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have to be out at work all day-and here there willclearly be plenty of opportunity for voluntaryeffort in looking after the children out of schoolhours. At farms allowance must be made for the

necessity in wartime of housing additional labourin order to increase agricultural production. Localauthorities are asked to make suggestions for theuse of empty houses and other buildings, such ashotels and boarding-houses, which might provideaccommodation for large numbers, schools beingexcepted. Potential or existing facilities in campsand hostels must also be noted. Should an emer-

gency arise school-children will as far as possiblebe moved school by school, and will be accompaniedby teachers or other helpers up to a maximum ofabout one per ten children. Householders will be

paid 10s. 6. a week for board and lodging whereone school-child is taken, or 8s. 6d. a week for eachchild where there is more than one. Childrenunder school age will be accompanied by theirmother or some other responsible person. Forthese householders will be asked to provide lodgingonly, and will be paid 5s. a week for each adult and38. a week for each child. The Government willarrange for the necessary transport and forincreased supplies at the local shops, and theBoard of Education has under considerationthe measures that must be taken for continuingthe education of the displaced children.The epidemiological repercussions of removing

large numbers of children from cities to rural areasare difficult to foretell. There is, of course, muchto be said in favour of keeping together mothersand their children of pre-school age, as well as ofdispersing them as widely as possible. Accommo-dation in private houses seems the best way ofdealing with this group. In the case of school-children, however, the situation is somewhatdifferent. There would be great administrativeadvantages in providing for them fairly large-scale

accommodation in camps and hostels under the careof teachers and other helpers. Also there are

many small country houses that would willinglybe offered and would comfortably take thirty orforty children, with three or four teachers, althoughon a strict count of their rooms their assignmentwould be much smaller. Where substantial numberswere grouped together, educational facilities couldbe more satisfactorily arranged, feeding would beeasier, and supervision, medical and other, wouldbe simplified. Indeed the evacuation of school-children to an area where they would be cared forin a school camp, in the neighbourhood ofwhich the mothers and pre-school children couldbe billeted, would seem to be an ideal arrangement.Systematic immunisation should banish the riskof such diseases as smallpox and diphtheria, andadequate spacing of beds in dormitories would

help to keep droplet infections within manageableproportions. Hospital accommodation and labora-tory facilities would be a necessary part of anyscheme of evacuation, and local public healthstaffs would have to be greatly strengthened. Theconcentration of children in school camps wouldmake for the more efficient utilisation of all

categories of staff.It is easy to ask local authorities to make surveys

and to promise to pay householders certain sumsfor every lodger received by them should an

emergency arise. It is more difficult to prepare a

really constructive scheme of evacuation and

temporary settlement for large numbers of people.For one thing such a scheme would involve capitalexpenditure, and until it is recognised that air-raidprecautions are just as much part of our nationaldefence as is the provision of weapons of offencewe shall not get anywhere. It is right that we shouldhave our surveys ; they are a necessary first step.But we shall need something more than that ifthe anxieties of the nation are to be allayed.

ANNOTATIONS

PAY-BEDS IN GENERAL WARDS

VOLUNTARY hospitals now expect in-patients tocontribute towards their keep according to their

means, and in 1937 about a third of the total incomeof the London voluntary hospitals was derived fromthis source. Those who can afford it are chargedthe full cost of their maintenance, which in Londongeneral hospitals ranges from E3 3 lls. lOd. a week at

University College to i:5 lls. lOd. at Guy’s, and thereis usually an income limit of about E400 a yearbeyond which patients are admitted only in excep-tional circumstances. At Guy’s forty curtainedcubicles are now being reserved in the general wardsfor patients who can pay for their keep but whoseincomes do not exceed E275 for single people, E325for married people, and E450 for married people withchildren. Most wards have two cubicles and some,including the maternity ward, have four. Patientsmust satisfy the inquiry officer that their income doesfall within these limits and must sign a statement tothat effect. The charge is five guineas a week, whichincludes all special investigations, and there are nomedical or surgical fees. For teaching purposescubicle patients may be demonstrated to students in

the same way as those in the general beds, and theymust conform to the ordinary rules of the hospital,except that they are allowed visitors every eveninginstead of only on specified days. Those whoseincome exceeds the limit for the cubicles are admittedto the paying block, Nuffield House, where theminimum charge is six guineas a week and wherefees are of course charged for medical attendanceand investigations.

PROGESTERONE AND THE ADRENAL

ALTHOUGH in certain species pseudo-pregnancytends to prevent adrenal insufficiency, attempts toprolong the life of adrenalectomised animals bygiving them progesterone have hitherto failed. Now,Gaunt and Hays report that they have succeededin maintaining adrenalectomised ferrets for a monthby injections of progesterone in doses of 0.5-5 mg.daily ; the animals died when injections were dis-continued. Whether the failure of previous experi-ments was due to inadequate dosage or whether theferret reacts differently from other animals is stillto be determined. A difference in the behaviour of

1 Gaunt, R., and Hays, H. W., Science, Dec. 16, 1938, p. 576.

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species is an important factor in experimental work ;thus the adrenalectomised marmot dies in hypo-glycaemia, but with normal values for serum sodium,chloride, and potassium. In Addison’s disease,even of severe degree, menstruation may continuenormally; but pregnancy is comparatively rare

though it may go on to term. The history given bywomen patients may reveal that some features ofthe disease appeared in a recent pregnancy but dis-appeared again after parturition. This, however,suggests an added strain on the adrenals duringpregnancy rather than benefit from a persistentcorpus luteum. In some animals, it may be noted,the adrenal cortex hypertrophies during pregnancy.The isolation of corticosterone from the adrenal

(Reichstein,2 Kendall 3) and the subsequent synthesisof desoxycorticosterone (Steiger and Reichstein 4),potent for adrenalectomised animals and in Addison’sdisease,5 have some bearing on the above experi-ments, since both compounds are closely relatedchemically to progesterone. A substance havingprogestational effects was obtained from the adrenalgland by Engelhart 6 in 1930, the work being con-firmed by Callow and Parkes in 1936.7 Beall 8 hasisolated progesterone from the adrenal cortex, andwe understand that de Fremery and his collaboratorshave shown that desoxycorticosterone has a pro-gesterone-like action in the rabbit. Whether theexperimental work of Gaunt and Hays will have atherapeutic application is perhaps doubtful. On abasis of weight the daily dosage of progesteronerequired by man would be in the neighbourhood of10-50 mg., and progesterone is even more expensivethan cortin or desoxycorticosterone. The possibilities

’ or oral therapy are suggested by the fact thatchemically related compounds of progesterone are

active by mouth (Miescher and Kagi 9). The wholesubject is in a fascinating phase.

NON-TROPICAL SPRUE

ALTHOUGH the main abnormality of nutrition innon-tropical sprue is the steatorrhoea, further analysisshows, according to Brull, Lambrechts, and Barac 10of Liege, that there are multiple deficiencies in

absorption of vitamins. These are not primary butpossibly result from a more or less generaliseddeficiency of digestive secretions leading to mal-

absorption. The researches of these and otherauthors have failed to reveal the essential mechanismof any such deficiency, which must be a manifestationof deeper biological processes of which we are ignorant.That these processes are fundamental is suggestedby the differences seen between closely related con-ditions. For example, although the anaemia associatedwith sprue appears very like that of perniciousansemia and responds to similar replacement therapy,subacute combined degeneration of the cord isassociated with pernicious anaemia but is almostunknown with the ansemia of sprue. Further, theprognosis of tropical sprue is relatively favourable andthat of non-tropical sprue ultimately unfavourable,the tropical variety has a peculiar geographical andpossibly racial distribution, and osteoporosis, which

2 Reichstein, T., Helv. chim. Acta, 1936, 19, 29, and 1107.3 Kendall, E. C., Mason, H. L., and Myers, C. S., Proc. Mayo

Clin. 1936, 11, 337.4 Steiger, M., and Reichstein, T., Nature, Lond. 1937, 139, 926.5 Simpson, S. L., Lancet, 1938, 2, 557 ; see also Lancet, 1938,

2, 1414. 6 Engelhart, Klin. Wschr. 1930, 9, 2114.7 Callow, R. K., and Parkes, A. S., J. Physiol. 1936, 87, 28P.

8 Beall, D., Biochem. J. December, 1938, p. 1957.9 Miescher, K., and Kägi, H., Chem. & Ind. 1938, 57, 276.10 Brull, L., Lambrechts, A., and Barac, G., Rev. belge Sci.

méd. October, 1938, p. 457.

is associated with idiopathic steatorrhoea, is an

uncommon development in tropical sprue. Suchdifferences and peculiarities may depend on funda-mental factors, and further research may more clearlyilluminate not only these particular disorders butalso the essential mechanisms of normal nutrition.

CLIMATE AND MORTALITY IN THE U.S.A.

IN two detailed statistical studies based upon thedeath-rates registered in the United States in 1921-30,Herrington and Moriyama 1 have analysed the associa-tion between the mortality attributed to a number ofmetabolic diseases, and to certain diseases of thecardiovascular and renal systems, and the mortalityattributed to various climatic and socio-economicfactors. The former group comprises five causes ofdeath-namely, diabetes mellitus, pernicious anadmia,exophthalmic goitre, Addison’s disease, and leukaemia.A fairly close association has previously beenobserved in the United States between diabetesmortality and climate, but by appropriate correctionfor recognised socio-economic influences the presentauthors cast doubt on claims as to the r61e of climateper se in the specific aetiology of the disease. Theirsocio-economic factors seem to be of much greaterimportance and reflect the frequently observedrelationship between urban prosperity and theincidence of diabetes. At the same time there issome residual relationship between diabetes mortalityand lowered normal temperature and increased windmovement. This association they believe can beexplained in terms of the cardiovascular complicationsand intercurrent respiratory infections to which thediabetic is predisposed. These secondary causes

are unfavourably influenced by rigorous climatesand they affect the diabetes death-rate throughthe precedence of diabetes in mortality tabulations.Pernicious anaemia and leukaemia also show a divisionof influence between climate and economic factors,in which the latter are again of predominant import- .ance. On the other hand their rates tend to risewith prosperous rural conditions in contrast to themainly urban associations of diabetes. Thoughsome economic factors are likewise the dominantinfluence in exophthalmic goitre, with an increasingincidence in urban life, there is a considerable increasein the death-rate from this cause in cold and unstableclimates. This may be the result of a stimulatingclimate, but the high rates come mainly, it is noted,from areas in which colloid goitre is common. Thelowest degree of association with climate and economicconditions is shown by Addison’s disease, whichhowever tends to show higher rates in the colderregions. With circulatory diseases, chronic nephritis,and cerebral haemorrhage economic factors once morepredominate over the climatic. On the other hand

angina pectoris is more affected by climate than bysocial conditions, the unfavourable environment beingone which is stable but cold and damp.From these results Herrington and Moriyama

are led to reject the conclusion of C. A. Mills 2 that" a whipping up of the activity of the glands ofinternal secretion ... seems to answer the questionas to how weather fluctuation affects the humanbody." The observed association of these causes ofdeath with climatic conditions can be largely explained,according to their results, in terms of the underlyinggeographical differences in social conditions; andthe relatively small fraction of the total geographic

1 Herrington, L. P., and Moriyama, I. M., Amer. J. Hyg.November, 1938, pp. 396 and 423.

2 Mills, C. A., Ibid, 1932, 15, 573.