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"walnut brain." Dr. Ironside divided the cases

into (1) cortical types (symmetrical) ; (2) striatal

types (symmetrical) ; (3) cortico-striate types (some-times symmetrical); (4) cerebro-cerebellar types.Transitional cases might also be seen. He had notfound any dependable relationship between the

physical failure and the mental failure. Thesechildren varied greatly in the degree of persistencewith which they pursued anything. The prognosisin any given case depended on the physiologicalresidue of power which a careful assessment revealed.Orthopedic treatment was important, and he advo-cated a closer discussion over these cases between theneurologist and the orthopaedic surgeon.

BRITISH INSTITUTE OF RADIOLOGYINCORPORATED WITH THE RONTGEN SOCIETY.

THE Annual Congress of this Institute was heldfrom Dec. 2nd to 4th, at the Central Hall, West-minster, under the Presidency of Dr. A. E. BARCLAY.It was officially opened by Lord RUTHERFORD,who spoke on the origin of the gamma rays, whichwere, he now thought, derived from the motions ofalpha particles in the nucleus and had nothing to dowith the beta rays.A cinematograph film by Prof. F. HAENISCH

(Hamburg) followed, showing experiments on theinflammability of films.

Sir JAMES JEANS then delivered the fourteenthSilvanus Thompson Memorial Lecture on

What is Radiation ?

He described radiation as a shower of discrete photons-or bullets-each carrying energy and momentum.The theory of relativity had brought the fundamentalcorollary that all energy had mass associated with it.A disturbance of a single atom produced one completephoton and one only, and the loss of mass of theatom was exactly equal to the mass of the resultingphoton. When the disturbance caused a rearrange-ment of the outermost layers of an atom only, theresulting change of mass was only a few millionthsof the mass of one electron and the photon had thewave-length of light. If the disturbance caused ’’

rearrangement of the inner electrons of the atomthe result was X radiation, and the photon had a massabout one-ten-thousandth of that of an electron.The photons of the most penetrating radiation knownhad a mass about equal to that of an atom of helium.Photons might be looked on as bits of energy whichhad broken loose from the electric charges of theuniverse. They were not simply bullets, but hadalso wave-like properties. Their motion was un-

hampered by the retarding effect of an electric chargethat caused electrons and protons to move always ata speed less than that of light. The sun distributedphotons through space at the rate of over four billiontons a second, but the electric light companies charged17,000,000 an ounce for them. Were it possible toannihilate matter, an ounce of it could be turned intoan ounce of photons.The second session was devoted to technical

physical papers on advances in X ray engineering,economy and quality in radiology, the X ray emulsion,the power factor in radiography, and experimentalradiography with gamma rays. Dr. R. G. Canti’sfilm showing the effects of radium on living tissuescultivated in vitro was shown.

The Twelfth Mackenzie Davidson Memorial Lecturewas delivered by Prof. HANS HoLFELMR (Frankfort-on-Maine), who took as his subject a comparison of

Medical, Surgical, and Radiological Conceptionsin relation to the treatment of disease. Surgicalconceptions, he said, were almost entirely topo-graphical and anatomical, rather than physiologicaland biological. Surgical prognosis was as definiteas prognosis could be, and depended largely on

the amount of radical treatment that was possible.Human life depended on the surgeon’s control of

bleeding and sepsis, and he operated as an artist,taking great responsibility and leaving relativelylittle to the organism itself. Surgeons looked forimmediate results, and found it hard to understandwhy the radiologist must wait for weeks before

deciding whether a growth would yield to his treat-ment. Close cooperation between surgeon and

radiologist had greatly improved late results. Eachmust appreciate the other’s position. The surgeonwas a great artist, whom no one might contradict, andwas the hero of the hospital.

Quite different was the physician, who had to studythe diseased organism as a whole and every singleorgan and function, often by prolonged and complexmethods. His work was much more contemplative,comparative, and detailed. He was the great scepticalobserver, always realising how difficult it was to

penetrate the veil that covered the diseased organism.He could never be satisfied with a symptomaticdiagnosis. Disease had been described as obstructionin the gear-box, and this well expressed the com-plicated mechanisms involved. He was bound totake a somewhat negativistic attitude towards

therapeutic results. The marvellous ability of the

organism to recover without treatment and theabsence of any effect from strong drugs had led to atherapeutic nihilism, which had been only slightlyshaken by modern chemotherapy. Most remedieswere altered or diluted by the body fluids before theyreached their object. Therefore the physician realisedhow small a power he had to modify disease and mustbe less the man of quick activity. than the manof critical judgment.

Radiological diagnosis, like surgery, went alongtopographical lines in many ways, but the functionof the gastro-intestinal canal had been an earlysubject of radiographic study, which combined thepowers of medicine and surgery and answered manyspecial clinical questions. Modern radiographic diag-nosis was a very scientific and artistic proceeding,demanding a thorough acquaintance with techniqueand with medicine. Radiotherapy had at firstfollowed surgery very closely, but had only triumphedwhen it had learnt to differentiate the surgical pointsof special value to itself. It was by no means confinedto malignant disease, though that was indeed itscentre. The earlier methods had been very similarto surgical operations, with the aim of completedestruction, and the radiologist had been rather aphysicist or technician. The modern radiologistmastered his Rontgen dose much as the surgeonmastered his knife, and would no more leave thecontrol of his work to a technician or assistant thana surgeon would hand his knife to the nurse during anoperation. Curiously enough, though, he could wellleave the actual treatment to a technician ; his greatskill and care were required while the field wasbeing localised, before the actual treatment dose wasstarted. His work demanded much time and devotion.Radiotherapy combined the topographical ideas of

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surgery and a complex technique into its own newmethod, and biological research and clinical observa-tion had shown that the single " surgical " dose wasless efficient than protracted dosage. His prognosiscould not be as definite as that of surgery, as theresult depended on the capacity of the organism totake advantage of the chance given it. Greatclinical and radiotherapeutic experience was necessary,for modern radiotherapy ; it had become an essentiallyclinical method. The parents should realise thattheir child had now grown to manhood and must begiven autonomy ; full control of the patient.

At the third session, Sir THOMAS HORDER opened adiscussion on the

Radiation Treatment of Leukaemia.

He urged the importance of cooperation betweenphysicians and radiologists. The essential pathologyof leukaemia still eluded workers ; the two chieftheories were the infective and the neoplastic. It was

unhelpful to view it as a primary anaemia. He thoughtradiation acted indirectly rather than directly, but itsmechanism was not really known. Its action was

symptomatic rather than curative. Life was not

greatly prolonged, but the patient’s comfort couldbe greatly enhanced by skilful and well-plannedradiation. Even if he felt quite well he remainedpotentially leukaemic. Its latency was one of the

striking features about leukaemia. The aim oftreatment was not a normal white cell count ; the

haemoglobin and red cell count should be restored tonormal if possible, but the important thing was thegeneral condition. The leukaemic were not immunefrom the aplastic anaemia produced by radiation in thehealthy. Re-treatment should not be given merelybecause the white cell count had risen, but only forgeneral relapse. Recumbency had a remarkableeffect on the blood count, and general therapeuticmeasures and rest are essential. The indicationfor re-treatment was a definite subsidence in the

general state. On the whole, arsenic and similar

drugs should be suspended during radiation treatment,and restored afterwards. Phenylhydrazine, benzol,and naphthaline tetrachloride were potent drugs andmany patients were peculiarly susceptible to them.The danger signals in radiation treatment were

pyrexia, myocardial weakness, renal insufficiency,and haemorrhages. Acute lymphatic leukaemia wasnot suitable for radiation, unless there was some specialpressure trouble ; nor should radiation be given duringacute phases of the chronic disease, or if Addisoniananaemia complicated the picture. Gout was a commoncomplication, not related to radiation. A hard spleenwas a great nuisance. When present thoracic radiationmight be useful. Glands should be irradiated inany case for the patient’s sake. This was a field forclinical research, and controls would be very valuable.

- Dr. N. S. FiNzi described the effect of radiationon cases treated by him. He thought that mostpeople under-dosed leukaemia, because. it was. quiteeasy to kill with X rays and because much too muchattention was given to the white count and too littleto the red count. After a typical spleen dose (F.D.24 c.cm ; field 20 cm. diameter ; Al. 5 mm. ; 7 H=378r=85 per cent. of an erythema dose) the whitecells fell rapidly, showed a secondary rise, anotherfall, and another rise. The red cells, on the other hand,after a small initial fall, rose fairly steadily, and thehaemoglobin with them. Radon solution had beentried in three myelocytic cases, with indifferentsuccess.

The survival, of acute and chronic myelocyticcases together, showed an average of over a year;

three had lived over three years and three over fouryears. The lymphatic type showed a survivalfrom four days to five years, with an average of18 months. The results seemed to be better in the.myelocytic type. In the terminal stages patientsmight fail to respond at all to radiation. Evenmoribund cases were included in the statistics.Treatment of long bones had been discarded, as theeffect of radiating the spleen was so much better.Improvement on radiating the lower chest was

slower than that following treatment of the spleen.In the lymphatic type radiation would reduce theglands without greatly affecting the blood picture;again, treatment to the spleen was better. Greatcare must be taken not to give too big a dose to theglands. Irradiation of the whole trunk had givengood results abroad.The best results were obtained with large final

doses and small initial ones. Heavier filtration and

higher voltages seemed likely to give better results.Dosage should be controlled by frequent blood counts,the red count and the haemoglobin being the deter-mining factors.

Dr. A. PINEY described work based on the principleof treating as mildly as was compatible with obtainingresults. Irradiation of the long bones and of thespleen had been used, and the results had beensatisfactory. The full effect of radiation was notobtained right away, but the cell counts of the

peripheral blood were not true indications of thestate of the marrow. It was safe to reduce the whitecells to approximately normal levels provided thedecrease was mainly in the abnormal cells and not inthe normal cells. In aleukaemic phases and cases thewhite cell count could be raised by repeated injectionsof sodium nucleinate.

Dr. J. H. DOUGLAS WEBSTER mentioned the greatdifferences of pathological opinion on leukaemia. Theacute cases were hopeless. A good deal of the effectof radiation was an indirect one; satisfactoryresults had been obtained by transfusion of irradiatedblood and by applying radium to the feet. Possiblythe effect was hastening the maturation of immatureforms. Immature forms could not migrate, so theycollected in the blood. Normal leucocytes were saidto be found in the saliva in great numbers aftertreatment. The metabolic changes were interestingand,had not been greatly studied. Dr. Websterdescribed his results in 50 cases, ranging in age from8 to 72. He thought the myelocytic type showed themost dramatic effects but that the end-results werebetter in the lymphatic type. The effect on theblood might continue for months after one course ofradium. Radiation should be held in reserve untilthe patient began to go downhill. Radon had alsobeen used, in tubes over the spleen. There seemed tobe no great difference in the effects of the variousX ray methods.

Sir THOMAS HORDER, in reply, emphasised theimportance of being sure of the diagnosis before

estimating results. The blood picture was; not thedisease but the indication of some disease much furtherback. A patient would not always respond to

leucocytic stimulants, and it was therefore wise tobe guided by the blood picture until a more reliablecriterion was found.

Lipiodol in the Diagnosis of IntrathoracicDisease.

A discussion on this subject was opened by Dr.L. S. T. BURRELL, who said that lipiodol could beintroduced nasally, orally, or through the cricothyroid membrane, and described the techniques.

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The chief indication for lipiodol was bronchiectasis ;it should be used before any operation of any mag-nitude. Treatment depended largely on the extentof the bronchiectasis, which was difficult to estimateclinically. Excision was a very satisfactory treat-ment if the disease was localised. Lipiodol was alsouseful for diagnosis in cases of haemoptysis, and had ; Isaved many bronchiectatic and other patients fromthe sanatorium. It was less useful in lung abscess Iwhich it did not enter. It would often suggest thediagnosis of bronchial carcinoma. In pyopneumo-thorax lipiodol might be used to locate a perforation,but a little pepperminted air or methylene-blueinserted with a pneumothorax apparatus gave sufficientindication of the existence of a hole. Lipiodol was,as a rule, so harmless that it could be given to themost ill patients, but in pulmonary tuberculosis itsometimes caused an exacerbation rather like that

produced by tuberculin. Iodine poisoning was some-times seen, therefore lipiodol should not be used as aroutine or indiscriminately. The chief contra-indication was when no benefit was likely to resultfrom its use.

Dr. STANLEY MELVILLE said that chronic coughwas no longer regarded as the important aetiologicalfactor in bronchiectasis. Haemoptysis was veryoften the only symptom. The initial lesion was

commonly in the bronchial wall, often an ulceration.There was as a rule extremely little fibrosis ; in factthe thinness of the bronchus was often striking.A large proportion of bronchiectasis might be con-genital. His bias was strongly in favour of the crico-thyroid route for lipiodol. The risk of laryngealspasm by the nasal route was not worth running.One injection was not enough to exclude bronchialdilatation. Dr. Melville showed a number of slidesof lipiodol radiological investigations.Dr. JAMES MAXWELL thought that the indications

for lipiodol were getting fewer every year. The oralroute had the disadvantage that the introducercould not tell where the lipiodol was going while hewas putting it in. With the nasal method it couldbe put in while the patient was being screened, butthe passage of the catheter was not always easy.The great advantage of the crico-thyroid route wasits certainty, but the cannula might be pushed toofar or not far enough. If air did not enter the syringeeasily on withdrawal of the plunger, no injectionshould be made. The nasal route might provelater to be the method of choice. Before under-

taking to use lipiodol it was important to test forsensitiveness to iodine and cocaine by giving potassiumiodide and cocaine beforehand. Some other sub-stance could be used for iodine-sensitive patients.The amount of lipiodol used should vary accordingto the nature of the case, from 20 c.cm. to 40 c.cm.If a blocked bronchus was suspected 5 to 10 c.cm. wasample to show the condition with no risk of collapse ofthe lung. In chronic empyema with sinus, lipiodolmight be valuable to show broncho-pleural fistula,and should be used as a routine.

Dr. DUNCAN WHITE advocated oral injection,which was simple provided that the patient wouldcooperate with confidence. The success of the methoddepended on control of the tongue. The patientwas first asked to breathe with his mouth open, thenwith his tongue protruded, and then with his tongueheld by the operator. Lipiodol should be used inall cases of haemoptysis, and to define the site ofstenosis in carcinoma of the lung with atelectasis.

Dr. W. J. FENTON described the technique of the

oral method, which, he said, depended entirely on theanaesthesia, which must be induced by a spray usedtogether with a laryngeal mirror. Patients were

quite contented. An assistant must hold the tongue.Dr. Fenton showed his electric laryngeal mirrorwhich dispensed with a head-mirror. Some form ofpressure was needed, and to avoid the difficultyof working a bellows he had designed an apparatusfor utilising compressed air. He preferred a metalsyringe because glass broke so readily. The injectioncould be watched the whole time by this method.It was easier if the patient was recumbent. The

quantity of lipiodol should be small; 5 c.cm. wassufficient in a good patient lying down. Mere-

physical or radiological examination was insufficient.to show bronchial dilatation. Lipiodol remaineda little time in the trachea and there was no need torush the patient to the examination couch. He

objected to the nasal route because it was a blindmethod. After crico-thyroid injection patients com-plained of difficulty in swallowing for 24 hours, andthere might be cellulitis of the neck, in unskilledhands.

Dr. J. V. SPARKS showed slides illustrating lipiodolinjections and their advantage in diagnosis.

Dr. PETER KERLEY said that more than half of hiscases of bronchiectasis in children lacked physicalsigns, and would have been missed but for lipiodol.It was better to do too many than too few lipiodolinvestigations. These children had been clinicallydiagnosed as chronic bronchitis or post-pneumonicfibrosis. There were three points in the differentialdiagnosis : (1) there was invariably persistent in-creased translucency due to compensatory emphysemain infantile bronchiectasis ; (2) the diaphragmaticmovements were usually better than those of post-pneumonic fibrosis and chronic bronchitis ; (3) whena lobe was collapsed there was invariably a congenitalbasis for the bronchiectasis. The lobe was collapsedbefore it was bronchiectatic.

Dr. A. ORLEY justified the nasal method. He said

laryngeal spasm was not so bad as Dr. Melville

thought. The method was not blind, as the patientwas put on the X ray table as soon as the catheterwas introduced. Pictures should be taken as soon as

possible to get a good outline of the bronchi, andevery step of the procedure should be watched.

Future of the British Institute.

Dr. A. E. BARCLAY, in his presidential address,traced the history of the Institute and the increasingimportance of its medical side. The object of theInstitute should be, he said, to attract all users ofradiations, but it was almost impossible to make aprogramme suitable for all. Sectional meetingsoffered a solution which had not, in fact, been favoured.Medical radiology in this country was crying outfor opportunity. The Institute was now well equippedto teach the technical side of radiology, and its

recognition as a training school was very important.Meanwhile it was hard to satisfy the needs of thephysicist members ; perhaps the Institute could

specialise in one section of radiological physics.Dr. Barclay recommended the foundation of autouo.mous sections without any change in the constitution.

I BETHLEM HOSPITAL : THE QUEEN’S PORTRAIT.-To commemorate the opening of the new Bethlem Hospitalby the Queen, the Lord Mayor of London last week at a.meeting of the Court unveiled a portrait of Her Majestywhich has been presented by Lord Wakefield.