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421 diagnosis between physiogenic and psychogenic cases, would however, Group Captain Symonds pointed out, be unprofitable. Dr. Aubrey Lewis spoke in detail about this problem. It is not possible by psychological tests to recognise with certainty physiogenic disturbances of function, except when the structural damage is gross or localised. The same difficulty about criteria prevails when other methods of differentiation are tried. Such tests do not make allowance for the large part played by individual and social factors in the causation of the post- contusional syndrome. A comparison was made between a group of men with this syndrome and an equal number of patients in a neurosis centre who had not had any head injury. The similarities between the two groups were striking and the significant differences few : the patients with postcontusional syndrome who are referred to a neurosis centre are much the same sort of people, and call for much the same sort of treatment, as the " non- organic " group. Moreover, among those who sustain head injury on the roads there will be a higher than average proportion of " accident-prone " persons who are perhaps psychopathic and predisposed to neurotic behaviour. The most potent causes of the postcon- tusional syndrome may be found in the situation arising out of the accident. It is not only compensation and other crude advantage that needs consideration, important though it is. Insecurity, loss of employment, and similar social factors operate, as well as the hypochondriacal, anxious, depressive and other latent trends made manifest and active by the threat to life, reason or health to which the patient believes he has been exposed. Both the speakers stressed the value of occupational and psychological treatment in the prevention and manage- ment of these cases. Group Captain Symonds held that the assessment of prognosis as early as possible, and its interpretation to the patient, were most important since many of the patient’s symptoms depend on his uncer- tainty and fears about what the future holds in store for him. Dr. Lewis insisted also on the harm done by needless repetition of special investigations, and on the care that should be given to the patient’s social and individual problems if the well-ordered programme of rehabilitation is to achieve its aim of restoring him to health and working capacity. OVERACTIVE CHILDREN IN THE MAKING THE child who is " never still for an instant " can exhaust his family without seeming to broach his own reserves. All healthy children are active, but in some this characteristic is exaggerated and coupled with other qualities even harder to manage. Russell,l reviewing the causes of hyperactivity, reminds us that the basis is sometimes organic, and that it is not always easy to distinguish such cases. Overactive children are described as restless, wild, impulsive, nervous or fidgety; they are often aggressive and mischievous, and may have brought their parents to such a pitch of morbid expectancy that all parties are on tenterhooks, the child skirmishing to outwit the parents and the parents manoeuvring to circumvent the child. By the time he is brought to the clinic this preoccupation has led to other. complaints-his school work has suffered, he can’t learn to read, he is always fighting, he doesn’t mind what anybody says to him, he can’t fit in with his school- fellows. The parents, willing enough at first to believe that he is not vicious but merely exhausting, come in time to believe that he is incorrigible. Russell regards hyperactivity as having many components. Children who become restless and impulsive after an attack of encephalitis lethargica are well known in colonies of mental- defectives ; in such cases the cerebral damage is’ in and about the basal ganglia, and probably birth injury or the infections of childhood sometimes damage the same region. Electroencephalographv has made it 1. Russell, J. A. Amer. J. Dis. Child. 1942, 63, 94. possible tb demonstrate physiological disturbances in the brains of some children whose behaviour disorders would otherwise have been called purely psychogenic. He suggests that the possibility of an organic basis should be considered whenever there is a combination of over- activity, significant history, poor coordination, tremors, athetoid movements, urge to talk with propulsive speech, too brisk reflexes, polyuria, palsy residuals, or signs of endocrine disturbance. Organic signs, however, may be entirely lacking, and the only pointer may then be a history of a change in development or behaviour after a head injury or an infectious illness-a change, that is to say, out of proportion to all factors in the environment or emotional life. Children with such an organic basis of their behaviour problem are likely to be mismanaged because their parents, unaware of any reason for leniency, treat them too strictly. On the other hand, organic damage can be used as a too-handy explanation of undesirable behaviour, and may lead to a defeatist attitude in treatment. Russell points out that only a very small proportion of children have significant cerebral changes after infections or head injuries, that environ- ment matters as much for a child with an organic lesion as for one with an emotional problem, and that in the management of either adjustment of the home situation plays an important part. He quotes the finding of Childers that the home of the overactive child is usually disordered and chaotic. Exposed to constant nagging, the child feels unwanted and insecure. At school he is too easily distracted, and too impulsive to play well with others ; he tries to get attention, seeks friends but cannot make them, and is regarded’ as a nuisance. The main object of treatment must be-in the organic as well as the emotional case-to relieve the unfavourable tension between him and his parents. BLOOD-PRESSURE READINGS THE variable factors responsible for the level of the peripheral arterial blood-pressure at any one moment are notoriously many, some can be standardised-for example, the effects of exercise, emotion, and pain, the position of the patient, and the accurate levelling of the sphygmomanometer in relation to the heart-but the correlation between the reading obtained and the actual intra-arterial pressure is still not very close. The Cardiac Society in this country, in collaboration with the American Heart Association, produced a useful memor- andum 1 which has done much to standardise technique ; but it is still unjustifiable to record pressure except to the nearest 5 mm.-there can be no significant clinical difference between a reading of say 123/78 and 125/80 mm. Hg. Using as their standard an optical mano- meter to record intra-arterial pressure, Ragan and Bordley 2 have investigated the accuracy of blood- pressure readings obtained by the usual cuff method in 51 relatively young adults. They found that the systolic pressure as recorded by the usual clinical method was affected by both size of arm and the contour of the pulse wave ; in patients with small arms the ausculta- tory readings are usually too low, while in those with large arms they are usually too high. Occasionally auscultatory readings are 30 mm. Hg different from those obtained by the intra-arterial method, but excluding those with arms greater than 35 cm. or less than 24 cm. in circumference and those with aortic incompetence the auscultatory systolic readings came within 10 mm. Hg of the intra-arterial pressure in 83% of cases. The diastolic pressure recorded by the auscultatory method was usually higher than the intra-arterial measurement, the difference increasing with increasing size of the arm. In accordance with general clinical experience the auscultatory diastolic pressure recorded was much too low in most cases of aortic incompetence. Excluding 1. Brit. Heart J. 1939, 1, 261. 2. Ragan, C. and Bordley, J. Bull. Johns Hopk. Hosp. 1941, 79, 504.
