1536 JUNE 30, 1956 VACCINATION AGAINST TUBERCULOSIS BimsH~~~~~~~~~~~~~~~~~~~~~~~~~~MEDICALJOURNAL

tuberculin test for this purpose at later ages, thoughthe benefits it would give during the next few yearsin Britain should outweigh this disadvantage.

While infection with tuberculosis remains a seriousrisk in childhood, as it still does in Britain, there is astrong case for vaccinating tuberculin-negative child-ren on entry to school at the age of 5. Doubts aboutthe length of time protection lasts are not as importantas the fact that vaccination has now been proved toprevent tuberculosis. If B.C.G. gives protection forten years or more, well and good, but, if not,revaccination is not a difficult or dangerousprocedure. It is possible that by the time a schemeof mass vaccination was working well the need forit might have passed. In such an event everythingwould have been gained and nothing lost.

DOWN THE DRAINThe synthetic detergents sold to-day in the form ofdomestic washing powders are derived from petroleumproducts and contain organic compounds having wetting,dispersing, and emulsifying properties (surface-activematerials) and phosphates and other " builders " whichhelp to make the powders more suitable for their in-tended uses. The annual consumption of surface-activematerials in the United Kingdom is now over 33,000tons, which is about three times what it was in 1949.Three years ago a committee, under the chairmanshipof Sir Harry Jephcott, was appointed by the Ministerof Housing and Local Government " to examine and re-port on the effects of the increasing use of synthetic de-tergents and to make any recommendations that seemdesirable, with particular reference to the functioning ofthe public health services." Less than a year later thecommittee presented an interim report,' which was re-assuring up to a point, in that no evidence had beenfound to show that the incidence of dermatitis was anygreater than it was when soaps and alkalis were the onlycommon washing ingredients. In this connexion thepaper by Drs. I. Martin-Scott and A. G. Ramsay else-where in this issue is of interest in that it discusses themechanism by which soap and detergents can damagethe skin. Fortunately the number of patients referred tohospital for the treatment of this form of dermatitis isfalling, and the most serious part of the committee'sinterim report was a warning that the problem of dealingwith synthetic detergents in sewage was likely to be adifficult one. The final report2 of the committee, pub-lished last week, shows that this warning was in no wayexaggerated.The first and least serious of the difficulties experi-

enced has been foaming at sewage works, and illustra-tions accompanying the report add point to the com-mittee's statement that this expensive and possiblydangerous nuisance must not be tolerated indefinitely.1 Ministry of Housing and Local Government, Interim Report of the Com-

mittee on Synthetic Detergents, 1954, H.M.S.O., London. See BritishMedical Journal, 1954, 1, 976.

2 Report of the Committee on Synthetic Detergents, 1956, H.M.S.O., London.Price 3s. net.

Foaming is not an essential quality of an efficient de-tergent, but according to the manufacturers non-foamingproducts would not be generally acceptable for house-hold use. The evidence for this belief may be questioned.A more serious difficulty than that of foam is the effectof synthetic detergents on the processes of sewage treat-ment and on the rivers into which the effluents con-taining traces of them flow and from which watersupplies are taken for domestic use. The report statesthat not only do the surface-active agents in syntheticdetergents probably lower the efficiency of the purifica-tion processes, but they have been passing through sew-age works in appreciable amounts. Further, the phos-phate content of sewage effluents is now 4 to 5 parts permillion greater than it was before the war, and thiscould stimulate an undesirable growth of weed in rivers.The available evidence confirms that water abstracted

for public supply from rivers below the outlets of sew-age works-about a quarter of the population derivetheir water from such sources-can generally be expectedto contain measurable quantities of surface-activematerials. Is this likely to be harmful ? From animalexperiments it seems that the answer is probably in thenegative, but " the possible occurrence of serious effectsover a much longer period cannot be ignored," and onthis point the committee has been guided by the views ofa committee of the Medical Research Council under thechairmanship of Professor A. Haddow. Although therewas no evidence to justify the committee in regarding thesynthetic detergents as harmful " in this respect" (pre-sumably in respect of a carcinogenic action), neverthe-less " the possibility will need to be kept under carefulreview." No short-term ill effects on health have beenreported as a result of the presence of surface-activematerials in drinking-water. The report mentions therather alarming possibility of a domestic water supplyfoaming as it comes out of the tap. So far this has nothappened in this country, but it has twice been reportedfrom abroad.The committee's report, which is a well-written and

indeed trenchant document, shows an admirable concernfor the welfare of the community and a disinclination totolerate anything which might conceivably endanger thepublic health. Although there is nothing demandingurgent action in the present situation, the evidence avail-able should be taken as a warning " against the risk tothe environmental health services which seems inherentin the nature of the household synthetic detergents nowcommonly sold, and also against the possibility thatother new domestic products having similar or evenmore serious effects might come into equally widespreaduse." After recommending the manufacturers to investi-gate the feasibility of using materials which can bereadily oxidized or eliminated and will not cause foam-ing during sewage treatment, the report discusses thethorny question of whether the public interest is beingsufficiently safeguarded while research goes on. By amajority decision the committee decided that it was notinconceivable that a worsening of the situation mightjustify the control of the composition of synthetic de-tergents. At present the powers for the exercise of suchcontrol do not exist.

JUNE 30, 1956 PERSONALITY AND CANCER MEDICBALRSHRNL 1537.~~~~~~~~~~~~~~~~~~~~~~~~~~EIA ORA

PERSONALITY AND CANCER

A recent review' by L. L. Leshan and R. E. Worthingtonof the relation, if any, between personality and cancerhas drawn attention to a considerable literature on thistheme. The authors, who are clinical psychologists,provide a useful if not very critical summary of theirsubject. Most of the older works are speculative innature and are limited to clinical impressions. Never-theless, a review in the editorial columns of thisJournal2 of the evidence then available in 1925concluded that " indirectly, therefore, nervous influencemust be regarded as of great importance in theproduction of cancer." A number of clinicians hadexpressed the belief that griefs and disappointments hadsome predisposing effect, and that sad emotions anddepressive states might activate a cancer. The fewstatistical papers report proportions of two-thirds to one-fifth of cancer patients having suffered the loss of nearrelatives or some other form of " psychic shock."

Later on we have a series of more sophisticated papers,reporting the use of interviews, questionaries, and pro-jective tests such as the Rorschach. The results obtainedby these methods are somewhat different. Thus aJungian analyst who studied 100 patients with cancerfound that they had lost a major cathexis before thetumour had developed, with the result that there was nooutlet for psychic energy, which had thereupon turnedinward and expressed itself through a primitive eroticoutlet. In another report women suffering from cancerof the breast and cancer of the cervix were alike in show-ing a pattern of feminine dominance with rejection of thefeminine role, the latter group having a higher incidenceof disorder of sexual life. There were eleven patients ineach group. Correlations have been found betweenneurotic defences of the personality and the rates atwhich cancers grow. Interest has deviated from thecommonplaces of bereavements and depressions to thesubtleties of personality structure, and in the modernpapers there is no confirmation of the clinical impressionsof earlier writers. Summing up, Leshan and Worthingtonbelieve that certain consistencies are shown in theliterature: first, the loss of an important relationshipbefore the development of the tumour; secondly, thepatient's inability successfully to express hostile feelings;thirdly, unresolved tension concerning a paternal figure;and, fourthly, sexual disturbance.There are some considerations which suggest a certain

degree of caution in accepting these views. The thoughtarises, on reading the summarized reports, that many ofthe workers found what they were looking for, and thattheir observations were in part determined by theirpreoccupations. Furthermore, for psychodynamicpsychology there is no such lusus naturae as a normalperson; we all have our unresolved parental fixations,our incapacities to express anger and hostility, ourneurotic defences. Evidence that such things play apart in the aetiology of cancer can be satisfactorilyderived only from controlled studies, of which there are

ILeshan, L. L., and Worthington, R. E., Brit. J. med. Psychol., 1956, 29, 49.' British Medical Journal, 1925, 1, 1139.3Stephenson, J. H., and Grace, W. J., Psychosom. Med., 1954. 16, 287,

very few. One such may be mentioned. J. H.Stephenson and W. J. Grace3 made a comparisonbetween 100 patients suffering from cancer of the cer-vix and an equal number of women with cancer at othersites, mainly in the gastro-intestinal tract, psychologicalfindings being obtained by interview. Some statisticallyhighly significant differences were found. Thus, 43 of thepatients with cancer of the cervix were divorced orseparated or had been deserted, only 13 in the controlgroup; and there were other large differences inobservations on sex life showing the patients with cervicalcancer at a marked disadvantage. However, some find-ings were suggestive of hereditary and constitutionalfactors: there were 25 Jewish women and 4 negroes inthe control series, 1 Jewish woman and 25 negroes in thecervical cancer group. Differences in sexual adjustmentwere still maintained when these racially different per-sons were excluded, but one is still left wondering howfar the two series were truly comparable. The authorshave some difficulty in giving any meaning to theirpsychiatric findings, but they refer to the occurrence ofchanges in blood flow in the female genitalia duringstress, and to the effect on the growth of tumours ofresection or stimulation of nerves supplying them.

If we regard the work that has been done up to nowwith some scepticism, we should not reject the desir-ability of further work in this field. In view of theassociation between emotional states and some otherphysical disorders, relevant observations may well bethere to be made if the right approach is taken. Thisimplies the study of properly collected control series.

CEREBRAL HEMISPHERECUIMYSince R. A. Krynauw's original papers4 5 reporting theresults of cerebral hemispherectomy for infantile hemi-plegia a number of papers have appeared reporting smallseries of similar cases, culminating in a recent article byD. Ferey6 describing ten personal cases. This form oftreatment has now been accepted as suitable for twowell-defined conditions-namely, infantile hemiplegiaand unilateral Sturge-Weber's disease. The indicationsfor operation are the coexistence of epilepsy, tempertantrums, and some mental retardation, with a hemiplegiaoriginating in the first year or two of life. Air studiesusually reveal gross hemiatrophy of the brain, oftenwith cysts in the territory of the middle cerebral artery,which suffers an occlusive lesion at birth. In cases ofunilateral Sturge-Weber's disease the hemiatrophy, asshown by dilatation of the lateral ventricle, is usuallyless marked, but extensive cortical calcification is to beseen. The aim of operation is to eliminate epilepsy andrelieve the behaviour disorder or temper tantrums, for,as E. A. Carmichael7 has pointed out, little if anyimprovement in the hemiplegia can be expected to occurexcept an occasional slight increase in facility in walk-4 Krynauw, R. A., S. Afr. med. J., 1950, 24, 539.'- J. Neurol. Neurosurg. Psychiat., 1950,13, 243.6 Ferey, D., Presse mdd., 1956, 64, 81.7Carmichael, E. A., Lectures on Scientific Basis of Medicine, vol. 3, 1953-4,

London.8McKissock, W., Proc. roy. Soc. Med., 1953, 46, 431.9- Zbl. Neurochir., 1954, 14, 42.

1538 JUNE 30, 1956 CEREBRAL HEMISPHERECTOMY-~~~MICLJUK

ing. There is no doubt that the operation is successful,though not invariably so, in relieving the patients ofconvulsive attacks, between 80 and 90% gaining freedomfrom epilepsy. It is also often successful in relievingthe patient of behaviour disorder. Indeed, the excellentchances of eliminating epilepsy and behaviour disordermake it the treatment of choice in properly selected cases.According to W. McKissock8 9 the mortality rate is low;the complications are hydrocephalus developing in theempty hemicranium and late infection.The neurological deficits that follow removal of the

hemisphere are slight, as Carmichael has noted, therebeing little or no change in motor and sensory function,while a complete homonymous hemianopia with splittingof the macula is acquired if it was not present pre-operatively. In his series speech was impaired in onlyone patient, the cause of whose disability was unusual.In all other cases speech was unimpaired irrespective ofhandedness and dominance of the hemisphere. Speechaffected by the initial lesion may even show improve-ment after hemispherectomy. If the patient is freedof epilepsy and temper tantrums he is easier to educateand to teach a trade, and these gains far outweigh theloss of visual field which he may experience. Anotherpotential benefit from the operation is that some ofthese patients show an increase in intelligence quotient.

VARICOSE VEINS IN PREGNANCYVaricoso veins commonly develop in pregnancy, oftengive rise to discomfort, and may be disabling. Therecent literature on the subject is extensive and contro-versial. Much of the controversy, according to P. H.Fried and his colleagues,' is due to failure to distinguishfrom the well-known saphenous varix another superficialvenous disorder. They call it the " angiectid," and con-sider it occurs only in pregnancy. The angiectid con-sists of a small, intradermal, raised, sharply circum-scribed mass of bluish vessels. Such lesions, manydoctors would argue, can be found in non-pregnantpatients, though undoubtedly they are much commonerin pregnancy. Hormone assays in 21 patients withangiectids showed normal amounts of chorionic gonado-trophin and urinary 17-ketosteroids, but variations inthe serum oestrogens (measured by a method of un-certain accuracy) and urinary pregnanediol. The sixwomen with symptomless angiectids had consistentlylow-normal amounts of oestrogen and progesterone;out of the 15 patients with painful angiectids, 14 hadsubnormal amounts of oestrogen or pregnanediol orboth. Severe pain and marked changes in the angiectidwere associated with the lowest subnormal oestrogenlevels. Four patients with saphenous varices hadnormal hormone levels, which suggests that the variceswere not connected with any endocrine factor. Treat-

1Fried, P. H., Perilstein, P. K., and Wagner, F. B., jun., A.M.A. Arch. Surg.,1956, 72, 253.

2 Rivlin, S., British Medical Journal, 1955, 2, 618.3 Mills, W. G., ibid., 1955, 2, 736.' Norreil, J. S., ibid., 1955, 2, 736.6 McClausland, A. M., Calif. west. Med., 1939, 50, 258.Rees, E3. R., British Medical Journal, 1955, 2, 852.Rivlin, S., ibid., 1955, 2, 1030.

ment of the 15 patients who had painful angiectids bymeans of oral oestrogens led to complete relief frompain; from which the authors deduced that deficiency,not excess, of female hormones was the cause of theangiectids.

This work recalls recent correspondence in the Journalon premenstrual varicosities. S. Rivlin2 pointed out thatin some women varicosities are exacerbated in theimmediately premenstrual few days, the lesions evendisappearing altogether at other times of the cycle. Hisexplanation was that before menstruation the internaliliac venous return is increased, damming back that fromthe external iliac. This view was rejected by W. G.Mills3 and J. S. Norrell,4 who thought that such anexplanation would imply the extreme development ofvaricose veins by every woman in the later stages ofpregnancy; they preferred the view, first put forwardby A. M. McClausland,5 that progesterone causes vascu-lar relaxation. However, it has been claimed that ifprogesterone were indeed the cause then every womanmight be expected to develop varicosities in pregnancy,6and also that the premenstrual varicosities appear atthe time in the cycle when production of progesteroneis rapidly falling.7 So, indeed, is the production ofoestrogen; and it may be that this falling level ofhormones is an important element in the development ofpremenstrual varicosities, as Fried and his colleaguesclaim deficiency of hormones to be in the developmentof pregnancy angiectids.

MEMORIAL TO SIR JAMES SPENCE

Sir James Spence was the type of man who will noteasily be forgotten by those who were fortunate enoughto know him, and he had a remarkable influence oncontemporary medical thought. In order to com-memorate his name in a lasting way his colleagues andfriends in the university of Durham and in the hospitalsof Newcastle-upon-Tyne are appealing for funds to beused for purposes which Sir James Spence himself wouldhave warmly approved. It is hoped that the memorialwill take the form of a medal to be awarded foroutstanding contributions "to the advancement orclarification of paediatric knowledge within the fieldsof clinical and social paediatrics, clinical science,epidemiology, and family practice," and of an annualprize to be awarded to the student of the NewcastleMedical School who submits the best essay on anypaediatric subject which has excited his interest and ledhim to personal inquiry during his clinical training. Inaddition a sculptured portrait head of Sir James Spencewill be placed in the new children's hospital which it ishoped will be erected within the precincts of the RoyalVictoria Infirmary. Finally, the University of Durhamis being invited to rename the chair which Sir JamesSpence was the first to occupy "The James SpenceChair of Child Health." All those who would like tosupport this deserving appeal should send their donationto Dr. A. W. Sanderson, the House Governor andSecretary, the Royal Victoria Infirmary, Newcastle-upon-Tyne.