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of gas embolism are much less in the conscious than theanaesthetised patient, for the diagnosis is immediatein the one and masked in the other. On the thera-

peutic value of insufflation KING is wisely guarded.BuBiN claimed that 17.5 % of his sterility cases becamepregnant after the operation, and nearly half of thesein under two months, an observation confirmed bymany subsequent writers. Such a result is more

empirical than scientific yet the figures are impressive.The conclusion must be that insufflation is a useful

procedure, that it should be carried out as an out-patient rather than an inpatient operation, that akymographic apparatus gives the best and onlycertain evidence of the functional behaviour of thetubes, and that if due regard is paid to the indicationsand the danger signals it is safe.

THE MENTAL HOSPITAL PICTUREIT is not perhaps generally realised how great a

contribution the mental hospitals of the country havemade to the Emergency Medical Service. Largenumbers of beds had to be found at the outbreak ofwar, and a considerable proportion of them wereprovided by the mental hospitals, some of which wereemptied for the "purpose, while others renouncedtreasured new blocks or sizeable annexes. Most ofthe big mental hospitals have given up a quarter oftheir beds. This meant that patients had sometimesto be. overcrowded. Moreover, shortage of nursingand medical staff, darkening of wards by protectiveblast walls and blackout curtains, and other unavoid-able war restrictions have impaired standards intreatment and living conditions. At one large hos-pital, for example, a modern block for newly admittedcases and a newly opened villa for convalescent

patients were vacated and handed over to the E.M.S.,to provide 250 casualty beds and a nurses’ hostel.Thereafter treatment of early mental cases had to becarried on in the wards of the old hospital, wheregrading and segregation were difficult. In this hos-

pital, as elsewhere in the country, the number ofvoluntary patients admitted has fallen, but the reduc-tion does not indicate that facilities for the treatmentof such patients have been seriously limited ; cer-

tainly in the London area not a single applicationfor voluntary treatment has been refused throughlack of accommodation. Taking the country as awhole, 100 admissions are made up of 40-60 certified,10-12 temporary and 30-40 voluntary patients.The falling off in total admissions that has been re-ported reflects the common experience that war doesnot increase the incidence of psychosis and neurosis.In London the drop in new admissions has been fargreater than it was in the last war, probably owing toevacuation. Nevertheless, in some areas, patientswho for social reasons ought to be in a mental hospitalare not being accepted, or are being discharged,because medical superintendents say quite fairly thatthey must keep their accommodation for the acutercases. These less acute patients may be found causingmild difficulty in their homes or in reception areas bybehaviour which would not be tolerated in peace-time.On the other hand, many patients of both sexes withrelatively mild mental and emotional disorders arebeing absorbed into regular employment, and are

finding occupational therapy in jobs for which inpeace-time they would never be taken on ; and per-haps in time to come we shall have to plan the rehabili-

tation of psychopathic people on the lines thus arti-ficially produced by war. It is possible, of course, thatmore patients who would normally seek treatment asvoluntary cases in hospital are being seen and treatedat outpatient clinics, of which there are 203 distributedover the United Kingdom and Northern Ireland ; butno such increase has been reported. Indeed, in manyof the clinics situated in.large cities there has been adecided falling off in attendances as a result ofevacuation. In general the position is that themental hospitals, though hampered by the sacrificeof accommodation which has been made to the

E.M.S., by shortage of doctors, and even more seriousshortage of nurses are standing up bravely to theirjob, and deserve much credit for maintaining a vitalsocial service approximating to peace-time standardsunder heavy difficulties.

SCHOOL MEALSOr the five million children in our elementary and

secondary schools only 300,000 are now getting a mealat school ; and, while in some areas school meals are,provided for a third of the children, in others there isno provision at all. In the reception areas childrenoften have to travel several miles to school with nochance of returning to their temporary homes for amidday meal ; if there is no meal at school theyhave to subsist on frugal packet lunches put up byharassed foster parents. These nosebags were in-

adequate in peace-time and must be more so now whencheese and meat are scarce, foreign fruit has dis-

appeared and home-grown substitutes are expensive.Moreover, with the vastly increased employment ofwomen in munitions there is often no-one to preparemeals at home and supervise their consumption. As

speakers in the Women’s Parliament pointed out intheir session reported on another page, universalschool meals would not only be a great step towardsensuring adequate nutrition of our children, but wouldalso release more women for industry than any othermeasure. In the House of Lords on Oct. 21 LordWooLTON foreshadowed a rapid expansion in school-meal organisation. The Exchequer is greasing theways with an additional grant of 10% towards theircost, making the average rate of grant 80 %, and schoolcanteens are to receive priority supplies of food. The

cooking depots which local authorities have been

holding in readiness for feeding the community ifcommunications or normal domestic arrangementswere put out of action are to be adapted for thechildren, and the British Restaurants are also to helpwith cooking school meals. Where new kitchensmust be started local authorities will be able to drawon the Ministry of Food’s central pool for their

equipment.These steps are encouraging, but as the Times

pointed out in a leading article on the morning ofLord WooLTON’s announcement it will hardly bepossible to provide a midday meal for all school-children in war-time unless some English variant ofthe Oslo meal is adopted. This has already beenattempted successfully in the East End of London,in Glossop and elsewhere. The theoretical principlebehind the Oslo meal is that if at one meal in the dayhighly protective foods, chosen front dairy foods,greengroceries, the oily fish and whole cereals, aregiven it will not matter much what foods are chosenby the child’s parents for the rest of the day. The

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Norwegian public-health services, on the advice ofProf. CARL SCM6TZ, chose milk (about D pint), half anorange, hard rye bread with butter and cheese, whole-meal bread and butter, and a whey cheese or cod-liverpaste. The meal was finished off with half an appleor a raw carrot. This meal is highly protective, givingsatisfactory amounts of calcium and iron and vitaminsA, B, C and D. It is easy. to prepare and demandsno cooking, so that kitchens and dining-hall can belargely dispensed with.

*

If the authorities could be induced to envisage any-thing but the hot cooked meal as essential in feedingthe young we should have gone a long way towardssolving the problem of safeguarding the health of theschool-child, for this Oslo meal is a better safeguardthan the ordinary hot meal. There would remainthe resistance of school-teachers and parents, for thechildren, conservative as they often are as regards thecontents of cooked meals, usually take to an Oslomeal. The staff have " never heard of such a meal "and the parents are apt to feel that their children arebeing defrauded by being given cold uncooked foods.That this kind of meal solves the problem of in-adequate equipment is clear from the experience ofdomestic-science teachers who have been allowed tointroduce a meal of the Oslo type because the demandfor school meals had outrun the school equipment.In one such school the Oslo meal largely invaded theprovince of the cooked meal. English variants are not

hard to devise. The milk should be the same in eachmeal, though there is no objection to giving it hot orflavoured with cocoa or coffee if it is thought essentialthat some hot food should be served. Wholemealbread could take the place of the Knac7cebrod, andvitaminised margarine the place of butter. Applesand raw carrots are still available. The main problemlies in supplying what the half orange, the cheese, andthe cod-liver paste supply. If.oranges are unobtainable,watercress, mustard and cress, and raw turnip or

swede will take their- place, or sandwiches with fillingsof chopped raw cabbage and parsley may be used.The cheese and cod-liver paste supply calcium andvitamin D, but these could as well be obtained fromfresh herrings and sprats, or more simply from tinnedherrings and salmon, and there should be no difficultywith the simplest of appliances in converting theminto a paste to spread on bread. If we wish toimitate’ the Norwegians in giving a teaspoonful ofcod-liver oil daily throughout the winter this can beincorporated in the fish paste. In the Times ofOct. 11 the director-general of Norwegian healthservices says that the significance of a hot meal hasbeen overestimated, and it seems that all the benefitsof hot food, with some others, can be obtained from acold meal with a hot drink. This looks like being theway in which school meals for all can be achieved.All that is now required is imagination and the droppingof our British resistance to the unusual in catering.

Annotations

BLACKWATER FEVER

THE cause of the paroxysmal haemoglobinuria whichgives blackwater fever its name has long been disputed.It is known to be associated with malaria, althoughparasites may not be found in the patient’s blood. Isthere a specific strain of parasites which is speciallyliable to cause haemolysis of red blood-cells in excessivelylarge quantities Do patients have hsemoglobinuriabecause their red cells, possibly from long exposureto malarial attacks, are exceptionally liable to hsemolysis?Is there a hsemolysin in the patient’s blood responsiblefor the destruction of the red cells? . Foy and hisco-workers 1 have tried to answer these questions bystudying the results of injecting blood from blackwater-fever patients into unaffected people, and conversely by

.

transfusing normal blood into blackwater-fever patients.The results in one woman are presented in detail. Thiswas a typical case with black, acid urine containingoxyhsemoglobin and methsemoglobin, and with methsem-albumin in the blood-plasma ; no malarial parasiteswere found in her blood. Twenty-five c.cm. of thispatient’s blood was injected intravenously into a normalhealthy man. Eleven days later, although he had beenkept strictly away from possible outside infection, theman developed a typical malarial attack and Plasmo-dium falciparum rings were found in thick films of hisblood, but he did not develop haemoglobinuria. Thisconfirmed Foy’s previous experience with a series of 106lunatics who were given intramuscular injections ofblood from blackwater-fever patients ; several of therecipients developed malaria, but none showed haemo-globinuria. From these results he concluded that thereis no specific hsemolysing strain of malarial parasites.The patient herself was given three blood-transfusionsfrom three different normal donors, and although theseraised the red-cell count at first it was soon reduced to itsformer level, the haemolysis continuing unabated. From

1. Foy, H., Kondi, A. and Moumjidis, A. Trans. R. Soc. trop. Med.Hyg. 1941, 35, 119.

this it is concluded that normal cells are just as liable tohaemolysis in a blackwater-fever patient’s blood-streamas are the patient’s own cells. At the time of thetransfusions the patient’s reticulocyte count was low andthe rise and fall of the red-cell count seemed definitelyrelated to the effect of the transfusions and subsequenthaemolysis ; later, when the reticulocytes rose, recoveryset in. Foy therefore infers that a circulating haemolysisis the active factor that produces the intense haemolysisof blackwater fever. The fact that no recipient ofblackwater-fever blood developed hasmoglobinuria heattributes to insufficient dosage or immediate neutralisa-tion of the haemolysin. This research has certainlycleared the ground and it is interesting that, like otherworkers on paroxysmal haemoglobinurias,2 his finalconclusion points to a haemolysih. So far, however,the haemolysin remains theoretical-its presence has yetto be firmly demonstrated. Fairley, also working on thispoint, thinks that it is an intracellular lysin and cannot

"

be detected by ordinary means. Whatever the finalanswer, it is clear that the information obtainable fromstudies of blackwater fever can usefully be applied tohaemolytic disease in general.

SULPHONAMIDES AND TISSUE-DAMAGE

REPORTS from various sources have so far indicatedthat the local use of sulphonamides in the treatment ofwounds has little or no damaging effect upon the tissues.The brain tolerates powdered sulphanilamide and sulpha-pyridine surprisingly well, as Russell and Falconer 3

demonstrated, and this might be regarded as a fairlysevere test. On the other hand Bricker and Graham ’ 4

have found that the oral administration of sulph-anilamide to dogs with experimental wounds seemsseriously to inhibit the fibroblastic response. On thé

strength of this Glynn 5 has investigated in rabbitsthe local effects of sulphanilamide, sulphathiazole andsulphapyridine on the development of granulation tissue2. Lancet, May 24, 1941, p. 667.3. Russell, D. S. and Falconer, M. A. Lancet, 1940, 2, 100.4. Bricker, E. M. and Graham, E. A. J. Amer. med. Ass. 1939,

112, 2593.5. Glynn, L. E. J. Path. Bact. 1941, 53, 183.