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iug, set out the main purpose of the Federation as toraise the standard of work among medical women andto promote active friendship among them, especiallyfor the support of those in isolated places. Dr. JaneWalker proposed " The Guests " in anecdotal vein.Mrs. Wintringham, M.P., and Sir George Berry, M.P.,responded. Mr. H. J. Waring proposed " The Chair-man," suggesting to the Federation the appointment ofan advisory body to weed out unsuitable entrants atthe outset of their career. Lady Barrett, in responding,laughingly disclaimed on behalf of medical women the.sagacity to foresee the successful practitioner in thegirl leaving school. She and other women speakersrefused to be pessimistic in regard to the outlook forthe woman practitioner or her ability to earn her ownliving.

GONORRHŒA, EPIDIDYMITIS, AND STERILITY.

THE treatment of gonorrhcea and its complicationsin the educated man may be one of the most subtleproblems that can confront a practitioner, and happyis one who can point to a series of cases where nopermanent damage, physical or psychical, has beensustained. The widely disseminated knowledge of theaetiology and possible end-results of gonorrhoea, thoughit may be, and probably is, to the interests of the,community as a whole, may complicate the positionof the individual sufferer without bringing him muchcompensatory advantage. For though much is knownin a general way, it is mostly impossible in the earlystages even for an expert to inform a patient exactlywhere he is likely to stand as regards the two greathorrors which may fill his mind with apprehension-infectivity and sterility. Of these it is easier toprophesy hopefully as regards the former. Thepractitioner may nowadays with a fair degree ofsafety assure the patient that under careful treatmenthe will eventually be non-infective. The secondremains a more doubtful proposition and dependslargely on the success with which complications areavoided. The danger of sterility following an attack ofgonorrhcea is, perhaps happily, less well known amongpatients, who do not realise that gonorrhceal epididy-mitis is the commonest of all sources of sterility in themale. The figures published 1 boy Benzler in 1898 areinstructive. This observer followed the record ofGerman soldiers with a previous history of gonor-rhoea who had been married for three years or over,special attention being directed to a history ofepididymitis. Of those who had escaped epididymitis,10-5 per cent. were childless, of those who had hadunilateral epididymitis 23-4 per cent. were childless,of those who had had bilateral epididymitis 41-7 percent. were childless. It is clear that a great numberof childless marriages must be due to a previous attackof gonorrhœa in the husband, and particularly to anattack complicated by epididymitis.On page 1020 of our present issue Mr. Kenneth

Walker sets out the main points of importance intreatment if inflammation of the epididymis, or at leastsuch extensive fibrosis of its minute channels as

may lead to sterility, is to be avoided. Physicalproblems, however, are less difficult to tacklethan the psychology of the patient at the time ofonset of the disease, at the time of the complicatingfactor of epididymitis, and at any future time whenhe may desire to marry. It is at these crucial moments,when the patient is suffering from the misery of self-reproach, that the practitioner may be called upon forinformation or reassurance, neither of which he is ina position to give without reserve. Here a word ofwarning may be in place. Many patients do notrealise that the rigorous so-called " marriage tests "insisted on by careful surgeons are tests for infectivityonly. It is unwise, however, to leave it at that-and to allow them to marry, especially if they havehad bilateral or even unilateral epididymitis, withouta hint that they are less likely to be fertile than thenormal man. The results of well-meant reticence onthis point may be unhappiness or even recrimination

1 Arch. f. Derm. u. Syph., xiv.

if the wife is subsequently examined and the probablecause of sterile marriage is traced to the unconscioushusband. On the other hand, the practitioner whoknows the temperament of his patient may fear toproduce morbid questionings which may wreck twolives without due cause. In hospital practice it maybe impracticable to do more than answer definiteinquiries, but in private practice the suggestion of afertility test would give opportunity for a discussion ofthe situation, even should no final verdict be reached.The best time to bring up the subject will hardly be thelast of the three stages of anxiety to which allusion hasbeen made. Rather let the first stage be chosen when,in the presence of personal physical discomfort andthe possibility of infectivity, the menace of ultimatesterility seems, as indeed it is, remote. A warninguttered then could hardly further depress the

, spirit of one afflicted, and might help to ensurethat rest in the early stages which Mr. Walker,in common with other authorities, regards as

one of the most important factors in the pre-vention of complications which may lead tosterility. ____

EXPERIMENTAL CHOLECYSTITIS.

NEARLY 100 years separate us from the time whenLouis first demonstrated the association of typhoidfever with lesions in the gall-bladder, but it was onlyin the " eighties " of the last century that experi-mental work on animals began to show us the trueimportance of such associations. These and subsequentresearches are admirably summarised in a long essay 1by M. G. Peterman, of the Washington UniversitySchool of Medicine. In the same paper he gives anaccount of his own work, which confirms previousexperiments and throws into strong relief certainimportant aspects of the problem of gall-bladderinfections. His experiments may be briefly summarisedas follows :--

1. Injections of cultures of Staphylococcus albus into theportal circulation of rabbits led to the appearance of theorganisms both in the heart-blood and in the bile withinthree minutes of the injection.

2. The same result followed injection of the organismsinto the veins of the ear ; but if the cystic duct and neigh-bouring vessels were tied the results were negative. If,however, the cystic ligature was performed ten days beforethe injection the results were positive.

3. In another series of animals virulent organisms wereinjected into the ear veins. Seven or more days later fourof the seven animals (rabbits) were found to have theorganisms present in the bile and the remainder had anacute cholecystitis, although in none of them did the heart-blood now yield organisms.

4. A series of seven dogs were injected with cultures ofStaphylococcus aureus into the portal vein, three of themwere given a second injection, this time of Streptococcushœmolyticus, two to six days later. In all these animals theautopsy revealed cholecystitis affecting the wall of the gall-bladder and leaving the mucosa almost intact., 5. In the above animals an acute hepatitis was demon-strable in addition to the cholecystitis, and in four of themthere was an interstitial pancreatitis as well.

6. In a series of rabbits a haemolytic streptococcus wasrecovered from the wall of the gall-bladder a few hours after

injection of the organisms into the portal vein, and thesame result followed injection of the organisms into theappendicular vein. In all such cases the liver and pancreaswere also affected.’ 7. In one rabbit in which the organisms were injected intothe walls of the appendix similar results were found.

Discussing these results Peterman lays stress onthe lymphatic route of infection both in the productionof cholecystitis and of its complications, hepatitis andpancreatitis, and argues that in cases of gall-bladderinfections secondary to lesions in the bowel and portalsystem the organisms travel first to the liver andproduce a hepatitis to which the cholecystitis is

secondary. If this be the case it seems probable thatthe path from the liver to gall-bladder is via thelymphatics. He also calls attention to the relativelysmall degree of damage to the mucosa, as compared

1 M. G. Peterman : Surgery, Gynecology, and Obstetrics,1923, p. 522.

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with the other layers of the wall of the gall-bladder incases where that organ has been removed for innam-matory disease in human subjects, and finds in thisconfirmation of his view that such cases are examplesof infection via the lymphatics from the liver. Wenotice that in this essay the author attaches consider-able importance to the work of Rosenow who claims 2 Ito be able to produce specific lesions in rabbits-appendicitis, cholecystitis, gastric ulcer-by injectionof streptococci recovered from abscessed teeth, or

similar lesions in human subjects with such diseases.It is perhaps significant that this dramatic work, whichwas published in 1915, has as yet received no sufficientconfirmation, and it is but fair to point out thatwithout some such confirmation of the origin of suchinfections we remain very much in the dark as to thetrue nature of the pathology of cholecystitis and itscomplications. _____

PITUITARY SECRETION.

IN a contribution to the current number of the.Jouraal of Physiology, Prof. W. E. Dixon deals withthe conditions which cause secretion of the pituitarygland to meet the needs of the animal economy.Anaesthetised dogs were used ; tracheotomy wasperformed, the blood pressure recorded, and all injec-tions were made into the right femoral vein. Thecerebro-spinal fluid was collected from the subcerebellarcisterna. The normal cerebro-spinal fluid showed everyknown chemical and physiological action of pituitrin,although the amount of this substance in the fluidvaries greatly. A very large number of negativeexperiments was obtained ; no form of stimulation ofsensory nerves or of vagus and sympathetic in theneck caused any change in the secretion of thepituitary, and the inhalation of oxygen and carbondioxide was likewise without effect. Certain drugs-e.g., alcohol, chloroform, urea, caffeine, histamine,adrenalin, several alkaloids, and glucose were injectedor given by inhalation, all with negative results.Preparations of the posterior lobe of the pituitaryinjected into the general circulation caused pituitrinto appear immediately in the cerebro-spinal fluid.What purpose the pituitrin serves in the cerebro-spinal fluid is not clear, but any excess rapidlydisappears. An excess in the blood is absorbed by thegland and some of it reaches the cerebro-spinal fluid ;an excess in the cerebro-spinal fluid is excreted rapidlyinto the blood. The pituitary gland secretes into thecerebro-spinal fluid ; pituitary extract injected into ]the circulation causes the gland to secrete, and whenit is injected into the cerebro-spinal fluid it rapidlycauses the ordinary systemic effects by passing intothe general circulation. A balance is struck betweenthe amount in the blood and the cerebro-spinal fluid.Many animal extracts were tried, and it was found thatovarian extract specifically excites the gland to secrete.The effect is immediate and lasts only two or threeminutes. The active substance is not in the corpusluteum. Duodenal extract causes a secretion after onehour, but neither so much nor so constant as thatcaused by ovarian extract; the effect, however, ismore prolonged. Some ingenious suggestions, hinginground the fact that the pituitary is a remnant of agland once secreting into the alimentary canal, aremade, so that it is perhaps not extraordinary that itssecretion should be associated in some way with thefunctions of the alimentary canal. Pituitary extractincreases tone in the small intestine, and diminishestone in the large intestine.

THE LIBRARY OF THE COLLEGE OFPHYSICIANS OF PHILADELPHIA.

THE libraries of the New World continue to flourish,and the Library of the College of Physicians of

Philadelphia ranks among the most prosperous. Thetotal number of volumes in this great collection nownumbers 136,489. During 1922, 6430 volumes werereceived, in addition to 10,418 pamphlets and 16,016

2 E. C. Rosenow : Collected Papers of Mayo Clinic, 1915, p. 276.

numbers of various periodicals. Donors in 1922numbered 412, who between them have made 955distinct presentations. The library is especiallyfamous for its incunabula, of which it possesses 316volumes. A score of works, some wellnigh priceless,have now been added, and these include the veryearly " Zophilogium " of Jacques Le Grand, printedby Rysch at Argentoratum (Strasburg) in about theyear 1470. This is the editio princeps of the oncefamous work, which Caxton translated into Englishunder the title " A Book of Good Manners." Othervery early books are the " Expositio LibrorumNaturalium" of Aristotle, printed by Valdarfer ofRatisbon at Milan, 1476, and " Quaestiones deTribus Principiis Rerum Naturalium " by AntoniusAndreas, printed at about the same date by Canoziusat Padua. The gem of these additions to an alreadyunique collection is perhaps the " Contra Pestem "of Johannes Mercurius, printed at Rome by JohannesBesicken in 1493. The book is not mentioned byHain, and is pronounced by Mr. Voynich to be theonly known copy. It is not, however, the earliesttreatise on the Plague, for Stainhowel, of Uhn, hadalready in 1480 published "Von der Pestilenz "

(" Regimen Pestilentiae "), although the latter factdoes not seem to have been known to his translator,C. Ehrle, who described his manuscript in 1880.Other specifically medical works are the " De Plinii etAliorum in Medicina Erroribus," of date 1492 (Ferrara),by Nicholaus Leonicenus, and Maimonides’ " DeRegimine Sanitatis ad Soldanum Babylonie," pub-lished at the Monastery of St. James de Ripoli inFlorence in 1477. The works we have mentionedhave been purchased by the " Fund for Rare Books "and the Funds of William F. Norris and Horace Magee.These agreeable resources are a feature of the Phil-adelphia Library for which English librarians canonly envy their learned colleague, Mr. Charles PerryFisher. To the Fund for Rare Books is also due theacquisition of a number of specially interestingsixteenth and seventeenth century works, includingeditions of David Abercromby, Abraham Aben Ezra,Henricus Cornelius Agrippa, Albertus Magnus, ValeriusCordus, Descartes, Raymund Lully, Simon Portius,to name only a few authors among many.

AN INDICTMENT OF THE PANEL SYSTEM.

THE panel system has been brought into the lime-light by the criticism of the coroner for North-EastLondon at a recent inquest. The conduct of thepractitioner concerned will be a matter for furtherinquiry, but it appears to be necessary to remind thepublic that the conditions of medical practice so

severely condemned by the coroner were in existencelong before the panel system was established. In theDaily N e’Ws there was recently published a veryinteresting article on " The Back-Street Practice,"by Dr. F. G. Layton, in which a true picture is drawnof the state of things which formerly prevailed. " Theclub doctor was willing to work for a capitation fee solow that only numbers, extraordinary numbers, ofcapitation fees made it worth while. He had so manynames on his list that he could deal with little, if any,of his work properly. In those days strangulatedhernias were poulticed until they sloughed ; appen-dicitis patients perforated and died..." " Readers ofTHE LANCET may recall the investigations whichresulted in the publication of the " Battle of theClubs." If the poor man’s doctor was overworked inthose days, he is more heavily burdened to-day,when the poor industrial centres are in question,because the provision of medical benefit brings to hissurgery insured persons who hitherto had recourse tothe out-patient departments of our large hospitals,or who were treated under the Poor-law.How is this state of things to be remedied ? Some

provision must be made for the great mass of illnesswhich occurs in the overcrowded industrial neighbour-hoods. The panel system has presented the bestsolution of the difficulty up to the present. Thestatement attributed to the coroner for North-East