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discussion, and it was hard to gain experience oiparticular methods of operation. For some years ithas been his practice to put on a hip-plaster with along plaster spica, arranging for the patient to beslung by a Balkan frame. This facilitated nursingand tended to avoid bed-sores. He put a sling oneither side of the pelvic part of the plaster, andattached the slings through pulleys to counter-

weights. Mr. Higgs had said little about after-treat--

ment. After an intracapsular fracture had beentreated by plaster, should a calliper splint be put onfor walking ? He did not use a calliper splint now,as he believed that it forced the patient to walk withan abducted hip. He gave the patient walking exer-cises whilst lying in bed ; then he got him up betweentwo heavy chairs and encouraged him to take thestrain on the affected hip by raising the pelvis on theopposite side. The wearing of a calliper splint wasparticularly a hardship to old and stout people.

Sir CHARTERS SYMONDS said that in the daysbefore X rays were available he had taken a gooddeal of trouble in investigating the kind of cases

now being discussed, and had been able to indicatetwo or three signs by which an extracapsular fracturecould be distinguished from an intracapsular. Hesuggested that in extracapsular fracture of theimpacted variety it was seldom necessary to do morethan use a Hodgen splint and extension. In onlyone case of his own had it seemed wise to disimpacta fracture, and always it required great force to undosuch a fracture. He had seen great advantages fromthe abduction method. With regard to open opera-tion, in 1907 a boy had been brought to hospitalwith a fracture, and he had cut down from the frontand undone the fracture with a chisel; after the legwas put up there had been a perfect functionalresult. He admitted, however, that this course

would not always be wise. He thought the Listonsplint was only a relic so far as extracapsular fractureswere concerned ; he did not think he had used itonce during his 30 years at Guy’s Hospital.

Mr. H. A. T. FATRBANE said that he quite agreedthat the results of treatment in cases of fracture ofthe neck of the femur were bad, and radiologistswould admit they saw only few cases in which unionhad occurred. He thought abduction and plasterwere not used in the right way. Abduction, hethought, should be left until the last, because abduc-tion had the effect of locking the fracture, and itinterfered with reduction. Internal rotation wasalso very important, and it should be carried outwith considerable force for a long time, particularlyif a long time had elapsed since the accident. Hefelt sceptical about any part of the capsule beingnipped between the fragments, as mentioned byMr. Groves. The decision as to operation must be Iinfluenced by the degree of atrophy of the head, and

Ithis atrophy, he held, depended on function. If Ithere was a sufficiently sound fibrous union, or thefragments were sufficiently hitched together, so thatthe inner fragment performed a function when thepatient began to get about again, the inner fragmentwas less likely to show marked atrophy. He thoughtan autogenous living bone-graft preferable to a peg.

Mr. W. BOWI.EY BRISTOW said the figures at a

large general hospital showed that the cases of truefracture of the neck of the femur admitted numbered,in 1921 and 1922 none, in 1923 two, in 1924 four, in1925 eight, therefore it was of little use to speak of thegeneral practitioner having had a chance of learninghow to treat these fractures. He did not iind anydifficulty in treatment by Whitman’s method, and heshowed skiagrams of a case which was successfullytreated by a general practitioner. Stiffness of the kneefollowing fixation in plaster he had found to be areal trouble. When union failed at the end of 9 to 12months the reconstructive method of Whitmanseemed well worth a trial in ordinary cases ; theshock was small, and it was not difficult to do.

Mr. W. McADAM EccLES said that there were twodistinct varieties of fracture of the neck of the femurother than the subcapital and the transverse at the

neck. There were cases in which the recurrent fibres ofthe capsule rernained intact posteriorly, so that therewas marked eversion, and a distinct separation of thetwo fragments anteriorly. But the fragments were heldtogether with very little longitudinal displacement..By internal rotation followed by abduction andfixation, it was usually possible to ensure bonyunion. He questioned whether it was necessary toput the plaster as low down as below the knee. Ifit was put on the lower fourth of the femur passivemovement of the knee was possible, and active move-ment later. When there was longitudinal deformityof the so-called intracapsular fracture a very seriouscondition resulted, and now that technique hadimproved he was coming to the view that this typeof case would have to be treated by operation. Heagreed with Mr. Groves that it was better to open ajoint and see where the bone-graft or peg was going,rather than trust to the guidance afforded byX rays.

Mr. E. M. CowELL referred to the ambulanceauthorities’ first aid regulations requiring that thesecases should be treated by extension and a Thomassplint immediately after the accident. After thisthe patient could be conveyed more comfortably tohospital, where he often arrived suffering very littlepain.

Mr. A. H. TODD stated his opinion that the mostimportant cause of failure to unite was lack ofapposition of fragments. Reliance on a singleantero-posterior radiogram of the region was a causeof much misinterpretation and therefore of mis-taken treatment. The actual position of fragmentsin relation to each other could only be judged bystereoscopic pictures. Radiology must be regardedas an integral part of the first examination of a case.A surprising number of medical men felt they couldbe sure whether or not a fracture had united by amere inspection of the radiogram. There was a

good deal of erroneous teaching in regard to fracturesof the neck of the femur. He used to be taughtthat the absorption taking place after fracture of theneck of the femur was principally that of upper frag-ments, whereas the absorption was in the neck, notin the head. It Was now known that faulty treatmentof these cases was the direct result of wrong tuition.

MANCHESTER MEDICO-CHIRURGICAL ANDOBSTETRICAL SOCIETY.

A MEETING of this Society was held on Nov. 17th,when Mr. A. C. MAGIAN read a paper on

Insufflation of the Fallopian Tubes.The method, he said, had been originally introducedby Rubin and afterwards simplified by Bonney andothers. Rubin’s figures for 1000 cases of sterilityindicated that about 9 per cent. had been cured,but his own results had not been so good, partly,perhaps, because the cases had been more carefullyselected. After many years of sterility a woman

might have a child without any intervention: further-more, the mere fact that the patient was undertreatment for sterility might affect the intercourseof husband and wife. The information given tothe gynecologist was often inaccurate, and takingall these things into consideration he doubted whetherinsufflation could cure sterility in more than 2 percent of cases ; in general the percentage was probablymuch lower. Cure could only occur where there wasno more than a very line obstruction in the Fallopiantubes. Insufflation would break down cobwebbyadhesions and straighten out a slightly distortedcanal, but that was all it could do with safety.

There was a good deal more to be said, continuedMr. Magian, for the use of insufflation in diagnosis,for with average skill and care it was possible to diag-nose obstruction in the Fallopian tubes in a verylarge proportion of cases. It must only be used, ofcourse, where no obvious or gross lesion could be

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detected. The surgeon would not employ such amethod if he suspected a pyosalpinx, for example,nor when there was the slightest doubt as to thepresence of active gonorrhoea, nor when any form ofsepsis could be discovered. Without due care septicparticles might be blown right into the abdominalcavity with disastrous results. The vagina shouldbe washed out twice daily for a few days, and justbefore insufflation it was well to paint the vaginaand cervix with tincture of iodine. Precautionsmust be taken as for a major operation. Rubinhad done his examinations without an anaesthetic,but this was inadvisable for the ordinary practitioner,as the operation might cause severe shock. Under

open ether the cervix was dilated up to No. 10 Hegar,and a hollow sound was passed right into the uterinecavity, so that the internal os could grasp it tightly.The apparatus was also connected with a manometer,which accurately registered the pressure. Underordinary conditions a pressure of 100 mm. wouldsuffice to blow air through the patent extremitiesof the Fallopian tubes, but where there was obstructiona pressure of over 200 mm. might be needed ; it wasunsafe to go much further than this, and it wascertainly risky to reach 250 mm. During insufflationthe observer listened the whole time with a wide-mouthed stethoscope over the iliac regions for thefaint rustling sound which showed that air wasescaping through the fimbriated extremities of theFallopian tubes. If one tube was obstructed, airwould only be heard escaping on the other side,and the manometer would probably register at least150 mm. If the manometer lirst registered, say,200 mm. and then suddenly the pressure shot backto 100 mm., it was probable that there had been someslight obstruction in one or other of the tubes whichhad been broken down by the increased pressure.Where the tubes were diseased-e.g., pyosalpinx orhydrosalpinx-the air pressure in itself might, ofcourse, burst the tube and cause peritonitis. Byinjecting a thick solution of barium or lipiodol intothe uterus and then taking an X ray photograph,it was possible in a fair number of cases to determinethe exact position of the obstruction. With obstruc-tion at the isthmus there was not much chance ofrecovery by operation or otherwise, but if the blockwas at the timbriated extremity it was quite likelythat the condition could be cured. If it was in themiddle of the tube, there was the possibility of makinga new and efficient ostium. The injection of theemulsion was always difficult, and results obtainedon the X ray plate were often rather unsatis-factory.

Dr. P. M. MILLIARD asked if insufflation couldsuitably be performed in the surgery of a generalpractitioner.

Dr. E. C. DuTTON inquired if the injection of

lipiodol into the uterus was a safe procedure, andif the results were worth the trouble.

Dr. MURIEL KEYES asked what percentage ofpatients whose sterility was diagnosed as due totubal occlusion afterwards consented to operation.

Mr. MAGIAN, in reply, said that he thought itbest not to undertake tubal insufflation except in ahospital or nursing home. The patient should remainin bed for 24 hours after the operation. There wassometimes complaint of a little discomfort, and inall cases the anaesthetic caused a certain amount ofsickness. The injection of lipiodal might be con-

sidered quite safe under the same conditions, butthe results of any X ray work were generally unsatis-factory unless the operator was an expert. Mostpatients who were keen enough to have tubalinsufflation done would go on with the treatmentafterwards suggested. In answer to a question asto the danger of the practitioner being imposedupon by an unscrupulous woman who concealed asuspicion that she was pregnant, it was necessaryfor him to be always on his guard. This was anadditional reason for the treatment being done in apublic institution or in a nursing home with thecooperation of a colleague or assistant.

Reviews and Notices of Books.WHY TUBERCULOSIS EXISTS.

Hozv it may be and has been Czcred and P-renerzted.A Book of Facts. By R. GouLBURN LovELL.London : John Bale, Sons and Danielsson. 1926.Pp. 211. 6s.Tms work is compiled from various sources by

Mr. R. Goulburn Lovell, a retired English architect,who is an old family friend of Mr. Henry Spahlinger,and has been closely associated with him in his worksince 1912. The reason why tuberculosis exists is,in the opinion of Mr. Lovell, first and foremostbecause the Spahlinger methods have not beenadequately applied to the treatment of the disease.The book contains a large number of letters and reportsas well as extracts from the lay press, and thereis a good deal of repetition in consequence. For

purposes of review it may conveniently be regardedas consisting of two sections, one dealing with themedical and scientific facts available on the subjectof Mr. Spahlinger’s work, the other with the strugglefor official recognition and financial backing.The treatment consists of two separate and distinct

methods of immunisation-active and passive. Thetechnique of preparation of antigen and antiserum isnot given here in sufficient detail to enable workersin other laboratories to carry it out. As regardsthe antigen, the tubercle bacillus is

"

separated intoits component parts," and from these are prepared" separate antigenic solutions which are injectedin successive doses " until finally the patient cantolerate the whole organism of the bacillus." Fromseparate toxins identified and isolated the antiseraare manufactured. " Each toxin is injected into oneor more horses.... No two toxins are injectedinto the same animal, and for preparing the completeserum not fewer than 28 horses are needed...When this process has been continued for perhaps12 months, the horses are painlessly bled. The28 partial sera thus obtained are combined, and theserum, now complete, is put up into ampoules readyfor use." Of these partial sera only seven are inexistence at the present time. " The possibilities ofa cure with these partial remedies are variable. It.may be that with one patient a certain combinationof the partial sera-if the right ones are to be hadwhen needed-will be enough to turn the scale andeffect a recovery. Another patient may need anothercombination of partial sera, and so on." To thesetubercle antitoxins appear to be added the antitoxinsof streptococci, staphylococci, and pneumococci. 1No details of standardisation of any of these numeroustoxins and antitoxins are given. On the therapeuticside the book contains records of guinea-pig experi-ments, bovine immunisation, and human patients.Between December, 1911, and March, 1912, a firstseries of five tuberculous (human strain) guinea-pigswere treated. In January, 1913, these animals werekilled, and found to be free from tubercle bacilli.when smears were made from the organs, whilstemulsions of inguinal and lumbar glands failed toinfect eight fresh guinea-pigs (Prof. Letulle’s report).Meanwhile a fresh series of 17 animals had been.started. Seventeen infected guinea-pigs were treatedfrom April to July, 1912. " In July of the sameyear 15 of them were completely cured : the othertwo survived for six months and then died." Controlswere also made (Dr. Lardy’s report). It is unfortunatethat no more precise details of these experimentsupon which a bacteriologist could assess their valueare given. They are exceptionally important experi-ments, and we regret that Mr. Spahlinger has not.repeated them or enabled others to do so.The statistics of the bovine experiments are vague.

In 1916 "some 20 cows" were immunised by Mr..Spahlinger with his vaccine. Six months after

1 Vide Report of Chief Medical Officer of Ministry of Health,1922. H.M. Stationery Office.