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excess were really due to other causes, Prof. Biggerobtained a further quantum of deaths (recorded asdue to senility in 1875) which were probably due tocancer. After applying these corrections to therecorded cancer deaths, the true cancer death-rate for1875 works out at 95-2, a. figure nearly identical withthat of 1925. Prof. W. D. O’Kelly, in opening thediscussion, asked if cancer was merely increasingbecause so many people were going into the towns ; he assumed that it was a disease of civilisation. ICriticising Prof. Bigger’s redistribution and the causes of death in 1875, he thought that a large proportion ofthose attributed to senility would now be regarded asdue to heart disease, pneumonia, or bronchitis.Cirrhosis of the liver would absorb a large number ofthe deaths from ascites ascribed by Prof. Bigger tocancer. Sir John Moore remarked on the part playedby surgery in enabling the diagnosis of cancer to beverified before the fatal onset, and on the prolonga-tion of life due to the gradual subsidence of some of themore dangerous epidemic diseases, which permittedthe population to live to an age when degeneration dueto cancer manifested itself. Dr. W. M. Crofton thoughtthat if the death-rate figures of some easily diagnosablecondition such as cancer of the breast or tongue werecompared there would be little or no differencebetween 1875 and 1925. Prof. Bigger, in summing up,said he did not believe that civilisation played anyconsiderable part in the production of cancer ; therewas, he thought, no great difference in the prevalenceof cancer in country and town. A friend of his inEast Africa wrote that he had done 12 operations forcancer on natives, thus dispelling the theory thatnative races are immune. He agreed with Sir JohnMoore that one reason for the apparent increase incancer was the prolongation of life owing to thediminution or almost complete disappearance ofsmall-pox, typhus, typhoid, and other infectiousdiseases. It was difficult, he thought, to place relianceon registration records of deaths in the old days ;the improvement in registration of recent times wasdue to increased medical knowledge among Irishpractitioners and dispensary doctors.

HEALTH INSURANCE CHANGES.

THE New Year sees some important changes in theadministration of the National Health Insurancescheme, the effect of which will be to simplify itsworking. Reference to these is made on p. 46. Thefirst change concerns the regulations governing thecalculation of arrears in payment of contributionswhile the insured person is out of work. Certainpenalties to be enforced when arrears had lasted so-and-so many weeks are abolished by the new Act,this concession to genuine unemployment beingrendered possible by an annual grant out of the StampSales Account. Difficulty in determining whether theunemployment is genuine or not may require theproduction of certificates by officials of the labourexchanges. Another important change is an extensionof what is known as the free year, which is lengthenedto 21 months. At the end of this period the approved

. societies will have sufficient evidence before them toshow whether an insured person is entitled to a furtherperiod of 12 months’ insurance on account of unem-ployment. The effect of these new provisions will begreatly to diminish the number of notices issued and ofcomplaints which arise from the reduction or suspension Iof benefits. A voluntary contributor who ceases topay contributions will remain insured for a period ofapproximately 21 months as in the case of an employedcontributor who ceases to be employed. There will,however, be no further extension, as in the case of anemployed contributor, if a voluntary contributorbecomes genuinely unemployed ; but in this case alsosickness will lead to extension of the free year. The

provisions relating to deposit contributors are alteredvery considerably. The fund is divided into two parts,a deposit section and an insurance section. Any depositcontributor may on application be transferred to theinsurance section on two conditions : (1) application

must be made within a prescribed time and in aprescribed manner, and (2) the applicant must provebhat the state of his health is such that he cannotobtain admission to an approved society. If hishealth improves he must try to obtain admission orfailing this he may be reinstated in the deposit section.To provide funds for sickness benefit in the insurancesection certain transfers will be made from moneysaccruing from interest on the whole funds of thesection or amounts standing to the credit of depositcontributors upon death or emigration. There arecertain changes relating to the sickness benefit ofmarried women ; one such provides that a womanshall not be suspended on marriage where unemploy-ment is due to inability to obtain work ; anotherincreases the amount of sickness benefit payable andalters the conditions to some extent.

Alterations in additional benefit chiefly affect theapproved society administration and the determinationof disposable surpluses. New additional benefits arethese :-

(1) The provision of specialist treatment, not beingtreatment within the scope of medical benefit or any otheradditional benefit.

(2) Payment to approved charitable institutions in respectof treatment of members.

At the same time certain additional benefits are

repealed -namely : (1) medical treatment andattendance for dependents of insured persons ;(2) payment of disablement allowance to membersnot totally incapable of work ; (3) payment of

pensions or superannuation allowances ; (4) paymentsof contributions to superannuation funds ; and(5) remission of arrears.

It must be a continued source of chagrin to all whoremain faithful to the health insurance principle thatthe Economy Act, under which the Treasury grants toinsurance funds were reduced, postponed the much-needed laboratory and specialist services. It maybe contended that many additional benefits will beavailable when the sickness claims are reduced, but atthe moment we have to face the fact not of surpluses,but for the first time of deficits in manv of the funds.The auditor’s report for 1927 shows that the totalreceipts for England were £33,670,000, while the totalexpenditure on benefits was 30,069.000 and on

administration £4,326,000. The English Fund wasthus $725,000 to the bad, while the Scottish deficitfor the same period was £273,000.

TRANSMISSION OF DISEASE BY TRANSFUSED

BLOOD.

WrTH the multiplication of blood transfusions in allcountries it is inevitable that their dangers should besometimes emphasised by the occurrence of accidents.The main sources of danger are two : incompatibilityof the transfused blood, and diseases that may betransferred with the blood from donor to patient.The first danger is now fairly fully understood, thanksto the researches of Landsteiner and Levine at theRockefeller Institute and of many others, and it isnot often that accidents happen. The transmissionof disease also occurs surprisingly seldom when it isrealised how difficult it is entirely to guard against it.The two diseases chiefly to be remembered are syphilisand malaria, and it is the duty of everyone entrustedwith the task of selecting blood donors rigidly to excludeany individual who could possibly be suspected ofharbouring either of them. For the elimination ofsyphilis the Wassermann reaction must be used as aroutine measure, except in an emergency when notested donor is available. The spread of organisationsof voluntary donors in London and the provinces is,of course, gradually eliminating the use of untesteddonors even when haste is essential. In the earlierdays of transfusion several cases were recorded fromAmerica in which syphilis was actually transmitted,in one instance from a son to his father ; but no casehas been published in recent years. Malaria is moredifficult to avoid, since there is no test and reliance has

35

to be placed on the donor’s statement that he has neverhad the disease. The moral of this is pointed by anoccurrence described by our Vienna correspondent(p. 44) where a donor, in spite of his statement thathe had never had malaria, was proved to have infectedfour people by transfusions. Other common diseaseswhich have been transmitted in the same way are someof the exanthemata. The transmission of measles intwo cases from a mother to her infant was reportedfrom Chicago in 1924,1 the blood having been takentwo days before the appearance of the rash. Small-poxhas also been transmitted recently,2 the blood againhaving been taken two days before the eruption

, appeared. The existence of an incubation period mustalways make the complete elimination of thisaccident impossible. Much queerer events than thesehave also been described. On one occasion a patientwas temporarily endowed with horse-asthma after

having received the blood of an individual subject tothis condition.3 Again, a recent report 4 fromScandinavia records the transfusion of blood from adonor who was seven weeks afterwards found to besuffering from acute myeloid leukaemia, from whichhe presently died. Fortunately for the patient, ifunfortunately for medical science, no symptomsdeveloped in the recipient, so that the questionwhether leukaemia can be transmitted in this way is

still unanswered. It is evident, however, that theseaccidents are relatively so uncommon that no exagger-ated fear need arise in the minds of either the publicor the profession. Comfort may also be derived fromthe statement 5 made in 1925 that the blood oftertiary syphilitics may be safely used for transfusion.It was a somewhat bold experiment, ten non-

syphilitic patients being transfused from six syphiliticdonors in a late stage of the disease. None of thepatients 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 ofthe suprarenal glands is often confusing, and inchildren such tumours are usually so misleading intheir clinical manifestations as to render precise diag noses very difficult. The subject is, however, notreally so complicated as is often made out, and arecent report 6 of a case of malignant suprarenaltumour in an infant, with a brief survey of literature,very much simplifies the classification. Tumours ofthe suprarenal cortex either give rise to no symptomsat all, like the simple adenomas, or produce curiousdisturbances of sexual development. Tumours ofthe medulla of the suprarenal are in reality newgrowths of the sympathetic nervous system, and theterm " neuroblastoma " is used for them, or more

simply " medullary sarcoma of the suprarenal."These latter tumours are especially liable to causedifficulty, for they metastasise so early that thesecondary deposits seem to dominate the picture,while the primary growth may only be discovered atautopsy. Tumours of this variety fall into two groups.The " Pepper " type occurs in babies between sixweeks and four months old, usually growing in theright suprarenal, and giving rise to an enormousenlargement of the liver which is diffusely infiltratedwith secondary deposits. The " Hutchison " type is,as a rule, found in children between one and fiveyears of age. The primary growth, usually in theleft suprarenal, is bigger than it is in the Peppertype, while secondary deposits occur in the bones,especially those of the skull. It is in such cases thatdifficulty may arise because secondary deposits inthe orbit, producing pioptosis, may occur before theprimary growth is discovered, and the diagnosisfrom 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 takenvan Veen describes a case of the Pepper type in aninfant aged only 18 days. The main clinical featurewas the huge size of the abdomen due to an enormousliver. Blood count showed a slight decrease in thered cells with an increase in the leucocytes. Thevan den Bergh reaction in the blood was negativeand so also was the Wassermann reaction. The childdied at the age of 6 weeks, and at the autopsy theliver 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 appearanceof the tumour and its relationship to the sympatheticnervous tissue. His observations may be correlatedwith those of Dr. D. M. Greig,l who in a paper whichhas just appeared gives an account of the histologicalappearances of the Hutchison type, describing fullya case in which there were secondary deposits in theregion of the right side of the face and skull. He isinterested especially in the nature of cephalic metas-tases in these cases, and points out that the secondarydeposit is in the soft tissues at first and infiltratesthe bone later. After a period of bone absorptionthere is great activity of the bone cells with localexcess of calcium salts leading to formation of newbone. This bone cell activity is the direct result ofthe excess of vascularity which the highly vasculartumour has ensured. In Greig’s case the primarygrowth was in the right suprarenal, which is a slightlyless common site than the left suprarenal for theprimary focus. He quotes the work of Frew to showthat the cephalic distribution roughly follows theside of the primary growth, owing, it is believed, tothe anatomical arrangement of the lymphatic drainageof the suprarenal glands.

HOSPITAL AFTER-CARE AT SHEFFIELD.

ANONYMOUS generosity has made it possible to

inaugurate a valuable scheme for after-care andconvalescence at the Sheffield Royal Infirmary.There, as elsewhere, it has been felt for a long time bythe infirmary board that the work of an institutionof 500 beds was incomplete if it ceased automaticallywhen the patients left the wards. It is desirable in theex-patient’s interest that his progress should becarefully watched, his diet supervised, arrangementsmade for further examination and treatment on thefirst sign of retrogression ; and equally desirable inthe interests of posterity that complete records ofprogress should be available as a guide and controlto the treatment of others. We are to-day at aperiod in hospital development when we mustappraise our results more intelligently in order moreaccurately to register what we are accomplishing.The patient must be followed actually to his home orplace of work in order to estimate how his physicalcondition is standing the strain of normal life.Valuable information will be obtained from an

after-care scheme with a well-organised follow-up anda collation of the data so obtained. In the case of theSheffield Infirmary scheme the primary functions areseveral, and may be epitomised thus : to gainknowledge of the patient’s condition after dischargefrom hospital; to cooperate with any and evervagency with a view to rapid restoration to health ; tohelp 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 ; tosupply drugs like insulin and special diet for diabeticswho cannot take the food of the ordinary household.The scheme is drawn up specially with a view toconvalescence ; in accordance with the wishes of thefounders expressed in a trust deed the fullest use willbe made of convalescent homes, particularly ofhomes offering special treatment. The word con-

valescence is to be construed in its broadest sense, andunder this heading will be provided home nursing

1 Edin. Med. Jour., January, 1929, p. 25.