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Brackenbury was elected to take Sir Jenner Verrall’splace on the Executive Committee.

Election Rules.-Dr. J. W. Bone, secondedby Dr. H. B. Brackenbury, carried a motion that itbe referred to the Finance Committee " to considerand report to the Council whether the regulationsfor the conduct of elections to the Council (Section 8 of Ithe Medical Act, 1886) and the Instructions to iVoters’ issued in connexion therewith might not be simplified and/or improved." Dr. Bone pointed out Ithat there had been a steady increase in the number ’’,of voting papers rendered invalid and that this increasehad been a subject of comment in the medical press.The regulation which covers the system of votinghad been laid down by the Privy Council, but therewere certain incompatibilities between the instructionsin the leaflet and those on the ballot paper. It wasnot certain, for instance, whether the paper was tobe sent off or received on the appointed day. Otherregulations appeared to be trivial ; for example, apaper was rendered invalid if it were folded in thewrong direction. Mr. H. L. Eason quoted the figures

. of the electorate and the spoiled ballot papers forseveral past years and showed that there was no realincrease in the number of papers rendered invalid. Hepointed,out that the majority of faults for whichpapers had been rejected at the last election werefaults of gross carelessness and not of trivialities. Alarge number of empty envelopes had been received,and many others had not been signed ; only eightout of the total had been wrongly folded. Sir RobertBolam pleaded for simplification of the procedure inorder that electors should not be deterred fromexercising their vote. The matter was referred tothe Committee and the Committee was authorisedto invite Dr. Bone to attend their meeting to discuss it.

Medical Societies.

ROYAL SOCIETY OF MEDICINE.

SECTION OF ORTHOPAEDICS.

AT a meeting of this Section held on Dec. 3rdthe chair was taken by the President, Mr. MCCRAEAITKIN, and Mr. W. H. OGILVIE opened a discussion on

MINOR INJURIES ABOUT THE ELBOW-JOINT.

He classified the minor injuries as partial fractures,partial dislocations, tears of the capsule, traumaticarthritis, and injuries to muscles. He discussed theanatomy of the joint, and demonstrated its divisioninto a posterior trochlear and an anterior condylarportion, resembling those of the lower end of thefemur ; and pointed out the crescentic facet on theolecranon surface of the ulna, which met the outerlip of the trochlea in full extension ; and the tri-angular groove between the outer part of the trans-verse groove dividing the greater and lesser sigmoidcavities. The strength of the capsule lay, he said, inthe lateral ligaments. The synovial cavity in bothradio-ulnar joints was sacciform, allowing for verticalas well as rotary movement. Intracapsular synovialpads were highly developed in the elbow and intra-articular synovial fringes were abundant.The elbow was designed for use primarily in positions

between 110° and 170° of extension and betweenhalf and three-quarters pronation. Only withinthis range was the olecranon portion of the greatersigmoid cavity fully engaged by the trochlear surfaceof the humerus. In flexion beyond 110° it rode ina groove which was shallow on the outer side. so thatpart of its bearing surface was exposed. The realhumero-ulnar articulation was between the anteriorparts of the trochlea and the coronoid articular surfaceof the olecranon.. The olecranon part of the ulna

combined the function of a muscular process likethe great trochanter and a steadying guidingmechanism like that of the malleoli, the latter functiononly being called into play in the later degrees ofextension. No real disability followed excision ofthe head of the radius ; the ulna formed a platformon which the radius, bearing the hand, was free torotate. The carrying angle was one of 10-15°and was present in the foetus and at all ages ; itdiminished as the arm was flexed and was due to thevarving depth of the inner lip of the trochlea. Theonly acceptable explanation of the carrying angle wasthe constant use of the half-pronation position.In the position of use-half pronation and nearlycomplete extension-the purpose of the carryingangle became apparent : to allow the radius to liein a continuation of the long axis of the humerus.The position of rest-slight flexion and rather morethan half pronation-was maintained by the brachialisanticus and from this position the elbow moved forits various functions.Two distinct sets of uses would be distinguished:

those concerning the outer world and those concerningthe individual. The exteroceptive range of theelbow embraced the positions from about 90° to170° of extension and from half to full pronation andinvolved such movements as attack, cutting food,climbing, and handling tools, and within this rangestresses were likely to fall on the elbow-joint. Thearticular surfaces were fully engaged and the joint wasstable. The proprioceptive range included all thosemovements concerned with the person ; from a rightangle to full flexion and from half to full pronation;the joint surfaces in this range were poorly adaptedand the joint depended on ligaments, but was notexposed to great stress. Full supination was rarelyused in extension or full pronation in flexion. Fullextension did not occur in natural use. True hyper-extension was rare. The apparent hyperextensionin some women was due to the demonstration byextreme supination of an exaggerated carrying angle.Upward movement of the radius was checked by theinterosseous membrane and downward movement bythe oblique cord. The up and down movements ofthe radius invited comparison with the knee.

Fractures and Dislocations.

Most injuries of the elbow were due to indirectviolence. The trochlea and still more the capitellumwere carried well forward and apt to be fracturedforwards into the joint. Full extension, however,was rare and could not be maintained in the face offorce. Falls on the outstretched hand tended toflex the elbow and not to hyperextend it. In theordinary fall on the outstretched hand the lines offorce passed out of the limb posteriorly at an angleand caused supracondylar fracture or backwarddislocation. The involvement of the radius dependedon the degree to which force applied to it was passedon to the ulna. In a fully pronated and radiallyadducted position the interosseous ligament wassomewhat relaxed and the radius was forced againstthe capitellum ; the blow would therefore tend tofracture the radial head. In partial supinationand ulnar adduction a dislocation at the elbow-jointor a fracture of the humerus would be more likely tooccur. If the arm was partially flexed the blowwould flex it further and the main force be taken onthe olecranon ; then the trochlea was driven like acold chisel into the sigmoid fossa and fractured theolecranon transversely. Direct violence usuallyaffected the ulna, but might break any bone.

Supracondylar fracture without displacement wasvery common in childhood and might be missed ina poor radiogram. Bruises and sprains caused verylittle limitation of movement in a child and only alittle swelling. Treatment involved a few days ofimmobilisation with active movements from the start.If there was no periosteal stripping there was no riskof bone formation in early active movements. Isolatedfractures of the internal epicondyle were due to muscular

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violence and were seen in adults. The joint was notinvolved and the loose fragment was pulled down bythe flexors. Correct position and bony union wereseldom secured but the disability was slight. Fractures

of the internal condyle were oblique, entered the joint,were common in children, and were usually due tofalls on the outstretched hand. The broken fragmentrode up and the displacement tended to recur whentraction was released. Fractures of the trochlea alonewere very rare. The external epicondyle was so smallthat only cracks or detachment of flakes could beincluded as isolated fractures. Fractures of theexternal condyle were much commoner and due toforce from the ground transmitted through the radius.Cubitus valgus and ulnar palsy were common

sequelae of inadequately treated cases. Isolated frac-tures of the capitellum were rare, and as they were intra-articular there was no deformity, and the diagnosisrested on excessive limitation of function and swellingof the joint. The causative force was more probablydirect. In general, direct fixation inside the capsulewas undesirable. If the parts could not be fixed byposture or extra-articular screws, traction in flexionby a pin through the olecranon should be tried. Partialfractures of the olecranon might be detachment of flakesor fissured fractures without displacement. Fracturesof the coronoid process were occasionally caused bymuscular violence, but much more often by posteriordislocation. Fractures of the radial head might be dueto falls on the elbow, but were more commonly dueto falls on the outstretched hand. They were dividedinto three types: the first with loose fragments,demanding immediate operation ; the second with grossdeformity, usually requiring excision of the head ; andthe third a fissured fracture without much displace-ment. In the commonest type, however, the frag-ments retained their normal position. These fracturesshould be treated as sprains and active rotation startedfrom the beginning. This often restored a full rangeof movement, whereas excision never gave more than70 per cent. Fractures of the neck of the radius wereusually due to indirect violence, and if correct align-ment could not be obtained the radial head should beremoved. Fractures of the tubercle were rare and theresult of muscular efforts.Forward dislocation of the head of the radius was

usually associated with fracture of the shaft, but ifisolated was usually the result of the radius strikinga rounded object on the ground. Partial subluxationswere not uncommon, but were hard to demon-strate without a stereoscopic radiogram. Sprain ofligaments was a clinical diagnosis and not a clearlydefined injury ; probably muscles were always involvedas well. Tears of muscles were due to sudden un-guarded movement, and could only be distinguishedfrom partial fractures by the X ray appearance and theabsence of crepitus. Spurs of bone were apt toappear in the muscles of this region in advanced yearsand the snapping of one of these might cause acutelocalised pain. Traumatic myositis might follow theprolonged and unaccustomed use of any muscle; thewhole muscle was tender and showed soft crepitus.

Tennis Elbow.

Tennis elbow eluded classification. It occurred inpatients who practised those sports and trades wherethe arm was suddenly jerked into full extension, whilethe hand grasped a large object: tennis players,fly-fishers, golfers, sabre fencers, and workers withhammers. The onset was rarely sudden ; a gradualache appeared in the outer side of the elbow, mostmarked in certain movements, and ceasing when the Igame ceased. A definite localised tender spot wasfound in the region of the external epicondyle andclenching the hand was painful, but passive movementwas painless. The main theories of its pathology were :(1) tearing of muscles; (2) periostitis; (3) tearing of Icapsule, involving the external, lateral, or orbicular ligaments ; (4) arthritis of radio-humeral joint ; and(5) Osgood’s bursitis. This bursa lay immediately 4

distal to the external epicondyle, deep to the common

origin of the extensor group. Mr. Ogilvie had beenunable to find this bursa or to obtain any success byOsgood’s operation. All bursw were abnormal, for theywere not present at birth, and might be developedanywhere in response to excessive movement or

pressure. Mr. Ogilvie believed that the commonestcause of tennis elbow was tearing of extensor muscle-fibres at their origin from bone, with periostitissometimes. The radial extensors came into powerfulaction in gripping movements in tennis. In the firststage the effusion of fluid, local hyperaemia, andround-celled infiltration caused pain and tendernessand were treated by firm pressure, massage, and rest.The second stage of early repair caused pain on certainmovements only, aching, and a localised tender spot.Firm pressure by a pad smeared with iodex andstrapping at 135°, and active movements, constitutedthe best treatment. In the third stage there mightbe adhesions calling for a manipulation such asMills’s. Patients usually came in the second or thirdstages, and the treatment suitable for one stage wasquite unsuitable for the other. Focal sepsis must besought, as few traumata ran a sterile course. Focalsubinfection prolonged the second stage and madeadhesions more likely.There were other types of tennis elbow, however,

and symptoms which could not be referred totearing of the extensor carpi radialis longior. Some-times there was a true inhibition of movement,causing the patient to drop things. This resembledthe sudden giving-way of the knee, and was probablydue to a similar internal derangement : a nipping ofsynovial fringes, especially those thickened by arthritis.Mild traumatic arthritis could be produced byoveruse alone-e.g., the return to a strenuous gameafter a season’s rest. Treatment was removal of thecausative fringe.

Mr. JENNER VERRALL said that internal derange-ment as a cause of tennis elbow had long appealedto him, and he agreed with Mr. Ogilvie’s remarksabout Osgood’s bursa. He regarded tennis elbow aspossibly a muscular rupture in some cases but moreoften as a combination of circulating toxins and localtrauma. In seeking Osgood’s bursa one often founddense fascia between the common extensor origin andthe head of the radius, and the opening-up of thisexplained the good effect of seeking Osgood’s bursaas well as of Mills’s manipulation, which undoubtedlycured about a third of the cases. Strains on the innerside of the elbow were strictly comparable with thoseon the outer side, and were nearly all due to tension onthe flexor carpi ulnaris. Carried still further, thiscaused displacement of the ulnar nerve which oftencould only be cured by shifting the nerve. Theforward-dislocated head of the radius did not limitflexion but nearly always caused chronic musculo-spiral neuritis, and it was most important, especiallyin children, to get the head back into place as soon aspossible. After a month or two it might become quiteirreplaceable. The construction of a new orbicularligament with fascia lata was most satisfactory.Early operation was the only possible treatment forfracture of the head of the radius. Excision of thehead in a movable elbow left a very weakened elbow,but early excision of small fragments was satisfactory.Fracture of the capitellum was not rare, and operationwas the only possible treatment. Fractures of theinternal epicondyle were not operated on oftenenough and were apt to limit movement.Mr. WATSON JONES showed slides illustrating

5000 cases of elbow injury and pointed out thatMbow injuries were most common and most significantn the second decade; in 94 cases of traumaticarthritis perfect cure had been achieved in 92. Theproblem was not how to cure but how to cure quickly.ft was curious that one method or another was oftencontinued as a routine without accurate weekly’ecords of the range of movement. It did not matterwhat treatment was used so long as progress was;hecked by measurement. Massage did no good;dded active movements tended to arrest recovery,

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passive movements were harmful, and manipulationunder anaesthesia was disastrous. We were apt to betoo anxious about rest ; results would improve bysteering a course between rest and movement. Thepatient was the best judge of the amount of movementneeded. Fractures of the head of the radius had agrave prognosis. The results might be improved bymore radical treatment ; the disability was less afterexcision of the head than after more conservativemeasures. The limitation of movement was limitationof extension, not of supination and pronation. Infracture of the neck with angulation the head shouldnot be removed but slung in position with anartificial ligament. Fractures of the internal epicon-dyle could also be produced by direct injury. Ulnarpalsies only resulted from indirect injury. The capsule,if pulled in with the epiphysis, dragged on the ulnarnerve and so caused palsy. Treatment was to freethe nerve and, if necessary, transfer it to the frontof the joint.

Mr. WHITCHURCH HOWELL said that tennis elbowwas the result of bad tennis, and rarely occurred inthe professional player. He reported a case of myositisossificans in the brachialis anticus in a man whofell from his horse and was dragged by the reins,and another of a tramwayman who had had noinjury save the constant jerking he sustained inclimbing the tram; he had developed two loosebodies in front of the joint.

Mr. R. C. ELMSLIE recorded two cases of tenniselbow ; one in his own arm. Most cases came on verygradually indeed and the toxic factor played a largepart. The sufferer was the player who went onplaying hard tennis at an age when many peoplegave it up. There were many causes other thantennis; his own might be ascribed to wrenchingclub-feet. Very characteristic signs were the exactsituation of the tender spot over the radio-humeraljoint and the pain caused by passive forced flexionof the wrist and pronation and-in more severe con-ditions-forced extension of the forearm. The com-bination of the three caused most pain. Supinationof the forearm with extended wrist was also verypainful. He excluded cases with arthritis fromordinary tennis elbow. His own " elbow " had beencured by removal of a molar tooth with an apicalabscess. He cordially agreed that a child whose elbowhad been injured would find for itself the movementsthat were safe and would cure itself better than anymasseur could. The masseur would pretend to doa lot and really do very little.

Mr. W. H. TRETHOWAN declared that nothingshowed a more constant clinical picture than tenniselbow and that the pathology was equally constant.He himself had a tennis elbow due to prawning, whichinvolved lifting weight in extension of the forearmand wrist. Osgood’s bursa was nothing more thanthe extension of the synovial membrane of theradio-humeral joint, and one cause of pain was com-pression of this pouch by the extensor carpi radialislongior. Tennis elbow was always a traumaticsynovitis of the radio-humeral joint. He did notbelieve sepsis was ever concerned. The results oftreatment depended upon the stage at which eachform of treatment was applied. Protracted cases

were the cases which would not lest.

Mr. ROCYN JONES said the pathology of tennis elbowwas little known. The lesion was produced by acombination of supination and extension. Mills’smanipulation was very valuable in selected cases wherethere was a pronated arm with flexed wrist and fingers.The treatment was rest, heat, and massage, and, ifthese failed, operation. Fissured fracture of the headof the radius was difficult to diagnose, except byX rays; there might be some tenderness and elasticswelling ; little treatment was required.

Mr. PHILIP FiGDOB emphasised the importance ofactive movements.

The PRESIDENT said that there was a very similarpain associated with the muscles arising from the

internal condyle. Some cases were relieved by apad and strap and others by manipulation.

Mr. OGTLVIE, replying, emphasised again theimportance of the exteroceptive range. Ankylosisshould be in the exteroceptive position; theclassical position was only useful to the man whoneeded two hairbrushes and wanted to get bothhands to his mouth at once.

SECTION OF ANAESTHETICS. ’

AT a meeting of this Section on Dec. 6th, withDr. R. E. APPERLY, the President, in the chair, adiscussion on

ANESTHESIA IN RECTAL SURGERY

was opened by Dr. J. K. HASLER. From the anoes-thetist’s point of view, he said, the surgery of therectum was particularly satisfactory. In giving ageneral anaesthetic his ministrations were well out ofthe way of the surgeon, and if a regional or localadministration was needed this part of the body waswell adapted for it. Apart from operation for rectalcancer, much shock was uncommon, and the anus-thetist was seldom worried by a patient being inextremis. Of the two groups of rectal operations-the abdominal and the perineal-the former weremostly for dealing with malignant disease connectedwith the rectum ; half of them were for colostomy,and the rest were abdominal resections or operationsfor insertion of radium into a high growth in therectum and the associated glands. The surgeonrequired good abdominal relaxation so as to avoidunnecessary coils of intestine being constantly forcedthrough the wound, and anaesthesia must be deepenough to allow of exploration of the abdomen ifnecessary in order to ascertain whether there weresecondary deposits in the liver. Colostomy was oftenthe precursor of a second operation, and the patientmust be kept fit to undergo this in about a fortnight.A good general anaesthetic satisfied the requirements,but each anaesthetist would have his own preference,and should employ the one which yielded him thebest results. A general anaesthetic was commonlygiven for the preliminary colostomy, and for thesubsequent operation a spinal anaesthetic was

employed in combination with some form of twilightsleep or a light general anaesthesia ; but there seemedto be no reason why general anaesthesia should notbe dispensed with altogether. Injection of a spinalanaesthetic between the third and fourth lumbarvertebrae caused anaesthesia well above the umbilicus,and gave good abdominal relaxation. Spinal anees-thesia did not always obviate chest complications,but the patients who developed chest trouble afterit would probably have fared worse under generalanaesthesia.

Perineal operations formed the second or largergroup, and here the field for anaesthetics was morevaried. The three most common complaints in thisregion were haemorrhoids, fissure, and fistula, and thesetroubles had generally caused much anxiety for anumber of years before operation, so that thepatients had a characteristic mental state-that oflong-continued suffering in silence. Many started toresist with the onset of unconsciousness, and completerelaxation was delayed, especially if the patientwas alcoholic. They had to be deeply under theanaesthetic before the operation was begun, other-wise contraction of the leg muscles made it difficultto place them in the lithotomy position, especiallywhen the sphincter was forcibly dilated. The generalanaesthetic must at first be given liberally, but thisrule did not apply to pure chloroform, whose usefor operations involving the anus and the rectalsphincters had been widely condemned. If chloro-form anaesthesia was not deep enough when the anuswas dilated there was a risk of cardiac inhibition orreflex inhibition of respiration. Yeomans, of NewYork, considered that chloroform had no place inrectal surgery.

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The forms of local anaesthetics used for perinealoperations could be classified in three groups :(1) local infiltration of the operation area ; (2) extra-dural anaesthesia brought about by caudal block andsacral block ; and (3) intradural or various forms of

spinal anaesthesia. In America the caudal block wasoften combined with trans-sacral block. At the MayoClinic intense anaesthesia was produced 10 to 15minutes after the completion of the injection, and itwas expected to last two hours. J. S. Lundy, of thatclinic, reported 99 per cent. of successful cases in thesmaller rectal operations with this method, and75 to 85 per cent. in cases of carcinoma of the rectum.Dr. Hasler did not himself expect spinal anaesthesiato last longer than an hour ; if an operation waslikely to be prolonged, the spinal could be combinedwith a caudal block ; this extra injection took butlittle time and certainly prolonged the anaesthesia.Recent papers by Pitkin and Kelly suggested thatspinocain would be a useful anaesthetic for purelyperineal anaesthesia. By tilting the body of thepatient either up or down, according to whether theheavy or the light solution had been used, the anaes-thetic effect could be limited to the pelvic region.But examination of the literature suggested thedrawback that there was risk in altering the patient’sposition relative to the horizontal plane for at leasttwo hours after the operation, though this risk couldperhaps be reduced by using less spinocain. It wasnot always desirable to produce full relaxation of thesphincters in cases of fistula ; it was usually necessaryfor the surgeon to be able to feel the sphincters whileoperating. Local anaesthetics, especially spinal ones,relaxed the sphincters too much.

Discussion.Mr. E. T. C. MILLIGAN said that for many years it

was thought that the value of an anaesthetic wasenhanced if it relaxed the sphincter ani; and if itdid not, the surgeon proceeded to stretch the sphincterforcibly so as to expose the piles. Now, however, thepiles were withdrawn from the anus and exposed withdissecting forceps, which made such relaxation need-less. But for extensive fistulae in which the internalopening in relation to the sphincter had not beendetermined beforehand it was important to feel thetightly gripping sphincters, so that an anaestheticwhich relaxed the sphincters was bad. This remarkdid not apply to simple fistulae in which the relationsof opening to track had been determined beforehand.He thought that both anaesthetist and surgeon should be familiar with all the possible anaesthetics for a "

given operation, so that a wise choice could be made.Operations for fissure, fistula, and piles were now 4

perfect, and in choosing the anaesthetic the ideal J

was to banish apprehension before, pain and appre-bension during, and pain after the operation. Though 1caudal block was ideal if it was reliable, he thought Ithat in practice it was uncertain. Local anaesthesia fwas one of the best forms of anaesthesia for haemor- <

rhoid operations, but many patients were appre- Ibensive, interpreting every movement as something 1that would produce pain, and for such rapid and simple (

operations gas-and-oxygen anaesthesia with prelimi-nary sedative medication seemed the best means of tblanking out consciousness. Low spinal or spinal ianaesthesia limited to sacral nerves had advantages 1which made it valuable for operations on the peri- (

neum. It was controllable, and had none of the dis- 1advantages of the higher spinal anaesthesia. Most ofthe bad results following spinal anaesthesia were dueto improper selection of cases, and some were ascrib- (able to faulty technique. Post-operative pain bore Ino relation to the method of anaesthesia. (’

Dr. A. L. FLF3MING asked whether it was con- 1sidered that stovaine fixed more certainly and quickly ethan novocain. He would have thought that the Iadministration of the anaesthetic with the patient in a

the sitting posture was dangerous. Dr. Hasler a

seemed to use only a small quantity of the drug. 1Pitkin apparently did not rely on the inclination or f

tilt of the patient; if he wanted a high anaesthesia heused a larger quantity of the solution.

Dr. W. HOWARD JONES said he did not know whystovaine was used so much in preference to novocain,which was much less toxic and irritating. The 10 percent. solution of novocain had a specific gravity of1-023, and the specific gravity of cerebro-spinal fluidwas between 1-004 and 1-008. When the solutionwas injected into the cerebro-spinal fluid there was,opposite the point of the needle, an equal quantityof cerebro-spinal fluid, and so the specific gravitywas reduced, the heavy solution becoming a lighterone. For a complete splanchnic block, 15 drachms ofthe 10 per cent. solution was injected between thesecond and third lumbar vertebrae, and the patientwas then placed in the Trendelenburg position. Thefluid would come to a halt at about the third dorsalsegment. On going higher up there was a progressivedecrease in the time the anaesthetic lasted, since theduration depended on the degree of concentration ofthe solution. With the new anaesthetic, percain, itwas stated that spinal anaesthesia would last up tofour hours, and even a solution of one-twentieth percent. was effective. He believed it would be veryvaluable for rectal operations. The first case he hadseen at hospital that day was a man of the navvytype who had been admitted as an

" emergency " onaccount of perforated gastric ulcer, and was inintense pain. Dr. Jones had injected a one-twentiethsolution of percain, flooding the subarachnoid spaceas far as the third dorsal vertebra. The pain dis-appeared immediately, and in ten minutes theabdomen was opened, the ulcer closed, and theabdomen was swabbed out without discomfort. Forproducing a complete splanchnic block 15 c.cm. wereinjected without withdrawing cerebro-spinal fluid andbhe solution would travel as high as the third or secondiorsal vertebra. If cerebro-spinal fluid was withdrawn,bhe subsequent injection would travel higher.

Dr. C. F. HADFIELD expressed his surprise thatstovaine could be caused to drop down by change3f posture in the way Dr. Hasler had described. His3wn practice was to place the patient in the Trende-enburg position as soon as the injection had beennade. He thought 45 minutes’ operating time was11 that could be reasonably expected of stovaine inhe light form. Formerly he had used 1.0 c.cm. of aLO per cent. solution, but now he used 0-6 c.cm., andle had noticed no reduction in the anaesthetic effect.

Dr. EvANS submitted that for haemorrhoids andistula nothing more than a fairly light anaesthesiavas required-i.e., enough to keep the patient quietmd prevent him kicking. Given a good gas-and-)xygen anaesthesia the surgeon could do all that was’equired in comfort.The PRESIDENT spoke of abdomino-perineal opera-

,ions for carcinoma of the rectum, for which hesometimes had to give the anaesthetic&mdash;namely,pinal anaesthesia. At the end of the abdominal part)f the operation, when putting the patient in theithotomy position for the perineal part of it, the bloodpressure, which previously had been satisfactory, fellconsiderably and was a cause of anxiety. Recentlyh surgical colleague at Middlesex Hospital had adoptedhe plan of doing the perineal part first-i.e., whenhe spinal anaesthesia was at its best-and concludingvith the abdominal stage. The result had beenxtraordinarily good, and since doing this that surgeoniad not lost a case.Dr. HASLER briefly replied. He said that " light

"

nd " heavy " solutions were relative terms; one

ontained glucose, the other did not. Both wereLeavier than cerebro-spinal fluid. With regard to.epth of anaesthesia for these operations, he liked toLave the patient well under, at the commencementspecially, partly because of the general mental andphysical state of the patient, partly because of therea of operation concerned. A patient who had hadspinal injection and had low blood pressure shoulde moved as little as possible for the hour or twoallowing the incision.

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SECTION OF OTOLOGY.AT a meeting held on Dec. 6th the chair was taken

by Mr. W. M. MOLLISON, the President, and a paper onRadiological Diagnosis of Mastoid Disease

was read by Dr. ELSIE MANN. She described thetechnique adopted in examining the mastoid, andsaid she now used two lateral views as a routine ; theprone position, although it had the advantage ofshowing the two mastoids on one plate, had notproved sufficiently useful to be made a standardpractice. The exposure should be as short as possiblewhen the patient was a child, and it was better togain the child’s confidence than to frighten him byusing a clamp. A successful plate from a child underthree was obtained more by luck than good manage-ment, and occasionally an older child would proverefractory to all persuasion, and would not keep still.Interpretation was not always easy. The mastoidswere usually symmetrical but might be cellular onone side and acellular on the other. When they werecellular on both sides the cells were usually sym-metrical, which was a useful thing to remember whentrying to decide whether a space were an enlargedcell or an area of absorption. Superficial cedema,eczema of the meatus, and furunculosis might allcause blurring of bony detail, but in the absence ofthese conditions the radiologist could diagnosemastoiditis and give help which, though not infallible,was very useful.

Dr. GRAHAM HODGSON showed slides illustrating theDiagnostic Value of X Rays of the Temporal Bone.

In one-third of the cases of otosclerosis, he said,X rays would reveal a loss of definition of the basalturn of the cochlea. In another third nothing abnor-mal could be seen, and in the remaining third therewas some lack of definition which the radiologistcould not distinguish with certainty from a normalvariation. In some advanced cases the changes-which might be described as the difference between araw grain of rice and the same grain boiled-couldalso be detected in the capsule of the posteriorlabyrinth. The extent of the changes did not seemto have much bearing on the symptoms, which per-haps depended more on the distribution than on theextent of the changes. Radiology could be of use inotosclerosis, however, in following the result of treat-ment and selecting the cases most likely to yieldto it. In tumours and fractures the X ray was ofdefinite value, as Dr. Hodgson’s slides illustrated,and might detect a fistula in the external canal.Showing slides of mastoids, Dr. Hodgson suggestedthat a child might be kept momentarily quiet if theradiologist made more noise than it was making itself.

I

Mr. T. B. LAYTON spoke on theValue of Radiography in Symptomless Mastoiditis.

He said there was no symptom of inflammation ofdiploetic tissue of the mastoid bone. All symptomswere evidence either of extension or of absorption oftoxins or organisms. Radiology would detect thecases in which there were no symptoms. Any caseof otitis media might actually be a mastoiditis, andif it did not quickly get well might be maintained byinfection from the mastoid end quite as often as fromthe nasopharyngeal end. If it did not recover inthree or four weeks the mastoid should be considered,and if there was any doubt the mastoid should bedealt with before the nasopharynx, or the case mightbecome incurable by small operation. Caries wasfollowed by sclerosis ; radiography should in the futurereveal the stage at which sclerosis began, probablytwo or three months after the onset of otitis media.Early operation gave perfect results without radicaloperation ; after the onset of sclerosis there was lesschance of getting the patient quite well. Clearing upthe nasopharynx had given most unsatisfactoryresults in very many cases of running ears. Radio-graphy would segregate the cases of symptomlessmastoiditis, and show whether in otitis media the

mastoid became inflamed and whether or not itwould get well with the otitis.

Mr. T. H. JUST read a paper on the ’

Diagnosis of Acoustic Tumours.Rare as these were, he said, every otologist must seethem, because some patients complained at first ofdeafness, tinnitus, and giddiness. From the welterof sometimes contradictory findings he selected asoutstanding symptoms : deafness, headache, fallingor lurching, failing vision, giddiness, sensory dis-turbances-usually of the fifth nerve-vomiting,diplopia, paresis, and tinnitus. Cases of endothe-lioma and cholesteatoma of the memnges showedpractically the same symptoms, due to pressure inthe posterior fossa. The signs were connected with(1) the eye ; (2) the cranial nerves ; (3) the cerebellum;and (4) the eighth nerve-i.e., (1) disturbance ofvision up to complete blindness; papilloedema ;contraction of the visual fields, particularly tocolour ; spontaneous nystagmus, and diminished orabsent corneal reflex ; the nystagmus had beenpresent in all of his 33 cases ; (2) diminution insensation or power in the area of the fifth nerve;(3) falling or unsteadiness, and weakness or loss ofpower in the limbs ; (4) middle-ear deafness and lossof function in the vestibular nerve. The simplesttest for the cochlear nerve was by means of a heavyand middle fork and a noise box. To be certain ofa small diminution of bone conduction was notalways a scientific possibility. Mr. Just had ceasedto use the rotation test, as all patients showed spon-taneous nystagmus and many were spontaneouslygiddy; The galvanic test was rather uncertain andhe preferred the cold caloric test, which producedmarked giddiness, errors in pass pointing, and markedand wide nystagmus if the vestibular nerve wereworking at all. Only the bad ear was syringed.

Dr. W. T. GARDINER read a paper on the samesubject, dealing with Edinburgh cases. His findingscoincided w;th those of Mr. Just. Deafness wasusually the first symptom. Giddiness, absence of

spontaneous pointing error, and spontaneous nystag-mus had been the next most common, and thenystagmus was the most useful diagnostic symptom.The cold caloric test was valuable, and had beenpositive in all the ten cases who had permitted it.Mr. Gardiner thought, however, that the sound earshould be syringed as well as the other. The diplopiawas due to the sixth nerve only. Loss of taste andsense of smell had been recorded in a few cases. Theradiogram had given great help in two cases, showingenlargement of the internal meatus. Acoustictumours should be suspected in cases of absolutedeafness and loss of vestibular function associatedwith spontaneous nystagmus in all directions withoutRombergism or spontaneous pointing error.

Cases.Mr. C. GILL-CAREY showed a case of objective

tinnitus in which a crackling sound, not exactly .

synchronising with the pulse, could be heard a footaway.-Mr. 0. POPPER declared that this conditionwas due to rhythmic contraction of the tensor tym-pani ; he himself could produce it voluntarily.-Sir JAMES DUNDAS-GRANT, Mr. L. GRAHAM BROWN,Mr. W. S. ADAMS, and Mr. GILL-CAREY commentedon the case and quoted similar ones.-Dr. D. A. IMRIEshowed a case of tumour of the nervus acousticusdemonstrated by radiography. The difficulties encoun-tered by the radiologist, he said, were the depth ofthe petrous portion and the impossibility of pro-ducing symmetrical views of two sides when thebeam was passed along the internal canals. Thetumour had been diagnosed by a stereoscopic trans-orbital view, as suggested by Conte, of Turin, the beampassing through both orbits. This method gave trulysymmetrical views of both petrous bones and shouldlead to earlier diagnosis of acoustic tumours.-Dr. T. B.JoBSON pointed out that this patient had first beenseen in the ophthalmological department, at a stagewhen it was really too late, and the operation had to

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be one of great magnitude and difficulty. Diagnosisshould rest on deafness, vestibular signs, facial

paresis, and radiography ; to wait for further symp-toms involved great risk.-Mr. G. H. STEELE remarkedthat the case had been an obvious auditory fibromabefore operation, yet at operation the growth had beenfound so deeply embedded in the cerebellum that thediagnosis had been doubted. Six weeks after thefirst decompression the cerebellum had extruded thetumour, but operation had failed because two largeblood-vessels running across the tumour had beenruptured.

Mr. E. WATSON-WILLIAMS showed skiagrams ofthe temporal bone. One showed extensive destruc-tion by choleastomata, and the second showedinfection in the mastoid cells in acute otitis media.He agreed with Mr. Layton that the mastoid was notopened early enough or often enough, but not thatit should be treated before the nasopharynx. Thepharynx should have been treated before three weekshad elapsed ; neither end should be treated to theexclusion of the other. In his experience radiologyfailed to help, and was vague in just those doubtfulcases of mastoiditis where help was most needed.The otologist must rely on his clinical findings.Mr. W. A. MILL showed a case of osteomyelitis of

the temporal bone. The man had had a Schwatzeoperation performed for acute mastoiditis. A monthlater he had suffered from swelling in the temporalregion, headache, and pain, all of which had persisted.Operation a month later had revealed granulations inthe mastoid cavity, malleus, and incus, and diseasedbone in the squama with thickened dura.

Sir JAMES DUNDAS-GRANT showed skiagrams froma man who had fallen down and been picked up deaf.There was a suggestion of a fracture in the back ofthe orbit, possibly the labyrinth had been fracturedby transmitted force.

Discussion on Papers and Cases.Mr. A. R. TWEEDIE said that clinical findings must

be regarded as more valuable than radiography indeciding what to do in otitis media. He would notopen an antrum while a child had offensive tonsilsand adenoids.Mr. LAYTON, in reply, said that radiology was only

one piece of evidence in mastoiditis, and that he foundit valuable in cases where there was no other evidence.He did not believe that post-aural drainage was avaluable thing if there were no disease of bone. Theonly way of finding whether bone was involved ornot was by radiography. Removal of tonsils whichwould not be removed save for a running ear nevergave any good result; he would not operate on thenasopharynx while an acute infectious process wasgoing on.

Sir JAMES DUNDAS-GRANT urged the value of theunilateral galvanic test for acoustic tumours, withthe cathode on the back of the neck and the anodeon the ear, and advocated his cold air apparatus.Mr. TWEEZE agreed that rotation was not of much

value but still hoped to get something from it quanti-tatively. The galvanic and caloric tests dependedvery much on the technique. The first thing to notewas whether the leaning or the nystagmus appearedfirst. In middle-ear cases it was possible to get ahyposensitive peripheral organ by the caloric test anda hypersensitive vestibular nerve by the galvanictest. The galvanic test result was in direct proportionto the integrity of the ganglion of the vestibularnerve. If the resistance were adjusted the patientwould not suffer from the test.

Mr. S. ScoTr said his experience had differed fromthat of Mr. Just in that the galvanic tests had provedof great value to him ; details of technique were veryimportant.Mr. BRO]UGHTON 13ARNEs asked whether any changes

had been seen in the middle ear.

Mr. JusT, in reply, said he had had no evidence ofmiddle-ear disease in the affected ear.

SECTION OF PSYCHIATRY.AT a meeting of this Section held on Dec. 10th,

the chair was taken by the President, Sir ROBERTARMSTRONG-JONES. Members of the Section forthe Study of Diseases in Children and of the ChildGuidance Society attended this meeting.

Dr. BERNARD HART opened a discussion onTHE DIFFICULT CHILD.

He defined the difficult child as one who presentedobstacles to the achievement of that internal andexternal adaptation which constituted the aim ofnurture and education. The point of view takentowards him had changed from an ethical to aphysical and then to a psychological one. Thedifficulty had been ascribed to congenital weaknessof moral fibre, diseases or defects in various organs,and lack of nervous stability, but these things neverfilled the whole picture, and failure of perspectivemust result from concentrating on them. The modernview was that the trouble was similar to that under-lying functional nervous disorders, and that thedifficult child was likely to become the neurotic adult.There was a failure in adaptation of the individualas a whole and not a disorder of any one system.The trouble could only be fully understood if psycho-logical conceptions were brought to the aid of physicaland chemical conceptions. The symptoms displayedby the difficult child were due to a fault in his reactionas an individual. Delinquency and behaviouranomalies were included as well as nervousness andneeded treatment along the same lines.The Child Guidance Movement was an attempt to

cope with the problem along those lines. It employeda team of workers, including a psychiatrist, psycho-logist, and social worker, for it was essential to knowmuch about the child, his mental and physical make-up, his home- and school-life, and the people he metin both environments. In some cases the externalagencies must be modified. Team-work of this kindwas always somewhat repugnant to the clinicallyminded physician, even when the team was weldedtogether by the method of the conference. Therewas also a fear lest the social worker tail should wagthe psychiatric dog, but all who had had experienceof the social worker’s aid would realise that this riskwas well worth taking.

The Point of View of the Pcediatrist.Dr. HECTOR CAMERON described the difficult child

as a problem in management, physical culture, andmetabolic instability, subject to a vicious circle ofconduct and metabolic disorder. His low fat tolerancehad long been recognised ; great emotional excitementor physical exertion and states of infection causedexhaustion of the slender glycogen resources of thebody, or glycopenia, in which condition metabolismof fat was incompletely carried out and intermediateproducts appeared. In this state vasomotor pallor,amyotonia, yawning, furring of the tongue, nausea,instability of temperature curve, low muscle tone,fainting, and indefinite aches and pains were the rule.Often vomiting dominated the picture ; sometimesit was absent or only occasional. In between attacksthe child was full of nervous energy, often squintingor stammering, pale, troublesome, incontinent ofurine, a bad sleeper, and restless. The hepatic andmuscular glycogen played an important part in

determining the sugar content of the blood. Opposi-tion, irritability, apprehension, terror, loss of con-fidence, and loss of the power to concentrate werecharacteristic mental states both of the nervous

child and of insulin hypoglycaemia. The metabolicdisorder often expressed itself in a nervous exacerba-tion. An excitement, a fright, a great intake of fator an illness might each produce a deterioration innervous control, showing itself as a failure of concen-tration culminating in a confusional state ; increasedopposition and irritability ; night terrors, enuresis,or a bout of vomiting. An attack on the metabolic

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disorder should precede psychiatric attempts toadjust conduct. An antiketogenic diet, glucose atshort intervals, a petrol mixture with low fat andhigh sugar all gave good results. There was often anexacerbation during the normal sugar shortage ofthe night. This might be why the child got up tired,yawning, with lines under his eyes, fussing and worry-ing over little things which later in the day gave himno trouble.

The Child Guidance Council.Dr. W. MOODIE said that " child guidance " had

unfortunately come to suggest interference with theparent’s duties. It had acquired an arbitrary mean-ing : a team method of approach to the study ofbehaviour problems of children. Workers had foundthat these problems could best be approached fromfour aspects : the physical, the temperamental, theintellectual, and the environmental. In practicethe psychiatrist usually did the first two, the psycho-logist the third, and the social worker investigatedthe history and environment. Sometimes a psediatristundertook the first line of approach. The ordinarypractitioner, if he was willing to give the time, couldobtain in his consulting room a history and descrip-tion of the child’s environment, but even if hevisited the home he did not usually see how the childand its parents behaved towards each other on manydifferent occasions, as the social worker could. More-over, it demanded a great expenditure of time tosort out and arrange chronologically the confusedand often inaccurate statements of the relatives ;this could quite well be done by the social worker.Intelligence quotients were inaccurate, and gave onlya vague idea of the child’s abilities, but the trainedpsychologist obtained much more information thanthis as to the child’s mental attitude towards hisenvironment, his attack on problems, and reaction tofailures, and also interpreted educational reports.Direct questions to the child about his emotions wereharmful, and provided just that limelight the desirefor which was the basis of so many problems. Theamount of psychiatric investigation carried out at aclinic depended on the age of the child ; the youngerthe patient the less the psychiatry. When all thereports had been collected a case conference was heldto decide on treatment. To the conference wereinvited interested parties : teachers, doctors, socialworkers, and students. Conferences were useful forinstructional purposes. The psychiatrist delegated tosuitable workers the appropriate branches of treat-ment. The social worker tried to modify the homeenvironment and, difficult as this was, achievedsuccess often enough to make it worth while. Trainedworkers soon became able to estimate the chancesof success. The psychologist would help the childover any educational difficulty by special tutoring.Further conferences were held from time to time todiscuss progress. The social worker’s visit was afriendly one and did not give the impression ofmaking inquiries. She could be used to produce anexperimental observation of temperamental reactions-an object which had not been achieved by any of themany methods of psychological investigation devisedfor the purpose. Although cumbersome and costly,the team method was not one lightly to be set aside,for it was a valuable experimental and therapeuticweapon.

Dr. EMANUEL MILLER confined himself to a groupof children in which there was no demonstrablephysical disorder which could reasonably be regarded IIas primary, although not denying the metabolic basisof conduct disorders. He briefly described the workat the Jewish Child Guidance Clinic. The greatdifficulty, he said, was the relating of the disturbanceto the environmental error from which it was supposedto have arisen. A behaviour disorder often corre-sponded with an error in the home or school, but themere existence of such an error was not enough toaccount for the disorder. The family, though sociallya unit, was largely a discordant collection of individualspulling in different directions. The complicated

dynamic perplexity of the situation on both sides wasimportant. A child might steal from one parentand not from the other, or steal one class of objectsonly. It was difficult to believe that these phenomenawere poised on a carbon atom. Circumcision or theweaning of the baby might cure a child in the mostlurid home. The social situation was a stimulus to thechild, but what happened was the reaction to asituation that had gone before, and the removal ofthe stimulus did not necessarily cure. Howevercarefully parents avoided favouritism, " foundling

"

phantasies or feelings of " not being wanted " wouldoften arise from such things as position in family orphysical peculiarities. Nothing could more readilystimulate disorders of behaviour. To differentiatebetween cases which were within and those whichwere without the realm of social correction wasdifficult. If the reactions were infantile the conditionwas probably a response to something that had gonebefore, by the mechanism of the conditioned reflex.Magical and symbolic gestures should be recognisedand differentiated from habit spasm and rheumaticmovements.

Lay Psychological Study.Miss FiLDES (Child Guidance Council) said that the

problem must be studied from the point of view ofpractical expediency, and it was waste of the doctor’s .

time to do much that was necessary if the difficultchild was to be adjusted in some circumstances. Onedirection in which difficulty might lie was the intel-lectual capacity, and this field belonged primarilyto the lay psychologist trained in the investigationof intellectual and emotional processes. Intelligencequotients were useful and very much abused ; theywere most abused by people who took short cuts tothem and failed to analyse the material from whichthey were derived. A child subnormal or super-normal in general intelligence found normal adaptationextremely difficult, and was apt to develop superaddedemotional situations. Special abilities and disabilitiesalso went to make up problems. Here again the laypsychologist could be of great use. Inability to speakor read could be analysed and dealt with by thetrained layman in a team ; he could also analyse theinherent and underlying temperamental factorsunderlying the child’s behaviour. Much of theinvestigation was carried out by observing the wayin which different children reacted to standard tasksunder standard conditions; this revealed manygeneral traits which might be the cause of thebehaviour difficulty. The team psychologist couldalso investigate and deal with school problems.The PRESIDENT spoke of the difficulty of getting the

parents to admit that backward children were in anyway abnormal, and of the difference between standardsof behaviour in different strata of society. Extremetypes of difficult child, he said, were easy to recognise,but there was a large, intermediate group which wasdifficult to recognise and treat; they were humanbutterflies, easily led, and hard to interest. Theparents must not be mere spectators of officialinterference.

Encephalitis and Dyspituitarism: : the Value ofBulbocapnine.

Dr. E. R. HILL spoke of chronic epidemic encepha-litis and non-encephalitic dyspituitarism, conditionscharacterised by crude and uncontrollable behaviourresponses, exaggerations of the crude outbursts seenin normal children. McDougall’s theory of instinctand emotion explained these cases satisfactorily.The optic thalamus underwent an exaggeration of itsfunctions in these cases. Bulbocapnine controlled theaberrant behaviour for several hours without anyother apparent effect. Dr. Hill quoted a typical caseto illustrate the action of the drug. Patients becamequiet and normal within ten minutes of a forcibleinjection of the alkaloid. The dose was followedby a light somnolence ; there was some evidence thatthis was natural sleep, not comparable with the usualnarcosis after a drug. There were no toxic or- cumu-

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lative effects, and tolerance was very slowly estab-lished, if at all. The patients relapsed when thedrug was discontinued.Behaviour disorders might occur in three types of

dyspituitarism : (1) patients with increased activityof the anterior lobe, and a tendency to gigantism ;(2) those with diminished activity of the posteriorlobe and the dystrophia adiposo-genitalis syndrome ;(3) mixed types. These disturbances were congenital,but formed a suggestive link between the mentaland physical aspects of emotion.

Discussion.Dr. D. W. WINNIcoTT said that the scientific

approach to the difficult child must come from astudy of the child itself, whose unconscious hadvery great power over his life, and was not alwaysdealt with sufficiently. All the dreadful things seenin the post-encephalitic child were present in thenormal child, but controlled by the ego. Any approachwhich did not include the unconscious of the childwas unscientific.

Miss MARY CHADWICK said there seemed to beexcellent equipment for diagnosis but little for treat-ment. Explaining repressed tendencies would notcure anyone. Questioning a child about its emotionswould not give much response. Something must bedone to release its emotions and phantasies. OneGerman clinic treated the parents when their neurosiswas held to lie at the root of the child’s trouble.

Dr. N. H. BURKE analysed 30 case-sheets from theJewish clinic to illustrate methods of treatment.Home had been wrong in 23 cases ; the mind in 24 ;the school in 7 ; and the bodily health in 14. Hometroubles included parental disharmony or neurosisand injudicious handling ; or minor difficulties, suchas sleeping accommodation. In a few cases tonsilsand adenoids had to come out ; there were rheuma-tisms and debilities, a few heart cases, and a case oftuberculous joints. There had been mental dullnessin a few cases ; two had been defective, and oneexcessively intelligent. All had had various degreesof anxiety, fear and neurosis. In two cases nothingcould be done with the parents, but partial adjust-ment had been obtained in 24 and good resultsin 4. Some cases needed a residential or defectiveschool, and removal from impossible homes ; othersneeded holidays from home-partly for diagnosis,and partly to give the mother a rest; some ought togo to better schools ; others were benefited byadjustment of sleeping arrangements, admission toscout or girl guide troops, or psychotherapy. Thecinema had only once appeared to have any influence.

Dr. J. D. REES said very few people in this countrywere doing serious analyses of children, and thosewho had done it in Vienna were giving it up. Doctorsdoing child guidance must have the analytical pointof view or

" environmental treatment " would be"

woolly." .

Dr. MARGARET LowENFELD said that removal toa more favourable environment might improve thechild, but on return he would react to the samedifficulty in the same way. The child who could notdeal with a difficult parent would fail later in life todeal with a difficult employer. The only method oftreatment was to provide a system of play by whichchildren could build their phantasies and slowly cometo understand the reasons for their own behaviour.The child would build within itself a world whichexpressed its need. The emotional difficulties ofchildhood were associated with biochemical andphysical disturbances, particularly of posture. Therelease given by the phantasy method was correlatedwith a change in the biochemical and physical picture.The problem could be approached by either path :physical or emotional.

Dr. HART, in reply, emphasised that we could notafford to neglect or be intolerant of any one of thefacets of the problem.

Reviews and Notices of Books.PSYCHOLOGY.

An Introduction to Individual Psychology. ByALICE RAVEN. Cambridge : W. Heffer and Sons,Ltd. 1929. Pp. 145. 3s. 6d.THE title of this book, though more or less accurate

in describing its- thesis, is somewhat misleading inthese days, when the term individual psychology hasbecome synonymous with particular views expressedby Dr. Alfred Adler. But that is scarcely the businessof the general reader, who can let the adherentsthemselves defend the pedestal of the idol. The bookis written in a clear style, and is illustrated by apleasant cultural breadth, but its eclecticism is alittle dangerous. For example, while endorsing thevery partially dynamic psychology of W. McDougallas regards the instincts and their related emotions,the author accepts fully the foundation principles ofFreud’s psychopathology, the power psychology ofAdler, and the type psychology of Jung. Treatingeach system superficially, and gleaning what she feelsto be most useful, she constructs a fairly coherentsystem of psychology. But careful analysis of herorigins will bring out the glaring inconsistencies ofthis eclectic method. However, the very readableanalyses of the plays of Eschylus, and of the characterof Meleager in Swinburne’s Atalanta, makes amends forhe offences against established systems and the lackof logical coherence in her philosophy. Those whoare familiar with the schools of thought from whichit has been evolved will find this little book aninteresting study.

PHYSICAL THERAPEUTIC TECHNIC.

By FRANK BUTLER GRANGER, A.B., M.D., Directorof Physiotherapy, United States Army. London :W. B. Saunders Company. 1929. Pp. 417. 30s.

On Prescribing Physical Treatment. By MATTHEWB. RAY, D.S.O., M.D. Edin., Physician to theSt. Marylebone General Dispensary. London:William Heinemann, Ltd. 1929. Pp. 179. 10s. 6d.

I Dr. Granger’s book is intended for the general

practitioner who wishes to apply physical treatmentonly occasionally. It is chiefly devoted to electricalmethods, and hydrotherapy and massage are passedover somewhat sketchily. The first part of the bookis encumbered with elementary theoretical matterwhich the physician with any aptitude for the use ofelectricity will not need, but the last 17 chaptersdescribe in close detail the treatment of variouspathological conditions and should be helpful. Twouseful features are Dr. F. A. Davis’s synopsis ofphysiotherapeutic methods, a tabular description ofthe chief devices in use to-day, and the chapter on ahospital department of physical therapy, whichsuggests a basis for the initial foundation of a physicaltreatment branch, with lists of personnel and

apparatus. The work is copiously illustrated, butwould have been improved by a more careful selectionof the pictures. It suffers from the common fault ofcontaining a large number both of manufacturers’woodcuts, and of photographs of treatment which donot teach anything in particular.

Dr. M. B. Ray in his smaller book places balneo-therapy in the foreground. He deals very little withtheory, and arranges his material according to method,giving the indications for each kind of treatment ashe describes it. This presentation has the defect thatthe practitioner who wishes to treat a certain condi-tion must turn up several places in the book andcollate the information. In many cases the descrip-tions have been curtailed to avoid a repetition whichwould have been useful, and the index is unfortu-nately not complete enough to support this methodof arrangement. Nevertheless, this short text-bookof medical hydrology and, to a lesser degree, ofelectrotherapy and other physical methods, is com-