1832

He dwelt on the great change in medical thoughtwhich the science of physiology had brought about, Iand he maintained that the clinical physician, by Iknowledge of physiology and with a system of (

pathology founded on that knowledge, is now able E

to treat many conditions with much the same icertainty that the surgeon can show when dealing (with an obvious injury. Professor PAUL EHRLICH’Sgeneral Address in Pathology contained much of i

direct interest to the physician. He gave an ex- Icellent account of the way in which the latest 4

remedies act against those microscopic foes whichthreaten the life and health alike of men andanimals. Before proceeding to discuss the principleof fixation in chemotherapy, he pointed out thatgradually we have come to learn something of the Icomplex method by which the animal defendsitself against the assaults of micro-organisms ; andour knowledge, incomplete though it may be, hasenabled us to devise methods of aiding the efforts ofthe body to get rid of the invading germs.The definite association of modern medicine with

the latest researches in genetics was emphasised inthe general Address on Heredity by ProfessorWILLIAM BATESON, President-elect of the BritishAssociation. While able only to give a bird’s-eyeview of the interesting position which has nowbeen reached, he added some valuable indicationsas to the far-reaching direction in which the studiescomprehensively described under the title of

heredity are being carried on.The Pathology of Heart Failure was the subject

of a discussion in the Section of Medicine. Itwas opened by Professor H. VAQUEZ, of Paris, whogave an account of the various methods of clinicalinvestigation that were of value when heart failurewas to be expected or diagnosed. Professor W. T.RITCHIE in his remarks drew attention to "auricularflutter," a condition akin to the auricular fibrilla-tion that had been brought so prominently to thefore by the electrocardiograph.

Dr. G. DOCK, of St. Louis, opened a discussion onDiabetes Mellitus, and went fully into the differentviews that have been published in the hope ofclearing up its etiology.

Professor C. VON NOORDEN presented a diagram-matic scheme in which the control of the glycogenicfunction of the liver was set out. The pancreas wasthe organ that tended to keep the consumption ofsugar down ; the chromaffin system (or, to mentionits chief constituent, the suprarenal gland) triedto increase its consumption. But the pancreaswas in turn controlled by the thyroid gland,the parathyroids, and the hypophysis, while thechromaffin system was under the control -of thecentral nervous system. All these controls, exceptthat of the central nervous system were exercisedby the medium of the secretions of the various

glands concerned, conveyed about the body by theblood-stream. When the blood contained an amountof glucose above the normal, this was due either tothe weakening of the inhibiting power of thepancreas or to the increase in the augmentingpower of the chromaffin system.In the Section of Therapeutics a discussion took

place on the Comparative Value of Cardiac Remedies.It was opened by Professor R. GOTTLIEB, ofHeidelberg, who pointed out that, in order to explainthe action of digitalis and other cardiac drugs andto construct a rational plan of treatment, the resultsof different methods of investigation such as those ofclinical observation and pharmacological experi-ments must be coordinated and brought into line.

Professor THEODORE C. JANEWAY, of New York,presented an interesting report dealing more

particularly with his experience in the clinical useof cardiac remedies from the standpoint of theirefficiency in combating definite perversions offunction. In his opinion the best results fromdigitalis were obtained in a special group of caseswhich he described-viz., cases of well compensatedmitral disease-in which auricular fibrillation withgreat . tachycardia set in acutely. Failure toobtain satisfactory results from digitalis therapyin suitable cases was evidence of an inefficient

preparation, insufficient dosage, or an impropermode of administration.In the Section of Bacteriology an instructive

discussion on "filter passers" was opened byProfessor F. LOEFFLER, who said that since heand FROSCH showed in 1898 that the virus offoot-and-mouth disease passed through filters a

large series of diseases had been attributed to" filter passers." Amongst these might be mentionedyellow fever, dengue, pappataci fever, poliomyelitis,and infective pleuro-pneumonia of cattle. Recentlyit had been asserted that the infective agentsof scarlet fever, measles, and typhus fever alsobelonged to this group. He urged that, in view ofthe great importance of filter passers in the etiologyof disease, laboratories should be devoted to thestudy in all countries. Sir JOHN McFADYEAN saidthat the demonstration of invisible viruses markeda new epoch.

____

SURGERY.The great event of the year in surgery, as in

other branches of medical science, has undoubtedlybeen the London meeting of the InternationalMedical Congress. Not only were many importantsubjects discussed, but the presence of manyeminent surgeons from the colonies and from

foreign countries gave the meeting an importancewhich it would not otherwise have possessed.

Malignant Diseases of Large Intestine.There were several set discussions. The first of

these was on the Operative Treatment of MalignantDiseases of the Large Intestine, excluding theRectum. It was opened by Professor R. BASTIANELLI.He agreed that in cases of obstruction it was wisernot to make an attempt at resection of the growthuntil the obstruction had been removed. Hefavoured a ceecal opening for the drainage of theobstructed bowel; the opening should be large,and yet it could be easily closed when the timecame. It was probable, he considered, that infuture we should be inclined to remove more ofthe bowel than at present. As to the results; since1900 he had had 84 cases with a mortality of 60 percent., but since 1905 the mortality had been only4’5 per cent.-that is, only 2 cases had proved

, fatal out of 44. He had also collected 739 cases,I and in these the death-rate had been 26 per cent., Professor KÖRTE, who followed, also held that in: acute obstruction the best treatment was to perform

colotomy, and to postpone to a later operation the: removal of the growth, and even in chronic obstruc-. tion he thought that the same two-stage operationE was the best. Dr. A. L. SORESI contributed to the

discussion by describing a new method of intestinalanastomosis which he had invented and which

; saved time. Mr. H. J. PATERSON laid stress on thef importance of exploring the abdomen thoroughly- in all cases in which there was a diminution in

the hydrochloric acid of the stomach, and thus

1833

malignant disease of the bowel might be discoveredat a very early stage. Sir FREDERIC EvE hadcollected the statistics of all the cases operated onat the London Hospital from 1901 to 1911. Of 127in which colotomy was done the mortality was54 per cent.; immediate resection was performedin 95 cases with a mortality of 48’4 per cent., whilewith secondary resection the death-rate was

38’8 per cent. Professor KRYNSKI was in favour ofimmediate resection if the indications were

favourable.

Early Renal and Vesical Tuberculosis.The second general discussion dealt with the

Diagnosis and Treatment of Early Renal andVesical Tuberculosis. It was opened by ProfessorVICTOR ROCHET. He expressed the opinion that itwas not advisable to operate on those early casesof tuberculosis of the kidney, in which the

only proof of the presence of tuberculosis was

the discovery of tubercle bacilli in the urine;it was well to wait for pyuria, for in earlier stagesgeneral treatment was indicated and not local treat-ment. When both kidneys were affected there wasno indication for surgical treatment unless therewas evidence that in one kidney there was somesevere lesion threatening life. The bladder wasrarely affected with tuberculosis primarily, andwhen the disease there was secondary the primarydisease was in the kidney or in the genital organsin the male, and then the primary disease should betreated. In the extremely rare cases in which thebladder is affected primarily general treatment isindicated if the disease is early, and only when thebladder disease is severe is local treatmentindicated. Dr. HANS WILDBOLZ held that reallyearly tuberculosis of the kidney is not recognisable,and when it is recognised the disease is alreadysomewhat far advanced. As soon as tuberculosisof one kidney could be diagnosed and the other washealthy then removal of the affected organ as soonas possible was the best treatment. Mr. C. A.LEEDHAM-GREEN thought that it was very difficultto estimate the stage of the disease, and that it waswise not to be in too much of a hurry to operate.Dr. G. VAN HOUTUM believed in the local treatmentof tuberculosis of the bladder. Professor ROVSINGmentioned that it was very rare to see tuberculosisof the kidney in an early stage, and practi-cally it. was only when a man was examinedfor life insurance that a really early tubercu-losis of the kidney was discovered. He had.a very small opinion of the value of tuber-culin in renal or vesical tuberculosis; on

the other hand, Professor E. HURRY FENWICKthought highly of tuberculin, perhaps hardly as acurative agent, but rather as a tonic. He con-sidered that it was possible to recognise tuber-culosis of the kidney as early as the third week.Early removal of the kidney was the best treat-ment, and it had a mortality of only 8 per cent.

Tumours of the Brain.The third set discussion of the Section of Surgery

was held in conjunction with the Section of Neuro-logy ; it dealt with " The Treatment of Tumours ofthe Brain and the Indications for Operation." Itwas opened by Professor BRUNS. He pointed outthat there were two operations for brain tumours,removal and decompression, and the latter mightbe done intentionally or it might be found whenthe brain was exposed that the tumour could notbe removed. The nature of the tumour and itssite were points of the greatest importance -in

estimating the chances of operation. A de-

compression operation was clearly indicated inthose cases in which the exact site of the tumourcould not be ascertained and the symptoms weresevere. The subject was discussed by many speakers,and there was certainly a majority who heldthat the cases in which a tumour could be com-

pletely and permanently removed were very few,and that the mortality from the operation must belarge. Professor HARVEY CUSHING believed thatthe cases in which a perfect restoration of the

general health was obtained were very few in

number, perhaps 5 per cent. Sir VICTOR HORSLEYheld that the results of the surgery of braintumours could only be improved by the earlierdiagnosis of the condition. So long as the text-books continued to say that headache, vomit-ing, and optic neuritis were the signs of cerebraltumour, so long would the cases come to the sur-geon at too late a stage. These three classical signsgenerally appeared at a time when the growth waspassing beyond the reach of the surgeon. ProfessorH. CLAUDE held that if decompression was to doany real good it should be performed early. SirWILLIAM MACEWEN also laid stress on the need forearly diagnosis if operation was to do any good.

Surgery of the Arterial System.A fourth discussion of importance was that on

" The Surgery of the Arterial System," which wasopened by Professor RUDOLPH MATAS, and his

speech consisted mainly of an account of the

operations on aneurysm which he had devised. Of225 cases operated on by one or other of his methods206 were successful; in four gangrene occurred.In all the four cases in which aneurysms of theabdominal aorta were treated death followed.Mr. C. A. BALLANCE considered endo-aneurysmo-rhaphy a very great advance. Dr. ERNST JEGER

reported a large number of experiments which hehad performed on animals; he had achieved a

large measure of success in the suture of vessels.He had been able to show that in animals it was

possible to unite the innominate artery to a branchof the pulmonary artery, so that a part of the lungwas supplied with arterial blood. Dr. CHARLESGOODMAN pointed out that thrombosis was themost important complication of blood-vessel

surgery, and he insisted on the need of isolating theoperation field from the rest of the wound. Dr. V.SOUBBOTITCH gave an interesting account of thevascular surgery met with in the recent Balkanwars. Dr. N. A. DOBROWOLSKUJA showed by a seriesof specimens how excellent may be the results ofvessel-suture. Dr. A. CHIASSERINI had had success inanimals in replacing a portion of the abdominalaorta by pieces of fascia.

Other Subjects at the International Congress.In the discussion on intrathoracic surgery which

was opened by Professor F. SAUERBRUCH it was clearthat the tendency was to replace the more elaboratemethods of maintaining the intrapulmonarypressureby some form of intratracheal insufflation. In thisdiscussion the most striking occurrence was a

demonstration given by Sir WILLIAM MACEWEN thatthe lung was not maintained in contact with thechest wall by atmospheric pressure, for he showedthat they still adhered together, even when theatmospheric pressure was reduced to two or threemillimetres of mercury.A large number of important papers were read in

the surgical section, and it is difficult to say’whichwere those of the greatest interest, but we may

1834

refer to Dr. RussELL S. FOWLER’S account of thetise of the position which is called by his nameand employed for the treatment of peritonitis, andthe paper by Dr. CHARLES GoODMAN on Arterio-venous Anastomosis for impending gangrene.’ Theresults so far obtained appear to show that the,method can prevent gangrene if the operation is notleft too late.

’

Appendicitis.Mr. EDMUND OwEN started a correspondence on

the time to operate in appendicitis, by the publica-tion of a paper which he had read at the MedicalSociety of London. The paper was entitled

Appendicitis, a Plea for Immediate Operation,"and put forward with great eloquence that thereshould be no delay in operating on a patientin whom appendicitis has been diagnosed. Mr.OwEN advanced reasons for this immediate action ;he showed that the surgeon can never tell theexact condition of the appendix, that it mayindeed be a mild inflammation of the appendixfrom which the patient may recover with a fewdays’ or weeks’ rest in bed; but it may, on theother hand, be a case where the appendix is readyto burst and to flood the peritoneal cavity withvery septic pus, and nothing in the signs or sym-ptoms can enable the surgeon to distinguish withcertainty the one from the other. He claimed thatimmediate operation would save many lives thatwould be otherwise lost; that the policy of pro-crastination must lead to many deaths which couldhave been avoided; while in those cases wheremere rest would have led to an arrest of the inflam-mation the patient had been saved once and for allthe risks and dangers of further attacks of thedisease. In politics the motto

"

Wait and see "

might suffice ; for the surgeon in a case which hasbeen diagnosed as appendicitis the motto should be" Look and see." It is not surprising that anaddress expressing sentiments such as these shouldevoke a number of replies. At the meeting of theMedical Society indeed there was unanimity, butthat was merely because opponents were absent.

In the subsequent discussion in THE LANCET therewas among some of those who wrote a tendency toadvocate a waiting policy in all cases which hadpassed the second day, as the statistics appear to showthat operation from this day to about the sixth orseventh day is accompanied by a large mortality.The discussion was of great interest, and though itmay be said that not one of the controversialistswas convinced by the arguments of his opponents,yet it is certain that the number of those whoadvocate a waiting policy is steadily diminishing.More and more every year those who have pre-viously adopted the watching method of treatingcases of acute appendicitis which have passed thefirst two or three days are becoming advocates ofthe immediate operation.

Traumatic Appendicitis.Cases of appendicitis attributea to injury are

rare, though some 100 such have been recorded.The relative frequency has been variously estimatedfrom 0’8 per cent. to 8 per cent., and this differenceis probably due to the difficulty of estimating therelation of cause and effect. Only one writer,SPRENGEL, has denied that trauma can ever be acause. A striking case has been reported by Mr.J. DANIEL. A woman, aged 18 years, was kicked inthe right iliac fossa by her husband, and the pain,though severe, passed off. A week later she feltacute abdominal pain, especially in the right iliac

fossa, and she was compelled to stay in bed ;vomiting and constipation were present. She con-tinued in this state with remissions for more thanthree weeks, and then was admitted to hospital,when her temperature was 103’5°; there was resist-ance over the right iliac fossa, and appendicitis wasdiagnosed. The temperature fell to normal withmedical treatment, and 12 days later an " intervaloperation" was performed. The appendix hadmany adhesions, but it contained no stercolith. Themedico-legal importance of traumatic appendicitis.can hardly be over-estimated, for claims may dependupon the view taken as to the origin of theinflammation.

The Black (Pigmented) Appendix.Mr. W. H. BATTLE has drawn attention to the

pigmented form of the appendix, and he hasdescribed four cases of the condition. In all ofthese the pigment was situated in the mucousmembrane and the colour was clearly due to iron.The condition has been noticed by several Germansurgeons, and they also have found iron to be present.Some years ago Dr. G. NEWTON PITT described acase of pigmented bowel in which the pigment waslead sulphide; the patient had been a worker inlead.

Bastedo’s Sign of Chronic Appendicitis.Dr. ARTHUR F. HERTZ has drawn attention to the

sign of chronic appendicitis, which was first de-scribed by BASTEDO in 1909. The large intestine isslowly inflated with air, by means of a rectal tubeand a small pump such as is used in sigmoidoscopy.Then if chronic appendicitis is present pain is feltin the right iliac fossa, and often there is tender-ness over McBurney’s spot. The test appears to beof some value in chronic ill-defined cases, for whenit gives a positive result chronic appendicitisappears always to be present, but a negative resultdoes not appear to be so conclusive.

Wounds of the Abdomen.Dr. JOHN A. C. MACEWEN has reported a case in

which a boy, 10 years old, fell on a spike; he wasable to walk home, but four hours later he wasremoved to the hospital. He was found to have asmall punctured wound in the epigastrium, with alittle local tenderness, but there was no shock. Soonhe vomited, but the vomit contained no blood. A

probe entered only a short distance. The right sideof the abdomen, however, remained rigid and tender.so an anaesthetic was administered, and it was.

found with a finger that the wound led into theabdominal cavity. When the abdomen was openedit was seen that the stomach was perforated, bothon its anterior and its posterior walls; there wasalso a wound of the mesocolon, with about a pintof blood in the peritoneal cavity. The perforationswere closed and the patient recovered completely.

.

Rupture of the Spleen.Major J. W. F. RAIT, I.M.S., has recorded a case of

rupture of the spleen, due to a blow received threehours before the patient was admitted into theCalcutta Hospital. There was abdominal dulness andthe patient was collapsed. On opening the abdomenmuch blood escaped, and a rent of the spleen wasfound near the lower margin; the spleen wasremoved after ligature of its vessels. An intra-venous infusion of saline fluid was given and somehot saline was left in the abdominal cavity. In thiscase the spleen appears to have been quite normal,though rupture of a malarial spleen is common.

Dr. R. SEHEULT has recorded also a case of

1835

ruptured spleen. A boy, aged 13 years, fell from aheight of 16 feet while climbing a tree. He was-seen by a doctor, but he was- sent home. As the

pain continued he was taken late the next dayto the hospital. On admission there was some

abdominal pain and the abdomen was slightly dis-tended, and there was some diminution of the liverdulness. The urine was drawn off but no bloodwas present. As the symptoms were not urgenthe was kept quiet, with an icebag on the abdomen.The next morning, however, as the pain continuedand there was dulness in the nanks, Dr. SEHEULTdetermined to operate. When the abdomen was

opened much dark-coloured blood escaped. Thewhole of the bowel was examined, but no injury wasfound; the liver was also found to be intact, butthe spleen was seen to be extensively lacerated.The pedicle was clamped and tied. In this case themost remarkable point was the long intervalof nearly 48 hours between the infliction ofthe injury and the removal of the spleen. It is

probable that the haemorrhage was not severe

at any moment, or the patient could not havesurvived.Mr. WILLMOTT EVANS has reported a case of

rupture of the spleen which was complicated withrupture of the liver. A boy, aged 15 years, was runover by a cart, one wheel passing over the abdomen.He was pale but not blanched, and he complained- of abdominal pain. He vomited two or three times,and the first vomit contained a little blood. Acatheter was passed into the bladder and clearurine was drawn off. There was some dulness inthe flanks. A diagnosis of rupture of the spleen wasmade. When the abdomen was opened near theouter border of the left rectus about two pints ofblood escaped and the spleen was found muchtorn ; its vessels were sutured and the spleen wasremoved. The surface of the liver was thenexamined with the hand and two tears in it werefelt. The wound on the left side of the abdomenwas closed and an incision was made on the rightside parallel to the margin of the ribs. It wasthen found that there were three tears in the liver.As the patient was very collapsed the wounds inthe liver were packed with aseptic gauze. Three

days later the gauze packing was removed and thepatient recovered completely and rapidly. The

noteworthy point about this case is the suc-

cessful result after rupture of both spleen andliver.

The Cause of Death in Acute Intestinal Obstruction.Mr. D. P. D. WILKIE has recorded a number of

experiments which he has made on the cause ofdeath after acute obstruction of the bowel. Heshowed that when the obstruction was high in thebowel the free loss of fluid by vomiting accountedin great part for the symptoms. When the in-testine was strangulated his researches indicatedthat the acute symptoms and the early fatal issuewere due mainly to shock and splanchnic paresis,and slightly also to the absorption of toxins fromthe strangulated loop. The practical conclusionsdrawn were: (1) that the surgery of intestinalobstruction should be as conservative as possible,and that only on imperative indications should thelumen of the bowel be opened, for the danger ofperitonitis is greater than that of absorptiontoxsemia; and (2) that in all forms of intestinalobstruction great improvement follows copioussubcutaneous infusions of saline and dextrosesolutions.

Foreign Bodies in the (Esophagus and AirPassages.

Sir STCLAIR THOMSON has reported a very rareand interesting case in which he removed a tooth-plate from the oesophagus after two and a half years.The patient was a man, 22 years old, and during thenight he swallowed half of a cracked vulcanite tooth-plate. He felt pain in the throat and a difficulty inswallowing. The pain and difficulty were referredto a particular spot behind the breast bone. Asthe symptoms persisted he was carefully examinedat several hospitals and the X rays were used, butnothing was found and the diagnosis given wasneurotic dysphagia. When Sir STCLAIR THOMSONsaw him the plate had been seen by direct oesophago-scopy by Dr. IRWIN MOORE, and a skiagram showedthe plate, but very faintly. Then under chloroformthe plate was seized through a Brunings tube andthe tube, forceps, and plate were removed together.The case shows well how such a foreign body maybe overlooked; it is also remarkable that so

irregular a body should have given rise to compara-tively little discomfort, although it had beenretained for two and a half years. Mr. GEORGE N.BIGGS had a similar case of some interest. A boyswallowed a piece of rabbit bone, and immediatelyfelt pain about an inch below the cricoid cartilage.Attempts to remove it with a probang failed. Whenhe was seen the next day an cesophagoscope waspassed and a swelling was seen on the posteriorwall of the oesophagus, and the piece of bone wasseen protruding from a small opening from whichabout a drachm of pus exuded. The bone wasremoved with forceps and proved to be about aninch long and pointed at both ends. He was fed byenemata for four days, but on the seventh day hehad dysphagia and dyspncea and his temperaturewas 105°. A swelling was felt externally, andpressure on this made the boy cough up about anounce of very foul pus. Immediately all the

symptoms were relieved, and the boy soon recovered.It is possible that in this case the probang hadpushed the piece of bone through the eesophagealwall.

Dr. WILLIAM MILLIGAN gave an interesting post-graduate lecture on cesophagoscopy and broncho-scopy for foreign bodies, and he related a numberof cases which showed the value of the method.Similar cases were also recorded of the removal offoreign bodies from the air passages. Mr. W. G.HoWARTH contributed to THE LANCET a paper onthe removal of foreign bodies from the larynx andbronchi. In one case a baby, 9 months old, wasfound to be gasping for breath and an X ray photo-graph showed a foreign body in the subglottic space.It was readily extracted with a pair of Brunings’sforceps, and it proved to be the mouth of a tintrumpet. In another case a man had worn a

tracheotomy tube for laryngeal stenosis; a part ofthe tube was missing, and he mentioned that hehad had a cough for some days. A skiagram showedthe foreign body in the right main bronchus,whence it was extracted with forceps. In twoother cases it was known that a foreign body hadpassed into the air passages; in one of these theobject was a pin, and in the other a hairpin; andin each case the body was lodged in a bronchus.The removal of foreign bodies from the oesophagusand the air passages has become a much simplermatter than even a few years ago, for by Killian’sor Brunings’s tube they may usually be readilyremoved.Mr. THOMAS H. KELLOCK has reported a case in

1836

which he removed a foreign body from the lung.The patient was a boy, 4t years old, and four daysbefore admission to the hospital he swallowed ashawl pin about 2 inches long. He seemed to be ingood health and no abnormal signs were present.A skiagram showed the pin in the right bronchus,though subsequently it slipped down lower. Attemptsto remove it through a bronchoscope failed both whenthe tube was passed through the mouth and whenit was passed through a tracheotomy wound. Thenwhen the tracheotomy wound had closed Mr.KELLOCK made an opening through the chest-wall onthe right side, forming a window about 3 inchessquare. The finger could feel the diaphragmaticsurface of the right lung, a hard spot was feltthere, and a small incision was made over it, andwith a litttle trouble the pin was felt and extractedwith forceps. The child recovered, though for thefirst few days it was a little restless.

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Dr. ROYAL WHITMAN has contributed a paper onthe method devised by him of treating fracture of the neck of the femur by placing the limb in theposition of abduction. He points out that in thisfracture the outer fragment is turned forwards anddisplaced upward, and the adjusting the outer frag-ment to the inner is accomplished as follows:—The ’patient is anaesthetised and placed on a sacral

support, and then an assistant abducts the soundlimb to the anatomical limit so as to demon-strate the normal range, which varies in differentpersons, and this also serves to fix the pelvis. Thenthe thigh on the affected side is flexed to disengagethe fragments. The hip is then extended and

longitudinal traction is made to overcome the

shortening. The limb is rotated somewhat inwardsand is abducted to the normal limit, as shown bythe thigh of the other side. In this position thefractured bone is fixed by a plaster spica, extendingdown the limb as far as the ankle. The method is

ingenious, and it has probably not been employed tothe extent which it deserves, though most of theobjections brought against it have been theoreticalrather than practical.Hyperextension and " Back-fire " Injuries of the

Wrist.Mr. CUTHBERT S. WALLACE has contributed a

paper on the injuries in the neighbourhood of thewrist which result from forcible over-extension ofthe hand. The lesions produced vary greatly indifferent cases. In one case there was dislocationof the semilunar, fracture of the neck. of the

scaphoid, and a vertical fracture of the lower endof the radius, taking off its styloid process. Thesemilunar bone and the loose piece of the proximalend of the scaphoid were removed. In a secondcase the whole of the second row of carpal boneswas dislocated backwards on to the back of the firstrow, and in addition the semilunar was dis-located. In a third case the semilunar and pyramidalbones were displaced forwards and upwards. Hediscussed the mechanism of the production of thesefractures, and showed how the angle of flexionaffected the result. The injuries of "backfire" wereexemplified by two cases ; in one the radius wasfractured three inches above its lower end, and theupper end of the lower fragment was displacedforwards. In the other case the fracture was of thelower end of the radius ; starting about three-quarters of an inch above the tip of the styloidprocess, it passed inwards and downwards to enterthe wrist-joint just external to -the radio-ulnar

articulation. This latter is the lesion which hasbeen called chauffeur’s fracture. There was no

displacement. ____

OBSTETRICS AND GYNÆCOLOGY.

The Ductless Glands and Pelvic Organs.The ductless glands and their relation to the

functions of the pelvic organs have excited a gooddeal of attention during the past year, and formedthe subject of the Arris and Gale lectures atthe Royal College of Surgeons given by Dr.W. BLAIR BELL, and also of a discussion atthe Section of Obstetrics and Gynæcology ofthe Royal Society of Medicine introduced byhim. The curious part played by the pituitarygland in the production of the so-called " dys-trophia adiposo-genitalis," the occurrence of sexualprecocity, premature adolescence, and early settingof the body in association with hypertrophy of thecortex of the suprarenal, and the arrest of the.

body growth accompanying atrophy of the thyroid-all these demonstrate how important a part inmetabolism is played by these secretions, and whatan intimate relationship they bear to the manyproblems associated with sexual characteristics andsexual development. Dr. BLAIR BELL’S lecturesform a useful summary of our knowledge, which as.regards actual facts is very small indeed. Unfortu-nately, at the present time there is a widespreadpendency to attribute all kinds of varying errors ofmetabolism to disturbances of one or other of theductless glands when practically nothing is knownwith any certainty. It is of the utmost importanceif our knowledge of this subject is not to be con-fused by unwarrantable hypotheses that we shouldaccumulate a much larger number of definite andproven facts, and refrain from crude generalisations,however fascinating and apparently illuminatingthey may be. The investigations required to detectchanges in the general metabolism of the body asthe result of disease or artificial removal of one ormore of the ductless glands are of the highest com-plexity, and must be carried out in very large seriesof cases carefully controlled before any definiteconclusions can be drawn from them.

Dr. BLAIR BELL holds that any influence the

ovary has over the general metabolism is related to,and dependent upon, its primary reproductive func-tions. He believes that the thyroid, the pituitary,and the adrenals influence the development andpreserve the activity and integrity of the genitalia,while the thymus, and possibly the pineal, appearto prevent sexual precocity. He further maintainsthat all the ductless glands control the metabolismin response to the necessities of the genital func-tions. When, however, the reproductive glands areremoved or atrophy the primary genital functionsof the rest of the ductless glands cease, and therearrangement of the metabolism that follows pro-duces the symptoms which are known as those ofthe menopause. On the other hand, insufficiencyof the thyroid, of the adrenals or of the pituitarybody causes the cessation of the genital functionswith atrophy of the uterus. That there is somedefinite relationship between the ductless glandsis, indeed, accepted by most workers, but whatexactly these relations are is very - debateableground. There may be much truth in the deduc-tions drawn by Dr. BLAIR BELL, who finds faultwith BIEDL’S well-known work on this subject,because nowhere in it is there any attempt to linkup the connexions that exist between the ductless