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THE

BRITISH MEDICAL ASSOCIATION.EIGHTY-EIGHTH ANNUAL MEETING AT

CAMBRIDGE.

SECTION OF SURGERY.

WEDNESDAY, JUNE 30TH.Gastric Ulcer.

THE discussion on Gastric Ulcer on June 30th wasopened by Sir BERKELEY MOYNIHAN. The burden ofhis message was a strong plea for the practice of

partial gastrectomy as the operation of choice in thetreatment of gastric ulcer, and he supported his viewwith impressive statistics of his results. He claimedthat the technique of operative treatment was nowsimple and perfect, and that good results had beenrendered almost certain. Surgery had, indeed, nowrisen beyond mere technique. It should be the surgeon’saim to discover if possible the primary source of the,condition which produced the ulcer and to rectify this.Often the source was to be found in the abdomen ; inother cases it lay in the teeth or the air sinuses, andit was therefore important to make an exhaustive exa-mination of the buccal cavity and its surroundings.Operative treatment was a confession that medicaltreatment had failed, and often such medical treatmentas was practised, especially in hospital out-patientdepartments, was from the beginning doomed to fail.Close supervision for months was necessary if so largean area as a gastric ulcer was to heal, and it was

always necessary to treat the poor condition of thepatient by rest in bed, with alkalies by the mouth,and sometimes by the transfusion of blood. Starvationtreatment he believed to be radically wrong, and pre-ferred to give as much fluid by the mouth as could betaken.Gastro-enterostomy, first done by Wolfler on Sept. 27th,

1889, was still the favourite operation, and no operation insurgery was followed by swifter or more striking results.Surgical enthusiasms were very contagious things, andsoon the operation came to be practised in cases in whichthere was no obstructive element; failures resulted, and forthese there were several reasons, such as that the anterioroperation was done instead of the posterior, that the openingwas too small, that the gut had been rotated, and variousother technical faults. Also there had been bad choice ofcases. Sir Berkeley Moynihan emphasised the fact thatgastric ulcer was a relatively rare condition. Operationshad been done on the strength of a symptomatic diagnosis,and he had in many instances undone a gastro-enterostomywhere the real source of the trouble was found to be anappendix abscess, an empyema of the antrum, cholelithiasis,tabes, or even the vomiting of pregnancy.Cases of gastro-enterostomy could be roughly divided into

three categories: 1. Those in which results were excellent.In these the ulcer was near the pylorus and perhaps hadhealed, so that there was a partial obstruction, or spasm ofthe pyloric end of the stomach. 2. Those in which resultswere poor; very many of these were attended by a non-healing ulcer of the jejunum after the operation. 3. Thosein which a carcinoma eventually developed, presumablyarising in the base of an originally non-malignant ulcer.No agreement was yet possible as to whether or no

carcinoma really did develop in the base of a simple ulcer,but the clinical histories of cases, pathological investiga-tions, and the histological examination of excised ulcers alltended to show that this did actually occur. Gastro-enterostomy had now, as an operation, ceased to satisfymodern expectations. Nevertheless, many surgeons stillrelied upon it, and he himself parted with it with reluctance.It had served him well. He had had no death in the last400 cases in which he had practised it, and he felt towards itno menace in his heart.

Sir Berkeley Moynihan mentioned briefly the variousmodifications of the operation that were practised, and drewattention to the value of occasionally performing a jejun-ostomy in addition to gastro-enterostomy. It was noticeablethat gastric and duodenal ulcers affected quite differenttypes of stomach. The gastric ulcer was found in atonic,lazy stomachs ; the duodenal was associated with the strongstomach, and often occurred in young men and athletes.Gastric ulcer was at once a rare and a serious disease, andhe had found a mortality of 17 per cent. occurring in thethree years following operation, which was in itself a con-demnation of gastro-enterostomy. He had found, on theother hand, that a partial gastrectomy was- actually a safer

who had undergone it ceased absolutely to be patients. Theynever came back with recurrent symptoms, or, indeed, withanything at all, except a heart full of gratitude. Sir BerkeleyMoynihan laid down with great emphasis that it was thelittle things that counted in the achieving of success. Carewas the keynote-care in the preliminary examination, inpreparing for the operation, and during the operation.Speed was also important, but could only be attained bylong practice ; it should be the child of experience and notthe parent of disaster.

Sir Berkeley Moynihan then gave some striking statistics toshow the relative mortality of the allied conditions-gastriculcer, 2-9 per cent. ; duodenal ulcer, 0’5 per cent.; jejunalulcer, 7 per cent. This very serious complication withjejunal ulcer was a strong argument in favour of partialgastrectomy as against gastro-enterostomy. He did not,however, claim that finality had been reached in this opera-tion. He was not yet satisfied, for happiness depended uponthe existence of unsatisfied, but still attainable, desires. Heconcluded with a technical point-that it is unnecessary touse silk or thread in these operations. It was perfectly safe,and far better, to use nothing but the finest catgut.

Dr. CHARLES H. MAYO (Rochester, Minn.), who nextaddressed the meeting, received a great ovation; hemodestly disclaimed this on his own account, butaccepted it as the representative of the medical pro-fession of the United States, Dr. Mayo did not attemptto refute any of Sir Berkeley Moynihan’s contentions.but contributed a learned and weighty review of thesubject under discussion. He gave statistics to showthat gastric ulcer was a relatively rare disease and thatthe ulcer was nearly always single. In discussingthe aetiology of gastric ulcer he put forward the theorythat the ulcer is produced by an association of localchemical effects, with a direct interference with circu-lation by infarction emboli of bacteria. Character-istic bacteria could be grown from an excised ulcer, andan injection of these into animals produced a high per-centage of similar ulcers. The chronicity of the diseasewas to be explained by the chemistry of the bacterialproducts. Medical treatment, the coordination of whichwas chiefly due to Dr. Sippey of Chicago, was directedtowards the control of acidity in the stomach by dilutionand neutralisation, but such treatment produced onlytemporary results and could not always be obtained.During the long periods of treatment which are

necessary urgent conditions, such as perforations, mayarise which demand surgical treatment, and not a fewcases develop cancer, resulting in death. In the pastsurgery had sometimes earned discredit through theperformance of gastro-enterostomy on the basis of amistaken diagnosis, and in the Mayo Clinic a fewhundred such operations had had to be undone.Dr. Mayo laid stress in making a diagnosis on the clinical

and dietetic history. He distinguished between qualitativeand quantitative food-dyspepsia, the former being usuallynot due to an ulcer. Hsemorrhage was not a symptom ofimportance in most cases. He placed great reliance onX rays in diagnosis, a correct diagnosis being arrived at bythis means in 95 per cent. of cases; it was particularlyvaluable in helping to distinguish between gastric andduodenal ulcer. He agreed with Mr. Herbert Paterson thatafter gastro-enterostomy had been performed the alkalinesecretions of the duodenum tended to reduce the acidity inthe stomach, and that this change in local environmentencouraged healing of the ulcer. At the Mayo Clinic themortality after operation for gastric ulcer was nearly doublethat for duodenal ulcer. Various statistics were given of theposition, age- and sex-incidence of gastric ulcer. Investi-gations that had been carried out led Dr. Mayo to reiteratethat gastric ulcer is potentially malignant.In discussing the various operations that could be per-

formed the anterior route of approach and anterior anasto-mosis were favoured. Gastro-jejunal ulcer was believed tobe due to the use of permanent suture material and to thepresence of chronic foci of streptococcal infection. Dr. Mayostated, in conclusion, that surgical treatment was the bestrecognition of the value of medical treatment by per-manently overcoming obstruction and by lowering aciditywith the patient’s own alkalies.Mr. HERBERT PATERSON (London) made a strong plea, ’

for clear-thinking concerning the indications for opera-tion and its results. In this connexion he accused SirBerkeley Moynihan of an admirable inconsistencybetween his scepticism as to there being any physio-logical factor in the results of gastro-enterostomy andsome of his other statentents. He was never afraid to

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change his attitude, but the change was made in sograceful and facile a manner that it was hardlynoticed even by his friends. Mr. Paterson believedfirmly himself in the reduction of acidity after opera-tion by the entry into the stomach of alkaline duodenaljuices. After undoing a gastro-enterostomy there wasa return to the previous degree of acidity, whereas adecreased acidity does not accompany the operation ifan entero-anastomosis be done at the same time. Con-cerning the development of cancer in a gastric ulcer,he considered that there was no clinical evidencefor it, and that the, pathological evidence was

unconvincing.Mr. A. H. BURGESS (Manchester) believed that too

much was expected of gastro-enterostomy. Its objectwas twofold-to get rid of the ulcer and to get rid ofhyperacidity. The best results were obtained froma combination of excision and gastro-enterostomy.But excision was often very difficult, and, conse-

quently, the best routine operation was a partialgastrectomy. This was not to be done when theulcer was very high in the lesser curvature andwhen it was too extensive. In these cases gastro-enterostomy with jejunostomy was the best treatment.The physiological effect of the operation he consideredto be proved. He discussed whether the edges of theopening in the transverse mesocolon should be attachedalong the line of anastomosis or at a distance, andfavoured the second alternative, having seen a izon-

stricting scar formed within 12 days of the operation.He emphasised the importance of giving alkalies inafter-treatment.Mr. CHARLES RYALL (London) regarded a gastric

ulcer as a simple inflammatory process with a predis-posing cause in hyperacidity and an undeterminedexciting cause. Ulcers do heal, and a gastro-enterostomyhad been proved to provide a physiological rest. Nofixed operation should be used, and excision should notbe done in every case. He believed that an exaggeratedimportance had been given to the development ofcarcinoma in an ulcer.

Professor J. M. T. FINNEY (Baltimore) stated that inpractice he had found it hard to diagnose the presenceof a gastric ulcer even with the abdomen open beforehim.. Sometimes there was no response to treatment,and he had failed often enough to be sceptical of anyrule. Speaking on behalf of " the common barnyardsurgeon " he considered that every case should betreated on its merits. He advocated pyloroplasty owingto the opportunities it gave for making a thoroughexamination of the stomach. The group for whichresection was suitable was ever widening. He had hadno mortality yet, but it was bound to come, and hewas therefore sorry for every patient upon whom heoperated.Mr. W. BILLINGTON (Birmingham) was still seeking

for a satisfactory explanation of the symptoms. Hediscussed the way in which the site of the ulcerinfluenced the success of the operation, and believedthat excision alone was a bad operation. He wasshaken in his belief in the physiological effect of gastro-enterostomy, as he had obtained better results bycombining it with a jejuno-jejunostomy, so thatalkaline fluids were prevented from reaching thestomach. Every ulcer in the body of the stomach hetreated as an hour-glass stomach by making a doubleopening, and had obtained good results in 50 cases.Mr. R. P. ROWLANDS (London) dwelt on the un-

certainties of diagnosis, and on the necessity for

examining the whole abdomen at operations. Gastro-enterostomy was like magic and should be used withcaution. He insisted that it was perilous to advocatethe extended use of so difficult an operation as partialgastrectomy by the general surgeon.After a few remarks from Sir GEORGE MAKINS,Sir BERKELEY MOYNIHAN made a short reply to his

critics. He defended his scepticism concerning thehydrochloric-acid findings, which in any case were

below normal in a large number of proved gastric ulcers,and he gloried in his inconsistency. The operativemortality from gastro-enterostomy, which was oftenfollowed by a fatal carcinoma, was equal to that

following gastrectomy, which cured all patients forever. Mr. Paterson, he said, had long been a devoutworshipper at the shrine of the goddess Hyperchlor-hydria, and he described him in the following linesfrom Shakespeare’s sonnets :-

0, know, sweet love, I always write of you,And you and love are still my argument;

So all my best is dressing cld words new,Spending again what is already spent.

Mr. FRANK KIDD (London) opened the second dis-cussion on

.

The Treatment of Calculi in the Pelvic Part of the Ureter.Stones in the ureter, he said, were usually single.There were several stages in the effects followingthe presence of a stone. Fibrosis gradually developedin the tissues of the pelvic wall surrounding the stone;then the ureter above the stone became dilated,bacterial infection arrived by the blood-stream or

lymphatics, and a pyonephrosis resulted. Sometimes,however, the calculus was silent for years, and thengave rise to symptoms resembling renal colic. Anaccurate diagnosis was absolutely essential, and forthis X rays should be used. There were fallacies in theshadows produced by various other opaque bodies inthe pelvis, and an opaque ureteric bougie or theinjection of 20 per cent. colloidal silver must alwaysbe used to confirm the X ray diagnosis before anyoperation was done.He considered that in treatment no operation was

necessary in the majority of cases. A chance should alwaysbe given for the natural passage of the stone, as there wasno time-limit for this; the ureter was rarely completelyblocked, and the kidney was often able to recover afterprolonged partial blockage. An operation, however, shouldbe done in cases that were infected, when the stone wasbilateral, where there was calculus anuria, or when therewas long-established and fixed pain. In many cases anoperating cystoscope could be used. A natural passage ofthe stone could be encouraged by the injection ofparolein round the stone, or incision and dilatation of themouth of the ureter could be practised, followed byextraction of the stone with forceps. In operating aninguinal or mid-line incision could be used. He himselfusually employed the inguinal route, reserving the middle-line incision for bilateral stones or for cases of unusualdifficulty. Sometimes stones moved in a dilated ureter, andan X ray photograph should always be taken just before theoperation. For purposes of diagnosis it was essential todetect blood microscopically in the urine. Mr. Kidd’s maincontention was for conservative methods in treatment.Mr. SWIFT JOLY (London) disagreed with Mr. Kidd

on his chief points. He preferred the median incisionin most cases, and considered that operation wasusually the most satisfactory method of treatment.This was determined in many cases by the size of thestone, since only those that were smaller than orange-pips could be readily dislodged by injections of theureter and similar methods. It was also helpful to 3take X ray photographs after successive attacks ofcolic, and so determine whether the stone showed anytendency towards moving or not. ’

’ Mr. GREY TURNER (Newcastle-on-Tyne) was againstthe performance of an operation if the stone was small.An examination of the patient per vaginam or perrectum was often helpful, though sometimes omitted.’ Mr. ROWLANDS had removed a number of ureteralcalculi which, though large, were not opaque to X rays.He regarded cystoscopy, combined with an indigo-carmine injection, as a useful method of confirming adiagnosis of obstructed ureter. He was opposed toexposing the kidney to the risk of destruction for solong a time as was advocated by Mr. Kidd.

Sir HAMILTON BALLANCE (Norwich) and Dr. MAYOalso contributed some remarks to the discussion.

. THURSDAY, JULY .1ST.’, Carcinoma of the Rectum.

The discussion on July lst on the Treatment of Car-cinoma of the Rectum was opened by Mr. ERNEST MILES(London), who appeared as the advocate of his abdo-mino-perineal method of resection of the lower bowel.He contended that all operations must be foundedon the pathological findings, and that removal of anygrowth must include the whole of the tissues affectedby the disease. Carcinoma of the rectum spread by

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three methods-by direct extension, by the venous, andby the lymphatic channels. Of these the extra-muralymphatic channels were by far the most importantand he illustrated by diagrams, which were based onhis own investigations, the various routes, disposed inthree zones, by which cancer cells might reach th,lymphatic glands situated at the bifurcation of th,common iliac artery. The most vulnerable tissues werethe perianal fat and the levator ani muscle, the retrorectal glands, and the parietal attachment of the pelvismesocolon.Mr. Miles then reviewed the various methods of perinea

resection of the rectum, and dismissed them all as

inadequate. He traced the various stages by which theoperation from below had been extended, but pointed out thathe most radical of these left the pelvic mesocolon behindwhich was still out of reach. He condemned as unsouncthose operations which attempted to preserve a continenanus. He arrived thus at the description of his abdominoperineal operation, which was planned with a view to th<removal of the whole of the pelvic mesocolon, " the axilla o:

the rectum." He admitted that his operation mortality hacbeen at first as high as 43 per cent., but it had now fallen t(18 per cent., whereas, if the pelvic mesocolon were n01removed, 100 per cent. died from recurrence of the diseaseHe contended that the operation’ was particularly suitablefor early cases, but should not be done in old patients, whccould not stand a severe operation. In these a colostomy 01a perineal excision could be performed as a palliative.The subsequent discussion resolved itself into a

contest between those who agreed with Mr. Miles andthose who were in favour of operating from below inmost cases.Mr. GREY TURNER, while agreeing with Mr. Miles as

to the mode of spread of the disease, believed that asan early diagnosis came to be more frequently made,so a local removal would be more often adequate. Hewas unable to understand how Mr. Miles came to have100 per cent. of failures if the pelvic mesocolon werenot removed, as he was himself able to record a numberof cases of apparent cure after a local operation. Never-theless, surgical progress must not be clogged by con-sidering operative mortality in a disease which resultedin 100 per cent. mortality if left alone. For growthshigh up in the rectum perineal or sacral resection wouldnot be enough, and he would not hesitate in that caseto remove the pelvic colon by the abdominal route. In

considering the range of operability he was not deterredby local fixation of the growth unless the bladder wereinvolved. Often a preliminary colostomy rendered agrowth operable when it had seemed at first inoperable.Mr. P. LOCKHART-MUMMERY (London) said he had been

one of the first surgeons in this country to practise theabdomino-perineal operation. He was still performingit in special cases, but had abandoned it as a routineand was now trying to develop a technique which, whilegiving a free removal of the growth, would reduce theoperation mortality to a reasonable level. During thepresent year he had had no deaths in 24 cases operatedupon. The operation was usually done in two stages,the first of which was a colostomy through the leftrectus muscle. The second operation for removal of therectum was done under spinal anaesthesia a week later.The anus is first closed and the rectum then freed bydissection from in front and from the perineum upwards.The bowel is divided with the cautery between clampsand the end is invaginated. The wound is closed with-out drainage. The late results appeared to be quite asgood as were obtained after the abdomino-perinealoperation, while the immediate mortality was reducedalmost to nil.Mr. BURGESS, while convinced on logical and

theoretical grounds that Mr. Miles was right, did notfollow him out in practice, being deterred by thehigh operation mortality. He agreed that if theabdomino-perineal operation were used at all, it mustnot be reserved only for bad cases. The earlier thecase the more extensive was the operation that wasindicated.Mr. RYALL was strongly of the opinion that no routine

operation should be performed, but that every caseshould be considered strictly on its merits. Mr. Miles’soperation he believed to be the only sound and scientificone, and he was confident that time would reduce the

d mortality to a low figure. He considered that an early;1 colostomy to remove sepsis and inflammation was ani, exceedingly important part of the treatment. Dr. H. H. BROWN (Ipswich) recorded several cases*that were alive and well after a relatively restrictede operation, and recounted an attempt to conserve the,e sphincteric action of the anus.e Sir GORDON WATSON (London) believed that the- treatment of this disease was still far from stabilised.e Even Sir Berkeley Moynihan had told him that he had

changed his mind on this subject more often than on1 any other surgical problem. He himself had beens convinced by Mr. Miles’s arguments and technique in3 1909, but his own results with the abdomino-perinealtoperation had been very discouraging. By a process of

statistical reasoning he had arrived at the conclusiont that the final results of Mr. Lockhart-Mummery’soperation were 1 per cent. better than those of Mr. Miles, and he consequently was now reserving thef abdomino-perineal operation for cases of cancer at the

recto-sigmoidal junction or above it.) Dr. MAYO stated that he had no use for any routine

operation. At the Mayo Clinic all the methods were: employed. He pointed out that the enlarged glands; in the mesocolon were often inflammatory and not. carcinomatous ; a rapid diagnosis with frozen sections

could be made during the course of the operation andthe procedure then modified accordingly. Dr. Mayothen diverged on to an interesting general considerationof the biological problems of cancer growth.Mr. JOCELYN SWAN (London) was a convinced adherent

, of Mr. Miles’s method. He himself had so far beenlucky enough to have had no operative mortality in11 cases.Mr. D. P. D. WILKIE (Edinburgh) put in a strong

plea for Mr. Grey Turner’s view of the great importanceof retaining sphincteric control if possible. He admitted

, that it was difficult to criticise Mr. Miles’s ideal opera-tion, but considered that its high mortality prohibitedits general use. The chief dangers of the operation hebelieved to be shock and sepsis, particularly septicpneumonia. He therefore suggested that the patientbe immunised before operation with vaccines or be pro-tected by inducing a leucocytic reaction.After a few remarks from Sir HAMILTON BALLANCE

and Mr. HAMILTON DRUMMOND (Newcastle-on-Tyne),the two speakers who had opened the discussion madeshort replies. Mr. GREY TURNER reiterated his con-viction that the local removal was far more importantthan removal of possible distant infection. Mr. MILESadmitted the absolute necessity for local removal, butwas convinced that the region of upward spread was ofequal importance. He was in favour of performing apreliminary c&aelig;costomy to drain the bowel, and con-sidered that spinal andasthesia with gas and oxygen wasthe best form of anaesthetic.

The Diagnosis of Glaztcoma.The second subject, the Diagnosis of Glaucoma,

was introduced by Lieutenant-Colonel R. H. ELLIOT(London). He stated that the history of the subjectcould be divided into three stages, marked by thenames of Hippocrates, Helmholtz, who introducedthe ophthalmoscope, and Legrange, who in 1906 intro-duced the operation of sclerectomy. The condition canbe arrested if a diagnosis be made early and if thetreatment be rational. The methods of diagnosiswhich Colonel Elliot described were: (1) Observa-tion of the pulsation of the retinal vessels; (2) themeasurement of intraocular pressure by the tonometer;and (3) the accurate investigation of limitation of thefield of vision by perimetry. He referred also toexamination of the light sense and to cornealmeasurements.There was a short discussion, in which Mr. WALLACE

HENRY (Leicester) and Mr. G. E. WHERRY (Cambridge)took part.

FRIDAY, JULY 2ND.Nerve Suture and its Results.

The discussion on Friday, July 2nd, concerning nervesuture and its results turned chiefly on the value ofnerve grafts and implantation operations; the speakers

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were in substantial agreement- as to the technique and results of the ordinary suture operation. The opening speech was delivered by Sir WILLIAM 1

THORBURN, who dwelt rather on the general principles. Beginning with the accepted fact that repair depends on ithe downgrowth of axons from the proximal end. hepointed out that a good anatomical result depends uponthe downgrowth of a sufficient number of axons into acorresponding number of sheaths. On the other hand, a good physiological result means that the right axons must have encountered those conducting sheaths whichwill have taken them to the right kind of end-organs-that is to say, motor nerve fibres to motor end-organsand sensory fibres to sensory end-organs. Usually,however, there was some nerve " shunting "-that is,the down growth of nerve fibres to end-organs otherthan those with which they were originally connected.Sometimes this was done intentionally, as when theproximal part of the hypoglossal nerve was suturedto the distal part of the facial. More often this tookplace on a histological scale, motor fibres growing downto sensory end-organs and sensory to motor. This waspartly due to the difficulty of accurate coaptation of theends, but also to the fact that the fibres of a nervewere twisted like the strands of a rope, so that anygiven fibre was constantly altering its relative positionin the nerve. This fact rendered futile some operations,such as that of making nerve flaps, which werepractised up to 1915 but had now been discarded. Itwas on the face of it improbable that a nerve graftshould give a good physiological result, however perfectthe surgical technique. A third point of view fromwhich results had to be considered was the economic.Often the economic result was better than either theanatomical or the physiological. He had seen, forinstance, a restoration of the function of the ulnarnerve which appeared economically to be complete,though there remained an anaesthesia of the areasupplied by the ulnar of which the patient was unaware.Sometimes, in spite of a good anatomical and physio-logical result, the economic result was bad owing to thepatient’s mental condition. Sometimes it was bad onaccount of " local ataxia "-that is to say, the functionseemed to be entirely restored if the patient’s attentionwas concentrated on the part concerned, but it quitefailed if the movements were attempted in the dark orwhen the patient’s attention was occupied by somethingelse ; this failure of the automatic function was due tothe imperfect recovery of some of the afferent conductingpaths.

Sir William Thorburn then gave statistics of resultsobtained by various operators in this and other countries.Good results seemed to be obtained in one- to two-thirds ofthe cases; very good results were seldom obtained, but com-plete failures were fairly numerous. He had no faith at allin the efficacy of grafting operations, and he pointed out thatsome of the bolder operations, such as nerve-stretching,transference of the nerves to new beds, and tendon trans-plantation, did much towards rendering grafts unnecessary.It had been found that certain general principles in resultsusually held good: large muscle masses producing coarsemovements recovered very much better than small musclegroups controlling finer movements; function nearer thetrunk was more readily restored than function at a greaterdistance ; homogeneous nerves, such as the musculo-spiral,recovered better than nerves controlling more complicatedmovements.Concerning the long time taken to obtain recovery after

operation, it had been estimated that downgrowth of theaxon, as determined by means of Tinell’s sign, proceeded atthe rate of about one millimetre per day; recovery offunction in the hand therefore took much longer thanrecovery in the upper arm. Much of the time, however, ineither case was taken up in establishing connexion of thenerve fibres with the end-organs. The work that had beendone at Manchester showed that a quite perfect result wasnever obtained, the recovery of sensation being particularlypoor. The best functional results were obtained with themusculo-spiral nerve. If a surgeon obtained good economicresults in 50 per cent. of his cases he was doing well; if heobtained them in 75 per cent. he was not only doing well butwas exceedingly fortunate.Mr. PERCY SARGENT (London) said that the condi-

tions in war wounds, which introduced so many seriouscomplications, were entirely different from those of i

simple experimental cases. There were two main

groups of cases-the one in which operations were done’or the restoration of the conduction of nervous impulses,ihe other in which they were done to improve dis-)rdered function. He proposed only to consider casesri which restoration of conduction was attempted byneans of resection of damaged nerve tissue and suture)f cut surfaces. He believed that end-to-end sutureivas the only means of obtaining restoration of conduc-iion, and that other operations need scarcely be con.sidered. In this connexion he described a case in/Vhich a lateral anastomosis of nerves was done withanatomical failure. He stated that no useful resultlad ever been obtained by carrying out a graft operation.Ln considering the results he assumed that only thebest technique had been employed-that is to say, theoperations had been done without deep fixation sutures,with accurate suturing of the nerve sheath ; that a gapf at least 1 mm. was always left between the ends ofbhe nerve-fibres ; that no sort of wrapping had beenput round the sutured nerve ; and that there had beenno sepsis. He made no distinction between " primary "and" secondary " suture.What, then, were the prospects of the operations In

general ? In considering this question, he had come to theconclusion that end-results "-that is to say, final results,as distinguished from "late results"-had not yet been.obtained in the majority of cases. The criteria that were,used in examining cases were the condition of the nerve inconduction capacity, its electrical reactions, the power ofvoluntary contraction, and sensibility of various kinds.The interpretation of results was often very difficult. Sometimes very misleading cases were put forward as evidence,and in illustration of this Mr. Sargent mentioned a case ofnerve-grafting, which had been reported as a success, butwas found on critical examination to have been erroneouslydescribed. If sensation alone was considered, too rosy animpression might be obtained. The power of voluntarymovement considered by itself was apt to be mis-leading, owing to the education of other muscles thatsometimes took place with the production of unsus-

pected " trick movements." If there appeared to be areturn of voluntary movement in the absence of sensoryrecovery these trick movements must always be suspected.Results differed widely in different nerves; they were

specially good in the musculo-spiral, but very much worsein complicated nerves, such as the median and the ulnar.The muscles of the forearm recovered much better than themuscles of the hand. Sometimes the sense of position waswholly absent when the results, as regards the voluntarymovements and electrical reactions, were good. It was veryimportant that sensibility should be restored, especially inthe case of the median, but the motor function of the ulnarnerve was of little importance. Late results might be badowing to coincident psychological factors. The value ofre-education might be very great, but the same degree ofsuccess must not be expected in all cases, since individualcapabilities varied greatly, some men being normallyincapable of any but very clumsy movements. So-called"trophic changes" were often the result of neglect or

immobilisation for too long a time, and could be improvedby suitable treatment. A disordered vaso-motor activitywas usually due to an irritative lesion and might affect theend-result, since it was accompanied by nutritional effects.Mr. Sargent referred, in conclusion, to the condition of

continuous or chronic pain, known as causalgia. Sometimesthis-tended slowly to abate; in other cases no treatment wasof any avail, though operations should always be tried.Causalgia was often associated with very little loss of move-ment or sensibility, and the trophic changes associated with,it could be arrested. Alcohol injections of various strengthsoften relieved the condition, but if it were necessary to injectconcentrated alcohol a lesion of the nerve would be produced.from which there would be no recovery.

Dr. MAUD FORRESTER-BROWN (Edinburgh) gave elabo-rate statistics derived from an examination of the resultsfollowing 643 operations done in Sir Harold St-,iles’sclinic. Her figures illustrated many of the pointsmentioned in Mr. Sargent’s paper. She recorded twocases which showed complete motor recovery afternerve-graft or nap operations, and stated that very goodresults had been obtained from tendon transplantations.Tinell’s sign was obtained in most cases, but in somewas entirely absent.Mr. COPLAND (Leeds) appeared to be in agreement on

most points with Mr. Sargent. He mentioned, however,some cases of nerve-grafting in which there had beenpositive results. In one case in which seven inches ofthe median nerve had been supplied by a graft there

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had been some return of sensibility in the median area ;in two other cases there had been some improvementof motor function. In the technique of the operation hebelieved that it was of great importance to make a newbed for the nerve to lie in. He pointed out that thetrick movements mentioned by Mr. Sargent may be ofvalue from the economic point of view, and shouldtherefore be encouraged ; they also produced a betterblood-supply to the limb. The most rapid recovery thathe had met with had been in a case of suture of themedian nerve, in which recovery was complete in ninemonths. The use of warmth he believed to be of greatimportance in after-treatment.Mr. J. L. JOYCE (Reading) said that too much

stress was being laid on the operation, which wasmerely an episode in the treatment. The operation ofchoice was end-to-end suture, but among 121 cases hehad found that 22 could not be treated in this way.For these 22 he had used autogenous grafts, homologousgrafts, double lateral implantation, and tendon trans-plantation. The results obtained compared favourablywith those following end-to-end suture. Double lateralimplantation, or, as he preferred to call it, a pedicledautogenous graft, gave better results than a free auto-genous graft. He felt encouraged to pursue his investiga-tions further.Mr. ROWLEY BRISTOW (London) agreed in the main

with Mr. Sargent. He drew attention to the fact thatthose cases which showed early signs of nerve regenera-tion did not necessarily give better end-results thanthose which were more delayed. He had seen sixcases of graft operations; these were all completefailures, except one, in which the signs of recoverywere probably due to the muscles having acquired aconnexion with other nerves. It was possible for anisolated nerve to show in this way signs of apparentrecovery. Tendon transplants had given good results.Mr. NAUGHTON DUNN (Birmingham) said he had found

that, contrary to his expectation, nerves sutured undertension recovered better than when there was no

tension. This emphasised the importance of Mr.Sargent’s statement that there should always be a

small gap between the sutured ends, and reduced thenumber of cases in which a graft need be attempted.He had never seen any signs of regeneration in a graftednerve.

Dr. L. E. SHORE (Cambridge), as a physiologist, pre-sented a point of view which was somewhat different fromthat of the other speakers. He said that the exact wayin which the axis-cylinders grew down was obscure, butthey appeared to be under a chemiotactic influence.One axis-cylinder usually divided into a bunch of finefibrils, which then grew out in all directions and seemedto hunt for the right track to grow into ; some weresuccessful, but many of them :failed to find a sheath.He described the way in which Professor Langley firstshowed that nerve fibres were twisted in the nerve likethe strands of a rope ; this fact made him look uponany attempt to obtain anatomically accurate union asquite hopeless. There appeared to be two classes ofmotor nerve fibres with physiologically different func-tions ; one was controlled by the lower brain centresand moved large muscle masses, the other by the highercentres and produced the finer movements. He believedthat the economic result of operations depended largelyon the degree of recovery of epicritic sensibility. He

finally inquired of the surgeons whether a gap in anerve had ever been bridged by shortening the bonyskeleton of the limb.

Sir WILLIAM THORBURN, in reply to Dr. Shore, statedthat shortening of the limb had been done on severaloccasions. The operation was particularly suitable forthe upper arm.Mr. SARGENT, in conclusion, dwelt on the difficulty

experienced by most surgeons of achieving absolutehonesty in the interpretation of their own results, andhe applied the criticism to himself as much as toanybody else. He repeated his conviction that no

true recovery after a graft operation had ever beenobtained.CChronic Suppuration in the Accessory Sin-uses of the Nose.The paper by Mr. HERBERT TILLEY (London) on this

subject was not of a controversial nature; it was intended

rather for the instruction of those who had not thoughtmuch about the diagnosis of sinus suppuration, whichwas nearly always the underlying cause of a so-calledchronic nasal catarrh. Mr. Tilley discussed the origin,signs, symptoms, and the treatment of sinus suppura-tion, and illustrated his points with anatomical draw-ings and diagrams. He followed up his lecture with ademonstration of the methods of endoscopy on theafternoon of the same day.

Dermonst’rations .

The secretaries of the section had arranged inaddition to the discussions a series of very successfuldemonstrations in the afternoons. On June 30th a demon-stration was given by Mr. P. P. COLE and Mr. H. D.GILLIES (London) of the methods and results of plasticsurgery of the face. The surgery of the war wounds ofthe face has been fully described in Mr. Gillies’s recentmonograph, and is therefore widely known. The

photographs and cases shown were for the most partalready familiar to those who had seen the book. Amore novel feature was the exhibition of several patientswho had been treated by plastic surgery for condi-tions met with in civil practice. These included anepithelioma of the nose, lupus of the nose, excision ofthe lower jaw, and cleft-palate. The results obtainedwere a vindication of Mr. Gillies’s faith in the brilliantfuture which lies before plastic surgery.On two afternoons, June 30th and July 1st, Major

MEURICE SINCLAIR gave a practical demonstration ofthe modern methods of treating fractures. He firstshowed the use of a Thomas’s splint as first-aid treat-ment for a fracture of arm or leg, and then carried outin detail the whole process of putting up a patient witha fractured femur in the Sinclair net-bed. The treat-ment of a series of different fractures was demonstratedand was made realistic by having the splints in positionon men posing as patients.On July lst Mr. ARTHUR COOKE and Dr. J. W. MACNEE

showed how to test prospective blood donors for theirblood groups and demonstrated the whole process of bloodtransfusion, first 4y means of a Kimpton’s tube and thenby the citrate method, employing an open operation onthe donor and Robertson’s bottle as originally described.The demonstrations were all well attended and "were

highly instructive. -

SECTION OF OBSTETRICS AND GYN&AElig;COLOGY.

WEDNESDAY, JUNE 30TH.

PUERPERAL SEPSIS.

THIS section opened on June 30th, with Dr. HERBERTWILLIAMSON, as President.Mr. VICTOR BONNEY (London), in opening the dis-

cussion on Puerperal Sepsis, said that the solution ofthe problem how to prevent, and how to cure, septicinfection of the puerperal uterus, necessitated thecorrect answering of three questions: 1. What is theoriginal source of the organisms ? 2. How do they getinto the uterus’? 3. What is their exact situation by thetime they have produced symptoms of sepsis ? He wasof opinion that the infection, in most cases, originatedfrom an intrinsic source, and not from organismsconveyed from patient to patient. Speaking broadly,the occurrence of the disease at the present day issporadic, not epidemic, a point in favour of the viewhe had expressed. He thought from a consideration ofthe facts that the antiseptic precautions in use up to thepresent time have been efficient in preventing infectionin which septic organisms are conveyed from one patientto another. There was no doubt that organisms capableof producing puerperal sepsis commonly pre-existin a woman, particularly in relation with the ano-

perineal skin. In other words, the commonest cause ofpuerperal sepsis was, in his opinion, faecal infection.

Although it was difficult to apply Listerian principles intheir entirety to obstetric work, he advocated the exclu-sion of the perineum and anus as far as possible byfixing over it a large gauze-pad soaked in some anti-septic. Practical sterilisation of the peri-anal skin maybe effected by the use of a 1 per cent. solution of equalparts of crystal violet and brilliant green in half-and-half alcohol and water. A 2 per cent. solution of iodine