1338

cost of permanent and perhaps painful hemiplegiais a prospect that will not commend itself to manypatients, even though they are already paralysedwhen they seek treatment. The hemiplegia produced

. by an invasive tumour of the hemisphere is probablymore often due to pressure on the pyramidal tractthan to actual destruction of its fibres, and it thereforeseems likely that some form of radiation will ulti-mately provide the best means of attacking deeplyseated gliomas. ____

JAUNDICE DUE TO MOVABLE KIDNEY.

IT has for long been known that jaundice maysometimes accompany movable kidney, but theexact relationship between the two conditions hasbeen a matter of dispute. The kidney is intimatelyin contact with the duodenum, and if in the courseof its descent it acts as a drag on this organ, jaundicemay actually be due to mechanical obstruction ofthe common bile-duct. A. J. Schole reports a casehistory which is of interest in this connexion. A mansustained an injury to the back which necessitatedan operation to suture the lacerated and displacedkidney and to restore it to its proper position. Heremained ’well for over 20 years, when another injurycaused an attack of pain and jaundice and, in fact,initiated a train of symptoms referable to the gall-bladder. These symptoms had already continuedfor 18 months when the patient came under observa-tion. At its height the jaundice was so intense thatno bile at all flowed into the intestine. A radiogramrevealed a collection of stones in the right lumbararea. These, together with the pyuria, led to a

renal investigation, when a right pyonephrosis wasfound to be present. After drainage of this lesionthrough a ureteric catheter the jaundice disappeared,but it returned immediately the catheter was

removed; the catheter was replaced and againremoved, with the result that the jaundice againdisappeared and returned. Nephrectomy perma-nently cured the gall-bladder symptoms. Dr. Scholebelieves that drainage of the pyonephrosis allowedsubsidence of the perirenal infection and thusdiminished the pressure upon the common bile-duct.In the literature on the subject there are to be founda certain number of cases where fixation of a droppedkidney has cured attacks of jaundice, but the asso-ciation is curiously rare considering the anatomicalrelations of the kidney to the duodenum close to theentrance of the common bile-duct. This may bedue to the fact that unless an infection of the movablekidney takes place, leading to some perinephritis,the organ slips rather easily up and down behindthe perineum without exerting any pull upon theduodenum itself.

____

THE ROYAL COLLEGE OF SURGEONS

MUSEUM.

IN his annual report on the museum of the RoyalCollege of Surgeons of England the Conservatorrefers to the continued increase in the size of thecollection and the problem of providing space forits accommodation. He anticipates, as a possible Inecessity, some limitation in the scope of the museum, isince enlargement of the building is precluded owingto the limited financial resources of the College.A similar measure was resorted to on the foundationof the Natural History Museum, South Kensington,when the subjects of zoology and comparativeanatomy were excluded from the aims of the College’museum. The report of the curator, Mr. Cecil

’

Beadles, on the present pathological collection givesevidence of a strenuous year’s work ; in addition tothe work of recataloguing the collection of specialpathology, which appears to have made fair progress,no less than 850 specimens, including the additions,have been remounted during the year. Of the newspecimens, 150 in number, the curator refers to manyof great interest, among which may be mentioned a

1 Trans. Amer. Assoc. Genito-urinary Surgeons, 1927, xx., 223.

, fine series from a case of Recklinghausen’s disease. showing widespread involvement of the cranial, spinal,and sympathetic nerves ; and a tibia from a second

. case showing the rare involvement of the periosteum

. in the hyperplastic process, with associated deformity, of the bone. Other specimens of interest are a femoralaneurysm of tuberculous origin, a chondroma of thelung arising from the bronchial cartilages, and alymphadenomatous enlargement of the thymus glandforming a tumour some six inches in diameter, whichwas removed by operation from the anterior medias-tinum. Mention should also be made of a series ofspecimens from cases of pernicious anaemia ; thesewere presented by Dr. William Hunter and illustratethe changes in the tongue, stomach, and intestineswhich, as is well known, he regards as characteristicof the disease. In the physiological department veryinteresting specimens are added by its curator, Mr.R. H. Burne, F.R.S., showing injections of the afferentvessels of the lymphatic circulation in fishes, thediscovery of which throws light on the nature andevolution of the lymphatic system generally. Theadditions to the museum will be on view in Room 1from July 5th, the date of election of new members to -

the Council, until July 28th. A passing referencemerely can be made to the active work in progress inthe osteological, odontological, and historical sections,detailed accounts of which have appeared in previousreports. A valuable series of casts illustrating thesurgical methods of treatment of cleft palate have beenpresented by Sir James Berry through Sir FrankColyer, and the museum now possesses an exact castof the Taungs skull, the gift of Prof. R. A. Dart.A task of some magnitude has devolved on the museumin connexion with the Strangeways collection ofspecimens of chronic arthritis, several hundreds ofwhich have been accepted from the trustees of thecollection. Dr. Strangeways never published theresults of his investigations and his manuscripts andspecimens have now been placed at the disposal ofMr. Lawford Knaggs, who has undertaken theirexamination and revision. A kindly reference ismade in the report to the serious loss sustained by themuseum in the death of Mr. Alban Doran; hiserudition and scholarship were devoted to themuseum during many years, and they have a lastingmemorial in the descriptive catalogue of the Collectionof Surgical Instruments, a work of a kind that veryfew have the learning and ability to undertake.

THE ACNE OF ADOLESCENCE.FACED with a stubborn case of acne it is not enough

to encourage a hope that the affliction will have passedby the end of the patient’s third decade of life. Theanticipation is not always fulfilled, and in the mean-time the victim of this complaint is suffering under adisability that may prove a serious handicap. Con-sidered in the light of its effect on careers and self-confidence, acne is often far from trivial, and everycase demands a serious attempt to use the meansof cure at our disposal. These were ably summarisednot long ago bv Dr. D. E. H. Cleveland’! He does

not pin his faith to this or that particular remedy,for the very good reason that there is no one causefor the condition to be treated. The setiologicalcomponents include both physiological and morbidtendencies, not forgetting an inherited predispositionof the skin, which may be either greasy (seborrhoeic)or dry. Though the presence of septic foci in teethand tonsils, constipation or chlorosis are doubtlessaggravating factors they are in no case causal, andvery few cures can be registered by their eliminationalone. These and many other subjects, such as

exercise, diet, habits, and fresh air, are rationallyconsidered by Dr. Cleveland, who passes on to discussin their relative importance the various methodsof treatment available. He condemns the use ofcosmetic creams and excess of tobacco, carbohydrates,and cooked fats. He does not favour hot baths

1 Canad. Med. Assoc. Jour., 1928, xviii., 261.

1339

unless they are followed by a cold shower, andrecommends that the patient should be made toshampoo the scalp every week. After a short listof simple and well-tried local applications recom-mended by Darier, Sabouraud, Duhring, and Ormsby,he concludes by devoting only a small space to theindications for ultra-violet and X ray treatment.In this respect he will have the support and com-mendation of most expert opinion. There is far toomuch resort to methods based on the fashion of themoment, and patients will often demand a particularkind of treatment because it was used with successin the case of a friend, or because they have readabout it in the lay press. It is interesting to comparethe reserved statements on treatment with X raysin this paper with those made by Dr. J. L. Webb.2The latter evidently has no qualms and appears touse the method in every case after removal of eachindividual comedone, the incision of pustules, andintradermal use of a vaccine. Whilst mentioningthe cost of the treatment he makes no mention ofits dangers, and if, as is stated, " three-quarters ofan erythema dose, unfiltered, are given each week,"there is reason to fear that these are not very remote.Dermatologists agree that X rays are a valuableadjunct to treatment in severe and intractable acne,but most of them would condemn its use as a routine,not only because it may do permanent damage toindividuals, but because one or two disasters wouldbring the method into disrepute. Assertions likethose made in this paper are not infrequently followedliterally by persons whose knowledge of the subjecthas been gained solely from text-books or by a shortattendance at some clinic. Few of them have had athorough training or an opportunity of seeing theappalling late results of X ray burns of the face-a harvest which we are now beginning to reapfrom the earlier treatment of lupus vulgaris andhypertrichosis. ____

INFECTIOUS DISEASE IN SCHOOLS.FORTY-FOUR years ago, when the Medical Officers

of Schools Association was founded, questions weresent to every important school in this country toascertain what precautions were taken to guardagainst infectious diseases. At this time many ofthe leading institutions maintained a policy ofsecrecy about the health and sickness of their pupils,a fact which had hindered THE LANCET SanitaryCommission on Public Schools in its inquiry a fewyears before. The attitude of others was typifiedby the proud advertisement that no doctor hadvisited them for several years, and it was not surprisingthat the Association’s questionaire revealed differ-ences in theory as well as laxity in practice. Theresult was that the Association issued a Code ofRules3 for the Prevention of Communicable Diseasesin Schools, which, in its numerous editions, hasproved of great value not only to school authoritiesbut also to parents and guardians. At the time of itsappearance we commended these rules as practicaland plain, and the same words apply to the ninthedition which has just been published. It contains,as before, chapters on general hygiene, the infirmary,the medical examination of scholars, general pre-cautions against the introduction and spread ofdisease, and measures to be adopted when infectionshave broken out; but its usefulness has been greatlyextended not only by expansion of these sections butby the addition of a " definition of terms " basedon data published by the American Public HealthAssociation in 1926. This includes a list of thecommoner infections, with brief notes on the infectious Iagent, the source of infection, the mode of trans-mission, the incubation period, the period of com- J

municability, the methods of control, and the time Jof return to school. It forms a concise and dogmaticstatement of our knowledge of infectious disease from 1

2 Clin. Med. and Surg., 1928, xxxv., 180.3 Code of Rules for the Prevention of Communicable Diseases

in Schools. Ninth edition. London J. and A. Churchill.1928. Pp. 74. 2s. 6d.

the point of view of schools, and it will be acceptableto every practitioner who wishes to have the factsavailable for ready reference. Two short appen-dices describe the modern methods of preventingdiphtheria and scarlet fever, and the treatment oftinea, whilst a third, also new, ’briefly discusses thepolicy of excluding infection from schools, in the lightof recent work on " herd immunity." Anotherappendix summarises the general theory of disin-fection, little understood outside the profession.

THE WATER OF THE METROPOLIS.

THE result of chemical and bacteriological exam-. inations of the London waters covering the yearending Jan. 1st, 1928, has just been issued inthe form of Sir Alexander Houston’s twenty-secondannual report as Director of Water Examination tothe Metropolitan Water Board. The report containsinteresting accounts of the chlorination of Thamesand New River water, of which we have now 12years’ experience, an experience so satisfactory asto have led to the discontinuance of protests on theground of doping. Evidence is here set out to showthat this treatment of potable waters not only providesa valuable measure of security, but has the greatfinancial advantage of producing a better water thancan be achieved by prolonged storage, although forother considerations additional storage accommo-

dation in the London areas may be necessary. Neitherthe Thames nor the Lee, which, excluding the Kentishwells, form the main source of the water-supply of" Water London," can be considered ideal for thepurpose which they serve, but though the pre-filtration fluid may be considered unsatisfactorycompared to a virgin mountain stream, yet thewaters, as judged by the B. coli test, can be, andare, improved from 100 to 1000 times by judiciousand unceasing treatment. This is certainly a matterfor satisfaction, but improvement in quality conse-quent on storage should not be used as an argumentfor relaxation in purification, as this report shows.Among the varied contents of a long and

closely packed document some interesting notes onthe meteorological circumstances of the year showhow a period of persistent wet affects the water-supplyof an immense urban community. We are thusreminded that last year February was dreadfullywet ; that March and April were wet; that, thoughMay was a rather dry month, June, July, and Augustwere wet and cold; and that September and Decemberwere exceptionally wet months. In November therainfall was about normal, and in October alone itwas really below normal. These circumstancesformed a trying year for all responsible for water-works. First, the water-supply was brown in colourover long periods, and it was hard for consumersnot to eye it with suspicion. Further, water mayactually deteriorate in quality during floods if accom-panied by seriously cold weather, as frost interfereswith the filtration processes. And this occurs

xactly when the rate of filtration has to be increasedto meet an augmented demand for water, arisingto an appreciable extent from the wily extravagance)f householders, who leave taps running in order toprotect themselves against the bursting pipes.Last year it may be remembered that, as a pre-

iminary to the scientific description of the water-upply of London and the chemical and bacteriologicalables ’ reinforcing the information, Sir Alexanderfouston described the Kent wells, and in so doinguggested that water-supplies should not be divorcedrom their historical settings or associations. Thislea is again present in the twenty-second annualport, wherein the river Lee is described at lengths a source of water-supply in an elaborate essaylustrating, by pen and photograph, the wholepurse of the river. The beauties of the stream as

1 Metropolitan Water Board : Twenty-second Annual Report.London: P. S. King and Co., Ltd. Pp. 102. Profusely illus-trated. £1 1s.