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a child settles down a few days after admission,only to be upset again and again by the parents’visits. It is a fact to be faced by all parentsthat with few exceptions no child mopes in a

children’s ward, and in a few days the young child,at any rate, cheerfully adopts the nursing andmedical staff in loco parentis. The child does notneed visitors in the same way as does the adult

patient, and this means that any visiting that isdone is for the benefit of the parents rather thanof the patients. If this is accepted it is surelylogical to forbid visiting altogether.

If no regular ward visiting is allowed parentaldistress must be alleviated by allowing access

to the ward door at any time, which is the ruleat the teaching hospital already mentioned.

Interviews there with the sister, the residenthouse-officer, and often the visiting honorary staff,supplemented by a peep through the ward doorhave been found to relieve all anxiety. A brief visitto the bedside at night when the child is asleep maybe needed to soothe the over-anxious mother, andwhen a child is dangerously ill visiting can beallowed freely if the child is put in a remotecorner of a ward, surrounded by screens, or better.still in a side ward. Some will still call thepolicy of exclusion hard-hearted, more especiallythose who know least about the child’s mind andhow it works in hospital, but infection in a chil-dren’s ward can be devastating and deadly, andsentiment is not a weighty enough argument toset this risk aside.

ANNOTATIONS

ACNE STILL UNEXPLAINED

ACNE affects young adults at an impressionable age,and the disfigurement it produces often has a deepsignificance that is not always appreciated. Spotty-faced boys or girls may be undergoing acute mentalanguish, regarding themselves as outcasts and notwishing to mix with their fellows, and this backgroundmay be the basis of a lifelong psychological disorder.Fortunately this is not always the case, for manyyoung people bear their affliction with remarkablefortitude, in spite of parents who tend to regardsuch a disfiguring manifestation in their offspring asa reflection on themselves. " I can’t understand it,"says the mother in injured tones, " I always had themost perfect skin." For these reasons and becausethe disorder is common much time has been spent bydermatologists in seeking the cause. Focal infection,allergy, and disordered metabolism of fats, carbo-hydrates and the halogens, among many other factors,have been blamed in turn, but the true setiology is asobscure as ever.

Lately, following the prevailing fashion, it hasbeen suggested that acne is related to endocrine dis-turbance. This view is based on the fact that thecondition begins at puberty and usually ends withsexual maturation, and on the observation that exacer-bations sometimes appear at the menses. From thispoint of view Lynch has studied a large group ofstudents, aged 17-21, at the University of Minnesota.Among students specially examined on entrance to theuniversity he found that boys were more often affectedthan girls and that the incidence increases with age.There were more severe cases among the olderstudents, and this suggested but did not prove thatseverity is related to the duration of the disease. Thetrunk was involved more often in boys than in girls,but in both sexes the face was the commonest site.The course of the disease was always irregular andin the girls of this series exacerbations did tend to beassociated with the menses. No relationship was foundbetween body build or body weight and acne. Anincreased basal metabolic rate was twice as commonwhen the trunk was involved as when the face alonewas affected, and the more severe cases had an

increased rate. The incidence of abnormalities ofmenstruation was roughly the same in girls with andwithout acne. The texture and colour of the hair wasfound to have no bearing on the disease. Boys werefound to have seborrhcea more often than girls and in

1. Lynch, F. W., J. Amer. med. Ass. 1939, 113, 1792.

both sexes seborrhoda was more common among thosewith acne, especially when the acne was severe. The

girls without acne washed their faces less than thosewith it, but in boys there seemed to be no associationbetween acne and washing. The incidence of consti-pation in all the cases observed was negligible. Theeffect of endocrine therapy was studied in a largenumber of cases with ample controls and proved to bevalueless. As a result of this extensive survey Lynchconcludes that there is no real aetiological connexionbetween endocrine imbalance and acne, so that anotherpromising theory has gone the way of its predecessors.

IS THERE A LAW OF DENERVATION?

MANY of us can remember being told as studentsthat the most sensitive test for small quantities ofadrenaline-such as might be liberated into the bloodby the suprarenal-was the response of the denervatedheart or iris. This was not different in kind from theresponse of the innervated muscles, but occurred atvery low concentrations. Although the fact excitedtransient interest, no explanation of why denervationshould have this sensitising action was forthcoming.But the observation itself explained why subjectsunder stress of emotion exhibit dilatation of a pupilin which the dilator is " paralysed " while the normalpupil remains unaffected, for adrenaline, dischargedinto the circulation, acts more strongly on thedenervated than on the normal dilator muscle.Forty years before the description of this para-

doxical dilatation, a curious phenomenon had beennoticed in the paralysed tongue. Stimulation of anerve (the lingual) which did not innervate themusculature at all, though it contained fibres supplyingblood-vessels, sent the denervated muscle into a con-tracture. It had no effect on the normal tongue.Recent work has disclosed an analogy between thesephenomena. It is supposed that pupillo-dilator fibresnormally excite the muscle by causing the localdischarge upon it of small quantities of adrenaline,or a like substance. Similarly, there is evidence thatvoluntary muscle, such as that of the tongue, mayreceive its stimulus from the motor nerve fibres inthe shape of small charges of acetylcholine. Just asremoval of its nerve renders the dilator of the pupilhypersensitive to circulating adrenaline, so denerva-tion of the tongue may increase its sensitivity to

acetylcholine. In this condition, acetylcholine liberatedon the local blood-vessels by their own nerves, andnormally insufficient to excite the striped muscle, findsthe latter in an abnormally excitable condition.