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helium available at a cost comparable to that of

oxygen in the United States. After Dr. Barach hadrelated his experience it was pointed out that incertain clinics anaesthetists are already using helium-oxygen mixtures. In Boston when operations upongoitre are in question it is usual for the anaesthetic .

apparatus to have a cylinder of helium attached.

AN EXHIBITION OF BRITISH ARCHITECTURE

THE Royal Academy is preparing for January andFebruary, 1937, an Exhibition of British Architecturein the Twentieth Century, in which it hopes to show,in a wide variety of examples and without restrictionas to style, the best work done by British architectsin the past thirty-six years. The work will be classedin six main sections-Domestic, Civil, Monumental,Commercial, Ecclesiastical, Bridges-and will consistfor the most part of the architects’ own workingdrawings; illustrated by photographs, perspectiveviews, and models. A retrospective section, surveyingBritish architecture from the seventeenth century,will be included. A representative committee ofmembers of the Royal Academy and other well-known architects has undertaken the selectionof the works. Architects who wish to offer one ortwo examples of their completed work for the choiceof the committee in any of the classes mentioned arerequested to apply without delay to the secretary,Royal Academy of Arts, Piccadilly, W. 1, for formsand instructions as to sending in works. With theextensive construction, reconstruction, and recon-

ditioning that is now taking place in hospitals, anexhibition giving examples of modern work andtheories should be of high value to the medical

profession.

THE HEART IN VITAMIN DEFICIENCY

THE fact that there is often cardiac enlargementin beri-beri has attracted attention to the possiblerelationship of disorders of the heart to deficiency ofvitamin other than B. Claims have been made fora scorbutic basis, for example, in cardiac rheumatism,and even vitamin-D deficiency has been suggestedas a possible cause of cardiac enlargement in youngchildren. Rabinowitz and Rogers 1 now reporta remarkable example of chronic avitaminosis in afour-year-old child with serious affection of the heartwhich became quite normal following adequate treat-ment. This child, who had been late in sitting andstanding, had been fed on a thoroughly unsatisfactorydiet in which the solid elements consisted of somebread, jelly, and cake, the only other food or medicinetaken being milk and Karo syrup. When he cameunder observation there was severe anaemia, haemor-rhages round the gums, fever, and muscular flabbiness.The most important findings, however, were in thecardiovascular system, of which the following is a

description: " the pulse was rapid, small, and

irregular with the presence of a transitory galloprhythm. A precordial thrill was present. The areaof cardiac dulness was markedly extended to theleft axilla. Loud blowing systolic and diastolic.murmurs were heard over the mitral area trans-mitted to the axilla and back, and entirely obliteratingthe heart sounds. A blowing diastolic murmur wasnoted in the pulmonic area transmitted down thesternum. The aortic first sound was louder than theaortic second sound, while the first pulmonic soundwas softer than the second pulmonic sound." X rayexamination of the chest showed much enlargement1Rabinowitz, L., and Rogers, E. J.: New. Eng. Jour. Med.,

Oct. 1st, 1936, p. 621.

of the heart shadow. The child was confined to bedand given a varied diet rich in vitamin C accompaniedby liver concentrate, iron, and a concentrate ofvitamin D. After quite a short period the tempera-ture dropped to normal and the anaemia improved,and after six months the patient was discharged ingood health with no evidence whatever of cardiacdisease, this regression being confirmed by a normalradiographic appearance of the cardiac shadow.

Perhaps the most interesting feature of this unusualcase lies in the evidence afforded that murmurs suchas those mentioned may occur in the absence ofvalvular disease.

A NATIONAL DENTAL SERVICE FOR SWEDEN

GROWING attention has been paid in Sweden

during the past twenty years to the possibilities of acomprehensive dental scheme on a national scale,and a committee of inquiry has reported to theGovernment. The proposals made by this committee,which are described by Dr. Nils Hellstrom, are

ambitious ; for skilled dentistry is to be available forevery Swede, irrespective of income, from the cradleto the grave. Dental work of a purely aestheticcharacter does not, of course, enter into the scheme,but otherwise there seem to be no limits to the dentalwelfare envisaged. It is anticipated that ultimatelythe public dental service will assure an annu.al over-haul for all who want it, but this will not be realiseduntil the scheme has been adopted throughout thecountry. The actual extent of dental caries indifferent parts of Sweden is unknown, and a surveywould have helped the committee to calculate theamount of work likely to be required in each dentalarea; but the cost of such an investigation wasconsidered prohibitive, and the committee has hadto be satisfied with an approximate estimate accordingto which a dentist employed by the public dentalservice would devote 1000 hours a year to schooldentistry and 1100 hours a year to other dentalactivities. Some 425 dental districts would becreated, staffed by 575 district dentists and 40assistants. Each district dentist would be aided byat least one dental nurse, who would be entitled to a

pension. Provision is also made for the dental careof the insane and mentally defective, for prisonersand the occupants of hospitals and sanatoria. It iscalculated that this scheme will cost the State4,658,000 kronor (:f256,500) a year, the localauthorities 2,034,500 kronor, and the four principaltowns with more or less independent health organisa-tions 408,000 kronor.

CHEMISTRY OF DERMATITIS

IN a paper read last month to the London sectionof the Society of Chemical Industry, Mr. H. E.Cox, D.Sc., points out that dermatitis is a biochemicalproblem requiring collaboration for its solution.The question is why does the dermatitis resulting fromone of the chemicals in Dr. Cox’s list, or from simplesalt or sugar, from cement or turpentine, continuefor months or years, long after every trace of thecausal irritant has been swept away ? There are ofcourse answers in plenty, but nearly all of themrest on a basis of theory that is hard to put to theproof. One great exception that escapes mentionin his otherwise admirable summary is the experi-mental work of the late Bruno Bloch, so far themost significant achievement in this difficult field,in that it definitely fixes the site of the reaction we

1 Bull. mens. de l’off. internat. d’hyg. pub., August, 1936.2 Jour. Soc. Chem. Indust., Oct. 5th, 1936.

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term dermatitis in the epidermal cell, and thusrenders experiments on permeability " to the under-side" of the skin as performed by Cox, Francis,Sachs, and others of questionable value. On theother hand certain substances undoubtedly have

great powers of penetrating the skin, and it mustnot be forgotten that the blood and tissue fluids canto some extent " dissolve " volatile oils or otherirritant substances and thus cause dermatitis fromthe "underside." Dr. Cox classifies such noxseintofour main groups: (1) reducing agents, (2) oxidisingagents, (3) substances affecting oxidation-reductionprocesses, and (4) special poisons such as arsenic.This classification has the merit of simplicity andserves both the biochemist and physician. Dyes arethereby relegated to the third group, although, as heremarks, it is impossible to form a clear picture ofwhat happens, and the wide variation of individualsusceptibility adds another difficulty. Those interestedwill be glad to have Dr. Cox’s list of textile dyes,25 in all, that have been experimentally found tocause dermatitis or irritation, and among them willbe noted picric acid, malachite-green, and methyl-violet, the first still used by many surgeons as a skindisinfectant and in the treatment of burns, the twolast by dermatologists in 1 per cent. aqueous or weakspirit solutions mainly in the treatment of eczematisedmycotic infections. Speaking broadly it seems thatthe more soluble the dye, the more likely it is to causetrouble, especially in the presence of weak acid.Of particular interest and importance is a paragraphon hair dyes, of which it is stated, on the authorityof C. Griebel, that no less than 10 million packets aresold annually in Germany alone ! Worth rememberingtoo is the assertion that henna dyes are by no meansalways innocuous, since they are sometimes mixedwith " pyrogallol or a diamine." On another pageof our present issue Dr. Semon shows that the currentpractice of shading the eyelids must be added to thelist of cosmetic hazards.

THE OUTLOOK IN ADVANCED CANCER

Two recent evenings at the Royal Society ofMedicine were given up to consideration of the

management of advanced malignant disease. Inhis presidential address to the section of surgeryProf. Grey Turner recalled a remark he had made inhis Murphy oration six years ago that there is a realrisk of a generation arising who are ignorant of whatsurgery can offer in the treatment of cancer. From

long experience and mature consideration he wasprepared to say that the outstanding feature aboutthe treatment of malignant disease is the not infre-quent great success of its local removal. But, headded, it must be the aim of the operator to removethe whole of the affected part together with a widearea of healthy tissue and the path of probablemalignant invasion. The surgeon must visualisethe extent of the proposed interference and planthe incisions so that the parts are thoroughly exposedunder the guidance of the eye. During the wholeoperation he must keep to the demarcated tissue andnot come nearer the growth than was originallyplanned, and there must be no niggardly dealing withthe tissues in proximity to the primary focus. Thearea of lymphatic invasion to be removed mustinclude not only the lymphatic glands that may beexpected to be involved but those in which there iseven a possibility of involvement, and this removalmust include the soft tissues in which they lie andthe intervening lymphatic channels between the

primary growth and such glands. Throughout such

an operation all manipulations must be deliberate.Good cancer surgery was bound to be time-consuming,and he suggested that operations successfullypractised by such men as Halsted and Lawson Taithad never been fully described. It was the fullaccount of an operation and the detailed notes ofprogress which were needed for real education in

surgery, and in the hope of dispelling some prevalentpessimism he went on to give details of cases whichhe had himself followed for many years-cancer ofthe rectum alive and well thirty years after operation;endothelioma of the gum removed sixteen years ago,and followed six years later by carcinoma of therectum which was in turn removed, the patient beingnow alive and well; with other examples of extensiveoperations for cancer of the breast, of the colon, andof bone. Even the continued attack on recurrences

might be of immense benefit to the patient.The second occasion was the visit of Prof. Hans

Holfelder of Frankfort-on-Main to the section of

radiology on Nov. 20th. The mode of action ofX rays on cancer cells was, he was satisfied, mainlyan effect on the cell nucleus and he made the interest-

ing suggestion that in certain cases damage to thegenes might have a lethal effect upon the daughterand grand-daughter cells while leaving the cellsactually irradiated apparently unaffected-thusaccounting for the cases in which the tumour onlybegins to disappear some time after irradiation.For the lethal effect on the cancer cell it was the

quantity and not the quality of the radiation thatwas the important factor. The optimum voltagewas 180-200 kilovolts, and nothing was to be

gained by the use of higher tensions. Fractionationof the dose was all-important, and he did not believein the superiority of the low-intensity irradiationof the Coutard school. Above all adequate dosagewas necessary if the best results were to be obtained,and this meant that skin reactions have frequentlyto be taken to a stage which looked alarming to theuninitiated. At the same time that techniqueshould be chosen which produced the least possiblegeneral effect upon the patient. If this was donebenefit could often be obtained even in very advanced

growths and even when the disease had become

generalised. In Holfelder’s clinic only the metastasescausing the most serious symptoms or that consti-tute the gravest threat to the patient’s comfort areirradiated and it was, he said, often observed thatuntreated metastases regressed pari passu withthose treated. Specially gratifying were the resultsobtained with secondary deposits in the bones fromcarcinoma of the breast, in which cases five-yearsurvivals were not uncommon. In carcinoma ofthe breast 22 per cent. of the primary inoper-able cases survived 5 years and 36 per cent.of the post-operative recurrences were aliveafter a similar interval. The 5-year survival-ratewith post-operative prophylactic irradiation was

53 per cent. He was very satisfied with his resultsin bone sarcoma, of which only the osteoblastic typewas sometimes radioresistant. The osteoclasticsarcomas, whether endosteal or exosteal, gave goodresults. Even metastases in the lungs from bonesarcoma were not necessarily fatal. On the otherhand giant-celled sarcoma was often truly malignantand tended to be radioresistant.

Dr. N. S. Finzi, who followed Prof. Holfelder inthe discussion, instanced cases of secondary depositsin the mediastinum following carcinoma of the breastthat were well 10 years after radiation treatment.One patient, who originally had bilateral supra-clavicular and mediastinal metastases, was alive and