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another occasion, a boy of 14 was found unconscious inthe street, an hour after eating eight mistletoe berries.It is said that the doctor suspected alcoholic intoxication,and at that season he may have had cause.

Holly berries may also be sampled, but this need causeeven less anxiety, for their effects are mainly purgative.The only report of holly poisoning we know of appeared inour columns in 1870, when a boy aged 3 ate a number ofthe berries. He soon had bilious vomiting and copiousdiarrhoea, berries being seen in the motions. Aftertwelve hours he lost consciousness, but had fullyrecovered next day. The winter cherry or Jerusalemcherry, commonly found as a decorative pot plant,is another berry which may prove too attractive atChristmas-time. Two species are Solanum capsicastrumand S. pseudocapsicum S. capsicastrum is the usual oneand is believed to be harmless, but children have diedafter eating S. pseudocapsicum, and even three or fourberries can produce symptoms. A 2-year-old boy diedrecently in Italy after eating these berries, which

apparently he found growing wild.2 Vomiting was verysevere and was followed by convulsions and coma. Awinter cherry is thus the most dangerous of the three.There is no specific antidote for any of these berries.

If any significant quantity has been taken, emesis orgastric lavage will give peace of mind. Thereafter, thetreatment is symptomatic.

1. Lancet, 1870, i, 573.2. Gaburro, D. Acta pœdiat. latina, 1952, 5, 431.3. Daniels, A. C. Dis Chest, 1949, 16, 360.4. Shefts, L. M., Terrill, A. A., Swindell, H. Amer. Rev. Tuberc.

1953, 68, 505.

"SCALENE NODE" BIOPSY

IT is occasionally very difficult to get histologicalevidence of intrathoracic disease. Abnormal tissue maybe sought by bronchoscopy, thoracoscopy, and thoraco-tomy, or by examination of sputum and pleural fluid.The search can be extended further by liver biopsy,sternal puncture, or removal of enlarged superficiallymph-nodes. But commonly no nodes are palpable,and the removal of the deeper, impalpable ones may seemworth while. Daniels,3 for instance, dissected out thenodes lying on the scalenus-anterior muscle in patientswith sarcoidosis, bronchial carcinoma., and silicosisand found abnormal tissue in them.

Shefts et awl. have made this investigation in a verymuch larger series. They report the results of 205dissections in 187 patients with intrathoracic disease inwhom histological evidence had not been obtained byother methods. There were abnormal findings in 67

(35%). These " scalene nodes " are said to be connectedwith the mediastinal nodes, and it might be assumedthat the pathological process in one of these two groupsis always the same as that in the other. But this isnot necessarily so. It is not known how commonlycaseous tuberculous changes affect the deep cervicalnodes of patients who have no radiographic evidence ofintrathoracic tuberculosis ; the nodes receive lymphfrom many sources, and the tuberculous infection mayhave travelled down from the throat and not up from the

lung. Moreover, microscopic tuberculous changes in themediastinal nodes are so commonly present withoutthe patient having " tuberculosis

" that, even if theinfection of the cervical nodes has been by way of themediastinum, there must’still be doubt whether theintrathoracic abnormality being investigated is tuber-culous. Similar caution might be wise in interpretingthe nodal changes associated with sarcoidosis ; for non-

caseating tuberculous lesions are sometimes found inthe mediastinal nodes of patients with pulmonarytuberculosis.

Shefts et al. suggest that this investigation may beuseful not only in detecting bronchial carcinoma whenother methods of investigation have failed, but also indetecting those proved cases of carcinoma in which

the disease is too far advanced for surgical treatment.If the sole aim of resecting bronchial carcinomas wereto eradicate all cancer tissue, this preliminary screeningmight save some useless operations. But removing theaffected lobe or lung in patients with small mediastinalmetastases may, even if it does not postpone death,make what is left of life happier. Additional evidencefrom the pathologist, although refining the diagnosis, maynot help either in treating the patient or in forecastingthe course of his illness. Excision of deep cervical lymph-nodes may be safe and cause the patient only slightdiscomfort ; but this investigation should perhaps bereserved chiefly for obscure intrathoracic conditionswhere histological evidence is necessary for rationaltreatment.

1. Reducing Emotional Trauma in Hospitalized Children. Fromthe departments of pediatrics and anesthesiology, AlbanyMedical College, Albany, New York. 1952. Pp. 82.

PREPARATION FOR TONSILLECTOMY

"... the emotional equipment required for dealingadequately with a hospital experience is no different fromthat needed in dealing with all the other problems of life."TRUE enough ; but the research team at the Albany

College, New York, who make this observation, are

aware that life, taking us by surprise, can sometimesrattle our emotional equipment considerably. The adult

may respond to such an experience with neurosis or evenpsychosis, but the child usually responds with behaviourdisorders.

It is no new finding that admission to hospital fortonsillectomy can be a harmful experience for children,and the research team, under the direction of Dr. Otto A.Faust, tried to find out whether careful preparation andhandling reduces the emotional injury. For one reasonor another their original plan for a controlled experimenthad to be given up ; but in the collected papers whichform the basis of their final report,! to which Dr.Mac Keith refers in a letter this week, they set out themethods they used to reassure children and to restorethem to their former pursuits free from emotional

symptoms. Briefly, their method was to choose oto-

laryngologists and anaesthetists with experience of, andsympathy for, children ; they ensured that the wardatmosphere was kindly ; they allowed one parent toremain in hospital with the child throughout his stay;and they sent a social worker to visit the child in hishome before operation, to tell him what to expect.

There were 140 children aged 3-8 in the experiment,and the key people in preparing them to face operationconfidently proved to be the social worker and the "-

anaesthetist. The social worker visited the home notless than a week before the child was due to be admitted,made friends with him and his mother, and noted hissetting in the family. She described to the child thesize of the hospital, what he would see as he entered thedoors, the ride in the lift, the way the doctors andnurses would be dressed (which some children find

frightening), the ward, the other children, and the kindof bed he would sleep in (for some, having graduatedfrom a cot to a bed, are affronted by the cots in a children’sward). She also advised him to take a favourite toy withhim. This interview fortified him for his arrival at

hospital, especially since his mother usually went withhim.On the evening before his operation the anaesthetist—

a woman-visited him and took pains to gain his confi-dence. She found out whether he had had an anaestheticbefore, and judged for herself how he felt about it. Shealso learned, from conversation with the mother, howhe had been prepared for the operation at home-whether,in fact, the suggestions he had received had been plannedor accidental, positive or negative. She explained tohim carefully that he would go to sleep and feel no painexcept for a sore throat afterwards, and she let him

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handle the mask, telling him that he could hold it over hisface himself, and that breathing the medicine on it wouldmake him fall asleep. She described simply the queeror dizzy feeling he might have while falling asleep, andalso told him about the theatre and the sort of clothesshe and the doctors would be dressed up in.Next day she came herself to take him to the operating-

theatre, and faithfully kept her promise to let him holdthe mask. She seldom found that a child wished to liftthe mask or throw it off ; and if a child became nervous alittle reassurance, and the placing of her own hand overhis-not as a restraint but to give confidence-usuallysufficed to calm him. Premedication was slight, or notused at all. She found that with this method theinduction time was shortened, the stage of excitement wasseldom severe (usually lasting only a second or two), andthe child needed less of the anaesthetic agent. She alsofound that such an experience, far from diminishing achild’s courage, usually reinforced it. Having taken theevent gamely he rose in his own esteem.Some other general principles were put into action with

these children. It was found that rectal temperature-taking was alarming, and so, of course, were enemata.Both were given up, and the temperature after the

operation was taken only at night, in the groin or theaxilla. Since the children dreaded injections, these toowere avoided, except for an injection of atropine justbefore operation, and a needle-prick for haemoglobinestimation.The social worker visited the child at his home ten days

after the operation, and again two or three months later,to see whether he was showing any evidence of increasedanxiety. She estimated that, of the 140, 13 showedunfavourable behaviour changes ; but some of these,because they had belonged to a group originally intendedas controls, had not been so carefully prepared for theanaesthetic as the rest of the experimental group. Thechildren treated with consideration for emotional factors

gave less evidence of trauma than those who were not.More than half of the 140 showed behaviour that waseither unchanged or improved, and about a third showeda mixed response, being improved in some traits anddisturbed in others ; in most of these cases, however, themother thought that on the whole the child was betterbehaved. The younger children in the series showed morebut milder adverse behaviour traits than their seniors.

BRONCHOGRAPHY IN PULMONARYTUBERCULOSIS

IT is a commonplace that pyogenic inflammation inthe lung may be followed by bronchiectasis, but thefrequency with which this takes place in tuberculosisis often underestimated. Apart from the dilatation

following an episode of bronchial occlusion during theprimary infection, bronchiectasis is often producedduring the resolution and repair of the long-drawn-outpneumonia of pulmonary tuberculosis. There is usuallyno point in attempting to distinguish between the shadowsof the active pneumonia and those of the fibrous repairthat may follow, but it is a fact that bronchiectatic areasof lung may produce an appearance deceptively similarto active tuberculosis, particularly in upper lobes whichhave been subjected to collapse therapy ; and that

shadowing thought to represent infiltration may largelyresult from bronchiectasis.The frequency of these events cannot be appreciated

unless bronchography is widely practised on the tuber-culous, and there are good reasons for not doing this.The most valid practical objections are the difficultythe retained Lipiodol’ may cause in future interpretationof the chest films, the danger that its presence maymask a spread of the disease, and the possibility-eventhough remote-of the investigation provoking a flare-up

of the illness. On the other hand, should the surgeonwish to know the state of the bronchi before operation,it may be necessary to undertake bronchography in spiteof these risks, and a new medium for bronchography hasrecently been introduced which is particularly suitablefor these cases. ‘ Dionosil ’ is a suspension of diodone inoil or water, and it is absorbed from the lung withina few days. It thus overcomes one of the main dis-

advantages of lipiodol, and there have been favourablereports on its use.1 2 At the moment, however, thesemedia have certain disadvantages not encountered withlipiodol. They are more irritating to the bronchi, andanaesthesia has to be more cautious and complete, andtherefore more time-consuming. Febrile reactions oftenfollow within twenty-four hours, accompanied some-

times by bronchitis, pneumonia, or collapse of the lung ;these complications may not be serious, but they arecertainly unwelcome and may tend to restrict the useof these media to patients in hospital. As they are lessviscous than lipiodol, the new media can be introducedthrough a smaller needle or catheter, and yet they donot run as readily into the alveoli. They are not quiteso radio-opaque as lipiodol, but the contrast they provideis usually adequate. They are still being developed, andif they can be made less irritating and more opaque,they may prove a valuable aid to the planning oftreatment and the evaluation of its results.

1. Don, C. J. Brit. J. Radiol. 1952, 25, 573.2. McKechnie, J. K. Tubercle, 1953, 34, 271.3. Schools under Pressure. Planning, 1953, 19, 265, 281.4. Graduate Teachers of Mathematics and Science : A report of

the National Advisory Council on the Training and Supplyof Teachers. H.M. Stationery Office. 1953. Pp. 11. 6d.

SCIENCE TEACHING AT SCHOOLS

THE shortage of teachers of mathematics and sciencein the schools, which has caused concern since the endof the war, is likely to get worse in the next few years,when the post-war bulge in the birth-rate will affect thesecondary-school population.3 A report by the NationalAdvisory Council on the Training and Supply of Teachers 4describes the findings of a subcommittee which workedunder the chairmanship of Sir Charles Morris. It ends bysaying :

" We consider that the shortage of graduate teachers ofmathematics and science constitutes a national problem... we feel bound to emphasise our conviction ... thatunless enough men and women with suitable abilities andqualifications come forward to teach in schools, there mustbe serious long-term effects both on the general quality ofeducation of the nation and on the future supply of scientistsand teohr’ologists."The report gives an estimate of the average annual

requirements of graduate teachers of mathematics andscience in grant-aided schools in the period 1950-60.This is 580 a year for the five years 1950-55, and 1020a year for 1955-60. These figures are on the low side,for the subcommittee takes as its standard the staffingconditions prevailing in 1950, though, like other authori-ties, it does not regard these conditions as satisfactory.The deficiency in teachers is not only quantitative butalso to some extent qualitative : in 1953 only 18 menwith first-class honours in mathematics or science leftuniversity departments of education, compared with 48in 1938 ; and the first-class and second-class honours

graduates together formed only 39% of the total in 1953,compared with 60% in 1938.The council suggests increasing the attractiveness of

school-teaching by improving its prospects and workingconditions-for instance, by providing laboratory assis-tants. At present the schools are at a disadvantage incompeting with the universities and industry for themost promising graduates. Unless, however, the totalnumber of graduates can be increased, this policy wouldinvolve robbing Peter to pay Paul ; and Peter himself