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after extraction of A substance, and the smaller thenappear similar to the fine filaments of the I-Z region.If fibrils previously treated with trypsin are extractedin this way, " ghost

" fibrils are left which easily passinto solution ; or if the extraction of A substance isfollowed by the removal of actin, the organised fibrilstructure disappears. Hanson and Huxley, then, presenta picture of discontinuous distribution of myosin fila-ments along the length of the myofibril. These filamentsare aranged in hexagonal arrays across the fibril, withthe actin filaments lying between them and formingthe continuous element of each sarcomere. This con-

ception of the structure of the muscle seems consistentwith established biochemical knowledge. If it can berelated to the contraction mechanism, it will be an

important advance.

1. Simpson, S. L. Lancet, 1938, ii, 557.2. Sorkin, S. Z., Soffer, L. J. Metabolism, 1953, 2, 404.3. Thorn, G. W., Jenkins, D., Arons, W. L., Frawley, T. F. J. clin.

Endocrin. 1953, 13, 957. 4. Relman, A. S., Schwartz, W. B. Yale J. Biol. Med. 1952, 24, 540.5. McConnell, A. A. Brain, 1953, 76, 473.

PREPARATIONS OF DEOXYCORTONE

ONE of the chief aims in treating Addison’s diseasemust be to prevent the depletion of salt from the bodywhich results from the lack of the salt-retaining fractionof the adrenal cortical secretion. This is sometimesachieved simply by giving extra salt. Usually, however,the patient needs also to have a hormonal preparationwhich enables him to retain the salt ; and cortisone,although a valuable adjunct to the treatment of Addison’sdisease, is not a potent salt retainer. This function iscovered by the synthetic steroid, deoxycortone, which,since it was introduced in 1938,1 has been put out inseveral forms.The acetate in oily solution has to be injected each

day or on alternate days ; dissolved in propylene glycolit can be taken sublingually, but this is a rather extrava-gant way of giving the drug. Pellets of the acetate canbe implanted ; and a single implant usually lasts sixmonths or longer. The glucoside of deoxycortone iswater-soluble ; this form is useful in meeting theoccasional need for rapid action.New esters may now supersede the others in the

maintenance treatment of Addison’s disease.2 3 Theseare aqueous suspensions of microcrystals of the trimethyl-acetate or of the phenylacetate of deoxycortone. A

single injection of the trimethylacetate lasts five to sixweeks and releases about a fortieth of its dose daily.Of 45 patients followed for six months, most required aninjection of 60 mg. monthly ; the range of doses was15-90 mg. monthly.3 The effects were similar to those ofthe acetate, but obviously the long-acting microcrystallinepreparation is very much more convenient. At leastthose patients who are having daily injections ofdeoxycortone acetate will be glad to change to the newpreparation if they can be maintained with it. In regula-ting the dose it is worth recalling that the effect of a

given dose of deoxycortone probably depends on theamount of salt the patient is receiving.4

POSTTRAUMATIC SYNDROME

MOST of those familiar with the methods commonlyused for reabling patients who have had a head injurywould agree that the posttraumatic syndrome withheadache, giddiness, and various psychological symptomshas become less common, and that, in the absence ofserious brain damage, it generally indicates inadequatesupervision and reablement before the patient hasresumed work. Professor McConnell,5 however, takes adifferent view. For many years it has been his practiceto operate on patients who are not getting on well aftera head injury, whatever their symptoms. Of 75 suchcases " 20 complained of headache, 7 of headache and

giddiness and 38 of headache, giddiness and somemeasure of mental disability ... many were depressed... 10 were compensation cases with litigation out- astanding." In 65 of these 75 cases he found at operation =-an accumulation of fluid in the subdural space, andwhere this was found " the results of its removal were ‘=

uniformly good even when the symptoms had persistedfor years." At operation the brain was often tight andbulged into the trephine opening. In such cases the

--

" subdural " fluid was not at first obvious ; but if a "raspatory was slipped under the dura in several directionsthe fluid would well up and the brain would relax. =

Professor McConnell thinks that the fluid he findsoriginates in a cerebrospinal-fluid leak into the subduralspace ; and in support of this view he has demonstratedair in the subdural space twenty-four hours after airencephalography. He now dispenses, however, with airencephalography in these cases and makes burr-holes inthem all. -

Professor McConnell put forward these opinions in1941 6 ; but they have not been widely accepted, andthis latest account contains little fresh evidence. Thusthere is no detailed comparison of the frequency ofsubdural air after encephalography in traumatic and innon-traumatic cases. A puzzling feature is the almostconstant finding of a tight brain, which is at variancewith the experience of other surgeons ; and one wonderswhat anaesthesia was used. The dramatic cure whichMcConnell reports in 9 out of 10 compensation casesmight testify more to his personality than to his opera-tion, especially as the wounds were reopened as often asnecessary if the symptoms recurred. The nature andvolume of the fluid is unfortunately reported for only afew cases in which the protein content was very high,and it is not clear whether these cystic collections werefound in the early or in the late cases.

There are many doubts about the mechanism of someof the postconcussional symptoms ; and evidently, whenthey have been allowed to develop, they can be cured inmany different ways. In this type of case the assessmentof separate remedies is extremely difficult.

6. J. Neurol. Psychiat. 1941, 4, 237.7. Report of the Ministry of Health, 1952. Part II : On the State

of the Public Health. H.M. Stationery Office, 1953.8. Hall, G. F. M., Cunliffe, A. C., Dudgeon, J. A. J. Path. Bact.

1953, 66, 25.9. Laurance, B., Cunliffe, A. C., Dudgeon, J. A. Arch. Dis. Childh.

1952 27, 482

PROLONGED GENERALISED VACCINIA

GENERALISED vaccinia is a rare complication of primaryvaccination. In England and Wales in 1952, it apparentlyarose in 1 in 20,000 primary vaccinations.’ Its incidenceis much greater in people with skin disease, especiallyeczema, than in those with healthy skins. In the latterthe secondary lesions of generalised vaccinia maturein the same way as the primary lesion, but rather morerapidly owing to increasing formation of antibody;thus all the lesions tend to regress simultaneously.This is " typical generalised vaccinia." The secondarylesions are undoubtedly viræmic metastases, whichbecome established as a result of unusually poor capacityfor antibody formation.

Hall, Cunliffe, and Dudgeon 8 now present the patho-logical findings of an extreme case, already reported byLaurance et awl. in which there was virtually completefailure of specific antibody formation. The result wasnumerous scattered secondary vaccinal lesions on theskin which did not heal, became ulcerated, and spreadto become large deep sores. Ultimately the patient died;and numerous necrotic foci up to 2 mm. in diameter werefound in the lungs, liver, kidneys, adrenals, and pancreas,but not in the spleen. Although no inclusion bodies werefound in these foci, there was every reason to regard them

37

as true secondary vaccinal lesions ; the virus was recoveredby egg culture from most of them. Serum-antibodytitres were less than 1 in 10 by both the complement-fixation and the haemagglutinin-inhibition tests, and theneutralisation test was also negative. Hall and his

colleagues refer to two similar reported cases in whichno circulating antibody was found. Their case is oneof " prolonged generalised vaccinia" a term appliedto such extreme cases, by Laurance et al.9 who havecited two published and three unpublished instances.They point out that similar small necrotic lesions havebeen found in the organs (except the spleen) in smallpoxand in the experimental generalisad vaccinia of rabbitslO 11;and that similar generalised lesions, except for obviousintramuscular inclusions, may be found in herpes simplex.Fortunately this type of case is very rare, probablyabout as rare as the odd case of the patient who has hadsmallpox three times.

10. Lillie, R. D. Arch. Path. 1930, 10, 241.11. Lillie, R. D., Armstrong, C. Pathology of Generalised Vaccinia

in Rabbits. National Institute of Health Bulletin no. 156.Washington, 1930.

12. Interrelations between the Social Environment and PsychiatricDisorders. New York: Milbank Memorial Fund. 1953.Pp. 263. $1.50.

13. King Solomon’s Ring. London, 1952.

SOCIETY AND SELF

" WHAT if this might be true in human beings ? "This is a fair question, Mr. J. P. Scott thinks, for thebiologist studying the social behaviour of animals toask himself. He was discussing, at the 1952 annualconference of the Milbank Fund (the report of which hasjust been published 12), the effect in animals of the timefactor on the process of learning social behaviour.Konrad Lorenz,13 in an experiment which has givenwidespread pleasure, showed that goslings allowed tohatch in the absence of a goose will follow the experi-menter so long as he gives a passable imitation of goosebehaviour ; and their attachment to him, if it is allowedto last for a few days, is almost impossible to break.Such goslings are virtually unable afterwards to becomeattached to a goose : the moment for forming such anattachment has passed, and the bond has been forgedinstead with a member of another species. Scott hada similar experience with orphan lambs. One of these,taken from the flock for ten days and fed by humanson the bottle, took little notice of the other sheep on herreturn, and soon became a lamb who walked by herself.She never ran from people or dogs, never followed theleader ; and when she became a mother in her turn shenever troubled to call her lamb, so that it was alwaysgetting lost and became an exceptionally nervous type.Lambs take the bottle well, but the substitute parenthas a different problem with a puppy, which is bornblind, deaf, and capable of only reflex behaviour. Oncontact with the nipple it sucks, and on being lickedby its mother it urinates and defaecates. It is difficultto get it to respond to substitute stimuli, and unless itresponds it dies. Its eyes open at 10 days, its ears at3 weeks-and not until then does it show the startle

response. During the first 14 days it seems incapableof learning anything, or of being conditioned in any way.After that it responds uncertainly for a few days, andthen at the age of about 3 weeks it suddenly beginsto respond readily to conditioning, and learns fast. Itis from this time onwards, Scott suggests, that the firstreal social relationships of the puppy are probablyformed. Because the early developmental periods of

dogs are so clear-cut he thinks they are particularlysuitable for experiments on the effects of early experience ;and he has already done some work showing the differentpatterns of behaviour to be expected from dogs whichhave been in close and friendly contact with humansduring their early weeks, and those raised by themselves

in a large field, with few human contacts. The secondgroup showed strong " avoidance reactions "-that is,they were more timid and harder to control than thefirst group, even though they were then taken into thecompany of humans. They resemble Lorenz’s goslings,in that once the " now-or-never " period is past it ishard to get the same results. The guineapig, too, hasa critical period for at least one type of social learning :it is born much more mature than a puppy, but if it istaken away from its mother for the first 3 days of itslife and then returned, it nestles against her but neverlearns to suck. What if humans have similar now-or-never periods in their early development ? Bowlby’sobservations on infants deprived of their mothers suggestsstrongly that they have ; and Scott believes that if wecould form more precise ideas of their nature andduration, we could say to the mother : "Look. Youcan do this to your baby at such-and-such an age, butit is quite dangerous to do it in another age becausethese definite things will happen." This might meanuseful progress in preventive mental hygiene.

Mr. William Henry pointed out another promisingline leading towards this desirable goal : instead of

studying the process of becoming mentally ill we mightstudy more closely the process of becoming well fromthe initial base-point of already having been ill. We

might also examine the processes by which some peoplefaced with stress survive it with advantage, whereasothers faced with similar stresses fall mentally sick. Ashe said, " the life stories of so many successful peopleread like the life stories of so many schizophrenic people."Stress of one sort or another is the human lot ; butthere is, he suggested, a flight into health as well as aflight into ill health, and it would be nice to know howit is done.

In part, of course, it must be influenced by the responseof the society in which the subject lives. Rejection bysociety, and the sense of loneliness it brings, are verydamaging ; which accounts for the stress experiencedby those who move into a new community. Dr. MarieJahoda mentioned two behaviour tendencies which canbe taken as criteria of mental health in such a situation :first, the tendency to face the problem, and secondlythe tendency to perceive it clearly without distorting itby one’s own needs. Facing the problem includes seekingsolutions and following them up. Neither a passiveacceptance of failure, nor a continued sense of the urgencyof the problem unaccompanied by adequate attempts tosolve it, can be regarded as mentally healthy. Some-

times, however, a person’s incompetent behaviour maybe such as to change a hostile society to a sympatheticone. Such was the case with a Guatamalan patient,named Maria, described by Mr. Benjamin D. Paul.Maria’s behaviour was so extravagant, provocative, andundisciplined as to set her whole family and society bythe ears ; at which point she escaped into psychosis.This shocked all about her into sympathy and guilt(for local beliefs encouraged everyone to think thatsome member of the family, and not necessarily Mariaherself, was to blame) ; and they rallied round so

effectively that she made a good recovery and retainedthe sympathy of all her friends. It is worth notingthat she was not required, by the culture in which shelived, to feel any guilt herself. Perhaps it is a weaknessas well as a strength, of modern psychiatry that it hasgiven us so much insight into our own self-seeking. Inthe last century Charles Darwin and Florence Nightingalecould have their neuroses without exciting censure, tothe great advantage of the rest of us. Nowadays, theirguilt might have got them off their sofas, and incapaci-tated them for their proper work. True, theirs wereconstructive neuroses of unusual type ; but it is worth

considering whether guilt over our neurotic motives isnot in itself a cause of neurosis.