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and have much of the responsibility for the treatmentof the patients." A little later in his address, howeverhe seems to have had doubts about the matter, forhe says, speaking of the advance of radiotherapeutics :" This process of encroachment will not stop, andperhaps in the end it will be the radiologists and notthe surgeons who will receive the rudest shock fromthe cry that cancer is conquered.’

"

Now, while it may in some cases be inevitable, it ison the whole, a bad thing for any body of medicalmen to be wholely dependent upon a single methodof treatment. Human nature being what it is, sucha state of affairs may conceivably clog the wheelsof progress. I suggest to the younger radiologistswho are interested in therapy that they shouldconcentrate on those diseases in which radiotherapyconstitutes the chief, or at any rate a very importantpart of their treatment. Cancer of the breast is anexcellent example. I think unbiased observersmust admit that in this condition radiation isnow of an importance at least equal so that ofsurgery. It should therefore be the aim of radiologiststo become the leading authorities on the disease.They will not attain this position by concentratingon the precise means by which to apply X rays orthe radium " bomb," any more than surgeonsreached their standing solely by skill in theperformance of the radical operation. In the past,surgical writings have been the source of practicallyall that is known of breast cancer-its aetiology,pathology, diagnosis, and treatment. Unless anduntil the radiologist knows as much about everyaspect of breast cancer as does the surgeon-apartof course, from operative technique-he must notexpect the medical and lay public to recognise himas the principal person to have charge of a case.

Radiologists have at the moment an opportunityto study breast cancer from a new aspect. The deadlinessof this disease lies in its metastases. When once these areclinically evident, though much may still be done, thepatients life is ultimately forfeit. If, however, we couldget warning of an outbreak at the pre-clinical stage, wemight perhaps do something useful, It is claimed bycertain biochemists that the vanadic acid sedimentationtest is capable of giving such a warning, by showing theblood picture to be moving in an abnormal direction.How long the warning is ahead of the active mischiefwe do not yet know, nor whether the seeming dangersignal is always justified.

Confining oneself to facts which appear well authenticatedone can say-that most breast cases show an abnormalblood at the time of diagnosis ; that with the removalof the primary growth whether by operation or radiationthe reaction becomes normal in some cases ; and remainsor again becomes abnormal in others ; and that it canin many instances be brought back again to normal bywidefield X-ray treatment of low intensity. The effectis constitutional and must be sharply distinguished fromintensive methods designed to produce a local reaction.We do not know for certain whether metastases can developin the face of a blood normal to the vanadic acid test, butthe investigation, linking up as it does radiology withbiochemistry, would seem to be worth pursuing.

Training of the RadiotherapistIt is obvious that our colleagues, and more especially

those who are in general practice, will not accept usas authorities on certain diseases-even when radio-therapy is admitted to be of prime importance intheir treatment--unless by training and qualificationwe can inspire confidence. At least three years spentin house appointments would seem desirable, andalthough it may perhaps be a counsel of perfection,a year in general practice would be of the utmostvalue. At the end of this time, a higher medicalqualification should be aimed at.With regard to the more technical side of radio-

logical education I am in agreement with Dr. R. S.Paterson who, in his presidential address last year,expressed a doubt as to whether the enthusiasm forphysics was not being carried a little too far. Itis not that any of us could know too much physics,

but when time is limited, as it must be, one has toconsider its value in relation to other studies. Forinstance, there is biochemistry, which I feel willbecome of increasing importance to the radio-therapeutist. And there is the general pathologyand clinical aspect of diseases amenable to X raytreatment. Concerning a physical problem we canalways consult a physicist; but faced with a patientwe must depend on ourselves.

Dr. Paterson, in his address referred to the matterof a higher diploma in radiology-which he saidwould have to be seriously taken up in the future.It is already the future by 12 months, and, in myopinion, it is time that some preliminary steps weretaken to realise this ideal. The first of these steps,which must be taken by radiologists themselves,might perhaps be the provision of some form ofrecognition for those who have done original workof value to radiology.In conclusion, if anyone says that the road I have

outlined is too hard a one for the neophyte to read,I would remind him of the old proverb which says that," he who wills the end must also will the means " ; or,if a classical quotation be preferred, per arduaad astra.

ACID METABOLISM IN RHEUMATIC CHILDREN

Dr. W. W. Payne approaches the theory of an" acid diathesis " in juvenile rheumatism in a newway (Arch. Dis. Child., August, 1934, p. 259). Heargues that in a normally functioning body a differencein the acid-base balance of the blood may well bebeyond the capacity of ordinary methods to detect,owing to the efficiency of the excretory organs.Of these the kidney is the most important and Dr.Payne has tried to get evidence of an increased acidexcretion in the urine in a group of rheumatic childrenattending a hospital rheumatic clinic. For controls,since normal children do not attend hospital out-patient departments regularly, he took two othergroups of children, one attending an asthma clinicand one in a residential school but in normal health.In all three groups three specimens of urine wereobtained by supplying labelled bottles containingsmall quantities of toluene. The children were

instructed to bring samples of the urine passed onrising, after breakfast, and on going to bed on the daybefore attendance at hospital, or at a suitablyconvenient time for the residential children.The urine was then examined for specific gravity,

hydrogen-ion concentration by means of indicators,free acid, ammonia, chlorides, phosphate, and urea.The difficulty of knowing the total quantity ofurine passed was got over by using as final results thetitration value of acid, alkali, and ammonia expressedas c.cm. of N/10 solution per 100 c.cm. dividedby the percentage of urea. The phosphate valuehas also been corrected for adventitious changesin volume. Two other ratios have been used : R, anammonia-acid ratio indicating how much acid hasbeen neutralised by ammonia, increased where acidexcretion is increased, and P, a ratio between phos-phorus and total free acid, which varies directlywith the phosphate and inversely with the amountof organic acid present.Both by frequency curves and by statistical

methods Payne shows that free acid and total acidwere excreted in greater amount by the rheumaticand asthmatic children in all three specimens. Fromcomparison of the three specimens it is seen that thenormal child has a less conspicuous alkaline tide in theafter-breakfast specimen, and the second specimenshows a difference of pH for the normal group whichis statistically significant. It appears legitimate toconclude that there is an increased excretion ofacid by the children in the rheumatic and asthmaticgroups. Unknown to Dr. Payne the asthmaticchildren were receiving hydrochloric acid in relativelylarge doses as a therapeutic measure, and when anallowance is made for this in the results the asthmaticgroup approaches closely to the normal group. This

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not only helps to get over the possible criticism thatthe normal group, being residential in a school andsubject to differences of diet and environment, is notstrictly comparable as a control group, but it alsoleaves the rheumatic group alone as excreting moreacid because of some essential difference in thebiochemistry of the patients.

Dr. Payne concludes that the rheumatic child in aquiescent interval excretes more acid than doeseither an asthmatic or a normal child. This excessproduction of acid is insufficient to disturb theequilibrium of the blood.

ANGIOKERATOMA

THE syndrome to which the name of angiokeratoma,or telangiectatic warts, is applied was described byMibelli in 1889. The patient is usually a youngwoman, often tuberculous and with a history ofwinter chilblains or other sign of circulatory weakness,and the condition is an eruption distributed on thedorsal surfaces of the hands and feet. Histologically,the lesions are composed of a na3void mass of dilatedpapillary vessels, with hypertrophy of the overlyingepidermis (hyperkeratosis, granulosis, and acanthosis).In a case described by L. E. Pierini and N. 0. SanchezBasso (Semana med., 1934, xli., 1940) the suffererwas a girl of 20, who had had haemoptysis at theage of 17. The disease became evident when shewas 7, affecting the hands only. At first there werechilblains, recurring each winter, and then thecharacteristic eruption began to appear. Physicalexamination disclosed a marked’ habitus phthisicus,’acrocyanosis, and signs of pulmonary tuberculosis,which X ray examination confirmed. The handswere small, with tapering fingers, the terminalphalanges especially being extremely slender, andthere was ankylosis of the terminal joint of the rightlittle finger, radiography revealing areas of decalcifica-tion. The eruption was irregularly distributed onthe distal part of the hand and the fingers, and wasalmost confined to the dorsal surface. The spotswere purplish, varying in size from a pinpoint to apea, disappearing on pressure with a glass slide,and rough to the touch. Histological examinationof an excised lesion confirmed the diagnosis.

" KEY OF ALL WALES" : A SEQUELWE have received from the office of the Western

Mail and Echo a pamphlet written by Sir John Lynn-Thomas in continuation of work published two yearsago and recording researches made during the previousfour years on the estuary of the river Tefi. Thesepointed to a Phœnician occupation of the countrybetween 1500 and 1000 B.C. Clearly only a skilledarchaeologist can decide on the value of the discoveriesand we cannot presume to judge between Sir Johnand various sceptical authorities of whose attitudehe complains in vigorous terms. The pamphlet isvery detailed and it is obvious that the author hastaken infinite pains to verify his theories. Heconcludes with a statement that Wales is in dire needof a professor of archaeology in its University and ofresearch workers who, speaking colloquial Welsh,would be able to obtain first-hand information fromthe inhabitants.

THE SPASTIC CHILDA LITTLE book/ written by the mother of two

spastic children, is a record of persistent and successfuleffort to overcome the disability of Little’s disease.The account of the method by which this result wasachieved is of considerable therapeutic interest.Mrs. Fischel’s first child was a severe case and diedin early childhood. In the second the disease tooka milder shape, and appears to have escaped diagnosisin the first few years. At the age of four energetictreatment was started and carried out, for the mostpart by the author herself, until at the age of 16the disablement had been reduced to comparativeinsignificance. The methods adopted are described

1 The Spastic Child. By Marguerite K. Fischel. London:Henry Kimpton. 1934. Pp. 97. 6s.

in full, and illustrated by excellent diagrams. Byfar the best part of the book is the description ofrelaxation and speech exercises. The author’s objectis to give assistance to parents of spastic children,and from this standpoint the book must be judged.It should bring conviction and encouragement tothose who are inclined to doubt that so great ameasure of cure could be attained. On the otherhand, the procedures described could, we think, beimproved upon in a few ways, and the treatment inthe early years rendered less exacting. But if usedas a supplement to detailed medical instructions thisbook should be extremely helpful to parents.

NEW PREPARATIONSACETYLCHOLINE BROMIDE.—A sterile stable solution

of this substance has been issued by BurroughsWellcome and Co., Snow Hill Buildings, London,E.C., as a Hypoloid " product. It is issued in" Hypoloid ampoules, each presenting O’l g. in1 c.cm. in boxes of 10. (The following notice isenclosed in the sample box which has reached us." As the ampoules are shorter than formerly, theymay be found to slip out of the rack when used inthe No. 62 ’Hypoloid’ Case. This can be overcomeby the use of paper tubes supplied free on request.")

Acetylcholine is the acetyl ester of choline. It hasbeen isolated in chemically recognisable quantitiesfrom the spleen and from the placenta, and is presentin minute traces in other organs. It is highly active ;dilutions of one in a million millions in the blood ofthe cat will produce a transitory fall of blood pressure.Its action is evanescent, as it is rapidly hydrolysedto acetic acid and choline in blood and tissues. Thedrug is usually administered by intramuscularinjection and has proved successful in counteractingparalysis of the intestine such as occurs afterlaparotomy and intestinal operations. It may beused to relieve severe post-operative gas distensionand pain, and has been found to relieve acute constipa-tion and to be of value in certain types of vasculardisturbances associated with arteriolar spasm.VALERIAN-DISPERT AND DESITIN OINTMENT.-We

have received these two preparations from Messrs.Coates and Cooper, Clerkenwell-road, E.C., acting as dis-tributing agents for the foreign manufacturers. Thedesitin ointment is a preparation of cod-liver oil,vaseline, lanoline, oxide of zinc, and purified talc,and has proved of service as a dressing for skinlesions, such as eczema and sunburn, and also invaricose ulcers and bedsores. Valerian-dispert is apreparation of valerian compounded in accordancewith the desiccation process-the Krause process-which is described in literature accompanying thepreparation. It is claimed that this process providesfor stability in the preparation and for certainty ofdosage. Valerian-dispert is made up in smalldragées, and is recommended for prescription in allcircumstances where valerian is well known to beuseful; these are numerous and a convenient mode forthe exhibition of the drug should be of practical value.MINTOES.-We have received from Messrs. William

Nuttall Ltd., Doncaster, specimens of a sweetmeatfor which they claim the advantage of particularpurity. The sweets are a combination of butter,treacle, and sugar. The day has gone by whennauseous preparations were commonly prescribed ;there are, however, useful medicines that childrendefinitely dislike, and here the bribe of a pure sweet-meat may be of service.LEMON BARLEY WATER.—We have received from

Messrs. L.B.W., Ltd., of 41, Eastcheap, London,E.C. 3, samples of a concentrated fluid preparedfrom lemons and pearl barley, from which a palatablebeverage can be made by the addition of three partsof water. No endorsement is needed of the claimmade by the manufacturers that lemon barley wateris a wholesome and efficient thirst-quencher. TheL.B.W. preparation is supplied in air-tight screw-capped bottles, with the statement that it can bekept on hand with safety as it does not deteriorate.