1323LIVERPOOL MEDICAL INSTITUTION.

malignant disease ; there was that big distressing group ofoases whose trouble and often never ended was colitis ; and,of course, there were the children in a well-markedgroup of their own. As regards the gastric group,an important point to remember was that the surgeonshould be very wary of exploring the stomach ofa patient who did not vomit, however large and

splashy the stomach might be, and whatever the skiagramsappeared to show. If, however, there was any suspicion ofmalignancy, that patient must not be left until the matterwas cleared up. Chemical examination of the stomach con-tents would usually give definite information. Concerningthe women with pain in the right side, there were certain

points well worth bearing in mind. Gall-stones were unlikelyto be present unless there was pain in the back ; 20 per cent.of women had some degree of mobility of the right kidney ;if a patient was told that she had a movable kidney she wouldnever forget this fact. Trusses and pads applied in the

hopes of supporting a mobile kidney often pressed injuriouslyon the caecum, damaged the appendix, and so produced a newcause of abdominal pain. One of the greatest harms thatcould be done to a patient was to tell her that the

pain was connected with the ovary; such a state-ment had often started a condition of chronic intro-spection, leading to mental and bodily ill-health. Inthe large group of cases in which the appendix was sus-pected there were two quite distinct classes. Firstly,these were the cases in which there were mild recurrentattacks of pain and uneasiness, which might be due to slightinflammation of the appendix ; and secondly, there werethose in which there was chronic inflammation of the

appendix producing constant uneasiness in the abdomen andgeneral ill-health. The two conditions might be combined,but the difference between them must be clearly remem-bered. In the former, if a diagnosis was made of mildattacks of appendicitis, the only wise plan was to have theappendix removed unless there was some good reason to thecontrary. He did not suppose that many would dispute thisstatement nowadays. Under modern conditions the risk of

appendicectomy was a long way below a half or even aquarter per cent. ; on the other hand, a diseased appendixwas a dangerous possession. Definite localised tenderness,especially after the pain had passed off, was usually the signwhich clinched the diagnosis, and the man who had painto-day and tenderness in the right iliac fossa to-morrow had adiseased appendix. Chronic appendicitis was the greatestsurgical discovery of recent years, but the disease was sur-rounded bya host of base imitations, and the surgeon must pickhis way carefully when dealing with this subject. No patientswere more satisfactory or more grateful than those who hadhad a chronic diseased appendix removed. The subject ofchronic appendicitis had usually been out of health for sometime ; he was a man who ought to be well and healthy butwas not. In a well-marked case the digestion was dis-

ordered ; pain and distension followed the taking of food ;the action of the bowels was erratic, usually constipationwith bouts of diarrhcea ; tongue furred and breath un-

pleasant. The abdominal unrest reacted on the generalhealth, which soon suffered. In such a case, if definiteevidence of trouble about the appendix was found, a

diagnosis might be made of chronic appendicitis, and

operation would assuredly restore the patient to goodhealth and enjoyment of life. The full benefit of operationwas not always apparent at once and careful after-treatmentwas essential, but the ultimate results were excellent.The colitis group of cases presented great difficulties. The

majority of the patients, unfortunately, could get no helpfrom surgery. For many of them, in fact, the worst thingthat could happen was that they should be operated upon.But there was a definite group in which the trouble wasassociated with an infected appendix. There was no doubtthat in certain cases the appendix was the primary focus ofinfection, and the patient could not be got well by medicalmeans until after the appendix had been removed. Themost careful judgment was necessary, for removal of a

diseased appendix might be essential to a cure, whilst, if theappendix was normal, the removal of the appendix waslikely to do harm. If operation should be decided upon,one point was of great importance : never lead thepatient to suppose that removal of the appendix would seethe end of all her troubles ; operation must be regarded asa preliminary step in a complete scheme of treatment.

In children the great majority of cases of abdominal

pain were due either to disease of the appendix or to

tuberculosis of the lymphatic glands. One of the most

striking revelations of abdominal surgery was the frequencyof glandular disease in the mesentery. It was a mostunfortunate thing for the children of this country that theovercrowded programmes of the Parliamentary sessions

prevented the passage of Bills for the control of milk-supplyand the inspection of dairies. One of the results was the

frequency of abdominal tuberculosis. Chronic appendicitisin children was a very definite disease, and Mr. CrispEnglish believed was at least as common as acute appen-dicitis. The text-books contained a scanty reference to thischronic condition, for it was only in the last two or threeyears that it had emerged from the obscurity of the intestinaldisorders of childhood. In the earlier days of appendicitisthere was a disinclination to operate upon children inthe quiescent stage, unless there had been at least onedefinite and severe attack. Later clinical observationshowed that some of the children with disorderedabdomens and unsatisfactory health had, from time to

time, attacks of pain and tenderness about the appendix.Removal of the appendix brought about a remarkableimprovement in the general health, and so it graduallybecame clear that these children had been suffering, andsuffering very decidedly, from chronic appendicitis. Astime had gone by the improvement had been maintained.The children operated upon three or four years ago hadnever turned back. This was convincing that the appendixwas beyond all doubt the cause of ill-health. Once themedical man felt sure about the diagnosis he should adviseoperation, and this for two reasons. One was that the childwould not get well until the appendix was out, and the otherwas the ever-present risk of an acute attack. Acute appen-dicitis was one of the worst catastrophes that could befall achild, and once a child’s appendix had shown signs ofinflammation it should come out. Remove the appendix andthe health would at once improve; good spirits and appetitewere regained, and the child was once more what Naturemeant that child to be.At the conclusion of his address a hearty vote of thanks

was given to Mr. Crisp English on a proposal by Dr. D. W.SAMWAYS, seconded by Mr. RUSSELL COOMBE.

Mr. Crisp English was subsequently the guest of the

society at the Exeter and South-Western medical dinner.

LIVERPOOL MEDICAL INSTITUTION.

Aseptic Technique of the Anæsthetist.-Enucleation of theTonsil. -8uppurative Diseases of the Labyrinth.

A MEETING of this society was held on Oct. 23rd, Mr.ROBERT JONES, the President, being in the chair.

Dr. G. F. R. SMITH read a note on the Aseptic Technique ofthe Anæsthetist, in which he insisted on the preparation ofthe patient’s mouth, on the use of sterilised apparatus-namely, the mask and its cover, the bottle for the anæsthetic,gag, &c. Also the anaesthetist should wear a sterilisedoverall, cap, mask, and gauntlets.-Mr. R. C. DUN spokeof the advantages of the method, especially in operationson small children, where the anaesthetist was of necessityclose to the field of operation.

Mr. THOMAS GUTHRIE read a note on Enucleation of theTonsil. Referring to the technique of the operation he pre-ferred the guillotine operation, introduced by Sluder inAmerica and Whillis and Pybus in this country, for thegreat majority of cases. The method, however, failed in a fewcases of very adherent tonsil, and in these he employedblunt dissection and a snare. Discussing the indications forthe operation Mr. Guthrie expressed the opinion that incases of pure hypeltrophy of the tonsils in children ton-

sillotomy was still the operation of choice, provided that notmore than the capsule and a thin layer of tonsil tissue wereleft behind. In such cases a tonsillotomy, properly performed,was almost always sufficient, and was a less severe operationthan enucleation. Bleeding after the two operations was asa rule about the same in amount, but there was certainly morerisk of troublesome haemorrhage after enucleation than aftertonsillotomy. When repeated inflammatory attacks hadoccurred and the tonsil was grossly diseased, or was formingthe portal of entry for glandular or systemic infection,

1324 EDINBURGH MEDICO-CHIRURGICAL SOCIETY.

enucleation was the only scientific and satisfactory operation.Lantern slides and specimens of tonsils and the instruments used were shown.-Dr. W. SANDERSON, Mr. J. BARK, Mr. C.YORKE, Mr. E. M. STOCKDALE, Mr. A. ADAIR DIGHTON, andMr. W. THELWALL THOMAS took part in the discussion.

Mr. ADAIR DIGHTON read a paper on Observations on theDiagnosis of the Suppurative Diseases of the Labyrinth.After reminding members of the fact that one of them, Dr. Edgar Stevenson, had introduced labyrinthology into Englandas far back as 1896, Mr. Adair Dighton demonstrated thetests upon a patient by means of the instruments of Briining.He then took up in detail the various pathological divisionsof labyrinthitis, together with the treatment of them. This

completed, he went into the differential diagnosis betweenlabyrinthitis, cerebellar abscess, meningitis and tumour ofthe auditory nerve. To wind up, he was of opinion that nooperation, however small, should be undertaken upon the earwithout the preliminary application of the functional tests.-Dr. PANTLAND HICK spoke of a case in which he had beenassociated with Mr. Adair Dighton where a successfuldifferential diagnosis of cerebellar abscess had been made

by the Briining tests.-Dr. W. B. WARRINGTON said thatwhilst the nervous mechanism of the vestibular nerve andits relationships to the Deiters group of cells and oculo-motor muscles were clearly known, the manner in whichdifferent kinds of stimuli excited the several semi-circular canals and so caused nystagmus in differentdirections was difficult to follow, so as to be able to applyreadily in practical work. Further simplification of the

technique was desirable, especially when it was necessary toexamine persons who were ill with intracranial complica-tions. Dr. Warrington alluded to the rarity of cerebellarabscess compared with suppurative disease of the labyrinth,and urged the importance of diagnosis inter operationem.- Mr. STOCKDALE said that suppurative middle-ear diseaseattacked the labyrinth in two positions: (1) the regionof the promontory ; and (2) the external semicircularcanal in the region of the antro-tympanic passage. Totaldeafness on the affected side would suggest invasion in thecochlear region, and if the auditory apparatus was intactthe application of the caloric test would decide whether thesemicircular apparatus were active or not. If an erosion ofthe external canal was found during operation it was usuallyadvisable not to interfere with it. The radical mastoid

operation on rare occasions was performed on patients suffer-ing from meningitis. A preliminary lumbar puncture wasmost helpful in doubtful cases. Deaths from meningitisfollowing a radical mastoid operation and due to lighting upa latent labyrinthitis, although it might occur, was extremelyrare.-Dr. EDGAR STEVENSON and Mr. HUGH E. JONES also

spoke, and Mr. ADAIR DIGHTON replied.

EDINBURGH MEDICO-CHIRURGICALSOCIETY.

The Need for Engenic Reform.A JOINT meeting of this society and the Edinburgh

Obstetrical Society was held in the hall of the RoyalVictoria Dispensary on Oct. 29th to hear an addressby Major LEONARD DARWIN, President of the EugenicsEducation Society, on ’’ The Need for Eugenic Reform." In

introducing the subject Major Darwin said that Linnæus,writing in the middle of the eighteenth century, declaredthat species were now as numerous as when Providence firstcreated them in the beginning, and that, in accordance withthe laws of generation then laid down, the beings originallycreated produced only forms similar to themselves, with theresult that the species now with us were no more numerousthan they were at the first. In writing this, this greatnaturalist was only expressing his belief in the immutabilityof the different forms of life almost universally held in allcivilised countries until the middle of last century. It wastrue that the suggestion that the world was the outcome ofa long series of continuous changes had been made byseveral philosophers in ancient days; whilst from time to timesome more advanced thinker would express the belief that

every animal, including man, was the lineal descendant ofsome more primitive type of living thing. But those who

i

held such views were always so few in number that the

general acceptance of their beliefs could only be described

as a complete revolution in thought. But must not theadoption of the belief that by evolution alone could weaccount for the visible facts of life tend to produce materialalterations in the way in which we regarded many practicalquestions ? The truth was that it was quite impossible forus to go on acting as if we held precisely the same beliefs asour ancestors, and the aim of the eugenist was both to,

guide and to hasten the reforms in social customs andin legislation which must in any case result from the

acceptance of the doctrine of evolution. Anyone whostudied our Poor-law statistics or who looked at our ever-

growing lunatic asylums, homes for inbeciles, and hospitals,or who considered our criminal records, or who merelytook a single walk in our city slums, must feel profoundlydissatisfied with the existing social conditions of his

country. Splendid efforts were no doubt being madeon all sides, but when we remembered how long this noblestrife had lasted we were absolutely driven to inquirewhether some other and hitherto untried methods were notalso essential to secure the progress of the nation, or indeedto safeguard it from decadence. If, as Major Darwin held,it would be necessary to continue in the future, as in thepast, to try to alleviate or mitigate the sufferings of ourfellow creatures by the application of immediate remedies, itwould be absolutely incumbent to recognise the necessity ofsearching for the ultimate sources of all these evils. In the

past the efforts of the social reformer had been almost

entirely directed to conferring immediate practical benefitson man by altering his mental and physical surroundings.We must, however, also in the future endeavour to ensurethat our descendants shall actually enter the world with abetter natural equipment than that which we possess. Aslong as complete ignorance prevailed as to the way in whichthe generations of man succeeded each other, it was

inevitable that all philanthropic efforts to help thehuman being should have begun at his birth. Nowthat this ignorance was being dissipated we were boundto see if something could not be accomplished beforehis birth, and that was the aim of the eugenists. Theyheld that the world was so constituted that all the goodqualities of man, as well as all his evil tendencies, had beenevolved in accordance with what were called the laws ofnature. Their hope and belief was that by studying theselaws we should now be able to take steps tending to ensurethat the man of the future should be a far nobler being thanthe man of to-day. Major Darwin said that eugenists werenot yet in a position to formulate a policy with great pre-cision. They, however, saw clearly that the selection of theancestry of the coming generations had been one of nature’smain methods of ensuring racial advancement. Nature had

always paid the closest attention to heredity, and this studywas imperatively imposed on them. It was essential to

adopt reforms based on heredity. The breeders of race-

horses did not quarrel as to which was the more importantfor their horses, good training or good pedigree ; and thebreeders of mankind should not wrangle as to which wasthe more important, environment or heredity. There wasmuch for eugenists to do, and he rejoiced that a eugenicsociety was likely to be formed in the capital of Scotland.Galton’s definition of the science was that it included " the

study of the agencies under social control that may improveor impair the racial qualities of future generations, eitherphysically or mentally." The evil effects of alcohol on thedrinker and his family were unquestionable, but how thedistant descendants would be affected was unknown. As tothe campaign against drink and disease, the eugenist shouldtake part in it. The same was true with regard to environ.mental reforms, such as better housing and sanitation. Butpending further knowledge as to the ultimate effects of allsuch reforms, if they wanted to ensure the progress of therace they must not confine their efforts to the cure of theseevils, but must also consider the factor of heredity, whichwas the key by means of which the door leading to the futureadvancement of mankind could be unlocked. Their mainobject should be to decrease the rate of multiplica-tion in the lower strata of humanity relatively to thatin the higher strata. The poorest classes containedmany individuals both very virtuous and very capable,whilst amongst the rich many most undesirable speci-rrens were found. A sorting process was always goingon, the naturally able amongst the poor often acquiringgreater wealth, whilst many of the naturally deficient