459

and the author uses it ruthlessly to explain thehypoglycsemia he discovered in one of six cases

described. He points out that the fasting blood-sugar is also low in Addison’s disease, as Porges firstdescribed, and that the other symptoms of thatcondition bear a close resemblance to those of sclero-derma. If nothing very positive has emerged fromthis report, it will at least create fresh interest, andlead us to regard with scepticism the almost acceptedaetiology of scleroderma on an endocrine basis.

TUBERCULOUS INFECTION IN INFANCY.

USEFUL information has been obtained from aninvestigation 1 entrusted to Miss M. A. Asserson bythe New York Tuberculosis and Health Association.The three-fold object was to ascertain the incidenceof tuberculosis among groups of infants in a large city,to determine the relation of exposure to infection, andto discover what was the significance and course ofinfection in very early life. The procedure adoptedincluded a study of hospital and clinic records.covering a period of five years, of all infants who hadbeen treated at two hospitals for various ailments andwho had had routine tuberculin skin tests at the timeof their admission. Skin tests were also employed todetermine the incidence of infection among the generalinfant population, being carried out both at clinicsand at health stations. It was found that in thehospital group 8’2 per cent. of cases (excluding thosewith tuberculous disease) gave a positive result,whereas the percentage at the clinics was 4’5 andamong the healthy babies at the stations it was only1-3. This shows that tuberculin statistics based uponhospital experience alone should not be accepted asapplicable to the general child population. The rateof positive reactions was higher in Manhattan ehan inBronx, which is in agreement with the conclusions ofthe Framingham investigators that the incidence oftuberculous infection is highest in poor districts. Thenext step was to ascertain the after-history of 460hospital infants who had yielded positive tuberculintests, and the cases were divided into the followinggroups :-

I.-Infants suffering from advanced tuberculosis (pul-monary, miliary, or meningeal), 112 cases. Of these, 96 percent. died soon after admission to hospital.

II.-Infants suffering from tuberculosis of bones andjoints or glands, 32 cases. Of these, 32 per cent. were foundto be dead, of whom just over half were stated to have diedfrom tuberculosis.

III.-These had yielded positive skin tests but no clinicalevidence of disease, 316 cases. Skiagrams suggested enlarge-ment of tracheo-bronchial glands in 61 cases. Of these,6-5 per cent. had died of tuberculosis, 14-5 per cent. fromother causes. Of the remainder (207), 39 per cent. had diedbut death was attributed to tuberculosis in only 3-7 per cent.

The conclusion drawn from these figures is thatresistance to tuberculous infection in infants is higherthan is generally supposed, a poor resistance totuberculous disease being contrasted with a vigorousresistance to infection. Histories of exposure toinfection are, of course, often unreliable, and attentionis drawn to an investigation made by the New YorkTuberculosis and Health Association in 1925, when itwas found that the hospital records of 135 cases oftuberculous meningitis stated that there had beenexposure to infection in only 19 per cent. of the total.More careful inquiries proved that 56 per cent. of thechildren had been contacts of sufferers from tuber-culosis, which indicates how misleading perfunctoryquestions may be. Miss Asserson rightly insists thatexposure to infection should mean contact with personswho are suffering from " open " tuberculosis, and thatthe type and length of such exposure should be noted.Comparison of contact and non-contact cases provesthat the mortality from tuberculosis is exceedinglyhigh among infants exposed to family contact withthe disease. Infants not so exposed, who receive einfection in a more casual or incidental way fromoutside sources, develop a surprising degree of resist-

1 Amer. Rev. of Tuberc., 1927, xvi., No. 4.

ance. This contradicts the opinion of those whomaintain that since infection is inevitable its source isa matter of small moment, and that the privilege ofmotherhood should not be denied to a woman becauseshe suffers from active phthisis. In this connexion itmay be noted that of 40 infants who remained incontact with phthisical mothers 65 per cent. died oftuberculosis, while of 37 infants " boarded out " onlyone died of the disease though all had been infected.The highest death-rates were recorded among thosewho had been exposed to infection at earliest ages.Miss Asserson concludes that " Such unnecessary wasteof infant life, as is shown in the deaths of the 120 infantsin this study who died of tuberculosis, the majoritybecause they were continuously exposed to the disease,must make us pause to consider whether or not we arefacing and assuming a responsibility which rests uponus to protect the most susceptible of human beingsfrom this preventable disease." The question isequally pertinent on the two sides of the Atlantic.

FASTING BLOOD DONORS.IT has long been recognised that the reactions which

may occur after blood transfusions can be differen-tiated into those caused by the group peculiarities ofincompatible bloods and those due to some otherundetermined cause. The former are sometimes veryserious, but fortunately rare ; the latter are relativelycommon in some operators’ experience, but are hardlyever serious, even if distressing to the patients. Manydifferent causes have been assigned for the lesserreactions-e.g., sodium citrate, cooling of the blood,use of rubber tubing, destruction of leucocytes-butnone has seemed to be conclusive, and the hunt hascontinued. A new hare has lately been roused by Drs.Brem, Zeiler, and Hammack, I at Los Angeles, whichmay reward pursuit. These observers had occasionto administer nine transfusions over a period of sixyears to a patient who suffered from a bleeding

duodenal ulcer. After some of the transfusions he hadsomewhat severe reactions, after others he had none.An attempt to discover the reason for the differentresults revealed the fact that a reaction appeared tofollow the use of a recently fed donor, but that itwas absent if he had fasted. The suggestion istherefore made that the reactions may be due to thetoxic effect of products of digestion in the donors’blood, and that a donor should avoid all protein foodfor some hours before giving his blood for transfusion.The suggestion is obviously still in the realm ofspeculation, the number of observations so far madebeing very small.

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NURSES IN MISFORTUNE.

I To make provision for old age, to prepare a fewdefences against misfortune-these are wise pre-cautions for all who earn their living. Nowadays thisis so generally recognised that many forms of employ-ment carry an obligation to subscribe to pension andinsurance funds, and a feeling has arisen in con-sequence that only the improvident can find them-selves in destitution. But the solicitude of employersand facilities for self-protection have not always beenwhat they are to-day, and in certain walks of life

there are survivors from another epoch whose unhappycondition, made worse by the war, demands generousassistance. In considering the hard lot of the womento whom attention is directed by the Nurses’ Fundfor Nurses, it will be remembered that those whoentered the nursing profession 30, 40, and 50 yearsago were little encouraged by the hope of a comfort-able life or adequate remuneration. Most of themmust have begun their work from a desire for usefulservice, and some of those who have most con-

spicuously failed to help themselves have done sobecause their heart was in helping others. For thisreason we have watched with sympathy the schemeof relief started by Miss S. Bulan and carried on under

1 Amer. Jour. Med. Sci., 1928, clxxv., 96.