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a few weeks before, the drum is not entirely normalin appearance, and the hearing is somewhat impaired.Apart from such rarities, acute mastoiditis willseldom pass undetected if it be remembered that itsdevelopment is by no means always accompanied bysuch obvious signs as severe pain and high fever.The " cortical mastoid operation is not in itselfa dangerous one-Mr. T. B. Layton lately said thatfrom the patient’s point of view it is a far smalleroperation than the removal of tonsils and adenoids 2-and nearly always it leaves behind a healed, intactmembrane, usually with little or no impairment ofhearing. If it were performed in all cases of acute

suppurative otitis which show no signs of recoveryby the end of the fourth week, a very large proportionof the great mass of chronic aural suppuration wouldbe prevented, a fruitful source of deafness abolished,and the intracranial complications of chronic otorrhcealargely eliminated.

AMBULATORY TREATMENT OF FRACTURES OFTHE FEMUR

IN cases of fractured femur it is by no meanseasy to provide support and fixation sufficientlyrigid to allow of weight-bearing from the outset.With all his enthusiasm for the unpadded plaster castand ambulatory treatment in fractures below the

knee, B6hler3 nevertheless states that the methodof continuous traction is preferred in his clinic forfractures of the femoral shaft. The trouble aboutfixation with plaster, in these particular fractures,is that the plaster cast does not grip the limb firmlyenough to resist the great tendency to deformityat the fracture site-a tendency due mainly to thepowerful pull of the thigh muscles, and also (inwalking) to the tendency of the upper fragmentto "settle down" in the splint. R. A. Griswold,4 4of Louisville, Kentucky, has been so much impressed,however, by the advantages of ambulatory treatmentthat he has evolved a method-analogous in mostparticulars to that used in many clinics for fracturesof the tibia-by which he believes that ambulatorytreatment has been rendered feasible with theassurance of good anatomical and functional results.For such treatment Griswold claims not only theobvious advantage that it shortens the time thepatient occupies a bed in hospital, but also thatthe use of the limb in weight-bearing and walkingencourages healing, and helps to maintain muscularstrength and normal joint function. Measurementof the circumference of the thigh and calf showslittle or no wasting, and, on removal of the cast, asmuch as 45 degrees of painless movement of the

knee-joint may be possible at once.The principles of Griswold’s method may be sum-

marised as follows : The length of the limb is restoredby extension; and after the shortening has beencorrected, two pins are inserted, one transverselythrough the distal fragment just above the adductortubercle, the other in an antero-posterior directionat, or slightly below, the level of the lesser trochanter.By manipulation of these pins, angulation androtation of the fragments on one another is corrected.The limb, with the correct alignment of the bone-endsrestored, and with the pins in situ, is encased in anunpadded plaster cast, which reaches from the

xiphoid cartilage to the toes. Walking is permittedas soon as the plaster has hardened. So that theplaster splint may act in the same way as a Thomas’s

2 THE LANCET 1935, i., 1445.3 Böhler, L. : The Treatment of Fractures, Bristol, 1935.

4 Surg., Gyn., and Obst., April, 1935, p. 848.

walking calliper-i.e., by counter-pressure on theischial tuberosity-a roll of padding about 8 incheslong, and of the thickness and firmness of a Thomas’ssplint roll, is placed in situ and incorporated in theplaster. On the perineal side of the thigh the

plaster is so modelled as to hold the pad in positionand to form a shelf against which the body-weightcan be partly supported.To certain points Griswold draws particular

attention. The pins, for example, are not usedat all for extension, the correct length being restoredbefore their insertion ; and they are thus free formanipulation. By experience, the importance ofthe proximal pin has been demonstrated. At firsta pin was used to correct the posterior angulationof the distal fragment of fractures of the lower thirdof the femur, trusting to the ischial pad to prevent"settling down" of the upper fragment in the

plaster case. This plan, however, proved unreliable,and use of the upper pin was adopted. For manipu-lation and support of the pins, special mechanicalarms are attached to the table on which the patientlies for reduction and fixation of the fracture. The

properly constructed plaster cast for an adult shouldweigh about 12-14 pounds. Five patients treatedby this method walked on the second to the eighthdays following injury ; in another 5 cases the samefixation was applied, but on account of otherfractures (2 cases), psychosis (2 cases) and transferto another hospital (1 case), ambulatory treatmentwas not adopted. The results have been verysatisfactory ; and for straightforward fractures,without complication, the stay in hospital has beenreduced to an average of twelve days.

SENSITISATION TO LIGHT

IT is not surprising that so vital an influence aslight should find its way into many chapters in thebook of medicine. In the fourteenth century Johnof Gaddesden used red light to diminish the ravagesof small-pox in the skin, and there are still practi-tioners who believe in the efficacy of coloured beams.Comparatively recently Finsen extended light therapyinto the invisible regions of the spectrum, and to-dayultra-violet and other forms of irradiation are verywidely used. Much remains obscure, however, inthe mechanisms by which these remedies do theirwork. A fact which has a bearing on their actionis that the presence of certain dyes and fluorescentsubstances in the blood stream is capable of sensitisingthe subject to light-a discovery which was oncetentatively applied in connexion with the Finsentreatment of light. The observation that haemato-porphyrinaemia is associated with hydroa vaccini-forme has pointed the way to an explanation of thewide range of diseases (both in man and in animals)which are due to light irritation or which show light-sensitiveness as a characteristic symptom ; summerprurigo and actinic dermatitis, lupus erythematosus,and pellagra are examples. In reviewing this

interesting subject Dr. Eidinow 1 describes some

original work which he has done using eosin, eryth-rosin, fluorescin, and rose-bengal as light sensitisers.He finds that after these preparations have beeninjected into the blood stream or the tissues infra-red or luminous rays produce effects comparablewith those of ultra-violet irradiation. Thus hemo-lysis of red cells suspended in saline, a lethal effectupon infusoria and a raising of the bactericidal powerof the blood follow exposure to luminous rays when

1 Eidinow, A. : Brit. Jour. Derm. and Syph., 1935, xlvii., 277.

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sensitisers are present. These are, however, noteffective when painted on the skin and they areexcreted within a few hours of being injected. Thiswork suggests a possible field of therapeutic research,and Eidinow claims to have had some success in thetreatment of lupus and chronic ulcers among otherconditions, by the local injection of sensitisers andsubsequent exposure to infra-red and luminousradiations.

IN MEMORY OF HUGHLINGS JACKSON

AMONG the tributes to Hughlings Jackson in thiscentenary year, those of foreigners have a specialplace. Elsewhere in this issue will be found anaccount of the commemorative address in whichProf. Otfrid Foerster spoke of the prescient geniusof the greatest of English neurologists. At theInternational Neurological Congress, Prof. OttoSittig, of Czechoslovakia, who has done much, bytranslation and exposition, to make HughlingsJackson’s writings accessible abroad, pointed outhow he had anticipated modern views about con-sciousness. From Hungary comes an impressivememorial volume in which the published writingsfrom the Stephen Tisza University in Debrecen arecollected and dedicated to Hughlings Jackson, withan appreciatory biographical foreword by Prof.Benedek, the director of the clinic in mental andnervous diseases there and editor of the volume.The papers cover a wide range of topics in neurologyand psychiatry, some of them in fields unexploreduntil recent years. One of the most interestingcontributions is a monograph by Prof. Benedek

concerning the effects of insulin shock therapy onperception. Insulin had been used in his clinic forseveral years as a means of combating the disinclina-tion for food in negativistic schizophrenic patients ;later it was employed to produce hypoglycsemicshock in schizophrenia, and to a less extent in con-fusional syndromes. In the patients so treated

special disturbances occurred in the perception of

forms, space, and movement. The experimentalproduction of psychopathological phenomena bydrugs is a field much cultivated of late years ; byit our knowledge of the functional capacities andresponses of the brain is being enlarged. Other

papers, here included, indicate the mutual dependenceof neurology and psychiatry, and their common useof the principles so brilliantly divined and laid downby Hughlings Jackson.

MEDICAL RESEARCH IN SHANGHAI

IN his introduction to the report of the first fullworking year of the Henry Lester Institute of MedicalResearch in Shanghai, the director, Dr. H. G. Earle,briefly discusses the principles which guide the workof the Institute as a whole, and which have persuadedhim to organise the division of medical research intothree categories-clinical, physiological, and patho-logical. In the division of clinical research, interesthas been centred upon diseases with a definite nutri-tional basis or which lend themselves to biochemicalinvestigation on the clinical side. On the surgicalside peptic ulcer, appendicitis, and urinary infectionsare being investigated, supplemented by experimentalwork into the underlying physiological and patho-logical processes. In the division of physiologicalsciences, Chinese diets and foodstuffs have been

analysed in regard to vitamin and mineral content.Chinese drug terminology is being studied as it applies1 Hughlings Jackson Memorial Volume. Edited by Prof.

Ladislaw Benedek. 1935.

to modern medicine, as well as the toxic effects ofchaulmoogra salts upon the liver and the reputeddiuretic and antipyretic properties of Chinese perilla.In the division of pathological sciences, typhoid,cholera, the bionomies of the mosquito, and thenatural history of schistosomiasis-all of which havea water factor-receive attention. A comprehensivestudy has been made of the distribution of blood

groups among the Chinese population in Shanghai,and the material of the associated Lester Hospital per.mitted the study of blood tests for syphilis-e.g.,the influence of high and low temperatures uponflocculation. But the chief interest of the report liesin the important investigations carried out by thedepartment of epidemiology and medical statistics,a section under the immediate supervision of thedirector. A wide-scale hospital survey-one of thegreatest voluntary collective investigations so far

attempted-has provided valuable and fundamentaldata relating to disease-incidence in various parts ofChina. Hospital populations are usually regardedas providing but a poor index of disease-incidence byreason of the selective factor, but in China, hospitalsperform in high degree the duties usually undertakenby general practitioners in other countries, and inthis survey a uniform method has been adopted ofcollecting and classifying data for in- and out-patientstreated in scattered hospitals. The survey hasstimulated a spirit of inquiry and investigation amongmany medical workers; it has shown what are theclinical problems with which hospitals have to contend,and had already increased the general stock of know-ledge about incidence and distribution of disease inChina. Though this work has been discontinued sofar as the Institute is concerned - although themachinery is being used in the other divisions-theNational Health Administration of China will continuea modified survey on the same lines, The Instituteis devoting much effort to popularising research

through the medium of public lectures and demon-strations; during the session 1933-34 something like50 lectures and demonstrations were given in thetheatre of the Institute, many of them being illus-trated by photographic and cinematographic recordsproduced in its laboratory. These are some examplesof what is being done by a well-staffed and liberallyequipped institution. Copies of the report, and ofpapers published by members of the staff, are avail-able on application to the registrar, Lester Institute ofMedical Research, Avenue Road, Shanghai, China.

THE ONION AS A SOCIAL PROBLEM

IN the laboratory of applied physiology at YaleUniversity, H. W. Haggard and L. A. Greenberg’ 1have been trying to find why an alliaceous odourpersists in the breath after eating onions or garlic.It is generally supposed that, like ether, alcohol, andacetone, the essential oil of onion passes into theblood stream and is aerated from the blood in thelungs, so passing into the expired air. Alternativepossibilities are that these oils are secreted into thesaliva or that the smell comes from the stomach byway of the cesophagus. Haggard and Greenbergwill have none of these hypotheses, and they seem toproduce conclusive evidence in favour of their ownexplanation. Their initial experiment was to give1-5 g. of raw garlic, chewed and swallowed in theordinary way and followed by the usual odours fora day or more. The same person then took the samequantity chopped in small particles but enclosed ingelatin capsules. No smell whatever was detected

1 Jour. Amer. Med. Assoc. 1935, p. 2160.