlying cause may be atherosclerosis in the large or small vessels supplying the extremities. Many of the associated clinical patterns have still to be worked out. Among the most puzzling is the youngish or middle-aged woman who develops, without any previous or family history, occlusive digital-artery disease leading to pulp atrophy and ulceration. Only in the occasional case does the small-vessel disease also involve other organs such as the lungs or brain: in the majority it remains restricted to the fingers. The microscopic appearance of the vessels is not very informative, the most striking feature being endothelial
hyperplasia. De Takats and Fowlerhave
investigated the
genic factor in Raynaud’s phenomenon.
That
neurovaso-
constrictor impulses can be a dominant or accessory partner in the production of vasospasm has long been recognised. In the days of extensive thoracolumbar sympathectomy for hypertension, hyperhidrosis and phasic colour changes in the hands developed in many patients after the autonomic ablation. Blanching of the 1.
Report
of the interdepartmental working party on Groundnut Toxicity Research. Department of Scientific and Industrial Research. 1962. Pp. 61. 6s. 6d. 2 De Takats, G., Fowler, E. F. Surgery, 1962, 51, 9.
fingers may clearly be linked with anger or emotional outbursts, and peripheral neuritis has been suggested as the cause of " vibrating-tool Raynaud’s. De Takats and Fowler investigated seven patients in whom the attacks were associated with abnormal electroencephalograms (E.E.G.S). All were women. Four below the age of thirtysix were hyperhidrotic; their E.E.G.S showed positive spikes at frequencies of 6 and/or 14 per second; no other abnormality could be found. The remaining three women had scleroderma or disseminated lupus. About 50% of patients with scleroderma are said to have abnormal E.E.G.S. De Takats and Fowler do not say clearly how they selected these seven patients, how severely their hands were affected, or how commonly the electroencephalographic technique would pick up abnormalities in healthy women of the same age-group. But pursuit of this type of investigation would be interesting-particularly in the rather inadequate individual with damp sweaty hands, high peripheral vascular tone, and phasic colour changes in the fingers. De Takats and Fowler emphasise that the treatment of Raynaud’s phenomenon should begin with recognition of the broad diagnostic problem involved. They claim that the results of sympathectomy depend more on the shrewdness with which patients are selected for the operation than on the type of sympathectomy performed. The milder the case and the larger the neurogenic component, "
the better the result. Patients with severe " local faults " or with systemic disease do badly. Paradoxically, occlusive disease (e.g., thromboangiitis obliterans or atherosclerosis) is often benefited, sympathectomy clearing up or ameliorating local ulceration or pulp necrosis. De Takats and Fowler reported that the results of sympathetic denervation were excellent in their patients with abnormal E.E.G.S. RUBELLA IN PREGNANCY
THE Swedish National Board of Health instructed
hospitals to find out from women, admitted between July, 1951, and June, 1952, for delivery or abortion, whether (1) they had had contact with any person infected with rubella, and (2) they had contracted rubella during their pregnancy. Women with the immediately preceding hospital-registration numbers served as controls. The common with that carried out in this in 1952,1 though the inquiry was made later in the country pregnancy. In no case of rubella had an attempt been made to confirm the diagnosis at the time of infection. The findings of the survey have been collated by Lundstrom.2 In general, they are very similar to those of the British survey, but they provide some useful additional information, particularly about chorioretinitis, microcephaly, and immaturity. At follow-up examination at three years of age, the overall frequency of malformation found in children born after first-trimester rubella was 58 in 425, or 14%-almost exactly the same as in the British series. In the British series audiometric examination of 57 such children revealed that 30% had some hearing loss; this was found in a similar proportion (8 out of 27) in the Swedish series. In addition, an ophthalmoscopic examination was made of 60 of the Swedish children; 12 (20%) were found to have some chorioretinitis, but no details are given of the extent to which sight was affected. As in the British series, there was no clear indication
survey had much in
Manson, M. M., Logan, W. P. D., Loy, R. M. Rep. publ. Hlth. med. Subj., Lond. 1960, no. 101. 2. Lundström, R., Acta pœdiat., Stockh. 1962. suppl. 133. 1.
496 that rubella in the first month was especially teratogenic, the malformation-rates in surviving children being 17%, 17%, and 8% for the first, second, and third months respectively. But Lundstrom points out that infection in the first two weeks after the last menstrual period is, in reality, preconceptional; at that time rubella is probably not teratogenic, and his figures therefore imply a higher rate for malformation in the first two weeks after
conception. In neither series, unfortunately, was the intelligence of the children adequately studied; this is now being investigated in Sweden. But 7% of first-trimester-rubella children, compared with 2% of the controls, showed some delay in acquiring the skills of sitting and standing without support. Moreover, at the follow-up examination, 10% of the rubella children, but only 2% of the controls, were found to have a head circumference more than two and a half standard deviations below the mean value related to height. As in other series, the birth-weights of many of the rubella children suggested immaturity; 36% of those with malformation and 12% of those without (but only 3% of the controls) weighed less than 2500 g. at birth. The birth-weight of 10% of the rubella children lay between 2000 g. and 2500 g., compared with only 1 % of the controls; this was the greatest disparity noted for any weight range. Comparison of the rubella immature with the control immature children was interesting, though limited by the rather small number in the second group. The rubella immature had a longer gestation period, a lower incidence of complications in pregnancy and at delivery, and a lower stillbirth-rate and neonatal deathrate. But a higher proportion of the rubella group were still undersized at the time of the follow-up examination. Among the children of Swedish women exposed to, but not contracting, rubella in pregnancy there was no increase in the frequency of malformation; this was true whether or not the mother had already had rubella before the exposure. Of a group of 251 women exposed to rubella in the first four months of pregnancy who were treated with convalescent y-globulin, the disease developed in 6 (2%). Of the children born of these pregnancies, 3 (1%) had rubella-syndrome defects; but only 1 of these 3 was born to a mother who had contracted rubella in spite of the prophylaxis. Among the 245 mothers who did not contract rubella the abortion-rate and stillbirth-rate were normal; of the 229 liveborn children, only 2 had malformations which could be attributed to rubella. Like the findings reported by Lock et al.3 from the United States, these appear fairly satisfactory. It is difficult to estimate how many women would have contracted rubella if not protected with y-globulin. YOGA
YOGISclaim that they can control essential bodily functions such as the heart-rate. In 1935 Brosse investigated this question in one Yogi, and reported her findings eleven years later.4 While the subject attempted to arrest his heart-beat, a single-lead electrocardiogram (E.C.G.) and a pulse-wave recording were taken; these revealed progressive decrease in the electrical potential, and apparent cessation of the heart-beat for a time. This same Yogi has since been reinvestigated along with three others.55 Electrocardiographic, digital plethysmographic, and 3.
Lock,
F.
R., Gatling, H. B., Wells, H. B. J. Amer. med. Ass. 1961, 178,
711. 4. Main Currents in Modern Thought, 1946, 4, 77. 5. Wenger, M. A., Bagchi, B. K., Anand, B. K. Circulation, 1961,
24, 1314.
tracings were made on a portable electroencephalograph. During attempts to stop or slow the heart, each subject adopted a similar manoeuvre-breath-holding, usually in inspiration, with forcible contraction of abdominal and other muscles against a closed glottis to increase the intrathoracic pressure. In Brosse’s subject (who permitted only limited investigation of the method he employed) this procedure produced some change in potential of the two E.c.G. leads, but the heart-sounds other
still present on auscultation. In two of the other there were changes in the potential of the E.C.G. without any evidence of cardiac arrest. The fourth subject had claimed only that he could slow his heart, and he produced bradycardia with the development of nodal rhythm and some change in potential. These results are in accordance with Anand and Chhina’s earlier report 6 that no cardiac arrest was demonstrable on the E.c.G. Dr. Brosse’s original observation of apparent cardiac arrest on a single-lead electrocardiogram was probably an artefact due to the decreased electrical potential subsequently demonstrated under these circumstances. Many of the associated observations - inaudible breath-sounds, impalpable arterial pulse, and obstruction to the venous return-were probably due to the Valsalva or reversed Valsalva manceuvre which the were
subjects also
Yogis employed. INFORMATION ABOUT VENEREAL DISEASE
CONCERN about the increasing incidence of some venereal diseases has led the Standing Advisory Committee of the Central Health Services Council to review the problem in a bookletwhich has been distributed to all general medical practitioners taking part in the National Health Service. The venereal-disease service was established in 1916, and since then clinics staffed by specialists in venereology have been attached to the outpatient departments of most large general hospitals in the United Kingdom. Venereal disease as defined by statute comprises only syphilis, gonorrhoea, and chancroid; but the clinics deal with all conditions transmitted by sexual intercourse and with some other non-transmissible conditions, so that patients who attend are no longer severely stigmatised as " v.n. patients ". One of the most important functions of the clinic is to act as a centre for investigation, advice, and reassurance of individuals who are anxious but may well be free from infection. In 1960, 130,130 patients attended clinics in England and Wales for advice, but only 37,927 of these were found to have statutory venereal disease. The principles which originally governed the operation of the clinics have been maintained; attendance is entirely confidential, and patients are entitled to attend without doctors’ letters or other introduction. Treatment remains free even to the extent that no charge is made for drugs. Promiscuity, by which venereal disease is spread, is regarded as a symptom of social or marital maladjustment, and many clinics now have skilled almoners or socialservice workers one of whose duties is to assist with difficulties arising from unstable marriages, unwanted pregnancies, homosexuality, and venereophobia. The main problems at present are gonorrhcea and the disease, or group of diseases, commonly called nonAnand, B. K., Chhina, G. S. Indian J. med. Res. 1961, 49, 90. See Lancet, 1961, ii, 90. 7. Venereal Disease Service. Prepared by the Standing Medical Advisory
6.
Committee for the Central Health Services Council and the Minister of Health.
the crop is pressed for oil, and the residue from the presses is destined for animal foodstuffs as meal or cake. Traces of aflatoxin can be found in the oil (which is one of the main constituents of margarine), but these are removed during the refining process. There were traces, too, in the milk of some cows fed experimentally on toxic meal ; but all tests of bulked milk from normal sources have been negative. No human disease attributable to this toxin has yet been detected; but inquiry is still in progress. An undertaking by the compounders of feeding stuffs to test all groundnut meal before use has reduced the risk to birds and beasts. Unfortunately, no method of detoxifying the affected meal has yet been devised. Groundnut growers hope that more careful harvesting and quicker drying will reduce fungal infection; but both the nuts and A. flavus flourish under similar atmospheric
conditions. The elucidation of this agricultural epidemic of hepatitis has been an elegant demonstration of epidemiological method, and that the working party1 has made its report within two years of the first signs of the illness is a credit to all who have taken part in the inquiry. We took a great deal longer to unravel the not dissimilar problem of
beriberi. NEUROGENIC BASIS OF RAYNAUD’S PHENOMENON
THE triphasic colour changes described by Raynaud are best regarded as a symptom complex common to many different disorders. Since the concept of a single " Raynaud’s disease " was abandoned, the underlying conditions with which white fingers may be associated have multiplied. In cold damp climates, many people have an inherited " local fault " first manifest around adolescence, which consists in an over-reaction of their digital vessels to cooling. Most of those so afflicted readily bear with the condition once they have been reassured that it is benign. Much more important is the group in which the colour changes in the fingers are an indication of general systemic disease-commonly, rheumatoid arthritis, scleroderma, or disseminated lupus erythematosus. In young men, thromboangiitis obliterans may well be responsible, whereas, in the elderly, the underlying cause may be atherosclerosis in the large or small vessels supplying the extremities. Many of the associated clinical patterns have still to be worked out. Among the most puzzling is the youngish or middle-aged woman who develops, without any previous or family history, occlusive digital-artery disease leading to pulp atrophy and ulceration. Only in the occasional case does the small-vessel disease also involve other organs such as the lungs or brain: in the majority it remains restricted to the fingers. The microscopic appearance of the vessels is not very informative, the most striking feature being endothelial
hyperplasia. De Takats and Fowlerhave
investigated the
genic factor in Raynaud’s phenomenon.
That
neurovaso-
constrictor impulses can be a dominant or accessory partner in the production of vasospasm has long been recognised. In the days of extensive thoracolumbar sympathectomy for hypertension, hyperhidrosis and phasic colour changes in the hands developed in many patients after the autonomic ablation. Blanching of the 1.
Report
of the interdepartmental working party on Groundnut Toxicity Research. Department of Scientific and Industrial Research. 1962. Pp. 61. 6s. 6d. 2 De Takats, G., Fowler, E. F. Surgery, 1962, 51, 9.
fingers may clearly be linked with anger or emotional outbursts, and peripheral neuritis has been suggested as the cause of " vibrating-tool Raynaud’s. De Takats and Fowler investigated seven patients in whom the attacks were associated with abnormal electroencephalograms (E.E.G.S). All were women. Four below the age of thirtysix were hyperhidrotic; their E.E.G.S showed positive spikes at frequencies of 6 and/or 14 per second; no other abnormality could be found. The remaining three women had scleroderma or disseminated lupus. About 50% of patients with scleroderma are said to have abnormal E.E.G.S. De Takats and Fowler do not say clearly how they selected these seven patients, how severely their hands were affected, or how commonly the electroencephalographic technique would pick up abnormalities in healthy women of the same age-group. But pursuit of this type of investigation would be interesting-particularly in the rather inadequate individual with damp sweaty hands, high peripheral vascular tone, and phasic colour changes in the fingers. De Takats and Fowler emphasise that the treatment of Raynaud’s phenomenon should begin with recognition of the broad diagnostic problem involved. They claim that the results of sympathectomy depend more on the shrewdness with which patients are selected for the operation than on the type of sympathectomy performed. The milder the case and the larger the neurogenic component, "
the better the result. Patients with severe " local faults " or with systemic disease do badly. Paradoxically, occlusive disease (e.g., thromboangiitis obliterans or atherosclerosis) is often benefited, sympathectomy clearing up or ameliorating local ulceration or pulp necrosis. De Takats and Fowler reported that the results of sympathetic denervation were excellent in their patients with abnormal E.E.G.S. RUBELLA IN PREGNANCY
THE Swedish National Board of Health instructed
hospitals to find out from women, admitted between July, 1951, and June, 1952, for delivery or abortion, whether (1) they had had contact with any person infected with rubella, and (2) they had contracted rubella during their pregnancy. Women with the immediately preceding hospital-registration numbers served as controls. The common with that carried out in this in 1952,1 though the inquiry was made later in the country pregnancy. In no case of rubella had an attempt been made to confirm the diagnosis at the time of infection. The findings of the survey have been collated by Lundstrom.2 In general, they are very similar to those of the British survey, but they provide some useful additional information, particularly about chorioretinitis, microcephaly, and immaturity. At follow-up examination at three years of age, the overall frequency of malformation found in children born after first-trimester rubella was 58 in 425, or 14%-almost exactly the same as in the British series. In the British series audiometric examination of 57 such children revealed that 30% had some hearing loss; this was found in a similar proportion (8 out of 27) in the Swedish series. In addition, an ophthalmoscopic examination was made of 60 of the Swedish children; 12 (20%) were found to have some chorioretinitis, but no details are given of the extent to which sight was affected. As in the British series, there was no clear indication
survey had much in
Manson, M. M., Logan, W. P. D., Loy, R. M. Rep. publ. Hlth. med. Subj., Lond. 1960, no. 101. 2. Lundström, R., Acta pœdiat., Stockh. 1962. suppl. 133. 1.
496 that rubella in the first month was especially teratogenic, the malformation-rates in surviving children being 17%, 17%, and 8% for the first, second, and third months respectively. But Lundstrom points out that infection in the first two weeks after the last menstrual period is, in reality, preconceptional; at that time rubella is probably not teratogenic, and his figures therefore imply a higher rate for malformation in the first two weeks after
conception. In neither series, unfortunately, was the intelligence of the children adequately studied; this is now being investigated in Sweden. But 7% of first-trimester-rubella children, compared with 2% of the controls, showed some delay in acquiring the skills of sitting and standing without support. Moreover, at the follow-up examination, 10% of the rubella children, but only 2% of the controls, were found to have a head circumference more than two and a half standard deviations below the mean value related to height. As in other series, the birth-weights of many of the rubella children suggested immaturity; 36% of those with malformation and 12% of those without (but only 3% of the controls) weighed less than 2500 g. at birth. The birth-weight of 10% of the rubella children lay between 2000 g. and 2500 g., compared with only 1 % of the controls; this was the greatest disparity noted for any weight range. Comparison of the rubella immature with the control immature children was interesting, though limited by the rather small number in the second group. The rubella immature had a longer gestation period, a lower incidence of complications in pregnancy and at delivery, and a lower stillbirth-rate and neonatal deathrate. But a higher proportion of the rubella group were still undersized at the time of the follow-up examination. Among the children of Swedish women exposed to, but not contracting, rubella in pregnancy there was no increase in the frequency of malformation; this was true whether or not the mother had already had rubella before the exposure. Of a group of 251 women exposed to rubella in the first four months of pregnancy who were treated with convalescent y-globulin, the disease developed in 6 (2%). Of the children born of these pregnancies, 3 (1%) had rubella-syndrome defects; but only 1 of these 3 was born to a mother who had contracted rubella in spite of the prophylaxis. Among the 245 mothers who did not contract rubella the abortion-rate and stillbirth-rate were normal; of the 229 liveborn children, only 2 had malformations which could be attributed to rubella. Like the findings reported by Lock et al.3 from the United States, these appear fairly satisfactory. It is difficult to estimate how many women would have contracted rubella if not protected with y-globulin. YOGA
YOGISclaim that they can control essential bodily functions such as the heart-rate. In 1935 Brosse investigated this question in one Yogi, and reported her findings eleven years later.4 While the subject attempted to arrest his heart-beat, a single-lead electrocardiogram (E.C.G.) and a pulse-wave recording were taken; these revealed progressive decrease in the electrical potential, and apparent cessation of the heart-beat for a time. This same Yogi has since been reinvestigated along with three others.55 Electrocardiographic, digital plethysmographic, and 3.
Lock,
F.
R., Gatling, H. B., Wells, H. B. J. Amer. med. Ass. 1961, 178,
711. 4. Main Currents in Modern Thought, 1946, 4, 77. 5. Wenger, M. A., Bagchi, B. K., Anand, B. K. Circulation, 1961,
24, 1314.
tracings were made on a portable electroencephalograph. During attempts to stop or slow the heart, each subject adopted a similar manoeuvre-breath-holding, usually in inspiration, with forcible contraction of abdominal and other muscles against a closed glottis to increase the intrathoracic pressure. In Brosse’s subject (who permitted only limited investigation of the method he employed) this procedure produced some change in potential of the two E.c.G. leads, but the heart-sounds other
still present on auscultation. In two of the other there were changes in the potential of the E.C.G. without any evidence of cardiac arrest. The fourth subject had claimed only that he could slow his heart, and he produced bradycardia with the development of nodal rhythm and some change in potential. These results are in accordance with Anand and Chhina’s earlier report 6 that no cardiac arrest was demonstrable on the E.c.G. Dr. Brosse’s original observation of apparent cardiac arrest on a single-lead electrocardiogram was probably an artefact due to the decreased electrical potential subsequently demonstrated under these circumstances. Many of the associated observations - inaudible breath-sounds, impalpable arterial pulse, and obstruction to the venous return-were probably due to the Valsalva or reversed Valsalva manceuvre which the were
subjects also
Yogis employed. INFORMATION ABOUT VENEREAL DISEASE
CONCERN about the increasing incidence of some venereal diseases has led the Standing Advisory Committee of the Central Health Services Council to review the problem in a bookletwhich has been distributed to all general medical practitioners taking part in the National Health Service. The venereal-disease service was established in 1916, and since then clinics staffed by specialists in venereology have been attached to the outpatient departments of most large general hospitals in the United Kingdom. Venereal disease as defined by statute comprises only syphilis, gonorrhoea, and chancroid; but the clinics deal with all conditions transmitted by sexual intercourse and with some other non-transmissible conditions, so that patients who attend are no longer severely stigmatised as " v.n. patients ". One of the most important functions of the clinic is to act as a centre for investigation, advice, and reassurance of individuals who are anxious but may well be free from infection. In 1960, 130,130 patients attended clinics in England and Wales for advice, but only 37,927 of these were found to have statutory venereal disease. The principles which originally governed the operation of the clinics have been maintained; attendance is entirely confidential, and patients are entitled to attend without doctors’ letters or other introduction. Treatment remains free even to the extent that no charge is made for drugs. Promiscuity, by which venereal disease is spread, is regarded as a symptom of social or marital maladjustment, and many clinics now have skilled almoners or socialservice workers one of whose duties is to assist with difficulties arising from unstable marriages, unwanted pregnancies, homosexuality, and venereophobia. The main problems at present are gonorrhcea and the disease, or group of diseases, commonly called nonAnand, B. K., Chhina, G. S. Indian J. med. Res. 1961, 49, 90. See Lancet, 1961, ii, 90. 7. Venereal Disease Service. Prepared by the Standing Medical Advisory
6.
Committee for the Central Health Services Council and the Minister of Health.