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THE BLOOD-SUGAR IN CHILDHOOD.
1088
ANNOTATIONS THE MINISTER OF HEALTH.
Sir Edward Hilton Young, who has become Minister of Health with a seat in the Cabinet, has been closely associated with medicine as Crown nominee since 1926 on the General Medical Council, and for the last three years a member of its executive committee. Although the Medical Act of 1858 requires only the representatives on the Council of the medical corporations to be qualified for registration under the Act, up to the time of Sir Hilton’s appointment no layman had actually sat on the Council. His name was put forward by the Privy Council as a result of strong feeling in Parliament that there should be some member of the Council to " represent the public," as this feeling was vividly if a little loosely expressed. Sir Hilton is a man of law and a man of letters who has served his country in many capacities, of which the most heroic was on the Vindictive at Zeebrugge Mole in 1918, when he was severely wounded. He has been on financial missions to India, Poland, and Iraq, three times delegate to the Assembly of the League of Nations, and chairman of the Royal Commission on the constitution of London University. Formerly Liberal M.P. for Norwich, he has since 1929 represented the Sevenoaks division of Kent as a Conservative. No appointment could have been more acceptable to the medical profession.
haamatomas of various sizes. He notes. the haemorrhage occurred during the.. development stage and in 26 during involution, but he thinks that some of the 26 probably started during development of the lutein body and that furtherbleeding took place during retrogression. General hypersemia of the ovary is, he considers, the underlying feature of this excessive haemorrhage, and he attributes it to associated pelvic disorders. Thus he found salpingitis in 27 out of his 32 cases and fibroids. in three, and he supposes " static factors retroversion of the uterus and prolapse of the ovaries. -in the remaining two. These findings are not, borne out by other observers ; Wilson’s cases, for instance, were in perfectly healthy young women with no suggestion of pelvic inflammation. It. seems likely therefore that while this condition may coexist with pelvic inflammation, we must look further for the underlying cause. Perhaps the most likely explanation of the haemorrhages is that they are the result of sudden outbursts of activity of the ovary-perhaps under the influence of the pituitary gland. They are reminiscent of the haemorrhagic. follicles produced in animals by injection of the urine of pregnancy, in the Zondek-Aschheim test.
containing
that in six
OVARIAN HÆMORRHAGE.
ovarian blood cyst is is generally supposed. Of late years in this country R. K. Wilson1 has reported six cases at the London Hospital, and D. Levi2 three at St. Mary’s, while on p. 1068 of our present issue Mr. Hodgson Boggon and Mr. A. J. Wrigley describe 13 seen at St. Thomas’s. These and other writers are all impressed by the difficulty of distinguishing the ovarian haemorrhage from acute appendicitis. Evidently diagnosis is usually impossible before operation, and since the HAEMORRHAGE from
probably
commoner
an
than
only other condition likely to give the same symptoms is an ectopic pregnancy, it is well to be on the safe side and operate if in doubt. Moreover, although this kind of bleeding may clear up without intervention it is sometimes quite copious (F. B. Block 3). Its origin has of course been much disputed, and the suggestion has been made that it represents an exaggeration of the normal process of rupture of the Graafian follicle. But several investigators, notably Wilfred Shaw4 have shown that rupture of the follicle and extrusion of the ovum is not accompanied by hsemorrhage into the central cavity, and that the corpus luteum is therefore in its earliest stages free from blood. During the stage of vascularisation, as the corpus luteum develops, a minute amount of bleeding normally does take place, to be organised and absorbed by the rapidly growing cells of the membrana granulosa, and again during the stage of involution there may be further slight haemorrhage. The reason why these minute physiological hoemorrhages should reach alarming proportions has been studied among others by S. A. Wolfe5 who has examined 32 ovaries removed at operation, all 1 THE LANCET, 1928, i., 1221. Brit. Med. Jour., 1929, ii., 641. 3 Amer. Jour. Obst. and Gyn., 1930, xix., 102. 4 Jour. Obst. and Gyn. Brit. Emp., 1927, xxxiv., 300 and 469. 5 Amer. Jour. Obst. and Gyn., 1928, xv., 513.
cases
THE BLOOD-SUGAR IN CHILDHOOD.
THOUGH the blood-sugar of adults has been closely studied in a great number of conditions, our knowledge of the corresponding physiological and pathological variations in infancy and childhood is still far from complete. Since metabolism in early life is known. to differ in many respects from metabolism in the., adult, it is clearly desirable that information about, the normal carbohydrate mechanism in different. age-groups should be collected so that we may assess the significance of our findings in disease. E. Svengaard has therefore made a valuable contribution in her extensive study1 of the blood-sugar, both in the fasting state and after glucose administration, in groups of children from 4 days to 13 years of age. She confirms the findings of several previous observers that the average fasting blood-sugar in early infancy is slightly lower (circa 0-08 per cent.) than in later childhood, when it approaches moreclosely to the adult figure, and she shows by repeated estimation in the same individual that variations in fasting blood-sugar tend to appear as broad waves rather than as sudden changes. She records a relatively slight rise in blood-sugar following theadministration of 2 g. glucose per kg. in the newborn period, whereas in the first year of life valuesabove 0-200 per cent. (with a duration of hyperglycsemia of under two and a half hours) are frequent. Four cretins investigated showed a somewhat slow rise in the blood-sugar curve before treatment, but marked hyperglycaemia after administration of thyroid. The findings of most interest from the pathological standpoint, however, are those in the coeliac state.. A. B. McLean and R. C. Sullivan2 and more recently 0. Macrae and N. Morris3 have described a flat type of curve in this disease, which, the latter authors show, contrasts with the normal rise in blood-sugar after a glucose test-meal seen in non-coeliac steatorrhcea. They favour the view that the cceliac curve-
2
1 Acta Pædiatrica, 1931, vol. xii., suppl. iv., p. 245, Copenhagen. 2 Amer. Jour. Dis. Child., 1929, xxxviii., 16. 3 Arch. Dis. Childhood, 1931, vi., 75.
INTOLERANCE IN PSYCHIATRY.
absorption of glucose. Svengaard confirms these findings, both with regard to the - cceliac and non-cceliac conditions. It appears that the blood-sugar curve may therefore prove useful in confirming a diagnosis of cceliac disease, though -further estimations are clearly needed both in the .active and latent periods of the disease.
is due to defective
THE BROAD TAPEWORM IN NORTH AMERICA.
THE spread of Diphyllobothrium latum in North America has exercised a good deal of attention during -the last three years.’2 As reported by our correspondent in the United States, in THE LANCET of Sept. 12th, .a further contribution to our knowledge has now been made by Thomas B. Magath and Hiram E. Essex.3 Examination of Minnesota waters has shown that the Mississippi watershed is free from infected fish, but that these are present in certain lakes which drain either into Lake Superior or through Lake Winnipeg into Hudson Bay. As to the likelihood of infection being carried down waterways, it has been found that development from the tapeworm egg will not occur at 4° C., and that this is the temperature which obtain at the bottom of the Great Lakes throughout the year. Lake Winnipeg, however, is in a state of continual turnover, its temperature is at most times suitable for larval development, it receives a large .amount of sewage, and its fish are more heavily infected that those from the Great Lakes, especially at its head or southern end. The free-living coracidium lives for 12 hours only after escaping from the egg, even in sheltered laboratory conditions, but as soon as it enters the arthropod intermediate host larval development proceeds and continues for .at least two weeks. There is, then, opportunity for considerable dissemination of these infected - creatures whether by passive transportation or active migration, and it should be noted that these writers Tiave added Diaptomus sicilis and D. siciloides to the arthropod hosts in which the coracidium can develop. As regards animals other than man which harbour the adult tapeworm, Magath and Essex have in the press evidence that while 80 per cent. of eggs from man develop active coracidia, only 1-5 per cent. of eggs from the dog do so. They accordingly - conclude that man is the essential source of infection for man, and sewage the means by which that infection begins its complicated chain. This, however, does not necessarily follow. For example, dealing with malaria, E. Walch and B. Walch-Sorgdrager4 showed that although in Sumatra the mosquito Anopheles - ludlowi was about 12 times more often infected with these parasites in nature than was A. sinensis, yet since the latter outnumbered the former about 120 times, it was about ten times more dangerous to man locally than A. ludlowi. Similarly, since Vergeer 2 has found as many as 19 specimens of this tapeworm in one dog, it is unwise to assume than the part played by the dog in spreading infection to man is - necessarily insignificant. But while this point remains to be settled, it is clear that adequate treatment of sewage must be held a prime factor in the prevention of dissemination. The complete avoidance of the mating of improperly cooked fish is a simple and certain personal preventive ; while if public measures be demanded, it is pointed out that the proper freezing of fish imported from Canada to the United States will
1089
prove effective, since a temperature of -9° C. maintained for 48 hours kills all the plerocercoids in their flesh, and so prevents this, the infective stage, from reaching and parasitising man. These writers cannot agree then with Vergeer’s suggestion that there is need for an embargo on the importation of susceptible fish into the United States from Canada, since by freezing these can be made quite safe. It is further clear that their investigations have made it possible, if not probable, that infection in Canadian fish is itself to some extent water-borne from the United States, so that the imposition of such an embargo would prove particularly difficult to justify.
INTOLERANCE IN PSYCHIATRY.
Bernard Hart’s appeal for tolerance and cooperation between all who are attacking the problems of psychiatry strikes a welcome note. Few things in medicine to-day are more distressing than the internecine strife of units that ought to be advancing together against the gravest health problem of our time. Nations are beginning to realise that the preservation of life is not the one thing of importance to a people ; what really matters is the kind of life that is preserved. A dozen living persons suffering from mental disorder and inability to adapt to their environment may cause a community far more damage than the loss of a hundred lives from cancer or tuberculosis. Mental disorder of every kind, major and minor, is on the increase, and there are a dozen promising lines of approach to its prevention and cure. These methods range from the estimation of the blood cholesterol on the one hand to an intimate personal relationship on the other hand. It is impossible at this stage to say which is ultimately going to prove the most successful. It is extremely improbable that any one method will succeed in every case or that any one method alone, without the others, is to be trusted for any case. Yet there seems to be in this branch of medicine a peculiar difficulty in understanding the principles or even in admitting the claims of any practitioner belonging to a different group. Greater extremes of intolerance are met here than in any other branch of medicine. The mental hospital superintendent will point mockingly to the " results " of psychoanalysis that he has received into his wards, and the psycho-analyst will sneer at the " archaic " methods employed in mental hospitals. To say that these are extreme instances is no mitigation ; they ought not to be possible at all in the face of the grave problem that superintendent and psychoanalyst alike are attempting to elucidate. The two should instead be making every effort to meet and talk over the patient whom they have in common with a frank readiness to confess mistakes and failures which ought to be no disgrace at this early stage of the development of psychological medicine. There is one point of agreement between these two schools, and that is their united condemnation of those who approach the problem from yet a third point of view, the point of view which has been named " mystical" as a term of reproach, though the term might well be accepted as one of reverent admiration. Here again Dr. Hart has said something Dr
that greatly needed saying. He has pointed out the essential mysticism in the modern developments of that which has always seemed its antithesis1 See THE LANCET, 1928, ii., 337. the higher mathematics, and that the much-vaunted 2 Ibid., 1929, ii., 780. 3 Jour. Prev. Med., 1931, v., 227. methods of science are after all only one approach 4 Meded. Burgerlijk Geneesk. Dienst in Nederl.-Indië, 1921, to the knowledge of mankind. Pt. 2, p. 2. What, after all,
ANNOTATIONS THE MINISTER OF HEALTH.
Sir Edward Hilton Young, who has become Minister of Health with a seat in the Cabinet, has been closely associated with medicine as Crown nominee since 1926 on the General Medical Council, and for the last three years a member of its executive committee. Although the Medical Act of 1858 requires only the representatives on the Council of the medical corporations to be qualified for registration under the Act, up to the time of Sir Hilton’s appointment no layman had actually sat on the Council. His name was put forward by the Privy Council as a result of strong feeling in Parliament that there should be some member of the Council to " represent the public," as this feeling was vividly if a little loosely expressed. Sir Hilton is a man of law and a man of letters who has served his country in many capacities, of which the most heroic was on the Vindictive at Zeebrugge Mole in 1918, when he was severely wounded. He has been on financial missions to India, Poland, and Iraq, three times delegate to the Assembly of the League of Nations, and chairman of the Royal Commission on the constitution of London University. Formerly Liberal M.P. for Norwich, he has since 1929 represented the Sevenoaks division of Kent as a Conservative. No appointment could have been more acceptable to the medical profession.
haamatomas of various sizes. He notes. the haemorrhage occurred during the.. development stage and in 26 during involution, but he thinks that some of the 26 probably started during development of the lutein body and that furtherbleeding took place during retrogression. General hypersemia of the ovary is, he considers, the underlying feature of this excessive haemorrhage, and he attributes it to associated pelvic disorders. Thus he found salpingitis in 27 out of his 32 cases and fibroids. in three, and he supposes " static factors retroversion of the uterus and prolapse of the ovaries. -in the remaining two. These findings are not, borne out by other observers ; Wilson’s cases, for instance, were in perfectly healthy young women with no suggestion of pelvic inflammation. It. seems likely therefore that while this condition may coexist with pelvic inflammation, we must look further for the underlying cause. Perhaps the most likely explanation of the haemorrhages is that they are the result of sudden outbursts of activity of the ovary-perhaps under the influence of the pituitary gland. They are reminiscent of the haemorrhagic. follicles produced in animals by injection of the urine of pregnancy, in the Zondek-Aschheim test.
containing
that in six
OVARIAN HÆMORRHAGE.
ovarian blood cyst is is generally supposed. Of late years in this country R. K. Wilson1 has reported six cases at the London Hospital, and D. Levi2 three at St. Mary’s, while on p. 1068 of our present issue Mr. Hodgson Boggon and Mr. A. J. Wrigley describe 13 seen at St. Thomas’s. These and other writers are all impressed by the difficulty of distinguishing the ovarian haemorrhage from acute appendicitis. Evidently diagnosis is usually impossible before operation, and since the HAEMORRHAGE from
probably
commoner
an
than
only other condition likely to give the same symptoms is an ectopic pregnancy, it is well to be on the safe side and operate if in doubt. Moreover, although this kind of bleeding may clear up without intervention it is sometimes quite copious (F. B. Block 3). Its origin has of course been much disputed, and the suggestion has been made that it represents an exaggeration of the normal process of rupture of the Graafian follicle. But several investigators, notably Wilfred Shaw4 have shown that rupture of the follicle and extrusion of the ovum is not accompanied by hsemorrhage into the central cavity, and that the corpus luteum is therefore in its earliest stages free from blood. During the stage of vascularisation, as the corpus luteum develops, a minute amount of bleeding normally does take place, to be organised and absorbed by the rapidly growing cells of the membrana granulosa, and again during the stage of involution there may be further slight haemorrhage. The reason why these minute physiological hoemorrhages should reach alarming proportions has been studied among others by S. A. Wolfe5 who has examined 32 ovaries removed at operation, all 1 THE LANCET, 1928, i., 1221. Brit. Med. Jour., 1929, ii., 641. 3 Amer. Jour. Obst. and Gyn., 1930, xix., 102. 4 Jour. Obst. and Gyn. Brit. Emp., 1927, xxxiv., 300 and 469. 5 Amer. Jour. Obst. and Gyn., 1928, xv., 513.
cases
THE BLOOD-SUGAR IN CHILDHOOD.
THOUGH the blood-sugar of adults has been closely studied in a great number of conditions, our knowledge of the corresponding physiological and pathological variations in infancy and childhood is still far from complete. Since metabolism in early life is known. to differ in many respects from metabolism in the., adult, it is clearly desirable that information about, the normal carbohydrate mechanism in different. age-groups should be collected so that we may assess the significance of our findings in disease. E. Svengaard has therefore made a valuable contribution in her extensive study1 of the blood-sugar, both in the fasting state and after glucose administration, in groups of children from 4 days to 13 years of age. She confirms the findings of several previous observers that the average fasting blood-sugar in early infancy is slightly lower (circa 0-08 per cent.) than in later childhood, when it approaches moreclosely to the adult figure, and she shows by repeated estimation in the same individual that variations in fasting blood-sugar tend to appear as broad waves rather than as sudden changes. She records a relatively slight rise in blood-sugar following theadministration of 2 g. glucose per kg. in the newborn period, whereas in the first year of life valuesabove 0-200 per cent. (with a duration of hyperglycsemia of under two and a half hours) are frequent. Four cretins investigated showed a somewhat slow rise in the blood-sugar curve before treatment, but marked hyperglycaemia after administration of thyroid. The findings of most interest from the pathological standpoint, however, are those in the coeliac state.. A. B. McLean and R. C. Sullivan2 and more recently 0. Macrae and N. Morris3 have described a flat type of curve in this disease, which, the latter authors show, contrasts with the normal rise in blood-sugar after a glucose test-meal seen in non-coeliac steatorrhcea. They favour the view that the cceliac curve-
2
1 Acta Pædiatrica, 1931, vol. xii., suppl. iv., p. 245, Copenhagen. 2 Amer. Jour. Dis. Child., 1929, xxxviii., 16. 3 Arch. Dis. Childhood, 1931, vi., 75.
INTOLERANCE IN PSYCHIATRY.
absorption of glucose. Svengaard confirms these findings, both with regard to the - cceliac and non-cceliac conditions. It appears that the blood-sugar curve may therefore prove useful in confirming a diagnosis of cceliac disease, though -further estimations are clearly needed both in the .active and latent periods of the disease.
is due to defective
THE BROAD TAPEWORM IN NORTH AMERICA.
THE spread of Diphyllobothrium latum in North America has exercised a good deal of attention during -the last three years.’2 As reported by our correspondent in the United States, in THE LANCET of Sept. 12th, .a further contribution to our knowledge has now been made by Thomas B. Magath and Hiram E. Essex.3 Examination of Minnesota waters has shown that the Mississippi watershed is free from infected fish, but that these are present in certain lakes which drain either into Lake Superior or through Lake Winnipeg into Hudson Bay. As to the likelihood of infection being carried down waterways, it has been found that development from the tapeworm egg will not occur at 4° C., and that this is the temperature which obtain at the bottom of the Great Lakes throughout the year. Lake Winnipeg, however, is in a state of continual turnover, its temperature is at most times suitable for larval development, it receives a large .amount of sewage, and its fish are more heavily infected that those from the Great Lakes, especially at its head or southern end. The free-living coracidium lives for 12 hours only after escaping from the egg, even in sheltered laboratory conditions, but as soon as it enters the arthropod intermediate host larval development proceeds and continues for .at least two weeks. There is, then, opportunity for considerable dissemination of these infected - creatures whether by passive transportation or active migration, and it should be noted that these writers Tiave added Diaptomus sicilis and D. siciloides to the arthropod hosts in which the coracidium can develop. As regards animals other than man which harbour the adult tapeworm, Magath and Essex have in the press evidence that while 80 per cent. of eggs from man develop active coracidia, only 1-5 per cent. of eggs from the dog do so. They accordingly - conclude that man is the essential source of infection for man, and sewage the means by which that infection begins its complicated chain. This, however, does not necessarily follow. For example, dealing with malaria, E. Walch and B. Walch-Sorgdrager4 showed that although in Sumatra the mosquito Anopheles - ludlowi was about 12 times more often infected with these parasites in nature than was A. sinensis, yet since the latter outnumbered the former about 120 times, it was about ten times more dangerous to man locally than A. ludlowi. Similarly, since Vergeer 2 has found as many as 19 specimens of this tapeworm in one dog, it is unwise to assume than the part played by the dog in spreading infection to man is - necessarily insignificant. But while this point remains to be settled, it is clear that adequate treatment of sewage must be held a prime factor in the prevention of dissemination. The complete avoidance of the mating of improperly cooked fish is a simple and certain personal preventive ; while if public measures be demanded, it is pointed out that the proper freezing of fish imported from Canada to the United States will
1089
prove effective, since a temperature of -9° C. maintained for 48 hours kills all the plerocercoids in their flesh, and so prevents this, the infective stage, from reaching and parasitising man. These writers cannot agree then with Vergeer’s suggestion that there is need for an embargo on the importation of susceptible fish into the United States from Canada, since by freezing these can be made quite safe. It is further clear that their investigations have made it possible, if not probable, that infection in Canadian fish is itself to some extent water-borne from the United States, so that the imposition of such an embargo would prove particularly difficult to justify.
INTOLERANCE IN PSYCHIATRY.
Bernard Hart’s appeal for tolerance and cooperation between all who are attacking the problems of psychiatry strikes a welcome note. Few things in medicine to-day are more distressing than the internecine strife of units that ought to be advancing together against the gravest health problem of our time. Nations are beginning to realise that the preservation of life is not the one thing of importance to a people ; what really matters is the kind of life that is preserved. A dozen living persons suffering from mental disorder and inability to adapt to their environment may cause a community far more damage than the loss of a hundred lives from cancer or tuberculosis. Mental disorder of every kind, major and minor, is on the increase, and there are a dozen promising lines of approach to its prevention and cure. These methods range from the estimation of the blood cholesterol on the one hand to an intimate personal relationship on the other hand. It is impossible at this stage to say which is ultimately going to prove the most successful. It is extremely improbable that any one method will succeed in every case or that any one method alone, without the others, is to be trusted for any case. Yet there seems to be in this branch of medicine a peculiar difficulty in understanding the principles or even in admitting the claims of any practitioner belonging to a different group. Greater extremes of intolerance are met here than in any other branch of medicine. The mental hospital superintendent will point mockingly to the " results " of psychoanalysis that he has received into his wards, and the psycho-analyst will sneer at the " archaic " methods employed in mental hospitals. To say that these are extreme instances is no mitigation ; they ought not to be possible at all in the face of the grave problem that superintendent and psychoanalyst alike are attempting to elucidate. The two should instead be making every effort to meet and talk over the patient whom they have in common with a frank readiness to confess mistakes and failures which ought to be no disgrace at this early stage of the development of psychological medicine. There is one point of agreement between these two schools, and that is their united condemnation of those who approach the problem from yet a third point of view, the point of view which has been named " mystical" as a term of reproach, though the term might well be accepted as one of reverent admiration. Here again Dr. Hart has said something Dr
that greatly needed saying. He has pointed out the essential mysticism in the modern developments of that which has always seemed its antithesis1 See THE LANCET, 1928, ii., 337. the higher mathematics, and that the much-vaunted 2 Ibid., 1929, ii., 780. 3 Jour. Prev. Med., 1931, v., 227. methods of science are after all only one approach 4 Meded. Burgerlijk Geneesk. Dienst in Nederl.-Indië, 1921, to the knowledge of mankind. Pt. 2, p. 2. What, after all,