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less effective, the survival of platelets becomes veryshort, and the bleeding manifestations are no longercontrolled. They have shown that this effect iscaused by the development of platelet agglutinins,and there may be several platelet groups whichdiffer antigenically. DAMESHEK and his co-workers 5have described a case in which these plateletagglutinins were,present; and they showed that theagglutinin, like other antibodies, is ’a globulin andis absorbed on to affected platelets.

All this means that for each patient the firstplatelet-transfusion is likely to be the most effective ;and such transfusion should be reserved until theneed is great-for example, to arrest cerebral haemor-rhage in a patient with idiopathic thrombocytopenicpurpura, or to ensure a relatively bloodless field

during splenectomy in such a patient. Platelettransfusions will not help to tide over the patientwith acute idiopathic thrombocytopenic purpura,since only the first transfusion is likely to be effective.Despite these severe limitations, however, it is

probably worth while for at least special centres tohave the equipment for giving platelet-transfusionswhen they are really indicated.

5. Stefanini, M., Dameshek, W., Chatterjea, J. B., Adelson, E.,Mednicuff, I. B. Blood, 1953, 8, 26.

6. Civilian Health and Medical Services. Vol. 1. Editor: SirArthur S. MacNalty, K.C.B., M.A., M.D., F.R.C.P., F.R.C.S. London :H.M. Stationery Office. Pp. 441. 45s.

7. H.M. Stationery Office, 1946.8. London, 1950. See Lancet, 1950, i, 631.

Annotations

CIVILIANS AT WAR

ONE by one the ships of " Admiral " Sir ArthurMacNalty’s fleet are built and launched, and eight statelygalleons out of a fleet of nineteen now ride safely atanchor. The latest volume 6 of the Medical Historyof the Second World War covers the medical servicesprovided by the Ministry of Health, including a sectionon the voluntary services ; those of the Ministries ofEducation, Labour and National Service, Supply, andWar Transport ; and in the Channel Islands. A secondvolume will cover Scotland, Northern Ireland, theColonies, and the Ministry of Pensions. Much of theground has already been covered piecemeal in officialreports, notably in Sir Wilson Jameson’s On the Stateof the Public Health During Six Years of War, 7 but hereit is expanded and collated as a more or less continuousnarrative. The story is told almost entirely from thecentral and the administrative angle. More might havebeen said of the work of local authorities and generalpractitioners, and it might even perhaps have been en-livened, at least in footnotes, with some human incidents,as in R. M. Titmuss’s Problems of Social Policy 8; but inan official history, provided the milk is there, we shouldnot expect too much cream.The account of the problems involved in air-raid

shelters, including the strange story of Culex molestus,is of great interest ; and other excellent sections arethose. dealing with the mental health services, maternityand child welfare, tuberculosis, nutrition, and malaria.

All in all, it is a triumphant tale-even though manyof the triumphs were disasters that did not happen.That our nation’s health remained basically unimpairedand indeed improved in many respects, after six yearsof a war which involved civilians to a greater extentthan any previous war of modern times, was due to anumber of factors. Firstly, to a soundly based pre-warpublic-health and medical-care system. Secondly, tocertain wise precautionary measures such as evacuationand the professional recruitment schemes, thought out

and in some cases put into action before the crisis arose.Thirdly, to the devotion of denuded staffs and overworkeddoctors of all types : almost half of those recruitablehad left the public-health services by the end of 1943,and the ratio of population to general practitioners rosefrom 2184 to 1 in 1938 to over 3000 to 1 in 1942 for morethan half the population, and in some areas to 4500 to 1.Fourthly, to prompt and practical improvisations by theauthorities in meeting emergencies such as the air-raid-shelter problems, the increase in venereal diseasesand scabies, and the pollution of water-supplies after

bombing. Fifthly, to advances in medical science suchas the introduction of the persistent insecticides and theuse of sulphonamides in the reduction of mortalityfrom cerebrospinal fever. Sixthly, to the valour andskill of our fighting men who so often fought the Germansto a standstill just when a breakdown-of rest centresor of food-supplies, for instance-seemed inevitable.And lastly, to luck. There was no serious epidemic ofany diseases such as influenza, whose ravages couldhave been neither prevented nor checked.

In his Harveian Oration of 1942, Sir Wilson Jameson 9

quoted Tennyson’s definition of England and askedwhether we could still afford to proceed " from precedentto precedent " In time of war the answer was clearlythat we could not, and this record is a monument to thesuccessful abandonment of precedent by those concernedto protect our nation’s health. _

9. Lancet, 1942, ii, 477.10. Bull. Hyg. 1952, 27, 397.11. Meyer, E. Byers, R. K. Amer. J. Dis. Child. 1952, 84, 543.12. Miller, H. G. Arch. Neurol. Psychiat. 1953, 49, 695.

POSTVACCINAL ENCEPHALITIS

Two pressing questions confront the doctor when hesees a new case of encephalitis following a virus infection- treatment and prognosis. At present there is somehope of modifying the disease by giving corticotrophin(A.C.T.H.),10 but confirmation of any substantial benefitis still required. The remote prognosis in the post-measles syndrome has lately been much clarified byMeyer and Byers," and now Miller 12 has added to ourknowledge of the outcome of the postvaccinal syndromeby a follow-up study of 27 cases, based on records of theMinistry of Pensions. The mortality was 30%, whichis the generally accepted average figure ; among P/4million personnel of the fighting Services vaccinatedbetween 1941 and 1950, there were 10 cases (an incidenceof 1 in 175,000) with 3 deaths. The degree of disturbanceof consciousness is a guide to prognosis : there were

only 2 survivors out of the 10 comatose patients inMiller’s series, and only 1 survivor out of the 4 withconvulsions in the acute stage. Clinically the diseasewas classed as pure encephalitis in 16 cases, as encephalo-myelitis in 5, as transverse myelitis in 3, and as focalcerebral lesions without encephalitis in another 3.Of those who died, the patients in the encephaliticgroup succumbed early-within a matter of hours or afew days. Although organic neurological sequelae weresurprisingly common in the survivors, there was an

astonishing capacity for recovery. Paraplegia, hemi-

plegia, radicular syndromes, dysarthria, epilepsy, andinvoluntary movements all tended to clear gradually.Few patients had any serious disability when they werere-examined after several years, and there was no instanceof progressive nervous disease, except in a case ofcoincidental parkinsonism. The nature of the focalcerebral lesions is obscure ; and there is a need for carefulhistopathological investigation of the occasional fatalcases of this syndrome. The most likely explanationis focal vascular thrombosis. The psychiatric sequelewere less clear cut than in the postconcussion syndrome,but with the exception of 2 cases of gross hysteria,Miller found that steady improvement had been recordedin all patients. In psychiatric cases the desire for a,

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pension may cloud the picture, but it is likely thatsevere brain damage may lower the resistance to environ-mental anxieties, and that secondary emotional mechan-isms may thus play their part in prolonging the disability.

1. Storey, C. P., Grant, R. A., Rothmann, B. F. Surg. Gynec.Obstet. 1953, 97, 95.

2. Davis, E. W., Klepser, R. G. Surg. Clin. N. Amer. 1950, 30, 1707.3. Hood, R. T. jun., Good, C. A., Clagett, O. T., McDonald, J. R.

J. Amer. med. Ass. 1953, 152, 1185.4. Wang, C. C. Radiology, 1953, 60, 536.5. Lodin, H. Acta radiol. Stockh. 1953, suppl. no. 101.6. Clegg, J. W. In the press.7. See leading article. Lancet, 1953, i, 1082.8. Cudkowicz, L., Armstrong, J. B. Thorax, 1953, 8, 152.

"COIN" LESIONS OF THE LUNGS

ISOLATED, well-defined, spherical shadows (" coin "

lesion is really a misnomer) are often discovered duringa mass X-ray survey. The patient usually has no

symptoms, and believes himself to be in perfect health,so difficult questions of diagnosis, management, andtreatment may be raised. Storey et al.1 have latelypublished an analysis of 40 such cases in which the

diagnosis was histologically verified. The patients weremostly healthy young men on active service, and 70%of the lesions were found to be tuberculous. In other

published series the cancer-rate has been as high as

55%,2 but the figures are bound to vary considerablywith the method of selection. In 156 cases of solitarycircumscribed lesions of the lung reported by Hood et al.3the mass was excised, and 35% of the lesions provedto be malignant.Most of these shadows are cast by tuberculous foci

or neoplasms, but a few are caused by cysts, variousgranulomas, infarcts, or vascular anomalies. Duringthe past twenty years, preoperative diagnoses havebecome progressively less confident, and it is now

generally accepted,that the true nature of these shadowscan seldom be’ established until the histological sectionsare examined. Indeed, many radiologists would agreethat their opinion on the nature of the lesion is no morethan guesswork. But this does not mean, of course, thatradiology has nothing to offer in the investigation ofthese patients ; for example, a few can be diagnosedas tuberculous with reasonable certainty. Wang 4has recently described the X-ray appearances of 19

pulmonary " tuberculomas," pointing out the featureswhich may lead to their recognition.Tomography should always be added to the routine

radiological examination, for by this method smallcavities and flecks of calcification may be demonstratedwithin the shadow, and other small opacities or hilar-gland enlargement may be revealed. Recent develop-ments 5 in the technique of tomography have enabledsmall bronchi to be displayed, and it is possible thatthe thickening of the bronchial walls, sometimes foundin tuberculosis 6 would be demonstrated. Cavitationand calcification do not afford conclusive proof of tuber-culosis, for quite small neoplasms may break down,and calcification is common in hamartomas ; moreover,a small number of bronchial carcinomas arise in or

around the calcification of old tuberculous scars. Butin the series of Hood et al.3 no lesion that showed areasof calcification visible on the radiograph was malignant.If more than one shadow is present, the likelihood oftheir being tuberculous is greatly increased, but multiplehamartomas or hydatid disease may occasionally causedifficulty.Angiocardiography does not help to differentiate

these various shadows but recent work on necropsyspecimens 8 has shown that there is an increase in thebronchial-artery supply to a primary neoplasm, and it ispossible that a special angiographic technique may bedeveloped to demonstrate these vessels. It is alsoknown that some tumours, in other parts of the body,selectively absorb and retain radio-active isotopes, andthis is another possible method of differentiation.

There seems to be little point in making an exhaustivesearch for a hidden primary growth, for small neoplasmsso frequently escape detection, and in any case it is oftenjustifiable to remove an isolated secondary depositfrom the lung. Bronchoscopy should always be under-taken ; for, although these lesions are usually out of sight,bronchial secretions or biopsy specimens of the mucosacan be examined, and occasionally a tuberculousbronchitis affecting the proximal bronchi may be seen.When all these investigations have been completed,

however, the answer is very often still in doubt. Thesafest place for these lesions is in the hands of the patho-logist, and it is probably wiser to remove them all,tuberculous and non-tuberculous, except perhaps in

patients under the age of 30 in whom the shadow liesat the apex of a lobe-i.e., in the posterior half of thechest-the usual site for tuberculosis. But any massin the anterior half of the chest should be regarded withgrave suspicion, for this is a very uncommon site for theisolated tuberculoma. A few of the single roundedtuberculous foci disappear spontaneously, sometimesafter as long as five years, and this possibility suggestsan alternative course of waiting, watching, and operatingonly if the shadow enlarges or excavates. In view of the

safety of modern surgery, however, this course is seldomjustified, and the advantage of increased certainty inpreoperative diagnosis is likely to be offset by thenumber of cases that are later found to be inoperable.

1. See Lancet, July 25, 1953, p. 170.

MEDICINE AND PREVENTIVE MEDICINE" THERE are fairies," we used to be mellifluously told,

" at the bottom of the garden." At the bottom of themedical garden, where, some would say, public healthcould be found in recent years, there are certain heavingsand stirrings in the compost heap of social and preventivemedicine which has incorporated the small pile of manurenow representing the older " public health." Three bookslately published, from Cambridge, England, from NewYork, and from Cambridge, Massachusetts, have focusedattention on these upheavals. Prof. A. L. Banks discussesthe social aspects of disease, Dr. Iago Galdston is editorof a book on the epidemiology of health, and Prof. H. R.Leavell and Prof. E. Gurney Clark deal with preventivemedicine. 1 The first two books receive notices in thisissue. All three cover much common ground and, whatis more remarkable, show a large measure of agreementon certain conclusions. These conclusions deal in the mainwith shifts of emphasis now perceptible, and they maybe considered in relation to medicine as a whole and

preventive medicine in particular.A theme running through all these books is the

emerging importance of diseases of the middle-aged andelderly, hence of the chronic diseases and the cancers, ascompared to those of the young, which are principallyinfectious diseases. Coupled with this there is an increas-ing emphasis on the minor mental and emotional dis-orders and their relation to physical health. Concernedin this change, besides the earlier neglect and ignoranceof these aspects of health and disease, is the swing of thependulum towards a consideration of Man in relationto his whole make-up and his complete physical andsocial environment, away from the mere collection ofclinical and laboratory data about his diseases-theso-called holistic or ecological approach. Also contri-

buting to the new attitude is the change from a staticto a dynamic approach, from anatomy and pathology,where things are, generally, what they seem, to thefunctional approach through physiology, biochemistry,and social medicine, in which the difficulty of isolatingfacts and the complicated interplay of factors are muchgreater.’ This leads us to the need for team-work and fora system of medical education that produces wise leaders,rather than brilliant technicians, whose techniques can,