Showing papers in "BMJ in 1924"

On the cancer-producing factor in tar

Abstract: Background The closed-loop stimulation (CLS) pacemaker algorithm is a system that permanently monitors the contractile state of the myocardium and converts the intrinsic information into rate regulation. The role that the CLS algorithm plays in the prevention of syncope recurrences still remains unclear. The aim of our prospective, randomised, single-blind, crossover study was to evaluate the effect of dual-chamber CLS in the prevention of syncope recurrence in patients with refractory vasovagal syncope (VVS) and a cardioinhibitory response to head-up tilt test (HUT) during a 36 months follow-up. Method sand results We studied 50 patients (mean age 53±5.1; 33 male) with the indication for permanent dual-chamber cardiac pacing for HUT-induced vasovagal cardioinhibitory syncope. They were randomised after 1 month of stabilisation period to CLS algorithm features programmed OFF or ON for 18 months each, using a crossover design. The number of syncopal and presyncopal episodes during active treatment was lower than those registered during no treatment (n syncopal episodes: 2 vs 15; p=0.007; n presincopal episodes: 5 vs 30; p = 0.004). Lead parameters remained stable over time, and there were no lead-related complications. Conclusions Based on these 36 months follow-up data, it is concluded that dual-chamber CLS is an effective algorithm for preventing syncope recurrences in healthy patients with tilt-induced vasovagal cardioinhibitory syncope.

An Address ON THE RESULTS OBTAINED IN SOME EXPERIMENTS IN WHICH THE FACIAL AND RECURRENT LARYNGEAL NERVES WERE ANASTOMOSED WITH OTHER NERVES.

Abstract: BEFOREK describing some of the experimenits w-hich have been performed, I must state that the results have beeni controlled by a team of workers, a.-nd that I am onily oIIe member of the team. Mr. Colledge has beenl responsible for reports on the condition of the vocal cords, and has actively helped me in many other ways; Dr. Lioniel Bailey hias reported on the electrical condition of muiiiscles; and Dr. Eidinow on the movement, or absence of movement, of the diaphragm. Further, I have had the FACIAfL great advantage of the inspiring C.

A British Medical Association Lecture ON THE ESSENTIAL SIGNS OF ARTERIO-SCLEROTIC DISEASE

Abstract: . ~rIti5I gtbhfat ;ox5StIlitIOnItsectunre noirtema room thla the operating theatre, the lesion hlas for him aliving interest, for in it he sees the fierce str-uggle ON between the forces of destruction and the forces of resistaneo and repair. Contrast this vital interest of the morbid THE ESSENTIAL SIGNS OF ARTERIO anatomist with the commonplace opinion of the clinician, SCLEROTIC DISEASE.* who is inclined to see in arterio-sclerosis mere evidence of senility and arterial decay. It cannot be only the (l,Vith Plate in Coloulrs.) failure of therapeusis that gives the clinician this hopeless BY outlook; it is due rather to an imperfect understanding of BYEFRYEASMDCM.F.R.C.P. vascular function and vascular disease. Thus it is not long GEOFFREY EVANS, M.D.CAMB., since arteries were regarded merely as pipes whose chief ASSISTANT DIRECTOR, MEDICAL UNIT, AND ASSISTANT PIHYSICIAN, funct was to wtsand terelssuresothe ood thie ST. BARTHOLOMEW'S HOSPITAL. function was to withstand the pressure of the blood they contain, and conduct it from the heart to the peripliery; NOMENCLATUIRE. as a result, most changes in arterial structure were attniIT will make the ultimate exposition of the subject clearer buted either to the continued effect of this pressure or to if I begin with a few explanatory remarks on the nomenthe use of bad material in making the pipes. These siinple elature of arterial disease. \" Arterio-slerosis \" is a term mechanistic views are being superseded as we recognize which includes both forms of arterial disease of uncertain variations in tone of the whole vascular system, including etiology as well as those so lacking in identity that there the ca)illaries, and a power of rhythmical contraction of the is no agreemenit on their names. The term \" arterioarteries-activities which bring the physiology of arteries sclerosis \" may, indeed, be compared to a creche for children into line with that of the heart. who have not knowni their parents, or who have so little An incomplete appreciation of the pathology of arterial individuality that they caniiot be distinguished apart. disease also lent support to the inanimate clinical view of Thus when the etiology of some form of arterio-sclerosis arterio-sclerosis. Thus, much of the thickening and becomes known, the creche loses one of its children, an hardeninig of arteries is due to calcification and fibrosisevent which took place witlh tlle recognition of tuberculous the end-result of processes of necrosis and repair; the -ndarteritis and syphilitic endarteritis and mesaortitis. fatty degeneration' so constantly present in arter ioAgain, altlhough the etiology may be unknown, there are sclerosis is evidence of mere arterial decay; even the forms' of arterial disease, such as thrombo-angeitis cellular proliferation, which is an integral part of the Dbliteranis and periarteritis niodosa, which are so distinct lesion, is open to explanation in terms of rieplacement pathologically anid cliniically that they cannot pass the test fibrosis and repair. If this were the whole explanation of of noneiitity that admits thein to the creche. the changes in vascular structure that make arteliosclerosis, the lesion would be simply evidence of a process of degeneration or repair. It would provide a natural If te cliildCeLs of the crOcF e are exaCined witl care explanation'of the fact that the majority of persons with lifyleid themhldrenso the crascar n examrne wit cre. arterio-sclerosis do not suffer from it, and the palpation they lenid themselves to classficatilon on alternative lines, of a thickeed radial artery or the inspection of r.etinal )n the one hand, i tr o e t arterio-sclerosis in the fundus oculi would approach in its presumed parentage, though they are lacking in distincclinical significance to the signs of a healed tuberculous tion, such as the arterio-scleroses caused by infections, of lesion in the apex of a lung. ivhieh tvphoid fever is aii example; on the other hand, in terms of morplhology, there are forms of arterio-sclerosis ACTIVITY OR QUIESCENCE OF THE LESION. hiat appear sufficiently distinct to deserve gr-oup names, TO a certain extent we are, indeed, rig.t in regarding nd examples of these are nodular, diffuse hyperplastic, To ascertainieterio-elere, edence of rceing ;enile, and M6nckeberg's sclerosis. The distinctioni between the piresence of arterio-sclerosis as evidence oflecovery ,hese several groups is a morphological one, and it is based from disease, but it is only right within strict limitations, Ies severiationlgrefoups othleintedsicinmutbecauise arterio-sclerosis tends to be a progressive or ani in variat on in the form f the lesion; the dist nction must active lesion and one that often leads to incapacity and not Lot be pressed to too fine a point, because, just as groups ifeunl odah of individuals, as families, lose some of their identity by infrequently to death. iarriage, so these groups of arterio-seleroses lose some of Whenever the diagneosis of arterio-sclerosis is m1ade, we heir distinction by coincidence and overlap. So long as wanet to know if the person t is suffering from it; t he first he etiology of arterio-sclerosis remains veiled in relative step in diagnosis is the determination of its piesence, tihe bscurity, the latter of these two lines of classificationi is second immediate step is the determination of its activity he more convenient, and, being based on variations in or quiescence. t'ucture, it is inl accord with the proper use of thle term The importallce of thlis distinction is more clearly realize(d arterio-sclerosis.\" by compar-ison with the same problem as it is presented by valvular disease of the heart. The first step in diagniosis THE SIGNIFICANCE OF ARTERIO-SCLEROSIS. is the recognition of the presence of ali organic chanige in Arterio-sclerosis is first and foremost an anatomical as the valves; the second step is the distinction betw eeni an pposed to a clinical conception. To the morbid anatomist active and an old lesion. When the lesioni is active we may terio-sclerosis has a definite significanice. It is a lesion speak of the person suffering from heart (lisease, and(I simiart lie can recognlize and describe, and thoulghlhe more larly, if we can (lefine the positioni in wlhich we are able to _make the? diagniosis of active artenio-scler osis, w-e shall be Delivered before the Mid-Cheshire Division at Altrincham on June 20th. able to speak of arterio sclerotic diseatse. [33141 t

The clinical use of insulin.

Abstract: Selection of a Suitable Patient. The first problem that suggests itself in the clinical use of insuilin is the selection of a suitable patient, and here I must stress the importance of a thorough clinical examination. The presenice of sugar in the urine is so impressive a fact that niot uncommonly after its discovery all the symptoms of which a patient complains are immediately attributed to diabetes. During the past six months I have seen in consultation 5 glycosuric patients in whom death appeared imminent from inevitable causes in no way connected with the loss of sugar tolerance. Three of these have since died. Treatment of this type of case wvith insulin is obviously undesirable. In some instances the use of insulin may be said to be imperative-for example, in cases of coma-and of extreme wasting; or when the patient has fallen into the hands of the surgeon and must be prepared for an anaesthetic and an operation; or, again, when he has been attacked by an infection like pneumonia or tuberculosis; and finally, it is essential to the treatment of young children. Ill such cases as these it is bad practice to withhold insulin if it can possibly be obtained. The time at my disposal will not permit me to discuss the methods appropriate to these emergencies, for I have been asked to devote my attention chiefly to the type of case most frequently met with-that is, to the diabetic of moderate severity. There is fairly general agreement that patients with mild diabetes, whose condition can be controlled by reasonable restriction of their diet, do not require further treatnlent, but there is still considerable difference of opinion as to the degree of restriction to which it is proper to ask a patient to submit before help is sought in insulin. Let me say at once that the aim of the clinical treatment of diabetes is neither the solution of a metabolic problem nior the demonstration of the fact that a diabetic can live a long time in a state of semi-starvation, but rather the comfort and efficiency of the patient. In my experience very few people in this country can live comfortably if they are unable to take a little bread daily, and, consequently, as a broad general rule I recommend insulin treatment to every patient who cannot take the appropriate basal diet that I shall describe presently and remain sugar-free with a normal blood sugar whiletaking it. Patients, I know, may live and work on diets very muich more restricted than mine, but they do not live happily and they do not work comfortably.

THE EFFECT OF DIET ON THE DEVELOPMENT AND EXTENSION OF CARIES IN THE TEETH OF CHILDREN : (Preliminary Note.).

Abstract: nervous energy tllrough the phreniio wi]l diminish and lead to movements of the vocal cord in which the excursions will be equal to, and not greater than, those of the vocal cord on the opposite or niormiial side? Another question also requires an answer: When the vocal cord is movinig normiially through nervous impulses conveyed to it through the phrenic, will the patient be able to phonate? This is the question asked by Sir Frederick Mott. The answer can hardly be decided by experiment on the monkey: operation on man will give the reply. This will be thle decisive experiment. The conlclusion, therefore, appears to be, that for the cure of recurrent laryngeal palsy and the attainment of normal movement of the vocal cord in tranquil respiration, anastomosis with the vagus or the descendens noni must be rejected, anid some form of anastolmiosis should be carried out with the trunk or with one of the roots of the phrenic nerve.

X-ray treatment of interstitial keratitis.

Abstract: REFERENCES TO LITERATURE. l Nothnagel: Diseases of the Intestine andIPeritoneumn, English translation, Philadelphia, 1904. 2 Cannon and Murphyv: Journ. Amer. Med. Assoc., 49, 1907. 3 Murphy and Vincent: Bostonl Med. anid Surg. Journ., 65, 1911. 4 Whipple and Stone: Johns Hopkins Med. Bulletin. 6 Craig: Amer. Journ. of Obst. and Dis. Women andl Children, 49, 1904. 6 Craig: New York Med. Journ., March 13th, 1905. 7 Moennighoff: Journ. Missouri State Med. Assoc., October, 1908. 8 Dale: Biochen. Journ., 4, 1909, p. 427. 9 Bidwcll: Journ. Amer. Med. Assoc., 1911. 10 Gunn and Underhill: Qitart. Journ. Exper. Physiol., 8, 1914. 11 Gunn and Whitelocke: British Journt. of Surgery, vol. 2, No. 5, 1914. 12Magnus: Pfluger's Archiv, 1904.

A British Medical Association Lecture ON GALL STONES AND CANCER OF THE GALL BLADDER: AN EXPERIMENTAL STUDY.

Abstract: WE have succeeded in producing cancer experimentally in animals by the use of various special agents. Fibigerl produced it by the nematode Spiroptera neoplastica,Bullock and Curtis2 by anotlher parasite, the Cysticercus fasciolaris, and Yamagiwa and Ichikawa3 by coal tar. In our own laboratory we have produced cancer by coal tar4 and tar extracts,5 by pitch,6 by soot, by arsenic,7 by shale oil and industrial oils derived from shale,8 by crude petroleums and lubricating oil, and by a tarry substance prepared from isoprene.9 Bloch,'5 and, probably before him, Malrie, Clunet, and Raulot-Lapointe," induced it by means of

The pathology and surgical treatment of angina pectoris.

Abstract: PSYCHO-NEUROSES. This group included 27 cases of hysteria and 8 of neurasthenia. With regard to cause, definite physical pelvio abnormalities, such as ovarian tumour, uterine prolapse, hysterectomv, etc., were found in 50 per cent. of the hysterical cases, thus justifying the ancient Greek name of the condition. In this group a previous sexual trauma in the Freudian sense was found to be especially prevalent, and the method of psycho-analysis was more applicable than in any other type of mental aberration. In my opinion, however, the employment of this procedure, while very useful in elucidating the vagaries of the patient, is more apt, considered as a therapeutic agent, to be followed by increased mental unrest and distress than by improvement. One case in every four had delusions or hallucinations2 most commonly of hearing. All the cases were improved after an average stay in hospital of three weeks, and one only passed on to a mental hospital as a voluntary patient. One neurasthenic was a morphine habitu6e, and in addition had had laparotomy performed several times, apparently to no purpose. This was the only case of drug addiction, which seems to be a much less frequent habit in Scotland than among more southern peoples. POST-EPILEPTIC STATES. The number of cases admitted to hospital because of some abnormal state following on epileptic seizure was 29. Of these, 12 per cent. were maniacal ol homicidal, 25 per cent. confused with a tendency to automatic behaviour, 25 per cent. had definite delusions, 25 per cent. were greatly depressed, and 13 per cent., after a period of stupor lasting from a few hours to several days, becamiie quite normal. The average age of the epileptics treated was 37 years, and onehalf of them were mental defectives in a marked degree.

EFFECT OF INSULIN ON THE SUGAR CONTENT OF ARTERIAL AND VENOUS BLOOD IN DIABETES: (Preliminary Communication)

Abstract: Two details may be mentioned. First, the dissection shoulld be donie as the inlcision is made and not at t'he end of the operation; for some bleeding may be caused, and if this occurs at the beginn-iing of the operation it will lhave stopped lonig before the enid. But if fresh bleeding is brQught on just before sutuiring it may cause delav or even lead to the formation of haematoma in the wound. Again, if there is much fat just outside thle peritoneum, this should be torn or clipped away. If it is not removed this fat may intervenie between the edges of the recti when the wound is closed, so preventing direct muscle-to-muscle union. Wlhen closing the wound, the spare peritonev.A, freed from fat, is bunched together in the mid-line with a continuous catgut suture. The sill:worm-gut sutures for anclhorinig the dressing are next put in through skin, fat, anid fascia. They perforate the fascia outside the redundant portion of the fascia-namely, close to the edge of the expcsed rectus muscle. These are left untied and the fascia is united with catgut so that its edges do not merely meet, but overlap or are bunched up sufficiently to draw the rectus muscles into contact in the mid-line. The skin edges are next drawn together with a subcutaneous catgut suture, the roll of gauze is placed over the incision, and the silk-v-orm-gut sutures are tied over it. Wheni this methlod is used, not only does the abdominal incision do no lharm, but tlhe parietes of the average woman are very nuucli imp:r)oved. She leaves hospital, in slhort, with one centr al rectus miiuscle below the umbilicus instead of two lateral cnes with a gap between them. The position of tl.e umbilicus varies very considerably, anid somietlimes an inicision below it will niot permit tli delivery of a fibroid or ovarian growth. In these cases, if the abdominal wall is a bad one, the best coui se is probably to excise the uimbilicus completely and unite muscle to miiuscle thr6uglhout the length of the incision requir-ed for the extraction of the growth. No doubt a certaini aesthetic 'loss is iilvolved when the umbilicus is removed. But our mrot. er Eve is presumed tb Wave had nio niavel, and lher dauglhtOrs cain afford to dispense witl this adoriinment in exchange for a sound abdominal wall. The books of the Mlancleist-er Royal Infirmary and the St. MNfary's Hospitals slhow that out of the last 1 725 patients wh.iose abdoamens I halae opened only 12 have returned for repair of the incision. This shows, a percentage of 0.7 defecti--e scars. In several of the cases drainage ha(i bccIn used, ini a few there was ihistory of chronic bronchitis, but the chief c;,Ue of failnu-e was, I think, the intruasion of porticis of ext-raperitoneal fat betweenlthe edges of the recti. TlhCre are ts-.o x-.-men' on wliom I lihave refused to cperate for a third ti;-ne; for no sooner are they up anid about thlantheir tissues ,tretch and give forthwith, in spite of the use of good belts On the otler hand, there is one patient whom 1 have deliv.ered five times by Caesaican section. Her abdvr inal Wall, stretchled -five timiies by the growth of large clhildren, required considerable trimmiing anid repairinog on the last occasion. But it remains sound and efficienit, for the patient still earns lier living as a stage daincer. Takiiilg thsese figures for wlhat hlley are worth, I blelieve that less thiani 1 per cent. of the patients aire any tlhe worse for the mediani incision; but thle point I wish -to einphaisize is that, since I began opening both muscle sheatlts, the majority are, not onlyl no worse but ar-e muclh botter, as to tlhe abdominal wall, tlhani tliey were before operation. Of triansverse ihcisions I Lave not mluclh experience. I ised thlemiii nineteen times sonme years ago and found that niakiilg the incision ancd closing it occupied, on the average, sevenl miiinutes loinger than using the 'Median incisioni. it was genierally necessary to tie two arteries. Access to the pelvis was fair, but it was niot good for otlier parts of the lower abdomen, or for the removal of growths of any size. Large areas of connective tissue are ra*ed and in certain cases miiiglht be infected, with serious consequences-as, for instance, if drainage should le necessary-. Tlhe only obvious advantage is the aesthetic-namely, th1at thle scar is partly concealed by tIe puhic hair. Judginlg by thle nlumber of thlese scars that I see, thle tranls.1 Verse incision is novt p)opular at present in thlis counltlry On thle other h1and, I see a very large number of laterli scais. In somze of these cases thle result is good, but in mlany there is pronounced atrophy of the rectus muscle between the incision and the mid-line of the body. It would appear that the lateral wound does not give good access, for I could give a long list of lesioins I have founid in patients whose abdomens had previously beeni ex-plored thlrough incisions that must have been either too small or too far from the middle line. But the main defect of the lateral incision is that it does niot improve the abdomiinal waill of the woman with separated recti. It leaves lher witl her parietes as bad as before, if no worse. I tlhink the incision in the mid-line below the uimbilicus is the best for gynaecological work, and that it miglht be used with advantage by general surgeonis wlheni the. diagnosis is not clear-as, for example, in cfases of appendicitis and diverticulitis complicated by the results of infection of the pelvic organs-for the mediani incisioni canniot injure the muscle or the fascia as the lateral incision may do. It gives better access to botlh sides of the lowar abdomen, and it can be extended upward as may be desired. Further, it gives the opportunitv for imnprov-ing the patient's abdominal wall in, all women whose reeti lie far apart.

Occlusion of the posterior inferior cerebellar artery.

Abstract: conduction of impulses have been described. The manner in which they pass through the body to be takeni up by the electro-cardiograph at the extremities is another aspect. This faculty of traversing unspecialized tissues so long as they are living is illustrated by a striking experiment. If the peripheral end of a cut phrenic nerve of a dog be laid upon the dog's heart, the whole diaphragm contracts with each beat of the heart. The impulses pass through the pericardium to reach the cut nerve, and the pericardium, beyond being composed of living cells, is not specially evolved for the conductioni of impulses. In noting these instances of the conduction of impulses, we see that there is something peculiar about the force which distinguishes it from any other force. In observing the effects it produces we gradually began to realize that it demonstrates peculiarities in the behaviour of the tissues.. In its passage through the tissues it does not necessarily stimulate them. The fact that impulses are so universal and readily permeate all living tissues raises the question how it comes about that only certain organs are stimulated. This has led to a review of the activity of cells and their susceptibility to impulses, and it has shown that this susceptibility varies in a manner that enables their activity to be regulated so that all organs, when they respond to impulses, do so in a fashion which enables their functions to be performed in 'a well ordered, purposive, and effective nmanner. This'inquiry has resulted in the discovery that the reception of impulses is governed by the law of fluctuation. The graded character of the response of the effector organ to impulse and stimulation and inhibition are dependent on this law of fluctuation.

An Address ON ADDISON'S (PERNICIOUS) ANAEMIA AND SUBACUTE COMBINED DEGENERATION OF THE SPINAL CORD

Abstract: NOMENCLATURE. IN a paper read before 'the South London Medical Society in 1849, Thomas Addison,' physician to Guy's Hospital, referred incidentally to a \" remarkable form of anaemia,\" and six years later his classical description of the disease appeared in his monograph, On the' Constitutional and Local Effects of Disease of the Suprarenal Capsules. 1/0 In 1871 Biermer2 of Zillich puboo lished a paper on progressive pergo nicious anaemia, in which, however, 80 he added nothing to our knowledge X of the disease described by Addison d 70 twenty-one years earlier beyond point6 40 u 6 IOOft ing out the frequency of retinal \"TO NMDR*, haemorrhage. On the other hand, he fO M 61P/.4 added much confusion by including 30 under a single name both Addison's / \"idiopathic anaemia \" and a great J 10 variety of other conditions associated /0 / with anaemia. The designatioln I . \" Biermer's anaemia,\" which is em3 4 J -7 ployed in Germany and Switzerland, 0/AM is therefore quite unjustified. The FIG. 1.-Curves of red name \" pernicious anaemia,\" having healthy persons, haemo ' ~~~Addison's anaemia. x been introduced by Biernier for an red corpuscles. (Price-J entirely different purpose, is equally unsuitable, as well -as being most undesirable on account of the depressing significance it has for the sufferer. As the investigations of the last twenty years have showii that the disease is almost certainly due to inifection of the intestinal tract, the original name of idiopatlhic is nio longer correct. Addison's description of the disease is so admirable that I am convinced that nio more suitable name could be devised than Addisoni's anaemia, as William Hunter3 first suggested in 1909.

The hippocratic fingers

Abstract: front of the bodies of the vertebrae instead of beiDg convex was somewhat concave forwards, a piroof that the tumour had exercised prolonged pressure on the spine. The lower border of the growth was leve-l with the suprasternal notch. I had never seen anytllinig like it nor could I find any reference to it in literature. The lengtil of the histor-y and the appearance and feel of the tumour made it highly improbable that there was either an abscess or an infiltrating growuth; a diagnosis of benign tumour was made and lipoma suspected. Mr. R. C. B. Maunsell, V.P.R.C.S.I., who saw the patient with me, agreed; operation was decided on and I lhad the advantage of his assistance at its performance. In debating how 'removal should be attemiipted subhyoid pharvngotomy was mentioned only to be dismissed, for, though that route might give good access, the danger of septic contamination from the pharynx was too great. Dyspnoea during the anaesthesia was certain, and of the two methods of avoiding it-namely, the administration of ether by the intratracheal method or preliminary laryngotomy-the latter was selected. Stertor began before anaesthesia was properly induced, but the insertion of the laryngotomy tube made matters quiet. After a change of gloves a free incision was made along the anterior border of the left sterno-mastoid muscle, the omo-hyoid was reflected, the superior thyroid artery ligatured and divided, and the tumour thus exposed. It was found to be a lipoma of a very large size. By gentle manipulation with the lhelp of gauze sponges the growth was gradually drawn from its bed. It was bigger than a man's fist, and quite filled a 2 lb. jampot. The sac of the pharynx where it was spread over the miass was quite thin, but it was not wounded. One or twio deep catgut sutures were inserted to lend the pharynx support during swallowing, and a drainage tube left in for a day. The patient was fed by enemata for the first forty-eight hours and subsequently by a tube for a few days, after which he swallowed well Recovery was uneventful. Fig. 2 is a correspondiing radiogram takeni some three weeks after operation. The contrast between the relations of the hyoid bone and larynx to the vertebral column before and after opleration is well shown.

Acute diabetes following mumps.

Abstract: This pain is commonly felt over the sacro-iliac joints, but I would again emphasize that it is not a deep pain, and a little practice will easily eniable us to discriminate betweeni this and the deep tendelness associated with paini on lateral eompl)ression of the pelvis which is characteristic of sacroiliac disabilities. It would seem that by calling attention to suclh a imultiplicitv of possible causes of lumbo-sacral l)ackache 1 lhave but added to the difficulties of the subject, but these cases are very trying and often the trouble is of very long duration. By realizing the possible causes we may often by systematic examination and exclusion reach the correct solutioni at once, or, even if we do not do so, we may appreciate the fact that the paill is due to several of these causes combinied in a vicioIIs circle, anid we may attack the different parts of that circle seriatim and achieve a cure. To summarize briefly: in examining a case of lumbo-sacral backache first exclude gioss disease, injury, and arthlritis, arid have a skiagram takeni. Then look for outside mechaniical causes and ouLtside causes of overstraini of the niervous system. Finally, remember the paramount importance of the sympathetic system and seek for referred pain. Treatmenit has beeil briefly indicated in each case, but the -alue of mobilizationi in suitable cases must be remembered, aiind this valuable therapeutic measure should nlot be relegated to outsiders.

The bacteriophage in the treatment of typhoid fever.

Abstract: cases of ovarian tumour required sectioni before the ovarian cyst could be disimpacted and removed. Tapping such a tumouir by the vaginia does not comumiend itself owing to doubt as to its exact nature. It was quite out of the question to push the tumour past the presenting part. Cerri ical and Vaginal Steloosis.-A patienit with cervical steliosis showed signis of obstructed labour, the os was closed, rigid, and difficeult to reach. She had been twice curetted. A nuimber of these cases imiet with have responded to incisioni of the fibrous ringy, but this was inot possible here. The vaginal stenosis could not be explained. Ain elder-ly niiiltip)ara with a rinig of contraction below the cervix was watched carefully in tlhe later months of pregnanicy and earlv in labour, but as the ring sho-ed no relaxation a Caesarean section was performned. Eclaiiip)sia, (two cases).-Both cases had in addition marked pelvic contraction, and obstructed labouir. One died later from sloughing of the lower uterine segment; the baby was dead. The other lhad a fit on the table aiid was operated on wlhile unconscious; an anaesthietic was given wihen stitchlinig uip. Both she and the baby survived.

Acute intussusception in children: fifty consecutive cases.

Abstract: Obstruction during Convalescence. Opierative treatment is necessalry in almost all cases in this period. Separation of organized adhesions about the lower ileum, followed by a gentle milking down of the intestiiial contents thlrough the liberated bowel, will be sufficient in the majority of cases, but in cases developing early on in this period or in cases presenting widespread adhesions an ileo-colostoimiy or even an enterostomy may be necessary.

Tuberculosis of the breast

Abstract: and results from failure of fixationi of the caecum and ascendinig colon, and is often associated with uindue mobility of the right kidney (see Fig. 9). But we must not ascribe all abaiorimial coniditions of the stomach, duodenum, and gall bladder to ptosis. As already pointed out, many cases of duodeiial obstructioni are primiiarily due to the anatomical arrangement of the colic and mesenteric blood vessels, to peridtuodeleitis, and other causes. Somiie surgeons have taken extreme views. They have, however, done good service by directing attentioni to this condition, and a reasonable and judicial attitude must lead surgeons as a body to a correct line of treatment. This nieed not be heroic, nor must it lead to surgical neglect by ignoring conditions which are obviously present anid demandingf treatmiienit. It mllust lead to surgical interventioni on reasoniable lines. In my view, those which should meet with general acceptanice are the division of bands wlheni leading to local obstruction, shortcircuiting operations wlhen the obstruction caninot be overcome iil any other way, and the fixation of viscera on the right side the mobility of wlhiclh is due to the failure of Natuire to establislh tlle usual anchorage. This is a sur-aieal p)ossibilitvand tllle fixationl of FIG. 10. FIG. 11.

Cervical ribs in children

Abstract: PRINCIPLES OF SUCCESS IN TREATMENT. It is manifest that a patient has a more sure hope of a quicker cure inside a well conducted sanatorium than he can expect otherwise. Even if he remains in a sanatorium only long enough to learn how to manage himself, this sojourn is highly beneficial. This is shown by the number of my cases which left Midhurst with the larynx still diseased but who kept up sanatorium principles and later on obtained complete and lasting cicatrization of their throat trouble. The chief local requirement is voice rest, which can be so easily carried out in a sanatorium buLt is elsewhere so difficult. Out of 119 cases which were cured, the Sealing was obtained without other local treatment than voice rest (whispers or silence) in no fewer than 73 instances. That such a simple treatment-though long and arduous for the patient-can be so effective should enicourage perseverance with it when indicated. Local surgical methods of cure have all been abandoned by me as useless and frequently harmful. My statistics show that a laryngeal lesion generally indicates an extensive lung lesion, or a very virulent infection, or lowered resistance. As thinigs are at present, the majority of patients with laryngeal tuberculosis soon die (70.5 per cent.); they generally die of their lung disease. Topical surgical measures in the larynx are only apt to hasten this; their successful local results have never been frequent or enduring; and we have, in the galvano-cautery, a safer and more certain help. The galvano-cautery has, in my practice, superseded all other topical measures-curetting, injections, insufflations, application of lactic acid or other caustics. I have never seen a single case in which it has done harm, although in some it has been abandoned as useless. It effected a cure in 46 out of 74 cases in which it was tried (=62.1 per cent.). Of these 46 cures, 29 are alive andwell; 12 of them have now maintained their cure for ten years. The galvano-cautery is the best local treatment we have at present. In suitable cases it has replaced all other methods.

Thrombo-angiitis obliterans

Abstract: the soldiers. The staff naturally consisted of specialists in every brancch of medicine, and I then discovered how advantageous it was to my mental patients to refer them to other members of the medical unit for advice in regard to any physical disabilities from which they suffered. My own knowledge was enriched, and the patient benefited by the conisultations. Such a privilege should be made available in every mental hospital, and already is in many of them. The complete union of psychiatry and general medicine can only be effected when the existing lunacy laws are so amended as to make it possible to treat the psychoses without legal formalities apart from institutions devoted exclusively to these disorders. The exclusion of mental cases fromii the great teaching hospitals which have special wards for every other type of illness is largely responsible for the divorce between psychiatry and medicine. That it is quite possible to treat many forms of psychosis in a hospital ward was demiionstrated in an article in the BRITISH MEDICAL JOURNAL bv Dr. Comrie.' Under present conditions of treatment the term \"insanity\" has come to carr-y with it the suggestion of chroniicity, detention, legal pitfalls, huge institutions filled with incurable patients, degeneracv, and forms of illniess for which \" nothing can be done.\" At the outset of a student's career an impression of this kind must ine-itably be created in his mind from the fact that he learnis nothilng of the psychoses, apart from his few visits to the asylum, where the majority of cases produced for demonstration are of the chronic anid incurable type; and inl his subsequenit career, whether as specialist or general practitioner, lie takes no part in the treatment of the psyclhoses which reach any degree of intensity. An enitirely freslh point of view would be gained if in lhis daily work he came into contact with cases of mental disorder. He would learn, above all things, that many morbid mental states are due to the same pathological conditions as are the svmptomiis of the various svstemic diseases, anid amenable to the same methods of treatmenit. In the out-patient department, moreover, he would see a type of case which lie will be called upon to deal with dailv in his consulting room, and gain some knowledge of the treatment of the psycholneuroses-conditions which will bulk largely in his practice. Similarly, in every urban area provision should be made for the treatment of the psychoses in their acute and early stages, and it is much to be hoped that this will be divorced entirely from the Poor Law. There is no possible reasoni whymental disorder should be taintedwith pauperism as it is at present. The municipal health authorities w-hich niow deal with fevers aind tuberculosis should obviously be entirely responsible for the care of the mentally sick wlho require in-patient treatment. With a suitable alteration of the law it slhould be possible also to treat 'certain certifiable cases by a simple system of notification in nursing homes. These more enlighltened methods would naturally fit in with the doctor's experience as a studenit, and make it much easier to deal with meental cases to the satisfaction of the relatives. I ha-e aimed to show that if psychiatry is to progress it canl no longer remaini an isolated specialty; the solutioni of its lproblems requires the full co-operlationi of workers in e-ery slhere of medicine, and this must naturally inielude tllose wlho are concerned in the prevention rather than the cure of disease. Mental lhygiene canlnot be dissociated from physical or general hygfienie. A French psychiatrist lhas exp?ressed the view that the causation of mental affections is dominated by tlhree great social scourges: tuberculosis, alcoholism, and syphilis. These, he feels, are the clhief infections whose influence is felt in the production of mental disorder, not only in its subjects but in the descendants. Certainly it is to-day firmly establislhed that we profit, both mentally and physically, from the good health of our ancestors, anid it is also equally true that we are the victims of their maladies, and more especially their chronic infections. The endeavours of our medical officers of health to stamp out syphilis would, if successful, considerably diminlish the inlcidence of admissions to OUr alsylums anld would probably diminlish the occurrenlce of