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haematin. Nitric acid, however, throws down a

heavy cloud.Although in this case the illness was precipitated

by quinine, it was definitely not a case of quininehaemoglobinuria, for the patient showed no sign ofquinine idiosyncrasy before or after the attack.Moreover, its association with an enlarged spleen,bilious vomiting, and jaundice leaves no doubt that itwas a case of true blackwater fever. The case canbe written down as but of slight severity, only on theground that it continued for so short a period, andit is suggested that the early treatment,within six hoursof onset, definitely aborted what might have been anattack as serious as the first one.Such simple treatment is available immediately for

any sufferer, however far removed from medicalattention. The pre-blackwater state should similarlybe treated with small doses of quinine combined withgenerous doses of alkali taken some hour or so before.It is hoped that medical men practising in endemicareas will make known the possibility of such treat-ment of this dangerous and much dreaded disease,and will report in confirmation or failure as resultsoccur, for any single practitioner has as a rule to waitsome years in order to collect a series of cases.

Medical Societies.

ROYAL SOCIETY OF MEDICINE.

SECTION OF OTOLOGY.THE summer meeting of this Section took place at

Gonville and Caius College, Cambridge (by permissionof the Master) on June 21st and 22nd, Mr. SomERviHASTINGS, M.P., the President, being in the chair.

Mr. W. S. TLTCKER, D.Sc., opened by reading a paperon the

Localisation of Sound.He said that localisation as applied to sound was ofpsychological rather than physical origin, and itdealt with sensation more than with physical measure-ment. And it differed from location, in that it did notfix the position of the source of sound. It had beencontended that human beings were endowed partlywith stereoscopic audition. We derived our sense ofdirection from an image which was subjective, andwhose direction relative to the sagittal axis of thehead enabled us to point to the sound-emitting centrewith some accuracy. The head was best adapted forlistening when held in the horizontal plane. For all-round listening-and the special case of listeningfor aeroplanes was taken throughout-accuracy oflocalisation was least for the overhead position.An aeroplane might be at the vertex and 10 degreeson either side without the observer having anyidea of a change of position-i.e., through the wholeof that angle the aeroplane seemed to be verticallyoverhead, because in that area the binaural facultywent out of action. Normally localisation was possibleby virtue of some difference in the stimulus receivedby the two ears. Such variations in stimulus couldarise : (1) by a difference of sound intensity ; (2) by adifference in phase of the oncoming sound waves ;(3) by a difference in the time of arrival of somecorresponding portion of the sounds received by thetwo ears. By a series of exhaustive trials Banisterhad shown that in normal observers no change oflocalisation occurred until the ratio of intensities of thewaves reaching the two ears had the value of at least2’6 ; short of this, no idea of direction was obtained.The localisation was towards the ear receiving thestrongest sound. It was found difficult to locate verylow notes, however, though this was not a disabilityin listening for aeroplanes, as the noise of their flight

was rich in high notes. Mr. Tucker proceeded to show

how the principles enunciated were practically applied,and how men were tested and trained to carry outthe localisation of enemy planes.

Mr. G. WILKINSON discussed the resonance theory.The work of Adrian showed that the frequency ofnerve impulses depended solely on intensity. It wasa law of the integration of impulses that the impulsefirst arriving inhibited that which arrived later ; andthere was no reason why an inhibition of the leadingphase impulse should not occur, so that the soundwas located to the opposite ear.

Mr. ALBERT A. GRAY read a paper entitledThe Application of the Pl’ineiples of Maximum

Stimulation to Clinical Otology.The contribution was based on the study of the caseof a highly musical patient who consulted Mr. Grayin April, 1928. Her complaint was not of deafness,but of hearing musical notes inharmonically. Herright ear, she said, troubled her ; the left one wasnormal. By watch and voice tests scarcely any deaf-ness was apparent in the right ear. In that ear lownotes were heard as a buzzing. Going gradually up thescale, a note was reached which, the patient said,seemed musical but of a higher pitch than was heardin the left ear. The first note heard pure wasfag sharp (French notation). The patient was muchreduced in health, and it was suspected that she hadsome lung mischief. She had middle-ear catarrhand inflation improved her. Obviously this was acase of paracusis dysharmonica-a different conditionfrom paracusis Willisii. Her lesion must be belowthe pons, because only one ear was affected; itwas in the cochlea, probably at its apex, and verylikely due to interference with the pressure of fluid inthe labyrinth because of the stiffness of the chain ofossicles resulting from middle-ear catarrh. The case,indeed, illustrated the principles advanced by thespeaker in a communication to the Journal ofAnatomy and Physiology in 1900, on the Principleof Maximum Stimulation. Adrian’s work was onmedullated nerve-fibres, and since the nerve-fibresclose to the organ of Corti were not medullated,the explanation put forward by Mr. Gray was notinvalidated.The paper was discussed by the PRESIDENT, who

said the cases of paracusis dysharmonica he had seenhad ordinary middle ear-deafness.-Mr. WILKINSONspoke of Helmholtz’s work in this connexion and ofthe integration of nerve impulses in the brain.-Dr.LOWNDES YATES said that a different note was heardwhen a vibrating fork was placed on the mastoid fromthat heard through the air.-Mr. GRAY replied atlength.

Mr. G. SECCOMBE HETT read a paper by himself,Dr. A. G. WELLS, and Dr. G. MURRAY LEVICK on

Ionisation as a Treatment for Middle-earSuppuration.

The importance of technique and of the selection ofsuitable cases was emphasised. Given suitable cases,the favourable results of the treatment were 100 percent. ; this did not apply to hospital cases, because ofdifficulties in ensuring proper selection and expertadministration of treatment. Mr. Hett thought thatclinics should have a special electrotherapeuticdepartment exclusively for ear, nose and throat work.He had found this treatment successful in three typesof case. The first was the acute suppurative otitis,which, instead of clearing up in ten days, continued,without acute symptoms, for three months. Thesecond was the type in which after the radical mastoidoperation suppuration did not cease. Every case ofthis type under his care had ceased discharging afterthe application of ionisation, and a healthy mastoidresulted. The third type of case was the acutemastoid, especially the kind with a deep spoon-shaped cavity which refused to heal.

Dr. WELLS spoke of his experience of themethod in a large number of cases. The poorresults reported by some of his colleagues wereattributable in his view to certain defects, of

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which the chief lay in faulty selection of cases. Acareful examination should be made of nose, throatand ear ; and suction should be made in suspectedregions to see if pus could be aspirated. Ionising adischarging ear in the presence of chronic disease ofthe mastoid bone must lead to failure. Generallyspeaking, acute cases were not suitable for the treat-ment, though he had cured a fair number. It wasnot necessary for the perforation to be a large one forsuccessful ionisation ; it was only necessary that thefluid should reach the whole of the septic area. Beforebeginning treatment the ear must be carefully cleanedpreferably with absolute alcohol. The fluid should beintroduced slowly, and should be allowed to run alongthe wall. In skilled hands a shunt resistance could beused, the current being taken direct from the supply,though admittedly accumulators were best. Whenbeing treated, patients should be in the recliningposition, the affected ear being uppermost. Thetreatment should only be given by an expert inelectrotherapeutics, working in conjunction with theaural surgeon.

Dr. A. R. FRIEL indicated the place of ionisation inthe economic aspect of an ordinary clinic. Any casein which the area of sepsis was accessible to fluid wassuitable for ionisation. If in such a case a secondfactor was present, the latter must be removed. Ifaccessible sepsis was present in a neighbouring organboth areas should be dealt with at the same time.He urged that reports of cases treated should describeexactly what was being done. It was not worth whileto treat by this means children with only a slightdischarge from the ear. It sufficed to cleanse the earand blow in boric powder. The speaker had beenaurist to the Tottenham Education Authority for fiveyears. At the beginning of that time ionisation wasextensively employed; but now most of the cases ofchronic otorrhoea had been wiped out from thoseschools, excluding mastoid cases.

Mr. A. B. PAVEY-SmzTH emphasised the importance ’’

of a careful toilet before applying ionisation ; it wasmuch more valuable than the usual syringing and theuse of drops.

Dr. JOHN ACOMB said ionisation had been success-fully applied to some of his patients, but in someit was followed bv dermatitis of the meatus.

Dr. W. S. SHARPE, as the result of observation ofseries of cases receiving ionisation and series ofcontrols, which had the same preparation and treat-ment except for ionisation, had formed the conclusionthat ionisation did not yield superior results.

Dr. T. B. JOBSON considered that ionisation was thegreatest advance in therapeutics whicn had beenachieved in the treatment of the discharging ear in thelast century. It had only been slowly accepted and wasstill very little used in the teaching hospitals ofLondon. To try to ionise inaccessible sepsis was toinvite failure. Ionisation should be done by tne auralsurgeon ; the electrotherapeutist could not beexpected to diagnose suitable cases. The results ofthe method in suitable cases of mastoid cavities ortympanic sepsis were dramatic, even in the mostobstinate and enduring cases. The method had beenwell described in - an instructive paper in THELANCET of May llth, 1929, by Mr. J. D. McLaggan.Dr. A. LOWNDES YATES contributed an exhaustive

paper entitledThe Evolution of the Sense of Hearing.

Dealing first with the more lowly forms of organism,Dr. Yates said that one of the otolithic organs in thefish,the lagena,wasnot present inadultman, andthe mannerof its disappearance was the key to the evolution ofthe cochlea. In amphibia, Nature had made severalattempts to form auditory organs. One, the maculaneglecta, appeared like a flash in the development ofthe human ear and disappeared. In reptilia the sense-organs of the pars basilaris lagenæ came to lie onthe basilar membrane ; in the crocodile were firstseen stretched diagonal fibres, and the elements of thecochlear sense-organ showed an orderly arrangement.In birds the cochlea was capable of very great power

of discrimination. In the parrot’s cochlea the numberof fibres was 1200, in that of man 2400, and theparrot could accurately analyse sound.

In regard to the human cochlea, Mr. A. Gray hadwell carried on the work of Retzius. As to the workingof the cochlea, there was little more than surmise toguide one. Helmholtz’s theory of resonators had beenrudely shaken, and recently Mr. Gray and Mr. G.Wilkinson had brought forward the theory of theformation of sound patterns in the cochlea, reinforcingthe contention by analogy with other sense-organs.In the brain there was a corresponding and probablysynchronous evolution of the auditory centre and ofthe whole of the neopallium. There was a fair amountof evidence that the human cochlea and semi-circularcanals were now, as a whole, in a state of involution.In man and the higher mammals the semi-circularcanals were noticeably less evolved than in the fish,presumably because the postural reflexes had largelyusurped their function and removed the need for themore primitive form of balancing apparatus. But inthe cochlea evolution in respect of the sensitivity ofthe organ continued, and reached its highest pointin mammals. Dr. Yates then minutely examined theevidence furnished by embryology. Ascending in thescale from the fish to the highest mammals, there wasseen an increasing complexity of structure of themid-brain which led, in mammals, ultimately to theformation of the inferior colliculus.

Dealing next with evolution of the power of auditoryinterpretation, Dr. Yates said the brilliant work ofPavlov had introduced us to the idea of reflexes whichoperate only under certain definite conditions. Itseemed that the analytical sense of hearing was themain cause of development of the intellect; yet therewere certain factors which might modify this law.These he set out in detail. Finally, he contended thatthe insistence on the maintenance of intellectualpowers in persons who were going deaf and the needfor making full use of their tactile sense, appeared to bea vital factor in the prevention of some forms ofdeafness. A similar reasoning could be applied to thecase of children who were going deaf.

The paper was discussed by the PRESIDENT,Mr. ALEx. TWEEDIE, Mr. WATKYN-THOMAS, Mr.NORMAN BARNETT, Mr. HAMBLYN THOMAS, Mr. A.GRAY, and Mr. G. WILKINSON.—Dr. YATES replied.

Mr. M. VLASTO read a paper on the

Chorda Tympani Nerve in Otology.He said tne paper owed its origin to a question asked,in conversation, whether any patients who had hadthe radical mastoid operation performed on them hadspontaneously reported a loss of taste on the side ofthe tongue corresponding with the operation. Thechorda tympani was a mixed nerve, and containedafferent fibres from about the anterior two-thirds ofthe tongue, and efferent secreto-trophic and vaso-dilator fibres to the sublingual and submaxillaryglands. The nerve made its appearance in the tympanic _

cavity immediately to the outer side of the pyramid,and thence (until its exit from the tympanic cavity)hugged the tympanic membrane in the sulcus tympani-cus. The nerve was practically stuck down to thelateral aspect of the upper part of the incus, then to themesial aspect of the neck of the malleus. It seemedthat removal of either malleus or incus must sever thenerve. In its later course the nerve joined the lingualnerve on the deep surface of the external pterygoidmuscle. Mr. Vlasto did not believe that the lingualnerve contained specific taste fibres.With regard to the effect on the chorda tympani

. of injury and disease of the middle ear, Mr. Vlastob said that no cases of ageusia after paracentesis hadcome under his personal notice ; but Sobotky reported

. a case in which ageusia followed paracentesis carriedout on one side. After ossiculectomy he thought

, disruption of the nerve was inevitable, but he had notperformed that operation. It followed, as a corollary

. to the distribution of the nerve, that the performance of

. the radical mastoid operation must be followed by

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ageusia over the area supplied by the chorda tympaninerve. And the loss of taste perception seemed to bepermanent. A considerable number of cases of middle-ear suppuration showed a lesion of the chorda tympani;also that nerve was most frequently damaged in casesin which the middle-ear disease was of long standingand affected the attic, and was attended by cholestea-toma. In many advanced cases of middle-ear diseasethe integrity of the chord a tympani was fully preserved.Thus no useful deduction as to the extent of the diseasein a particular case could be drawn from the integrityor from the destruction of the chorda tympani nerve.Mr. Vlasto gave the results of the testing of nine malepatients in a hospital ward.

Dr. JOBSON said otologists frequently learned ofdistortions of taste after the radical mastoid operationhad been done. Several times his patients had com-plained of a foul taste after such operation : some saidthey had a metallic taste.

Mr. G. J. JENKINS said that occasionally patientswith chronic suppuration complained of a burningsensation on the anterior part of the tongue, on oneside. Tumours in the neighbourhood of the ear alsosometimes caused aberration of taste in the tongue, ataste as of ink, or a burning sensation.

Dr. C. S. HALLPIKE read a detailed paper on thesubject of

Bone Conduction.

He submitted that increased bone conduction, asexemplified by the Schwabach test, in cases ofaffections of the conducting mechanism of the ear,was one of the basic facts in otology. The theoriesof Bezold and others, which attributed the phenomenonto changes in rigidity of the ossicular chain, Dr.

Hallpike regarded as unsatisfactory. He himselfbelieved that the increase in the bone conduction wasdue to a screening effect upon cochlear functionof the damaged middle-ear mechanism. Two lines ofinvestigation suggested themselves. First, there wasa disappearance of the increase under conditions ofequal screening for the observer’s cochlea. Theseconditions were supplied by the absolute bone conduc-tion test. The truth of findings with this test was nowdefinitely established. The second line of investigationwas the disappearance of the increase in conditionsof absolute silence, where screening effects would beinoperative.Examination of cases of conducting deafness in

absolute silence showed a tendency for the increasedbone conduction found under ordinary conditions to bereduced to normal limits. In many cases of chronicdeafness, cochlear loss was present, but it was latentbecause of the concomitant screening effect of themiddle-ear damage, which tended, under ordinarycircumstances, to lengthen the Schwabach response.This cochlear loss, from the point of view of prognosis and treatment, was a sign of the first importance. As shown under ordinary conditions it was latent.The absolute bone-conduction test, the logical out-come of the theory put forward, rendered it manifest.The main part of Dr. Hallpike’s contribution wasconcerned with the consideration of sensory fields ingeneral, and of screening effects in those fields.Dr. Hallpike described a new apparatus to showscreening effects in the retina.The PRESIDENT remarked on the fact that the

Section had appointed a Committee to consider eartests.-The paper was discussed by Mr. WATKYN-THOMAS, Mr. JENKINS, and Dr. YATES.

Mr. ALEX. R. TWEEDIE gave a demonstration of an

Apparatus for Control of Conversation Test.

By this means a person speaking into a magnetomicrophone would be able to note the exact point atwhich a person ceased to hear. It was so designedthat the person being tested could, if required, repeatwords spoken by the observer who was conductingthe test. The receiver was quite inactive unless bothswitches were closed. Tests were made of the apparatusby various members.

Reviews and Notices of Books.THE MODERN TREATMENT OF HAEMORRHOIDS.

Second edition. By JOSEPH FRANKLIN MONTAGUE,M.D., F.A.C.S., of the Rectal Clinic, Universityand Bellevue Hospital Medical College. London :J. B. Lippincott Company. Pp. 298. 21s.

IT is evident that the author’s views on the treat-ment of llaemorrhoidshave undergone no marked changesince the publication of the book three years ago. Pro-nounced internal haemorrhoids mostly demand opera-tion. He uses the method of transfixion and ligaturewith catgut for clean cases, and the clamp and cauteryfor ulcerated, thrombosed, and gangrenous piles. TheWhitehead operation is condemned. Dr. Montagueshows a preference for local anaesthesia, and speaksstrongly against the current practice of preparingcases for operation by purgation and enemata ; a

much less drastic preparation is suggested which hethinks leads to lessened post-operative discomfort andquicker recuperation. This plan is certainly worthyof trial.As regards the injection treatment, the author still

prefers a 20 per cent. solution of cresylic acid inglycerine and water, and places 5 per cent. quinine-urea and 10 per cent. carbolic acid in olive oil next inorder of merit. He makes no particular reference tothe method, advocated strongly by Albright and byBlanchard, in which high submucous injections of5 per cent. phenol in vegetable oil are given ; thissolution is considered by many to be more effectiveand free from risk than the stronger solutions. Dr.Montague’s recommendations as to dosage are veryvague, amounting only to the advice that theinjections should be stopped as soon as the slightestblanching of mucous membrane is seen. He practisesinjection into the centre of the pile mass ; this is apoint in technique on which there is considerabledifference in opinion, but we cannot recommendanyone to follow closely the technique illustrated inFigs. 97, 99, 101, in which the needle is shown insertedinto the lowest border of the pile, at the upper endof the anal canal. This is the one place, being soclose to the sensitive epithelium of the anal canal,where the injection should not be made. Themucous membrane should be punctured at least aninch or more above the point shown. In Chapter 15the results of treatment of haemorrhoids by radiumare given. The method of implanting and leavingin situ glass radon seeds proved unsatisfactory onaccount of the irritation caused by the presence ofthe foreign bodies, and Dr. Montague now advocatesremovable platinum-screened seeds (4 millicuries).Cessation of haemorrhage and fibrosis are said to

I unfailingly follow their use, but whether this or thevarious electrical methods described in the followingchapter will ever be found as practical as the injectionmethod seems to us doubtful. The use of a suction-pump, here illustrated and recommended for thediagnosis of haemorrhoids, is regarded as obsolete bymost authorities. Practitioners would probablyappreciate the elaboration of the chapter on theinjection methods, and the supply of detailed descrip-tions of technique and dosage, together with somefacts about recurrence-rates.

DISEASES AND DEFORMITIES OF THE SPINE AND

THORAX.

By ARTHUR STEINDLER, M.D., F.A.C.S., Professorand Head of the Department of OrthopaedicSurgery of Iowa State University Medical School,Iowa City. London : Henry Kimpton. 1929.Pp. 573. 52s. 6d.THIS is an authoritative and well-balanced treatise

on the subject of diseases and deformities of thespine and thorax. The opening chapter on cungenitaldeformities of spine and thorax contains wen-arrangedinformation, and is illustrateci by plates showing