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toxic or infective group are catarrhal jaundice,spirochsetosis ha3morrhagica. acute necrosis of theliver. Various protozoal and bacterial infectionsmay give rise to this type of jaundice, also chroniccardiac disease with back pressure, and some formsof poisoning or toxemias, such as those associatedwith pregnancy. Considering the group as a wholethere is less bilirubinaemia than in the obstructivegroup, and grave liver derangement may coexist withslight jaundice. Bile-salts may be absent from theblood even when jaundice is well marked (the so-called" dissociated jaundice "). Some bile generally reachesthe bowel so that the stools are not clay-coloured,but they are often offensive owing to the absence ofbile-acids.

Points in the differential diagnosis of the variousmembers of the group are as follows :-

In Spirochmtosis haemorrhagica (Weil’s disease) there is apolymorphonuclear leucocytosis and later a secondaryanaemia ; in the early stages the Leptospira icterohcemorrhagiceis present in the blood and later in the urine. In acuteyellow atrophy the blood shows delayed coagulation, a

moderate leucocytosis, and diminished cholesterol ; thecolon bacillus is sometimes present on culture. In catarrhal

Ijaundice there is a secondary anaemia with leucopenia.

REACTION OF DELAYED TYPE.

When the van den Bergh reaction is of the delayedtype, or gives no direct response at all, heemolyticjaundice may be suspected. In this type of icterusthe underlying factor is an excessive bilirubinaemiadue to the production of more bile-pigment than evena healthy liver can deal with. This excess may be dueto : (1) increased destructive agents ; or (2) increasedfragility of the blood cells.When it is due to increased destructive agents

(so-called secondary cases) the cause of the haemolysisis more or less known. Blood transfusion withunsuitable donors, streptococcal infections, parasiticinfections, poisoning from snake-bite, Addison’s

ansemia, or blackwater fever may induce haemolyticjaundice of this kind. On the other hand, thehaemolysis may be due to increased fragility of theblood cells-for example in congenital, hereditary, orfamilial acholuric jaundice or in acquired acholuricjaundice (often after some infection). How far thesetwo types of acholuric jaundice are separate entitiesis a debatable points

Taking the group as a whole heamolytic jaundiceis a " dissociated jaundice," since the bile-salts arenot retained in the blood. The tissue reactionmay be slight compared with the amount ofbilirubinsemia and, finally, the kidney threshold forbilirubin is decidedly higher than in the obstructivetype. The icterus is inconstant and varies greatly,there is some degree of secondary anaemia, andthe spleen is often enlarged. With regard tospecial members of the group, the blood picture isthat of the primary disease in those of the secondarytype. In acholuric jaundice the presence of reticulatedred cells (only shown by vital staining) and the unduefragility of the red corpuscles is a constant feature.If normal red corpuscles are placed in varyingdilutions of hypotonic saline, haemolysis starts atabout 0-50 per cent., is well marked at 0-45 per cent.,and is, as a rule, completed at 0-35 per cent. Inacholuric jaundice haemolysis starts at about 0-70 percent. and is often completed at 0-50 per cent.

FOUCHET’S TEST AND THE ICTERIC INDEX.

The van den Bergh reaction is quantitative andqualitative. There are two other quantitative testsfor bilirubinaemia—Fouchet’s test and the ictericindex. The former, which is largely used in France,is not so sensitive as the van den Bergh test, but issaid to give a positive result in a dilution of 1-60,000of bilirubin. In estimating the icteric index theyellowness of the serum is compared against a

known standard. The normal lies between 4-6, overtjaundice is present when the index is above 15, andlatent jaundice lies between 6-16. The index israised in uncomplicated cases of haemolytic anaemias,

in chronic sepsis especially of the biliary tract, inpneumonia, and in cardiac insufficiency. A source oferror is coloration due to pigments from ingestedfood so that the blood should be taken from thefasting patient. Since the test can be done with theblood available from a finger prick it has certainadvantages, but if any doubt exists it should bechecked by the van den Bergh reaction. In a case ofovert jaundice it presents an easy method of notingthe progress of the bilirubinaemia.

I CONCLUSION.

In addition to their value as a diagnostic agent injaundice, the van den Bergh reaction and to a lessextent the icteric index are of use in checking treat-ment and in prognosis. A routine examination ofthe blood shows the progress of the bilirubina3miabefore any change is visible in the skin. The detectionof a latent jaundice may be of great value, particu-larly in cases undergoing treatment with arsenicalcompounds.

JOHN H. ANDERSON, C.M.G., C.B.E., M.D. Melb.,

I Physician, Ruthin Castle.JOHN H. ANDERSON, C.M.G., C.B.E., M.D. Melb.,

Physician, Ruthin Castle.

Special Articles.RADIOLOGICAL TREATMENT OF

CANCER.

RECOMMENDATIONS ON STANDARDS AND TECHNIQUE.

A FORTNIGHT agol we drew attention to the recentwork of the Cancer Commission of the League ofNations in connexion with the radiological treatmentof malignant disease. The Commission felt that thegreat publicity now being given to radiotherapy, andthe elaborate and costly apparatus and arrangementsrequired for its practice, demanded a collection ofinternational experience. They therefore appointeda subcommission consisting of Prof. C. Regaud(Chairman), Sir George Buchanan (Chairman of theCancer Commission, ex-officio), Mr. Comyns Berkeley(London), Prof. A. Döderlein (Munich), Dr. J.Heyman (Stockholm), Prof. W. Lahm (Chemnitz),Prof. E. Pestalozza (Rome), and Prof. A. H. M. J.van Rooy (Amsterdam). Dr. Janet Lane-Clayponwas appointed special investigator, and the sub-commission was charged to report upon: (1) theradiotherapeutic methods which can be regarded as ofestablished utility for the treatment of cancer of thecervix ; (2) the possibility of presenting radio-therapeutic results statistically ; and (3) the principleswhich should be accepted to ensure most effectiveorganisation of radiotherapeutic treatment of uterinecancer and to avoid dangers as far as possible.The Commission met three times during the year

1928-29, and appointed Prof. F. Voltz, Dr. A.

Lacassagne, and Dr. Heyman, together with Dr. E.Tomanek (the Secretary of the Commission), to pre-pare special reports from the clinics of Munich, Paris,and Stockholm. These reports are published in thevolume just issued.2 As we have already noted, thework entrusted to Dr. Lane-Claypon was a statisticalstudy of the results supplied by the three institutes.She spent much time and labour on an attempt todraw conclusions as to the relative value of differentmethods of treatment, but she found that the threeclinics had not followed the same principles in classi-fying the different forms of utero-vaginal carcinoma.that they had not adopted the same grouping ofdifferent stages, and that the methods in use over a

: number of years had varied even in the same clinic.

1 THE LANCET, August 3rd, p. 235.2 League of Nation’s Publications: Health. 1929. III., 5.

Pp. 82. Obtainable from Constable and Co., Ltd., London, W.C.

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The Commission concluded that no fair correlationof the work of different clinics could be made withthe material at present available ; its recommendationsare designed to ensure a happier result from futureinquiries.Rules for Obtaining Full and Comparable Statistics.The three institutions submitting reports have

agreed to accept a model case-record drawn up by thesubcommission (see Figure) and to follow certain ruleslaid down. The Commission hopes that all radio-logical institutes will adopt this scheme.Only cases microscopically diagnosed should be

included ; adenoma, pre-cancerous conditions, sar-

carcinoma of the body extending to the cervix, thedistinction is of theoretical rather than of practicalimportance. These growths behave like, and shouldbe classed as, growths of the body unless themicroscopical picture forbids.The stages of anatomical extent are given as follows.

Stage I.-The growth is strictly limited to the cervix uteri.Uterus mobile.

Stage II.-Lesion spreading into one or more fornices withor without infiltration of the parametrium adjacent to theuterus, the uterus retaining some degree of mobility.

Stage III.-(a) Nodular infiltration of the parametria onone or both sides extending to the wall of the pelvis, withlimited mobility of the uterus or massive infiltration of one

I I I I I I I

Model case-record card. The front of the card also leaves room for details of accessory treatment, whilst the back is devoted toresults. The elaborate particulars of treatment to be entered under the various headings are set out at length in the report.

coma, and other non-carcinomatous growths must bedifferentiated. Growths are to be divided into vaginal,cervical, and corporal as before. A growth should beclassed as vaginal only when the cervix is intact, andthere is no ground for supposing that it is anythingbut a primary growth in the vagina. Cases in whicha small cervical lesion has disappeared under radio-logical treatment, while the main part of the tumouris still in the vagina, are to be classed as vaginal.When the cervix has not been examined at the begin-ning of treatment, diagnosis must be postponed untilthe situation has been clarified. If, even after radio-logical treatment, the cervix cannot be examined,the growth should be classed as vaginal if rectalexamination shows the cervix and parametria to beclinically free from growth. Carcinoma of the bodyshould be diagnosed only when the cervix is healthy.In the absence of sufficient indications for determin-ing the point of origin, the microscopical report shouldprovide a reasonably safe basis for diagnosis-e.g.,pure squamous-celled carcinoma and adeno-carcinomawith mucous secretion are both cervical types ofgrowth. If the cavity of the uterus is enlarged andclinical examination does not differentiate betweenendocervical carcinoma extending to the body and

parametrium with fixation of the uterus. (b) More or lesssuperficial infiltration of a large part of the vagina, with amobile uterus. (c) Isolated metastases in the pelvic glands,with a relatively small primary growth. (d) Isolatedmetastases in the lower part of the vagina. Generallyspeaking, all cases not falling into Stages II. or IV. to beplaced under Stage III.

Stage IV.-(a) Cases with massive infiltration of bothparametria extending to the walls of the pelvis. (b) Carci-noma involving the bladder or rectum. (c) The wholevagina infiltrated (rigid vaginal passage), or one vaginalwall infiltrated along its whole length with fixation of theprimary growth. (d) Remote metastases.For statistical purposes, only cases of cervical

carcinoma which have been under observation for atleast five years should be included, grouped into (a)those treated in the first instance by radiotherapy ;(b) post-operative recurrences and cases treated bypalliative operation; (c) those treated by post-operative prophylactic irradiation. Records shouldalso include the total number of patients seekingtreatment for cervical carcinoma and the numbersaccepted and rejected together with the reasons forrejection, specifying whether it was the general con-dition or complications, lack of accommodation,refusal to undergo treatment or failure to keep

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appointment, radiological treatment elsewhere, or anyother reason. Clinical diagnosis should be confirmedmicroscopically, and the number of cases in each ofthe different-stages should be stated among all thoseaccepted for treatment and among those with no signsof the disease five or more years after treatment.Recurrences after total hysterectomy should beclassified as local recurrence in the scar, or as distantrecurrence. In setting out the results of the treatment,no deduction should be made for patients whosetreatment was interrupted or who died or were lostsight of during the first five years after treatment.Figures should be based on the number of cases

treated and not on the number examined.Detailed instructions are given in the report for

supplying data relating to technique.’

Reports from Stockholm, Paris, and Munich.Dr. J. Heyman provides a report of the work

carried out by Prof. G. Forssell at Radiumhemmet,which was founded in 1910. Forssell graduallyarrived at a technique which had as its main principlesa small number (three at most) of applications ofrelatively large quantities (100-120 mg. of radiumelement) with heavy filtration (equivalent to 3 mm.of lead), concentrated into a period of three or fourweeks with an interval of one week between the firsttwo and of three weeks between the last two treat-ments, and a total irradiation of about sixty hours.In 1920 leading gynaecologists of Sweden agreed tocease operating for cancer of the -cervix in order togive radiotherapy a chance to show its worth. Sosuccessful was it that few radical operations forcervical carcinoma have been performed since. Inthe last ten years the number of operable cases

treated by radium has increased tenfold, while thenumber of inoperable cases so treated has trebled.Dr. Heyman describes in detail the organisation of theclinic, the applicators and the various types of tech-nique. His five-year result in all cases of cancer of thecervix treated between 1914 and 1923 is 23-1 per cent.alive and free from recurrence. Of the operable casestreated during the same period 43-6 per cent. arealive and well, and of inoperable and border-linecases 16 per cent.

Since 1913 no case of uterine cancer has beentreated by operation at the University GynaecologicalClinic at Munich. The principle of radiological treat-ment involves several treatments at intervals of eightweeks. On the first day after admission, deep therapyis applied to the pituitary body with the object ofsensitising the cancer. On the following day, X raysare applied back and front over a large field. If thegeneral condition of the patient demands a split dose,the irradiation is given on two or three consecutivedays. The tubes used are run at 200 kilovolts and2-5 milliamperes, and the rays are filtered through1 mm. of copper. The pituitary areas receive 30 percent., and the uterine areas 90 per cent., of anerythema dose. On the day after X ray treatmentthe patient rests; the next day is occupied by anynecessary surgical measures-biopsy, fulguration,cauterisation, or cataphoresis-and after anotherday’s rest radio-active substances are applied. Theprimary filtration is 0-2 mm. of silver ; 1 mm. of brassand a layer of thin rubber are added for radio-activesubstances placed within the womb. The maximumdose is 1400 mg.-hours. Usually 55 mg. radiumelement are left in for 24 hours. After another day’srest, the patient leaves hospital on the ninth day.Eight weeks later the patient returns for six days,and the treatment is repeated with the omission ofthe pituitary irradiation. If a third treatment isconsidered necessary, the second scheme is repeatedeight weeks later. Of the operable cases treatedbetween 1913 and 1923, 50-2 per cent. were cured ;of the border-line cases, 28-3 per cent. ; and of theinoperable cases, 10-7 per cent. The crude survivalrate for the whole series is 18-2 per cent. Analysis ofthe figures shows that the results are much better ifX rays are combined with radio-active substances :that the best results are obtained after the thirty-fifth

year of life ; that the end of the third year aftertreatment shows well enough what the later resultsare going to be ; and that the poorer classes of thecommunity have a much lower survival rate than thewell-to-do. Prof. Voltz lays stress on the importanceof systematic treatment and the accurate completionof the plan when once determined. He also sees thepossibility of improved results from better after-careof poor- patients. He describes the organisation ofhis clinic, and illustrates his apparatus with someexcellent photographs.

Radio-active bodies were first used in Paris forcancer in 1919. Dr. Lacassagne surveys the historyof the work, the present organisation of the service,and the conditions which affect the efficacy of radio-therapy. Radium is applied within the cavity andalso at a distance, and most cases are treated by thecombined method. For intra-uterine application,three tubes are placed end to end in a rubber sheath1’5 mm. thick ; the primary filtration is 1 mm. ofiridio-platinum. Two of the tubes contain 13-33 mg.and one contains 6-66 mg. Three similar tubes areplaced in the vagina, the 13-33 mg. tubes lying in thelateral fornices. The primary filtration is 1-5 mm. ofplatinum and the secondary is a cork holder 0-5 cm.thick. Distant radium is administered by means of acup-shaped container made of lead 6 mm. thick con-taining 4 g. of radium, placed at a distance of 10 cm.and irradiating through a rectangular aperture of150 sq. cm. The dose is a 10-hour exposure through1 mm. of platinum, and is divided over 25 days andeight fields. It usually causes dry desquamation andmarked pigmentation.X rays are also given in intensive doses twice daily

for an hour or more for 15 to 25 days. The totaldistance is 60 to 80 cm., the tension 180 to 200, theintensity 4 to 5 ma., and the filter 1 to 2 mm. of zincor copper. The percentage of cures between 1919 and1923 is 20.

The Conditions for an Effective Campaign againstCancer of the Uterus.

Prof. Regaud supplies a chapter summarising thegeneral conclusions of the subcommission, which arebelieved to be truly international in their application.He stresses the supreme importance of early diagnosis,and the value of public propaganda and of periodicalexamination of all women who have borne a child.A centre for gynaecological diagnosis need not neces-sarily be directed by specialists, but it must have, orbe in touch with, a department of micropathology.Experience shows that a few good laboratories arebetter than a large number, scattered in small towns;liaison can be satisfactorily established through thepost. While consultation centres for diagnosis shouldbe numerous and easily accessible, treatment centresshould be few, and it is important that the diagnosticclinic should not become a radium institute.

" For those who have not reflected on the amount ofknowledge and experience lying at the back of apparentlysimple actions," writes Prof. Regaud, " the manipulationof radium and rontgenotherapy seems so easy that manyare tempted to adopt the treatment in their own practicewithout undergoing the necessary preparation for the work.Individual surgeons and gynaecologists, in private practiceor running small clinics, constitute themselves the radio-therapeutists of their patients. Some radiologists, morefamiliar with radiodiagnosis than with cancer and gynee-cology, undertake the treatment of uterine cancer."He points out that no such assumption of operative

ability could be made, and foreshadows the greatdifficulty in proper organisation of radiation treat-ment which will be caused by this attitude on thepart of practitioners, and the public assent given toit through ignorance. He deprecates the supply ofradium-which may be insufficient in quantity or

contained in out-of-date apparatus-to small localhospitals, and the hire of radium by practitioners whoorder it as they would a drug. The abuse of X raysis, he thinks, less harmful than the abuse of radium.

" The mischief of bad rontgenotherapy lies not so muchin that it deprives patients of treatment by other methodswhich might cure them, as that it deprives internal radium

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therapy of a valuable ally, which might help to increaseconsiderably the number of patients capable of being cured.’’The subcommission recommend the concentration

of treatment of cancer of the uterus in a small numberof perfectly equipped institutions. It desires todraw the attention of the various authorities con-cerned to the disastrous results which might ariseeither by encouraging, or by allowing without anycontrol, the widespread use of radiotherapy for thetreatment of cancer, notably cancer of the uterus, inthe hospitals or institutions which are maintained bypublic authorities. Without being able to express adogmatic opinion on methods of technique, aboutwhich specialists still disagree, the Commission wishesto warn medical men and the public against the useof insufficient quantities of radium-the few needlesor one or two tubes with which practitioners andsmall clinics sometimes attempt to treat patients.It insists on the difficulty of providing an effectiveand harmless deep pelvic irradiation, on the necessarystrength of machines and tubes, on the great labournecessary for efficacious treatment, and on theobligation resting on doctors not to allow radio-therapy to pass into unskilled hands.

MEDICINE AND THE LAW.

Dangerous Drugs Regulations : Keepinga Register.

THERE still seems to be some misunderstandingabout the obligation to keep a register under- theDangerous Drugs Regulations. A medical practitionerwas fined 10 guineas including costs at Manchesteron August 7th for failing to keep a register and toenter therein the true particulars of the drugs namedin the summons. The defendant had undertakenwork at Hull last April, as locum tenent during theabsence of a local practitioner on holiday. He hadordered tincture of opium and liquid morphinehydrochloride from a local chemist, but made noentry of these purchases though there were 15 entriesin the day-book of drugs used. On the defendant’sbehalf there was produced in court a small handbookcontaining particulars of the purchases, and it wasapparently common ground that, if these particularshad been entered in the dangerous drugs register,they would have complied with the regulations. ’

Defendant said he considered he had no other bookto keep because he had never dispensed drugs abovethe strength laid down by the regulations. TheHull stipendiary magistrate, in imposing a fine asalready stated, held that the statute required thekeeping of a proper record of where the drugs camefrom and what became of them.

Section 7 of the Act of 1920 expressly authorisesthe Home Office to make regulations requiring personsengaged in the manufacture, sale, or distribution ofdrugs within Part III. of the Act to keep such booksas may be prescribed ; it would thus hardly be possibleto argue that the regulations were ultra vires. Theconsolidated regulations, issued afresh last December,contain specific provisions as to the form of the registerand the time and method of making entries therein ;but there is a special exemption for any duly qualifiedmedical practitioner who " enters in a day-bookparticulars of every drug or preparation supplied byhim to any person, together with the name and addressof that person and the date of supply, and enters ina separate book kept for the purpose of this regulationa proper reference to each entry in the day-bookwhich relates to the supply of any drug or

preparation." "In the recent proceedings at Hull, instituted by

the Director of Public Prosecutions, the prosecutingsolicitor mentioned that when the resident practitionerreturned from his holiday he found nothing remainingin the surgery of various quantities of tincture ofopium, liquid morphine, and morphine tablets whichhad been left there at his departure. From the

, necessarily abbreviated report of the case it is not, clear how far this statement was relevant to thesummons, but apparently there was no sufficientrecord of the disposal of these drugs. Practitioners,when making holiday arrangements with a locumtenent, will bear in mind the desirability of takingsteps to avoid the chance of misunderstanding in

such circumstances.

Falsification of Prescription by Addict.The Dangerous Drugs Acts and similar legislation

cannot prevent every danger of abuse of drugs.Poisonous disinfectants are readily purchasable bywould-be suicides. Last month a mother (found bythe jury to have been " guilty but insane ") poisonedher child by administering two dessertspoonfuls of aliquid consisting of a pint of water in which she haddissolved 300 aspirin tablets. Nevertheless, the Acts,so far as any legislation can, make things more difficultfor those who would make improper use of drugs, andespecially for the drug addict. In another case lastmonth the evidence disclosed a long story of attemptsto obtain drugs illegally ; the case ended in prosecution’and imprisonment, and the defendant will have achance in prison of curing himself of drug addictionagainst which, it was said, he had made a good fight.The accused man, Leslie James Stonelake, aged 34,charged at Marlborough-street on July 14th, wasstated to have been in April last an assistant engineerin a ship sailing from Australia to London and tohave been treated on the voyage by the ship’s doctorfor asthma and drug addiction. The doctor succeededin reducing Stonelake’s drug consumption from 15grains to half a grain a day. When the ship reachedLondon at the end of the month, the doctor gave hima prescription for one tablet of hyoscine and onetablet of morphine sulphate ; the total amount inthe tablets was half a grain, and the prescription wasmarked " Not to be repeated." Stonelake presentedthe prescription to a Piccadilly chemist on May 6th,having altered " 1 " into " " and " 1 " in each caseinto " 12." The chemist, believing the prescriptionto be genuine, furnished the drugs. On April 27th,28th, and 29th he had presented prescriptions fromanother doctor who authorised a " repeat " and hadobtained morphine thereby. On April 30th hepresented a further prescription from yet anotherdoctor and obtained 24 tablets ; on May llth hepresented yet another prescription from a fresh doctorand obtained 24 tablets again. These large suppliesat last aroused the chemist’s suspicions, and theprosecution followed. A member of the staff of theMarylebone Hospital said the accused came to himfrom a nursing home which he had left for want ofmoney to continue the treatment there ; he wastreated with daily reduced doses till June 19th whenhe ceased to take morphine ; he had taken none since.The witness said the defendant had put up a goodfight against the drug and could be cured ; he hadlittle of the physical or mental degeneration whichusually accompanied such cases.. The magistrate,Mr. Mead, sentenced the accused to three months’imprisonment in the second division on the charge ofbeing in unauthorised possession of 12 grains ofmorphine sulphate (under the altered prescription)and dismissed the charge of procuring the drug onMay 6th. The accused had, of course, committedseveral offences ; there was also the element of forgery,but with this the magistrate could not himself deal ;it was clearly unnecessary to commit the man fortrial. The case shows the administration of the lawin the best interests of the accused.

Medical Titles.

So far as it is a personal matter, Lieut.-ColonelKynaston is to be congratulated on the success ofhis recent appeal to the London Sessions. The upshotof the decision is that he has committed no offenceagainst the Medical Act in continuing to use the title," M.R.C.S. (Eng.)," though the Royal College hastaken that title away. Apart from the personal aspect