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clinical laboratories, I have no doubt that there are manymore excellent opportunities in clinical medicine than

your editorial would suggest.Department of Bacteriology,

St. Thomas’s Hospital Medical School,London, S.E.1.

RONALD HARE.

ROYAL COLLEGE OF MIDWIVES

gj—jy I call attention to the appeal that is beingmade to the Nation on behalf of the Royal College ofMidwives.

’

Briefly the facts are that present accommodation is quiteinadequate for the purposes and needs of the college. Accord-

ingly a very suitable corner site has been secured at 15, Mans-field Street, London, W.1, on which to erect an appropriatebuilding. It is calculated that to acquire the site, to erect thebuilding, and to maintain it on completion, 150,000 is required.It is therefore hoped to raise this sum in the course of theappeal.Apart from the many and increasing services contributed

to British midwifery, the Royal College also serves worldmidwifery and undertakes the secretariat of the InternationalConfederation of Midwives. A number of your readers willrecall the first World Congress of Midwives which was held inLondon last year and was sponsored, organised, and financedby members of the Royal College and attended by repre-sentatives of 47 countries.No doubt many of your readers will have a kindly sympathy

for the good shape of the college and indeed many will havepersonal contacts with its officers and offices, and may wellfeel disposed to support the appeal by sending a chequemade payable to the " Royal College of Midwives BuildingAppeal," at 57, Lower Belgrave Street, London, S.W.I.Midwife members of the many branches of the college

throughout the United Kingdom will in various ways be takingsteps to raise funds for the benefit of the appeal, and the helpand encouragement of your readers by cooperation with theirefforts would be most valuable and warmly appreciated.Royal College of Midwives,57, Lower Belgrave Street,

London, S.W.1.

C. S. B. WENTWORTH-STANLEYChairman, Appeal and Building

Committee.

TONSILLECTOMY WITHOUT TEARS

SiR,—Last week’s letter from Dr. Robertshaw promptsme to describe experience of rather more than 1000 casesin the years 1951-54 :

As regards premedication, all the children were given’Nembutal’ by mouth according to a rule-of-thumb methodof dose-for-age. The results were assessed three or four weeksafter the operation by asking parents the following questions :(1) Does the child remember induction ? (This was ethylchloride on a mask in all cases.) (2) If it does, was thereany sign of nervous upset or fright on return home ? (3) Ifso, do you think any nervous upset remains ?These questions were put to the parents of 389 consecutive

and unselected children. The replies showed that of childrenaged 8 years or less, 86% had no memory of induction, 96%were not noticeably upset on return home on the third day,and 0-4% were said by their parents to show nervous dis-turbance a few weeks later. In children over 9 years theresults were bad, 40% remembering the induction. Of 50consecutive children operated on in nursing-homes, not 1had any recollection of any part of the proceedings afterswallowing the nembutal, mainly, I think, because in thesecircumstances induction was always carried out in bed.

It therefore seems to me impossible to agree that theuse of oral barbiturate is ineffective, and personally Ihave never seen any disadvantage offsetting the benefitfrom it. Admittedly the majority of the children requirea postoperative injection of ’ Nepenthe ’ or other sedative,but the ward staffs (and the children) regard this as

most helpful in getting through the first few uncomfort-able hours. I do not think there can be any questionbut that in young children oral premedication is preferableto any form of injection, and that this applies withequal force to induction. As a result of this survey,however, I have now abandoned this method in childrenover the age of 8, and use preliminary ’ Omnopon ’ and

scopolamine followed by thiopentone. But perhaps themethylpentynol-hyoscine mixture suggested by Dr.Gusterson may be an improvement on the former.As to maintenance of anaesthesia,, I confess I find it

difficult to understand the justification for endotrachealtechnique in these children. Apart from the risk oftrauma to teeth or larynx, either deeper anaesthesia orthe addition of an unnecessary relaxant is required toinsert the tube, not to mention the waste of time ; andthe advantage of greater control of the airway appearsto me only theoretical.May I finally offer myself as a target by saying that

the thousand children under review, several thousandsbefore them, and I fully expect more thousands to come,were and will be kept anaesthetised, after induction, withchloroform After twenty years of managing thesecases, I find no other drug so satisfactory. And in myexperience the administration of no other drug is so freefrom anxiety as that of chloroform rightly used.

Windsor. DOUGLAS BELFRAGE.DOUGLAS BELFRAGE.

POLISHED FLOORS

SiR,—In certain hospitals occupational therapy takesan exceedingly dangerous form-the excessive polishingof ward floors. I speak from personal experience, havingfractured two ribs from this cause. Each morning thepolishing process was pursued vigorously, an electricmachine being brought into play ; the bathroom wasthe only place where one could walk in safety. It ishard to understand why this dangerous practice isallowed.

Twyford,near Winchester. C. B. L. HASLEWOOD.

SEPARATION EXPERIENCES AND MENTAL

HEALTH

SIR,-The subject of the article by Dr. Howells andMiss Layng (Aug. 6) is of considerable topical importance-not to mention controversy.

" Separation anxiety " as the basis of subsequentneurotic ill health is by no means a new theme in analyticpsychiatry, though its historical origins have been some-what obscured by the hullabaloo of its rediscoveryduring and just after the late war.

It will be found in the teaching of a school of psychiatristsworking at-the Tavistock Clinic between the wars, of whomHadfield Suttie,3 and Dicks 4 were outstanding exponents.As used by them, the term was but a convenient expressionto denote the feelings of anxiety engendered in the youngchild- when normal protective contact with the mother wasinterfered with for any reason. It did not necessarily implygross and complete physical separation of mother and childbut could be brought about by various forms of psychologicalrejection (= separation). For instance, Hadfield repeatedlyrefers to "fear of loss of love " as a source of neurotic conflict.It is only since our experiences with evacuated childrenduring the war that physical separation of mother and childas a source of anxiety has come into such prominence.

In this connection there is much confusion of thought.It is not the externals of the situation that matter, butthe internal repercussions in the child. The key to thesituation, not to be lost sight of, lies in the child’s feelingsin response to the separation. Let me quote : .

" It is now generally accepted that the deepest psychologicalneed of the young child in its early years is for an inneremotional security such as can only be maintained in thepresence of steady and persistent parental protection andaffection.... Where it is lacking or more accurately wherethe child feels it to be lacking there may follow a wholeseries of psychopathological reactions." 5

1. Gusterson, F. R. Lancet, 1955, i, 940.2. Hadfield, J. A. Psychology and Mental Health. London, 1950.3. Suttie, I. Origins of Love and Hate. London, 1935.4. Dicks, H. V. Clinical Studies in Psychopathology. London, 1939.5. Edelstbn, H. Earliest Stages of Delinquency. Edinburgh, 1952