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seek damp surroundings, but rather surroundingsin which damp is incidental. Rats and rheumatismcoincide more closely in Kensington than dampand rheumatism. These interesting results certainlysuggest that Dr. Clarke’s theory should be investi-gated further. The authorities of the borough believe ethat the solution of the rheumatism problem liesin eradicating the conditions which constitute poverty,overcrowding, deterioration of house property, and.difficulty in obtaining the necessities of life. Theydo not record what many other investigators havenoticed-namely, that the incidence of rheumatismis considerably higher among the comparativelypoor than among the very poor. This is perhapsbecause actual destitution is rare in the Royal borough.Nevertheless, if this observation of other workers.is correct, it would further support Dr. Clarke’stheory, for rats would naturally infest the dwellings,of untidy and wasteful persons rather than thosewhose inhabitants consume every particle of food.

The second part of the report is a valuable treatiseon juvenile rheumatism from the clinical aspect,by Dr. R. C. Lightwood and Dr. M. L. Davies.In the absence of a specific remedy and of a certain,means of protecting the heart of the rheumaticchild, the primary object of a supervisory centre is,they say, to prevent relapses by providing as goodmanagement and surroundings as possible, and to- supervise the after-care of children whose hearts are.already affected. The chief measures directed againstrecurrence are correction of unsuitable environmentalconditions, attention to general health, treatmentof diseased tonsils, and education of the parents.Temporary removal to a convalescent home is largely.a line of least resistance and can be permanently.,effective only if the children return to improved,surroundings and better management. Much goodwork is done by the Invalid Children’s Aid Association,-which visits the homes of all rheumatic children.and gives advice and instruction to the mother.Moreover, many housing defects are remedied by’the Public Health Department. It is important,when diagnosing the conditions of each child, todecide whether the disease is in an active or aquiescent stage. Active cases require thorough and.sustained treatment. If the family can afford a

,private doctor, they are advised to call him in ;if they cannot, the child is sent to a hospital. Quiescent,cases are examined at appropriate intervals, andinany of them, together with all children dischargedfrom hospital, are sent to convalescent homes. Thespecial schools for physically defective children areinvaluable for some of the older children who sufferfrom relapsing rheumatism or for those whose hearts.are too badly damaged to allow them to attendthe ordinary County Council schools. It appears,from the analysis of 200 cases of rheumatic children,:that the females preponderate at all ages, but especially.between 11 and 13. The highest relative incidencein male children is between 5 and 8, but the highestpeak is at 12 for both sexes. Heart disease wasfound in 17-5 per cent., none of whom improvedunder observation. Fifty-four per cent. had normalhearts when first inspected, but four of thesesubsequently developed heart trouble. The remaining28-5 per cent. were classed as doubtful ; 12 improvedunder observation and one deteriorated.

There appears to be no relation between the state ofthe heart and tonsillectomy, but the investigationshowed that the tonsils had been incompletely removedin 45 out of 85 tonsillectomised children, a proportionwhich suggests that the guillotine operation needsmuch skill and experience. The fact that rheumatismbegan in 27 children after an incomplete operation.and in only 10 after a complete one indicates thatcomplete removal gives a certain amount ofprotection. Moreover, the rheumatic manifestations,according to the report, were much lighter in thosechildren who developed the disease after completetonsillectomy. Only two children whose tonsils hadbeen completely removed suffered from heart disease.Dental caries does not appear to be related to

rheumatism, and constipation occurred in only11 per cent. of the children examined. The proportionof children with a history of exanthemata was muchthe same as that noted by other workers. The firstpart of the report is by Dr. James Fenton, the medicalofficer of health, and Dr. Lightwood ; whilst thesecond part is, as we have said, the work of Dr.Lightwood and Dr. Davies. The whole forms auseful contribution to the current knowledge ofrheumatism, and we await its successor with greatinterest.

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THE REDUCTION OF INTUSSUSCEPTION.

THE danger of delay in the acute intussusceptionof children makes one chary of putting off operationin order to try other forms of treatment, and

manipulation and enemas have e therefore beenabandoned in favour of immediate surgical interference.A method of reduction by manipulation and bariumenemata under close radiological control neverthelessseems worth consideration, and the results of treat-ment on these lines in five acute cases in youngchildren have lately been described by Dr. JacobNordentoft.1 In three of them reduction was

effected successfully. In the fourth case manipulationfailed ; operation revealed an ileal intussusceptionwhich had progressed further and invaginated thecolon ; and the child died after this had been reducedwith great difficulty. In the fifth case, which was ofthe colo-colic variety, manipulation was a failure butoperation proved successful. In all the cases theintussusception had a characteristic appearance underthe X rays. At its apex the barium was held up by aconcave line which embraced its head by two slenderarms, whilst from the mid-point of the concavity athin streak of barium could be seen trailing up thelumen of the invaginated gut. In the first threecases reduction was secured by external manipulation,by injection of enemas under pressure, and byinversion of the child if necessary. The actualprocess of reduction could be clearly watchedradiologically, the whole colon and appendix graduallyfilling with barium, which finally flowed unhinderedinto the small intestine. Nordentoft draws attentionto the value of X rays in the diagnosis of intussuscep-tion in doubtful cases, and points out that it rarelyinvolves the use of an anaesthetic. The advantageof avoiding both an anaesthetic and an operationneed hardly be emphasised, and the only question iswhether preliminary manipulation affects the chancesof the child surviving an operation should this beneeded later. Nordentoft considers that sometimesit may actually make the operation less severe bybringing about a partial reduction.

THE HUNTERIAN MUSEUM.

ADDITIONS made during the vear to the collectionsin the Museum of the Royal College of Surgeons ofEngland will be on view in Room I from Thursday nextuntil Saturday, July 27th. Many of them are of interestto medical men, more especially the fine series of speci-mens illustrating von Recklinghausen’s disease. Thisdisease, although uncommon, is of sufficient frequencyto exclude it from the category of pathologicalcuriosities, and usually comes before the practitionerin the form of multiple fibromata. The specimensillustrate the remarkable convoluted masses ofenlarged nerves, and the extensive involvement, notonly of the peripheral nerves, but also of the greatplexuses, the vagi and other cranial nerves, and thesympathetic system ; pigmentation of the skin is alsowell shown, and the less recognised alterations ofbones and joints occurring in cases of elephantiasisdue to the disease. The 30 new specimens of variousdiseases of the central nervous svstem form a serieswell worthy of study ; and the same may besaid of the numerous specimens of disease of thethyroid gland. Attractive single specimens cannot

1 Acta Chir. Scand., 1929, lxiv., 519.