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major fits in 1938 and the EEG’had then shown bilater.ally synchronous slow waves of epileptic type. In 194Cthe patient was readmitted in status epilepticus and diedThe fits were now jacksonian in type, with localisatiorto the right hand and face At autopsy a glioma wasfound in the left frontal lobe. In this case the geneti(background had been such as to allow very readily thEproduction of generalised convulsions. Mr. Grey Walteisuggested that the problem of traumatic epilepsy couldbe solved only by the cooperation of a large number ojworkers studying it from all angles.

Colonel COLIN RusSELL, RCAMC, asked what propor-tion of alleged idiopathic epileptics were not reallysymptomatic. Birth injury was an important factor inthose cases with an onset at about the age of 12 years.It was not only the difficult labour which might producecerebral haemorrhage. The moral was that minor headinjuries should be taken more seriously and that everycase should have a lumbar puncture.

Mr. D. W. C. NoRTHFiELD, FRCS, asked Dr. Green-field whether a scar acted by contracting down orwhether by reason of its presence as a mass of tissue.Also, had Mr. Grey Walter any views as to the channelsby which material should be drawn.

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Dr. J. G. GREENFIELD said that gliosis was muchslower than connective-tissue scarring, and, while therewas a certain amount of evidence of a slow pull in theformer case, whether it could disturb the ventricles wasdoubtful. He could not agree with Mr. Dott that theeffect was purely on the vessels but thought that it wasmore focal damage to the brain that resulted in epilepsy.

Dr. RUSSELL BRAIN said that the fundamental problemof epilepsy remained unsolved-namely, whether theattack was primarily excitatory or inhibitory. Was theepileptogenic property of a scar in the brain due to irrita-tion or loss of function ? If the latter, the effects ofexcision must be limited to improving the function ofsurrounding areas. In the present state of the law,claims for compensation were settled within a year ortwo of a head injury. If epilepsy developed later, nocompensation could be obtained. This injustice shouldbe removed by allowing the case to be reopened.

Prof. GEOFFREY JEFFERSON, FRCS, said he wascautious of accepting EEG evidence as final. Sincepractically every patient with a slow-growing gliomadeveloped fits, the proportion of persons with predisposi-tion must be higher than 10%. He recalled that Foersterthought that about half the population could haveepilepsy. In traumatic epilepsy he wondered whetherthe late cases were due to the trauma. While in thesecases the peak age was 30, in idiopathic epilepsy thepeaks were infancy and adolescence. He thought thatthe size of the scar mattered and not so much its attach-ment to the meninges. The exciting cause must be thechange in circulation and later biochemical changes inthe cell itself. He agreed with Dr. Russell Brain thatnew legislation was required in these cases.

Mr. DoTT said he thought proneness to epilepsy wasa sliding scale, rather than that 50% were susceptible.According to Mr. Grey Walter there were only a few whowere totally resistant to the convulsive phenomenon.-Mr. GREY WALTER thought the MRC subcommitteescould do very valuable work in collecting and collatingmaterial. Regarding Dr. Russell Brain’s question, therecould be inhibitory and,excitatory fits, but it was possibleto demonstrate which only by taking the electrical recordsfrom agonists and antagonists during the convulsion.

In conclusion, the CHAIRMAN said he was sure theMRC subcommittees could and would cooperate alongthe lines mentioned.

WAR-TIME NURSERIES.—The Royal College of Nursing is togive further courses for nurses taking up posts as matrons andsisters in war-time nurseries, day and residential. The coursesare arranged in conjunction with the National Society ofChildren’s Nurseries and the Association of Sick Children’sHospital Nurses. The fourth course of two weeks of lecturesand observation visits, with a further optional week of practicalwork, will start on July 6. It will be free to suitable nurses onthe general and sick-children’s part of the Register who under-take to work in a war-time nursery. Particulars can be obtainedfrom the director in the Education Department, Royal Collegeof Nursing, la, Henrietta Place, Cavendish Square, W.l.

COLLECTIVE FEEDING IN WAR-TIME

THE third scientific meeting of the Nutrition Society,which took the form of a conference on the problems ofcollective feeding in war-time, was held on May 30 at theLondon School of Hygiene. The chair was taken at themorning session by the Dowager Lady READING and atthe. afternoon session by Prof. V. H. MOTTRAM., Thechairman of the society, Sir JOHN ORR, who was unableto attend, sent a message of appreciation to the Ministerof Food, who opened the conference, and his advisers,Professor Drummond and Lord Horder in which he saidthat a recent survey in Scotland had shown that a largenumber of people including children were actually betternourished now than before the war. The presence of theminister at the society’s meeting indicated his desire toestablish, and to maintain after the war, a food policybased on the nutritional needs of the people.

In his opening address, Lord WooI,TON spoke of hisfaith in his nutritional advisers. There had been, and hewas convinced there always would be, sufficient food togo round-the only problems were what types of foodsto supply and how best to distribute and prepare them.Evacuation, large numbers of women working in factories,and the increased hours of industrial workers, meantthat much could be done by collective feeding. Duringthe last year 1400 British Restaurants were opened and 94million meals a week were now being served. It wasnecessary to provide not just " food " but the right sortof food for different sorts of people. Particularly was itimportant that the needs of children, so different fromthose of adults, should be carefully planned. We nolonger thought that school meals should be provided onlyfor poor and malnourished children ; the problem ofphysical need had nothing to do with the ability to pay.Now we have the knowledge for correct and adequatenutrition we should be sinning against the light if we didnot use this knowledge.The Dowager Lady READING said that the conference

would do a great deal of good in bringing together thepractical and the academic aspects of nutrition. Acade-mic and theoretical knowledge could be best imparted tothe practical cook by an appreciation of her efforts, bypraise and encouragement of the women who had animportant but little appreciated task to perform.

ORGANISATION OF MASS CATERING

Squadron-Leader SALMON gave an account of large-scale catering as seen in the RAF. An attempt hadbeen made to meet the needs of the serving men andwomen by careful consideration of the type and nutri-tional value of the food and of the best way of preparingit. This was ensured by frequent and regular meetingsof the mess committees, comprising the catering officer,the cooks and representatives of the service personnel.The committee planned the week’s menu in advance andconsidered as much as possible the desires of the peopleconcerned. It was not always realised that goodsrationed to civilians were also rationed to the forces.The aim was not only to see that the quantities of foods,especially those which are rationed, were not overdrawnbut also to see that they were not underdrawn since thesefoods have high nutritive value. On the larger stationsa great deal of saving could be effected by centralisation ;thus in a central depot fat could be rendered, meatscarved and sausages prepared. In spite of this .centrali-sation, excessive rigidity was avoided and varying typesof meal were supplied to suit the different requirements ofthe different types of personnel. The training of cookswas planned in such a way that theoretical and prelimin- -ary teaching, necessarily in small scale cooking, wasfollowed by practical teaching in large scale cooking.The great number of cooks now being trained in theServices might have an important effect after the war, inindustrial canteens and institutions, and, perhaps moreimportant, in the home.Major R. G. LEGGETT, RAMC, spoke of conditions in

the Army. On the whole, the problems arising and thesolutions adopted were similar to those in the Air Force.There were, however, certain differences, in particularthe fact that there were in the Army many small unitssuch as searchlight and coastal posts.-Surgeon Rear-Admiral J. W. McNEE pointed out that whereas con-ditions in shore establishments of the Navy resembled

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those in the other two Services, conditions afloat werevery varied, ranging from the large battleship, with itsproblems of mass-catering, down to the mine sweeperand corvette ; conditions in submarines were clearlyespecially difficult.-Miss R. H. HAMILTON CRIGHTONof NAAFI told of the part played by her organisation inproviding food for the Services. It supplied certaincommodities such as bacon, butter and unrationedgoods to the catering departments -of the services inaddition to the provision of refreshments in their owncanteens.-Mr. F. LE GROS CLABK reminded the confer-ence that the classical example of collective feeding wasto be seen in the Soviet Union where " kitchen factories "or depots were begun in 1925. By 1935 there were 27 ofthese in Leningrad, 25 in Moscow and many others.

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One of the Moscow depots prepared 200,000 courses andfed 55,000 school-children a day. To a large extent,these depots sent out prepared foods, that is, foods notcooked but ready for cooking. Some of the factories alsohad restaurants attached and, in addition, some providedpartially cooked meals on a " cash-and-carry " basis.

Dr. W. A. NICHOLSON and Miss KEAY suggested thatthere was possibly more waste than was known to theauthorities and that the keeping of pigs on stations mightactually encourage waste.-Miss E. H. TRECHMAN wasenvious of the Services because they had most of theavailable young women who could be fairly easily trainedas cooks; civilian canteens in consequence had mostlyolder women who found it more difficult to adapt them-selves to the new conditions of mess-cooking.

Squadron-Leader SALMON, in reply, said they weretrying to encourage those with experience to becomecooks in the Air Force. The consumption of vegetableswas on the whole satisfactory and there were almostalways two vegetables offered in addition to potatoes.Among recent improvements were a great reduction inwaste and an attempt to increase the interest of themedical officers in food and nutrition.

FOOD-SUPPLIES FOR COLLECTIVE FEEDING

In the absence through indisposition of ProfessorDrummond, Mr. MAGNUS PYKE, Ph.D., described someof the work of the Ministry of Food. The aim of theBritish Restaurant was to supply in one meal a third ofthe day’s requirements of protein and calories and two-thirds of the vitamins and mineral salts. Two difficul-ties, however, had to be faced. One was that therewas still a great deal not known about nutritionalrequirements ; this meant that as far as possible itshould be food that was supplied rather than dosesof vitamins. The second was that requirements differedfor different classes of people, such as factory workers andschool-children; this was met by supplying varyingtypes of meal in the varying types of canteen. Eventhese meals, however, could only be evaluated on thebasis of average requirements and Dr. Pyke gaveexamples of some of the investigations carried out todetermine the range of variation in canteens. Thus, in36 specimen meals from British Restaurants the amountof potatoes varied from 1 oz. to 14 oz. ; the amount ofvitamin C was less than 10 mg. in 8 of the meals and over40 mg. in 5 meals. As far as vitamin C was concerned,the main difficulty was the destruction of the vitaminwhich occurred when vegetables were kept hot; owingto transport problems this was often unavoidable. Butit was nevertheless possible to obtain 10 mg. or more vita-min C in a meal which had been kept in containers for2 hours or longer.

Mr. R. 3-. L. ALLEN, Ph.D., stressed the value of driedfoodstuffs in war-time, especially from the point of viewof ease of storage and transport. The aim in themanufacture of these foods was to provide somethingpalatable and nutritious and the preparation of whichwas simple and resulted in no loss of nutritive value.-Prof. J. R. MARRACK described some tests he had con-ducted on the vitamin-C content of school dinners. Ingeneral, his results agreed with those of Dr. Pyke. Aninteresting fact was that the vitamin C in the meals wasgreater in those schools which grew more of their owngreen vegetables and the children showed betterresponses to the " saturation " test. It was important tokeep a proper sense of perspective in recommending theconsumption of raw vegetables ; the amounts eaten wereusually small and consequently the amount of vitamin C

was frequently much less than in an ordinary portion ofwell-cooked vegetables.-Surgeon-Commander C. C.UNGLEY confirmed the finding that the quantity ofvitamin C was often low in meals cooked on a moderateor large scale.-Mr. L. W. MAPSON, Ph.D., pointed outthat one way of reducing the loss of vitamin C in cabbagewas to cut it into thick slices before cooking so as tominimise the amount of water necessary. Another waywas to use water in which the outer leaves had beencooked first: in this way, very little more would bedissolved out of the edible portion.EFFECT OF LARGE-SCALE PREPARATION.ON NUTRITIONAL

VALUES

Squadron-Leader T. F. MACRAE pointed out how littlewe knew of the changes in nutritional values producedduring the preparation of food. Most of what wasknown concerned vegetables and the loss in them ofvitamin O. Half of the vitamin might be destroyed’between gathering and cooking. This problem was beingtackled by increasing local supplies of vegetables.Another source of loss was in the cooking. This couldbe greatly diminished by adding the vegetables in severalportions at intervals to the boiling water so that thetemperature remained sufficiently high to destroy theenzymes which acted on the vitamin. Loss was alsofavoured by keeping the vegetables hot for some timebefore serving, and cooks were now instructed to cookthe vegetables last and serve as soon as possible.By careful instructions to the cooks, and by rousing theinterest of the medical officers as well as the cateringofficers, these improvements could be effected.

Miss M. OLLIVER felt that the interest of investigatorsin vitamin C was justified in view of the shortage of fruitsand the fact that almost the only source between Decem-ber and late June was vegetables. The possibility of milddeficiency was very real, particularly in the late springand early summer, when the supply of green vegetableswas short and the vitamin C of potatoes had reached avery low value. To avoid this possibility, the productionof green vegetables near the feeding centres, especiallyof broccoli in spring, should be encouraged, and the waterused in cooking the vegetables should be used for graviesand soups.-Miss TRECHMAN said that in practice it wasdifficult to carry out these suggestions, at any rate incivilian canteens, owing to a shortage of staff.-Mr. A. L.Bacharach, B.Sc, said that the present extensive large-scale cooking afforded a unique opportunity for extendingour knowledge of the effect of preparation on thenutritive values of foods. -

In reply, Squadron-Leader MACRAE agreed that vita-min C was of great importance and said that our aimshould be to provide more than was necessary merely toprevent scurvy.

GENERAL DIETETICS OF COMMUNAL FEEDING

Four papers were read on this subject. Miss M.ABRAHAMS spoke on the role of the dietitian. Beforeattempting to assess the value of civilian communalfeeding, we should consider the domestic diet whichcanteen food was to supplement. An analysis inJanuary, 1942, had shown that a diet of 3000 caloriesbased on rationed and unrationed goods could beobtained for 9s. 6d. a week and would be adequate in allrespects except calcium and vitamin C. The positionwith regard to calcium was to some extent alleviated bythe extra milk and cheese rations for special classes, andas a result it was likely that only adolescents between12 and 17 continued to be short of this mineral. VitaminC was a more difficult problem, since in the winter andspring vegetables were expensive. An analysis of 41canteen meals showed that the calorie content variedfrom about 500 to 1800 and the calories for a penny from41 to 163. Only 6 meals gave over 1000 calories, a thirdof the requirements of a person needing 3000 caloriesdaily. ,

Miss I. M. CLIFT, speaking of industrial canteens,pointed out that factory inspectors had powers to insiston the provision of a canteen in factories employing morethan 250 workers. There were now 7500 factories withcanteens compared with 1500 before the war. The pro-blem of providing an adequate meal in a short time, forpeople working longer hours and under conditions ofstrain, was worthy of considerable attention and effort.One difficulty was in overcoming conservative food habits,

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but by making dishes as attractive as possible and byperseverance much could be done. Miss Clift pleadedfor an increased recognition of the importance of thevegetable cook, whose status at present was consideredto be inferior to that of the pastrycook or meat cook.

Miss M. C. BROATCH described school canteens. Owingto evacuation and the subsequent return and re-evacua-tion of children, it had not been easy to arrange effectivelythe school canteens in London. But the importance ofdoing so had increased with the call-up of so many women.In some cases the food was cooked in the school, but moreoften it was cooked at a central kitchen and then distri-buted to neighbouring schools. About 50,000 schoolmeals were now served daily in London. The feeding ofchildren was in many ways- not so easy as that of adults.It was often difficult to get the child to eat, either becauseof conservatism, or because of unattractive surroundingsor because it- wanted to get out and play. These diffi-culties could be overcome but frequently there wasinsufficient staff to deal with them adequately.

Mrs. W. PARSONS discussed collective feeding and thehousewife. There were, she said, a number of house-wives who could not easily avail themselves of canteenfacilities. It should however still be possible to relievethese women of the drudgery and boredom of preparing

meals each day for one or a few people, a state of affairswhich was incidentally highly inefficient. One solutionwould be a "

cash-and-carry " system at the BritishRestaurant, so that these centres would be used forcollective cooking as well as collective feeding. Anotherpossibility would be the provision of prepared but un-cooked foods, as was done in the Soviet Union. Thismight perhaps be done in smaller units and one couldenvisage the delivery by tricycles of clean potatoesinstead of ice-cream.

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Summarising the day’s proceedings, Sir JOSEPHBARCROFT said that the conference had shown the needfor a new attitude towards food preparation. A ’’ NewCookery " was required and its development would beaccelerated by discussions such as those today. Thefunction of the society would perhaps best be served, andits deliberations implemented, if its general conclusionscould be made generally available, and it was hoped topublish regularly proceedings of the meetings. LordWoolton had specifically asked for the advice of thesociety, and Sir Joseph suggested that, perhaps by form-ing a few subcommittees to deal with special problems,members might undertake to furnish the minister withauthoritative nutritional data.

Reviews of Books

Health of the FutureALECK BOURNE, M.B. Camb., F.R.C.S., F.R.C.O.G.Penguin Special. Harmsworth, Middlesex: PenguinBooks. Pp. 192. 9d.

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THOSE who have been successful are usually thestaunchest exponents of laissez-faire, but Mr. Bourne isa notable exception. In this small book written for thelay public he restates the case against medical service asit exists in this country today and his criticisms, thoughfamiliar, are largely unanswerable. In poverty, ignor-ance, economic insecurity and boredom he sees the quiteunnecessary obstacles to the achievement of positivehealth; unnecessary because they are remediable inthe light of modern knowledge. He is a whole-heartedadvocate of state medicine but, like many avowedsocialists, he brushes aside, a trifle too impatientlyperhaps, the arguments of the opposition. He shuts hiseyes, for instance, to any evidences of apathy in existingstate medical services and attaches little importance tothe spur of economic competition ; no doubt theseundesirable things can and will be educated out of theprofession in time but it is idle to deny that they arethere’in places, to be reckoned with at the moment.Nor would it be useful to remove the economic incentiveuntil another and better stimulus can be substitutedfor it. The dread of a general levelling of performancedown (rather than up) produces, often among the mostconscientious doctors, some antagonism to state medicine.

Nutritional DeficienciesJOHN B. YOUMANS, M.S., M.D., associate professor ofmedicine and director of postgraduate instruction, Vander-bilt University medical school, Nashville, Tennessee.London : J. B. Lippincott Co. Pp. 385. 30s.

MANY clinicians must have been bewildered by thevariety of claims made for the share of vitamin deficienciesin disease. Many such claims rest on slender evidenceand the clinician, often too busy and not always suffici-ently specialised to appraise the evidence, tends eitherto prescribe vitamin preparations indiscriminately or tobecome sceptical of even the genuine recent develop-ments. For the first time, a book has been writtenwhich can be recommended to the most general ofpractitioners. Dr. Youmans insists on assessing theevidence for any deficiency by several tests. A historyof inadequate diet or faulty absorption, the presenceof signs and symptoms, the use of special laboratorytests-by critical examination along such lines it is oftenpossible to avoid rash diagnosis and irrational therapy.He emphasises the difficulty of detecting mild or earlydeficiency disease. Frank xerophthalmia, beriberior scurvy are easy but rare in Western countries ; slightdeficiencies of vitamins A, Bl or C are more difficult butmuch commoner ; since they are probably responsiblefor much ill health and decreased resistance to infection

they are important. The book includes chapters onprotein, iron, calcium and iodine deficiencies, and at theend there is a summary of information about the vitamins,and a list of their principal sources. An account oflaboratory methods- of diagnosis is timely and accurate.Apart from a few small errors, mainly in some of thechemical sections, the book is clear, reasonable andwholesomely lacking in dogma.Treatment of FracturesJOHN A. CALDWELL, M.D., professor of clinical surgery,University of Cincinnati ; director of the fracture service,Cincinnati General Hospital. London : Bailliere, Tindalland Cox. Pp. 150. 19s.

IN the preface to this manual on fractures ProfessorCaldwell says that it has been written to elucidateprinciples of procedure rather than detail. It is evid-ently an account of the methods which he has found ofvalue in the fracture service of the Cincinnati GeneralHospital, and most of them are being taught andpractised in this country. But not all of his views willfind acceptance ; many will differ from his view thatstiffness and disability after splinting can be preventedby " frequent changing of the splint and by judiciousmassage and passive motion." This method is advo-cated in the chapter on the treatment of fractures ingeneral ; but since no further mention is made of itin the detailed descriptions which follow, it may beassumed that it does not really express Dr. Caldwell’spractice. He advocates open operation (Bunnel’s) fordislocation of the acromioclavicular joint’in cases whichcannot be maintained in reduction by strapping, andseems to have found reduction extremely difficult tomaintain ; this does not tally with experience here,where conservative treatment is more usual for thisinjury than operation. In fractures of the shaft of thehumerus below the deltoid insertion, he uses Middle-dorf’s splint, and advocates immediate exposure of theradial nerve in cases complicated by wrist-drop. Thetreatment of fractures of the patella by excision is notmentioned, although Brooke’s paper is listed in thereferences. This operation is sometimes essential forcomminuted fractures, and deserves a place. He ad-vocates internal fixation for torsion fractures of theshafts of the tibia and fibula ; his choice of Parham’sbands as internal splints is unusual. Fracture surgeonsshould be able to deal with the fractures of the skullwhich in war-time so often complicate-or rather are

complicated by-fractures of trunk and limb bones ;Professor Caldwell is to be congratulated on the shortbut practical and complete chapter he has written onthis subject. References to outstanding recent publica-tions are given at the end of every chapter, and the bookamply fulfils its purpose of serving as a guide to students,house officers and general practitioners.

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Functional Pathology " by Dr. L. Lichtwitz can behad from Messrs. William Heinemann, price 42s.