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and doctor-thinking " are discouraged, and theattendants devote themselves to " courage therapy."Carefully prescribed games are interspersed withrest, and as the patients improve they undertakework in the garden or workshops, again accordingto prescription. They have to do none of the house-work, and in this the institution compares favourablywith some English convalescent homes, where tiredmothers find a duller repetition of their home duties.In a word, it is clear that the success or failure ofsuch a home depends not so much on organisationas on atmosphere. If indeed the heterogeneous patients" return to the surgeon and the social adjuster erect,colourful, courageous, crutch and whim-free persons,"then the triumph is a personal triumph for themembers of the staff. To read statistics of admissionto this institution is to gain some idea of the numberof foreigners in New York, and it is impossible notto sympathise with the ambition to make these

largely undesirable elements fusible. In a convalescenthome there exist golden opportunities to instilAmerican ideals, and these are not missed at WhitePlains. But apart from this the Foundation is aninteresting experiment, and is designed to solveproblems which are English as well as American.

SCANDINAVIAN VIEWS ON RENAL

TUBERCULOSIS.

IN 1923, at the fourteenth meeting of the Scandi-navian Surgical Society, it was decided that in theinterval between this meeting and the next, to be heldin the summer of 1925, Scandinavian surgeons shouldcollect their cases of renal tuberculosis and shouldprovide a digest thereof for discussion at the fifteenthmeeting. A scheme was drawn up, so that the samedata should be provided by the different Scandinaviancountries, and while Prof. P. Bull undertook tocollect the cases from Norway, Prof. Rovsing wasresponsible for Denmark, Prof. G. Ekehorn for Sweden,and Prof. Runeberg for Finland. In a communicationwe have received from Prof. Bull we learn that thefifteenth meeting took place between June 25th and27th of this year in Copenhagen. The paperswhich were read on this occasion (some of which hehas kindly sent us) give a very favourable impressionof the value of this system of pooling the experiencesof a great number of surgeons who have been givenplenty of time to collect and study their material.Prof. Bull’s Norwegian material consisted of 580 casescollected by 21 surgeons; Prof. Rovsing’s Danishcases numbered 632, provided by 31 different hospitals;Prof. Ekehorn’s Swedish cases numbered 1498,reported from 22 different hospitals, and Prof.Runeberg’s Finnish cases numbered 213, all of whichhailed from Helsingfors. It is interesting to note howuniform is the experience of practically every surgeonin Scandinavia with regard to certain features oftuberculosis of the urinary tract. It would seem,for example, that in every Scandinavian countrythis is a disease which is confined to the third and fourthdecades of life in most cases. In Prof. Bull’s material,.for instance, 74-7 per cent. of all the cases were

observed in this age-period, and much the sameobservation was made in the other Scandinaviancountries. His ratio of males to females was as

59 to 41, while the corresponding ratio for the Swedishcases was as 57-6 to 42-4. Prof. Bull found that 40 percent. of his male patients suffered from tuberculosisof the reproductive system, but, curiously enough,this complication of the tuberculosis of the urinarytract did not greatly impair the prognosis. Withregard to the complications of nephrectomy, he foundinfection of the operation wound, which occurred in27 per cent., the most important, and he emphasisesthe seriousness of any step which, when taken duringthe operation, is calculated to infect the wound withtubercle bacilli. Recovery could be claimed for51 -6 per cent. of his cases in which nephrectomy was Iperformed. We have in these lines given but thescantiest of summaries of these important papers, I

the contents of which might justly be called encyclo-paedic. It is to be hoped that means will be found toprovide a translation of them into English, French,or German, so that the information they containneed not be limited to the countries of their origin.

THE ROLE OF THE BLOOD PLATELET.

CONCERNING the source, nature, and function of theblood platelet many theories have been put forward.It has been suggested that it is an entirely independentcell, the function of which is at present almostunknown (Achard, Morawitz, Deetjen, Aynaud, andothers) ; that it is the primordial or embryonal stageof the red corpuscle, a view maintained by Hayemand his followers ; or that-it is a simple corpuscularelement or rudimentary cell-one, however, whichplays an important part in the coagulation of theblood, the retraction of the clot, and, as some recentresearches seem to show, in the processes concernedwith immunity. Again, it may be only a fragmentaryprotoplasmic residuum of other blood elements, orperhaps a pure artefact which has no existence in thecirculating blood. In the course of a thesisl publishedat Rio de Janeiro, Dr. Arnaldo Cavalcanti Marquesreviews each of these theories and unhesitatinglyrejects the last. After considering the physico-chemical properties, physiological functions, andprobable source of the platelets, he discusses their rela-tion to various pathological states, including internalparasitic affections, suppuration, protozoal infections,affections of the blood and blood-forming organs, andshock conditions. The following statement on varia-tions in the platelet count due to certain morbidconditions is given as representing conclusions withwhich most observers would agree, and which areconfirmed by Dr. Marques’s own work. An excess ofplatelets is present in the blood (hyperglobulinaemia)in intestinal verminoses, suppurations, recovery fromloss of blood (after a certain lapse of time from the loss),convalescence from acute illnesses, and in the courseof chronic disease. The reverse condition (hypo-globulinaemia) is found in the acute stage of haemor-rhagic purpura, in pernicious anaemia, and in theactive period of enteric fever. Dr. Marques considers,however, that globulinometry, or platelet counting,is at present of little value in diagnosis or prognosis.None of the methods used for the count (Hayem,Aynaud, Fusari, Giudiceandrea) are free from theliability to serious error, though those of Hayemand Aynaud, singly or combined, furnish approximateresults accurate enough for clinical use. He is con-vinced that the blood platelet plays a very importantpart in therapeutics. ____

NEW YORK ACADEMY OF MEDICINE.

THE Academy of Medicine, which is about to moveinto a new building in Fifth Avenue, was founded in1846. Since that time it has fulfilled its original objectsby holding regular meetings, by maintaining a largelibrary, and by interesting itself in public healthproblems. At first the Academy was homeless andused for its gatherings the premises of other medicalinstitutions, but in 1875 it bought a house of its own,and in 1890 moved into its present quarters. It hasnow 12 sections which meet for discussions or to hearpapers by distinguished visitors, and its increasingmembership and activities long ago made it evidentthat the present buildings were inadequate. Thelibrary, which is the only public medical library in NewYork and contains over 140,000 books, cannot expandas it should, and its reorganisation has had to bedeferred until new premises are found. This state ofaffairs attracted the attention of the Carnegie Corpora-tion and the Rockefeller Foundation. They appre-ciated the potentialities of the Academy as an educa-tional centre and decided to devote large sums to its

1 Sobre o globulino o sua importancia em clinica (concerningthe blood platelet and its clinical importance). By Dr. ArnaldoCavalcanti Marques. Rio de Janeiro : Typ. Revista dosTribunaes. 1924. Pp. 164 and 3 plates.

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development. About 2300,000 has been given by theCarnegie Corporation for building purposes, and theRockefeller Foundation has contributed towards theendowment fund of 2500,000. These gifts are con-ditional, however, on an expansion of activities onrather new lines. A full-time director of the Academy’s swork has been appointed ; the library service is tobe developed, and a bureau of clinical information

under the direction of a committee on public educationis to be set up. Public health work at the Academyhas hitherto been in charge of a committee which hasmade important studies in communicable diseases,quarantine, hospitals, dispensaries, day nurseries,convalescent homes, and the problems of chronicdisease. That this side of the Academy’s work willnot be neglected is evident from the appointment asfirst director of Dr. Linsey R. Williams, who wasDeputy Commissioner of Health for the State of NewYork, and for three years was at the head of theRockefeller Commission on Tuberculosis in France.Associated with him in the reorganisation andmanagement of the Academy will be Colonel FrederickP. Reynolds, M.D., the head of the Committee onPublic Health, and Dr. E. H. Lewininski Corwin who Ihas for some time been connected with the library. I

From the British point of view one of the most interest-ing features of the reorganisation is the proposedclinical information bureau, which is to publish amonthly bulletin. In travelling to or from Europe,American and foreign doctors generally pass throughNew York, and the bureau is to be a clearing house ofinformation on every kind of medical study availablein the States, and also on the facilities existing inEurope. New York itself, with its huge foreignpopulation, is a big field for study and research, andit is felt that by coordination and information thisfield can be made to yield a far larger harvest. TheAcademy intends to supply efficient machinery.

IODINE AND ENDEMIC GOITRE.

THE successful results obtained in different partsof the world in the treatment of endemic goitre bymeans of iodine are known, but the aetiology of thedisease is not completely cleared up, and it seems tobe going too far, as some authors have done, to saythat a geographical deficiency of iodine in the air,food, or water is the specific cause of endemic goitre.The more information which can be obtained fromdifferent situations as to the distribution of thisdisease and the relation between this and iodinedeficiency, the easier it will become to prove ordisprove such a sweeping statement. Prof. D. B.Blacklock has now reported his observations on theoccurrence of endemic goitre in Sierra Leone.l Heendeavoured to put to the test the theory of a geo-graphical distribution in relation to goitre by tracingthe Bagwe river up to its sources in the mountains.Goitre occurs endemically over the area drained bythis river, and it was expected that since a naturaldeficiency in iodine in the soil and water wouldprobably be greater at higher levels, a definite increasein the incidence of goitre would be found in theseupper regions. The whole expedition occupied threemonths and had to be done on foot, and so frequentlywas a village hut the only accommodation at thevarious stopping places that there was ample oppor-tunity for observing the sanitary conditions of thepopulation at close quarters. The total number ofcases examined for goitre amounted to 2465, whichincluded inhabitants of 37 villages. The incidenceof goitre amounted to 10 per cent. among the malesand 23 per cent. among the females examined. Fromthe geographical point of view the results were

interesting. At lower levels along the course of theriver goitre was found to be prevalent, while it wasabsent at the highest villages ; but the whole distribu-tion was so irregular that it became necessary tosearch for some other factor in its causation. It wasdiscovered that in certain villages pollution of the

1 Proc. Royal Soc. Trop. Med., xviii., No. 8, 395.

water by excreta occurred to a much higher degreethan in others, and this marked pollution was asso-ciated with the highest goitre rates. Prof. Blacklockpoints out that mere deficiency of iodine in an other-wise unimpeachable water-supply does, no doubt,account for the occurrence of endemic goitre in certainareas, as in many parts of America, but at the sametime he emphasises the fact that such iodine deficiencymay, in other countries, be artificially produced bycontamination. He suggests that the faeces whichpollute the water-supply in the district he was

investigating may fix or deviate the iodine in someway, or, alternatively, that " faecal substances or

substances formed from faeces by bacteria in thewater before ingestion are absorbed and alter themetabolism in such a way as to increase the iodinerequirement," thus producing a relative deficiencyof this element. As Sir George Newman said in hisrecent survey of public health, the question of causa-tion is at least a two-sided one, deficiency of iodineintake on the one hand and an abnormal conditionpreventing its proper assimilation on the other.Although these and similar hypotheses have been

suggested by many workers, it must be borne in mindthere is little experimental proof to base conclusionsupon. It has been shown that inorganic iodine isreadily absorbed into the circulation, and is stored inthe thyroid, mainly in the form of organic iodinecompounds. However attractive these theories maybe, they must be regarded with suspicion until definitechemical and experimental evidence is adduced tosupport them. It is important that a careful studyof all suspected waters with a regard to their iodinecontent be made before any conclusions can bereached on this question. This has already beenextensively investigated in America, but it alsorequires to be done in regions where the pollutionfactor is more prevalent. Dolbey and Omar haveshown2 that in certain of the Nile villages wherepollution is present to a marked degree goitre isprevalent, although the iodine content of Nile wateris higher than that of the metropolitan water-supplyof London. It would appear that in Sierra Leonealso the prevention of endemic goitre is more closelybound up with sanitation than with the administrationof iodine.The investigation of the distribution of endemic

goitre in America is gradually being extended to covermost of the country, and a report3 has been publishedon the occurrence of this disease in Colorado. Varioussurveys have been made from time to time in thisState in approximately 57 localities, and on the wholethe prevalence of goitre appeared to be greater inthe western part of the State, where drinking wateris obtained from mountain streams and not from wellsas in the eastern districts. No information as to theiodine content of the different waters is, however,available, and in the report it is stated that " it isproblematical whether the source of the drinkingwater has any considerable bearing upon the occur-rence of endemic goitre in Colorado, except in so faras the water may be deficient in iodine." The com-bined results of four different surveys in Colorado,in which nearly 4000 boys and over 13,000 girls wereexamined, showed that 25-6 per cent. of the boysand 30’i per cent. of the girls had some degree ofthyroid enlargement. These results show a muchsmaller difference between the prevalence rates forboys and girls than in other parts of the country.For the moment the usual methods of iodine pro-phylaxis and treatment are to be instituted, but amore intensive survey of the State is suggested todiscover the nature of the iodine deficiencies indifferent localities and their relation to the prevalenceof goitre. All such information is of the greatestimportance if the problem of the aetiology of endemicgoitre is to be solved in as satisfactory a manneras the problem of its prevention appears to havebeen.

2 Dolbey and Omar : THE LANCET, 1921, ii., 649.3 Public Health Reports, Washington, Jan. 2nd, 1925, No. 1,

vol. xl.