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ship, on the basis of allergy, between the various condi-tions described. It all depends, so the argument ran,on which tissue is picked out : transient infiltrationresults if the tissue is the parenchyma of the lung,spasmodic bronchitis if it is the bronchi, and eosinophiliceffusion if it is pleura. If, on the other hand, the blood-vessels are attacked (and Dr. PHILIP ELLMAN gave twoinstances in which this " vascular allergy " appearedprobable) periarteritis nodosa, certain forms of glomerulo-nephritis, and possibly even manifestations of rheumaticinfection may be the outcome.

SarcoidosisSarcoidosis is a puzzling disease. The aetiology is

uncertain, diagnosis is often difficult, and treatment is

unsatisfactory. Several of these topics were reviewedat a meeting with the section of dermatology.

Prof. L. M. PAUTRIER (France) confined his remarksto the superficial lesions and to the problem whethersarcoidosis is a disease sui generis or a manifestation oftuberculosis. There is much, he said, in favour of theview that the disease is a genuine but modified form oftuberculosis, a non-caseating variety : it is based largelyon the fact that caseating tuberculosis not uncommonlydevelops later. On the other hand inoculation experimentson guineapigs have given negative results, and theMantoux reaction is usually negative. The validity ofeach of these points of evidence was questioned : theformer by Dr. A.’T. RoBB-SMiTH (Oxford) who said thatinoculation may be positive if enough time is allowed

(6-8 months) ; the latter by Dr. CLIFFORD HOYLE whopointed out that a patient with sarcoidosis may exhibita negative Mantoux test either because it has neverbeen positive or because sensitivity to tuberculin neverdevelops.An interesting account was given by Prof. H.

HAXTHAUSEN (Denmark) of the specific antigenicreaction (the Koim reaction).

This antigen is prepared from a suspension of the constitu-ents of a superficial lesion (a gland) and injected into the skin.A positive response is indicated by the appearance after 1-2weeks of a nodule at the site of injection which may persistfor up -to 2 years. The reaction appears to be specific and isnegative in lupus and other tuberculous affections of the skin.

It was felt, however, that this has not yet settled thesetiological controversy.The widespread nature of the disease was emphasised

by Prof. CHARLES CAMERON (Edinburgh).It can attack the skin, mucous membranes, tonsils, eyes

(uveitis), salivary glands, lymph-glands, lungs, liver, spleen,kidneys, and bones. More rarely involved are the pituitary(diabetes insipidus) and the heart muscle. Pulmonary involve-ment is frequent. A common association is the skin, lymph-glands, and uveoparotitis. The bones are implicated in about20% of cases-generally the small ones, but occasionallythe larger. In the active phase of the disease the blood-sedimentation rate is raised, eosinophilia and monocytosisare seen, and hyperglobulinaemia may be found.

Dr. HoYLE, confining himself largely to the respiratoryform, emphasised the lack of definition and the con-

siderable difficulty experienced in diagnosis.Of 135 patients, suspected of sarcoidosis., whom he has

studied, the diagnosis was endorsed by histology in only 16,being probable in 14 others. In another 32 tuberculosis wouldhave been a reasonable alternative diagnosis. Of the remainder,53 proved to be miliary tuberculosis and 3 atypical Hodgkin’sdisease, while lymphatic leukemia, carcinomatosis, adenoma-tosis of lung, pulmonary congestion, chronic respiratoryinfection with bronchiolitis, dust, diseases, and variousexamples of the pneumonias accounted for most of the others.A long period of observation is often needed before thediagnosis can be established. Caseating tuberculosis withcavitation not infrequently results.

Dr. J. G. SCADDING called attention to the value of liverbiopsy in diagnosis : he has been able to demonstrate

characteristic changes in the liver in three consecutiveexamples. _

The disease is protracted but often remarkably freefrom symptoms. It may remain stationary for a longtime, and may retrogress. Death takes place from theinvasion of vital organs and from the supervention ofactive tuberculosis, and disability results from blindnessand from fibrosis of lung with emphysema. Dr. S.LoMHOLT (Denmark) informed the meeting that thesepatients tolerate calciferol less well than those with

lupus. Apart from this, reference to treatment was

conspicuously absent.

PSYCHIATRY

This section did not exhale its characteristic flavouruntil the’ second meeting. At the first meeting the talkwas all of genes, and there was little to distinguish themethods and modes of thought in evidence from thosethat might have been displayed at any of the other sectionsif they had been dealing with heredity and constitution.Genetics

Prof. T. SJÖGREN (Sweden) led off with a report of thesurvey he has been making into the incidence of psychosisand severe mental defect in the population of an islandoff the Swedish coast during the period 1900-44:Among these 9000 farmers and fishermen approximately

the same amount of insanity, idiocy, and imbecility was dis-covered as in the population of the Danish island, Bornholm,which Professor Stromgren of Aarhus had investigated beforethe war : this incidence was about twice that reported inthe Swedish census of 1940, but greater nicety of ascertain-ment would account for much or all of the discrepancy.

‘

Dr. F. J. KALLMANN (U.S.A.) developed some stimula-ting views about the inheritance of mental illness, based-on his classical studies of schizophrenia and his unrivalledtwin-material.

He emphasised that genetic factors determine the resistanceto the development or continuance of an illness such as

schizophrenia, and that this resistance is apparently connectedwith the mesodermal tissues. He also stressed, as did subse.quent speakers, that discovery of the hereditary causes of anillness in no sense implies that treatment will be futile. Oneof the most striking points he made had reference to mono-zygotic twins : if such twins differ in respect of the occurrence Iof mental illness when observed over a sufficient length oftime, they represent research material that is more valuableand rare than monozygotic twins who are concordant, andit is a grave omission if any doctor who comes across a dis-cordant pair of

" identical " twins fails to report them to anappropriate laboratory, where they can be studied.

Dr. FRASER ROB"ERTS offered a simple answer to aperplexing question in mental deficiency. In place ofthe disputed criteria for distinguishing between"

primary " and "

secondary "

defect, he offered a dis-tinction between those with an i.Q. over 45 (or there-abouts), and those with an i.Q. lower than this ; theformer are the subcultural defectives, representing thelower end of the curve of distribution of intelligence inthe general population, whereas the under 45’s are thepeople whose defect is due to a damaged brain. His

arguments in favour of this simplification were statistical,and were not wholly acceptable to Prof. L. S. PENROSE,’

‘

who later opened the general discussion. Dr. ELIOTSLATER bravely tackled the problem of psychopathicpersonality, and reminded his listeners that it is

imprudent to make changing social values the criterionfor a diagnosis as is customary with psychopathicpersonality. Professor PENROSE anticipated one of

Thursday’s incidental topics when he asked (as plaintivelyas one can in a rhetorical question) if someone wouldtell him what schizophrenia is.

Depression -

Next day the section went to the Maudsley to talkrather cheerfully about depression. Dr. T. A. MUNRO.

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began with a reminder that depression as a psychiatricterm had taken the place of melancholia, but that

depression might be met with elsewhere than in mentalillnesses ; its causes are too far-reaching for the

psychiatrist to speak otherwise than humbly about themand their eradication. He painted the picture withbroad strokes, and deprecated sharp distinctions betweenneurotic and psychotic depression. Dr. D. E. SANDS,who spoke later, asserted the contrary ; he holds that itis how more than ever necessary to distinguish the

endogenous psychotic depressions since it is among themthat electrical convulsant therapy scores its successes.

Dr. CLIFFORD SCOTT then gave a psycho-analyticalinterpretation of the origin of depression in which heemphasised that the crucial happening occurs at the

stage when the young child fuses the mother whom itloves with the mother whom it hates, and recognisessimilarly that the loving and the hating self are one ;the vicissitudes of the balance between these oppositeschiefly determines the occurrence of morbid depression inlater life. Dr. E. STENGEL, who has studied intensivelythe obsessional phenomena in some organic diseases ofthe brain and who combines neurological with psycho-analytic modes of thought, reviewed the significant groupof cases in which obsessional and depressive symptomsoccur together, and he paid particular regard to the

cyclical obsessional conditions. He finished his paperwith the shrewd comment, appropriate enough in a

discussion of psychodynamics, that we are so eager nowto explain and to cure that we sometimes fail to makeure what exactly it is that we are explaining and curing.

Prof. W. S. DAwsorr (Australia), who opened thediscussion, and many subsequent speakers, did not likethe psycho-analytical line of thought which had beenapparent intermittently during the morning, and theywanted metabolic and hypothalamic functions studiedfurther, though they had no precise new data or sug-gestions about method to offer. Dr. D. W. WINNICOTTheld, on the other hand, that the psychodynamics ofdepression can best be studied in the child, especially inrelation to apparent or real physical disabilities-amatter of paediatrics, in short. Another speaker alarmedthose of the more gloomy members of the audience whowant to keep their brains intact by remarking thatsome depressed people who have failed to recover theirspirits after electrical convulsions have responded wellto prefrontal leucotomy.

’

In the afternoon demonstrations in the Maudsley’sdepartments of electrophysiology, neuropathology, andpsychology showed that psychiatrists do not rely solelyon psycho-analysis to clear up all the mysteries ofmental illness, and that there is no lack of sound andvigorous research.

CARDIOLOGY

Clinical Value of Chest LeadsDr. F. N. WILSON (U.S.A.) paid tribute to the work

of British cardiologists, and described the researches ofThomas Lewis as the most important in the history ofelectrocardiography. He thought, however, that no.

one man had at any particular time introduced chestleads, but that they had " just come naturally."

The unipolar (V) chest leads allow the diagnosis of rightand left ventricle hypertrophy whereas the standard limbleads do not. They also give reliable information on thepresence or absence of bundle-branch block, and may showthe suggestion of this condition in limb leads to be faulty.Finally in some types of cardiac infarction where the patternsof the limb leads’ are normal or only doubtfully abnormalthe pattern in the V leads is quite characteristic.

Dr. CuRTis BAIN (Harrogate) believed that the V leadswill soon be generally adopted and that the chest leadIV is finished. With leads CR and CF there is distortionwhich sometimes makes them unreliable. He also thought

that the standard limb leads may disappear, though itshould be noted that lead III may’show most change inposterior infarction. Dr. TERENCE EAST thought thatfour chest leads (V2, V4, VL, and VF) will prove to be allthat is required for routine use. z -

.

The Phonocardiogra’YnThis subject, which turned out to be the most con-

troversial discussed by the section, was introduced byDr. WILLIAM EVANS.He referred first to the value of the phonocardiogram in

determining the position of the additional sound of triplerhythm in the cardiac cycle. Next the significance or other-wise of a systolic murmur may be decided by a sound recordbecause its exac position, which is more important thaneither its quality or intensity, can be determined by thismethod. Dr. Evans’s phonograms showed that the systolicmurmur of a normal heart always begins later than the" s line " of the electrocardiogram, while with rare exceptionswhat is heard as a systolic murmur in mitral stenosis is seenin the phonogram to begin usually during the P-R intervaland never later than the s line. He also described distinctiverecords of murmurs of hypertension and congenital heartdisease, and maintained that diastolic sound vibrations aresometimes present in these conditions when no murmuris audible.

Prof. C. LIAN (France) believes that the main valueof sound-records is in establishing the presence of triplerhythm. They enable the triple rhythm of left-ventriclefailure to be differentiated from the unimportant redupli-cation of the first sound, and the third heart sound ofmitral stenosis from reduplication of the second sound.Professor Lian’s remarks were illustrated by veryclear phonocardiograms taken with the Lian-Minottelestethophone. Continuing the discussion Dr. G.MINOT (France), whom Dr. EvAN BEDFORD describedas " the world’s leading cardiac engineer," gave anaccount of the various techniques employed for sound-recording of the heart and defined the essentials of suchapparatus.

’

The French workers seem to regard phonocardiographyas a means of recording what can actually be heard,and thus differ from the British view as representedat this meeting. Agreement on the best type of apparatusand on its calibration will have to be reached by theseworkers, who have done so much to advance the subject,before the instrument comes into more general use.

Coronary VesselsProf. C. LAUBRY (France), the doyen of Continental

cardiologists, described his technique for injecting thecoronary arteries post mortem and his findings on

coronary anastomoses.

He has found, contrary to previous conceptions, thatanastomoses may exist in the young healthy heart, whilethey might be absent in the aged heart. Coronary sclerosisincreases with age and after 60 is of the third or highestdegree (of his classification) in about 80% of subjects. Freeand extensive anastomoses may or may not develop aftersevere coronary sclerosis and the unfortunate subject in thelast category gets cardiac infarction.

Repetitive Paroxysmal TachyeccrdiaDr. JOHN PARKINSON and Dr. C. PApp gave a com-

munication op. this condition based on 40 cases including7 children.

It is a distinctive disorder of rhythm in whie]4 short

paroxysms of tachycardia arising in auricle, ventricle, or

A-v node, or runs of multiform extrasystoles, are constantlyrecurring. Sinus beats are few, and the difficulty is not somuch to record a paroxysm as to record the normal basal

rhythm. The heart is’nearly always free of disease, symptomsare slight or absent, and the prognosis is good, for althoughthe disorder may last many years it often subsides in theend. In treatment digitalis is rarely effective thoughoccasionally quinidine has controlled the ventricular form.

Dr. J. LENBGBE (France) said he had found intravenousdigitalis of ’ value in paroxysmal tachycardia, but