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in some respect under county and county boroughadministration so that excessive sickness could beanalysed and investigated.

OCULAR NEUROSES AND SO-CALLED

EYE-STRAIN,How are we to treat a patient who complains of

persistent pain and discomfort in the eyes when themost painstaking examination can find no error ofrefraction, except such as has already been correctedby appropriate glasses, no defect of muscle balancethat could possibly cause the symptoms complainedof, no undue demands on the accommodation, andno abnormality of the conjunctiva, cornea, fundus,lens, or other structures of the eye, or defect in theirfunctional activity ? In these cases there is a tempta-tion to tell the patient that he is suffering from"

eye-strain " and to prescribe rest from near work,when there is no certainty that the diagnosis is thecorrect one or the treatment likely to be effective.Or it may be that discovering an error of a quarter ofa diopter, or even of one-eighth, in the astigmaticcorrection that the patient is wearing, or an error of5° in the axis of a weak oblique cylinder, we areinclined to attribute everything to that. It maybe that there are patients to whom such diagnosesare applicable, but they are certainly very rare.

Dr. George S. Derby, of Boston, speaking at the

eighty-first annual session of the American MedicalAssociation last June,l expressed the opinion that in hiscountry the ophthalmologists produced more neurosesthan they cured. "Eye-strain," he says, " is a

terrible and serious bugbear to the public; wouldthat the word had never been coined." And again," It is far more dangerous to tell a patient to rest ahealthy pair of eyes than to use them. Many asensitive patient has been made hypersensitive bythe prescription of rest and dark glasses." Without

questioning the importance of correct refraction heimplies that the injury inflicted by incorrect glassesis far less than that due to the unnecessary prescriptionof glasses at all for patients who are inclined to beneurotic. As an example, he cites the case of a

healthy man of 48 who, complaining of some dis-comfort of the eyes with normal vision but a hyper-metropia of plus 1.0 D., had had spectacles of plus1-0 prescribed for distance. He had further beenadvised to give up smoking, card-playing, the, movies,driving a car, and reading, and to lie down everyafternoon to rest his eyes. All this advice he hadfollowed without the slightest benefit, and he stillsuffered from aching eyes. On returning to a

normal life and giving up his distance glasses,so that his attention was taken away from his

supposed eye troubles, he was cured. Dr. Derby’streatment of these cases is to discuss with them theirhabits of life and suggest improvements. Rarely,he says, is it necessary to call in a trained psychologist.In 95 per cent. of these cases what is needed, he finds,is a willingness to spend some time in studying thecase, and sound common sense. In the discussionthat followed Dr. Derby’s paper there was generalagreement with his point of view, though somespeakers were inclined to criticise him for laying toolittle stress on the necessity for an absolutely accuraterefraction. This sort of criticism would also probablybe made by many in this country who believe, withMr. Ernest Clarke, that the difference of a quarter,or even an eighth of a diopter, in the strength of acylinder may make all the difference between comfortand discomfort for the patient. It probably depends

1 Jour. Amer. Med. Assoc., Sept. 27th.

upon the patient, and no rule can be laid down whichshall be applicable to everyone. In the case of purelyspherical corrections of a minimal degree, however,there can be no question that it is a mistake to insiston the wearing of glasses for distance in the hope thatit will cure symptoms, unless the prescriber relieson the power of suggestion rather than on that ofcommon sense.

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FUNCTIONAL ALBUMINURIA IN CHILDREN.THE occurrence of albuminuria in children and

adolescents in a functional, cyclical, or orthostaticform has attracted attention for many years. Exten-sive investigation has always been difficult, becausethere are obstacles in the way of collecting numerousspecimens of urine from groups of healthy youngpeople, and apart from H. H. Bashford’s studies atthe General Post Office, most of the information

published in this country has been derived frominsurance work and examination of recruits for theArmy. The results of a large inquiry are now recordedfrom Kharkov in the Ukraine by F. Levitus andW. Rabinowitsch,2 who have observed the incidenceof functional albuminuria in a group of 1421 healthyschool-children ranging from 8 to 14 years of age.From a single analysis 197 children were found tohave abnormal urine, a percentage of 13-8. Up tothe age-limit of 14 the occurrence of albuminuriaincreased with age, and a sex difference, noted byother authors, was shown by the fact that girls inthe younger age-groups, between 8 and 12, had ahigher percentage of albuminuria than boys. Somewriters have maintained that the presence of acetonebodies in the urine in addition to albumin is a featureof these functional cases, but Levitus and Rabino-witsch found no such association in two-thirds of thecases. The amount of albumin varied from a traceto 3-3 parts per 1000. The presence of renal epithe-lium besides albumin was noted in 69 per cent. ofcases, and casts as well in 12-7 per cent. Thus the

presence of these bodies did not by any means nega-tive the diagnosis of functional albuminuria. It wasrealised that a single specimen of urine is useless forexact diagnosis of functional -albuminuria, so two

groups of 100 children were selected in one of whicha single examination had shown normal, and the otherabnormal, urine. In both groups four specimens ofurine were collected during the day. By making thechildren micturate once during the night, two tothree hours after they had gone to bed, it was arrangedthat the morning specimen should contain none ofthe previous day’s urine. Three other specimenswere obtained, at midday, afternoon (3 to 4 P.M.),and evening (8 to 9 P.M.). Although the morningspecimens contained albumin much less often thanthose obtained later in the day, they were by nomeans always free from it, and there seemed to beno definite optimum time of day for obtaining eitherpositive or negative specimens. Thirteen cases ofalbuminuria were found among the 100 children whohad shown normal urine on a single examination, sothat the true percentage incidence in school-childrenwas raised from 13-8 to 26-8. It has often beenmaintained that children with functional albumin-uria complain of various vague symptoms such aspoor appetite, headache, and dizziness, but com-

paring two groups of albumin-free and albuminuricpatients, Levitus and Rabinowitsch could findneither quantitative nor qualitative differences insuch subjective symptoms. No difference could befound, either, in the previous occurrence of the

1 THE LANCET, 1926, ii., 1305.2 Jahrb. f. Kinderh., Oct. 1930, p. 188.

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specific fevers in the two groups, nor was there anyobvious difference in the habitus of the children whohad albuminuria ’3>S compared with the other children.Blood counts, blood-pressure readings, and tuber-culin tests all gave the same result-namely, thatalbuminuria as a " functional " condition does not

appear in any special type of child. There is therefore,they hold, no definite clinical picture apart from theurinary findings. The occurrence of alternating posi-tive and negative phases is looked upon by theseinvestigators as the essential feature for diagnosis,and in five cases in their series where albuminuriawas constant the diagnosis of chronic nephritis wasconsidered to be the correct one.

THE HAUSA AND THEIR DIET.

THE northern provinces of Nigeria are inhabitedlargely by a negroid mixture of races spoken of as theHausa, and by a semitic race known as the Fulani,which has given up its original nomadic life andsettled in towns. Dr. W. E. McCulloch 1 hasconducted an inquiry into the dietetic habits of thesenatives and has attempted to correlate certain

specific food deficiencies which his investigationshave revealed with the very unsatisfactory state ofhealth existing in this part of the world. Theinhabitants are by no means savages, but general ill-health is widespread among them, and their infantmortality-rate is appalling. Their physique is notstrikingly different from that of European races,but their weight is less than that of individualEuropeans of the same height, and they reach theirmaximum height at an earlier age than white racesof mankind. Their resistance to infections isnotoriously low, as it appears to be throughout thenegroid races of Africa. Epidemics of relapsingfever and small-pox sweep through the country withdevastating results, and bronchitis, pneumonia, andtuberculosis steadily claim large numbers of victims.Gastro-intestinal disturbances are common, and mayfurnish half the cases that attend the native hospitals.The teeth of the women are usually well preserved,possibly owing to their habit of chewing the flowersof the tobacco plant which stain the teeth and appearat the same time to protect them from caries. Theteeth of the children and of the men are rarely good,and cannot be compared with the remarkably goodteeth of the West Indian negro who habitually chewssugar-cane. The birth-rate is low, largely on accountof the reduced fertility of the male, who indulges inpolygamy; abortions are very frequent, althoughsyphilis does not appear to be particularly wide-spread. In one of the chief towns the infant mortality-rate for 1927 was 412 per 1000. Specific fooddeficiency diseases are not uncommonly met with.Beri-beri and scurvy occur during times of scarcity,goitre is fairly prevalent both among the inhabitantsand among their cattle, and xerophthalmia is metwith in young children. Rickets appears to be arare disease ; chronic anaemias are common.The staple foods of the natives are millet seed,

Guinea corn, adulterated sour milk, and soup composedof green leaves. Ground nut oil and meat are usedsparingly by the masses and in relatively largequantities by the more wealthy families. Condi-ments, spices, and sweets are widely consumed.The native " salt " contains little or no chlorine.The glaring fault of the dietaries is that they are apt

1 An Inquiry into the Dietaries of the Hausas and TownFulani of Northern Nigeria, with some Observations of theEffects on the National Health, with Recommendations arisingtherefrom. By W. E. McCulloch, M.D. West African MedicalJournal, 1929-30, vol. iii.

to consist almost entirely of cereal products. Milkis purchased in fairly large quantities, but in view ofthe fact that it is habitually adulterated with morethan half its bulk of water before it is sold, the trueconsumption is not large, which means that thepopulation suffers from a deficiency of calcium andof protein of good biological value. Fat-solublevitamins must be markedly deficient, and though thelack of vitamin D in the food is to a great extentmade good by abundant sunshine, the shortage ofvitamin A is probably related to the susceptibilityof the population to infections. Vitamins B and Care present in insufficient quantities, so that with anyrestriction of diet definite symptoms of the correspond-ing deficiencies may become manifest with greatrapidity.

’ The recommendations made by the author for

improving the nutritional status of these peoplesare based on strictly practical and economic lines.In the first instance, every encouragement should begiven to increase the quantity and improve the

quality of the milk consumed by the masses. Thiscould be brought about by exempting milk-bearingcattle from the cattle tax on condition that they werekept for supplying milk to urban populations, andby making the adulteration of milk an offence punish-able only by imprisonment and not by fines. The

deficiency of mineral salts and vitamins could bepartly corrected by planting in the neighbourhoodof the towns large reserves of trees with edible leaves,of which a considerable variety are known. Thesweet potato is a valuable crop, not merely for thesake of its tubers but on account of the richness incalcium of its green leaves, and its cultivation shouldbe strongly encouraged. These comparatively simplesuggestions should help very materially to correctthe very imperfect diets in vogue at present, andthe obvious benefits to be expected from their wideadoption would make it easier to introduce in thefuture still further dietary improvements.

ANTITOXIN TREATMENT OF DIPHTHERITICPARALYSIS

THE employment of antitoxin in diphtheritic para-lysis, which has been advocated by several clinicianson the Continent, notably by Comby in France andHeubner and Jochmann in Germany, has receivedlittle support in this country, in view of the naturaltendency of this condition to spontaneous recoveryand the failure of the treatment in experimentaldiphtheritic paralysis. Commenting on a case

recorded by the late Dr. G. S. Middleton in thesecolumns many years ago, Dr. J. D. Rolleston 1

suggested that the success attributed to this treat-ment was due less to a specific than a psycho-therapeutic action. Last month, however, Prof.U. Friedemann and Dr. A. Elkeles, who appear tobe rather in favour of the method as the result oftheir clinical experience, record some experi-ments on rabbits which they think give some

evidence supporting the serum treatment of

diphtheritic paralysis. They found in the first placethat both in the normal rabbit and in the human

subject suffering from diphtheria, antitoxin could notpenetrate to the cerebral circulation, so that it mightbe supposed that diphtheritic paralysis could not beaffected by serum treatment. This supposition,however, was met by the fact that intracerebraldiphtheritic intoxication in the rabbit could be curedby large doses of antitoxin injected intravenously,

1 THE LANCET, 1908, ii., 261.2 Deut. med. Woch., Oct. 10th, p. 1725.