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and to eliminate any danger to vaccines prepared frommonkey-kidney cells. The precautions against virus B setout by Perkins and Hartley 6 would have prevented thisoutbreak, which emphasises the need to quarantine all

monkeys for at least 6 weeks, no more than two to a cage,before taking tissues from them. For those handlingmonkeys or material from them, protective clothingallowing no exposure of bare skin is essential, especiallyduring the disposal of carcasses and cleaning of post-mortem tables. All instruments and tissue cultures andother materials exposed to monkeys must be sterilisedbefore they are washed up.Monkeys whose tissues are to be used for vaccine

production are required to be quarantined for at least6 (and it is often many more) weeks before their tissuesare handled. Since the infection kills monkeys, it ismost unlikely to persist through the quarantine period.At present there is no evidence about inactivation of the

organism, but the filtration steps carried out duringvaccine manufacture should remove it. Finally, there isa means of detecting it. The danger of this agent gettinginto vaccines made in monkey-kidney cells seems verysmall, certainly no greater than that due to other extraneousagents such as virus B; but its discovery will surelystimulate further investigations into an alternative to

monkey-kidney cells for vaccine production. At a recentmeeting of the National Institutes of Health the feelingwas definitely in favour of the adoption of diploid-cellstrains as a substrate for vaccine production.

EARLY EXPERIENCES

WE are becoming increasingly self-conscious about theimportance of harmonious parent-child relationships asmore and more evidence is collected about the ill-effectsof family disruptions on the emotional development ofthe young child. Prof. A. D. B. Clarke, however, believesthat the emphasis, in studies of the long-term effects ofearly experiences, is misplaced. In his Maudsley lecture,last week, to the Royal Medico-Psychological Association,he suggested that experiences in the first few months oflife (generally believed to be the critical period foremotional development) will have no long-term effectunless they are continually reinforced, and this hypothesis,he said, is supported by much published work that atfirst sight seems to contradict it.One of the most famous studies on maternal deprivation

is the Harlows’ work on motherless monkeys. Infantrhesus monkeys reared in isolation were unable to makenormal social contacts in adult life, and few succeeded inreproducing. The females which did produce offspringwere either indifferent or hostile towards their young.Deprivation of maternal care certainly had a deleteriouseffect on the development of the monkeys’ behaviour, butan important point that has been overlooked, saidProfessor Clarke, was that the females became bettermothers in successive pregnancies: their behaviour couldstill be modified by experiences in adult life.

In human beings, too, the formative years probablylast much longer than was previously supposed. Studiesof the association between bereavement and subsequentdepressive illness in children, for example, showed thatthose aged 10-14 years were the most vulnerable. Some6. Perkins, F. T., Hartley, E. G. Br. med. J. 1966, i, 899.

years ago, two distressing cases in the U.S.A. gavepsychologists an opportunity to study the effects ofisolation in children. Two young children, in differentparts of the country, were discovered to have been keptlocked up for several years, almost since birth. Deprivedof human contacts, neither had learned to speak, butwithin a few years of their release one-of these children,who had been given more encouragement and expertteaching than the other, had learned to speak and read,her i.Q. was normal, and she seemed to be emotionallystable. Severe sensory deprivation in early life had not sofar seriously affected her later development. In America,Burt carried out a simple experiment to test the extinctionof memory and the significance of reinforcement in learn-ing. When his son was 15 months old he began to readto him a short passage in Greek, and he repeated thepassage at frequent and regular intervals until he was3 years old. This material was reinforced at the age of

5, 8, and 14 years, at which times the boy’s powers ofrecall were compared with newly learned material. At5 years he relearned the prelearned passage considerablyfaster than the new material, but by the age of 14 theeffect of prelearning was extinguished.Our views on the importance of early experiences have

been influenced to some extent by animal studies. Somebirds, for example, become imprinted on the mother ata very early age; if the mother is not there, the youngmay become imprinted on a human being, a bird of adifferent species, or an inanimate object. It is commonlybelieved, Professor Clarke added, that human babiesshow a similar sensitive period of fairly short durationbut ending less abruptly than in geese and ducks. Butwhen we come to think of it, it seems much more likelythat behaviour in a slowly maturing species such as oursshould remain plastic for a long time. William Jamesonce said that behaviour remains flexible until the age of30: after that it is immutable. Perhaps he had greaterinsight than we imagine.

RHEUMATIC FEVER IN APPROVED SCHOOLS

THE other day a family doctor who graduated from aLondon medical school some twenty years ago diagnosedrheumatic fever in two patients in a hospital for mentallydefective children. He admitted that these were the first

examples of the disease he had ever seen. Had he beentwenty years older he would, as a student, have seenthis number or more in any children’s ward at any time.Rheumatic fever is notifiable in only twelve areas in

England and Wales, and in them the incidence of recentyears has been about 1 per 10,000 children up to the ageof 15 years. The reasons for this decline are not altogetherclear. The traditional predisposing causes-poverty,squalor, and overcrowding-are less obvious than theywere, but the hxmolytic streptococcus, which beyondreasonable doubt plays an important part in precipitatingthis disease, is by no means extinct. All experiencepoints to an unusually high incidence in semi-closedcommunities of children or young adults, especiallywhere the host-parasite relationship is periodically dis-turbed by the admission of new entry. Thus, nearly25,000 men suffered first attacks during recruit trainingfor the U.S. Navy during the 1939-45 war.1

1. Coburn, A. F., Cone, I. A. Am. J. Dis. Child, 1966, 111, 115.

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There is much of interest in a recent paper 2 on theincidence of rheumatic fever in approved schools in

England and Wales during the years 1960-65. In 89

boys’ schools with a total population averaging about7000,. there were 108 cases and an annual incidence

ranging from 1-92 to 3-54 per 1000. No school had

more than 2 cases in any year. In contrast no cases

whatsoever were reported during this period from ratherover 1000 girls in 38 schools. As a general rule rheumaticfever coincides with or follows shortly after a streptococcalinfection, and in 18 out of 26 boys’ schools which werestudied in some detail there was a fairly clear history ofepidemic respiratory infection, but the bacteriologicalinformation was scanty.

The inmates of approved schools are not there of theirown free will. The State is temporarily in loco parentisand therefore has a particular responsibility to keep themfree from illness. In general their health benefits almostcertainly from an adequate diet, regular hours, andabundant exercise. The common epidemic diseases ofchildren which are inescapable in these communitiesseldom inflict permanent damage, but the sequel to

rheumatic fever may be a lifelong invalidism. It is nota preventable disease like diphtheria, but timely measuresagainst epidemic streptococcal infection can go a longway to limit the harm it does. Even in the most expensiveprivate schools there is a tendency to make light ofepidemic sore throat: a gargle-tasting nasty for pre-ference-is still the customary treatment in some places.Not all such epidemics are due to streptococci; and thecause need not be left to guesswork. Nowadays there canbe few places in this country where adequate help froma laboratory is not available. A single streptococcalinfection may not be of much account, but three withinone week (and especially if the organisms are all of onetype) is clear warning of trouble ahead. Of course, notone of the victims may get rheumatic fever or chorea oracute nephritis, but if he does the damage may beirreversible. Though circumstances are so variable thatit would be purposeless to prescribe a routine method ofcontrolling an epidemic, all haemolytic streptococci aresensitive to penicillin and this is the treatment of choice.The origin of the epidemic may be a nasal carrier or aboy with a discharging ear: he will, quite likely, beamong the newest arrivals. New admissions should be

stopped until the epidemic has waned or, if this is

impossible, there is much to be said for giving a largedose of penicillin intramuscularly to each new entranton admission.3 3

Why was there no rheumatic fever in the approvedschools for girls ? The disease shows no strikingdifferences in sex-incidence among the public at large;and chorea is, in fact, commoner in girls than in boys.The girls’ schools are on the average smaller than thosefor boys. The girls’ regimen is usually less vigorousand perhaps complaints of minor illness are receivedmore sympathetically-and therefore treated earlier andmore thoroughly. We do not know. The incidence ofthe disease in the boys’ schools is at least ten times thatin the areas where the disease is notifiable-and this isdiscreditable. No doubt the Home Office will take noteof this valuable paper; and it should be a warning to allwho undertake the medical care of young people ininstitutions.

2. Bates, M. M. Mon. Bull. Min. Hlth, 1967, 26, 132.3. Stollerman, G. H. Bull. rheum. Dis. 1962, 13, 293.

ADVICE ON ADDICTION

PAPER schemes for the treatment of addiction abound,and the latest advice set out in the Ministry of Health’srecent memorandum and circualr describes how it is

planned to translate the Brain proposals into practice.They make good reading, for there will apparently becooperation between all branches of the health services,including the local authorities, mental hospitals, treat-

ment centres, and general practitioners. Such a degreeof cooperation has not been very manifest in the past; andthat it will occur in the future is a pious hope-and thetreatment of addiction has been the graveyard of pioushopes.

Under the new administrative arrangements,! thefoundation for the treatment of heroin addiction is to bethe hospital service. So far much of the most successfultreatment has been given by independent organisationsoutside the hospitals, but of late successful hospital workhas been achieved in the United States, and in this

country the experiments being carried out at All SaintsHospital in Birmingham and the Salter unit at Cane HillHospital are hopeful. If the hospital service is able totreat addiction this would be a tremendous step forward,but it seems unwise to rely on any single approach. Thereis a hazard that orthodoxy will develop before even thesuperficial premises have been explored.

Recent legislation departs from many recommendationsof the Brain Committee. As the General MedicalCouncil was unwilling to accept responsibility for dis-ciplining doctors, the new Act has given this authority toa court of law, and this may increase the feeling of in-security among doctors at a time when it is hoped thatmore of them will take part in the new treatment service.Moreover, the occasional unscrupulous doctor will merelyneed to change to different narcotic drugs than thosenominated. Morphine will be prescribed for heroin,and the present dangerous rash of methylamphetamineprescribing will in no way be impeded. Would it beinappropriate to suggest that the G.M.C. should re-

consider this issue ? .

The Ministry has also circulated its views on reable-ment and aftercare. The memorandum 2 is cautiousand recognises that no system of rehabilitation promisesa high rate of success and no standard formula can be laiddown. Even so, to people who are working among addictsits approach to the problem of drug dependency will seemunrealistic. The treatment of narcotic addiction is un-known and not agreed, and any treatment must be experi-mental (a word nowhere mentioned), empirical, pro-visional, and uncertain. It is not a question of objectiveestimates of prescribing, but even whether heroin shouldbe prescribed at all; not whether rehabilitation is a goodthing, but whether narcotic addiction is amenable to treat-ment at all; not whether a patient should be passed on toany hostel or hostels that may be available, but whetherunder a voluntary system there will be any patients left"

at the end of six months to pass on; not whether theywill have a " family doctor but whether any family willbe unwise or daring enough to have them back and anygeneral practitioner bold (or stupid) enough to take themon. Nor is any mention made of biochemical tests for thecontrol of addiction; yet these remain essential in thecontrol of any treatment service.

1. H.M. 67(16).2. H.M. 67(83).