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those lymphoid organs of the pharyngeal ring inwhich there is an intimate relationship between theoverlying epithelium and the lymphoid tissue. Theprimary tumour was small and seldom showed ulcera-tion ; cervical lymph nodes were involved early and,as a rule, bilaterally but remained relatively ’smalland did not ulcerate ; the tumours were extremelyradiosensitive, with complete disappearance of theprimary growth and the lymph nodes under radio-therapy, though distant metastases might appear inthe lungs, liver, or bones. Histologically the tumourwas an anaplastic actively mitosing carcinoma withno tendency to cornification, in which there waslittle if any demarcation between stroma and tumour ;a characteristic feature was the penetration of thetumour masses by lymphocytes, and this was evenseen in the visceral metastases. It was not suggestedthat the lymphoid elements had undergone blasto-matous change but that the tumour was a peculiarform of epithelioma with a marked lymphotropismin keeping with the features of the normal lympho-epithelial organs. More recently Ewing and Cappell ghave described a number of these cases. Harvey,Dawson, and Innes in their summary illustrate thehistological features of these tumours by a series ofexcellent photomicrographs. They stress the import-ance of a knowledge of the histology of normal andhyperplastic lympho-epithelial tissue, and althoughadmitting the existence of an undifferentiated carci-noma which corresponds with Regaud and Schmincke’sdescription of a lympho-epithelioma, they do notregard the lymphotropism as a specific feature, andwould be inclined to group all carcinomata of the naso-pharynx and tonsils together. On the other hand,they note that many so-called " lympho-epithelio-mata," particularly those occurring in children, arereally reticulum cell sarcomata ; this is undoubtedlytrue and unless special attention is paid to cytologytheir differentiation is very difficult. Although it isagreed that the lympho-epithelioma is only an undif-ferentiated carcinoma, its clinical characters-smallnon-ulcerating primary mass, early bilateral lymphnode involvement, and extreme radiosensitivity-aredistinctive. These characters mark it out from themore differentiated type of epithelioma which showsa liability to ulceration and direct extension to thebase of the brain with early cranial nerve involve-ment. In the lympho-epitheliomata the primarytumour soon disappears under irradiation, and evenin untreated cases it may be difficult to find at post-mortem. This has been emphasised by Gräff 9 anda more widespread use of his excellent autopsytechnique for displaying the nasopharynx and upperair passages would increase our knowledge of this" debatable tumour."

THE RELIEF OF PARKINSONISM

THE damage to the brain left by an attack ofencephalitis is irremediable, but muscular stiffness andslobbering can often be mitigated so as to make lifeless irksome to the sufferer. The response to extractsof various members of the nightshade family isvariable and any of them may fail completely togive relief. The tremor and the oculogyric attacksare more resistant to treatment, and, as Sir ArthurHall has reiterated,1O under no circumstances does theParkinson syndrome completely disappear. Untilrecently the best results claimed seem to have been by A.Kleeman using doses of atropine up to 20 mg. or more

7 Ewing, J., Amer. J. Path. 1929, 5, 99.8 Cappell, D. F., J. Path. Bact. 1934. 39, 49.9 Gräft, S., Beitr. path. Anat. 1934, 94, 276.

10 Brit. med. J. 1937, 1, 795.

a day, after F. W. Bremer had shown the remarkabletolerance of parkinsonians to this alkaloid. Duringthe last two years another preparation of belladonnahas sprung into prominence in Germany and Italy.From an apothecary’s shop in a Bulgarian village ithas, with the aid of royal bounty, become well knownin Rome and other Italian cities. In another columnDr. Fenwick and Dr. Neuwahl summarise the resultsso far attained on the continent, and give an accountof two patients of their own in Rochdale whoresponded to this Bulgarian treatment when theyboth failed to get relief from other preparations ofnightshade. It is possible, as is claimed, that bella-donna grown on Bulgarian soil has some specialquality ; or that its extraction with the white wineof the country may give a more potent extract.There is however no type of case in which it is moredifficult to assess the direct value of therapy than thehighly suggestible parkinsonian. The origin in a

monastery garden has news value and carriessuggestion to the prejudice of scientific assessment.We understand from the two Rochdale doctors thatSir Alfred Law has offered free treatment to necessi-tous post-encephalitic patients in a nursing-home.Even here it may be difficult to eliminate the factorof mass suggestion ; but the need for research, bothpharmacological and clinical, is recognised in Rochdale.A skilled assessor would help.

OXYGEN AND FRESH AIR

THE increased interest now shown in oxygen asa therapeutic measure is reflected in a number ofstudies of the relative value of different ways of givingit. Many of these are unfortunately mere repetitionsof previous work which reveal no new facts. L.Dautrebande and his co-workers have recentlyhowever 1 brought forward one or two suggestions.They measured the oxygen percentage of the alveolarair in trained subjects who were receiving coursesof this gas by various channels, and through nasalcatheters of different lengths or through a mask.The best results were obtained by the use of a maskbut when a wide reservoir tube was used the alveolarair was not affected by the length of this tube withinlimits of 30 cm. and 1 metre. The concentration ofalveolar air was definitely improved by the addition ofa 30 cm. tube to the mask. These results held with astandard flow of 3.2 litres of oxygen per minute, andthe mask was still superior at this rate of flow to anyof the other methods with flows of 6-3 litres per minute.The result with delivery of oxygen just within thenares by means of a bilateral nasal catheter was

surprisingly good, apparently more than doublingthe oxygen content of alveolar air, the prolongationof the catheters into the nasopharynx making verylittle difference. This held with flows of 3.2 litresper minute, and was also more or less true withincreases up to 6.3 litres per minute. The increaseduse of oxygen in this way, however, has an economicside, and in private practice the cost of the oxygentent, for example, may be very heavy. A return,therefore, to the use of fresh air in the treatment ofpneumonia in childhood is, on grounds of economy,one to be recommended, and H. L. Wallace 2 recentlydescribed the excellent results obtained in Edinburghat the Sick Children’s Hospital by these means, themethod being the simple one of placing the child onthe windward side of the ward opposite a widelyopen window, so that cold air from without playsdirectly upon the child’s face. Prof. R. Degkwitz 3

1 Pr. méd. July 21st, 1937, p. 1097.2 Brit. med. J. 1937, 1, 657.

3 Münch. med. Wschr. 1937, 84, 1043.

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supports this type of treatment in a recent accountof fresh air as employed at the University Children’sClinic, Hamburg. Broadly speaking, he claims thatwith strictly comparable treatment in all other

respects young children kept freely in the open airduring their pneumonia had a mortality-rate onlyone-third of that when this benefit was not employed.In the Hamburg series a particular point was thatthe children were carried about by nurses in thefresh air for so many hours a day, a method whichis said to combine the value of fresh air, change ofposition, and a certain amount of " mothering."Enthusiasts, therefore, for oxygen therapy mightbe reminded of these cheaper measures, and themedical man who likes to combine instruction with

pleasure might well read or re-read the descriptionof an adult case of pneumonia treated in the openair with success in " Cupid Goes North " from the penof a member of the profession under the pseudonymM. Swayne, now unfortunately out of print.

THE ADMINISTRATIVE SIDE OF PSYCHIATRY

THE socialisation of medicine has in most countriesgone to its furthest lengths in the fields of publichealth and mental disorder. The provision of treat-ment, not only for the certified insane, but also forthose neurotic and other psychiatric patients whosedisorder is not of a kind that calls for institutionalcare, has come more and more to be a responsibilityof the State, as openly recognised and fully borne asthe prevention of epidemics. The extent of this

development in the field of psychiatry is not to bejudged solely by mental hospitals, though they arestill the main medium and concern of public mentalhygiene. The administration of a modern mental

hospital demands some things that would not haveentered the head, much less furthered the success,of an " asylum superintendent " of the past. Manyof the essentials for running a mental hospital are, ofcourse, the same now as formerly, but with the

development of social psychiatry and of a wider

conception of mental disorder, the outlook and thefunctions of the medical superintendent have beenenlarged. With this growth have come complexitieswhich differ from place to place, and certainly fromcountry to country; yet the basic problems are every-where much the same and the recorded experienceof a skilled and distinguished administrator in

any country can be a most profitable stimulus tocolleagues abroad. Dr. W. A. Bryan, in a bookreviewed on another page, shows that mental hospitaladministration is by no means the soulless steward-ship often denounced by enthusiastic workers in otherbranches of psychiatry. The combination of qualitieswhich it demands is rare. In Dr. Bryan’s view thefunctions of the mental hospital are sound clinicalpractice, research, teaching, and prevention. It hasbeen possible at the Worcester State Hospital,Massachusetts, of which he is superintendent, to seeall these functions working. In research especially,the hospital has, through exceptional circumstances,acquired international renown for the unusuallyambitious and thorough plan of investigation into

schizophrenia carried out there. It is not to be

expected that in teaching and the prevention ofmental illness the achievement could be as notable.Many factors conspire to make this, like research,more the work of the university clinic and psycho-pathic hospital, where a wider range of materialoffers and a closer contact with the rest of medicineand the public can be maintained. Nevertheless, evenin teaching and prevention the mental hospital has

much to do. With what most of us would regardas excess of zeal, Dr. Bryan sees the mental hospitalof the future as the coordinating agency which willlink up " all activities dealing with human beings."Such ambitions overleap themselves. More sober

prophets will be satisfied if it becomes, more conspicu-ously than at present, a progressive, as well as

indispensable, part of every organised scheme ofpublic mental hygiene and research.

CIRCULATORY FUNCTION IN LIMBS

THE last few years have seen an intensive study ofthe obliterative arterial diseases, especially thrombo-angiitis obliterans. In dealing with these disordersthe surgeon is confronted with the difficulty of esti-mating the circulatory value of the limb-an accurateestimate being important both in choice of treatmentand in judging results. The symptoms and theordinary clinical examination will reveal only thegrosser changes, and this is true also of oscillometricmethods. Hence a simple mechanical method thatwould give a numerical result would be extremelyvaluable. Early last year, in our own columns,lSimmons of Manchester described such a method,making use of a simple ergometer, and Ratschow 2now gives an account of an almost identical apparatuswith which he employs similar weights and time-intervals. The findings closely agree, except that theManchester clinic used the more powerful group offlexors instead of the extensors, and so their numericalresults are higher. The flexors appear to be the moresuitable muscle-group for testing purposes, for it is

nearly always these muscles that are affected inintermittent claudication. Ratschow repeats an

observation, often made, that this method is of

great value in differential diagnosis from neuritis,rheumatism, and other conditions, and he points outthat the work is more easily performed when the limbis dependent. This latter observation supportsTelford’s teaching that the limbs must not beelevated on pillows, but must be as dependent aspossible. Unfortunately the medical text-book andcurrent nursing practice do not as yet, in this respect,differentiate between an arterial and venous

thrombosis.The German school also claims that graduated

exercise by means of an ergometer is an importanttherapeutic agent; but it is doubtful on whatgrounds this claim is made and it will be interestinglater to hear whether it is being maintained.

TEETH IN TRISTAN DA CUNHA

FivE years ago H.M.S. Carlisle paid an officialvisit to this isolated group of small islands in thesouthern Atlantic, and the opportunity was takenof making a dental survey of the inhabitants. Atthat time these were found to show a remarkableabsence of caries. When the ship visited the islandagain in February of this year the survey wasrepeated, and Surgeon Lieutenant-Commander (D)W. E. A. Sampson, who carried out the work with thehelp of Mr. J. R. Moore of Capetown (the nearesttown), has recently published his results.3 In the

five-year period the population has increased from162 to 183 and, mainly owing to the efforts of thechaplain, education has been greatly improved, allchildren under 10 years now attending school. Ten

ships have visited the islands in the last 3t years, aconsiderable increase over previous years, and these

1 Simmons, H. T., Lancet, 1936, 1, 73.2 Ratschow, M., Münch. med. Wschr. July 16th, 1937 p. 1128.

3 Brit. dent. J. July 15th, 1937, p. 86.