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epithelium, numerous in the neighbourhood of thefistula. The patient made a good recovery.The interest of this case lies primarily in the

fact that the symptoms which brought the patientto the clinic were secondary to the haemorrhagefrom the stomach ; the diaphragmatic hernia wasfound in the process of examination. The positionof the hernia behind the heart was unusual, andtogether with the adhesions from the previousthoracotomy made operation difficult. The techniquewas that recently described by Mr. T. P. Dunhill to theRoyal Society of Medicine. In practice, he said, hehad found it impossible to control the hernialcontents without an abdominal incision to allow ofthe hand of the assistant retaining the viscera inthe abdomen. Dr. Remel found it equally impossibleto free the contents of the hernial sac and to returnthem to the abdomen without the thoracic approach.He claims it as the first recorded case of a gastriclesion and a diaphragmatic hernia dealt with radicallyat the same time. Dr. Remel mentions the variousexplanations of the association of gastric haemorrhagewith diaphragmatic hernia since it was first observedin 1875-e.g., torsion of the stomach, strangulation,ulceration, carcinoma, and gangrene. Ulceration,when it occurs, may involve surrounding organssuch as the liver or lung. Some of the cases havebeen dealt with by thoracotomy and repair of thehernia alone, in others the abdomen has been openedand gastro-enterostomy performed, with or withoutan associated repair of the hernia. Three cases arerecorded in which thoracotomy, for the repair ofthe hernia, and laparotomy, for the performance ofa gastro-enterostomy, were done-in one case afteran interval of six days, in the others at the same time.

AN ATTACK ON EXAMINATIONS

TEACHERS were at least as vocal as doctors in

criticising the insistence upon the passing of examina-tions to which school-children are subjected, whenthe question of school life and nervous stability wasdiscussed at a session of the congress of the RoyalInstitute of Public Health at Eastbourne on June 1st.Mr. R. E. RQper, late director of physical educationfor boys at Bedales School, opened the discussion,and showed, with the help of diagrams, that an

investigation into a school where feeding and generalconditions of hygiene left nothing to be desired hadrevealed a tendency to fall markedly below normalweight in a large percentage of children, and curva-ture of the spine of varying degrees in a considerablenumber, especially at the ages when they are pre-paring for such examinations as school certificateand matriculation. The stress is not confined to

any group of schools or scholars ; children at dif-ferent ages in every type of school are encouragedto put forth the maximum of effort in order thatthey may gain some qualification which will serveas a passport into a money-earning post. Mr. Roperbelieves that the focusing of energy upon meetingthis external demand, frequently at the expense ofinternal harmony, may militate against the pro-duction of the harmonious personality upon whichnervous stability depends. He suggests that theelement of anxiety should be removed by allowingevery child in his last term at school to submit aconsidered course of study, upon which, togetherwith his general record, the headmaster or head-mistress would base a report. Such a report wouldindicate the line in which the child shows the greatestability, and would, Mr. Roper believes, be quite asuseful to the prospective employer as the holding ofa standardised diploma. Following in the same strain

the president of the National Union of Teachersfelt it to be a matter for confession rather than self-

congratulation that he had allowed all his childrento matriculate; he had done so not because he

approved of it, but because there was practicallyno door open into either professional or business lifewithout some such qualification. Another speakerregretted the tendency for boys and girls to takesuch examinations as the first M.B. from school.Apart from the fact that few schools are equippedfor the efficient teaching of scientific subjects, hewas convinced that the maturer brain of 22 or 23years was able to face such examinations with farless strain. Speaker after speaker emphasised thevalue of rest lying down for children at school.Dr. Helen Boyle spoke of the typical tired girl whose-parents spend their time in trying to " buck her up "when what she needs is a rest in bed. It is a pity,Dr. Boyle thinks, that we have formed a habit ofmind which regards it as odd for an upper schoolchild to lie down in the day ; children should have-the opportunity to lie down when they feel tiredrather than at stated times. Again, children ought,to be able to meet the demands of life easily andhappily ; control is a faculty to be used with economy,and the effort to hold down life by control for longperiods together is a waste of useful energy. In order-to help children to discover their capacities and usethem to best advantage, it is necessary, as Mr. Roperexpressed it, to change our ideals of education, and.to teach children instead of subjects.

RECURRENCE OF STONE

THE liability of symptoms to recur after operationsfor stone in the urinary tract is notorious, but fewstudies have been undertaken by follow-up investiga.tions to express this risk statistically. It is a studyof this kind which Dr. J. Hellstrom, of the MariaHospital in Stockholm, has published in NordiskMedicinsk Tidskrift for April 29th. His study covers.the period 1911-1930, and deals only with thosecases which have been followed up after dischargefrom hospital. He classifies his cases according asthey were or were not operated on. In the lattercategory there were 17 patients, 25 of whom (17 percent.) had a recurrence of their stone symptomsafter discharge. In as many as 21 of these 25 cases

signs of recurrence of the disease appeared withinthe first four years after discharge from hospital.It would thus seem that if this four-year intervalcan be tided over uneventfully, the chances of therecurrence of symptoms in a case which has notbeen operated on are small. These chances differ,however, very considerably according as the stonesare formed of oxalates or uric acid ; a new formationof oxalate stones was observed in only 13.5 per cent.of these cases and then only once, whereas the rateof recurrence of uric acid stones was as high as70 per cent., and it was common for one and the samepatient to suffer from several such recurrences.

Turning to the 232 patients on whom operationswere performed, Dr. Hellstrom shows that 58, or

25 per cent., suffered from a recurrence of theirailments. He included among these 58 cases thosein which stones subsequently developed on thatside on which no operation had been performed.As in his non-operated series of cases, he found thatthe recurrences were most common during the firstfew years after discharge ; of 26 recurrences on thesame side as that on which an operation had beenperformed, as many as 13 occurred within the firstthree years after the operation. The chances ofrecurrence varied greatly according to local conditions;

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the lowest rate of recurrence was observed after

aseptic operations on stones in the ureter, andthe highest rate after nephrolithotomies in septiccases. Dr. Hellstrom concludes that recurrence ofstones after operations have been performed on themin the urinary tract is more common than surgeonshave been inclined in the past to confess. The causesof such recurrences are numerous. Their numbers

might be reduced were great care to be taken inlocating all the stones before an operation byskiagrams taken from a variety of different angles.The chances of the migration of a stone just beforean operation are such that the interval between thetaking of a skiagram and the operation should beas short as possible. It is also, of course, most

important to keep the urinary tract as sterile aspossible, and in this connexion Dr. Hellstrom refersbriefly to neosalvarsan as often having a surprisinglygood effect on staphylococcal infections of the urine.

VIDI

WHEN a student after a demonstration, whetherin the laboratory or dissecting room, or merelyon the blackboard, can say " I have seen" he isa long way on the road to be able to add " I canremember." Many teachers have excelled in illustra-tion of their words by effective diagrams, and at arecent meeting of the section of pathology of theRoyal Academy of Medicine in Ireland a plea wasentered by Prof. T. T. O’Farrell for more realistic

drawing on the blackboard. His words received

_______

direct endorse-ment trom ur.

McGrath, the

president ofthe Academy,who said that,while he him-self couldremember rcertain illus-trations of lec-tures which hehad attended,he could alsoremember thatit was oftendifficult to

recognise theappearance ofthe object fromthe usual out-line on theblackboard.The significant

word in Dr. McGrath’s comment was "outline,"because the force of Prof. O’Farrell’s plea forrealism depended upon his statement that actualitywould be better introduced into blackboard drawingby the employment of shading. Prof. O’Farrellpointed out the obvious fact that with a pencil upona white surface the lights are left untouched, theshadows being indicated at the depths required tobring out contours, whereas in drawing on the black-board the lights are chalked in, the blackboard

representing the shadows. But it is clear that amiddle term between the blackness of the boardand the whiteness of the chalk is needed to givedifferent shadows their appropriate depths, andProf. O’Farrell pointed out that if the middle termwas too light the drawing would be unduly pale, andif’,7,too dark it would have the mystifying appearanceof an over-exposed photographic print. His sugges-

tion was that the draughtsman on the blackboardshould establish the density of his middle tone,and then fill the spaces between the outlines withthis tone duly graded, leaving the surface of theboard for the deep shadows. He allowed that thedistribution of light and shade would thus becomea matter of judgment and practice, and many willfeel that he suggested a problem in draughtsmanshipwhich few lecturers, who were not well-taught artists,would be able to solve, except when dealing withcertain simple subjects. As a matter of fact theamount of information that can be conveyed bysimple outline in a form easy to recall, is very large,as the curves and drawings to illustrate statistics

sufficiently show. We have received from theKathleen Boland studio (Great Queen-street, W.C.2),a booklet entitled " Vidi " with some amusingexamples of this fact. In simple subjects nothingis gained by the addition of shade, and, indeed,the lessons in many discourses might be obscured

by elaborate drawing. But the addition of a

little shading often makes a picture much clearer ;for example, the marginal illustrations in Mr.Souttar’s " The Art of Surgery "gain much in clearnesswhere they are reinforced by shading. Prof. O’Farrellused the drawing of a head on the blackboard asan example where the proper placing of high lightsconsiderably added to the clearness of the picture,adding that experiment on the blackboard wouldhelp by training the observation in light andshade in the production of good photographs forpathological supplements. These illustrations willappear in the Irish Journal of Medical Science; wereproduce here a sketch of a skull which hehas sent us. The subject is one of real import-ance, for students can learn and remember valuablelessons from blackboard demonstrations. But tomake the drawings on the blackboard effectivemore is needed than a general idea on the part of thelecturer of what he wants to show; it is necessarythat he should feel certain that he is showing it.And where something more than outline is called for,something more than an elementary knowledge, ofdrawing may be needed. Prof. O’Farrell suggestsfor the teacher a range of accomplishment whichis not easy to acquire, but we are certain that for theelucidation of some subjects of medical interest itis worth acquisition.

PARIS CONGRESS OF THERAPEUTICS

IN the coming autumn there will be held in Paristhe first French congress of therapeutics under thepresidency of Prof. Maurice Loeper. Six subjectshave been chosen for discussion during the three days,Oct. 23rd to 25th-viz., (1) parenteral treatment ofpeptic ulcer ; (2) treatment of coli bacilluria ;(3) therapeutic associations ; (4) adrenalines ; (5)pyretic treatment ; (6) treatment of radiodermatitis.The congress will be held in three sections : Dr.Babonneix will preside over the section of medicine,Prof. Tiffeneau over the section of pharmacodynamics,and Prof. Strohl over the section of physiotherapy.The opening papers in each of these subjects are to beprinted in advance and circulated to all membersof the congress by Oct. 1st. Anyone who wishesto take part in the discussion of these reports or tocomment on them should apply before Sept. 10th toDr. G. Leven, 24, rue de Teheran, Paris (8). Paperson subjects not mentioned in the programme willonly be accepted subject to time being available.The entrance fee of Fr.100 (for students Fr.50)is payable to the treasurer, Dr. G. Doin, 8, place de1’Odeon, Paris (6). Cheap railway fares will be