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407 announcing that the International Ophthalmo- logical Congress, which was to have been held at St. Petersburg on Monday, August 10th, has been postponed. ____ WE are asked to state that the library and offices of the Royal Society of Medicine, 1, Wimpole-street, London, W., will be closed for cleaning until Sept. lst. ____ Mr. E. Saville Peck, M.A., of Cambridge, has been elected President of the British Pharmaceutical Conference. The next annual meeting will be held at Scarborough. THE CLINICAL CONGRESS OF SURGEONS OF NORTH AMERICA. FIFTH ANNUAL SESSION HELD IN LONDON DURING THE WEEK OF JULY 27TH. THE Congress, which came to an end last week, went throughout its course without a hitch. The sessions were well attended and the metropolitan hospitals were daily visited by appreciative groups of earnest students. The interchange of knowledge and of point of view was wide and intimate and nothing but good to surgery can come of such a meeting. We are particularly glad to feel certain that the surgery of this country emerged from the strict trial of its merits with an increased reputa- tion, and those members of the public who conceive it to be necessary to rush abroad for specialists’ opinions will, we trust, note the fact. Dr. W. L. Rodman, of Philadelphia, the President- elect of the American Medical Association, on his inauguration as Vice-President of the Clinical Congress, spoke of the feelings of American members of the medical profession towards the mother country in words which should be recorded. " Great as our obligations are as Americans," he said, " they are vastly greater as members of the medical profession, since from the birth of our country England has been the chief source from which our inspiration has been drawn. In becoming the hosts of the Clinical Congress of Surgeons of North America on this unique occasion, and one eloquent of opportunity for us all, the pro- fession of Great Britain has enormously increased the indebtedness. We can best show it, for the nonce, by becoming their attentive and appreciative pupils and taking back to our brothers, who, unfortunately, cannot be with us, the many good things we have seen, and shall see, from masters in surgery. Recognising the occasion to be an unusual one, I am here to extend to the British profession the very cordial greetings and thanks of the American Medical Association." Dr. Rodman then outlined the activities of the American Medical Association, whose Council on Medical Education and Council on Public Health have worked so successfullv for a high standard of scientific training among doctors and of sanitation among the people, both in peace and war. ____ The visit of members of the Congress to the Royal College of Surgeons of England was one of the things which impressed our visitors most. They were conducted over the largest and most complete pathological museum in the world by the President of the College, Sir W. Watson Cheyne ; the late President, Sir Rickman Godlee ; Professor Arthur Keith, curator; and Professor S. G. Shattock, pathological curator. The library also was visited, and this collection has claims which, without ranking quite as high as the Hunterian Museum, yet are very important. Professor Keith delivered a brief address to the visitors on the Nature of Peritoneal Adhesions, which we publish this week. Before the discussion of the papers by the General Surgical Division on Thursday evening, July 30th, 9 the President-elect, Dr. Charles H. Mayo, of Rochester, U.S.A., was introduced to the meeting. and briefly returned thanks for the honour done to him. ____ EVENING SESSIONS. A.-GENERAL SURGICAL DIVISION. THURSDAY, JULY 30TH. The Non-operative Treatment of Cancer. Professor KRONIG (Freiburg), who was to have read a paper on the Treatment of Uterine Cancer by X rays and by Radium, was unable to attend the Congress owing to his recall on account of the war in Eastern Europe. In his absence Dr. C. JEFF MILLER (New Orleans), who has paid a recent visit to Professor Kronig’s clinic, narrated his impres- sions in a paper entitled "A Review of Professor Kr6nig’,% Work in the Non-operative Treatment of Carcinoma." One of the questions which he put to Professor Kronig was whether the latter is in favour of radiation treatment for early operable uterine tumours as well as for advanced cases. The reply was that at the present time operation has been given up entirely. The results of X ray treatment are regarded as superior to those of hysterectomy for fibroids. though in women under 40 myomectomy is undertaken when it is feasible. Treatment extends over three or four month!’, and must be repeated at several sittings. Malignancy, according to the Freiburg statistics, develops in only 1 per cent. of fibroids, and even when it does radiations will cure- it. Contrary to the statements of Professor Bumm that. deep-seated cancers cannot be influenced by X rays, Professor Kronig and Professor Aschoff are convinced that cases of unquestionable cancer of the stomach have been made to,- cicatrise, and that even when there have been secondary growths in the liver complete retrosression has been on occasion brought about. Radium and thorium in heroic- doses are also very much employed in the Freiburg clinic, and special arrangements have been devised there for using these laree doses without burning the patient’s- skin. Professor Kronig holds that high dosages of radium, strongly filtered, have great possibilities for malignant disease in deep organs. He believes in powerful radiations, carefully measured and properly controlled, administered over long periods. He uses these large quantities of radium and thorium from a greater distance than many other workers do ; thus for carcinoma of the cervix he does not apply radium through the vagina, but only from outside the abdomen. He does not believe in the implantation of radium into actual growths. Dr. Miller con- fessed himself as much impressed by what he saw, but not by any means convinced that Professor Kronig is right. Nevertheless, he praised the latter’s enthusiasm, and said that in course of time his work will yield definite conclusions. Dr. J. F. PERCY (Galesburg, U.S.A.) read a paper illustrated by lantern slides of the special instruments which he uses in the treatment of cancer of the uterus by heat. The paper was published in THE LAl CET last week (p. 309). Professor T. WILSO-N (Birmingham) read a paper on Cancer of the Uterus, which also was published in THE LANCET last week (p. 318). Dr. T. W. EDEN (London) directed the attention of the Congress to the fact that in the three papers read three separate lines of treatment were advocated for the same disease. As a critic he thought it his duty to warn against implicit faith in any of the three methods. An open mind should be preserved, though but for the consciousness of this necessity he would have felt inclined to reject at once the views of Dr. Percy. But he recognised that if the latter can prove his claims by statistics, properly and independently controlled, then in years to come everyone will do him honour. As regards the Freiburg treatments, Dr. Eden
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announcing that the International Ophthalmo-logical Congress, which was to have been held atSt. Petersburg on Monday, August 10th, has beenpostponed. ____

WE are asked to state that the library and officesof the Royal Society of Medicine, 1, Wimpole-street,London, W., will be closed for cleaning until

Sept. lst. ____

Mr. E. Saville Peck, M.A., of Cambridge, has beenelected President of the British PharmaceuticalConference. The next annual meeting will be heldat Scarborough.

THE CLINICAL CONGRESS OF SURGEONSOF NORTH AMERICA.

FIFTH ANNUAL SESSION HELD IN LONDON DURINGTHE WEEK OF JULY 27TH.

THE Congress, which came to an end last week,went throughout its course without a hitch. Thesessions were well attended and the metropolitanhospitals were daily visited by appreciative groupsof earnest students. The interchange of knowledgeand of point of view was wide and intimate andnothing but good to surgery can come of such ameeting. We are particularly glad to feel certainthat the surgery of this country emerged from thestrict trial of its merits with an increased reputa-tion, and those members of the public who conceiveit to be necessary to rush abroad for specialists’opinions will, we trust, note the fact.

Dr. W. L. Rodman, of Philadelphia, the President-elect of the American Medical Association, on hisinauguration as Vice-President of the ClinicalCongress, spoke of the feelings of Americanmembers of the medical profession towards themother country in words which should be recorded." Great as our obligations are as Americans," hesaid, " they are vastly greater as members of themedical profession, since from the birth of our

country England has been the chief source fromwhich our inspiration has been drawn. In

becoming the hosts of the Clinical Congress of

Surgeons of North America on this unique occasion,and one eloquent of opportunity for us all, the pro-fession of Great Britain has enormously increasedthe indebtedness. We can best show it, for the nonce,by becoming their attentive and appreciative pupilsand taking back to our brothers, who, unfortunately,cannot be with us, the many good things we haveseen, and shall see, from masters in surgery.Recognising the occasion to be an unusual one, Iam here to extend to the British profession thevery cordial greetings and thanks of the AmericanMedical Association." Dr. Rodman then outlinedthe activities of the American Medical Association,whose Council on Medical Education and Councilon Public Health have worked so successfullv for ahigh standard of scientific training among doctorsand of sanitation among the people, both in peaceand war.

____

The visit of members of the Congress to theRoyal College of Surgeons of England was one ofthe things which impressed our visitors most.They were conducted over the largest and mostcomplete pathological museum in the world by thePresident of the College, Sir W. Watson Cheyne ;the late President, Sir Rickman Godlee ; Professor

Arthur Keith, curator; and Professor S. G. Shattock,pathological curator. The library also was visited,and this collection has claims which, withoutranking quite as high as the Hunterian Museum,yet are very important. Professor Keith delivereda brief address to the visitors on the Nature ofPeritoneal Adhesions, which we publish this week.

Before the discussion of the papers by the GeneralSurgical Division on Thursday evening, July 30th, 9the President-elect, Dr. Charles H. Mayo, ofRochester, U.S.A., was introduced to the meeting.and briefly returned thanks for the honour done tohim.

____EVENING SESSIONS.

A.-GENERAL SURGICAL DIVISION.

THURSDAY, JULY 30TH.The Non-operative Treatment of Cancer.

Professor KRONIG (Freiburg), who was to have read a

paper on the Treatment of Uterine Cancer by X rays and byRadium, was unable to attend the Congress owing to hisrecall on account of the war in Eastern Europe. In hisabsence Dr. C. JEFF MILLER (New Orleans), who has paid arecent visit to Professor Kronig’s clinic, narrated his impres-sions in a paper entitled "A Review of Professor Kr6nig’,%Work in the Non-operative Treatment of Carcinoma." Oneof the questions which he put to Professor Kronig waswhether the latter is in favour of radiation treatment forearly operable uterine tumours as well as for advanced cases.The reply was that at the present time operation has beengiven up entirely. The results of X ray treatment are

regarded as superior to those of hysterectomy for fibroids.though in women under 40 myomectomy is undertaken whenit is feasible. Treatment extends over three or four month!’,and must be repeated at several sittings. Malignancy,according to the Freiburg statistics, develops in only 1 percent. of fibroids, and even when it does radiations will cure-it. Contrary to the statements of Professor Bumm that.

deep-seated cancers cannot be influenced by X rays, ProfessorKronig and Professor Aschoff are convinced that cases ofunquestionable cancer of the stomach have been made to,-

cicatrise, and that even when there have been secondarygrowths in the liver complete retrosression has been onoccasion brought about. Radium and thorium in heroic-doses are also very much employed in the Freiburgclinic, and special arrangements have been devised therefor using these laree doses without burning the patient’s-skin. Professor Kronig holds that high dosages of radium,strongly filtered, have great possibilities for malignantdisease in deep organs. He believes in powerfulradiations, carefully measured and properly controlled,administered over long periods. He uses these largequantities of radium and thorium from a greater distancethan many other workers do ; thus for carcinoma of thecervix he does not apply radium through the vagina, butonly from outside the abdomen. He does not believe in theimplantation of radium into actual growths. Dr. Miller con-fessed himself as much impressed by what he saw, but notby any means convinced that Professor Kronig is right.Nevertheless, he praised the latter’s enthusiasm, and said thatin course of time his work will yield definite conclusions.

Dr. J. F. PERCY (Galesburg, U.S.A.) read a paperillustrated by lantern slides of the special instruments whichhe uses in the treatment of cancer of the uterus by heat.The paper was published in THE LAl CET last week (p. 309).

Professor T. WILSO-N (Birmingham) read a paper on Cancerof the Uterus, which also was published in THE LANCET lastweek (p. 318).

Dr. T. W. EDEN (London) directed the attention of theCongress to the fact that in the three papers read threeseparate lines of treatment were advocated for the samedisease. As a critic he thought it his duty to warn againstimplicit faith in any of the three methods. An open mindshould be preserved, though but for the consciousness of thisnecessity he would have felt inclined to reject at once theviews of Dr. Percy. But he recognised that if the lattercan prove his claims by statistics, properly and independentlycontrolled, then in years to come everyone will do him

honour. As regards the Freiburg treatments, Dr. Eden

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distinguished between radium and X rays. The latter are

admittedly useful; of the former he is much less certain.Professor Bumm said, only three weeks ago, that if anadequate effect is produced at a depth of 3 to 4 centimetresby radium, then the superficial tissues are so extensivelydestroyed that death may result ; and the speaker com-mented on the wide discrepancy between this view and thatheld by Professor Krönig. But as regards X rays theposition is different. Dr. Eden has no doubt that a verybeneficial local effect can be thus obtained, even though thedisease may at the same time be advancing in the deepertissues. As to operation no better or more extensive operationis likely to be devised than that of Wertheim, yet ProfessorWilson’s curability rate of 10 per cent. cannot be regarded Ias satisfactory. The best promise of improvement is seen in iX rays combined with operation ; one method alone should Inot be relied on, but combinations of methods adopted. Andit must also be remembered that when in advanced casesoperation is out of the question the use of X rays will freethe patient from many of her troublesome symptoms, eventhough it will not cure the disease.

Mr. W. E. MILES (London) has never treated cancer ofthe uterus with X rays or radium, and therefore confinedhimself to the question of surgical treatment. In order to

carry out a radical operation it is necessary, not only toremove the organ in which the primary growth originates,but also the tissue through which spread has taken place andthe tissue through which spread will take place if the diseaseis unchecked. In mapping out these zones of spreadsurgeons and pathologists cooperate ; and three such zoneshave been definitely determined in the case of cancer of thecervix. There is the downward spread into the vagina andthe connective tissue on either side of it; in all radical

operations as much of the vagina as possible should beremoved. The lateral zone of spread is into the parametriumand mesometrium, which must in all cases be completelyremoved. The upward zone of spread is along the lymphaticpaths. The statistics of the Cancer Hospital do not agreewith those of Roger Williams, quoted in Professor Wilson’spaper, to the effect that in 54 per cent. of cases of fataluterine cancer there is no involvement of the pelvicglands. In such patients, dying from inoperable cancer

at the Cancer Hospital, the interiliac glands are alwaysaffected, and they should always be removed when operating,whether they are obviously enlarged or not. If these glandsat operation are found to be definitely infiltrated, then thecommon iliac glands should also be removed. The inner

groups of the external iliac glands are also often involved,and sometimes the inguinal glands secondary to these. Thelateral sacral glands, however, are never involved. Mr. Milesconcluded by emphasising that the crux of the cancer

problem is early diagnosis.Dr. JOSEPH C. BLOODGOOD (Baltimore) said the preceding

papers revealed truthfully the results of operations for fullydeveloped cancer diagnosed clinically. But surgeons havebeen so overwhelmed with the details of technique of theseextensive operations that they have not given enough con-sideration to the beginnings of cancer. Cancer practicallyalways gives warnings to those in whom it develops, andtherefore any campaign of education in the beginnings ofcancer is justifiable, no matter what it costs. At the stagein which cancer ought to be treated the mortality shouldbe practically nil in well-trained hands. The earlypreventive treatment of cancer is all-important, forcancer never begins in a healthy spot. Slides were thenshown in illustration of these contentions, and also of casesin which after apparent cure of superficial cancer by X rays,

Iradium, cauterisation, and curetting cancer cells were demon-strated under the healed epidermis.

FRIDAY, JULY 31ST.Professor W. L. RODMAN (Philadelphia), President of the !IAmerican Medical Association, opened a discussion on !

Carcinoma of the Breast.He devoted especial attention to the question of the ’,diagnosis of malignant from benign growths and inflam-matory conditions. Twenty years ago benign tumours wereestimated to be only 9 per cent. of mammary neoplasms,owing to some faulty German statistics published by Gross.In these same statistics sarcoma was given undue promi-nence at that time, and its frequency was over-estimated.Dr. Bloodgood finds that at the Johns Hopkins Hospital I

sarcomata constitute only 1 -5 per cent. of breast tumours ;and they are, in fact, so rare as to be almost a negligiblequantity. During the past ten years much more attentionhas been paid to chronic fibrous and glandular hyperplasia,the result of abnormal involution of the breast, which hasoften been mistaken for cancer. This condition is verycommon, especially about the menopause. Since the age ofoccurrence is so similar to that of cancer, it is important todifferentiate the two lesions. Chronic fibrous hyperplasia isfrequently bilateral, whereas only 2 per cent. of breastcancers are bilateral. Early cancer is not painful, whereasabnormal involution is always painful. The pain is

exaggerated just before each menstrual period, and enlargedsuperficial veins are then seen over the breast. These arealso seen in sarcoma, but not in carcinoma. 20 per cent. ofcancer of the breast occurs between 20 and 40 years of age.Cancer, unlike benign neoplasms, soon becomes fixed byinfiltration, though the amount of this fixation may be veryslight at first and only to be detected by very carefulexamination. If there be atrophy of the superficial fascia,however small, or dimpling of the skin, however slight, theprobability is that carcinoma is present unless chronicmastitis has previously existed. Comparison of the twobreasts is of great importance in diagnosis, but retraction ofthe nipple has been given too much attention-it does notoccur in 48 per cent. of all carcinomata of the breast, whereasit does occur in 5 per cent. of benign growths and more often

still in abnormal involution. There is a difference, however,in that in cancer the nipple, as well as retracted, is infiltrated,fixed, and immobile, whereas in benign growths there is

mobility and no fixation of the nipple. Volkmann’s carcino-matosis of the breast is so like inflammatory conditions thatfive out of the seven cases which Professor Rodman has Sdenhad already been operated on for abscess, and this usuallyhappens ; the diagnosis is not easy. This disease is not con-fined to pregnant women ; it is more frequent in those who arenot pregnant, and it often occurs in maiden women about themenopause. It is so rapidly fatal-in a few weeks to threemonths-that in Professor Rodman’s view it should not be

operated upon at all unless for palliative purposes or

for psychical effects. The differentiation of benign frommalignant cysts is even more difficult than in the case ofsolid tumours. Thick granular discharge from the nipple is

strongly suggestive of carcinoma, and so are serous or

sanguinolent discharges. The latter, however, may beseen in abnormal involution, even long before carcino-matous change has supervened, for this condition is

very prone to undergo malignant degeneration. Pure bloodfrom the nipple nearly always means papillary cyst-adenoma, which also is often subject to malignantchange. In at least 25 per cent. of cases a skilleddiagnostician may fail to make the right diagnosisclinically. There is a safe way to proceed-that of explora-tory incision. Benign growths are convex on section, pinkor pinkish-white in colour ; malignant are usually concave,creak under the knife, and practically always have more orless of a grey tinge. Though the expert may be able withfair certainty to tell the benign from the malignant growthby inspection, the less experienced cannot do so; onlyfrozen sections, examined at the time of operation, will savethe operator from mistakes. Professor Rodman has employedthis method for 20 years with only one case of error, andeven in that case the error was discovered in time to savethe patient by a second operation. In his experience thechance of mistake in the examination of a frozen freshsection is actually less than in that of fixed tissues. The

paper concluded with a lantern slide demonstration of theauthor’s operative technique.During the reading of Professor Rodman’s paper a woman

suddenly rose in the body of the hall and began to make asuffrage speech. Only the first sentence, "I I am a mouse,"was audible ; the rest was drowned by the protests of theaudience. Efforts were made to persuade the woman toretire, but in vain. Finally, still speaking, she mounted achair, from which she was then removed by a commissionaire,who carried her out of the hall.

Mr. W. SAMPSON HANDLEY (London) differed on one or twosmall points from Professor Rodman. Cancer of the breast isnot always a fixed tumour, nor does the skin always dimpleover it. He agreed with Professor Rodman as to the import-ance of frozen sections, but said that unfortunately patho-logists as good as those with whom Professor Rodman works

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are rare. A few years ago the embolic theory of cancerousdissemination was held. According to this supposition, thedistribution of secondary foci is the result of chance. Yetthe legs below the knee and the arms below the elbow arepractically never affected by metastases from cancer of thebreast. Secondary deposits are very rarely found at a greaterdistance than 24 inches from the primary growth. Mr.Handley’s researches showed him that the embolic theory istrue for the axillary glands, but that other metastatic

deposits are due to permeation, which is the true method ofgrowth and dissemination of cancer of the breast. The reason

why permeation so long escaped observation is that it is at firsta fugitive process. A lymphatic blocked by cancer cells soonbecomes free again and only an almost imperceptible fibrosisremains. Permeation was then illustrated by a number of

Ilantern slides showing microphotographs of the process. IIntestinal Stasis. ’

Sir BERKELEY MOYNIHAN (Leeds) opened a symposium on c

Intestinal Stasis. He asked, What is meant by intestinal ]stasis ? It is asserted, first, that at definite points along the Iintestinal canal certain membranes, veils, or webs are 1

frequently found ; secondly, that because of these delayoccurs in the passage of the intestinal contents, and that inconsequence a process of intoxication takes place ; thirdly,that by this intoxication some diseases are directly caused,and many others, even most others, are indirectly encouraged.Sir Berkeley Moynihan admits that these membranes are

frequently present, as described. This is entirely beyondcavil. But the question of the origin and bearing of thesebands can be disputed. Most of them he confidentlybelieves are congenital. As long ago as 1899 he publishedan account of the dissection of a large number of foetusesand infants in whom these membranes were found. Jackson’smembrane is most commonly of congenital origin. Butthe bands found at the hepatic and splenic flexuresof the colon are seldom congenital ; about the originof these he agrees with Sir Arbuthnot Lane. SirBerkeley Moynihan was disposed to doubt if thesebands were responsible for intestinal delay and obstruc-tion, for the gut is generally not hypertrophied as itshould be if some obstruction existed. Delay un-

doubtedly occurs in the typical case of intestinal intoxica-tion, not from obstruction by the bands but from incapacityof the enfeebled intestine to empty itself. There is a typeof individual recognisable at sight who can be said to besuffering from Lane’s disease. After describing the typehe said these are really cases for surgical treatment,though early cases can be helped very greatly by massageand paraffin. What operation should be selected ? Ileo-

sigmoidostomy results nearly always in regurgitation backalong the colon to the csecum. Anastomosis is of no use,for it is impossible to prevent this regurgitation. Whenthese operations relieve symptoms, then intestinal stasis hasnot been the cause of the symptoms in those cases. In trueintestinal stasis removal of part of the intestine should bepractised. The lower end of the ileum, the caecum, and theascending colon are the parts which it is best to remove.If surgical treatment is to be adopted it is wiser not todo a short-circuiting operation, but to take out these

parts only. What are the diseases which are affectedby intestinal stasis ? What are the relations of intes-tinal stasis to gastric and duodenal ulcer and chole-lithiasis ? Sir Berkeley Moynihan believed that the causelies more often in the appendix, not in intestinal stasis.Therefore when surgical treatment is directed to thesediseases the surgeon is exceeding his duty towards his

patient if he deals with anything beyond the demon-strable lesions of the case. It is claimed that joint Ituberculosis, rheumatoid arthritis, and many other diseasesare often caused by intestinal stasis and cured by colectomy.Sir Berkeley Moynihan has seen cases of rheumatoid arthritisimproved beyond the wildest expectation by operativeabdominal measures. But it has to be remembered thatdrainage of an infected gall-bladder or removal of a diseasedappendix will cure some cases of this disease ; and ithas to be remembered that most of these cases are notbenefited by operative measures intended to preventintestinal stasis. The same holds good of tuberculousjoints. Some of the worst kinds of these cases show mar-vellous improvement after the whole of the surgical assaulthas been devoted to the intestinal caral. The causal

- relation is worthy of a wider trial and investigation, butnore than that cannot yet be said. The enthusiasts, how-ever, want us to travel with them much further than this,Mmost all the diseases that afflict patients submitted tosurgery, as well as many of those which are still for thepresent in charge of physicians, are regarded as amenablej0 surgery directed to the intestines. Sir Berkeley Moynihanwas very strongly disinclined at present to accept the evidence50 far put forward in support of these views, but was eager toexamine all new evidence bearing on the subject. Hebelieves the subject must be inquired into very carefully,for among much dross there is a nugget of pure gold.

Sir BERTRAND DAWSON (London) pointed oat that thephrase intestinal stasis" is being used in two differentsenses. One means the actual delay in the passage ofthe intestinal contents ; the other as indicating the clinicalpicture of the results of such stasis. Now the routineuse of bismuth meals shows that many persons have

delayed ileal effluent without suffering from any sym-ptoms attributable to it. The large intestines play the prin-cipal part in the production of the symptoms of intes-tinal stasis ; and the best results of colectomy are seenwhen the large bowel is definitely diseased. It is importantto put aside any bias against the colon, and not to get thehabit of regarding it as a useless organ which is just as wellremoved as left. The indications must be definite before the

operation is advised. Apart from the mortality of the opera-tion of colectomy, which is not negligible, it is often followedby frequent actions of the bowels at irregular intervals.The intestines are also easily affected after colectomy bychanges of temperature and by fatigue. These incon-veniences are of little moment when the patient’s entireoutlook on life has been changed, but they are drawbackswhich should not be ignored. The successes of the operationare very striking, but side by side with these there are greatfailures. This is not in itself a condemnation of the

operation, but merely constitutes a plea for critical selectionof cases, for the failures are not due to any faults oftechnique. If an appendix is removed, but the symptomsare not cured, at least no harm has been done to the

patient. A gastro-enterostomy which is unsuccessful can beundone again. But a mistaken colectomy can never beundone, and a further reason for careful selection of cases isthe fact that we do not yet know the full effects of colectomyon the future nutrition of the patient.

Professor J. C. BLOODGOOD (Baltimore) made an emphaticappeal for facts in the consideration of this subject.For example, in how many cases in which the appendixhas been removed is there a failure to cure the patient’ssymptoms ?-that is, in cases where it was doubtful whetherthe appendix had been the cause of those symptoms. Again,in how many cases of gall-bladder disease, acute or chronic,with or without gall-stones, is there a failure to cure

symptoms by drainage of the gall-bladder, removal of thestones, or by removal of the gall-bladder ? In the last25 years 700 such cases have been treated in the JohnsHopkins Hospital, and so far only three of them havereturned with symptoms referable to the colon. For the

purpose of analysing their cases at the Johns HopkinsHospital the cases of colon disease are divided into five groups.In one of these groups, in which clinically the symptomshave been those of intestinal stasis, the patients have beenrelieved by the proper treatment of naso-pharyngeal andsinus infections. In the second group abdominal operationshave been performed. In Baltimore gastro-enterostomy isan operation which is not done if it can be avoided, butwhen it has been done the results have been uniformly good.The third group includes those in whom adhesions have beenfound, whether embryonic or acquired. The results ofoperations for division of the adhesions, though good, havenot been so good as those in similar cases from operationsof a different type. The fourth group includes the terminalcases, those now under discussion. Professor Bloodgoodcannot convince himself that side-tracking is an operationof choice, though it may be one of necessity.

Sir W. ARBUTHNOT LANE (London) said that in view ofthe lateness of the hour he would not keep his audiencemore than a minute or two. He had nothing whatever toadd to what he has said over and over again upon intestinalstasis. If his views were correct they must, he said,triumph ; if not, they would perish. He was content to

leave it to his audience to judge the result.

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B.-SPECIAL SURGICAL DIVISION.

TUESDAY, JULY 28TH.Congenital Obstruction of the Post-nasal Orifice.

Dr. CHARLES W. RICHARDSON (Washington, D.C.) saidthat the occurrence of this condition is described by manywriters as a very infrequent form of nasal deformity, but thathe had come to the conclusion that it was one of the most

frequent types of congenital malformation in the nasalchambers. If many specialists of large experience had neverseen a single case it was because so many of the infants

speedily died with the condition unrecognised or wronglyclassified as asphyxia neonatorum. The number of observedcases in children and adults had, he said, greatly increasedduring the last 20 years, but the number of cases in the

newly born had not increased in the same proportion,the general practitioner and the obstetrician alike not

having been sufficiently taken into the confidenceof the rhinologist. He remarked that the form of

deformity affected the female more frequently than themale, while the relative frequency of the bilateral to theunilateral form was in proportion of 3 to 1. Dr. Richardsoncontinued with an elaborate description of congenitalatresia, discussing the pathogenesis, the morphology, andthe views of those authorities who have mentioned the

subject.lDr. DuNDAS GRANT expressed the indebtedness of the

meeting to Dr. Richardson for the interesting communica-tion. The condition, he said, especially when bilateral, is arare one ; possibly it passes unobserved and the cases are

included among those of asphyxia neonatorum as a whole.During ten years of considerable experience of midwifery hewas convinced that he had never met with a case, but it isso serious when overlooked that the characteristics cannotbe too well known. He read the following graphic accountgiven by Dr. Ronaldson, an exceptionally gifted man andone of Lord Lister’s earliest house surgeons in Edinburgh :-When the child was born I at once noticed that there was some

peculiar obstruction to its breathing. On attempting to inspire thelungs were not inflated, while the under-lip and cheeks were suckedin. On slapping the buttocks to make the child cry there was nodifficulty to free respiration when the mouth was opened. On keep-ing the mouth open by a spoon and pulling the tongue a little forwardit breathed well and steadily and cried lustily. There was therefore,no obstruction to the respiration through the mouth and larynx. Iaccordingly proceeded to examine the nostrils, when I found that theywere filled with a substance translucent in appearance and glue-like inconsistence, and which, on being taken hold of, could be pullpd outen masse, like a piece of tough glue. It was evidently a collection ofinspissated mucus. After clearing the nose of this mucus I attemptedto blow air through the nares, but failed. Passing the forefinger of onehand to the back of the pharynx, with the pulp directed upwards, Itried carefully and repeatedly to pass a probe, bent at the end,along the floor of either nostril and through the posterior naresso as to touch the finger in the r,harynx. I failed to do this. andcame to the conclusion that there was some organic obstruction ofthe posterior nares. As, on watching the child, I observed thatwhenever it reached a point of moderate asphyxia it opened itsmouth to cry, and thereby had an opportunity of inflating itslungs through the open mouth, I thought I might with safety takethe case to avizandum before attempting to do anything for itsrelief. On returning next day I found, to my great disappointment.that the child had died an hour after my departure. I fortunatelyhad an opportunity of making a post-mortem examination which,though imperfect, was sufficient to show that the posterior nares wascompletely occluded by a firm membrane. The firmness of thisoccluding membrane was such that an ordinary surgical probe couldhardly be forced through it without bending on itself; indeed, it didso bend on itself before perforation was accomplished. After theprobe perforated the membrane it passed freely into the pharynx.I did not discover any other abnormality. The nose, anterior nares,cavities of the nostrils, the hard and soft palate, were normal. Thechild was plump and well developed generally. (Edinburgh MedicalJoitriial, 1881, p. 1035.)" It is known," Dr. Dundas Grant continued, "that in someof the lower animals the vestibule of the larynx extends

upwards in the form of a tube into the naso-pharynx, andthat in the human infant the epiglottis is for some timeafter birth at least behind the soft palate. The late Dr.Robert Bowles relieved asphyxia by drawing up the

epiglottis, and the late Dr. James Foulis invented a lever fordepressing and drawing forward the base of the tongue incases of threatened asphyxia, such as occurred in the

apparently drowned or in advanced alcoholic intoxication.In unilateral cases the same dangers do not exis.t and the

symptoms are not those of asphyxia but of nasal dischargewhich consists of mucus and lacrymal secretion. The

appearance of this peculiar discharge has been variouslydescribed, but I have long taught my students that nasal

1 We hope to publish the full paper later.

discharge resembling laundress’s starch’ was an indicationof complete posterior occlusion. In the adult it is not likelyto be overlooked, but I have to confess to having oncemissed it in a young woman who was casually referred to mefor removal of adenoids in a large out-patient department,when after such removal there was still a complete obstruc-tion, which I found to be one of the class which we are nowdealing with. In regard to treatment Dr. Richardson hasindicated to us the necessity for enforcing mouth-breathinguntil the patient acquires it, as is usual in the course of someten days. A small gag might be fixed between the gums,and no doubt a discreet attempt might be made to push aprobe through the obstruction if happily it was purelymembranous and ’yielded to moderate pressure, but anyviolent attempt with the risk of making false passages shouldin the new-born child be discouraged. Many of us have madeuse of very small post-nasal forceps, such as StClairThomson’s, for the diagnosis of adenoids in infants inwhom the naso-pharynx is too small for the finger to be used,and a similarly shaped instrument might be thought of foropening the posterior nares. A perforation is readily madethrough whatever portion of the obstruction may be mem-branous, but as a rule there is a very thick layer of bonewhich can only be removed by judicious chiselling. Themaintenance of the opening without the prolonged retentionof a tube has been a problem, and the key to its solutionwas, I think, first given by Charters Symonds, who describedthat in such cases he removed a portion of the posteriorpart of the vomer. This principle has been further developedby Uffenorde as described by Richardson, but still furtherby von Eicken, whose process in the light of our familiaritywith the submucous resection of the septum is likely to findfavour. He performs complete submucous resection, removingthe bone to its posterior margin and chiselling away thethickenings at the side of the septum and on the floor ofthe nose ; he then replaces the muco-periosteum, puncturesany fibrous septa that remain, and then cuts away with aninstrument analogous to a conchotome working backwardsthe posterior part of the thin remaining membranousnasal septum. For those who are not familiar withintranasal surgery a perforation far back in the septum madefrom the sound side by means of a sharp spoon will meetmany of the requirements of the case, so far at least as to-enable the patient to blow the secretions out of the obstructedside. Reference has been made to the asymmetry of theface which ought to follow congenital occlusion of one

choana. I can only say that when the late Mr. CresswellBaber and I looked for the atrophy in our two cases we foundthat any trace of it which existed was on the wrong side.I can only hope that this work of Dr. Richardson will be

carefully studied and properly appreciated by those whopractise midwifery and who have the responsibility ofmeeting this condition when it occurs in the new-born child,the matter being then a question not merely one of nasal

discharge but of the life or death of the little human being.’THURSDAY, JULY 30TH.

A symposium was held in the ballroom of the Savoy Hotelon

The Sitrgery (If Ol3ft Palate,when the subject was introduced by Dr. GEORGE 1. V.BROWN (Milwaukee), who stated that all operations-and heenumerated the procedures in vogue-should be directedin three ways :-first, to covering the gap ; secondly, to

obtaining of speech ; and thirdly, to improving general health.Therefore the warnings to the surgeon were : first, to do nocorrecting method where natural physiological developmentwould obviate its need ; secondly, to destroy nothing thatmight be wanted in such development; and thirdly, to do no-more than was wanted at each step. He therefore con-demned destruction of the premaxilla, and was critical ofcompression of the maxillse. He considered that the

operation should begin with closure of the lip as early as.the first day, to be followed by closure of the hard palate,and lastly of the soft palate, completing the case at one anda half to two years. He approved of lateral incision torelieve tension where necessary. He showed slides of the" before " and " after " condition of the patients illustrativeof remarkably good results.

Dr. JOSEPH R. EASTMAN (Indianapolis) followed with apap" which was published in THE LANCET of August lst,p. 312 ,

Page 5: THE CLINICAL CONGRESS OF SURGEONS OF NORTH AMERICA

411

Dr. TRUMAN W. BROPHY (Chicago) began by insisting thatthe gap at birth was only potential ; ’’ the normal amountof tissue is there," he said, "and should be used immediatelyto close what is in effect a wound. What surgeon waits two

years to close a wound 1 " He laid stress on the broadness

of the upper jaw in these cases, whereas the normal upperjaw is narrower than the lower jaw. If left alone the

tongue increases the cleft, and the upward pressure of thelower jaw does the same. The two sides should be broughttogether by compression, the necessary wiring being abovethe tissues and between the teeth. Lateral incisions were

unnecessary, produced needless and troublesome scar-tissue,while blood and nerve supply were interfered with, anddeafness might be caused by cicatrices in the neighbourhoodof the Eustachian tube. By lead-plate compression andtension wiring perfect speech was produced, and he showedthree patients on whom he had operated for different con-ditions and at different ages, the perfect results being illus-trated by their delivery of recitations.

Sir W. ARBUTHNOT LANE said that he could only claimfor his procedure perfect simplicity. Impressed with thedanger many years ago of following a teaching that was souniversally accepted as that of procrastination for four years,he decided to close the cleft in the lips and hard palatesof infants at the earliest possible moment. In a month orso he closed the cleft in the soft palate. His procedure wasbased on restoring to the infant at the earliest possibleopportunity the proper chances for development of the bonesof the face.

Mr. JAMES BERRY (London) said the operation by mediansuture was the only one which restored the palate to itsnatural condition. If properly performed it gave the patientthe best prospect of subsequent good speech. The age atwhich he preferred to operate was the earliest at which thecleft could be satisfactorily closed by median suture. The-exact age depended largely upon the nature of the cleft.Narrow clefts, especially if limited to the soft palate, could beoperated upon with advantage by this method within thefirst few months of life. The common, single or double,complete cleft associated with harelip should be treatedby closure of the harelip in earliest infancy, the

operation on the palate being postponed until the secondor sometimes the third year. He had never advocated

,postponement of operation to any later period. At and soonafter birth the cleft was usually very wide and the palatinearch low. If any median operation were attempted at thisperiod it would usually fail unless preceded by the wiringoperation of Brophy, which he thought too dangerous to begenerally employed. The reason for postponing the palateoperation for a year or two was that after suture of the harelip the cleft in the palate underwent rapid spontaneous,narrowing, and the development of the alveoli madethe arch higher. In proof of this he showed photo-graphs of three similar cases of complete single cleftpalate. One showed the usual very wide cleft as seen atbirth. Next was an exactly similar case in which aftersuture of the harelip and then a delay of two years, thecleft had become so much narrower that he had easily closedit by median suture with excellent result. The third caseof the same kind showed a still greater degree of spontaneous Iclosure. The patient was not seen by the speaker until shewas 10 years old and had been left unnecessarily long withoutoperation. He entirely agreed with Sir Arbuthnot Lane as tothe "simplicity" of his turnover flap operation, and alsowith the statement that most mothers of cleft palate babies(and often their doctors) were exceedingly anxious thatoperation should be performed as early as possible. Thiswas but natural and accounted largely for the frequencywith which such operations were performed at the

present day, especially by many who d) not followup their cases and ascertain the actual results as regardssubsequent speech. Sir Arbuthnot Lane, so far as he knew,had never brought forward any proof that the ultimateTesults of such turnover operations were really good. At ademonstration of post-operative cleft palate cases arrangedby the Royal Society of Medicine a few years ago 2 with theobject of comparing the results of the various operations,Sir Arbuthnot Lane produced but one patient who un- Ifortunately was too young to speak. He himself, Alr.R. W. Murray, and others had on the same occasion

1 For these see Brit. Med. Jour., Oct. 28th, 1911.2 THE LANCET, vol. i., 1911, pp. 1251, 1406, 1607.

shown large numbers of patients successfully operatedupon by the Langenbeck operation. He thought thatexact information as to the subsequent results of their

operations should be brought forward by the advocatesof the turnover flap operation in early infancy. Whydid they not publish long series of consecutive cases

giving actual after-results, as Mr. Berry himself had donemore than once with regard to his own operations ’? With

regard to lateral incisions, he employed them much lessthan formerly, as he found that the wide mattress stitch inthe soft palate, similar to that employed by Brophy for thispart, often rendered them unnecessary. The most difficultcleft to close satisfactorily was that in which the lip andalveolus were unaffected, but in which a very wide cleftinvolved all the rest of the palate and had a rounded anteriorend. In such cases he thought it best, as a rule, to closethe soft palate at some period during the early part of thesecond year, and, if necessary, to postpone operationupon the hard palate for some months, at the end of whichthe opening would be found much narrower. In conclusion,he showed three patients after operation for the three

principal varieties of cleft that he had described, and demon-strated the satisfactory nature of their speech by makingthem pronounce various difficult words suggested by theaudience.

Mr. PERCY LEGG (London) closed an interesting debateby asking the audience to remember that while to securegood speech was the great aim of all procedures, speechcould only become good by careful education.

FRIDAY, JULY 31ST.Mr. WALTER JESSOP presided over an interesting meeting

of ophthalmologists, at which Lieutenant-Colonel R. H.ELLIOT, I.M.S., Mr. F. RICHARDSON CROSS-(Bristol), and Mr.J. B. STORY (Dublin) made valuable contributions. ColonelELLIOTT’S paper on the Sclero-Corneal Trephining Operationfor Glaucoma was discussed by Mr. TREACHER COLLINS ;Mr. BISHOP HARMAN replied to Mr. Cross’s conclusions onthe Operative Procedure for Strabismus; and Mr. HOLMESSPICER answered Mr. Story, who dealt with Operations forSenile Cataract. The meeting was incommoded by the lossof the Savoy ball-room on the last evening of the Congress.

ROYAL COLLEGE OF PHYSICIANS OFLONDON.

MEETING OF COMITIA.A COMITIA was held on July 30th, Sir THOMAS BARLOW,

Bart., K.C.V.O., the President, being in the chair.The following gentlemen were admitted Members of the

College, having passed the necessary examination :-

Adolphe Abrahams, M. D. Cantab., L. R. C. P. ; Cuthbert DelavalShafto Agassiz, M.D. Aberd. ; Harold Wordsworth Barber,M.B Cantab.; Frederick Charles Davies, M.B. Cantab.,L.R.C.P.; Arthur GeoffreyEvans, M.B.Cantab., L.R.C.P.;Herbert Thomas Evans, M.B. Oxon.; Thomas Lionel Hardy,M.B. Cantab., L.R.C.P.;SohrabShapoorjiVazifdar, L.R.C.P.;and Henry Owen West, M.D. Lond.

Licences to practise physic were granted to 97 gentlemenwho had passed the required examination.Diplomas in Public Health were granted in conjunction

with the Royal College of Surgeons of England to 39 gentle-men who had satisfied the examiners.The Murchison Memorial Scholarship was awarded to

Charles Jennings Marshall, M.B. Lond., of Charing CrossHospital.The following gentlemen were elected to the under-

mentioned offices :-Censors : Dr. Percy Kidd, Dr. HowardHenry Tooth, C.M.G., Dr. Theodore Dyke Acland, and SirWilmot Parker lierringham. Treasurer : Sir Dyce Duck-worth, Bart Emeritus Registrar: Dr. Edward Liveing.Registrar: Dr. Joseph Arderne Ormerod. Harveian Librarian :Dr. Norman Moore. Library Committee : Dr. Cyril Ogle,Dr. Leonard George Guthrie, Dr. Herbert Morley Fletcher,and Dr. Thomas H. Arnold Chaplin. Curators of theMuseum: Dr. John Mitchell Bruce, Dr. Seymour John

Sharkey, Dr. Frederick William Andrewes, and Dr. WilliamHunter. Finance Committee : Dr. Donald W. C. Hood,(’,.V.0., Sir James Reid, Bart., G.C.V.O., K.C.B., and Dr.James Taylor. _


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