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In order to obviate this unwelcome result, should theoperation be performed in adults for other stomachconditions, Pannett suggests an oblique division ofthe sphincter or the interposition of a large pad ofomentum between its severed ends. Miller, Bowing,and Stepp were able to show that there was no

weakening of the wall of the pyloric canal at the siteof the operation, when tested by hydraulic pressure.The strength of the wall of the alimentary canaldepends apparently upon the fibrous submucous coat.Nevertheless it must be remembered that fibroustissue subjected to continued tension withoutsupport from muscular tissue will always stretchand a diverticulum will be likely to form with thepassage of time. Whether it will give rise to symptomsis extremely doubtful, and this consideration need notnecessarily be a contra-indication to the performanceof the operation. Finality has not yet been reachedin the surgical treatment of gastric ulcer, but presentmeasures on the whole give commendable results.Before we can consent to change them the newprocedure must be proved to be more effective or morephysiological, or to entail a smaller risk to the patientand less mutilation of the stomach.

REFORMS IN THE TREATMENT OF

GALL-STONES.

IN a recent paper on the subject of gall-stones, Dr.Svend Hansen,1 of Copenhagen, has published somestatistics and comments thereon which are calculatedto provoke a spirit of reform rather than of self-complacency. During a period of 21 months he hassystematically examined the biliary system for gall-stones in every case coming to necropsy at his hospital.Among 1191 consecutive necropsies in persons over theage of 20 he found 293-i.e., 25 per cent. of the total-to harbour gall-stones. This was the case among19 per cent. of the men and 31 per cent. of thewomen. This ratio of 2 to 3 differs considerablyfrom the operation ratio, the proportion of men towomen operated on for gall-stones being approximately1 to 9. The divergence obviously depends on thefact that gall-stones cause inflammatory changes intheir surroundings far more frequently in women thanin men. Dr. Hansen found that when the biliarysystem was unaffected by the presence of gall-stones,there was no divergence in the sex incidence, butamong the cases showing morbid changes as the resultof gall-stones, the ratio of men to women was as1 to 2. In as great a proportion as 23 per cent. of allthe cases of gall-stones they were found in other partsof the biliary system than the gall-bladder, andDr. Hansen emphasises this finding for the benefit ofsurgeons who are apt to neglect a thorough search ofthe whole biliary system for gall-stones. They areelusive things, and their presence is apt to be over-looked by the surgeon even when he probes andpalpates most conscientiously ; not infrequently gall-stones escape detection till every biliary passage is slitopen by the pathologist. Even pathologists may err,and Dr. Hansen notes that the frequency with whichgall-stones have been found post mortem has rangedfrom 1 to 18 per cent. These astonishing discrepanciesdo not, in his opinion, indicate differences in theactual incidence of gall-stones determined by racial,dietetic, and other factors, but they depend on theskill and diligence with which pathologists have soughtgall-stones. In the period under review necropsieswere made on 40 persons who had died of cholelithiasisand its sequels. Nine of these persons died in medicalwards. In the same period necropsies were made ononly 26 persons dying from appendicitis. Thesefigures are in themselves illuminating. They are alsodeplorable, and Dr. Hansen, writing with the impar-tiality of the pathologist, suggests that the physician’sattitude towards gall-stones at the present time iswhat it was a short time ago to appendicitis. Onlywhen the great frequency of gall-stones becomes

1 Ugeskrift for Læger, April 27th, 1922.

general knowledge, and the necessity for cases of thiskind to be under the unhampered observation of thesurgeon becomes recognised, will the treatment of

gall-stones emerge from the most unsatisfactoryposition in which it stands to-day. To wait for

biliary colic and jaundice before diagnosing gall-stonesh, often to wait until disaster has overtaken the patient.Test the urine for urobilin is Dr. Hansen’s hint in thisconnexion. ____

OCCUPATION CENTRES FOR MENTALLY

DEFECTIVE CHILDREN.

OCCUPATION centres are, so far as this country isconcerned, the most recent development in thetraining of defectives. The definitely educable typeis already provided for in many areas by the specialschools of local education authorities, and institutionaltreatment is now to some extent available for the" permanent care " cases, but both are far short ofrequirements, and in addition there are intermediatecases-chiefly low-grade feeble-minded and high-gradeimbeciles-some of whom can, with a degree ofsecurity, be kept at home under supervision. Hometraining is in most cases hopelessly inadequate, andthe children tend to become more and more a burdenon account of their bad habits. It is for these especiallythat the occupation centre is designed, so as to provide" opportunities for learning muscular control, clean-liness, obedience, and simple manual work." TheCentral Association for Mental Welfare has just issueda pamphlet for the guidance of local voluntaryassociations in organising such centres. Useful adviceis given in regard to staffing, work, and apparatus.The Association is prepared to assist practically withthe initial steps and to provide training for teachers.A list is given of 16 centres already in existence, andthe number is gradually increasing ; in a few areas afurther development is the formation of specialclasses for defectives over school age who are unem-ployed or unemployable. The Association is, wethink, to be commended for its support of this newmovement. It may appear to some a mistakendeparture from the ideal of permanent institutionalcare which the Mental Deficiency Act embodied.But the Association is merely recognising an existingsituation-insufficient provision of institutions throughpost-war economies-and providing a useful temporarystop-gap on the well-tried principle that half a loaf isbetter than no bread.

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THE THERAPEUTIC ADMINISTRATION

OF GASES.

THE description by Mr. Stanley Rowbotham onpage 24 of a new and convenient form of apparatusfor administering nitrous oxide and oxygen with orwithout admixture of ether vapour reminds us that,in order to obtain a fair test of any method of anaes-thesia the materials must be easily available. Thisis a matter of much more difficulty in the case ofgases than of liquids. It appears that, for some timepast, cylinders of compressed oxygen are kept instock at nursing homes and other places whereoperations are frequently carried out, but thathitherto the anaesthetist who wishes to administernitrous oxide has often been in the position of havingto bring his gas cylinders with him. This incon-venience can hardly result otherwise than in con-demning the patient, should the supply of nitrousoxide fail, to the administration of some other moreportable anaesthetic which had been considered lesssuitable for his individual needs. All those who hadduring the war practical experience of the use ofnitrous oxide and oxygen as an anaesthetic in casesof injury associated with severe shock were confidentthat the extended use of these gases in cases of similarnature in civil practice would be a boon to the patient.The time seems to have come for nitrous oxide to beavailable in quantity at any place where emergencysurgery is likely to be practised. With oxygen, onthe other hand, the supply as a rule is there, or, if not

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someone interested in limelight or oxy-acetylenewelding is near by, but the methods of administra-tion leaves much to be desired. With the increasingelaboration of surgical technique it is surprising thatmedical equipment has remained archaic. It is stillquite familiar for the oxygen cylinder to have a tapwhich at first refuses to turn, and, when it does,promptly blows off the rubber connexion if it doesnot burst the tubing. The issuing gas is thenadministered cold through a funnel which the unwillingpatient can readily dodge by moving his head fromside to side. To administer oxygen like this is thesame kind of extravagance as washing a motor carwith petrol. Dr. John Ryle described in our corre-spondence columns last week a method wherebyoxygen may be administered with economy andacceptably to the patient. The portable apparatusdescribed in the current issue of THE LANCET byDr. Geoffrey Bourne has been in use for some timein the wards of the medical unit at St. Bartholomew’sHospital, and has excited much interest there. Itmarks an advance in exact medication which mightwell be followed elsewhere.

RANVIER AND HIS WORK.

IT is the penalty of a long and peaceful old agethat the achievement of a great man’s activities maybe forgotten. Louis-Antoine Ranvier was born atLyons on Oct. 2nd, 1835, and died on March 22nd, 1922,,at ’I’’h6lys (Loire), where he retired many years agoafter completing his life’s work at the College deFrance. After completing in the year 1860 hismedical education in Paris, he devoted his attentionto pathological anatomy, and with his friend, Cornil,founded a private laboratory in the Rue Christine, asmall street off the Boulevard St. Michel, whence wasissued a text-book of pathological histology whichbecame classical. Ranvier then turned his attentionmore and more to normal histology, and in 1867became assistant to Claude Bernard, who securedfor him the first appointment to the newly foundedchair of general anatomy at the College de France.Until the time when he re-investigated the structureof medullated nerve fibres it was assumed that themedullary sheath, or white substance of Schwann,formed a continuous envelope or sheath round thea,xis cylinder. In 1871 Ranvier showed that themedullated sheath, or myelin, is entirely interruptedat regular intervals along the whole course of theperipheral nerve fibres, now universally known as

Ranvier’s nodes. It is, however, remarkable thatRanvier himself failed to notice the incisures in themedulla, which break it up into cylinder-cones, adiscovery made later by Schmidt and Lautermann.Further studies in the connective tissue, blood-vessels,and lymphatics enabled Ranvier to complete our

knowledge of peripheral nerve trunks. He also addedto the sum of knowledge concerning non-medullatedfibres, fully describing the lamellated character of theperineurium, which he called " the lamellar sheath,"the number of lamella3 lined by endothelium beingabout 10-12. Turning his attention in 1872-73 tothe degeneration of nerve fibres after sections, Ranvierdescribed the histological changes included under theterm " Wallerian degeneration." He was amongstthe first to recognise that in the regeneration of nervefibres growths of the axis cylinder are pushed outfrom the central segments. In 1875 came the demon-stration that the medullated fibres of the centralnervous system have no nodes and are not providedwith the sheath of Schwann. The latter is usuallycontinued beyond the last node of the fibres of thespinal roots and accompanies the nerve fibre until itpierces the pia mater and then disappears in theneuroglia surrounding the cord. No nucleus is presentin the last inter-annular segment furnished with a

sheath of Schwann. In 1885 Ranvier resolved theintimate structure of the neuroglia itself. In 1882he solved the relation of the nerve fibres of spina]ganglia in mammals to the nerve cell. The emerging

fibre divides at a node, sending a branch towards thecentre and one towards the periphery. Followingnaturally on these studies came those on tire termina-tions of nerve fibres in muscles, striped and smooth ;in sensory surfaces, cornea, skin, and in electrical

organs. In 1869, by the simple method of interstitialinjection of a suitable fluid under the skin, lie producedan artificial ocdema, and in this way was able tounravel the relations of the connective tissue cellsto the fibrous elements of the tissue and to disprovethe views of Virchow on the connective tissue cor-puscles. He contributed greatly to our knowledge ofthe structure of the vascular system-includingthe arrangement of smooth muscle in arterioles,the structure and morphological significance of thefibres of Purkinje, the valves of veins, and the forma-tion and signification of the fibrin network. Perhapsthe most compact piece of his work was an elegantcontribution on lymph hearts. The development ofblood-vessels and red blood were successfully studiedin the " taches laiteuses," or milk-spots in theomentum of the young rabbit, and the knowledgethereby obtained and of the vaso-formative cells hasbecome an integral part of histology. In his observa-tions on the glandular system Ranvier corrected someresults of Heidenhain. To him we owe the divisionof secretory glands into merocrine and holocrine glands.He studied the morphological changes in vivo underthe microscope, and established fundamental viewson the mechanism of secretion. With Cornil he wasthe first to show the glandular atrophy that followsligature of the excretory duct in the submaxillarygland. After the manner of his master, ClaudeBernard, Ranvier published his lectures for severalsuccessive years. These and many subsequent publi-cations embodied much original work. He was amaster of technique and the keynote of the wholewas simplicity and accuracy in detail. He took thetissues and organs that lay ready to hand and studiedthem with a seeing eye and a penetrating brain. In hisgreat work, " Traite technique d’histologie

" (1875-82 1lie enshrined his methods and his main results.

THE DECOMPOSITION OF HÆMOGLOBIN.

THE interesting lecture delivered last week byProf. A. A. Hijmans van den Bergh, of Utrecht, underthe scheme of London University for interchange ofEnglish and Dutch lecturers, of which we print anabstract on p. 34, deals with some aspects of thepathology of haemoglobin which have not attractedas much attention as they deserve. The cases ofcurious cyanosis due to the conversion of a proportionof the circulating haemoglobin into met- or sulph-haemoglobin are rare and in consequence the conditionis difficult to investigate. But like other out-of-the-way diseases they are commoner in the experienceof those who are on the look-out for them and Prof.van den Bergh and his colleagues have now had a con-siderable experience of them. Very interesting is-hisobservation that pharmacopoeial doses of sulphur,and even Apenta water, may produce a slight degreeof sulphaemia. Sulphuretted hydrogen does noteasily enter the circulating red corpuscles, but oncethe change is produced the new compound is stableand durable and hence the effect tends to be cumula-tive. A systematic search might well reveal moreexamples of these mild cases than are supposed tooccur. The recognition of these " paraemias," as he callsthem, was originally largely due to English workers,but even Prof. van den Bergh’s generous appreciationof our contributions to the knowledge of haemoglobincannot pretend that the occurrence of haematin andbilirubin in the blood has hitherto excited much interestin this country. Both are found in, for instance,pernicious anaemia and large haemorrhagic effusions,and he summarises the evidence which is now con-clusive that bile pigments may be made in largequantities by tissues other than the liver. In hisexplanation of what is generally known as haemolytic(that is, non-obstructive) jaundice he puts forward a