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Selected cases respond satisfactorily and it appears thatradio-iodine will have a useful place in the treatmentof cases of hyperthyroidism which recur after surgery.There is probably little risk of ’late carcinogenesis, butcaution is obviously necessary. Only a small proportionof all cancers of the thyroid retain the function of iodineconcentration sufficiently to deliver therapeutically usefuldoses of radiation with radio-iodine, although there areextremely rare cases where functional secretion is a

striking feature of both the primary and metastases andwhere dramatic results can be obtained by radio-iodinetherapy.

In general, it must be concluded that therapeutictrials of radioactive isotopes administered internallyshould be limited to cancer and allied diseases, includingpolycythaemia vera. Professor Mitchell expressed theopinion that it w91d be wise to avoid the therapeuticuse of radioactive isotopes in any conditions in children.

This section held a joint meeting with the section ofchild health to discuss Malignant Disease in Childhood(see below).

CHILD HEALTH

President : Sir LEONARD PARSONS, F.R.S.The most notable events in this section were the

discussions on Neonatal Morbidity and Mortality and onMalignant Disease in Infancy and Childhood.

Neonatal Morb-idity and MortalityThis discussion was opened by Dr. AGNES R.

MACGREGOR whose experience of neonatal pathology is

unsurpassed in this country. She spoke of the greatadvances which have followed routine necropsy of still-born and newborn infants, and insisted that there is nobranch of-medicine in which close collaboration betweenclinician and pathologist is more rewarding. In a teach-ing maternity hospital she has found that 71 % of newborninfants coming to necropsy are prematurely born.

Asphyxia, intracranial haemorrhage, and infections werenotably commoner in premature than mature infants ;

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and the same was true, to a lesser extent, of congenitalmalformations. The escapist term " atelectasis " as a

cause of death was rightly condemned, for it is neverprimary.

Prof. L. S. PENROSE discussed the 2etiology of con-genital malformations.. He believes it is often impossibleto differentiate between congenital malformations causedby inherited mutant genes, new mutations, and aberrantintra-uterine development. He recalled the need to studythe pedigree when investigating the origin of congenitalcharacters and anomalies. Most congenital abnormalitiesare inherited-particularly minor ones, since childrenwith major defects often perish. There is a 5% chanceof an anencephalic foetus being followed by a sibling withspina bifida, and another 5% chance of siblings havingother malformations. The incidence of congenital mal-formations is higher in offspring born at the extremes ofthe reproductive period and particularly towards theupper extreme ; 24 years is probably the safest

child-bearing age from both this and the obstetricviewpoint.A pertinent account of modern trends in the nutrition

of premature infants was given by Dr. WINIFRED YouNG,who recalled that premature infants retain more protein,calcium, and phosphorus per unit of weight than domature infants. This fact deserves wider recognition,as also does her assertion that even small prematureinfants are able to digest their full requirements, whichare small during the first few days owing to a low meta-bolic-rate, and thereafter exceed those of mature infants.Appreciation of these facts has produced more rapidweight gain and better health in premature infants thanformerly, with closer approximation to normal intra-uterine nutrition in the later weeks of pregnancy.

The contribution of obstetric factors to neonatalmorbidity and mortality was reviewed by Prof. N. B.CAPON ò He pointed out that the premature infant’sbrain is particularly liable to be traumatised at birth,owing to the softness of the immature protective bonesand membranes. Intracranial haemorrhage is a less

important cause of signs of cerebral irritation thanexcessive compression, venous congestion, and oedema.Anoxia is a major danger, particularly with antepartumhaemorrhage and trauma to the foetal head. Professor

Capon commended the modern obstetric practices of

avoiding unduly long labour and of more often per-forming elective caesarean section ; for these trends have

improved the prognosis in many cases of complicatedbirth. He spoke of the need for caution in the use ofanalgesics and anaesthetics, which are a major cause ofapncea after birth, and of consequent morbidity andmortality in the newborn.

Dr. J. L. HENDERSON emphasised the greater risk ofinfants contracting infections in crowded institutionsthan in the home. He deplored the prevailing trendtowards confinement in maternity hospitals and nursing-homes, since few institutions have been built in accord-ance with modern opinion. Mammals instinctively leavethe herd and seek isolation to give birth to their young;and tend them in the early days : human mothers areno exception-a fact often ignored in this materialisticage. In the first week of life the incidence of infectionsis low, but thereafter it is high, causing more morbidityand mortality than all other disorders. The tissues ofthe newborn infant react poorly to infection, for there isa lack of specific active immunity, and local tissue

response is poor. Inherited passive immunity is a

partial safeguard ; but active immunity develops undulyslowly in the first six months. The common neonatalinfections-staphylococcal dermatitis, conjunctivitis, andoral thrush-are usually contracted after birth. Staphylo-coccal infection, which is endemic in maternity hospitals,is much the commonest cause of neonatal infection.The frequency of staphylococcal infections in infants,mothers, and nurses can be correlated. In addition tothe various forms of dermatitis, such as paronychia andbullous impetigo, Sta]J’hylococcus aureus causes most casesof conjunctivitis. Oral penicillin therapy is reliable insthe first month of life ; it may be given in doses of two10,000-unit tablets, crushed and dissolved in a littlemilk at each feed. Thrush should never be regarded asa benign disease since it may occasionally invade theoesophagus when it may cause death. Epidemic gastro-enteritis, the most dreaded neonatal infection, is probablycaused by a variety of organisms. The need for constant

vigilance and immediate isolation of cases of suspectedinfection in institutions is paramount ; and dispersal ofinfants with their mothers in single rooms or very smallunits is desirable.

Malignant DiseaseThis discussion was introduced by Prof. WILFRID

GAISFORD who summarised contemporary knowledge ofthe clinical features and pathology. He showed thatthe problem is by no means negligible, since 4429 childrenunder 14 years had malignant disease in Britain in arecent 5-year period. He insisted that with recent

therapeutic advances the old pessimistic attitude is no

longer warranted. Tumours are commoner in the first5 years than in later childhood. The three principalgroups of malignant tumour in children are intracranialtumours, leuk2emia, and renal tumours. The mostcommon intracranial tumours are medulloblastomas andastrocytomas ; both are curable-the former by radio-therapy and the latter by neurosurgery. Unfortunately,it is usually impossible to differentiate these tumourswithout surgical exploration. Malignancy should be

suspected when persistent swellings and persistentadenopathy are found. The curability, in many

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instances, of Wilms’s tumour of the kidney by surgeryand of suprarenal neuroblastoma by radiotherapy under-lines the need for the early diagnosis of abdominal

swellings.Radiological diagnosis was reviewed by Dr. C. G. TEALL

who emphasised the limitations of radiology in earlydifferential diagnosis, but pointed out that it is betterto be unsure early than sure when the patient isbeyond aid.

Radiotherapy was discussed by Prof. J. S. MITCHELL,who said that malignant-cell degeneration rather thanmitotic inhibition is the object of radiotherapy. Thereis special danger of producing degenerative vascular

changes and katabolic toxic effects in childhood. The

radiosensitivity of tumours with identical histologydiffers widely. He opposes the use of radioactive

isotopes in non-malignant conditions in childhood, owingto the danger of long-term degenerative effects.

Dr. A. M. BARRETT said it seemed paradoxical thattumours should be so rare in intra-uterine life when

.growth is more active than at any other period, and hesuggested that tumours are more commonly of multicentricorigin than has hitherto been believed.

OPHTHALMOLOGY

President : Mr. O. GAYER MORGAN

Ophthalmic Problems associated with Gyracecological andObstetric Conditions

Mr. F. A. JuLER must have echoed many -people’sperplexity when he expressed surprise at the infrequencyof damage to the eye from obstetric forceps. Longexperience as ophthalmologist to Queen Charlotte’s

Hospital has confronted him with a few babies sufferingfrom conjunctival haemorrhage and orbital haematoma,but he has seen no instance of severe forceps injury tothe eye itself. Retinal haemorrhages, as Mr. Juler haspreviously pointed out,! are not rare in the newborn,but their incidence has never been shown to be raised

by the use of obstetric forceps. Such bleeding is presum-ably due to compression of the chest, and it reminds usof the retinal hemorrhages found in crush injuries.Haemorrhage into the retina has also been reported asa consequence of hyperemesis gravidarum, but Mr.Juler regards it as rare. Nor has he often seen puerperalfailure of vision. This lamentable sequel of child-birth, so far as can be judged from nineteenth-centurytextbooks, was relatively common, and arose from

postpartum haemorrhage. Gastro-intestinal and uterine

haemorrhage jointly account for most of the cases inwhich severe bleeding is followed by optic atrophy, andit seems clear that improved obstetric technique, includingantenatal supervision, deserves the credit for stemmingpostpartum haemorrhage.

Opposite opinions concerning the efficacy of silvernitrate as a prophylactic against ophthalmia neonatorumhave been expressed in recent years. Many cliniciansstill believe in Oredé’s method, whereas others regard itas dangerous. At Queen Charlotte’s Hospital observationswere made on 300 babies. Those of one sex were sub-

jected to silver nitrate instillation at birth, while no dropswere used for the others. Subsequent clinical and

bacteriological investigation revealed no differencebetween the two groups, suggesting that silver nitratehas little or no prophylactic value.Although obstetricians must bear the main respon-

sibility for terminating pregnancy, cases do arise in whichan ophthalmologist’s opinion may decide the issue.

Concerning the significance of retinopathy among expec-tant mothers, Mr. Juler emphasised that prognosisdepends on a number of factors, including the patient’sage, the duration of symptoms, and previous attacks.Other speakers mentioned maternal rubella as a reason

1. Trans. ophthal. Soc. U.K. 1926, 46, 47.

for emptying the uterus, especially when the infectionis acquired during the second month of pregnancy. Itwas suggested, however, that the two epidemics ofrubella investigated in Australia near the beginning ofthe present decade were unusually severe, and that thechances of congenital malformation may well be lessamong mothers infected with the milder forms of germanmeasles seen in this country.

Speaking of cyclical extragenital bleeding, includinghaemorrhage into the conjunctiva and the weeping ofsanious tears, Mr. A. R. NuTT remarked that the conceptof vicarious menstruation has been questioned, but heasked what other explanation will account for repeatedextragenital haemorrhages at or immediately before themenstrual flow which cease during pregnancy or whenthe woman attains the menopause. Mr. Nutt suggestedthat periodical swelling of the pituitary gland offereda possible explanation for menstrual headache. Asmembers of the endocrine orchestra, the ovaries and thepituitary are closely interrelated, and the pituitary mightwell be influenced by vascular congestion, especially inpatients whose sella turcica is of less than the averagesize.With regard to the aetiology of iridocyclitis in women,

Mr. Juler and Mr. Nutt granted that some cases aretuberculous, but they deprecated the use of systemicinjections of tuberculin against local ocular disease-indeed, in their view tuberculin often aggravates anocular lesion.

Significance and Interpretation of RefmctionOnce again refraction has proved a fertile ground for

discussion. Mr. E. G. RECORDON deplored the use of smalloblique cylinders and other forms of finicky prescription.He urged the need for careful objective examination withthe patient’s eyes relaxed, and is- opposed to the" better or worse " system of subjective testing. Refrac-tion is not a mere sideshow to be grasped within a fewmonths. It should be -regarded as an artistic productof experience-not simply mechanical repetition butrather a multitude of tests conducted with criticalacumen.

Mr. ARTHUR LISTER contended that so long as a

refractionist uses one method efficiently, it does notmatter which technique he adopts. The reason why mostpeople laud their own system is that A’s failures drift toB’s consulting-room, and vice versa-a generalisationwhich may explain many a series of successful resultsin other realms of medicine and surgery ! Mr. Listermaintains that small refractive errors are seldom impor-tant, and that most headaches are not of ocular origin.He laid stress on the importance of taking a history,because refractive changes often represent only one

aspect of a deep-seated ocular lesion, and sometimesthey point to systemic disease, such as diabetes.Among the instruments recommended by Mr. VICTOR

PuRvis were the streak retinoscope, the focimeter, andthe letters of the duochrome test, but he agreed withMr. Lister’s contention that many different roads maylead to the goal of a successful prescription. Both ofthese observers held that refractive errors are not toblame for styes or conjunctivitis, or for many of the otherdiseases for which they are often held responsible.Mr. Purvis insisted on speed as well as care in subjectivetesting. The refractionist must, he said, take charge ofthe patient.Occasional Papers

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Discussing the Present-day Position of Contact Lenses,Mr. A. G. CROSS reviewed the evolution of technicalmethods and then considered the contact lens as a form

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of treatment and as an optical aid. Of 1850 peoplefitted with contact lenses during the past ten years, athird have since ceased to wear them. Technical advances

may augment the proportion of satisfied wearers, but