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hormone preparations. He concluded that no simplerelationship existed between the anterior pituitaryand vitamin E.

Mr. A. L. BACHARACH discussed the difficultiesinvolved in the biological assay of vitamin E. He

emphasised that though vitamin E seemed to beessential for normal pregnancy in the rat, depriva-tion of the vitamin was without effect on gestation inthe goat. It was not safe therefore to argue directlyfrom one species to another as far as vitamin-E needswere concerned. He had found that 100 per cent.gestation-resorption occurred in rats fed exclusivelyfrom the time of weaning on an E-deficient diet. Ifsuch animals were given vitamin E in graded dosesduring pregnancy the percentage of live litters seemedto be a function of the dose employed. A rat whichowing to deficiency of the vitamin had had oneresorption of pregnancy showed greater resistance tothe implantation of a further ovum than its virginsisters and its response to vitamin-E therapy was alsoreduced. In testicular degeneration, mildly damagedtestes were only repaired when extremely big doses ofvitamin E were given, while severely damaged testesdid not respond at all.

Miss M. M. 0. BARRIE stated that a partial lack ofvitamin E was probably worse than a complete lack,since it resulted in pathological pregnancies while acomplete lack led only to a failed pregnancy. Partialdeficiency might have three results: (1) a tox2emiaof pregnancy, (2) prolonged gestation, (3) productionof E-deficient milk. Miss Barrie said that rats fedon an E-deficient diet and then given vitamin E aftermating developed muscular dystrophy and bleedingfrom nose and rectum. At autopsy gross lesionswere found in both liver and kidney, associated withpigmentation of the uterus. When the deficiency wasmild the rats might deliver a normal litter, but about18 days after birth the young began to show signs ofE-deficiency. This deficiency she attributed to lack ofthe vitamin in the mothers’ milk, because if the youngwere raised by a normal foster-mother they remainedwell, while the litter of a normal mother suckled byan E-deficient rat developed signs of E-deficiency. InMiss Barrie’s view the close similarity in appearanceof the hypophysectomised rat and the E-deficientrat suggested a close relationship between the vitaminand the anterior lobe of the pituitary. She hopedthat vitamin-E therapy might prove to be of clinicalvalue in women subject to habitual abortion and inthose with toxaemia of pregnancy or deficientlactation.

Prof. F. J. BROWNE said that published reportssuggested that treatment by vitamin E of habitualabortion in women resulted in the birth of a livingchild at term in 75 per cent. of cases. He himselfwas unconvinced by such results, since equally satis-factory findings were reported from the use ofextremely varied therapy-for instance, progesterone,vitamin C, weekly injections of small amounts ofserum from pregnant women, and cold baths. Hedescribed 18 cases of habitual abortion which hadbeen treated at University College Hospital ; 8 caseswere given progestin, 3 vitamin E and 7 good advice,2 of the latter being admitted to hospital. The7 control cases all had living healthy children atterm. Prof. Browne urged the need of greatercaution in interpreting the results of vitamin-Etherapy in women in the absence of adequate controls.

Mr. F. BERGEL, Ph.D., emphasised the importanceof using stable preparations of vitamin E for clinicaltrial.

Prof DRUMMOND, in reply, said that Prof. Browne’sfindings suggested that in humans the process of

normal pregnancy, like that in the goat and unlikethat in the rat, may not be dependent upon vitamin E.He reminded the meeting that the diet of the poorerpeople in this country is extremely deficient invitamin E.

HUNTERIAN SOCIETY

AT a meeting of this society on March 20, withMr. A. C. McALLISTER, the president, in the chair,a discussion on

Misleading Leading Symptomswas opened by Lord HoRDER. He said that thepredominant misleading leading symptom was pain.A symptom might be local but the disease whichproduced it general. A local symptom of typhoidmight be an intense neuralgia relating to some

division of the fifth nerve and suggesting an acutesinusitis. In poliomyelitis retention of urine andpain in the back might be the presenting symptoms.A symptom that had several times threatened todistract his attention from the true position wasthe " cardiac shock" which replaced the rigor incertain acute diseases. Pneumonia, especially in

elderly people, might start without shivering, and thephysician might not think of taking the temperature,or the temperature might be equivocal. The picturewas like that of a cardiac attack, with cyanosis, apoor pulse, and the features of an acute ventricularinsufficiency. Conversely, a local disease processmight produce general disease symptoms. In anadult a small patch of erysipelas or of streptococcaldermatitis, or an early cellulitis with slight lymphan-gitis, might be present in a patient who was broughtto the physician for headache, delirium and highfever with a request to perform lumbar puncture.The symptoms were not due to meningitis but to theother focus of infection. The practitioner was some-times misled by severe anginal or lower sternal painin gall-bladder disease. The patient might, however,be suffering from both diseases. Anginal symptomsmight indicate diaphragmatic pleurisy. Some patientswith a duodenal ulcer presented all the classicalsymptoms and the diagnosis was confirmed by radio-logy or surgery, although the pain and tendernesswere left-sided.

Functional disorders, Lord Horder went on, some-times simulated organic trouble. Migraine with

hemianopia, aphasia, anaesthesia, paresis, and ophthal-moplegia might occur in a patient suspected of

organic disease. In a patient with hyperpiesis anda certain amount of arteriosclerosis who was not yetold enough to have emerged from the migrainousstate the symptoms were very misleading. Manycases of strabismus and some of diplopia were merelydue to excessive fatigue, although these symptomsmight linger for some time. A patient might havevery intense headache with slight mental confusion,slight pyrexia, and a stiffness of the neck suggestingmild meningitis, after a long and exacting motordrive under bad conditions. Such patients some-times had a suspicion of disseminated sclerosisattached to them for years on that evidence alone.The angioneurotic patient might be suspected of

organic disease, and it was the fashion now to lookfor an underlying inflammatory trouble. Epilepsymight be missed in a patient who complained offlatulence and attributed " nerve storms " to it :in other words, the aura of epilepsy was a misleadingsymptom. Very many anginoid patients said that

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their pain disappeared when they got rid of wind ;this association was synchronous rather than causal.The crises of tabes were apt to be misleading. Somehsematurias did not connote stone, neoplasm or arenal lesion. The patient with chronic interstitialnephritis who was getting on in years and had beentaking hexamine for rather longer than was advisablemight sometimes show hsematuria, and it was not

always realised that haematuria was quite commonin acute pyelitis. Anuria when the patient wasvomiting or suffering from diarrhoea might be mis-leading, and so might the pain which preceded therash in herpes. Lord Horder still saw, he said, theshiny red foot or hand of acute gout with incisionsin it, which did not heal well even on the Prontosilwhich some physicians tried. Epileptiform attacksmight occur in hard drinkers, and true epilepsymight begin late in life without syphilis. The enlarge-ment or ptosis of an organ, such as the spleen or liver,might cause puzzling symptoms.

Mr. W. H. OGILVIE declared that misleadingsymptoms could only be misleading to one who wasable to be misled. " Leading " conveyed the ideaof motion, and surgeons were more likely to bemisled than physicians because they were more likelyto do something. A policy of masterly inactivitywas an absolute safeguard against " misduction."Pain could not be analysed and was capable of limit-less misinterpretation by the patient and the practi-tioner. Its real severity might bear little relationto the patient’s account of it, and depended onthe age, sex, courage and general background of thepatient. Each physician must construct his ownscale of values from his personal experience. Themost severe pain was that of perforated duodenalulcer, closely followed by that of coronary disease,which might mimic a surgical emergency. Nextcame gall-stone colic, slightly behind it renal colic,and then acute pancreatitis ; much later came thepain of appendicitis and intestinal colic. A goodmalingerer could describe and mimic the pain of

perforation, and spurious or imaginary pains weremore likely to mislead when they were associatedwith a real organic lesion.The practitioner must decide not only what disease

the patient had but what he was suffering from.An expensive medical education rather predisposedto mistakes, and clinical experience was the onlysafeguard. The specialist would detect the slightestabnormality in the organ or system of his own

particular study, but could swallow a whole camelof coincident general disturbances. The vomiting,distension and constipation typical of colonic carci-noma were often seen with ursemia. The vomitingof large quantities of blood, usually an indicationof organic disease, was frequently practised byhysterics and malingerers. He had been led astrayby pigmentation that was not due to residual jaundicebut to Asiatic extraction. Symptoms should not leadthe physician, but came to him to be put in theirproper place. When they had been marshalled andassessed the physician would often find that themost noisy symptom was not necessarily the leader.The medical profession would be very foolish toabandon the system of clinical training whichprevailed in this country and which had been foundedby Sydenham and Boerhaave. Mr. Ogilvie said hehad suffered throughout his life from a completeignorance of psychology. Students should be taughtthe working of the normal mind as part of theirordinary physiological training, and should laterbe given enough psychological instruction to showthem how the normal mind reacted to the stress of

circumstance and modified the signs and symptomsof disease.

DISCUSSION

Dr. F. M. R. WALSHE said that there were nomisleading symptoms, only symptoms that thedoctor failed to interpret. One reason for suchfailure might be the natural tendency to -accepta patient’s description as bearing some relation toreality. The " headache ’’ and " giddiness " mostoften described to the neurologist should be takento mean nothing at all until the exact meaning thatthe patient attached to those words had been elicited.Giddiness might mean unsteadiness due to tabes orrotary vertigo from labyrinthine disease, or mightmerely be a figure of speech in a psychoneurotic.Out of ten neurological patients complaining ofheadache, there might not be two with the samephysical basis for it. Interpretation could onlybe reliably made after observation of the entireconstellation of symptoms. If clinical medicinecould only be learned at the bedside, he asked,how could psychology, a much more complex subject,be taught to an adolescent medical student out ofbooks I The understanding of the minds of one’sfellow-men could only be gained in the battle of life.To add more precise psychological study to themedical curriculum would be a completely futilelast straw on the back of the wretched camel.

Dr. GEORGE RIDDOCH spoke of the difficulty ofestimating the patient’s normality, capabilities andintelligence in a comparatively brief interview.The physician might also be misled by statementsof relatives and friends. Especially dangerous weresymptoms on the borderline between physical andpsychological interpretation. In a case of head

injury symptoms which appeared to be psycho-neurotic-e.g., pain and discomfort in the head-were sometimes laid aside in that category and

proved later to have an organic basis. Defects ofmemory and difficulty in concentration might be theresult of disturbances which would lead in time topermanent disability. Pain might be absent in aneurological condition where it should be present,such as cerebral tumour ; and elation or depressionwith delusions might be absent in an early generalparalytic. General paralysis might develop insidiouslyunder the appearance of neurasthenia.

Mr. L. E. C. NORBURY spoke of a patient whosebaffling symptoms of pain had been produced by aseries of misguided operations. Some patients couldproduce symptoms at will-e.g., those of dislocatedankle-and capitalised them round the hospitals.

Mr. C. P. G. WAKELEY gave a warning againstfailure to put to the patient questions which appearedirrelevant. A diagnosis was sometimes missedbecause of a negative report from the radiologist.Diagnosis tended to be made in a department ratherthan on clinical evidence, and there was today a lackof clinical observation.

Mr. W. D. DOHERTY complained of the tendencyto send patients to a specialist because the leadingsymptom seemed to fall within his specialty, whenthe real condition was not one for that specialist atall. Many infant boys were circumcised because theyappeared to cry whenever they passed water. Inhis opinion these children often only passed wateras a mechanical result of screaming due to some othercause of pain.

Dr. F. HOWARD HuMFHRis told how he had oncemistaken a diabetic coma for alcoholic stupor, anddeduced from the experience the precept always totest the urine.

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Dr. ALASTAIR McGREGOR mentioned a case inwhich a tapeworm had caused glycosuria on whichdiabetes had been diagnosed.

Mr. H. L. ATTWATER recalled the case of a womanin whom a subacute congestion of the bladder leadingto the single symptom of frequency had been dueto a local smouldering inflammation of the rightfallopian tube.

Mr. A. E. MORTIMER WooLF thought that thesemi-fraudulent patient was more baffling than themalingerer, and instanced a girl who had repeatedlyappeared with pins in the intestinal tract. The mostmisleading symptoms were common symptoms thathad unusual bearing. Hsematuria might be causedin children by eating peardrops, which were flavouredby certain acetanilides.Dr. G. L. ATTWATER spoke of a mysterious pyrexia

in a nurse whose integrity was undoubted ; she hada bowed shoulder and a hunched back and complained

of pain on the right side, but there was no tendernessor tumour and the urine was normal.

Dr. F. A. RICHARDS discussed the vagaries ofamenorrhcea, and mentioned that pregnancy mightbe overlooked in an obese patient.

Mr. A. DicKsoN WRIGHT drew attention to thedanger of regarding as fraudulent or neurotic patientswho really had an organic disease, and gave as anexample a case of malignant disease dismissed as

pseudocyesis. Lesions in the feet or hands of patientssuffering from arterial disease were sometimesmistaken for whitlows and incised.

Dr. W. H. F. OXLEY, proposing a vote of thanksto the openers, said that more careful search forphysical signs would prevent some mistakes.-Mr.D. C. NoRRis, seconding the motion, stressed thevalue of taking an all-round view of patients, andgave an example of confusion between symptoms ofappendicitis and of pneumonia.

REVIEWS AND NOTICES OF BOOKS

The Social Function of Science

By J. D. BERNAL, F.R.S., professor of physics in theUniversity of London, at Birkbeck College, London:George Routledge and Sons. 1939. Pp.482. 12s.6d.IN this fully documented and closely written

treatise, supplemented with notes and appendices,Prof. Bernal surveys science in the past, present andfuture. The frustrated scientist speaks his mind,and to those who complacently think and speak ofscientific progress as one of the outstanding meritsof the age his representations will be something of ashock. In his view the teaching of science at schoolis deplorable : "physics and chemistry, as requiredfor university entrance examinations or schoolcertificate, has been worked into one of the mostrepulsive routines imaginable." Their curriculacontain nothing concerning twentieth-century dis-coveries. At the university things are hardly betterand the lecture system in particular is condemned.The conditions and character of research work donein university, government and industrial depart-ments is examined at length and its parsimoniousbacking, lack of coordination and often desultorycharacter are frankly exposed. It certainly reflectspoorly on the present state of our civilisation thatthe annual grant to the Medical Research Council isonly ;E195,000 (1938) in comparison with -E204,OOOfor the Chemical Warfare (Defence) Department.Nor is it encouraging to find that we lag behind otherand poorer countries in our expenditure on research.Bernal concludes that relative to its wealth andimportance in world affairs, England spends verylittle on science and makes less of its potentialscientists than do any of the other great powers.This and other equally formidable charges are

supported by facts and figures.In view of our fine tradition and opportunities the

time has clearly come when we should review thesituation and decide upon our future policy. Andhere there is little doubt that those who like to keepscience and politics in watertight compartments willjib at many of the suggested remedies. Funda-

mentally the reform must come through improvededucation combined with greater support from thestate. Such education should cater also for the manin the street who, with.better and fuller newspaperreports and popular expositions of scientific matters,perhaps including televised experiments, would takea greater interest in science and appreciate morefully and intelligently the part it plays in his daily

life. In short a real understanding of science shouldbecome a part of the common life of our times.

Bernal makes many practical suggestions for themore effective running of laboratories and the recruit-ing and training of workers in all lines of research, andhe emphasises the desirability of forming a greaternumber of institutes where specified lines of researchmay be pursued by teams of suitably qualifiedworkers. The function of scientific periodicals is alsoexamined and the view expressed that we are withinmeasurable distance of suffocation by the volume ofmatter published-an event only to be avoided byabolition of nearly all existing journals and rationalisa-tion of scientific intercommunication. The pursuit ofscience along Bernal’s lines might well create a worldboth brave and new, and his utopia has an appearanceof practicability as well as an absence of priggishness.Any prospect of immediate achievement is howeverseriously handicapped by the present epidemic ofnationalism which, in more ways than one, threatensa severe setback to scientific progress.

This review mentions only a few of many interestingsections of this book, and all who have the welfareof civilisation at heart are advised to give it theirserious and unprejudiced consideration.

Ker’s Manual of Fevers(4th ed.) Revised by FRANK L. KER, M.B. Edin.,senior assistant and deputy medical superintendent,Little Bromwich Hospital, Birmingham. London :Humphrey Milford, Oxford University Press.1939. Pp. 354. 12s. 6d.THE preparation of the fourth edition of the late

Claude Ker’s Manual of Fevers has been undertakenby his son, Dr. Frank L. Ker. Eleven years havepassed since the last edition, edited by Dr. ClaudeRundle, appeared and Dr. Ker says that while thegreater part of the text remains unaltered advancesin the bacteriology and treatment of the infectiousdiseases have necessitated considerable revisions andadditions to these sections. Claude Ker’s clinicaldescriptions of the common fevers are among the bestwe know and it is well that in the main they have beenleft untouched. Unfortunately however the reviser,in a laudable attempt to preserve as much as possibleof his distinguished father’s work, has retained a gooddeal that is obsolete and has omitted much newwork. The Paschen bodies, now recognised as thevirus of smallpox and vaccinia, and the analogouselementary bodies to be found in the vesicles of

chickenpox, are not mentioned. The arguments