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amongst some 7000 immunised. It is of interestthat the earliest recorded cases which I have beenable to trace were in 1934, more than 20 years afterthe introduction of the Schick test. Moreover, Ihave found only seven recorded instances of allergicphenomena, although up to the present many hundredthousand Schick tests in different countries havecome under review. I have notes of seven others,hitherto unpublished, and altogether fourteen cases arereviewed in this paper. I have long suspected theoccurrence of other cases, and Freedman, in a recentpersonal communication, has kindly informed me thatseveral physicians in America have observed allergicreactions of varying degree following a Schick testperformed some time after a previous Schick test.An allergic response to a Schick test does not appear

to occur except after previous injections of foreignserum, prophylactic, Schick test fluid, and so forth.It is probable that asthma or hay-fever would alsopredispose to its occurrence, and in two cases pub-lished in America there was a past history of eczema.Recent investigations by Bousfield on a patient whogave a more severe reaction than any so far recorded,suggest that the Witte peptone in some of the stabi-lisers of Schick test fluids now in general use indifferent countries may be an important factor in

inducing the phenomena. Incidentally, two of thecases reported in this paper were known to be allergicto Witte peptone.

In view of the rarity of the hypersensitive state,practitioners need not be unduly alarmed, nor hesitateto perform a Schick test where indicated. The worstof the reactions caused some anxiety for a time,but the subjects soon recovered completely. Pre-cautionary measures however are indicated. Prob-ably all practitioners carry adrenaline in their bags,and there should be no difficulty in improvising atourniquet for application above the point of injec-tion, as recommended by American workers.

SUMMARY

The Schick test has in very rare instances beenfollowed by an allergic reaction.

I wish to acknowledge my indebtedness to variousclinical colleagues who very kindly sent me informationabout their cases; also to Dr. Joyce Wright for her helpin most unusual emergencies.

REFERENCES

Freedman, H. J. : Jour. Ped., 1935, vi., 695.Massey, A., and Gilmore, E. R. W. : Brit. Med. Jour., 1934, i.,

803.Monroe, J. D., Volk, V. K., and Park, W. H. : Amer. Jour. Pub.

Health, 1934, xxiv., 342.Volk, V. K. : Ibid., 1935, xxv., 430.

BRITISH MEDICAL ASSOCIATION

MEETING AT OXFORD

SECTIONS OF ANESTHETICS AND

OBSTETRICS AND GYNIECOLOGY

Prof. H. BECKwITH WHITEHOUSE (Birmingham)presided at this combined meeting of two sectionswhen a discussion was held on

Anaesthetics in Labour

Dr. K. G. LLOYD WILLIAMS (London) stated thatthough chloroform was still often the only possibleanaesthetic for use in domiciliary practice (especiallyin country districts) the use of gas and air or gas andoxygen was still steadily increasing. These mixtureswere chosen for their low toxicity, though it wasdoubtful if either alone was really sufficient foractual delivery. To procure relief of pain, and thiswas now generally accepted as necessary, was moredifficult in the first than in the second stage of labour,though not less desirable of achievement, as thatwas often the most wearisome and painful part of thewhole confinement. The relief required was thatwhich would induce some hours sleep and refresh-ment rather than the intermittent relief suitable inthe second stage between pains. Drugs-notablymorphine and scopolamine in the first stage, followedby the barbiturates with gas and oxygen later in thesecond stage-were useful in normal labour, buta number of long drawn-out cases occurred in whichfurther analgesic measures were desirable; and forthese, rectal anaesthetics—avertin, paraldehyde, ether-had proved of value at the Royal Free Hospitalduring the last three years. Tables showing theresults obtained in 50 cases with the use of the twolatter were shown by Dr. Lloyd Williams. Etherwas generally preferred to paraldehyde, which causedsome restlessness after injection and had a smellwhich made it unpopular in a general ward.

Rectal ether was preceded by potassium bromidegrs. xxx., chloral hydrate grs. xxx., given in glucoselemonade at an early stage. This might be followedby 1 c.cm. opoidine in 2 c.cm. magnesium sulphate

given intramuscularly as pains increased. If reliefwas not obtained rectal ether was injected accordingto Gwathmey’s formula :-

in iv. olive oil.

The mixture was warmed and run in slowly andolive oil 3 i. added; three to four hours’ excellent anal-gesia and amnesia were thus obtained. The techniquefor paraldehyde was similar with the omission of theopoidine. Gas and air or gas and oxygen were usedfor the second stage, with additional ether if necessaryfor actual delivery. Vinyl ether had also been usedat this stage and in rapidity of action much resembledchloroform. The advantages of such a method werefourfold : (1) Three to four hours’ excellent analgesiawas obtained. (2) It was cheap and safe and thedrugs used could be safely kept as stock mixtures.(3) No elaborate technique was necessary. Anyskilled person could give the injection. (4) Themethod was suitable for pathological cases-i.e.,patients with heart disease. While this was in no waya new technique the series was of special interest, sincerectal methods had not obtained in this countrythe popularity they deserved.

Dr. R. J. MINNITT (Liverpool), speaking on gas andair analgesia, gave details of over one thousandadministrations to obstetric cases between 1933 and1935. Good relief from pain had been obtained in952 (92-8 per cent.). The length of time duringwhich gas-air was administered varied within thefollowing limits : over 4 hours (80 cases) ; between2-4 hours (169 cases) ; between 1-2 hours (239 cases) ;under 1 hour (464). The number of forceps deliveriesin the series was 56 (5-5 per cent.) and the number ofstillbirths in the series (all but one being due toobstetrical causes) was 19 (1-8 per cent.). Dr. Minnittemphasised the fact that this method was analgesicrather than anaesthetic. While it might still be foundadvisable to resort to ether or chloroform for actual

delivery, such analgesia as gas and air afforded wasthe more urgent need during the long hours beforeactual delivery was possible. The relief of pain

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obtained was remarkable, and contractions becamemuch more effectual. The only known contra-indication to this form of analgesia was the

presence of cyanosis-e.g., in cases of heart diseaseor of recent bronchial cold. Various forms of

apparatus were shown by Dr. Minnitt including:(1) A hospital model on movable stand. (2) A doctor’smodel, with two 50-gallon cylinders (weight, withoutcylinders, 15 lb.). (3) Midwives’ models, withoutcylinders : (a) the original apparatus (weighing141 lb.), in which a cylinder could be connected to theside of the case, overhanging a table ; (b) a latermodel (weighing 91 lb.) embodying the same principlemade to fit the carrier of a bicycle, and for use withcylinders sent in a special box which acted as a stand.This would be supplied by the manufacturers ofnitrous oxide to any patient’s house.

Mr. L. CARNAC RIVETT (London) considered thatwhen instruments were to be used or any form ofoperation was to take place, a second medical manwas essential, and even in a normal labour his presencewas often desirable ; but since 65 per cent. of birthswere conducted by midwives in patients’ homes, itwas for such births that analgesics were sought andthese were hard to find. He still considered thatchloroform was the best analgesic, easiest to regulate,and per se the most satisfactory. The occasionalintolerance for the drug which produced (thoughvery rarely) chloroform poisoning made it, however,unsuitable for the use of midwives. He, too, hadthought out an apparatus for gas and air for the useof midwives, and in view of the fact that spannerswere tools not easily handled or understood by womenhe had devised a machine in which they did not occur.The weight of the apparatus was 18 lb., including thecylinder. This had been in use for three monthsnow at Queen Charlotte’s Hospital and had provedvery satisfactory. Mr. Rivett paid a tribute toDr. Minnitt’s work. He felt sure that we were

exploring on right lines, but he still felt that gas andair were insufficient for the delivery of the head.

Mr. LEONARD PHILIPS (London) also expressedappreciation of the work done by Dr. Minnitt inthe popularisation of gas and air analgesia. Unfor-

tunately for the production of analgesia no twowomen were alike in their reactions. Mr. Phillipshad had success with rectal anaesthetics but foundthem subject to certain disadvantages-i.e., difficultyof retention if the foetal head was low, possibleproctitis, and an unpleasant smell lingering even afterdelivery. Moreover rectal anaesthetics ceased tobe safe if labour was protracted for three to fourdays. His own technique was that of drugs variedaccording to the need of each patient. Usually,after the establishment of regular pains, he gaveomnopon gr. 1/3 and scopolamine gr. 1/150, followedtwo hours later, when their effect was wearing off,by two capsules of nembutal, and within half anhour the first dose of chloral, gr. 30 in three ounces oflemonade, taken slowly. Two hours later a furthercapsule of nembutal, followed again by chloral, wasgiven, both to be repeated if required in another twoto three hours. Such technique he had found wouldkeep a patient unconscious of her labour until thehead was on the perineum. As for avertin, hisexperience was that patients given this drug lookedgrey and pallid even after delivery, and it was oftensome hours before they became conscious, or could bevisited by an anxious husband.

Dr. H. W. FEATHERSTONE (Birmingham) was

enthusiastic in his praise of Dr. Minnitt’s gas and airapparatus and its service to the community. He

had found nembutal useful but apt to cause vomiting;it was only suitable for use in small quantities andby qualified practitioners. Chloroform was still of

great value, but not suitable for midwives exceptin capsule form. He had submitted himself to

experiment with the gas-air apparatus, but was ofopinion that that shown by Mr. Rivett required toomuch effort on the part of the patient.

Dr. HELEN RODWAY (London) spoke of the difficultyof ensuring analgesia or loss of sense of pain withoutloss of consciousness. She stressed the need for

previous examination of the patient in order todetermine the most suitable analgesic to use. Drugsshould not be given till uterine contractions werewell established, and she thought it wiser to reserveinhalation analgesia till the second stage.

Mr. C. S. LANE-ROBERTS (London) thoughtDr. Minnitt’s work gave a line for future investigation.The Junker with chloroform would always remain ofvalue, either given by a medical man or by the patientherself, but in his opinion the head could be safelycrowned under gas and oxygen provided the breathingwas carefully regulated.

Dr. Z. MENNELL (London) spoke in favour ofchloroform properly used ; he considered that its

disrepute was entirely due to improper administration.No analgesia produced by other methods was as

complete as that obtained under chloroform, and ithad the additional advantage of being practical forself-administration in a Junker apparatus. Heexpressed himself as strongly in favour of chloro-form ; its danger lay in the re-anaesthetising of

patients. No other anaesthetic agent gave such

complete analgesia and amnesia as chloroform.Dr. R. FRANCIS JoNES (Tamworth) showed an

ingenious modified Shipway for use with etherwhich he had found remarkably useful in his ownpractice ; it was fool-proof in its connexions and

compact for transport.Dr. LLOYD-WILLIAMS, in replying, emphasised

the fact that rectal analgesics were for use only incases of prolonged labour ; otherwise gas with eitherair or oxygen was the anaesthetic of choice. She

expressed her agreement with Dr. Mennell that incountry work chloroform was still of the greatestvalue.

_____

SECTION OF NEUROLOGY ANDPSYCHOLOGICAL MEDICINE

AT a meeting of this section on July 23rd, withDr. THos. SAXTY GOOD (Oxford), the president, inthe chair, a discussion on

Delirious States

was opened by Dr. BERNARD HART (London). Severalproblems arose, he said, in considering these states.Had they a specific causation and mechanism ?Did they differ according to the causal agent, so

that the nature of the cause could be deduced fromthe clinical picture ? What part did constitutionaland psychogenic factors play, and did the studyof delirious states provide information about theorigin of psychotic symptoms in general ?While febrile delirium was an easily recognisable

and characteristic syndrome, there were imper-ceptible gradations between it and conditions whichseemed only remotely related to it. Delirium tremens,with its confusion, disorientation, hallucinations,associated fear-affect, and short course, was a typicaldelirium produced by the abuse of alcohol; butother deliria caused by other exogenous toxins

313BRITISH MEDICAL ASSOCIATION ’

lacked some of the characteristic features. A second

group comprised cases presumably due to endogenoustoxins-in uraemia, after operation, or in extremeinanition. A third included delirium in senile

psychoses, general paralysis, and traumatic con-

ditions. These might by analogy be regarded as

toxic, but the theories of Hughlings Jackson sug-gested that this might not be the true explanation.Less typical forms which might be styled " attenuateddeliria " included those states known to Englishpsychiatrists as " confusional insanity." Theirfeatures included confusion with imperception anddisorientation, hallucinations of all the senses,motor restlessness, a duration of some months, anda fairly good prognosis. The disorder had beenshown to follow definite toxic states, either endo-

genous or exogenous, and it could also be a sequelto excessive fatigue and emotional stress ; thelink might be through chemical processes associatedwith fatigue or emotion. A further difficulty was thattypical deliria might develop in the course of otherdisorders such as schizophrenia and in psychogenicdisorders such as hysteria. It was impossible at

present to say how far delirium could be consideredan entity; it could only be said that it was usuallypreceded by certain factors bearing a genuine resem-blance to one another and included under the some-what indefinite term " toxic." In discussing theprobable pathogenesis it was therefore necessary toenter the sphere of hypothesis and speculation.

Hughlings Jackson had postulated that injuryto any layer or centre of the brain might be either"

destroying," whereby function was diminishedor abrogated, or

" discharging," whereby it wasstimulated. Destruction of a higher centre meantliberation of a lower from normal control. Jacksonhad applied these theories to delirium, which heascribed to over-activity of normal lower centres

owing to a destroying lesion of the higher centre.This explained most of the phenomena of deliriumand especially the various nature of the conditionsin which it occurred and the variability of the symp-toms produced. It did not however explain thecontent of a delirium, and it had been suggestedthat this depended on the individual equipmentand experience of the patient. It was, moreover,possible that the lower centre was not only over-acting but was acting abnormally because it also wasaffected by a " discharging lesion."

Discussing the relative significance of the terms"

organic " and " psychogenic " as applied to deliriumDr. Hart pointed out that the word " functional "was sometimes used as an equivalent to " psycho-genic " and sometimes as meaning a lesion for whichno structural basis had yet been found. He suggestedthat the term " psychogenic " should be regardedonly as meaning that with our limited knowledgeof neurological processes a psychological conceptionof it was the more helpful. A " functional " conditionmight be regarded.as one in which the causal factorsacted through the ordinary channels-e.g., a hystericalhemiplegia in which the arm is kept still by the normalmechanism. An " organic " condition was one

in which the causal factors, so to speak, impingedon the machinery from outside-e.g., a hemiplegiadue to haemorrhage. Applying this to delirium theprimary causal factors were usually " organic "and consisted in a modification of the brain substanceproduced by a toxin, degeneration, or conceivablyby neurological modifications resulting from processesat present regarded as psychogenic-e.g., in hystericaldelirium. And the activity of the lower centres in

delirium was either functional or (at least partly)organic, according as the lower centre was merelyreleased (owing to cortical damage) or was itself

damaged.Dr. DESMOND CURRAN (London), speaking on

prognosis, said that this became more difficult incases that departed from the typical delirious syn-drome. No single manifestation of a delirious statecould be traced to one aetiological agent and thatalone ; the same disturbance was produced by manycauses differing only in so far as the " noxious dose "differed in intensity and duration. Certain peopleappeared to have a personal and constitutionalpredisposition; thus the young and the elderlyarterio-sclerotics were especially prone to delirium.These facts were helpful in predicting occurrence andalso recurrence and also anomalies and complications.Most cases cleared up when physical recovery tookplace. In three-quarters of a series of 106 cases ofdiverse origin the duration was less than three weeks,but some of the patients died. Moreover there weresome important exceptions in regard to mental

recovery. For example, delirium might be only anepisode complicating a pre-existing psychosis, or it

might be a prelude to the development of a psychosis.An important group was that of the puerperal con-fusions. Delirium had a worse prognosis if it had noobvious exogenous cause. There was considerabledifference of opinion about prognosis in the Korsakovsyndrome, but this was now so uncommon in GreatBritain that few people had much experience ofit. The great importance of the constitutional andpersonal factors in assessing prognosis must never belost sight of.Dr. IAN SKOTTOWE (Aylesbury) said that, setting

aside delirium associated with frankly definablepoisons such as alcohol, and localised lesions such aspneumonia and typhoid, there remained the toxicand exhaustive delirious states which came underthe term " acute confusional insanity "-a deplorableand misleading expression. In this group of casesthere were profound changes at the somatic level,characterised by pulse and temperature changes,gastro-intestinal disturbance, and rapid loss of flesh.These changes in turn caused further changes atthe central nervous level, so that the sensorium

presented an untrue picture of reality to the subject.Emotional and conative patterns were releasedin the more personal part of the psyche. It was not

easy, however, to be sure at which level the changebegan; treatment must be based on recognitionthat we are dealing with a vicious circle. This couldbe attacked from several points. Nourishmentwas probably the first necessity : a generous dietarywith glucose was essential, artificial feeding shouldbe started at once if food was refused, and 6-8 pintsof fluid should be taken in the 24 hours. Some

generalised attempt at detoxication was also neces-sary. The wet pack, heat bath, and continuousflow bath involved risk of syncopal. attacks. He

preferred to have patients nursed in bed in the openair, even in the winter, for the incidence of broncho-pneumonia was thus greatly reduced. At thepsychic level treatment by prolonged narcosis withbarbiturates was the most successful. By puttingthe mind and body at rest death from exhaustionwas avoided and patients were given every chanceto regain their balance. The toxicity of the bar-biturates did not in his opinion constitute a contra-indication. Quastel’s researches into brain metabolism,and oxidation in particular, had practically laid thebogy of barbiturate poisoning. On recovery the

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patient was in a suitable state of suggestibilityfor psychotherapeutic treatment. The system oftreatment outlined required mental hospital con-

ditions ; delirious patients should never be certifiedbut should be admitted in the " temporarycategory.

Dr. WILLIAM BROwN (Oxford) said that psycho-neural parallelism was accepted to-day by everyphilosopher, although psychophysical parallelism wasstill an open question. In 1 per cent. of his casestreated by prolonged analysis, mild delirious statesdeveloped. A possible toxic factor could not beexcluded, but he believed that these states were

largely due to disturbance of the vegetative nervoussystem and endocrine glands as a result of the rapidrelease of certain repressions and the evolutionof reactions at a deeper psychological level. He

thought that analysis was useful in the recoverystages of the Korsakov syndrome.

Prof. BuRRiDGE spoke of the modern viewthat there was no evidence for the existence ofhigher and lower " centres."-Dr. FOSTER-KENNEDY(New York) said that in delirium there was a reversionto a primitive type of thinking.-Dr. MARY BERKELEYbelieved that the ingestion of fluids in greaterquantities by women might sometimes prevent theonset of delirious states.-Dr. FREwEN MOOR

(Norwich) said that as a general practitioner his

experience of delirium was largely related to theterminal stages of life in old people-what CliffordAllbutt had termed " cardiac delirium." This wasof course usually fatal. Disorientation of place was atypical feature. The patient was normal during theday and delirious at night. Treatment was of littleavail.

Dr. LuciE VAN DAM (South Africa) stated that theprognosis of the Korsakov syndrome was very badin South Africa.-Dr. W. MAYER-GROSS (London)said he had been studying senile delirium at TootingBec Mental Hospital. If we could find special symp-toms associated with special lesions it would be of

great help. He thought the theory of the " centres "discussed by Dr. Hart was unsatisfactory.-Dr.ELIZABETH CASSON (Bristol) suggested that we mightlearn something of the content of deliria by studyingour own delirious experiences. She thought there wasa high degree of amnesia which might account inpart for the increased suggestibility.-Dr. RICHARDEAGER (Exminster) attributed deliria partly totoxins and partly to constitutional factors. Heagreed with Dr. Skottowe about the importanceand value of tube-feeding which was often delayedtoo long. He also approved strongly of prolongednarcosis.-Dr. RIDDOCH pointed out that in traumaticdelirium there might be some cerebral anoxsemia.

Oxygen was a help. Hughlings Jackson was referringto " levels " of the brain and not to " centres " in theanatomical sense.-Dr. NEUMANN, Dr. H. T. GILLETT(Oxford), Dr. CHAMBERS, and Dr. BATES also tookpart in the discussion.The PRESIDENT, in summing up, did not approve

the use of the feeding-tube, or prolonged barbituratenarcosis, but agreed that it was necessary to buildup the patient’s resistance. Gramophone recordsof patients’ delirious ramblings had led to muchinformation about the psychological causes of theirillness.

Phantom Limbs

Dr. GEORGE RIDDOCH (London), in a paper on

phantom limbs, said that after amputation it wasusual for the patient to experience sensations as ifhis limb were still present. These phantom limbs

might be painless or painful. The former mightdevelop not only after amputation but also after

damage of peripheral nerves (rare and partial), ofplexuses (usually brachial), of posterior roots (e.g., intabes), or of posterior columns, or after completedivision of the spinal cord. Painful phantom limbsin his experience developed only after severe lesionsof peripheral nerves (e.g., amputation of a limb or,occasionally, the removal of a tooth) and aftergreat damage to a plexus or to posterior roots. The

pain usually appeared immediately or soon after

operation ; in a limb it usually affected the hand orthe foot predominantly but might represent the wholeamputated part. Pain might show periodic exacerba-tions, but was persistent, usually as a dull ache orburning or throbbing. The painful phantom wasfelt to move with the stump, but voluntary movementof the phantom itself was limited and attempts tomove it aggravated the pain. Any lowering of thepatient’s health or resistance aggravated the pain andemotional instability was an almost inevitablecomplication, as in all disorders where incessantsevere pain was present. Lateral chordotomy orsection of the lateral spinothalamic tract oftencured the pain while leaving the phantom still in

apparent connexion with the stump.The phantom, said Dr. Riddoch, was a manifesta-

tion of the sensory function of projection-thatis to say of those aspects of sensation by which werecognised, without touch or vision, the constantlychanging outline of our bodies and the relationshipof one part to another. When a limb was cut offstimulation of the proximal ends of the dividednerves evoked sensations which were projected andinterpreted as if the limb were still present. It was

only as the phantom became fainter with diminishedstimulation of the healing nerves that it approachedthe stump and finally disappeared ; in other wordsthat the individual accepted a new shape of his

body. Phantom limbs following lesions of the plexus,posterior roots, or spinal cord usually appeared to bein positions other than those of the real limbs whenthese had not been amputated; the importantfactor here was probably the extent to which posturalsensibility was lost. In cases of persistent and painfulphantoms structural changes in the nerves of the

stump had been demonstrated ; there were tenderend-bulbs and interstitial neuritis. In such cases

physiological as well as psychological inhibitiondiminished and the patient could not learn to adjusthimself to a new body shape. This was anotherillustration of the dominance of pain over adaptivefunctions. ,

Dr. FOSTER KENNEDY asked what result chordo-tomy had on pain in the stump and painful phantomlimbs.-Dr. RIDDOCH replied that the pain dis-

appeared.-Dr. J. R. BENSON (Salisbury) said thatin a case of his own of congenital amputation, therehad been no perception of any phantom.-Dr.SCOTT (Penshurst) spoke of the occurrence ofunreality feelings, in relation to the body, in psychoses,and of delusions of multiple limbs in depersonalisationcases.-Dr. SILVERMAN asked whether children andinfants after amputations developed phantom limbsin later life.-Dr. CURRAN asked whether massagewas of value in such cases.-Dr. NEUMANN askedwhether right- and left-handedness played any part.The PRESIDENT pointed out that idiots often

had no appreciation of pain. Prof. le Gros Clark haddemonstrated fibres connecting the thalamus withthe prefrontal lobe. Could changes be demonstratedin these fibres in such cases ?-Dr. MAYER-GROSS

315BRITISH MEDICAL ASSOCIATION

asked how it was that in some cases the hand, wrist,or elbow phantom was preserved and the rest of thestump faded out of consciousness.-Dr. LAMORNAHINGSTON (Hove) asked whether the different

positions of the phantom limb could be accountedfor by the nature of the trauma.

Dr. RIDDOCH, in replying, said that no phantomlimbs developed after congenital or infantile amputa-tion. The parietal sensory cortex was the part of thebrain concerned with spatial relationships, and wasthe only one affected in these cases. The fibresdescribed by le Gros Clark had no direct relationto the condition. Those parts most endowed withsensation, such as the hand, wrist, and elbow, per-sisted in consciousness, because they were more

heavily represented in the cortex. There was no

special relation to right- or left-handedness. Psycho-logical factors played a part, but the phantom limbwas of organic origin and quite a different matterfrom functional or psychogenic imaginings.

SECTION OF MEDICAL SOCIOLOGY

AT a meeting of this section on July 24th SirGEORGE NEWMAN (London) took the chair and openeda discussion on

Medical Problems of School Life

by saying that no doctor could, in practice, helpbeing a medical sociologist. Out of such fundamentalsocial needs as sanitation, one day of rest in seven,

daylight saving, public water-supplies, the relief andhousing of the poor, schooling, industrial welfare,and the provision of hospitals, with the assistanceof the art of medicine, the public health services ofthe nineteenth century had arisen. The Mosaic lawhad been largely negative, but government by statutewas now more positive than negative, and with thegrowth of compassion government had grown morehumanitarian. The nature of man was a complexbiological unity of the physical, the intellectual,and the spiritual, and these needs must all be regardedby government. Not the best could be our aim, butthe best that was practical.

Dr. G. E. FRIEND, medical officer to Christ’s

Hospital, spoke onSCHOOL DIETETICS IN RELATION TO PHYSICAL

EFFICIENCY

He based his remarks, he said, on a review covering20 years, which included the war period, of the 830boys living under centralised conditions in Christ’sHospital. Besides the construction of the dietary,the purchase, preparation, and ingestion of food, andits proper absorption and disposal all requiredcareful thought and control. The commoner faultsin institutional feeding were : (1) the basis of diettables was too often purely empirical, and over-

feeding was as potent a cause of .malnutrition as

underfeeding ; (2) too short a time was allowed formeals ; (3) early school and chapel before breakfastwere harmful; (4) lack of variety in the daily menu ;(5) lack of proper service of meals ; (6) a diet schemenot sufficiently adapted to seasonal change ; (7) lackof proper supervision of meals and too little regardfor the amenities of the table and appurtenances ;(8) bad cooking, which should perhaps have comehigher in the list ; (9) insufficient free time aftermeals, especially after breakfast and dinner. Childrenof school age, especially in a boarding-school, wereanimals living in a state of physiological captivity.Indications were not wanting that the ideal diet

would be found to contain less protein and more fatin relation to carbohydrates than was at presentregarded as necessary. Vitamins A, B-complex,C, and D were necessary to health and growth, andan excess of one would not compensate for the shortageof another. To guard against deficiency, as great avariety of foodstuffs as possible should be used,always including milk, cheese, Australian or NewZealand butter, fresh vegetables, and fruit. In the

average school diet some lack was most likely in thecase of B and D. The vitamin content of whole-meal flour depended on the amount of coarse branand middlings removed and on the amount of whiteflour added to produce an economic texture in theloaf. There might be much less vitamin and mineralsalts present than the term whole-meal suggested ;it did not necessarily imply "whole-grain." The

daily food was best divided between breakfast,dinner, and tea. A five or five and a half hourinterval between meals was not too long and conducedto a sharpened appetite. Some of the more strikingfeatures in the 20 years’ survey were as follows :the attack-rate of fractures rose with the substitutionof margarine for butter, and returned to normalwhen butter was reintroduced into the diet; a pro-gressive fall in the incidence of acute and subacuterheumatism was coincident with an increase of animalfat in the diet ; gastro-intestinal disorders haddeclined with improved feeding ; cases of pyrexiaof unknown origin had decreased, but catarrhalconditions and the complications of influenza hadincreased, with an increased diet; minor sepsis, boils,and whitlows had increased with increased sugar ;the height and weight records showed an improve-ment corresponding to the increase in diet. But

although normal bodily growth had been achievedthere was not yet proper resistance to infection.He believed this to be a matter of right and wrongbalance.

Dr. E. H. M. MILLIGAN, medical officer of healthand school medical officer of Glossop, discussed

DIETETICS AND THE NUTRITION OF THE SCHOOL-CHILD

He had carried out investigations, he said, to decidewhether the diet of the lower-paid wage-earnersand their children in Glossop was deficient, andhad found that the weight : height ratio of childrenin the distressed area was lower than that of childrenelsewhere, and that children of the unemployed hadshown a lower ratio than children of the employed.Moreover, 44 per cent. of the children of professionalparents, as compared with 7 per cent. of the childrenof labouring class families, had shown a haemoglobinpercentage of 80 or over. It became necessary todecide what was an adequate dietary to maintainhealth, and how far the home dietary of school-children fell short of this standard, and this wasdone. But as a preliminary measure school-childrenwere given milk and sandwiches, in which theyreceived those articles of diet which the parentswere unable to provide in sufficient amount. One,two, or even three bottles of milk, of t pint each,were given with every sandwich. The sandwichesconsisted of brown bread and butter with raw vege-tables, lettuce, or tomato, or cheese, and, recently,added yeast. The heights and weights of the childrenwere recorded, and in addition their strength wastested by the dynamometer and their endurance

by getting them to hang on to a horizontal bar aslong as possible. Defective nutrition was a complexof lack of growth, clinical defects, and deficient

strength and staying power. He emphasised the

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importance of finding out what the child was havingat home before deciding what to give at school,and of controlling the results by weighing andmeasurements.

Dr. WILLIAM BROCKBANK, medical officer atManchester Grammar School, introduced the sub-

ject ofHOMEWORK

Most parents, he said, and strangely enough mostboys working for the higher school examinations,were in favour of homework, regarding it as a regret-table necessity. Members of the teaching professionconsidered it an essential part of education, andthough it had often been pointed out that they hadnot to do it, they spent many weary hours correctingit. The point was that the boy did it alone, with, orbetter without, some slight unskilled help from hisparents. It had been suggested that homeworkshould be done at school in the form of " prepara-tion," and that school hours should be correspondinglylonger, but there were serious objections to this.The boy doing homework learned the art of privatestudy. A day school usually had many outside

activities-debating, dramatic, scouting, musical,literary, or scientific-timed to begin at the end ofschool. If " prep." were done at school these wouldhave to be discontinued. At a boarding-school thework was spread through the day from 7.30 A.M.

to 8.30 but in a day school it would be crammedin between 9.30 A.M. and 5.30 P.M. Would that begood for the boy The hardworking master wasthe one who set most homework, while the lazymaster set little or none. Clever boys, who finishedtheir homework too quickly, could be encouraged todo collateral reading, but the difficulties of the slowboy were important. They could be removed byplacing him in the appropriate division of the form,and giving the parent the right to initial the home-work at the end of a stated time. He was satisfiedthat homework did not affect a boy’s health. Occa-

sionally when a boy became listless and lost resilience,homework was a predisposing factor. The mostserious cases had all occurred in boys working forscholarships or higher examinations, and without

exception they had been working longer than wasdesirable or necessary. Some boys were overworkedby pressure from their parents ; these might eitherget the school certificate too early and then collapsementally, or they might become worried and losehealth. Lack of sleep, in other cases, was responsiblefor- decline of athletic prowess. Masters were agreedt] t the standard demanded bv the matriculatione: mination was too high, and the subjects unsuit-a for the average boy. They requested an examina-ti i independent of that set up by the universitiesf< their own needs; if this were done educationVI lId become less of a cram course. The solution1: in moderation and common sense. He thoughtit should be possible to ease the burden on the averageboy ; to train the studious boy to understand thepitfalls of overwork ; to keep a watch on the indivi-dual boy who was suffering from the system, and seethat there was close collaboration with the parent ;and to make sure that the staff did not expect toomuch of their boys. But he did not think it desirableto abolish homework.

Miss 1. M. DRUMMOND, head mistress of the NorthLondon Collegiate School, spoke upon

HOMEWORK AND PHYSICAL EDUCATION

She thought homework had been discussed too muchin isolation. The aim was to encourage private

study and to make children independent of theteacher. Schools now included aesthetic and athletic

training. Games or gymnastics should find a placein the school day, and the school week included

periods for music, art, and handicraft. Criticisms ofthe intellectual demands made upon the child tookno account of the recreational activities of the school

day. In some schools the plan of giving time forpreparation at school had proved successful, inothers it had been found that the work done afternormal school hours lacked freshness. If some

pleasures had to be put aside in order to get home-work done, this was good character training. Someoccupation for the mind was needed between5 o’clock and bedtime in the adolescent period. Pro-tests against homework usually came from parentswho wanted to take a hand in the child’s educationthemselves-and these had all the holidays at theirdisposal ; or from fond and foolish parents whowanted the child to be a companion after schoolhours. Some parents filled up the child’s eveningswith dramatic and dancing classes. Miss Drummondfelt that a little quiet homework was better for thechild than additional guided activities after schoolhours.

Mr. F. R. G. DUCKwORTH, H.M. Chief Inspector,Board of Education, discussed

PHYSICAL EDUCATION

It was not easy, he said, for schools to fit into theirtime-tables a full course of physical training. Thefirst time-table had come down from Mount Sinai,and even that had presented problems which hadnot yet been entirely solved. A test had been carriedout in a secondary school in the north of Englandinvolving two forms, equal in age and ability. Oneform had held to the existing time-table whichincluded, weekly, two periods of physical trainingand one of organised games. The other form hadbeen given a daily dose of physical training, in timewhich had been taken from other school subjects.At the end of two years the physical measurementsof the second form showed an improvement overthose of the first form ; and in the end of termexaminations the second form sometimes did betterbut never did worse than the first form. The resultswere not conclusive but they were sufficientlyencouraging to extend the experiment, and now fivesecondary schools were carrying out similar tests.Even if loss of time on physical training meant poorerschool work, that did not mean that physical trainingwas any less necessary. But if it helped the boyto maintain existing school standards with less

expenditure of time, the change to a curriculum

containing a daily physical training period couldprobably be effected with less friction.

Mr. A. D. LINDSAY, vice-chancellor of Oxford,said he had a strong impression that boys to whomscholarships mattered vitally were likely to over-

work in such a way as to make it less possible forthem to obtain scholarships. And some boys suc-ceeded in getting a scholarship and then appearedto be finished intellectually. Would it some day bepossible to arrange a plan on the lines of Rhodesscholarships, by which the boy had to give evidenceof other capacities A medical examination woulddiscover whether he was mentally or physicallyexhausted.

Dr. CYRIL NORWOOD, president of St. John’sCollege, Oxford, endorsed Dr. Brockbank’s plea formoderation and common sense. He was not con-vinced that the change of one article of diet

317REVIEWS AND NOTICES OF BOOKS

produced all the results it seemed to do. Each childneeded studying individually, and he would like

every school to have a medical officer who knew

every child personally. Boys survived the effectsof too much homework by refraining from doing it.The burden should be measured according to the

ability of the individual child. It was essential to

give children some free time after breakfast, and tobring them directly from work to the midday meal.If there was a gap, they filled it with a visit to thetuck shop.

Miss E. M. TANNER, head mistress of RoedeanSchool, remarked that girls had not the same self-protective ability as boys when afflicted with toomuch homework.Dr. E. K. LE FLEMING said that the physical

education committee had discussed the burnt-outathlete with Mr. H. M. Abrahams, who had saidthat boys were often so worn out by physical trainingthat they failed to develop to a maturity of excellence.Mr. Lindsay had found the same thing on the intel-lectual side. It was difficult enough to assess physicalfitness ; and the present methods of mental assess-ment were wrong. Qualities of value in outside lifewere not examined for, under our present system,and therefore were not cultivated as they should be.

Miss M. T. TALBOT said she was a cookery instructorin a poor district, and she considered not enoughattention was given to local tastes in drawing updietaries. Tastes varied greatly in different districts,and it should be possible to begin with those articlesin the local diet which were good and build up adiet based upon them.

Dr. J. G. WOOLHAM drew attention to the valueof the Royal Air Force tests for assessing physicalefficiency.-Sir ROBERT MCCARRISON urged the

value of a proper supply of vitamin B, which wasmainly distributed in grain ; the more purified thecereal the less the vitamin-B content. He also putin an approving word for the herring as an articleof diet.-Dr. MoRTLOocK BROWN entered a plea fora piped water-supply in labourer’s cottages. Muchmoney had been spent to subsidise certain food-stuffs but very little to ensure safe and adequatewater-supplies. This handicapped particularly themothers in the management of their homes.

Dr. GEORGE V. PORTER, of Toronto University,said that physical training was compulsory at alluniversities in Canada and the United States. As aresult, all students had to submit to examinationby the medical staff, and this made it possible forthe doctor to advise the student on points affectinghis choice of career and his future.

Mr. WARREN DERRY, head master of Wolverhamp-ton Grammar School, reminded his hearers that

people who talked of the hard lot of children in

secondary schools seldom compared them withchildren of the same age employed in industry. Asixth form boy did 40 hours work a week and had15 weeks’ holiday yearly.Dr. D. R. EDWARDS mentioned the value’ of

swimming as a form of physical training.-Dr. R. E.SMITH, medical officer of Rugby School, said thatone symptom of overwork was for a boy to be woundup like a clock. If you put him to bed and gave hima Strand Magazine he instantly began to do the

"perplexities." These boys responded well tosmall doses of bromide. He thought the scale of

games should be reduced for small boys. Boys atpreparatory school played cricket on a pitch 21instead of 22 yards long, but it should be muchshorter.-The openers of the discussion replied.

REVIEWS AND NOTICES OF BOOKS

The Extra-Ocular MusclesA Clinical Study of Normal and Abnormal OcularMotility. Second edition. By LUTHER C. PETER,A.M., M.D., Sc.D., Professor of Diseases of the

Eye in the Graduate School of Medicine of theUniversity of Pennsylvania. London : HenryKimpton. 1936. Pp. 351. 21s.

Dr. Peter’s monograph, long a standard work,has now been brought up to date. The first part-nearly a quarter of the whole book-gives a goodaccount, first of the anatomy and fascial connexionsof the eye muscles and the paths of the nerves whichconnect them with the brain, then of their physio-logy ; and in this connexion the point is stressedthat in any movement of the eye all the musclesand not merely one or two are concerned. Thereis also a section on the theoretical aspects ofbinocular vision.The second part of the book deals with hetero-

phoria and its various forms, their symptoms andtreatment. Heterophoria implies that the externalmuscles are not perfectly balanced, so that even inthe position of rest some of them have constantlyto do extra work in order to maintain binocularvision. Some sorts of want of balance may be com-paratively innocuous, others may prove too great astrain on the nervous system and may thereforerequire treatment either by prismatic glasses or

in rare cases by operation. Errors in the verticalmeridian are always more important than those inthe horizontal, but the sort of error that is liableto produce most disturbance of all is a want of

balance in the muscles causing torsion of the eyeball-cyclophoria. It is often associated with obliqueastigmatism, and an accurate correction of the refrac-tion may be enough to relieve it. If it is not, theauthor discusses treatment by exercises with cylinderscalculated to strengthen the weak muscles or thepossibility of prescribing weak cyclinders calculatedto relieve them of some of their work. In any casethe first essential in treating any form of hetero-phoria is accurate refraction.The next part of the work deals adequately with

" heterotropia" or concomitant squint, and someattention is paid to the modern treatment by orthopticexercises, though for a full account of the methodsnow being tested it would be necessary to go else-where. Paralytic squint is then fully discussed, andthen follows a section on surgical technique in whichthe author’s favourite methods of operation are

described. The work closes with a short sectionon nystagmus. The book affords a comprehensiveview of its subject.

Manual of EmergenciesThird edition. By J. SNOWMAN, M.D., M.R.C.P.London : John Bale, Sons and Danielsson Ltd.1936. Pp. 401. 10s.

IN this third edition Dr. Snowman has incor-

porated the modifications and advances which haverecently been made in our knowledge of the natureand treatment of the dangerous emergencies of

medicine, surgery, and obstetrics. The book covers