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was happening, taking every physical, psychological,and economic factor into consideration ; and up-to-date knowledge.

Mr. J. E. H. ROBERTS emphasised the importanceof doing things at the right time. Some physicianscalled in the surgeon too late ; some expectedmiracles ; some cooperatecl throughout the case andboth together decided when the time had come andwhat particular kind of collapse should be performed.Often a temporary phrenic operation was indicated :alcohol injection or crushing. Results could not beassessed unless clinical details were known. Phrenicoperations might be performed for pain or urgenthsemorrhage and succeed in their object, yet the

patient might die of the disease. Nor were all

thoracoplasties the same.Dr. JAMES WATT thought it unfair to quote against

collapse therapy such very rare accidents as Dr.

Wingfield had described. Nor was he so dubious asprevious speakers of the value of mass statistics.Phrenic evulsion, he said, had value as a terminalstage of artificial pneumothorax, to reduce the areainto which a lung had to re-expand. Effusions werethe commonest complication and much had yet to belearned in their prevention and management. In his

opinion they should be drained off freely.Dr. L. S. T. BURRELL regarded pneumothorax as a

medical method and the other methods of collapse assurgical. The immediate results of his cases ofartificial pneumothorax were extremely good. Overhalf the unilateral cases had stood the test of 10-14

years. When the better lung was slightly involved- the later death-rate went up enormously, and whenthe disease was advanced the results were unsatis-

factory. These figures, however, did not include

good early cases ; they were those who were gettingworse after six months in a sanatorium. If the

patient were treated early enough there was at leasta 50 per cent. chance of arrest in unilateral cases ; ifthe other lung were involved at all the chance fell toone-sixth. In extensive bilateral disease life mightbe prolonged in some cases but the disease would notbe arrested by pneumothorax. The operation shouldbe carried out much earlier. One of the greatestrisks was pyopneumothorax ; it was not so rare thatit could be ignored. Another disaster was thateffusion which sometimes followed cutting offadhesions. The patient too often took the attitude thathe was not bad enough for serious treatment, andmight more easily be persuaded to accept treatmentif he were offered pneumothorax than if nothing butregular sanatorium life were put before him. Forthis reason pneumothorax in early cases had value.Modern dramatic methods of treatment might be verystriking, but the physician’s duty was to try to

prevent his patients from ever getting into such aposition that they needed drastic measures. Thoraco-

plasty should only be done when there was resistanceand the lung had a sporting chance of resting.Apicolysis exposed the patient to far less shock andwas useful for apical cavities. Phrenic evulsion hadproved a broken reed as a method of treatingtuberculosis.

Dr. F. R. G. HEAF observed that in certain casescollapse therapy was a distinct failure, either becausethe lung could not be collapsed properly or becausethe patient had no resistance. For the former caseattention must be directed to the adhesions whichset up tension in the lung and prevented success. The

lung must be relaxed by surgical methods. The

galvano-cautery, rather than diathermy, considerablyreduced the risk of effusion. Phrenic evulsion was-of great value in the early apical case. There was

great need for a standard of guidance. Insufficientattention had been paid to the blood ; this improvedremarkably after collapse therapy and provided avaluable mine of information. The combination ofrest and collapse therapy was absolutely essential.

Dr. F. G. CHANDLER asked whether Prof. Ristmeant a temporary or permanent cure of bronchiec-tasis ; he himself had never dared to remove the

collapse. He believed that artificial pneumothoraxwas one of the most dramatically successful methodsever devised, but would not apply it to every earlycase, only to lesions which were spreading, or breakingdown, or failing to heal after good sanatorium treat-ment. Oleothorax had not fulfilled its early promisebut had its place, particularly to maintain collapse inthe face of obliterative pleurisy. The oil did notrupture into the lung unless an active process remained,in which case the oleothorax should be terminated.

MEDICAL SOCIETY OF LONDON

AT a meeting of this society held on Jan. 22nd, thechair was taken by Sir JOHN THOMSON-WALKER, thepresident, and Dr. F. J. POYNTON opened a discussionon the value of

Pre-operative InvestigationHe said that he made a rule of asking the surgeon todiscuss the case with him before the crisis. Heendeavoured to gain the confidence of the patient byshowing a personal interest in him, so as to removethe " cold wonder" with which so many patientsapproached the ordeal. He made every effort toavoid hasty operations and to give time for a reviewof the case and a rest for the patient. Empyema inchildhood, coronary thrombosis, and surgical appendi-citis were often looked upon as emergencies, but itwas rare to have no time for a preliminary survey.Pre-operative measures were particularly importantin pyloric stenosis in infancy. The physician mustmake sure of his diagnosis with the least possible taxon the infant’s resources. Dr. Poynton never used abismuth meal or gastric lavage. Nurses should bechosen with special knowledge of this type of case.

In planning pre-operative methods of ansesthesia.it was important to take account of the blood-pressurereadings. Paraldehyde given slowly per rectum for20 minutes in a 1 in 12 solution worked well withchildren. Highly strung children were grievouslyaffected by forcible ansesthesia. Nevertheless,methods of diminishing fear must not add to thedanger of the operation. Avertin lowered the bloodpressure by 10 to 30 mm. of mercury and depressedthe respiration ; it introduced the need for a carefulexamination of the renal conditions and was notadvisable in hepatic disease. It was of special valuein toxic goitre, where rest and calm were essential.The success of nembutal varied, and dependedsomewhat on the temperament and the body-weight;sodium-evipan and pernocton given intravenouslywere not so suitable for children.

: Pre-operative investigations were proving of: increasing value, but long-established precautions: must not be overlooked. A clinical examination should: be made of the chest of an elderly patient withL bronchitis or congestion ; careful attention shouldB be given to any history, especially of recent influenza: in the young. When there had been much vomiting,. acidosis must be combated with glucose and salines.B A physician could sometimes detect cases in which theB cardiac muscle could be improved by rest and tonics.

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Where the heart was under suspicion, electro-

cardiography might help by indicating coronarythrombosis and a damaged myocardium. Childrenwith valvular heart disease stood operations remark-ably well, but in dealing with rheumatic carditis

’ there was great advantage in a firm clinical knowledgeof the condition and in a recognition of how rarelya paracentesis or opening of the pericardium wasrequired. After discussing the value of the blood tests,Dr. Poynton said that a diabetic patient should befree from ketone bodies and have a normal sugarcurve ; high carbohydrate diet and insulin might helpmuch in preparation. Persistently low specificgravity of the urine pointed to much impairment ofthe renal function. In renal surgery it was importantto ascertain accurately the functioning power of thekidneys. Lipiodol was of great value when employedby an expert team. The difficulty of all radiographicmethods was interpretation. In hepatic and gall-bladder disease there was a danger of haemorrhage afterthe operation. A low platelet count gave warning ofa tendency to haemorrhage. The physician or surgeonshould always consider whether a particular investi-gation would so tax the patient’s strength as toout-balance the extra information it gave.

Mr. NORMAN LAKE, presenting the surgical side,said that while a complete set of investigationsmight be advisable, these tests were time-consumingand apt to be expensive. Many practitioners main-tained that the older clinical methods gave resultscomparing favourably with those obtained by thenewer aids. But in considering comparative figuresit must be remembered that 25 years ago a largenumber of exploratory laparotomies were performed,whereas nowadays fewer patients were submittedto unjustifiable operations, and fewer left withoutintervention when operation was necessary. Thethree chief categories of pre-operative tests were :

those devoted to the attainment of greater precisionin diagnosis, those directed to the estimation of theoperative risk, and those which attempted to estimatethe prognosis of the suggested operation. The abilityto test the functional capacity of the kidneys didmuch to reduce the mortality of prostatectomy.Lipiodol had only a limited application in the radio-graphy of the male genital tract, but it was mostvaluable in demonstrating the patency of the

Fallopian tubes. Intrathecal injection of lipiodolsometimes corrected errors of localisation ; ventriculo-graphy might be of considerable value to the surgeonin localising the obstruction in hydrocephalus. Thebarium meal gave accurate results in gastric ulcerbut much depended on the phase of the ulceration,for the appearance could be modified by surroundingoedema and muscular spasm. In duodenal ulcerationthe results were far less satisfactory, for the pictures ofpre-ulcerative conditions and duodenitis were verysimilar to that of true ulceration, while in anasto-motic ulceration barium was rarely of value. Norwas it much more useful in investigating the appendix,for large numbers of appendices showed slightvariations from the normal, and a vicious circle ofargument might be established if these skiagrams weretaken to represent authentic pathological conditions.The barium enema might also be misleading, especiallyin the early stages of colonic carcinoma, but indiverticulosis it was paramount and it would readilyconfirm a diagnosis of Hirschsprung’s disease.The fractional test-meal might prove of supreme

value in distinguishing between ulcer and carcinomaif the many pitfalls of the method received considera-tion. In the presence of an acid curve a partialgastrectomy was indicated rather than a gastro-

enterostomy. The test for occult blood was a betterindicator of the presence of disease than of itsnature. The practical results of cholecystographywere far from satisfactory. Perhaps the test was tooaccurate ; the surgeon was more concerned to learnwhether the patient’s pain was due to some grosspathology in the gall-bladder than whether someslight abnormality was present. The diastase testwas valuable in acute disease of the pancreas ; if theindex was not considerably raised, acute pancreatitiswas unlikely ; if it was raised, Mr. Lake would nothesitate to make a diagnosis. The prognostic testswhen operation upon the sympathetic system wasproposed should not be accepted as accurate withoutcritical scrutiny. Finally, Mr. Lake declared thatinterpretation and not the tests themselves was theweak point, and was certainly capable of improvementwith experience. The acumen of the physician was asnecessary as in a previous generation. If attentionwas directed more to the experimental tests and lessto clinical, however, the patients would not be losers.

Dr. EDMUND SPRIGGS said that radiology wassometimes valuable in appendicitis ; with an appro-priate technique over 80 per cent. of appendices couldbe demonstrated. The enlargement of a bariumshadow into a Y-shaped appearance where the bariumwas trying to creep round a concretion was a help,and so might be the observation that the appendixdid not fill and that the region was tender. Cholecysto-graphy, in both negative and positive results, was ofvalue. But to find some abnormality was not to’make a diagnosis, and the contrary belief was thesource of many mistakes. While giving more time to<the study of experimental work the physician shouldnot give less to clinical study. In 500 consecutivecases under his care, mostly difficult ones, the

diagnoses made before and after the results of

investigations were known had been compared :in 40 per cent. the first opinion had been confirmed ;in 19 per cent. the revised diagnosis had been quitedifferent ; in the remainder it had been modified bythe tests but remained essentially the same. Suchmistakes as operation on patients with amoebiasis,achlorhydria, or a gastric crisis would be avoided iftime could be given to careful investigation. Labora-tory tests should never be used as an excuse to cutdiagnosis short or dispense with clinical investigation.

Mr. W. H. OGILVIE said that he used cholecysto-graphy less and less as time went on. A great manygall-bladders had been reported by eminent radio-logists as normal which had been found on operationto be diseased, especially the type which containeda considerable number of small stones and the straw-berry gall-bladder. The degree of concentrationcould not be used as a guide. Some normal gall-bladders did not fill at all. Moreover, the methodhad a mortality. The value of the fractional test-meal lay rather in enabling the surgeon to decide on.the method of operation. It was quite as importantin gastric surgery as was the investigation of renalfunction in prostatic surgery. Gastro-enterostomywas too frequently done without consideration af a;high acid level and rapidity of emptying.Dr. T. JENNER HosxiN remarked that thyroidectomy

for Graves’s disease and prostatectomy both requireda good deal of preliminary investigation. The basaJ.1,metabolic rate was not so accurate a guide as hadbeen hoped, and the resting pulse was very nearly as-reliable. Substernal goitre should be eliminated byradiography, and the larynx should be examined to.see that both cords were satisfactory. Cardiographyand cardiac examination were vital. Nevertheless,the most important measures were preliminary rest

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and medication and careful selection of cases. Before

prostatectomy the most important tests were thewater excretion test and the specific gravity. Hestressed the need for cardiovascular investigation forelderly patients. A low rather than a high bloodpressure was a warning sign, Surgeons were inclinedto operate too soon and to pay too little attention topreliminary investigation.

Mr. EARDLEY HOLLAND emphasised the importanceof examining the whole patient and not merely thepelvis. Haemorrhage might be due to microcyticanaemia or local purpura, conditions which a bloodcount would indicate.

Mr. A. TuDoR EDWARDS confirmed Dr. Poynton’smaxim that empyema was not an emergency. Too

many chests were opened, he said, before the empyemawas ripe, and an extensive empyema or a generalisedsepticaemia resulted. Some tests, such as the injec-tion of lipiodol into the lung, were a minor operationin themselves and constituted an unjustifiable riskunless done with meticulous care.

Sir WILLIAM WILLCOX held that the proper placeof a radiological examination in appendicular diseasewas after a full clinical investigation, when it servedto convince the patient and his friends. Jaundicewas sometimes due to the toxic action of drugs suchas the atophan group, and this form might be mis-taken for catarrhal jaundice. Toxic jaundice was adangerous condition for operation, and the patientshould be given intravenous glucose and strongsaline, with large doses of alkalis. In the acute stagelumbar puncture was indicated. Operation on

diabetic patients was not alarmingly dangerous butshould be preceded by carbohydrates and insulin.Acidosis was a contra-indication, but a certain

quantity of sugar was not a disadvantage.Prof. V. B. GREEN-ARMYTAGE mentioned backache

as a fruitful souce of gynaecological mistakes whichould be avoided by orthopaedic knowledge andradiography. Lipiodol was of great value not onlyin the diagnosis but also in the treatment of sterility.

Sir JAMES DUNDAS-GRANT spoke from personalexperience of the value of palpating the appendixin a hot bath, and asked whether gastric ulcer couldbe diagnosed by the analgesic effect of a powder suchas orthoform.

. Mr. ERIC LLOYD remarked that in a fracture ofthe os calcis the pain was much greater than thefunctional disability, and was sometimes difficult tolocate, but one was entitled to assume that it wasin the subastragaloid joint. When the fracture didnot involve the joint generally or when the fractureproceeded to ankylosis the discomfort was small, butin the intermediate group it wag considerable. Itwas possible that the ankle-joint might be the causeof the pain, through a tilt in the astragalus. Thetreatment of fractures of the os calcis might bearthrodesis of the ankle rather than of the subastra-galoid joint. If injection of the ankle-joint with alocal ansesthetic relieved the pain, the source wasalmost certainly here and not in the subastragaloidjoint.

Mr. WILLIAM IBBOTSON declared that the questionof what was a diseased tonsil could only be settledby collaboration with the physician and the bacterio-logist. The operation should not be performed on apatient with bad teeth.Mr. J. ALBAN ANDREWS gave as a good exampleef the need for collaboration between the clinicianand the pathologist the case of early renal tuber-culosis.

Dr. MAURICE SHAW asked for a means of fore-

telling whether the patient would suffer from pul-

monary complications, instancing a case in which apatient had died although spinal anaesthesia hadbeen chosen in order to avoid this risk. He divided

pre-operative investigation into the four categories oflungs, circulation, liver, and kidneys.

ROYAL ACADEMY OF MEDICINE IN

IRELAND

AT a meeting of the section of laryngology held lastmonth, with Dr. P. J. DEMPSEY, the president, in thechair, a paper on

Hoarseness

was read by Dr. 0. T. GRAHAM. He pointed out thathoarseness or huskiness is a symptom of disease notnecessarily in the larynx but sometimes in regions soremote as the brain or aortic arch. Always it calledfor prompt and thorough investigation. There weresome 50 possible causes of interference with thefunction of the vocal cords. For clear phonation thecords must be able to (1) approximate, (2) drawtense, and (3) vibrate.

Approximation may be interfered with by (a) tumourbetween the cords, (b) feebleness of the muscular action,(c) paralysis, or (d) fixation.

Tension may be interfered with by (a) paralysis, (b)feebleness, or (c) fixation.

Vibration may be interfered with by (a) thickening ofthe vocal cords by inflammation, infiltration, or neoplasms,or (b) growth causing fixation of the vocal cord.

Sometimes, especially in young women, there wasfunctional or hysterical aphonia without evidence ofdisease ; but here one must be careful in prognosis,because what appeared to be a functional aphonia,occurring intermittently, might be the precursor oftuberculous laryngitis. As in other situations, so inthe larynx, one of the crucial problems was to decidewhether a swelling or ulcer was due to a tumour(benign or malignant), syphilis, or tuberculosis; or

a combination of them. To arrive at a correct

diagnosis might require a complete history ; indirect

laryngoscopy ; bronchoscopy and cesophagoscopy ;a general examination ; radiography of the skull,neck, and chest; a Wassermann blood test; bacterio-

logical examination ; and microscopical examinationof piece of growth.

Evipan in Oto-rhino-laryngologyDr. P. J. KEOGH read a paper in which he said that

from experience of Evipan both for pre-ansestheticmedication and as an anaesthetic he had come to theconclusion that it was pleasant, rapid, and reliable.In all his throat cases the cough reflex had beenpresent throughout anaesthesia. In intranasal work a

difficulty was the preservation of a very vigoroussneeze reflex ; this, however, could be eliminated bycocainisation. In two cases he had observed a well-marked resistance to the drug, coming on after7-10 days and persisting for over two months.Dr. G. P. MELDON said that in a large experience

of evipan he had come to conclusions similar to thoseof Dr. Keogh. He also had observed the sneezingreflex.

Dr. T. G. WILSON showed a patient who hadremained well during the three years since he wastreated for carcinoma of the tongue. The growthwas excised by diathermy and radium needles wereinserted into the surrounding tissues.Dr. L. J. CURTIN showed a patient upon whom hehad successfully performed the Rudel frontal sinusoperation.