NUTRITIONAL SURVEYS

NUTRITIONAL SURVEYS

353 just over 1000 mothers with families containing an infant born in May or June, 1947, 7% went out to work in the first year, and 18% were working ...

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just over 1000 mothers with families containing an infant born in May or June, 1947, 7% went out to work in the first year, and 18% were working during 1951 ; and, rather more than half of these

in full-time but occupations. Analysis economic need was, not unexpectedly, the main reason for working, and in only 18% of cases was there a Threedeliberate choice of work for its own sake. looked after of the children were within the quarters circle while the mother was at work, with granny carrying the main share of the burden. Four out of five of these infants appeared to be growing and developing as well as those who were with their mothers at home. In the remainder, where development and behaviour were less satisfactory, the mother’s going out to work was only one element in the general inadequacy or instability of the family. Happiness and sound emotional development are, however, less easy to measure than growth or infective illness. This is still a minority problem ; at least threequarters of the mothers in this country stay at home with their young children. With the rising cost of living and the renewed demands of industry the proportion at work may be increasing ; and it is disturbing that so many of the elementary facts necessary for deciding social policy in this matter are unknown. The Newcastle conference, with all its limitations, has served a useful purpose. Moreover, the pattern of the conference, which brought together public, local authority, and university, might well be followed for other subjects and in other of

were

motives’ is

difficult ;

family

nlaces. CARDIOLIPIN ANTIGENS a complex acid phospholipin containing the active principle contained in the is nitrogen, tissue extracts used as antigens for the demonstration of syphilitic reagin. The isolation of this reagent from ox heart-muscle, by Mary Pangborn and her associates at the New York State Department of Health laboratory in 1942, caused great interest among those engaged in the serodiagnosis of syphilis. In 1943 a protective patent was effected in order to ensure the purity of cardiolipin manufactured in the U.S.A. The resulting supervisory work soon proved too much for the laboratory, and W.H.O. was requested to take over the international control of the reagent. The W.H.O. subcommittee on serology and laboratory aspects of venereal diseases1 suggested that technical information on the isolation, purification, and standardisation of cardiolipin and lecithin should be made available to major laboratories all over the world ; and W.H.O. aims to control cardiolipin by the establishment of international standards. The organisation’s Expert Committees on Biological Standards and on the Unification of Pharmacopoeias, together with the serological subcommittee, is now engaged on this work, and cardiolipin antigens of guaranteed chemical purity and tested serological activity should soon be obtainable by all laboratories which need them. As part of this campaign, W.H.O. have issued a monograph,2 by Pangborn and her associates, which should be of great help to all concerned with serology in venereal

CARDIOLIPIN,

no

disease.

The first section deals with the preparation and the chemical examination of cardiolipin and lecithin ; the various techniques are described in detail, but concisely. The second section deals with the serological examination of cardiolipin antigens used in the Wassermann reaction and the microscopic slide-test techniques of the New York State Department of Health; this part would have been of greater value if the methods used in arriving at the formulae of the antigens had been described in detail. It is, however, noteworthy that 1. W.H.O. Technical

Report Series, no. 33. Geneva and H.M. Stationery Office, 1951 ; p. 19. 2. Cardiolipin Antigens. By MARY C. PANGBORN, F. MALTANER, V. N. TOMPKINS, T. BEECHER, W. R. THOMPSON, and MARY R. FLYNN. W.H.O. Monograph Series, no. 6. Geneva and H.M. Stationery Office

1951.

statistical methods have been applied to the results of the serological examination of batches of antigen submitted for investigation as to suitability for use in routine tests. Here again, while a brief account is given of the direct probability sequential analysis, there is no guide to the reasons why certain limiting figures are adopted. No doubt these deficiencies will be remedied in further editions. Cardiolipin antigens have been applied to innumerable

Wassermann and

precipitation techniques.

It is

possible,

therefore, that W.H.O. will feel it desirable to issue short

monographs describing the serological standardisation and use of cardiolipin antigens as applied to well-known and internationally accepted techniques of assessing these reactions. Most serologists agree that cardiolipin antigens are more sensitive and specific in the detection of syphilitic reagin than the ox-heart extract antigens generally used. Work in this country 3 seems to support this view, and now that cardiolipin is to be had more attention might be given to the merits of this reagent. NUTRITIONAL SURVEYS IN his Statistical Account of Scotland (1791-99) Sir John Sinclair aimed at portraying the living conditions of the Scottish people ; and his description showed, among other things, that their dietary had vastly improved during the eighteenth century. Sir John’s great-grandson, Dr. Hugh Sinclair, in giving his Cutter lecture on preventive medicine,4 must have contemplated wistfully the confidence with which his ancestor took nutrition in his stride as one of many interests. Increased knowledge, improved technique, and the continuing search for accuracy bring with them a heavy sense of scientific responsibility. Dr. Sinclair’s lecture shows a deep knowledge of the history of his subject. His views are built out of ten years’ intensive research with the Oxford Nutrition Survey, which was born in the critical days of early 1941. With the support of the central authorities and financial help from the Rockefeller Foundation the team began with family studies ; they then cooperated with V. P. Sydenstricker in rapid clinical surveys consisting essentially in an inspection of skin, hair, tongue, and mucous membrane of the mouth, a slit-lamp examination of the. cornea and scleral conjunctiva, and recording of certain data about the teeth. Sydenstricker’s technique had been developed to meet conditions in certain southern States of the U.S.A., and it was valuable here in war-time. because it reassured us that the grosser manifestations of malnutrition were absent. The Oxford unit also carried out large-scale analyses of blood-samples, obtained through the transfusion services, which gave a rough but useful gauge of the national trends in haemoglobin, protein, vitamin-A, and ascorbic-acid levels. At the end of the war the unit turned its attention to European problems, studying the conditions resulting from acute famine in the Netherlands and chronic malnutrition in

Germany. Survey work

of this kind, if it is to serve its administrative purpose of influencing food policy and bringing relief when and where it is most needed, must be carried through rapidly. During the war this aim was achieved by teams consisting of a clinician, a biochemist, a dietist, a technician, and a clerk ; and a specially designed Hollerith punch-card was used. These methods, valuable as they were, are insufficient for peace-time research, and since the war there has been a great refinement in technique. Now the purpose of the survey is to define the cause, severity, and distribution of nutritional defects ; and this can be accomplished only by the careful assessment of individuals. There are no short cuts. The search for cause must take account of the fact that deficiency of any of several nutrients can produce the same clinical signs, and of the more puzzling finding that combined lesions produced by combined deficiencies may 3. Price, I. N. O., Wilkinson, A. E. Lancet, 1950, i 14. 4. Sinclair, H. M. New Engl. J. Med. 1951, 245, 39,

354 be very different from the sum of the lesions ascribed to the individual deficiencies. The study of severity must also take into account duration of deficiency, since short errors are more easily corrected than those of long duration. In addition, the pitfalls of sampling are many, as the European survey showed : " In one study in the Netherlands houses were chosen on a sound statistical basis and all occupants were asked to attend a clinic. Had the apparent refusals not been followed up, the worst cases of malnutriture would have been missed because no person was unwilling to attend but some were too ill to do so. When attending a committee in Germany I was shown the results of a nutritional survey in a certain town and was surprised at the gloomy picture presented. I was assured by the medical officer in charge that they were correct. I asked about the sampling and was shown the letter of instructions sent to the Oberburgermeister. I spoke to him, and he told me that as the army authorities were making a nutritional survey he supposed they would like to see cases of malnutrition, so he sent them as the sample those persons who were to be given extra rations on the grounds of malnutrition. In another town, I watched a street corner weight survey carried out by an allied sergeant with two GIs and a German interpreter with scales and measuring-rod at a busy street junction. Here nothing but the errors was random. The GIs selected ,the pretty girls, the interpreter (and the onlookers) discouraged fat Germans and pushed forward thin ones ; the brighteyed healthy streetwalkers came up to see what was going on and were weighed ; the listless malnourished passed by on the other side ; the worst were at home in bed."

In the second part of his lecture Dr. Sinclair considers the place of nutritional surveys in the university and in the field. Nutritional science, he holds, should be a as branch of experimental science, and is regarded fundamental in its application to man, or as supplemented by animal experiment ; and its aim is to advance knowledge for its own sake. On the other hand, the application of scientific knowledge to man in his environment is important, but it is not a proper subject for a university. Between these two lies the -field. survey-for example, " to determine the needs of the population for health in terms of the more important nutrients." 5 The function of these surveys is useful to science, but limited in scope. A university institute of human nutrition is of course entitled to pursue any method that will further its research ; but it is not to be bound by the survey method, which is essentially a function of the Ministry of Health and other public authorities. PREGNANCY AND RHEUMATOID ARTHRITIS ONE of the observations that led Hench and Kendall to predict that rheumatoid arthritis was not incurable In was remission of the disease during pregnancy. " in the blood must, they pregnancy some " substance X argued, cause the rheumatoid inflammation to abate ; and in their search for this " substance X " cortisone was discovered. Kendall 6 believes that the two are identical or closely related. Nevertheles’s there are anomalies : active rheumatic fever, for example, occurs during pregnancy and may be notably severe 7; yet the symptoms of this disease are alleviated by cortisone. On the other hand,. Wolfson et al.s have reported a case where allergic symptoms were regularly abolished by pregnancy but were unaffected by cortisone. In 1947 Barsi9 claimed some success in pregnancy remissions by transfusions of blood from pregnant 10 women to rheumatoid arthritics. Lately Granirer has described the successful use for this purpose of postpartum plasma-i.e., plasma from blood withdrawn from mothers twenty-four hours after delivery. This material, given in weekly doses of up to 250 ml., can, he claims, cause gradual and sustained, 5: U.N. Conference on Food and Agriculture. Hot Springs, 1943.

imitating

6. Kendall, E. C. See Lancet, 1951, ii, 586. 7. McKeown, E, F. J. Obstet. Gynœc. 1948, 55, 50. 8. Wolfson, W. Q., Robinson, W. D., Duff, I. F. J. clin. Endocrinol. 1951, 11, 793. 9. Barsi, I. Brit. med. J. 1947. ii, 252. 10. Granirer, L, W. J. Amer. med. Ass, 1951, 146, 995.

though not always complete, improvement. His patients gain weight and feel better ; their arthritis subsides:

and such abnormalities of the blood as anaemia and reversed albumin/globulin ratio return to normal. The sedimentation-rate, however, does not improve regularly -a fact which emphasises that this treatment is not equivalent to cortisone therapy. Moreover Granirer reports that seven patients refractory to cortisone have

responded to postpartum plasma. In an attempt to explain the action of postpartum plasma Granirer has assayed it for A.C.T.H. activity, by the Sayers adrenal ascorbic-acid depletion test. He has shown that it is active by this test ; even after five weeks of

at 5°C about one-third of the original A.C.T.H. Control plasma from non-gravid remained. activity This result presents us women contained no A.C.T.H. with a problem, for the remissions produced by post. partum plasma do not have all the features of those evoked by A.C.T.H. ; and the doses of plasma given would be equivalent to about 0-5 mg. of A.C.T.H. per week. Moreover other workers, such as Parrott," have found that the A.C.T.H. activity of drawn blood is normally very transient ; its almost immediate breakdown can be prevented only by special precautions. Perhaps postpartum plasma contains a stable form of A.C.T.H., or possibly it contains a new factor which itself destroys the normal A.c.T.H.-removing mechanism, in the same way that acetylcholine is potentiated by anticholin. esterases. If so, do these substances originate from the maternal or the foetal pituitary gland, or are they elaborated by the placenta ? Jailer and Knowlton 12 have reported the case of a woman with Addison’s disease whose need for adrenal-cortical hormones decreased during pregnancy-presumably because of placental secretions. Can the placenta also produce A.C.T.11. ?‘1

storage

ANTIBACTERIAL EFFECT OF COW’S MILK

THE antibacterial action of cow’s milk was discovered in 1894, but at first little work was done on it. The antibacterial substance, which Jones 13 called " lactenin," was found to have a bacteriostatic rather than a bactericidal action ; only the most sensitive of the test organisms, Streptococcus pyogenes, was actually killed, and then only when present in small numbers. Streptococcus agalactiae, the organism causing bovine mastitis, was inhibited for a few hours, after which it multiplied rapidly. Jones found lactenin in the whey, where it could be concentrated by dialysis since it did not pass through semi-permeable membranes. An alcoholprecipitated active fraction was obtained from this concentrate, but was not chemically pure. No better method of concentration has yet been described. Lactenin may be present in the milk when it is absent from the blood/3 14 and presumably it is synthesised in the mammary gland. It withstands heating to 60°C for 20 minutes and is thus unlikely to be a serologically active compound. Similarly it is not an antibody. Human milk is rich in lysozyme, which may possibly account for most of its antibacterial activity; but lactenin is unlikely to be identical with lysozyme since only very little of the latter is found in cow’s milk.’5 Jones thought that lactenin played a part in resistanèe of the mammary gland to infection ; and Foley and Lee 18 tried to explain the sudden appearance of bovine mastitis in terms of the development of lactenin-resistant strains. Jones and others also suggested that lactenin helps to prevent milk-borne epidemics due to Strep. pyogenes. More recently, however, McEwen and NVbite 17 have :confirined that lactenin occurs to about the same extent in udders with and without infection. Moreover, 11. 12. 13. 14. 15. 16. 17.

Parrott, D. See Lancet, 1951, i, 1212. Jailer, J. W., Knowlton, A. I. J. clin. Invest. 1950, 29, 1430. Jones, F. S. J. exp. Med. 1928, 47, 877. Chambers, W. H. J. Bact. 1920, 5, 527. Thompson, R. Arch. Path. 1940, 30, 1096. Foley, E. J., Lee, S. W. Cornell Vet. 1948, 38, 367. MoEwen, A, D., White, M. B. Vet. Rec. 1950, 62, 27.