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also exercises great care in anaesthetising the parietalperitoneum. Intra-abdominal photography, de-scribed by HORAN and. TEDDY is also done underlocal anaesthesia. A conscious patient is almost anessential, for during the exposure the breath has to be

, held. The main obstacle encountered at the outsetwas that the lamp supplied with the peritoneoscopewas an insufficient source of light, so that a very smalllamp with a very powerful beam had to be invented.According to present technique this lamp must beintroduced through a separate peritoneal opening,but a trocar is being designed which will carryboth peritoneoscope and light-carrier through twoair-locks. ’c

The value of peritoneoscopy depends on the possi-bilities of extending its scope. Up to now it hasbeen useful in the differential diagnosis of liverdiseases, in deciding whether or not to operate incases in which secondary malignant growth is suspectedand in determining the nature of pelvic tumours.The parts of the abdominal cavity readily seen arethe under surface and anterior border of the liver, and,2. Horan, T. N. and Eddy, C. G. Surg. Gynec. Obstet. 1941, 73, 273.

by tilting the patient into the Trendelenburg position,the upper surfaces of the pelvic organs ; between thesetwo regions the intestines get in the way. In obscurecases of jaundice it has been possible to diagnose withcertainty cirrhosis, syphilis and secondary depositsin the liver. An enlarged gall-bladder may be clearlyseen, but the pancreas is not in sight. Tuberculous

peritonitis has been correctly diagnosed, and biopsiesof the omentum and of the liver have given valuableinformation. Fibroids and ovarian cysts are readilydemonstrated. The differential diagnosis of ascitescan be made. Early leaking of blood from an

ectopic pregnancy gives an unmistakable picture.The advocates of peritoneoscopy say they have beenable to save unnecessary laparotomies and givematerial aid in arriving at a prognosis in difficultcases. They do not claim that this is an infalliblemethod of diagnosis, and in fact have found it of mostaid in confirming a diagnosis already strongly sus-pected. The question remains whether surgeons inthis country will think the risk and inconvenienceof an exploratory laparotomy sufficient to makethem adopt this alternative.

Annotations

BACTERIA IN DISTILLED WATER

IT is important at any time to have reliable standardswhen assessing the bacterial content of water, and inwar-time, ’when supplies may be contaminated, suchstandards need to be especially trustworthy. Biggerand Nelson 1 have cleared up some doubts about the

significance of variations in coliform-bacillary counts, andhave called attention to fallacies in methods of filtration.

Though their experiments were primarily concerned withthe technique of water examination, their findings have adirect bearing on everyday medicine. Thus they notethat water which is pure in other respects may acquirefrom rubber tubing, corks or filters traces of powderedtalc, asbestos, silica or other earthy matters ; and thoughthese may be sterile and protein-free their presencemakes it possible for bacteria to grow in the water assoon as it comes into contact with air. These solids donot form the nourishment of the organisms, which live,it seems, on carbon dioxide, traces of ammonia and per-haps other minor gaseous constituents of air. Theaction of the siliceous particles appears to be catalytic ;in their presence distilled water-which normally willnot permit contaminating coliform bacilli to multiply-becomes strongly favourable to their growth. Thisfinding throws light on the work of Knott and Leibel,2who reviewed the factors inducing pyrogenic properties infresh and stored distilled waters used to prepare solutionsfor intravenous injection. Their experience suggestedthat a reaction in the patient was more likely to beprovoked by traces of protein (often bacterial in originand detectable by a rise in albuminoid ammonia) thanby particulate or inorganic matter. Yet they remarkedthat it was a commonplace of the preparation roomthat solutions showing inorganic deposits were veryliable to prove pyrogenic, and if such reactions were to beavoided deposits of any kind were inadmissible. Thework of Bigger and Nelson seems to bring these appar-ently conflicting experiences into line. In the absenceof siliceous matter, bacterial contamination of doublydistilled water is not followed by growth of organisms ;but if sufficient particles of silicate are present multi-plication begins even at room temperature. Bothfactors are thus necessary, but neither the initial con-

1. Bigger, J. W. and Nelson, J. H. J. Path. Bact. 1941, 53, 189.2. Knott, F. A. and Leibel, B. Lancet, 1941, 1, 409.

tamination nor the number of particles present need belarge for organisms to grow. Thus small lapses fromtechnical perfection may produce serious and far-reachingpyrogenic results. No special silicate and no particularcontaminating organism can be held responsible; Biggerand Nelson produced the same results with varioussilicates and with most of the common coliform organ-isms and their variants. It is thus unnecessary to

postulate a special strain of " distilled water bacillus,"

as once was the fashion, or to blame a particular bit of thecustomary apparatus. Those charged with the preparationand care of intravenous supplies must beware of traces ofcatalytic silicate and of the chance coliform contaminant.

CATGUT SUTURES

CATGUT has been employed for the ligature of vesselssince the time of Galen ; it was not until last centurythat it came into use as a suture material. Since thenit has been almost universally adopted, for its qualitiesconform closely to those of the ideal suture, but it has tobe used with discrimination. Howes 1 points out thatcatgut is a foreign body and excites a tissue reactionwhich is sometimes accompanied by infection, parti-cularly when it is used in the skin and mucous mem-branes. Apparently catgut encourages infection byacting as a culture medium. It is also not well toleratedby muscle and in fat, where the poor blood-supply is prob-ably responsible for a low-grade inflammatory reactionwith considerable necrosis and induration. To minimisethe risk of infection and the foreign-body tissue reaction,Howes advocates the employment of catgut in fine sizesarguing that in any case the strength of a sutured woundis limited by the power of the tissues to retain the suture.The tensile strength of chromic catgut no. 1 is about tentimes that of aponeurotic tissue. To employ such a sizeis clearly unnecessary, although allowance-must be madefor the weakening of the thread from absorption, itstensile strength being probably reduced by half four daysafter insertion. Howes suggests that no size greaterthan no. 0 is needed in suturing any tissue and that muchfiner gauges (0000 or even 00000) should be used intissues which have a poor holding power for catgut. Ifadditional strength seems necessary he advises a largernumber of interrupted sutures, although he points outthat there is no advantage to be gained by placing themcloser together than 1 cm. Bowen 2 savs tha,t larger

1. Howes, E. L. Surg. Gynec. Obstet. 1941, 73, 319.2. Bowen, A. Amer. J. Surg. 1940, 47, 3.

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sizes of catgut are actually digested more rapidly and lose. their thread strength earlier than finer ones, because ofthe greater tissue reaction produced by the larger sizesand. the more certain impregnation of the smaller gaugesof chromic catgut during manufacture. Howes main-tains that the incidence of wound infection is reducedand healing hastened by paying attention to these points.These views are supported by previous experimentalwork. Bates 3 points out that the edges of a healthywound do not adhere firmly for the first four days butthereafter the strength of the junction rapidly increasesuntil by the tenth day it approaches normal. The idealsuture must therefore retain its strength during the firstten days of healing. Bates’s experimental studiesshowed that the finer sizes of chromic catgut (000)retained an adequate tensile strength for a fortnight, andthat healing was rapid’when they were used, whereaslarger sizes (3) had little to do after a week, although thewounds were poorly healed even at this stage. Plain

catgut of all sizes was even more rapidly absorbed andaccompanied by inflammatory reaction and delayedhealing. Bower, Burns and Mengle,4 from experimentalwork on dogs, reached similar conclusions regarding thehealing of intestinal wounds and laparotomy incisions.They have applied their experimental findings clinicallywith success. Unabsorbable suture materials have been

growing in popularity in recent years, particularly inAmerica. Those who advocate their use have empha-sised the disadvantages of catgut. Whipple 5 points outthat among the factors influencing wound healing theuse of fine needles and sutures is important, in order toavoid trauma and foreign-body tissue reaction. Hetherefore advocates the employment of silk, but it seemsthat when catgut is used in suitable sizes most of theobjections to it disappear.

VAGINAL EXAMINATION DURING LABOURSo much has been written about the potential dangers

of making a vaginal examination during labour that inthe ranks of the extremely cautious this procedure hasbeen totally vetoed and replaced by the routine employ-ment of the rectal route for diagnosis and prognosis. A

vaginal examination in labour undoubtedly carries withit a small but ever present risk of introducing infectionfrom the perinaeum and the lower reaches of the vaginainto the cervix and uterus or further ; sueh an infectionmay be endogenous from the patient herself or exogenousfrom the examiner’s hand . or person, especially his

nasopharynx. Whatever precautions are taken therestill remains a small risk. Such precautions include theintelligent use of an impervious mask to cover mouth andnostrils, the exclusion from the labour ward of all per-sonnel harbouring any form of nasopharyngeal infection,however mild, not forgetting the common cold and theseasonal sore throat, the employment of complete surgicalasepsis for the examining hand and the use of a drysterilised glove, careful toilet of the area of examination,and the generous exhibition of some reliable antiseptic,such as Dettol cream. If all these precautions are

faithfully observed we have at least given as few hostagesto fortune as we can. But the determining factor is notonly the method but still more the number of examina-tions. One or two vaginal examinations carry but asmall risk, but every repetition increases the danger,especially if the repetition involves a number of differentpeople, such as the outside practitioner, the admittingmidwife, the pupil midwife or medical student, theresident house-surgeon and perhaps as a final court ofappeal the consultant. These multiple vaginal examina-tions constitute a real -danger and should always bediscouraged, since universally accepted figures show thatthe morbidity-rate rises in ’direct proportion to the

3. Bates, R. R. Ibid, 1939, 43, 702.4. Bower, J. O., Burns, J. C. and Mengle, H. A. Ibid, 1940, 47, 20.5. Whipple, A. O. Surg. Gynec. Obstet. 1939, 69, Internat. Abstr.

Surg. 109.

number of antepartum examinations, and moreover it isa contra-indication to cacsarean section should this beultimately advisable.

‘

On the other hand, there is no doubt that vaginal.examination is the only certain method of exactlyassessing the degree of dilatation, of the os in difficultcases-for example, when the presenting part is coveredby a thin membrane of undilated cervix and yet fulldilatation is diagnosed on rectal examination. It is alsothe only accurate way of diagnosing the presentationwhen this is masked by oedema of the presenting partand the rectal findings are equivocal. The enthusiasticsupporters of the rectal route claim that as muchinformation can be obtained by this as by vaginalexamination, but they admit that practice and experienceare essential, and they are mostly prepared to resort tovaginal examination when in difficulty or doubt. Thedangers of the rectal approach are that it leads to a senseof false security and therefore too frequent employmentby too many different people on any one case. Masksand antiseptics are apt to be neglected and the verymethod of examining the rectum readily becomeshaphazard ; thus the inadequately sterilised thumb maybe placed on the introitus. Erving and Meister ask’whether a finger in the rectum which rubs the surgicallydirty posterior vaginal wall into the cervix and over thepresenting part is any less risky than a ’properly andcarefully performed vaginal examination. They sup-port the limited use of the vaginal route with someconvincing figures. In 1000 cases consecutively deliveredin the maternity unit of the Millard Fillmore Hospital,Buffalo, 97-5% of whom were examined vaginally anaverage of 1-4 times, there were no maternal deaths, andthe corrected foetal mortality was 2.7% ; 4-5% of themothers were febrile according to the League of Nationsstandard. In extenuation of even this small morbidity-rate, it must be noted that Erving and Meister’scases were largely complicated and 75% were deliveredoperatively, a fact which in itself accounts for

any sepsis. The conclusion to be drawn is that a

carefully conducted- vaginal examination, done once ortwice only, is no more dangerous than a rectal exami-nation, while its diagnostic exactitude renders it greatlypreferable.

WHY DO MEN MAKE WAR?

VVAR, says Mr. D. W. Harding in " The Impulse toDominate " (London : Allen and Unwin. Pp. 256.7s. 6d.) is a social institution, sanctioned alike by theaggressor nations and ourselves. During the quietperiods between wars the ordinary citizen has no desirefor war, but he has acquiesced in the principle ofdomination or submission as the rule in private life andconfronted with dominant intentions on the other side

(as the citizens on both sides feel sure they are) he cansee nothing for it but resistance. Now come in allkinds of exacerbating influences : innate aggressiveimpulses; propaganda; and rumour—directed or

spontaneous-aided by that process of rationalisationwhich leads even the most intelligent to manufacturereasons for their emotional responses, and by thecitizen’s dim understanding of international affairs.The author notes- the view that psychological theorybelittles efforts to exclude war ; but he maintains thatthe human nature we know is institutionalised humannature, not the biological product that an uncriticalreading of psycho-analysis would suggest. If the psycho-analytic view is correct it means that the emotionsleading to war are "neurotic," for the greater theinfluence of repressed impulses in determining behaviourthe more neurotic it is.

Mr. Harding seems to put his finger on the primaryknot in this tangle when he writes : " The early family1. Erving, H. W. and Meister, E. F. Amer. J. Obstet. Gynec. 1941,

42, 326.