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the dura mater is reached with rapidity and apparentlywithout discomfort to the patient. He lays stress onopening the dura only after reducing cerebral tensionby ventricular puncture, hypotonic intravenous injec-tions, or rectal injection of magnesium sulphate.Mr. PERCY SARGENT (London) (also unable to be atthe Congress) presented a paper of great interestfounded upon his own series of 336 operations forcerebral tumour. He laid great stress upon a know-ledge of the exact situation of a tumour, its pathologicalnature, and the degree of intracranial pressure to whichit had already given rise. He pointed out how mis-taken was the idea that the trinity of headache,vomiting, and optic neuritis was the true index ofcerebral tumour, regarding these rather as indicationsof impending death, and he urged the importanceof learning to appreciate early symptoms, and

especially the first signs of papiroedema. It was

possible, he thought, to diagnose the situation of atumour correctly in 90 per cent. of cases by clinicalmeans alone, and he deprecated the necessity for suchmethods as ventriculography. A consideration of thehistory of the case and of the ascertained situation ofthe tumour often made it possible to form a shrewdidea of its histological nature. Thus cerebello-pontinetumours are mostly neuro-fibromata, pituitary tumoursare adenomata, and cerebellar tumours are gliomata.Tumours of the cerebrum are almost invariablygliomata or endotheliomata, and even in the frontaland post-central regions where endotheliomata are

most common, the gliomata out-number them bytwo to one. Mr. SARGENT’S statistics repay study. In

summing up his experience of cerebral glioma, he statedthat about 25 per cent. of the patients die shortlyafter operation, about 50 per cent. within eight months,leaving 25 per cent. to make a good recovery, manyof them being able for several years to live usefullives and earn their own living. The outlook is morefavourable than this with cerebellar glioma, for

symptoms tend to arise at an earlier stage, the tumoursshow a remarkable tendency to cystic degeneration,and lost cerebellar function is readily compensated.As compared with glioma of the cerebrum the operativemortality is less than half, the proportion of goodrecovery is higher, and the average survival nearlytwice as long. Oddly enough the operative mortalityof endothelioma exceeds that of glioma, presumablyowing to the radical nature of the procedure, butMr. SARGENT can point to 46 per cent. of good recoveriesafter removal.

Later in the sitting Prof. ARCHIBALD YOUNG

(Glasgow) contributed some interesting statistics anddescribed a novel procedure for supporting the

bulging brain after extensive trephining for decom-pression. Prof. ADSON, of the Mayo Clinic, gave afine cinematograph demonstration of trigeminalneuralgia and its treatment. The discussion concludedwith a debate on different methods of opening theskull. Mr. A. R. JENTZER (Geneva) showed an

ingenious trephine by means of which a disc of bone,two and a half inches in diameter, can be rapidlyremoved without the slightest risk of injury to thedura; and Mr. H. S. SOUTTAR (London) showed a newform of craniotome in which a cutter, fitted to a

powerful lever, turns round an axis which has firstbeen fixed to the skull itself, so that large osteoplasticflaps can be fashioned with ease and rapidity. The

sitting suffered, as all such international occasionsmust suffer, from the volume of material presentedand the limited opportunity available for discussion.All who are interested in cerebral surgery should readthe papers as they appear at length in the printedproceedings of the Congress.

THE TECHNIQUE OF PERORAL ENDOSCOPY.DIRECT visual examination of the bronchi and

cesophagus has its home in Jefferson College,Philadelphia, where the genius of a CHEVALIERJACKSON has brought its technique to a high levelof exactitude. In his Lumleian lectures, deliveredbefore the Royal College of Physicians of Londontwo years ago, one of Prof. JACKSON’S colleagues,Prof. THOMAS MCCRAE, told the story of the broncho-scopic clinic associated with the University Hospitalin Philadelphia as seen by the physician attachedto it. In a series of 1300 cases of foreign body in thebronchus JACKSON, we learn, did not fail once toremove the body by means of the bronchoscope,usually within a few seconds. This exploit was broughthome graphically to the medical profession in thiscountry by Prof. MCCRAE’S illustrations of the variedforeign bodies removed in this way. These pictures,which were reproduced in our columns 1 at the time,showed dental plates and instruments of variouskinds found impacted in the air-tubes, numberlesssafety-pins removed from trachea and bronchi,tacks and staples retrieved from all parts of thebronchial tree, a variety of toys, of which the largersorts had lodged in the oesophagus, and a wonderfulcollection of seeds and shells which had found anidus in some part of the respiratory tract. The inhaledobjects of vegetable origin had a certain local colour,for in 100 consecutive cases a pea-nut or a portionof one was found in 45, a grain of maize in 17, and awater-melon seed in 15. Prof. McCRAE’s lecturesdealt in detail with the signs and symptoms producedby foreign bodies so introduced, with the diagnosiswhich was often only made after radiological examina-tion, and quite briefly with the treatment. We arenow able to publish a description from Prof.JACKSON’S pen (see p. 924) of the technique used atthe bronchoscopic clinic.One of the outstanding features of this clinic is

the team of perfectly trained assistants of which,as Prof. JACKSON says, " every member is drilled formonths in the steps " of the routine of endoscopicprocedure; as a result, in easy and in difficult casesalike, the necessary manipulations are performedas though by clockwork. Doubtless the number ofcases dealt with at the clinic, and the consequentopportunities for practice, are far greater than fallto the lot of any institution in this country. This is

partly due to geographical conditions, partly to thepea-nut habit-and it may be noted in this connexionthat the majority of foreign-body cases occur inbabies--but largely, no doubt, to the reputationwhich Prof. JACKSON and his clinic have acquired.Where the opportunities are less, such a high degree ofperfection is unattainable; and it is difficult to seehow an approach to this perfection can be made ina London hospital, with its frequent changes of housesurgeons and clinical assistants. Nevertheless, a care-ful study of Prof. JACKSON’S methods must be ofgreat value to any endoscopist, particularly in thematter of the " Boyce position " for the patient, andof the duties and attitude of the first assistant. Afurther point of great interest is the question ofanaesthesia ; at the Philadelphia clinic generalanaesthesia is not used for any endoscopic procedure,the chief reason being that " it is dangerous in certaincases and needless in any case." Cocaine is used inadults for direct laryngoscopy and for broncho-.

1 THE LANCET, 1924, i., 737.

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&bgr;coPYJ but not for aesophagoscopy, and not at all inchildren; morphia is usually given before a first

bronchoscopy, and is sometimes combined with

atropine or hyoscine. It is well known that the

oesophagus is almost insensitive ; the bronchial tree is.now shown to be less sensitive than has been supposed.and doubtless the endoscopist might dispense withanaesthesia more often in this country. But the

temperament of patients is a very variable factor ;in nervous cases, with throats rendered irritable

by tobacco and alcohol, it is sometimes difficult tomake an adequate examination even of the tonsils.We all know the spoilt, undisciplined, frightenedchild of 7 or 8 years old, in whom the simplest examina-tion is very troublesome; and it is hard to understandhow such a child is persuaded to submit quietly tobronchoscopy without the use of any form of anoes-thesia. The highly perfected team-work of the

Philadelphia clinic doubtless makes for great dexterity,but the American, as a race, is not more phlegmaticthan the Briton, and it is probable that the occasionalbronchoscopist will still have to resort to generalanaesthesia, at any rate, for his more nervous andirritable subjects.

THE ARCH OF THE FOOT.

ALTHOUGH the various forms of pes cavus andclaw-foot are common enough in England and arein general adequately treated, not much has beenwritten about them in this country. In some of thelargest and best known works on orthopaedic surgeryin our language the subject is dismissed withoutmuch consideration of details, as though its importancewere small or its cure easy by obvious methods. Yetthis deformity often gives rise to grave disability andpain, and shows itself most obstinately defiant ofmany attempts at cure. In considering pes cavus,as to a lesser degree in considering flat-foot, we aremet at the outset with the difficulty of defining thenormal arch of the foot. At the two ends of thescale of severity it is easy enough to distinguish flat-foot and pes cavus respectively, but the further wego from the extremes the more difficult does definitionbecome. Races of men and individuals differ verywidely in the shape of their foot-soles ; the aristocraticfoot " under which a mouse could run " on the onehand, and the foot with an almost non-existent archon the other, may both be perfectly good feet froma functional point of view, and give no trouble totheir owners. Some years ago an attempt was madeat a large New England hospital to forecast the futureof the feet of some hundreds of nursing probationers.The result was disappointing, for the observers failedto find any constant relation between defects detectedon entry and subsequent breakdowns in training inthe wards of the hospital. In severe and advanced

cases, where radical operations on the bones are

justifiable, treatment may no doubt be simple ifsevere. But in the vast majority of cases in whichsuch mutilating procedures cannot be justified, thecure is often uncertain and the treatment is nearlyalways tedious. Dr. Hackenbroch 1 describes anddiscusses the pathological anatomy of the differentgrades of deformity and their operative treatment,ranging from fasciotomy to tarsectomy, not omittingthe various tendon-transfer operations which havefound favour with some surgeons. In something like30,000 words and with the help of 40 illustrationshe has given us a very full account of the subject,and one which should be of practical use to allsurgeons who may be in doubt as to the best meansof treating this deformity, for in this monograph theymay find recorded most, if not all, of the proceduresthat have been devised for its relief.

1 Der Hohlfuss. Seine Entstehung und Behandlung. VonDr. M. Hackenbroch, Privatdocent, Oberarzt der OrthopädischenKlinik, Köln. Mit 40 Abbildungen. Berlin: Julius Springer.1926. Pp. 83. G.M.6.60

Annotations.

THE MAUDSLEY HOSPITAL.

" Ne quid nimis." ol

PSYCHIATRY, which among primitive peoples is theearliest and most important branch of medicine, is,in civilised countries, only just coming into its own.In the middle of the last century many great physiciansrecognised that the mind had its diseases, and gavethemselves to its study ; then came a sudden expansion of interest in pathology and a dark period duringwhich men declined to believe in the reality of diseasesfor which they could find no physical cause. Fromthis attack of " parallelism " the science of mentaldisease is just rallying. Although it has not yetreached the position it deserves, it has attractedsome of the greatest minds in medicine, and is subduingthe forces of pathology to its own ends. It was onlyto be expected that the swing of the pendulum wouldbring uppermost the opposite view, that all disease,physical and mental, is the result of mental disturb-ance ; the schools of psychology have increased andmultiplied, and signs are not wanting of a tendency toneglect the demonstrable facts of biology and to intro-duce into the study of mental disease an element ofingenious psychological speculation that, while afford-ing great satisfaction to its exponents, is not likelyto contribute much help to the clinician, who is, afterall, the person who matters most. Against this dangerthe Maudsley Hospital is a valuable defence. Thosewho direct its policy are not only psychiatrists ofexperience and skill, but they have a deep respectfor hard work and patient research in pathology,biology, and chemistry. The essence of their attitudeis that mind and body are one, that one cannot becomedisordered without the other, and that the only wayto a full understanding of the secrets of mental diseaseis the proof, step by step, of the accompanying physicalchanges. Everyone knows in what a chaos the scienceof psychiatry is to-day; each author has his ownclassification and his own explanation of its problems,and nearly everything is empirical. But clinicalcertainty can only be built on a basis of pathologicalproof, and the workers in the well-equipped modernlaboratories of the Maudsley Hospital have everychance of building the foundations of a scientificpsychiatry. Their work on metabolism, vaso-motorreactions, hydrogen-ion concentration, and many othersubjects is well-known, and they are fortunate alsoin being connected with a hospital where the nursesare enthusiastic enough to give up their time andcomfort to act as controls, and where the medicalofficers add to their heavy routine work by collaborat-ing in or initiating research work.

It is regrettable that the issue of the report ofthe Maudsley Hospital, in common with many otherofficial publications, is so-tardy. The booklet justpublished only takes the history of the institutionup to Jan. 31st, 1925, and the work reported is alreadyout of date. It serves to remind us, however, thatthis important experiment of the London CountyCouncil is fulfilling the hopes of those who conceivedit and achieving its objects of facilitating researchand teaching in psychological medicine and providingtreatment for voluntary patients suffering from mentaldisorders of all degrees of severity. During its secondyear 1304 patients were treated, an increase of 300over the number in 1923. The preponderance offemale applicants for admission was so unexpectedlylarge that the accommodation had to be rearranged,until finally 96 out of the 144 beds were allotted towomen. The hospital’s policy of admitting mild,severe, and psychophysical cases together has metwith a good deal of criticism, but the results havejustified the innovation. The Maudsley has amplefacilities for treating cases of slight mental disturbanceaccompanying such physical conditions as exoph-thalmic goitre and chorea, for it has the advantageof the cooperation of the consulting staff of King’s