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do business in the same field. But the policieswhich they issue are apt to be worded with suchforensic finesse that doctors may find it much easierto pay their subscriptions than to reap any benefitfrom them.

A DROP IN THE GOLD STANDARD

A recent discussion at the Societe Medicale des

Hopitaux made it clear that the treatment of tuber-culosis with gold has reached the negative phasewhich is apt to occur with all new treatments. Withfew remedies has the positive phase been so marked.For several years past gold treatment has been sopopular that you had only to cough a little to qualifyfor it. The attack on it on this occasion was led byProf. Emile Sergent, who referred to cases of goldpoisoning he had seen in hospital and private practiceas a sequel to the indiscriminating enthusiasm of hiscolleagues. As for the successes associated with it,he was inclined to suspect that the inherent tendencyof tuberculous changes to retrogress had been-more or less unconsciously-exploited in favour ofthis last newcomer in the therapeutic field.

GOITRE

The tenth session of the Assises Nationalesde Medecine Generale Francaise was devoted to adiscussion of recent collective research into the natureof goitre. In many parts of this country goitrewould seem to be on the wane, an improvementcommonly attributed to better hygiene and, aboveall, to a better water-supply. In one area the diminu-tion of goitre was associated with the introductionof sea fish and more meat in the dietary. In anotherarea the influence of heredity was found to be sogreat that it was demonstrable on the distafe sidein about 40 per cent. of all the goitres. Whileendemic simple goitre, when found in the largetowns, would usually seem to be imported and notto have developed in them, the hyperthyreosesappeared, on the whole, to be more common in thetowns than in the country (a difference less markedsince 1918), and among the rich rather than thepoor. Contributory factors are acute articularrheumatism, the infections of adolescence, typhoidfever and other water-borne diseases of the intestinaltract. In some areas hyperthyreosis is construedas a sign of resistance to tuberculosis ; when thethyroid signs diminish, there is apt to be a recrudes-cence of an old pulmonary tuberculosis. Whilethe advocacy of complete and prolonged rest in theearly treatment of Graves’s disease found littleor no contradiction, opinions diverged on the meritsof radiotherapy and operative treatment. Theresults of radiotherapy in 658 cases collected byDr. J. Belot from various sources in Paris were veryencouraging : 4 failures 5 per cent., improvement in25 per cent., recovery or great improvement in70 per cent. Dr. H. Welti maintained that the resultsof thyroidectomy were superior, and that the claimsmade by the radiologists were not substantiated

by surgeons who saw patients whom the radiologistshad failed to cure. During the past five years he hadperformed 289 operations on 207 cases of exoph-thalmic goitre, with only one operative death. Hehad also operated on 167 goitres showing no signsof hyperthyroidism, and among them he had onlytwo deaths to record. Another speaker tried torestore the balance by remarking that the radio-logist is now beginning to see the operativefailures of the surgeon. This was an interestingdebate.

NEW RADIOLOGICAL DEPARTMENT AT

THE CANCER HOSPITAL

ON Wednesday last H.M. the Queen opened thenew buildings of the Cancer Hospital (Free) consistingof a private wing for paying patients, to be knownas Granard House after the President of the Hospital,and of a new radiological department under the careof Prof. J. M. Woodburn Morison. The buildingalso contains the new out-patient department whichhas long been badly needed. Our illustration showsthe attractive frontage of the building on its cornersite. The total cost of the new wing has been aboutE150,000.

BEDS FOR PRIVATE PATIENTS

The first, second, and third floors of the buildingcontain accommodation for 29 patients of limitedmeans who can contribute towards the cost of their

Profile of Granard House.

maintenance and treatment. The scale of mainten-ance fees, which has been approved by the CharityCommissioners, is 6 guineas per week in a singleroom, 5 guineas in a two-bedded, and 4 guineasin a three-bedded room. For radiological investigationthe maximum charge is 5 guineas for a completegastro-intestinal examination (exclusive of enema)with 3 guineas extra for an opaque enema ; 3 guineasfor examination of the urinary tract, with an

additional fee for intravenous and retrograde pyelo-graphy ; 2 guineas for investigation of the heart andlungs, or 3 guineas if stereoscopic films are taken ;1 guinea for investigation of either upper or lowerextremity, or 2 guineas for a stereoscopic film of theshoulder. Other charges are in proportion. There isalso a schedule of maximum charges for pathologicalexaminations ; the highest is 2 guineas chargeablefor sugar-tolerance determination, preparation ofautogenous vaccines, estimation of basal meta-bolic rate or histology of a frozen section taken atoperation.

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RADIOLOGICAL DEPARTMENT

This has been designed to fecurethe closest possible cooperationbetween clinical work on the onehand and scientific investigationon the other. Under the directionof the late Dr. Robert Knox thework of the department was foundto be increasingly cramped for

space and Prof. Woodburn Morisonwill now have three completefloors (fourth to sixth in the profile)under his direction. These are

allotted to (1) physical investiga-tions and the teaching of students,(2) X ray diagnostic work andradium treatment, (3) high voltageX ray therapy, artificial sunlight,and electrical treatment.

In association with the Univer-sity of London and the RoyalColleges provision is made for

post-graduate instruction of medicalstudents in both clinical andscientific aspects of radiology. For this purpose anew lecture theatre and experimental laboratoriesare provided. Facilities are also available for theinstruction of radiographers. The diagnostic sectioncomprises rooms devoted to X ray investigationboth by screening and by radiography, as well as therequisite dark-rooms, consulting- and dressing-rooms.We give an illustration of the arrangement of oneof these rooms devoted to diagnosis. The highvoltage X ray apparatus on the fifth floor (alsoillustrated) has been specially designed for the

production of penetrating X rays. Special attention

Deep X ray therapy

has been given to the protection of patient andoperator and to the measurement of dosage. Thereis a wireless device by which the patient can speakto the operator some distance away.

PHYSICS DEPARTMENT

This department, which is in charge of Mr. W. V.Mayneord, D.Sc., has been mainly concerned withthe problems of X ray and radium dosage. Whenwork was commenced, the only method of X raydosage was with a barium platinocyanide pastilleand a standard parallel plate was set up and calibrated

Part of an X ray screening room

in German r units before this wasadopted internationally. Problemsof distribution were next attacked,measurements in a phantom beingmade at 130 KV. pulsating poten.tial, the maximum then available.Quite recently these measurements,with vastly improved apparatus,have been carried up to 400 KV.,and demonstrate the strikingimprovement in depth dose andoutput now available.The work on radium therapy

has two aspects, theoretical andexperimental. The distribution ofradiation around various containershas been studied mathematicallyand experimentally, affording in

many cases a fairly accurate ideaof radiation fields. This work ledto the design of surface applicatorswhich give uniform irradiation, aswell as charts enabling the correctamounts of radium in applicatorsof various sizes and various dis.tances to be read off. Meanwhile,work has been done on the estab-lishment of the r unit in gammaray therapy, work which is now

fairly complete. This should helpin the standardisation and ration-alisation of gamma ray therapy.Work has also been done on thevariation of electron emission andpossible sensitivity variations oftissues with wave-length, and some

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theoretical work is about to be published on thephysical basis of biological action. Recently too thecondenser dosimeter has been developed for bothradium and X ray work, enabling both the quantityand quality of the radiation received in naturalcavities of the body to be measured accurately.

Experimental work has also been carried out in

conjunction with Prof. E. L. Kennaway on the opticalproperties of the carcinogenic hydrocarbons andallied substances. Biophysical problems are likelyto be attacked in the future, now that means areavailable for measuring accurately and easily thevarious radiations used in clinical and experimentalwork.

Research in this department is financed chiefly bythe hospital itself, but help is given by the BritishEmpire Cancer Campaign, the Medical ResearchCouncil, and in certain directions by the InternationalCancer Research Foundation of Philadelphia.

"ACCREDITED MILK"

(FROM A CORRESPONDE1VT)

THE proposal of the Milk Marketing Board to addone more to the list of specially designated milks onthe market will be received by the medical professionwith rather mixed feelings. At the same time it is a

highly important development and deserves detailedconsideration, both on its merits and as an indicatorof future developments in the long drawn out strugglefor a clean safe milk-supply. It is a designated milknot sponsored by the Ministry of Health but intro-duced from the agricultural side, and those producerswho comply with the requirements will be rewardedby receiving a bonus in the form of payment for theirmilk above the standard price given by the MilkMarketing Board, independent of their own exertionsto sell the milk. The money will come out of thepool and is as such a contribution from all the milkproducers. From this point of view it is whollyadmirable, since the general effect must be to inducemore and more producers to take the requisite stepsto qualify for this additional payment and be placedon the roll of " Accredited Producers." Probablywithin a reasonably short time, a material proportion,even a majority, of the milk producers, will so qualify,and the whole standard of milk production will beraised and something which may fairly be called aclean milk-supply will be the general rule and not theexception. Put another way, those who do notconform to the new standard will be regarded asdis-credited milk producers, and it is not unreasonableto assume that as such their milk will be rejected forliquid consumption and they will have to be contentwith the much lower price payable for milk used formanufacturing purposes. Such no doubt is thelaudable aim of the Milk Marketing Board, and theirmethod of procedure is calculated to attain thisobject, using as it does the only practicable methodto obtain a clean milk-supply, that of financialinducement.But unfortunately, however, there is another side to

the picture which induces considerable misgivings.To appreciate this aspect we have to consider therequirements necessary to be placed on the Roll ofAccredited Producers. These are set out in the

Report of the Reorganisation Commission for Milk(1933) and include :-

(a) The clinical inspection of herds and the elimina--tion of diseased animals.

(b) The inspection of buildings to ensure compliancewith a reasonable standard.

(c) The inspection of methods of producing andhandling milk to secure compliance with a reasonablestandard.

(d) The taking of, say, three surprise samples ofmilk over a period of three months and the satisfactionof a prescribed bacteriological standard.

Leaving out of consideration their indefinitenature and the considerable administrative problemsinvolved, and assuming efficient control, it is obviousthat at the best it is Grade A milk over again butwith rather relaxed standards. And Grade A milkis fairly universally accepted as failing to give a safemilk-supply. It is well known that at least 40 percent. of dairy cows are infected with tuberculosis, andit is notorious that clinical inspection will onlyeliminate a percentage of the infective animals, anda milk-supply free from tubercle bacilli cannot beguaranteed. The other three requirements refer tocleanliness of production. A cleanly produced milk-supply is highly desirable but merely a clean milk-supply is not a safe milk-supply. The risks of

conveying to man tuberculosis, undulant fever, septicsore-throat, and the acute infectious diseases will becomparatively little reduced in the herds of accreditedmilk producers as compared with the ordinaryproducer. Stated briefly, the scheme of the Milk

Marketing Board will materially assist in the produc-tion of a clean milk-supply but will do comparativelylittle to give a safe milk-supply, and it is a safe milk-supply which is insistently demanded by the medicalprofession.The hope of the Milk Marketing Board that the

new step will lead to an increased public confidencein the milk-supply with an added consumption is

unlikely to be realised because an essential factor islacking, the confidence and support of the medicalprofession. This can only be won by a safe as wellas a clean milk-supply, and it is important to statethis clearly. The proposal is one step in the rightdirection but not the only one and not even theessential step. In view of our infected herds and theimpossibility of obtaining disease-free herds within areasonable period, the only method available to givea safe milk-supply is efficient pasteurisation. A rollof accredited producers combined with pasteurisationof the milk supply would be a most valuable combina-tion, but the Milk Marketing Board gives no sign thatit appreciates this essential requirement. Without itthe hope of a much larger consumption of liquid milk,which is so much needed both from the nutritionalpoint of view and to help the milk producers, is likelyto remain a hope unrealised. The medical professionwishes to help but it is unalterably opposed to any-.thing short of a safe milk-supply.

One minor criticism may be mentioned. The name" accredited milk is not a happy one. The expres-sion " accredited has become closely associated inU.S.A. and elsewhere, and is now being introducedinto schemes in England and Scotland, for dairy herdswhich are accredited as free from tuberculosis. It isconfusing to use the same term for milk supplied fromherds which are not free from tuberculosis and whichare not required to be so free. This expression" accredited " is firmly fixed in its usage for tuber-culosis-free herds and should not be used with a quitedifferent meaning. The nomenclature of designatedmilks is already confused and misleading and it isunfortunate that a fresh source of confusion is

proposed to be introduced.