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this course would be greatly enhanced if he wereasked to supervise all the conditions of health andhygiene. The question of expense may be crucialat the moment. The committee asks for the ’

report to be read as representing its views of the’ I.steps which in normal financial conditions wouldbe appropriate for dealing with the defects revealedin the course of its proceedings. It deprecates Ipiecemeal treatment by such preliminary measures.as can be taken without incurring new expenditure.

This may mean that no action can be looked foruntil the economic urge has passed. But no onewho reads the report will be content to let mattersremain as they are, and public opinion may insiston immediate improvement. At all events localauthorities may decide to make fuller use of thepowers they have, and should find their task lightenedby magistrates who have read the report. Prudent

parents will seek medical advice before sendingtheir children to an unknown school.

ANNOTATIONSAWARD TO PROF. THEOBALD SMITH.

THE Manson medal for tropical medical research, ’I.given triennially by the Royal Society of TropicalMedicine and Hygiene, has this year been awardedto Dr. Theobald Smith, director emeritus of thedepartment of animal pathology of the RockefellerInstitute of Medical Research. In association withKilborne in 1893, Theobald Smith showed that red-water fever in cattle was transmitted by ticks, andat the same time demonstrated the passage of infectionthrough the ova of one generation of ticks to the next.This discovery proved for the first time that a

protozoal parasite of mammals could be disseminatedby the bite of a blood-sucking arthropod. Probablybecause Theobald Smith was dealing with a cattlerather than a human disease this great event in thehistory of medicine received scant recognition, thoughit preceded the better known work of Bruce on thetransmission of sleeping-sickness and that of Ross onmalaria. Furthermore, in 1893 Manson’s hypothesisregarding the mosquito transmission of -Filariabancrojti constituted only half the truth, since hethought man was infected via mosquito-contaminatedwater either by swallowing the escaped micronlariseor through their penetrating the skin of man. Indeed,it was not until March, 1900, when Low demonstrated ifilarial embryos in the proboscis of infected mosquitoessent to Manson from the younger Bancroft that thetrue mechanism of their entry during biting wasunderstood. It is thus no over-statement of the caseto say that Theobald Smith was the first to transferthe insect transmission theory of protozoal diseasefrom the realms of hypothesis to those of establishedfact. In 1904 Theobald Smith reported anaphylactic Isymptoms in dogs and rabbits, and in a letter toEhrlich wrote the original description of the classicalanaphylactic shock in guinea-pigs, often known as theTheobald Smith phenomenon. In 1907 he provedthat it was possible to immunise guinea-pigs activelyby the injection of a balanced mixture of diphtheriatoxin and antitoxin and two years later suggestedfurther investigations of the method with a view toits ultimate application to human beings, thus antici-pating Behring and Park’s work by several years.The previous recipients of the Manson medal have

been Sir David Bruce (1923), Senator EttoreMarchiafava (1926), and Sir Ronald Ross (1929).

CEREBRO-SPINAL FLUID IN CEREBRAL TUMOUR.LUMBAR puncture has been followed by death in I

so many cases of cerebral tumour that it is considered Iby many to be an essentially dangerous operationin that condition. And this is undoubtedly trueunless a careful technique is followed. F. FremontSmith1 from a large experience concludes that whenpapilloedema is present the dangers of lumbar puncture

1 Arch. Neurol. and Psychiat., March, 1932, p. 691.

more than counterbalance the information which is

likely to be gained from it. In such cases punctureof one or both lateral ventricles is safer and moreuseful. When, on the other hand, there is no

papillcedema, lumbar puncture is of great value. Afine needle with a manometric attachment is used,and the patient is kept in the horizontal positionduring and after the puncture. The pressure of thefluid is measured, and the absence of block at theforamen magnuin and at the point of the needle istested first by jugular and then by abdominal com-pression. Besides the usual examinations for colour,cells, and protein, a more detailed chemical examina-tion may be made with the view of excluding uraemia,but usually only the minimum quantity requiredfor the essential tests should be removed. With theseprecautions lumbar puncture is not dangerous initself, and it may be of great service in indicating thepresence and the degree of intracranial pressure.But when the patient has been dehydrated bycathartics or by the rectal administration of hypertonicsaline, pressure readings are valueless. Normalreadings may also be obtained with small tumoursin the pituitary region, and with some infiltratinggrowths of the pons.

Ventricular puncture has a special value in thatthe fluid drawn from the ventricle on the side of thetumour may be yellow, and often contains appreciablymore protein than that from the opposite ventricle.The combination of ventricular with lumbar puncturealso has its uses in showing by manometric or colori-metric examination the degree of blockage betweenthese two points on the cerebro-spinal fluid system.A block may be caused by tumour in the posteriorfossa, by closure of the foramina round the fourthventricle, or by a cerebellar pressure cone. Whileit may not always be possible to distinguish betweenthese, there are cases in which combined puncture-has a definite diagnostic value.

In a table attached to his paper, Fremont Smithgives many valuable hints on the differential diagnosisof cerebral tumours from other conditions by suchcomplete examinations of the cerebro-spinal fluid.It would be impossible even to summarise these ina limited space, but they indicate the great numberof questions which must be answered before we canmake the diagnosis of cerebral tumour in the earlierstages. It is not yet generally recognised that aconsiderable proportion of patients with cerebraltumour die without having developed papillcedema,and even when this is present it is necessary toexclude other possible causes for it, of which the mostimportant are sinus thrombosis and hydrocephalus.It is probable that ventricular puncture might solvesome of the difficulties with which these cases aresurrounded, but the difficulties and dangers of theoperation are likely to delay its acceptance as a routinemeasure in obscure cases.