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apt to do after any protein injection. The authorsthemselves have little doubt that monilia is insome way related to psoriasis. They remind usthat it is the undoubted cause of thrush, and has beenclaimed as the cause of sprue, some cases of bron-chitis and pneumonia, and erosio interdigitalis andepidermycosis. That this organism can function asa pathological agent in the production of diseases isnot disputed; but here, as elsewhere, the presence ofmonilia may be only of secondary significance. Medi-cine teems with examples of such symbiotic relation-ships. It is generally acknowledged that many ofthe symptoms of pulmonary tuberculosis are due tostreptococci and staphylococci, and that the majorityof fatal cases of malignant disease eventually die ofsepsis. It is possible that the relatively poor reactivepowers, which it is safe to assume for the psoriaticlesion itself, is the probable cause of the relativeabundance of monilia organisms to be found there,and also the indirect cause of the invasion of the bloodstream by the organism and of its excretion in thefaeces.

It is surprising that in setting out their conclusionsthe authors have not discussed the possibility of sucha mechanism. Their paper, however, is worthy ofconsideration as a serious contribution to dermato-logical research.

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THE DRAFT POOR LAW ORDER.

A FEW years ago the Minister of Health found itimpossible to proceed with the reform of the poor-lawuntil the relevant existing statutes had been writtenout in intelligible form. The result was theconsolidating Poor Law Act of 1927 which, though itpreserved many provisions which were about toundergo drastic reform, offered the reformer a reason-able chance of reconnoitring the ground he was to.attack. Something of the same sort seems to behappening to the Minister’s poor-law Orders. Thetangle of the present Orders has still some strands ofa code issued as long ago as 1847. The Minister hasproduced a new draft Poor Law Order in nine parts,re-writing the previous provisions under such heads asInstitutions, Hospitals, Children’s Homes, Boarding-out of Children, Apprenticeship, Casual Poor, andOfficers and Servants. His draft is expressly statedto be a consolidation of the existing orders withadaptations consequent upon the passing of the LocalGovernment Act of last year. This means that, asthat Act abolishes boards of guardians and substitutesthe councils of counties and county boroughs, thenomenclature of the poor-law orders is in this and otherrespects brought up to date in the light of the table of liequivalents contained in Schedule 10 of the Act.Other changes have, of course, to be made.References to the overseers disappear because thoseofficials were abolished by the Rating Act of 1925 ;and the central authority which in 1847 was set up asthe Poor Law Board and which in 1871 became theLocal Government Board, now the Ministry of Health,must naturally be referred to by its modern title. Onthe other hand poor relief has not yet been replacedby the new label "public assistance."

The draft Poor Law Urder, theretore, it seems, is a mere modernisation of outstanding provisions, a neces- Isary preliminary to any fresh developments. Thedraftsman appears to have done his work neatly andconcisely. The three-page " Paupers Conveyance(Expenses) Order " of 1898, for example, seems tohave been reduced to seven lines in Article 19 of thedraft, while the 17 pages of the " Boarding-outOrder " of 1911 seem to be contained within the fourpages of Part VI. of the draft. There is only onecomplaint to make. Article 7 of the new code saysairily that all rules, Orders, and regulations, whethergeneral or special, heretofore made by the Ministerunder the law in force from time to time relating tothe relief of the poor, so far as not already rescinded,are hereby rescinded (except certain sets of orders andregulations which are expressly saved). This is aslovenly method of legislation, unfair to the public

and exasperating to anyone who honestly tries tofind out the law. The draftsman knows perfectlywell which Orders he is superseding and reproducingin his new document. Why does he not set them outin a list and remove uncertainty by definitely revokingeach one ?The draft Order, it will have been understood, seems

to involve no change in the law. No medical officerof health or medical practitioner will find himselfany the worse. Everyone, in fact, must welcome theclearer and more concise statement on a subject whichis so rapidly changing. Already the consolidatingPoor Law Act of 1927 is to be replaced by a freshconsolidating Act which has passed through Parlia-ment. It remains nothing less than a scandal thatthe same process is not applied to the general law ofpublic health and local government based on statutespassed half a century ago. The law is uncertainas well as out of date. Anyone who tries to searchout the powers of county borough councils, forinstance, has a dismal task ahead of him. It is notwell that a department should be the only repositoryof knowledge in these matters. Let the Ministryof Health carry the process of consolidation further.

ŒSOPHAGEAL OBSTRUCTION IN CHILDREN.

AN anatomical or physiological defect of theoesophagus, serious as it is at all ages, is doubly so inchildhood, when it threatens the efficient performanceof the functions needed for growth and development,as well as for maintenance of bodily health. Exceptin such conditions as atresia and congenital stricture,it has long been recognised that there is a possibilityof recovery under prolonged and careful treatment,but there has been considerable divergence of opinionon the mode of treatment yielding the best results.It seems likely that the conflicting evidence on thispoint has been to some extent due to an imperfectclassification of the defects encountered, and that aclearer conception of the pathology of these cases willdivide them into diverse types, for each of which adifferent therapeutic technique is indicated.The work which has been done by J. A. M. Cameron,

G. W. Raike, and others has shown that the conditionof cardiospasm, or achalasia, is a definite clinicalentity dependent on a defect of neuromuscularmechanism, associated with degeneration of Auer-bach’s plexus in the lower end of the oesophagus.Good results have been obtained in this disorder bythe passage of mercury bougies, continued over a longperiod, as described by A. F. Hurst.! The treatmentof oesophageal obstruction has, however, beendecidedly less satisfactory in small children than inolder ones and in adults. A valuable communicationby Dr. Wilfrid Sheldon and Dr. A. G. Ogilvie 2strongly suggests that this may be due to the factthat the obstruction in children is usually occasionedby some factor other than achalasia. These authorshave made a careful study of six children observed bythem at the Hospital for Sick Children, Great Ormond-street, and of the records of six cases previouslytreated there. Of these 12 cases, two only showedobstruction at the level of the diaphragm, and theyappeared to be cases of congenital stricture. In theremaining ten the obstruction was at the level of theseventh thoracic vertebra, and they appear to forma clinical group with well-defined characteristics.In all the severe cases the vomiting dated from birthor the first few weeks of life ; it usually became moresevere when solid food was added to the diet. It waspossible to observe some of these children at intervalsduring a number of years, and to compare the radio-graphic appearances at different ages. The authorsare of the opinion that these children did not obtainreal benefit from the passage of bougies. In the

case-histories of some of them immediate improvementis recorded as following this measure, but it was

1 THE LANCET, 1927, i., 618.2 Arch. Dis. Child., 1929, iv., 347.

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usually followed by re-admission with recurrence ofthe symptoms, sometimes in an aggravated form ; inno case was a lasting benefit or a cure obtained. Thecases in which the greatest improvement-sometimesamounting to cure-was obtained were those whichwere treated by prolonged restriction to a fluid diet,without the passage of bougies. Only two of thesecame to autopsy ; in one of them the symptoms hadbeen cured at the age of 3, and death from tubercu-losis occurred later, the oesophagus being found to beabsolutely normal.

Sheldon and Ogilvie make some interesting sugges-tions on the pathology of this type of oesophagealobstruction. They believe that the abnormality iscongenital. This conception is supported by a highincidence in premature children and a four-to-oneratio of males to females, as well as by the onset ofthe symptoms in early infancy. They suggest thata narrowing may take place at the junction of thetwo segments (retropharyngeal and pre-gastric) ofthe foregut by the union of which the oesophagus isdeveloped, or that the lower segment may be narrowedas the result of inadequate growth. If suitableconditions can be maintained-the most importantbeing a purely fluid diet-spontaneous cure of thesymptoms may be achieved by the growth of theoesophagus to a calibre adequate for the transmissionof solids. They have certainly made out a case forregarding the majority of cesophageal defects inchildren as something different from achalasia, andfor giving prolonged trial to this method of treatment.

LIVER IN ANÆMIA.

WITHIN the last four years a great deal has beenadded to our knowledge of the use of liver in thetreatment of anaemia, and Dr. Janet Vaughanl findsa general consensus of opinion that it is a certainremedy for those forms associated with a megalo-blastic hyperplasia of the bone-marrow. The bestknown of these is, of course, " pernicious

" anæmia,but a good deal of evidence has now accumulatedtending to bring under this heading the anaemia ofsprue and also the type described by Channing, inthe ’forties of last century, as the " grave anaemia ofpregnancy." It has still to be directly proved whetherthere is megaloblastic hyperplasia of the bone-marrowin this last type of anaemia, but the condition ischaracteristically associated with a high colour-index,and this is indirect evidence of such hyperplasia.In all these states there are signs that the therapeuticaction of liver is seriously inhibited by sepsis, butthis is not to be taken as an indication that sepsis is inany way their cause. It is further generally agreed,says Dr. Vaughan, that liver is useful in the treat-ment of anaemia secondary to gastric and otherhaemorrhage, and that in these conditions its action isenhanced by simultaneous administration of iron.It is also of value in certain of the nutritional anaemias.Whether the principle effective in anaemia of themegaloblastic type is the same as in the others remainsuncertain. There is little doubt that in the megalo-blastic forms the effective principle is the polypeptideisolated by E. J. Cohn ; in the secondary anaemias theinorganic salt content of the liver may be of import-ance, and this may explain the observation thatliver extracts are useless in certain types of anaemia,particularly those with a nutritional basis, whichrespond well to whole liver. On the evidence todate Dr. Vaughan comes to the conclusion thatpernicious anaemia must be regarded as a, deficiencydisease, having as its basis the absence of someprinciple normally present in both liver and kidney,without which the bone-marrow cannot produce orliberate its normal quota of red cells. As to the modeof action of the liver, two different views are held.J, Muller believes that pernicious anaemia is dueto over-action of the reticulo-endothelial system,resulting in the production of megalocytes at the

1 Quart. Jour. Med., January, 1930, p. 213.

expense of normal red cells ; he thinks that liver acts.by inhibiting the megalocytic hyperplasia and giving,an opportunity for formation of normal red cells.-G. R. Minot believes that the primary deficiency isfailure of the red cells to attain maturity and thatliver acts by stimulating the cells to complete their-growth cycle. His view gains much support fromembryology, and bids fair to be established. Buteven so. the nature of the force causing this abnor--mality in the growth of the red cells remains obscure..

CLINICAL EFFECTS OF OVARIAN HORMONE.

IN a preliminary communication to the RoyalSociety of Medicine (Section of Therapeutics andPharmacology), on Tuesday last, Prof. E. C. Doddsand Dr. J. D. Robertson put the landmark in the-history of ovarian hormone research at the timewhen Allen and Doisy first standardised the materialby the vaginal smear method. Characteristic cells.appear in the smear during the three stages in the..cyclical changes, and Allen and Doisy showed that theinjection of extracts made with the use of volatile-solvents would cause these changes to reappear.As there is a definite quantitative relationship betweenthe amount of hormone injected and the changes in,the vaginal smear the biochemist is now able toestimate the strength of his preparations. This hasenabled him to proceed with the purification of thematerial so that whereas in former years thepreparations were in the form of a stiff oil, insoluble in.water and with a rat-unit of only 10-15mg., nowadaysit is possible to obtain a water-soluble materialcontaining several hundred rat-units to the milli-gramme. In this form it can be injected into human.beings without causing any of the severe local and-general reactions that it produced in the past.When injected subcutaneously oestrin has been knownto produce: (1) oestrus in ovariectomised animals,(2) premature puberty in young immature femaleanimals, and (3) abortion of pregnant animals. It.does not follow, however, that it will therefore causemenstruation and abortion in women, and it is notfair to expect it to induce processes in human beings-which possibly bear only a distant biologicalrelationship to those occurring in the lower animals.The preparation employed in the clinical experiments..

related by Prof. Dodds and Dr. Robertson was madeby the process already published from the Courtaulcl’Institute of Biochemistry and contained 10 rat-unitsper c.cm. Since the investigators were quite in thedark on the dosage all the patients received 1 c.cm.par day for two months. It was thought that the-best results would be obtained by giving a series ofsmall doses over a considerable period, as it had beenshown in animal studies that a better response wasevoked by small doses spread over a period of daysthan by one large dose. The patients injected werecases of amenorrhcea in both married and unmarriedwomen, patients from whom both ovaries had beenremoved, and attempts at the induction of labour-The following table summarises the results, cases

which could not take the full two months’ coursehaving not been further analysed.

Unmarried. Married.

In the successful cases slight bleeding usually occurred.within a week or ten days of the treatment, sometimesamounting to a full period, and this was followed inthree or four weeks’ time by a perfectly normalperiod. After two months’ treatment the periodscontinued to appear regularly and the patients all.felt much better. This improvement in health,however, as also in the cases when menstruation didnot occur, was partly due to psychological causesas excellent tonic effects were observed in manycases receiving normal saline injections who thoughtthey were getting the active preparation. In three