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results in selected cases can be distinctly gratifying.In other parts of the thorax plugging is a satisfactorymethod of obtaining adhesions as a preliminary to atranspleural operation.

Thoraeoplastic Operations.Several types of operation on the chest wall are in

use, but the most common is the paravertebral(Wilms-Sauerbruch) thoracoplasty ; the Schede andEstlander have been discarded. Anterior and lateraldivision of the ribs is employed only in cases where theparavertebral has proved inadequate. Failure ofA.P. is the usual indication for the operation. Itprovides a permanent, rigid collapse and throws theresponsibility of ventilation on the opposite lung forall time, and therefore should be reserved until theless drastic measures have been tried and failed.Total thoracoplasty is a severe operation, and shouldonly be performed on patients whose general conditionis comparatively satisfactory, and who show no signsof activity in the other lung, otherwise a fatal exacer-bation is bound to ensue. About 40 per cent. to50 per cent. are able to return to work within a year,and with judicious selection the results are reallyremarkable, since the majority have been operatedupon more or less as a last resource when they arecomplete invalids. In Sweden, especially, thoraco-plasty is regarded as a common surgical measure.Operation mortality is from 6 per cent. to 10 per cent.Failures and deaths are due to acute " flares" orgradual spread of the disease in the uncollapsedlung. The risk of right heart embarrassment inright-sided rib collapse has to be kept in mind. Shouldthe thoracoplasty prove inadequate as a collapsingagent-as may happen with a very rigid apical cavity- supplementary rib resection or extrapleuralplugging may be called for. Profs. Clairmont (Zurich),Key, Nystrom, and Denk use a two-stage thoraco-plasty ; others prefer a single stage operation, which isbound to produce a severe degree of shock in analready debilitated subject, but which is free from thepossibility of faulty rib-fixation which may occur ifthe interval between the stages is unduly prolonged.Partial upper thoracoplasty, often supplemented byphrenic evulsion, finds favour with Dr. Gravesen, butnot with the above-mentioned surgeons.

Ansesthesia is generally local with the patient in a Ihalf-sitting position. Gravesen supplements localwith light open ether and has no ill-effects therefrom.Speed is important, and if good collapse is to be pro-cured, four to eight inches of the ribs must be removedright up to the level of the transverse processes.Division of the first rib is essential, and if possiblean inch should be resected with due regard to thepresence of great vessels and nerves. Prof. Key’sresections are more extensive than those of othersurgeons, and, with the exception of Prof. Nystrom,resections are subperiosteal. All insist on theavoidance of any inward thrust or pressure duringoperation lest the parietal pleura be damaged, andthe success of the whole proceeding endangered.

After-treatment is very important. The painfollowing the operation is severe and must be relieved.Sputum from cavities which are being compressedhas to be evacuated, therefore coughing is encouraged,and the posture of the patient best arranged for thatpurpose. Sleep is necessary, but not at the expense ofover-filled cavities. The object of the operation isattained when the mobilised ribs, having graduallyfallen in and down towards the vertebral column,remain fixed against it. This may be assisted in theearly stage by pressure with bags of shot, and laterby some form of elastic belt. The resulting deformity issurprisingly small, and includes but a slight droppingof the shoulder with emphasis of pre-existing hollows.Scapular function is invariably excellent. Mostsurgeons who have performed this operation are

impressed by its efficiency, and comment on thegratitude of patients who have been transferredfrom a state of chronic ill-health to comparativewell-being.

MEDICINE AND THE LAW.

Doctor’s Successful Appeal : Alleged PartnershipDocument.

A MEDICAL practitioner has successfully appealedagainst conviction in a recent case which, thoughlacking any special feature of medico-legal concern,is perhaps of general interest as showing how forensicand judicial irregularities can vitiate a criminal trial.The appellant was charged at the London Sessionssome time ago with the larcency of stamps. In thecourse of his defence he had, as the lawyers say,put his character in issue. That is to say, he hadclaimed that his character was good and had putthe fact forward as a reason why the jury shouldbelieve him innocent of the charge on which hewas being tried. Now if, in defending himself, anaccused person makes any positive assertion of hisown good character or makes any attack upon thecharacter of witnesses for the prosecution, he isliable to be cross-examined as to his credit. Underthis rule the accused doctor was asked questionsin cross-examination as to an alleged confession whichit was suggested that he had signed, admittingdishonesty, on the dissolution of a medical partner-ship. He denied having made any such admission.The document was not produced to him thoughcounsel for the prosecution seems to have displayedin his hands a paper which was visible to the jury.The accused man was pressed with a stream ofquestions about the alleged confession and, whensome controversy arose as to whether the cross-

examination was proper or improper, the jury-in spite of the protest of counsel for the defence-were asked to retire while legal argument was heardupon the point. This proceeding naturally tendedto intensify the atmosphere of suspicion. TheCriminal Procedure Act of 1865 lays down that awitness may be cross-examined as to his previouswritten statements without the writing being shownto him, but that, if it is intended to contradict thewitness by the writing, his attention must first be calledto the parts of the writing which are to be used againsthim. Apart from this specific statutory provision,the proceedings at the London Sessions seem tohave been conducted with less than the usual fairness.In the upshot the accused man was convicted andwas remanded in custody to the following sessionswhen sentence was passed to the effect that he bebound over for two years. The Court of CriminalAppeal found that three irregularities had occurred.In the first place, in cross-examining the defendantabout the alleged document which was not produced,there had been a breach of a statutory rule. Secondly,in allowing the jurors to be sent out of court thetribunal had introduced an element of mystery andsuspicion ; indeed in the opinion of the Court ofCriminal Appeal it is difficult to imagine any occasionwhen the jury could be asked to leave the box exceptat the request or with the assent of the defencewhile statements were made in their absence. Finallythe judge at trial had summed up unsatisfactorilyto the jury on the issue of criminal intent. Forthese reasons the appeal succeeded and the convictionwas quashed.

It has befallen not a few medical practitionersto be mulcted in substantial damages for some allegedfailure or mistake in the professional treatment ofa patient. They will observe with envy that dis-tressing mistakes can be made in the administrationof justice without any liability being imposed uponjudges or prosecuting counsel to pay any compensationwhatever.

Suicide at Christian Science Home : Jury’s - Censure.An inquest at Ealing on Dec. 14th upon a

case of suicide at a Christian Science home atGreenford disclosed a difference of opinion betweenthe jury and the coroner. The deceased woman wasnot a Christian scientist but was sent to the home

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at the instance of a relation who was presumably aChristian scientist and who had supported herfinancially ; he explained to the coroner that hesuggested her removal to the home as preferable tohaving her certified and sent to an asylum. Thedeceased’s daughter stated that her mother hadthreatened to jump out of the window. When hermother was taken to the home her case was fullyexplained to the proprietress ; it was then said thatthe windows were fastened. Next morning thedeceased asked for some hot milk with her breakfast;as the attendant nurse went downstairs to get it,there was a call that someone was at the window.The dead woman had taken a chair from her bedroomand had climbed from it to the landing window.This happened at 9 A.M. ; some 12 hours later she diedfrom her injuries. Dr. M. H. Renall, in his evidenceat the inquest, said that death was due to a compressedfracture of the spine. At 9.45 A.M. the daughtertelephoned to the home and was told that her motherhad passed a restless night and was being kept inbed ; the daughter was not told of her mother’sinjuries till 11 P.M., when her uncle (the relativealready mentioned) brought the news of her death.There was evidence that after her fall the deceaseddid not complain of pain or ask for a doctor, andthat her injuries would have been difficult to detectwithout expert aid. There was also evidence thatthere had been no previous complaint of the conductof the home ; an attendant had slept in the sameroom as the deceased. The coroner summed up thecase as one which might have happened in any home,and suggested that fault should not be found merelybecause the accident occurred in a Christian Sciencehome. The jury, nevertheless, in returning a verdictof suicide during temporary insanity, added a riderthat they accepted Dr. Renall’s evidence that thedead woman must have suffered considerable painand that they considered the proprietress guilty ofneglect (1) for not taking any precaution to protectthe deceased from the tendency of which she wasmade aware ; (2) in not immediately calling a doctor ;and (3) in omitting to inform the relatives at onceof the occurrence. On these grounds they consideredthe proprietress of the home deserving of censure. Thecoroner dissociated himself from this verdict. Itshould be noted that earlier in the proceedings thecoroner had asked the proprietress of the home,whether she would have called in a doctor if she hadrealised that the deceased had been badly hurt.The answer was " Yes." The proprietress had alsoexplained that her husband was a trained medicalattendant and had examined the deceased after theaccident without finding any serious injury. Thiswas not, therefore, it seems, a Christian Science homewhere the rules entirely forbade recourse to ordinarymedical and surgical treatment. The incidentindicates that, if the admission of mentally unstablepersons to such homes is to be regarded as an

alternative to skilled treatment in institutionsprovided or supervised under the Lunacy Acts,Parliament may have to pay attention to theconsequent dangers.

THE LEAGUE OF MERCY.

THE Prince of Wales, Grand President of theLeague, took the chair at the thirtieth annual meetingof presidents, which was held at St. James’s Palaceon Dec. llth. After reading a congratulatorymessage from the King, he referred with regret tothe death of Lord Lambourne, a most valuable andenthusiastic supporter of the League. The new

charter of the League, he said, would give it anopportunity of increasing the numbers of thoseserving on the council, and he mentioned that theball held at Grosvenor House in June last had broughtin a sum of .81535. Among the splendid contributionsto the League during the past year was a donationof .61000 from Lady Melchett, while the gift of a

League of Mercy film, the expenses of which had beenborne by Mr. John Maxwell and Mr. Joseph Grossman,of the British International Pictures, Elstree, wasgreatly appreciated where it had been shown. LadyTree’s broadcast appeal had brought in .6700.

The Voluntary System.As a result of recent legislation affecting the health

services of the country an attempt was being madeby the county councils and county boroughs to bringall hospitals into close touch with one another, andit seemed clear that authorities still recognised theimportance of retaining the voluntary system. Itwould be the privilege of the workers of the Leagueto persuade people to open fresh districts for carryingon the work of the League. Only by this meanscould the ever-increasing financial demands of modern.medicine and surgery be successfully supplied.

Financial Position.Lord Cornwallis having been appointed chairman

in place of the late Lord Lambourne, the Rev. W. H.Hornby Steer, deputy chairman, and the Rev.E. G. Gordon, hon. secretary, the members of theexecutive council were appointed, and presentations ofthe Order of Mercy were made by the Prince of Wales.Lord Marshall, the hon. treasurer, then made a

statement with regard to the income of the Leaguewhich had more than equalled last year’s total.The income from collections amounted to ;812,727,.amounts promised to ill ,373, while the estimate ofamounts to come was 62300, making a grand total of626,400, compared with .826,14:3 last year. A specialdonation of 21000 was given to the ThanksgivingFund for the King’s recovery, the donation to KingEdward’s Hospital Fund was 617,000, the same aslast year, and the grants to extra-metropolitanhospitals amounted to 68399, making a total of.626,399, compared with 625,200 in 1928.Lord Moynihan, in an address, said he welcomed

the opportunity to express on behalf of the medicalprofession their profound respect and congratulationsto the members of the League for all that they haddone for the hospitals. There never was a time whenhospitals were so well equipped and served by membersof his profession, or were held so high in public esteem.A vote of thanks to the Grand President and the

Lady Grand President, to which Princess Marybriefly replied on behalf of her brother and herself,closed the meeting.

IRELAND....L...J...BI..J....J.L1...L’ 1J z

(FROM OUR OWN CORRESPONDENT.)

National Health Insurance : Views of the ApprovedSocieties.

THE annual meeting of the Approved Societies’Association of the Irish Free State, held last week,gave an opportunity for consideration and criticism,both of the present working of National HealthInsurance and of the changes proposed in the Billat present before the Irish legislature. The mostimportant decision of the representatives at themeeting was a resolution stating : " That this Asso-ciation is of opinion that a National Medical Serviceshould be instituted in the Free State." This is thefirst time that the approved societies have giventheir support to the demand for a National MedicalService, as distinct from a demand for medicalbenefits. Hitherto, indeed, some of the societieshave insisted that a system of medical benefits, ifestablished, should be administered by the societies.That they have now adopted the policy supportedand urged by the medical profession is a matter forsatisfaction. The Association, in another resolution,again expresses its dissatisfaction with the presentmethod of providing evidence of sickness, and statesthat " there is grave and increasing laxity on the partof certain medical certifiers in the issue of certificates’of incapacity." The Association asks the National