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survey of the literature is included in Dr. Leitner’spaper, and the case he makes out for optochin in thepneumonia of early childhood deserves criticalexamination and trial at other centres.

RICHARD THRELFALL

Sir Richard Threlfall, chemist and engineer, whosedeath occurred on Sunday last, was personallyengaged in a line of physics which seldom broughthim into contact with actual medical science, althoughhe had a large number of personal friends who weremedical men. But during the war, when his serviceswere most valuable to the country, he was a memberof the Scientific and Industrial Research Council,of the Food Research Board, and of the FoodPreservation Board, and this last appointment ledto intercommunication with some of the best-knownresearchers in nutrition. All who worked withThrelfall will remember his outstanding qualities ofdirectness and simplicity, his resolution to endorsenothing which had not received sufficient trial, andhis fairness in the course of discussion. He hadbeen in bad health for some time, but his grasp ofbusiness, in the large and in detail, were unaffected,while he persisted, with full knowledge of the risks,in pursuing the field sports he loved. His death atthe age of 70 is a public and private loss.

NON-SPECIFIC THERAPY IN MENTAL DISEASE

Psyma.TRisTS° recognise that there is a class ofmental disorders due, not to the toxaemia of an acutefever or infection, but to the slow poison of a smallresidue of the infective process. Dr. T. C. Graveshas made a study of these cases, and in a paper, theconcluding half of which we publish this week, hegives an account of the pathology of the conditionand a selection of cases which illustrates how thekind of patient he is discussing may be successfullytreated. The usual origin, he says, is an attack ofmeasles, scarlet fever, or influenza after the patientrecovers, a small area in the nose, throat, or ear

remains infected. For a time it maintains a chronicleucocytic reaction which appears as nasal catarrh ;when this defence fails the toxins invade the system.In patients who become certifiable the syndromeprogresses through a series of neurological disturb-ances-anomalies of taste, vision, and balance-andmetabolic disturbances which include disorders ofnutrition, sleep, and heat regulation, to psychosisdepending on toxic or organic changes in the nervoussystem. Dr. Graves describes three cycles of symp-toms : depression, fear, and confusion ; depressionis the first result of psychic invasion, and in somepatients continues in a mild chronic form for manyyears, but when the invasion is more severe thetoxins disturb the functions of the thyroid andpituitary so that the fear reaction of the adrenals isstimulated. Thus fear and anxiety are imposed onthe depression, in waves that correspond with thefluctuations of temperature in a normal subject.The psychic disturbance is at first intermittent, butthe lucid intervals become shorter until the " psychoticcontinuation "°

stage sets in, with a mental statethat may in a mild case be paranoid but which inothers is little better than acute confusion. Thischronic confusional state, Dr. Graves says, deservesthe name dementia but is not due to dissolution ofthe neurones, and so may be cured, but recovery isslow. A second systemic phase usually sets in with

pneumonia or some new infection, and the end is ina dementia which is presumably organic.

Dr. Graves attacks the toxsemia by stimulating alocal reaction in the focus ; by this time the diseaseis usually fairly far advanced: fresh foci havedeveloped, and all the systems of the body have beenpoisoned for a long time. Lavage and antisepticsmitigate the toxxmia locally, and alkalis and anti-sera mitigate it generally. Calcium lactate in large dosesby the mouth appears to stimulate a focal reaction,but the most potent weapons are said to be injectionsof colloidal calcium oleate, colloidal sulphur, andT.A.B. vaccine. In many cases the help of surgeryis enlisted to open, closed foci, drain off pus, andremove old exudates and necrotic material, but sur-gery has not been found sufficient without the localreaction produced by the injections. Artificial sun-

light is one of the auxiliary measures. Specificvaccines are not, apparently, so efficient as the non-specific agents. The ease-records only mention themore drastic ad hoc remedies, but presumably thewhole armament of general measures and, wherenecessary, psychotherapy were brought to bear.There are no figures to show the rarity of chronicinfection of a sinus, ear canal, or tonsil in the non-asylum population. Since it became fashionable toseek toxic foci as a cause of "rheumatic " mani-festations, many thousands of them must have beenrevealed in persons who showed no mental symptoms.It may be that yet others have no recognisable symp-toms, and either lead active, healthy lives or are

doubtfully subnormal; a number are susceptibleto colds and influenza, perhaps some are handicappedby fluctuant depression. It is arguable that Dr.Graves’s patients must have some factor which pre-disposes them to mental disorder or lack some

resistance mechanism which ought to protect thenervous system against bacterial poisons. Researchinto this predisposing agency should yield valuableinformation.The cases selected as representative of a con-

siderable mass of material seem to bear a stronglikeness-which, in fact, Dr. Graves himself analyses.Some patients, it is true, tend to exaltation andideas of grandeur rather than melancholy and per-secution, but the disease seems to preponderate inthe " depressive " type and not to favour the euphoricand well compensated. Dr. Graves, and his colleagueDr. F. A. Pickworth, who has done much valuablework on the insanity associated with sphenoidalsinus infection and invasion of the pituitary fossa,are to be thanked for directing attention to a classof mental disorder which has not received muchnotice. They make out a case for watchfulness onthe part of the practitioner, so that care in earlystages may avert further evils.

A LIVING TEXT-BOOK OF SURGERY

THE production of an expansible and alterabletext-book was an ideal which seemed a physicalimpossibility when the publishers of the NelsonLoose Leaf Surgery first mooted it some three yearsago. It was pardonable to admire their enterprisewhile speculating on the chances of their being able tocarry on their scheme of issuing supplements andreplacements for any length of time. The servicepages and renewal pages which have been publishedsince the book was launched have shown the successwith which the original intentions of the work havebeen pursued. Hitherto, reviews of current literaturehave been issued half-yearly to those who purchased

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the original volume. Now the publishers 1 are sendingout supplements and replacements every month. Thebatch which came to hand last month deals with pro-gress in anaesthesia, including local, spinal and theuse of accessory drugs, avertin, nembutal, and so on ;with general gynaecology ; with mouth surgery ; andwith genito-urinary surgery. This month’s batchincludes the conclusion of the additions to the sectionon anaesthesia by Dr. J. T. Gwathmey ; sections onthe diaphragm and aneurysm of the hepatic arteryrespectively by Dr. P. E. Truesdale and Dr. Robertoglessandri ; a supplementary index ; and a survey ofcurrent literature dealing with diseases of the intestine. <

All these reports and reviews are by recognisedauthorities. Such clear directions are given thatinsertions and discards can be made with very littletrouble. It is a splendid service.

DR. ALFRED COX TESTIMONIAL FUND

THE presentation of the portrait of Dr. Alfred Cox,painted for the subscribers to this fund by Sir ArthurCope, will take place on Saturday, July 23rd, at3.30 P.M., at the B.M.A. House. At the same time,a book containing a list of the subscribers and acheque will be handed to Dr. Cox. The committeewho organised the fund express a sincere hope thatas large a number of subscribers to the fund as canpossibly attend will do so. The subscribers amountto some 4000 in number and the committee havefound it impossible to issue individual invitations toall, but the presentation of a visiting card will secureentrance.

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THE ROYAL COLLEGE OF SURGEONS MUSEUM

THE progress made during the year in the schemewhich has been initiated for the encouragement ofresearch, and more particularly of surgical research, atthe Royal College of Surgeons of England is recordedby Sir Arthur Keith in his annual report on the Collegemuseum. Laboratories have been built and equipped andare now occupied by research workers. The schemehas recently been placed on a sound financial footing,thanks to the services of Lord Moynihan in enlistingthe aid of contributors to the Scholarship Fund. TheBuckston Browne laboratories at Downe are now

nearing completion. During the year Sir ArthurKeith himself has been working on the skeleton of achild recently discovered in the Mount Carmel cavesin Palestine. The skeleton, which was embedded ina mass of solid rock with certain bones exposed atthe surface, has been completely laid bare by Mr.-Ernest Smith. The additions to the Museum during;the year, which have been contributed by manydonors, are described in detail in the reports ofthe several curators. On the pathological side126 new specimens have’ been added ; these are

now on view, and will remain so until August 2nd.Mr. C. F. Beadles, the pathological curator, draws.attention to the following among other specimens:dura-matral tumours (meningioma), various lesionsof the gall-bladder, a large series illustrating the-pathology and treatment of ovarian cysts, a repre-sentative series of lesions of the small intestine, moreespecially carcinoma, a fine specimen of sarcoma ofthe posterior tibial nerve affected with Reckling-hausen’s disease, and two interesting appendices-namely, an intussusception and a mucous appendi-citis. The latter had ruptured and the mucous-

secreting cells, discharged into the peritoneal cavity,1 New York: Thomas Nelson and Sons. London: Waverley

Book Co., Ltd.

had continued to proliferate and secrete, producing acondition almost exactly resembling colloid carcinomaof the omentum and peritoneum, but doubtless

non-malignant. A donation due to the liberality ofProf. Sebrechts and Dr. Glorieux, of Bruges, consistsof three bones from a case of diffuse osteosclerosis or" marble bone disease," a condition in which thebones of the entire skeleton consist throughout of

compact osseous tissue of ivory-like texture.

THE LEAGUE OF NATIONS AND DANGEROUS

DRUGS

THE Government has, through the Home Office,transmitted to the League of Nations its annualreport on the control of traffic in dangerous drugsin this country, in accordance with the obligationsof the Hague and Geneva International Conventions.So far as internal trade in the drugs dealt with inthe Acts of 1920-25 is concerned, the position is asatisfactory one. Seizures of smuggled drugs have.been few and small in amount, and it is confidentlyasserted that " drug addiction is not prevalent inGreat Britain." Some 69 prosecutions under theDangerous Drugs Acts were recorded in the year1931. Seven firms are licensed to manufacturemedicinal opium, two to manufacture morphine andheroin, and one to manufacture cocaine. Raw opiumis again being imported, in considerable amount,from Turkey and less from India. The total amountof morphine and its salts produced in 1931 was

32,585 oz., while 16,284 oz. were exported. Thisshows a decrease on the figures for 1930, and anenormous reduction on the exports in the years1914 to 1918, when the amounts of British morphineand its salts exported ranged from 100,000 to

500,000 oz. a year. The exports of heroin andcocaine are also considerably less than in the previousyear.The question of prepared opium-i.e., opium used

for smoking-is passed lightly over. This matter,arising out of the report of the Bangkok Conference,has recently been before the Council of the League ofNations and its advisory committee. It is contendedthat smuggling in the Far East still prevents thecountries trading in prepared opium from carryingout the intentions of the Hague Convention of 1912in regard to its suppression. The British and Indiandelegates protested that financial considerations hadnothing to do with the continuance of the traffic. Itwill, however, be remembered that the British dele-gate, reporting on the Geneva Conferences in 1925,drew attention to the fact that " a very considerableproportion of the revenues of certain of the CrownColonies is drawn from the traffic in opium for

smoking," and added that " this is a point of whichmore will undoubtedly be heard."

Reference is made in the Home Office report tocooperation of the British Government with thoseof Holland, Germany, the United States, and Egypt,with a view to restrict or suppress the extensiveillicit traffic which still prevails. In THE LANCETfor June 25th the successful efforts made by J. W.Russell Pasha, of the Egyptian Narcotics IntelligenceBureau, were recorded ; and more recently he- hasbeen instrumental in securing the arrest of six personsin Constantinople engaged in smuggling 7 kg. ofheroin into Alexandria. The advisory committee ofthe League is drawing up a model code to assistgovernments in preparing legislative and adminis-trative measures for the application of the variousopium conventions to their respective territories.