599

inguinal canal and the femoral triangle. The transversalisfascia should in theory be sutured, but this is very often atechnical uncertainty.A wide strip (i/4 in.—/g in.) is then raised from the upper

flap of the external oblique aponeurosis, as in the standardMeArthur repair for inguinal hernia. It is left attached

firmly to the pubic bone at its medial end and fixed to a smallGallie fascial needle by a single transfixion ligature of double60 linen thread. The strip is then passed behind the medialend of the spermatic cord or round ligament, which is retractedupwards. This fascial suture is inserted into the pectinealligament over the upper surface of the superior pubic ramus,thence through the recurved edge of the inguinal ligament andthe pectineal ligament again; and the second insertion intothe inguinal ligament should be up against the femoral vein:The vein is protected by a 2 in. Langenbeck retractor insertedthrough the ring upwards, held by the assistant with the frontof the blade against the vein. The fascial strip is then passedthrough the conjoint tendon with one or two insertions,bringing it towards the inguinal ligament and not to thepectineal fascia, thus strengthening the posterior wall ofthe inguinal canal. The closure of the external obliqueaponeurosis and the femoral dead space is straightforward.

It is not claimed that this is a guarantee of perfectionand certain in cute; the absence of any substantiatedclaims to have found previous methods entirely satis-factory points to the difficulties both of cure and of proofof cure if such exists. Precision in technique is perhaps,in the cure of a lesion, more important than principlesfounded on different interpretations of the same problemof anatomy.

Medical Societies

ROYAL SOCIETY OF MEDICINE

Primary Treatment of Varicose Veins A MEETING of the section of surgery was held on

April 7, with Prof. ERNEST FINCH in the chair.Mr. A. DICKSON WRIGHT said that the problem of

recurrences after any form of treatment for ’varicoseveins had led in the past to extensive and mutilatingoperations. Injection treatment had seemed full ofpromise when first introduced, but recanalisation wasdisappointingly common, particularly when there werea number of communications between deep and super-ficial channels. It was important to realise how high thevenous pressure in the varices in the erect posturecould rise, once the valves were incompetent ; with acannula in a vein at the ankle, the column of bloodmight reach the level of the right auricle. The essentialstep in treatment was, therefore, careful proximalligature, and it was necessary to study the three venoussystems-great saphenous, small saphenous, and gluteal-and to determine the sites where ligature was needed.Mr. Wright illustrated with a film the technique of

ligating the great saphenous vein at its junction withthe femoral vein, followed by retrograde injection.Though this technique was simple, care was needed.A wild stab at a bleeding-point with a haemostat mightdamage the femoral vessels. It was possible to tie thefemoral vein in error, though this was not always asserious as feared, but tying the femoral artery was amajor disaster, especially if retrograde injection had alsobeen done, and usually cost the patient his leg ; thoughhe had known one such case where recognition ofthe injury and immediate end-to-end suture had beensuccessful. Postoperative phlebothrombosis could beavoided by always operating under local anaesthesiaand forbidding the patient to stay in bed afterwards.When it occurred it began in the lower calf, and shouldan actual pulmonary embolus take place it was best totie off the femoral vein and administer anticoagulants.He had never known an embolus in patients operatedon under local anaesthesia with immediate ambulation.There were a few patients whose vessels were hyper-sensitive to any form of injection, with widespreadreflex vasospasm of arteries as well as veins, possiblyleading to gangrene. The technique of small-saphenousligature in the popliteal fossa was also illustrated with

a film. After any ligating operation it was usuallynecessary to sclerose off residual varices with injections,either lithium salicylate or (in the unconscious patient)30 % saline.

’

Mr. J. B. KINMONTH discussed some results of veno-graphic and histologic studies. Injection therapy mightaim at an immediate clot in a stagnant pool below atourniquet, or at a delayed clot resulting from intimaldamage when the medium was allowed to enter thecirculation ; but, if the latter method failed fromrecanalisatiori, the varices would be worse than beforeowing to the injury produced in the valves. Radio-graphic studies of the fate of opaque media given asretrograde injections into the saphenous vein "at the groinshowed how inefficient this technique is. Much of thedye went straight into the deep veins and, partly-becauseof this and partly owing to spasm of the saphenous,very little reached below the knee. A fluoroscopicstudy of injections into calf veins showed the dye topass upwards in the erect position in normal veinsand downwards in varices. In the horizontal position,with the limb at rest, a pool of medium remained at thesite of injection for as long as a minute or two, and theobvious form of treatment was to use this methodand so secure the maximum local effect; and then,by vigorous movements with the leg elevated, to sweepthe irritant rapidly into the general circulation. Neverthe-less, however carefully it was done, large amounts ofmedium collected rapidly in the deep veins. Veinsremoved for section after injection showed macroscopicoedema and inflammation of their walls. Microscopically,there was usually a surprisingly large amount of muscleto be seen, and this suggested that varicosity -was, aprimary valvular failure with secondary venous hyper=,trophy. In treatment, Mr. Kinnionth’s investigationsindicated ligation at the groin for severe incompetence,but without retrograde injection, plus a ligature atknee level. Later, the calf veins could be injected ifneed be. For milder cases injection by the empty veintechnique in the horizontal position should be used,.employing no more than 1-5 ml. of solution, and withthe limb kept quite still for five minutes. ,

Prof. A. M. BoYD regretted the paucity of end-resultstudies. The recurrence-rate was anything over 30 %.and increased year by year after the primary treatment.He thought that the essential cause of varicosity was acongenital deficiency of the valves in the communicatingchannels between superficial and deep veins, and thatthis was a progressive failure and not to be cured byany single operation. In the thigh the communicationswere short and direct, and pain was rare. In the calf thecross-channels traversed the muscles, and here musclevaricosities always preceded, and were more extensivethan, the visible superficial dilatations ; hence the fre-quency of quite severe pain and cramps below the knee.Experimental injections with mixtures of opaque mediaand sclerosing -substances showed that the materialintroduced in the thigh rapidly enters, and stays in,the deep veins, and this was true only to a lesser extentin the calf where there is a larger superficial pool totake it up. Therefore proper ligature must be the key-stone of treatment, and the greatest hazard here was tomiss tying off an internal superficial femoral vein whichhad pierced the deep fascia at an abnormally distal levelon its way to enter the termination of the greatsaphenous.

In the discussion, Mr. SoL COHEN questioned whetherdeep venous thrombosis was necessarily a contra-indication to any form of operation ; he had donedeliberate femoral ligatures on some of these cases

with beneficial results. The rapidity with which injectedmatter entered the deep veins could be well shown byinjecting Thiopentone’ into a varicosity, when generalanaesthesia was very little delayed. Because post-operative embolism arose from deep clot due to just suchseepage, operation under local anesthesia and imme-diate getting about were very important, and the useof general anaesthesia introduced a very real risk ofthrombosis and embolism.

Mr. DiCKSON WRl&HT, in his reply, said that any formof treatment during pregnancy, apart from bandaging,was inadvisable. It was true that haexnoglobinuria

600

sometimes occurred after injections, but this was due tohaemolysis at the actual site of injection and did notindicate any renal damage. A varicose ulcer could alwaysbe made to heal by proper supportive bandaging, thoughrecurrence was of course always likely unless ligation wasperformed later.

Reviews of Books

Psychotherapy : its Uses and LimitationsD. RHODES ALLISON, M.D., M.R.C.P.; R. G. GORDON,M.D., D.sc., F.R.C.P. London : Oxford University Press.1948. Pp. 156. 8s. 6d.

THIS clear-headed little book does not take long toread. Neatly and precisely the authors strip away frompsychotherapy the disguises in which credulity anddetraction have combined to wrap it, and give a fairestimate of what may be done for patients by this method,and what kinds of patients can profit by it. They areaware that every good doctor practises psychotherapywhether he knows it or not, and are concerned only thathe should give good, not harmful, treatment. The chapteron the patient’s reaction to bodily disease, indeed, isone of the most interesting in the book ; for though itcontains little that the sound general practitioner doesnot know already, it sets out plainly the background ofhis knowledge, and suggests some guiding rules whichwill help the impulsive doctor to keep his sympathy inbounds, and encourage the cautious one to spread himselfat times. Most of the book, however, is properly given toan account of the uses of psychotherapy in the treatmentof the psychoneuroses, temperamental instability, psycho-somatic conditions, visceral neuroses, mental deficiency,and psychopathy. A chapter on the relation of rheuma-tism to mental illness helps to sort out the componentsof this little-understood disorder, and another on theendocrine background reminds us how much man’snature depends on chemical tides within his body. Thefinal chapters--on the organisation of psychotherapy andthe combined approach to treatment by doctor, patient,relatives, and specialists-point the way to the betterunderstanding of man as a whole which must be achievedby the instruction of medical students and public in ourgrowing knowledge of the mind.

Recent Advances in Sex and Reproductive Physiology(3rd ed.) J. M. RoBSON, M.D., D.sc., F.R.s.E., reader inpharmacology to Guy’s Hospital medical school, London.London : J. & A. Churchill. 1947. Pp. 324. 21s.

THE general scope of this book remains the same,covering the nature of the sex cycle in certain loweranimals and in man, and the changes that occur in thereproductive organs ; the character, origin, and actionsof the various hormones concerned ; and the physiologyof reproduction, pregnancy, parturition, and lactation.There are new and valuable chapters on the androgens,on the chemical composition -and relationship of thevarious gonadal hormones, and on international standardsand methods of assay. The sections dealing withovulation, viability of ova and spermatozoa, and variousother problems connected with fertility are disappoint-ingly brief and sketchy, but there is a useful chapter atthe end where pregnancy diagnosis tests are described(including the xenopus test) and the therapeutic uses ofthe sex hormones are discussed.

Surgical Disorders of the Chest(2nd ed.) J. K. DONALDSON, M.D., F.A.C.S., associateprofessor of surgery and i/c of thoracic surgery, Universityof Arkansas. London: H. Kimpton. 1947. Pp. 485.42s.

j .

THIS is one of the few surgical works which manages tokeep abreast of the rapid advance of chest surgery. Thebalance has been much improved in this new edition,though of course it has not been possible to cover thesubject comprehensively in 500 pages. A section on thebasic principles would introduce the subject more easilyto the beginner. Lung abscess, cesophageal diseases, andsubphrenic suppurations are clearly described, but theimportant chapter on empyema, though it gives a goodclassification, loses force in the treatment section. Theneed for dependent and adequate drainage might be

more forcibly stressed, and so might the value of physio-therapy in obtaining lung re-expansion. The section onthe anatomy of the bronchi would be improved byreference to Brock’s work. War experiences have madethe discussion on haemothorax much more authoritativethough decortication is perhaps over-valued. The bookis a reasonable and welcome survey of a growing field.

Modern Plastic Surgical ProstheticsA. M. BROWN, M.D., associate, Eye and Ear Infirmary,University of Illinois, Chicago. London: W. Heinemann.1947. Pp. 289. 35s.

IN spite of the great improvement in modern plastictechnique, there is still room for the use of prostheticappliances in many situations where surgical treatmentis either inadvisable or impossible. This book describesin detail the design and manufacture of artificial noses,eyes, ears, hands, fingers, and other structures in materialssuch as latex, acrylic resins, and vinylpolymers. Inaddition it covers the use of foreign-body implants incontour deformities, particularly of the chin, nose, andmalar region. This section has less to recommend it inthat there are few plastic surgeons today who do notuse such methods with considerable reserve. A badfeature of the book is that the 180 illustrations are groupedat the end, so that reference to the text is difficult.On the whole, however, the book can be thoroughlyrecommended.

Differential Diagnose der Lungenröntgenbilder(2nd ed.) R. ZEERLEDER, M.D. Berne Huber. 1947.Pp. 296. Sw. fr. 28.

THE author has approached in a novel way theproblem of differential diagnosis in chest radiography.He divides and subdivides pathological X-ray appear-ances into about sixty different types. Each type isintroduced by a black-and-white drawing from a charac-teristic film. These pictures are then followed by a fewtypical case-histories and a resume of every conceivabledisease which could produce similar appearances. Allthis is coupled with brief details of the literature of eachsubject. The result is an enormous mass of valuablematerial so put together and abbreviated as to be almostunreadable. It is hard to find one’s way, even whenusing it for reference. Dr. Zeerleder is to be congratulatedon his industry and wide knowledge, but we wish hehad not adopted this method of presenting it.

Principles and Practice of the Rorschach PersonalityTest

’

W. MONS, M.R.C.. London : Faber and Faber. 1948.

Pp. 164. 12s. 6d.

THE Rorschach test does not lack exponents. AsDr. Mons says,

"

by now, some three hundred books onthe test have been published, apart from countless treatisesin periodicals, and a paper of its own, The RorschachExchange Research. Already a _ host of conflictingtheories have taken the battlefield ... ," and perhapsin such a private fight only those with extensive practicalexperience of the test should take part, The beginnermay start to arm himself, however, with this book.Dr. Mons’s account is thoroughly intelligible : it doesnot conceal the difficulties of using the test, nor introduceunnecessary complications. On the other hand, it doesnot offer convincing evidence on the test’s reliabilityor validity. This is not a criticism of Dr. Mons, however,since the extremely wide scope allowed for personalinterpretations of results makes it impossible to producegeneral evidence of that kind. Some will feel that theuse of the Rorschach test is as far removed from scientificpsychology as palmistry or graphology ; but this impliesno disrespect, for the practitioner who has made anextensive study of human hands can learn a great dealabout a man’s character from the pair presented to him,especially if he is skilful in the conversation he makesin the meantime. The Rorschach expert conducts histest in the same way, using all the additional informationhe can assemble to help him in interpreting the result.Can we, then, safely attribute to the test the successesachieved by the skilled practitioner, or blame it for thefailures and indiscretions of the unskilled ? Is it not,perhaps, a measure of the examiner rather than theexamined ?

" - , ’