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35 to be placed on the donor’s statement that he has never had the disease. The moral of this is pointed by an occurrence described by our Vienna correspondent (p. 44) where a donor, in spite of his statement that he had never had malaria, was proved to have infected four people by transfusions. Other common diseases which have been transmitted in the same way are some of the exanthemata. The transmission of measles in two cases from a mother to her infant was reported from Chicago in 1924,1 the blood having been taken two days before the appearance of the rash. Small-pox has also been transmitted recently,2 the blood again having been taken two days before the eruption , appeared. The existence of an incubation period must always make the complete elimination of this accident impossible. Much queerer events than these have also been described. On one occasion a patient was temporarily endowed with horse-asthma after having received the blood of an individual subject to this condition.3 Again, a recent report 4 from Scandinavia records the transfusion of blood from a donor who was seven weeks afterwards found to be suffering from acute myeloid leukaemia, from which he presently died. Fortunately for the patient, if unfortunately for medical science, no symptoms developed in the recipient, so that the question whether leukaemia can be transmitted in this way is still unanswered. It is evident, however, that these accidents are relatively so uncommon that no exagger- ated fear need arise in the minds of either the public or the profession. Comfort may also be derived from the statement 5 made in 1925 that the blood of tertiary syphilitics may be safely used for transfusion. It was a somewhat bold experiment, ten non- syphilitic patients being transfused from six syphilitic donors in a late stage of the disease. None of the patients was infected, but the use of such donors is, of course, not to be recommended. SUPRARENAL TUMOURS IN CHILDREN. THE exact terminology applied to new growths of the suprarenal glands is often confusing, and in children such tumours are usually so misleading in their clinical manifestations as to render precise diag noses very difficult. The subject is, however, not really so complicated as is often made out, and a recent report 6 of a case of malignant suprarenal tumour in an infant, with a brief survey of literature, very much simplifies the classification. Tumours of the suprarenal cortex either give rise to no symptoms at all, like the simple adenomas, or produce curious disturbances of sexual development. Tumours of the medulla of the suprarenal are in reality new growths of the sympathetic nervous system, and the term " neuroblastoma " is used for them, or more simply " medullary sarcoma of the suprarenal." These latter tumours are especially liable to cause difficulty, for they metastasise so early that the secondary deposits seem to dominate the picture, while the primary growth may only be discovered at autopsy. Tumours of this variety fall into two groups. The " Pepper " type occurs in babies between six weeks and four months old, usually growing in the right suprarenal, and giving rise to an enormous enlargement of the liver which is diffusely infiltrated with secondary deposits. The " Hutchison " type is, as a rule, found in children between one and five years of age. The primary growth, usually in the left suprarenal, is bigger than it is in the Pepper type, while secondary deposits occur in the bones, especially those of the skull. It is in such cases that difficulty may arise because secondary deposits in the orbit, producing pioptosis, may occur before the primary growth is discovered, and the diagnosis from chloroma can often only be made from a blood 1 Amer. Jour. Dis. Child., 1924, xxvii., 256. 2 Ann. Clin. Med., 1926, iv., 722. 3 Jour. Amer. Med. Assoc., 1919, lxxiii., 984. 4 Act. Chir. Scand., 1928, lxiv., 369. 5 Amer. Jour. Syph., 1925, ix., 470. 6 Jahrb. f. Kinderheilk., December, 1928, p. 214 count. In the paper from which this review is taken van Veen describes a case of the Pepper type in an infant aged only 18 days. The main clinical feature was the huge size of the abdomen due to an enormous liver. Blood count showed a slight decrease in the red cells with an increase in the leucocytes. The van den Bergh reaction in the blood was negative and so also was the Wassermann reaction. The child died at the age of 6 weeks, and at the autopsy the liver was seen to be very large, pale, speckled, smooth, hard, and infiltrated throughout with metastases, while the primary growth was in the right supra- renal with a somewhat compressed right kidney. Dr. van Veen discusses the histological appearance of the tumour and its relationship to the sympathetic nervous tissue. His observations may be correlated with those of Dr. D. M. Greig,l who in a paper which has just appeared gives an account of the histological appearances of the Hutchison type, describing fully a case in which there were secondary deposits in the region of the right side of the face and skull. He is interested especially in the nature of cephalic metas- tases in these cases, and points out that the secondary deposit is in the soft tissues at first and infiltrates the bone later. After a period of bone absorption there is great activity of the bone cells with local excess of calcium salts leading to formation of new bone. This bone cell activity is the direct result of the excess of vascularity which the highly vascular tumour has ensured. In Greig’s case the primary growth was in the right suprarenal, which is a slightly less common site than the left suprarenal for the primary focus. He quotes the work of Frew to show that the cephalic distribution roughly follows the side of the primary growth, owing, it is believed, to the anatomical arrangement of the lymphatic drainage of the suprarenal glands. HOSPITAL AFTER-CARE AT SHEFFIELD. ANONYMOUS generosity has made it possible to inaugurate a valuable scheme for after-care and convalescence at the Sheffield Royal Infirmary. There, as elsewhere, it has been felt for a long time by the infirmary board that the work of an institution of 500 beds was incomplete if it ceased automatically when the patients left the wards. It is desirable in the ex-patient’s interest that his progress should be carefully watched, his diet supervised, arrangements made for further examination and treatment on the first sign of retrogression ; and equally desirable in the interests of posterity that complete records of progress should be available as a guide and control to the treatment of others. We are to-day at a period in hospital development when we must appraise our results more intelligently in order more accurately to register what we are accomplishing. The patient must be followed actually to his home or place of work in order to estimate how his physical condition is standing the strain of normal life. Valuable information will be obtained from an after-care scheme with a well-organised follow-up and a collation of the data so obtained. In the case of the Sheffield Infirmary scheme the primary functions are several, and may be epitomised thus : to gain knowledge of the patient’s condition after discharge from hospital; to cooperate with any and everv agency with a view to rapid restoration to health ; to help the patient to understand the treatment recom- mended, prescribed, and often supplied by the hospital; to furnish where necessary surgical appliances, artificial limbs, splints, trusses, and the like ; to supply drugs like insulin and special diet for diabetics who cannot take the food of the ordinary household. The scheme is drawn up specially with a view to convalescence ; in accordance with the wishes of the founders expressed in a trust deed the fullest use will be made of convalescent homes, particularly of homes offering special treatment. The word con- valescence is to be construed in its broadest sense, and under this heading will be provided home nursing 1 Edin. Med. Jour., January, 1929, p. 25.
