669

the antenatal period and dianng labour are included, since wefeel that they are, to a certain extent, still our responsibility.TOTAL NUMBER OF PREGNANCIES SUPERVISED 566Primiparae ........ 223Multiparae ........ 343

TOTAL NUMBER OF INFANTS BORN .. 574Live births........ 565Stillbirths 9 15-7 per 1000

total birthsXEONATAL DEATHS........ 4 7-1 per 1000

live birthsMATERNAL DEATHS........ 0FORCEPS DELIVERIES ........ 87 15 % of total

birthsBREECH DELIVERIES ........ 8LACERATIONS

First and second degree...... 169Third degree ........ 1Episiotomy 64

POSTPABTUM Haemorrhage ...... 55(This is an approximation, since the blood

lost was not routinely measured.)MANUAL REMOVAL OF THE PLACENTA.... 6BLOOD-TRANSFUSION ........ 2CaeSAREAN SECTION 6(One of these was performed in the cottagehospital, the rest in a specialist hospital.)

PUERPERAL PYREXIAAbove 100’4°F on any occasion ..... 4199°-100’4°F .......... 267

TORIEMIADiastolic blood-pressure 90-99 mm. Hg 110

" ,. " 100-109 mm. Hg 46" " 110 mm. or above 12

POSTNATAL ATTENDANCESOf the last 100 patients, 88 attended post-natally, 2 of the 12 who did not havingleft the district.

CASES REFERRED TO A CONSULTANTSeen by a consultant in the cottage hospital 51 9 % of total

pregnanciesTransferred to a specialist hospital.. 35 6 % of total

pregnanciesReasons for transfer :

pregnancies

Disproportion ...... 9Toxaemia ........ 5Breech ........ 4Placenta prsevia ...... 3Essential hypertension.... 3Posterior position...... 2Bed shortage ...... 2Unstable presentation .... 2Face presentation .... 1Postmaturity ...... 1Prematurity ...... 1Erythroblastosis foetalis .... 1Previous caesarean section .. 1

REFERENCES

British ’Medical Journal (1950) ii, suppl. p. 126.- (1953) ii, suppl. p. 138.

Browne, F. J. (1951) Antenatal and Postnatal Care. London.Hamlin. R. H. J. (1952) Lancet, i, 64.Maternity in Great Britain (1948) London; p. 63.Ministry of Health (1950) Annual report. Part 11 : pp. 105, 107.Neonatal Mortality and Morbidity (1949) Publ. HUh med. Subj.

no. 94, pp. 7, 33.Nicholson, C. (1938) J. Obstet. Gynaec., Brit. Emp. 45, 950.- Allen, H. S. (1946) Lancet, ii, 192.

1. Lancet, March 20, 1954, p. 583.

EARLY CARE OF THE DEAFA SCHOOL FOR MOTHERS

HEARING is a matter of interpreting signals. Anydeaf child who has a trace of hearing left, however small,will get-some signals ; but because they are reduced-often grossly reduced-compared with those reachingother people he finds great difficulty in interpretingthem, and is soon apt to disregard them altogether.What begins as a severe degree of organic deafness maybecome, through neglect, a complete functional deafness-for there are none so deaf as those who won’t hear.Last week Miss Edith Whetnall, F.R.C.s., and Mr. D. B.Fry, PH.D.,l demonstrated the importance of trainingdeaf children very early in life to make full use oftheir residual hearing. As they pointed out, we learnto interpret speech very young. Children of a fewmonths are able to distinguish much from the toneof the voice, and by the end of the second year oflife can use quite a large vocabulary of single wordsand are beginning to construct simple sentences. They

have a still wider vocabulary of words and phraseswhich they understand without attempting to use them.This feat is so familiar to us that we hardly realise howtruly remarkable it is. The deaf child who is not taughtyoung to use what hearing he has misses this importantphase, in which the powers of attending to and interpret-ing auditory signals are extraordinarily acute. Butwho is to teach him, other than his mother ? And howis the mother to acquire the quite complex technique ofgiving him signals he can follow ?

HEARING-AIDS

The Royal National Throat, Nose and Ear Hospitalhas established at Ealing a small school for such mothers- the Hostel for Deaf Children and their Mothers-under the direction of Miss Whetnall. In a comfortablehouse with a garden, the mothers come with theirchildren to stay for three weeks at a time. Four or fivecan be in residence together, and they have continuoustuition and practice in getting their children to under-stand, and perhaps begin to copy, speech. If the mothercan give her child this good start, he reaches his schoolfor the deaf, at the age of four or five, with some of hiswork behind him : he has learnt to lip-read, and he isbeginning to try his tongue at speech. Moreover heis familiar with the use of a hearing-aid, and is thereforeusing what hearing he has.

It is not perhaps generally realised that small childrenare very amenable to the use of a hearing-aid. Theyaccept, without demur, a small plastic earpiece, and donot-as might be expected-continually pull it out.If a child is to wear one steadily, however, he needsa simple harness to carry the microphone and batterybag. Such a harness, easily made at home, has beendevised by the Deaf Children’s Society, who publisha leaflet illustrating the pattern and the stages in itsconstruction.2 2

LEARNING TO LIP-READ

At the Ealing hostel, the children have definite lessonsin lip-reading twice a day. They are taught one at atime by Miss Wendy Galbraith, the headmistress ; butthe other children and their mothers stay in the room,so that the mothers can be watching and learning allthe time. When the school was visited there were fivechildren in it, three of them aged 2 or under. These threehad been deaf from birth or were deafened by illness soonafter. The other two, aged 9 and 7, had also beendeafened by illness-the elder as the result of treatmentfor tuberculous meningitis at the age of 8.

This girl has retained her speech, and she picked up lip-reading while she was in hospital, simply by watching thenurses. She is intelligent, restless, domineering, and anxious-a child with many adjustments to make, but affectionateand longing to succeed, though not very persevering. Fortun-ately her mother, also intelligent and affectionate, is verypersevering. The problem of the teacher, as far as this childwas concerned, was to get her to catch up on the school workwhich her illness has interrupted. She has plenty of ability,but still tires easily and loses interest.A deaf child who has lost interest has a perfect defenceagainst the importunate : he simply removes his eyesfrom the speaker’s face.

Lessons for deaf children who have not yet learntto lip-read or speak have to be planned in a broad way,to get them to attend to the signals coming to them fromthe speaking world. Unless a child is completely deaf-which is rare-some of these signals will be in the formof sound, but because his range of hearing is limitedhe will need to attend closely and have a great deal ofpractice before he can interpret them successfully.He must therefore supplement his defective hearing byattending to signals of other kinds ; and on these hecan begin to build a system of communications.2. Hearing Aid Harness for Young Children. The Deaf Children’s

Society, 1, Macklin Street, London, W.C.2.

670

The teacher’s first task is to get him to watch hermouth. Toys and pictures are used to gain his attention,and as soon as he is interested she brings the toy closeto her own mouth, but to one side. of it, so that her lipsare plain to see. As the child’s eyes follow the toy shespeaks a simple direction to him, like : " Put the duckon the. car." At first she has to show him what iswanted, and say his name : " Peter do it " ; but hesoon begins to connect her lip movements with theinstructions-and this is a first step in lip-reading. Theinstructions are then varied, but the phrases used aresimple, the teacher building always on what he knowsalready. Soon he starts making lip movements on hisown account : "

Bye-bye " is easily seen, and his firstresponsive " B-b-b- " is welcomed warmly by his world :he has got the principle of another means of communica-tion ; and so the work goes on.

THE MOTHER’S RESPONSIBILITY

It is hard work, making great demands on the teacher.During the short period the mother spends in the schoolshe begins to see how every moment in the child’s day

gives her chances of lco’aching him, though it is exactingand tiring to remember to use these chances. She comesto understand that the child, cut off from so manysignals, relies implicitly on those he gets from his mother.She has to learn to school herself, as well-to give uppointing with her finger, for instance (which draws thechild’s attention from her face) and to nod with her headtowards the object she wants to indicate, while at thesame time giving the spoken direction : at first he willobey the nod ; later, when he has learnt to interpretthe smaller signal, she will be able to give’the spokendirection alone.

Any deaf child reaching school after such early trainingis at a considerable advantage. He has learnt muchwhich the other deaf children have still to be taught,and he has learnt it at the time when his mind bendsitself most easily to the task. He may even be fit totake his place in an ordinary school, anyhow after a time,and anything which brings the deaf person into thestream of ordinary life is highly valuable to him.

This is a pioneer school, doing important work. Wehop 3 it is the first of many.

1. Balfour, F. M. Biol. Zbl. 1881, p. 1.2. Henle, J. Z. rat. Med. 1865, 24, 143.3. Kohn, A. Arch. mikr. Anat. 1898, 58.4. Oliver, G., Schäfer, E. A. J. Physiol. 1895, 18, 230.5. Rogoff, J. M., Stewart, G. M. Science, 1927, 66, 327.6. Hartman, F. A., et al. Proc. Soc. exp. Biol., N.Y. 1927, 25 69.7. Pfiffner, J. J., Swingle, W. W. Anat. Rec. 1929, 44, 225.8. Linser, P. Beitr. klin. Chir. 1903, 37, 282.9. Bulloch, W., Sequeira, J. H. Trans. path. Soc. Lond. 1905.

10. Thomas, E. Beitr. path. Anat. 1911, 50, 283.11. Kern, H. Dtsch. med. Wschr. 1911, 37, 971.12. Elliott, T. R., Armour, R. G. J. Path. Bact. 1911, 15, 481.

13. Tähkä, H. Acta pœdiatr., Stockh. 1951, suppl. 81.14. Lanman, J. T. Medicine, Baltimore, 1953, 32, 389.15. Emery, J. L., Stoner, H. B., Whitely, H. J. Arch. Dis. Childh.

1952, 27, 301. Stoner, H. B., Whitely, H. J., Emery, J. L.J. Path. Bact. 1953, 66, 171.

16. See Lancet, Feb. 13, 1954, p. 354.17. Lucadou, W. Beitr. path. Anat. 1938, 101, 197.18. Labhart, A., Spengler, M. Helv. med. acta, 1953, 20, 352.19. Holtz, P., Baohmann, F. Naturwissenschaften, 1952, 39, 116.

Occasional Survey

FŒTAL CORTEX OF THE ADRENAL

GLANDS

THE adrenal glands were described in 1563 byEustachius, but very little additional information wasgained until the middle of the 19th century when Addisondescribed their destruction or atrophy in the diseasewhich bears his name. In the following years Balfour,1Henle,2 Kohn,3 and others established the dual originof the adrenal gland, the cortex originating from theccelomic mesothelium and being homologous with theinter-renal organ of lower fishes, while the medulla hasits origin in ectodermal cells of the neural crest whichmigrate to join the mesodermal component.

Chemical research lagged behind Addison’s discovery,and it was not until 1895 that Oliver and Schifer 4

isolated a pressor substance from the adrenal medulla ;effective cortical extracts were prepared between 1927and 1929 by Rogoff and Stewart,5 Hartman and hisassociates,s and Pfiffner and Swingle. 7 In the followingyears this line of research led, by the work of Kendall,Reichstein, Pfiffner, and their associates, to spectaculardiscoveries which culminated in the isolation of a numberof cortical hormones in crystalline form and the charac-terisation of their action and the relation of theirchemical structure to their biological effects.

. Meanwhile another stimulus for research came from

reports on neoplasms of the adrenal in cases of precociousgrowth, masculinisation, and pseudohermaphroditism.Occasional observations on this syndrome, now generallyknown as the adrenogenital syndrome, date back as faras 1803, but interest in the fcetal and neonatal adrenalgland was awakened only after the report of Linser 8 andparticularly after that of Bulloch and Sequeira.9 A fewyears later Thomas,1o Kern,ll and Elliott and Armour 12almost simultaneously discovered the peculiar involutionwhich takes place in the neonatal adrenal gland. Finally,Selye’s description of the " general adaptation syndrome "and of the changes in the adrenal glands in various

stages of shock. stimulated renewed study of them inneonatal life, in the hope of explaining the low resistanceto all kinds of injury. An exhaustive study of adrenalglands in the first two years of life was published byTahka 13 in 1951 ; Lanman 14 has reviewed the work onthe foetal or transient zone of the adrenal gland, andEmery and his associates 15 have described extensivestudies on the histology and histochemistry of infantileadrenals in various pathological conditions.

Three features make the human adrenal gland uniquein the animal kingdom, except possibly for anthropoids.The first is the postnatal increase in medullary tissuetogether with a differentiation of sympathicogonia intonerve-cells and chromaffin cells. This takes place simul-taneously with the regression of extra-adrenal chromaffintissue, particularly of the organs of Zuckerkandl, so thatthe adrenals become the main factory of pressor amines."The second is the intussusception of the cortex into themedulla so that the former not only surrounds the latter,as it does in most laboratory animals, but also forms aninner layer, the so-called central cortex ; and thus thecortex and medulla are most intimately related. This

phylogenetic feature of continual increase in theanatomical approximation of the two components ofthe adrenal gland-the inter-renal and the suprarenalorgans, as they were named by Balfour 1-from completeseparation in sharks to closest approximation in man, islikely to have some physiological significance. Lucadou 17published histological work which suggested that cortexand medulla form a functional entity, cortical hormonesbeing secreted through gland-like lumina into the

medulla ; and Labhart and Spengler 1a have latelyreported that adrenaline lowers the blood-level ofcortisone and appears to increase the consumption ofcortisone in the target organs. It has been suggestedthat the adrenal cortex manufactures a co-enzyme for

dopa-decarboxylase and is thus essential for the synthesisof the pressor amines of the medulla,19 and that corticalhormones induce the methylation of noradrenaline toadrenaline ; but these hypotheses have not been provedand we- are still far from understanding the cortico-medullary relationship in the adrenal gland.The third feature of the human adrenal gland is the

postnatal involution of the cortex which is associated