Abstract: 4. The difficulties surrounding the radiology of heart disease largely disappear if, instead of looking for general enlargement, attention is centred upon the particular chambers or great vessels which may be modified in size, shape, or position. 5. If electrocardiography has reached its present sound position by the support of physiology, radiology of the heart will establish best its rightful position by enlisting the support of anatomy and morbid anatomy. In conclusion, special care should be taken not to distress a patient by confronting him with. x-ray findings as if they implied an additional diagnosis or a complication which magnified his disease. For instance, the cardiac enlargement of hypertension is an associated sigIn which should Inot be regarded as a disease in itself, but as a completion of the diagniosis.

Abstract: more vulnerable and their healing power less. Next, employers should see that the handling of noxious substances is reduced to a minimum by the substitution of machinery, and should supply all possible facilities to the worker for the proper cleansing of his skin. The workman should be instrUcted in this essential procedure, and warned against the undue use of deleterious skin cleansers-for example, alkalis and defatting agents. Attention to the proper cleansing of workers' clothes is also often necessary. When required the use of gloves, or the preparatory treatment of the skin with unguents, varnishes, protective soaps, should be obligatory, and close-woven overalls tightly buttoning at wrists and neck may be necessary. Dust should be reduced to the utmost by means of special ventilators, electric fans, etc. In certain cases dermatitis may be avoided by the use of pure products where the crude substance may be baneful. The next essential in treatment is that the afflicted worker should be removed immediately from the irritant. The remedial applications employed will in every case depend on (a) the appearance of the skin lesion produced, and (b) the nature of the irritant producing it. It may require exp'erience and careful investigation to determine the latter. In general, methods of desensitization appear to have met with only limited success. Radon is of special use in the malignant cases. Whateverremedies may be employed the importance of protection of the skin should never be lost sight of. Scratching may give rise to a vicious cycle of prolonged irritability, even apart from secondary infection.

Abstract: condition of her tongue also supported this impression. The abdomen felt very resistant but not rigid. At operation there was a large quantity of blood-stained fluid. The last two feet of the ileum were a brilliant scarlet colour, and showed numerous small black areas of haemorrhage. The gut wall was markedly thickened, owing to the blood in the tissues, and this explained the mass felt per rectum. The haemorrhage stopped abruptly at the ileo-caecal valve, leaving the caecum almost normal. The appendix, apparently normal, was removed, and was found to contain masses of threadworms. The rest of the ileum was mottled, the mottling gradually decreasing towards the jejunum. The other abdominal viscera failed to reveal any further relevant pathology. Recovery was complete and convalescence normal, except for the following incidents. For three to four days after operation the motions were mixed with dark blood, and on the third day the urine was similarly discoloured. The post-anaesthetic vomitus contained blood. On about the tenth day she had a severe attack of epistaxis, and about the same time a marked purpuric rash appeared, involving both feet and the outer sides of the ankles. This was so severe that the feet were almost blue. There was also considerable swelling of the ankles. Blood examination after operation was as follows. Blood filmn: marked preponderance of mononuclear cells. Differential count: mononuclears 35 per cent., large lymphocytes 22 per cent., small lymphocytes 8 per cent., polymorphonuclear leucocytes 35 per cent.; coagulation time 5 minutes; blood platelets, 114,000 per c.mm. ; red blood cells, 5,500,000 white blood cells, 16,500. It is interesting to note that, although the case was a definite example of purpura, the internal signs appeared long before the surface rash, and although the girl was operated upon when the disease was at its height haemorrhage at this time was not greater than usual. The scar showed some keloid formation. There are many examples such as this in the literature, but usually some petechial spots are present to help. If Pulex irritans can be excluded-difficult in the hospital patient-such a rash should raise suspicions.

Abstract: Recent advances in haematology clearly indicate that nutrition may play an important part in the production of anaemia. The evidence on which this statement is based is obtained from experimental work on animals and from clinical investigations in human beings. Thus Waddell, Hart, Steenbock, and Elvehj?m1 have shown that when rats are fed for some weeks on milk alone a hypochromic anaemia invariably develops, while the rate of growth of the animals is seriously reduced. So constant is this effect that anaemia produced in this way is regularly used for the assay of therapeutic agents. That the anaemia is nutritional in origin is shown by the fact that the addition of iron and traces of copper to the diet will prevent the occurrence of the anaemia, or, if it is already present, will rapidly effect a cure. A similar type of hypochromic anaemia has been shown by Helen Mackay2 to be present in many infants of the poorer classes who are fed exclusively and over prolonged periods on cow's milk. Prevention and cure are readily obtained by the addition to the diet of a few grains of iron and ammonium citrate daily. While it is admitted, there fore, that milk is probably the nearest approach to a complete food that we have, it is certainly deficient in its blood-building qualities. Evidence on the importance of iron in relation to anaemia and general health has also been obtained in the case of the larger domestic animals. McGowan and Crichton3 found that, unless given access to iron-rich food, sucking-pigs develop anaemia, which can be cured or prevented by iron salts. This condition appears to be common. Professor Knox of Guelph, Canada, in a recent personal communication to one of us, states that in Ontario the death rate of young pigs was very high until iron feeding was instituted, since when the mortality has been reduced to normal. A condition of acute anaemia also occurs in various parts of the world in cattle grazing on a special type of pasture which, accord ing to Aston,4 is poor in iron. This anaemia can also be prevented or cured by iron salts (Aston,4 Orr and others5). It is well recognized that after famines, espe cially in tropical countries, anaemia, defective growth, poor resistance to infection, etc., are widespread ; a similar condition of affairs was observed in Central Europe after the war. In view of the gross quantitative and qualitative deficiencies in a diet during times of famine, it would be difficult to allocate these ill effects to in dividual defects in the dietary. These anaemias may be classified as direct deficiency diseases resulting from a definite deficit of iron in the dietary, but in human beings recent researches indicate that some very important types of anaemia should be classed as conditioned or virtual deficiency diseases. Pernicious anaemia is probably the best example. Minot and Murphy6 have shown that this anaemia develops as a result of the deficiency of a substance (the specific anti-anaemic factor) which is found in liver, and which has been shown to be necessary for normal blood forma tion. Castle7 and others have shown that this factor is elaborated in the stomach as the result of an interaction

Abstract: Osteo-arthritis of the hip is a condition which presents a characteristic clinical picture. When, however, the history and the pathological changes as seen in x-ray photographs are taken into account, it becomes clear that there are a number of different aetiological factors. The initial symptom may be pain or stiffness. The pain is most often felt in the groin or down the inner side of the thigh. Sometimes, however, it extends down the sciatic nerve, and occasionally at the onset it may be felt in the buttock or even in the back. There is progressive loss of movement characterized particularly by diminution of abduction and of inward rotation, and this eventually leads to a fixed deformity, the joint becoming adductcd, flexed, and rotated out. Finally, with complete fixation in this position, the pain tends to disappear. Most often only one hip-joint is affected, although not rarely both are involved.

Abstract: are structurally diseased. In 'assessing the significance of ON THE CLINICAL RECOGNITION OF cyanosis it is to be remembered that with equal rates of STRUCTURAL DISEASE OF THE blood flow high-coloured skin will be bluer than pale PERIPHERAL VESSELS * skin, for the vessels that contribute most to the excessive coloration of the skin-the venules-are those in which BY the blood has been largely robbed of its oxygen.

Abstract: 2. That it is not a sound argument to contend that anatomical reduction is the best means of assuring a good result. Alignment, not apposition, is the factor which counts most in producing good function. The damage produced in obtaining anatomical reduction should always be taken into account. 3. That skeletal traction is unnecessary for the reduction of fractures of both bones of the leg. It is harmful, in that it adds further insult to an already traumatized limb.

Abstract: Accounts of bronchiectasis which have appeared hitherto Symptoms.-The symptoms recorded in the few cases have connoted almost invariably the accumulation and of dry bronchiectasis hitherto published have been few, decomposition of secretions in the bronchi. Until Sicard and of these haemoptysis has been the most common, and Forestier1 began to investigate the condition of the having been noted in nineteen out of thirty patients (see bronchial tree by radiography after the introduction of Table). In many of the patients the bronchiectasis lipiodol there was no certain method by which bronchiwas discovered only when investigation for the cause of ectasis could be recognized during life if the characan unexplained haemoptysis was undertaken. In our teristic sputa were not present. It is now possible to series haemorrhage was not the most prominent symptom, prove that bronchi may be dilated even when there is and had occurred only in five out of twenty patients. not any expectoration. The purpose of this paper is to Cough was the commonest symptom, and was present describe a series of cases in which bronchiectasis of this in all but three of our patients. In nine it was slight, \" dry\" or \" silent\" type was -demonstrated, and to in eight definite. Sputum was absent in nine, scanty discuss the symptomts and signs with which it may be and occasional in six, up to approximately half a drachm associated, together with problems which arise with regard daily in one, and to about two or three drachms daily to aetiology, prognosis, and treatment. in four cases. In all those patients-where sputum could The first account of dry bronchiectasis was given by be obtained for examination tubercle bacilli were not Bezancon, Weil, Azoulay, and Bernard in 1924.2 In a found. The characteristic cumulative fetid expectorapaper entitled Seche he'noptoique de la dilatation des tion of infected bronchiectasis had not been present at bronchis, they described two patients in whom recurrent any time in any patient. Of other lccal symptoms, haemoptysis was found by lipiodol radiography to be pain in the chest was noted in eight and dyspnoea in associated with bronchial dilatation. Neither patient nine cases. Constitutional symptoms were generally mrld; had any sputum or other symptoms apart from haemopthey were eompletely absent in nine patients; in the tysis. A few other examples of the condition have been other eleven loss of weight, or failure to gain weight described by various writers,3 4 5 6 7 8 9 10 and Pinchin normally, occurred in nine, night sweats in five, and and Morlock1' have recorded nine cases in all of which, weakness in two. with one exception, there was recurrent haemoptysis. In Physical Signs.-Abnormal physical signs in the chest his recent paper on bronchiectasis Moll\"2 also mentions were present in all but two patients. One of these had two dry cases, but gives no details. some degree of clubbing of the finger-tips, but this was The important features of all the cases of which we absent in the other. Clubbing of the fingers was present have found records are given in Appendix I, and they in four only out of the twenty patients. In all four will be mentioned later in the discussion. Nevertheless, cough with sputum was present ; in three this was scanty, it appears that dry bronchiectasis has not been generally in one up to two drachms daily. Evidence of some degree recognized, because several recent reviews give it no special of constitutional disturbance was shown by a history of mention.13 14 15 16 17 18 19 20 We believe, however, that it loss of weight in three out of the four. Dullness on is comparatively common. percussion with weak breath sounds and crepitations were the usual abnormal signs on physical examination of the ANALYSIS OF CASES chest. Dullness was present in seventeen, and varied

Abstract: understanding of them. Kurzrok, 13 for example, has shown that whereas in cases of artificial menopause by radio-destruction or removal of the ovaries the ovarian hormones are necessarily absent, in cases of spontaneous menopause these hormones may or may not be absent. Manifestly, it is only where they are absent that their therapeutic injection can be expected to do good. Many papers have been published in the last two or three years on the treatment of menopausal symptoms. by oestrincontaining substances in which there is no evidence of uniform success, just as in earlier years there was the same discrepancy of results in the use of the solid and largely inert ovarian extracts. The psychical factor in the menopause is probably as important as in dysmenorrhoea, and must always be taken into account in estimating the success of any trea,tment, especially treatment by hypodermic injections. But, when all is said and done, it is certain that if only patients whose urine showed an absence of oestrin were treated by oestrin therapy, the results would be more uniform, the treatment would be rationalized, and our understanding of the real physiology of the menopause would be increased.

Abstract: hip, and pain on attempted extension, not infrequently leads to a diagnosis of acute arthritis, but thorough examination of the hip will show freedom of all other movements if the flexion of the joint is respected. Where the condition is not too acute for the patient to walk, a limp is always complained of, and there is considerable apparent deformity in the standing position. This, however, readily disappears when sitting, although a slight scoliosls may persist. There is no tenderness on percussion over the vertebrae, and no spasm of the erector spinae. muscles, but occasionally deep tenderness may be elicited in the lumbar triangle. Examination of the abdomen reveals some muscular rigidity on the corresponding side, and an underlying tumour may be felt. If the upper part of the psoas sheath is involved the thickening and tenderness found on bimanual palpation of the loin are strongly suggestive of a perinephric abscess. The acute abscess tracks outwards into the sheath of the iliacus, and, unlike the chronic one, seldom passes deep to Poupart's ligament into the thigh. A radiogram of the spine and pelvis will be negative, but it is said that there may be haziness of the sacro-iliac or hip-joints if the abscess overlies them, and this may be sufficient to cause a suspicion of early involvement of these joints.'

Abstract: The very considerable increase in the number of road accidents during the last ten years has led to a corresponding increase in the incidence of severe head injury with compound and comminuted fracture of the vault of the skull. The de'bridemnent of wounds and the removal of depressed fragments is in these cases a matter of urgency. Moreover, in a region where infection and pressure from displaced bone may be of the utmost significance, the emergency surgeon is usually justified in abandoning the conservative methods which he would apply to compound fractures elsewhere. In actual practice displaced and detached fragments of bone are freely removed. It follows that we are seeing to-day an increasing number of patients with skull defects. These defects, through which may be seen and felt the pulse of the cerebral circulationi, are associated with a certain definite risk of injury to

Abstract: FOOD AND GOITRE* Rats fed on a milk diet are resistant to hyperthyroidization: excessive increase in metabolism and the nervous symptoms, occasioned by thyroid administration to these SIR ROBERT McCARRISON, C.I.E., M.D., D.Sc., animals, are marlkedly lessened (Abelin). LL.D., F.R.C.P. The mobilization of hepatic glycogen, consequent on IHO.NORARY' I'HYSICIAN TO THE KIIG;¶ COLONEL, INDIAN IMEDICAL SERVICE; hyperthyroidization is evidence of the gland's relation to DIRECrOR, NUTRITION RESEARCH LABORATORIES, PASTEUR ca oism INSTITUTE, COONOOR, S. INDIA carbohydrate metabolism. Here also this mobilization can be prevented by the increased ingestion of animal In some circumstances the thyroid gland is among the fat, such as beef fat or cod-liver oil, although it is not most, in others it is among the least, variable of all prevented by the increased ingestion of carbohydrate organs with respect to its weight and proportionate size it can also be prevented by the increased consumption in the body. There is no stable biometric constant of of casein (Abelin). Another evidence of this relation is variability associated with thyroid glands under all conafforded by the increased consumption of glucose by the ditions. It is not an organ whose size is unalterably perfused heart (cat) under the influence of hyperthyroidizafixed, but one designed to adapt itself to environmental tion. coniditions. Some latitude must therefore be allowed it, One of the most important of the thyroid gland's some arc through which the pendulum of its normal activimetabolic relationships is that to the katabolism of fats. ties may swing without the charge of abnormality. These This is illustrated in the well-kniown e-ffect of thyroid activities involve variations both in size of the gland administration on obesity. There seems to be little doubt and in its histological appearance, the latter varying with that an antagonism exists between thyroid activity andthe phases of its activity. At one extreme its vesicles the metabolism of fats; an excess of thyroid hormone are filled with colloid; at the other its store of colloid inhibits the anabolism of fats, and, inversely, the enrichis dispersed and active secretion predominates. It is ment of the organism in fats diminishes the activity of essential to be aware of these extremes of histological the thyroid hormone. The favourable effect of fats in variation, lest normal appearances be described as pathohyperthyroidism depends upon the phase of this condition logical. \" so long as the cells hlave lost onily in part the capability Similarly, it i§ necessary to recognize that the gland has of using up the fat or of depositing the fat, just so long a normal range of size. Recent biometric studies have does the supply of fat act favourably \" (Abelin). When defined the limits of this range (McCarrison and Madhava, the metabolism is already abnormally high the administra1932).1 It is demarcated by the formula: M + 2.5 times tion of fat is not beneficial and may be harmful (Abelin). the standard deviation from M, where M is the mean size The gland's relation to mineral metabolism is also close, of the gland in a normal universe of animals or men, especially in regard to calcium -and phosphorus. Witness or in any section of that universe. Glands not exceeding the increased excretion of calcium consequent on hyperthe value given by the formula M + 2.5 aare not abnorthyroidization, the negative calcium balance in Graves's mally large, however else they may be altered histologicdisease when the diet is low ini lime, and the effect of ally. Supposing we take a sufficiently large number of iodine ad'ministration in diminishing the excretion of thyroid glands from individuals comprised within a normal calcium in this disease. The thyroid secretion appears to universe, estirnate their weights or proportionate size in the have a direct stimulating katabolic effect on the calciumn body, and construct a frequency distribution diagram of deposits in the bones (Aub). The administration of inthese weights or sizes, then we find that this diagram organic phosphates intensifies the effect of thyroid medicacan be fitted by a normal probability curve. But it is tion, that of calcium diminishes thyroid action. Rats different when the universe is one in which goitre prevails; can consume much larger quantities of thyroid substances then the frequency distribution diagram exhibits positive without an excessive increase in metabolism if they be \" skewness \" in proportion to the prevalence of thyroid given calcium at the same time; other symptoms of enlargement. hyperthyroidization-nervous hyperexcitability, perspiraThe factors influencing the size of the thyroid gland tion, disturbance of respiration, etc.-are also minimized are multiple and their interactions manifold. They inIclude (Abelin). hereditary influences, individual idiosyncrasy, age, sex, The gland's relation to iodine metabolism is likewise sexual activity, psychic factors, season, locality, altitude, close, though still tot -fully understood. It controls the distance from the sea coast, sanitary condition, and diet. utilization of iodine in the body-an important function, Of these diet is the most important. There are two since iodine, apart from\"the fact that it is an essential conaspects of the relation between food and the thyroid stituent of thryroxine, is an essential element in nutrition. gland: the influence of the gland on the metabolism of The thyroid has also a concern with the metabolism of food and the influence of food on the gland. The latter water; the diuresis produced in myxoedematous subjects is my main theme, but brief mention may be made of by thyroid administration and the loss of water by the certain known facts relating to the influence of the thyroid skin, bowels, and lungs in hyperthyroidism are examples on the metabolism of thie proximate principles of foodof it. Thyroid administration diminishes the capacity of proteins, carbohydrates, fats, mineral salts, and waterthe tissues to retain water; thyroid deprivation augments since these have a practical interest for the physician. it (Blanchard).

Abstract: confirmed this observation and has noted further that the phosphatase excretion in all types of jaundice is also but slightly increased. This implies that an early case of obstructive jaundice would show a relatively low phosphatase figure, but no case of obstructive jaundice of less than a week's duration has been met with in the course of the work. The point might be settled by ligature of the common bile duct in animals, but opportunity to do this has not occurred. ANt the same time, the idea that the whole of the differences observed may be accounted for solely on the duration of the jaundice is untenable, since several of the toxic cases were of long duration. The optimum pH for the blood phosphatase in jaundice is the same as that for the phosphatase in osteitis deformans, and it may well be that the same enzyme is concerned in the two conditions, being produced in the liver and concentrated at the site of bone formation. In this connexion it is interesting to recall the observation of Buchbinder and Kern,' 0 who found that a low blood calcium and osteoporosis followed the ligature of the common bile duct in dogs, which findings have been attributed to inefficient absorption of calcium from the intestine owing to the absence of bile. Reasons are given by Kay5 for thinking that in bony diseases the high blood phosphatase is a result, not a cause, but in obstructive jaundice the high blood phosphatase precedes any bony change, so that it is possible that in these cases the increased blood phosphatase leads to some disturbance of calcium-phosphorus metabolism. Finally, it is necessary to draw attention to two classes of case in which the phosphatase activity of the blood may not elucidate the cause of jaundice. 1. When the patient is already suffering from a disease in which the phosphatase is raised, as in Case 51, already discussed, in which jaundice developed during the course of Graves's disease. Apart from obstructive jaundice, however, the phosphatase is considerably raised only in conditions in which extensive bony changes are occurring.4 5 2. Cases in which the jaundice is slight, where there may be difficulty in deciding whether the phosphatase figure is raised or not, owing to the fact that the method of phosphatase estimation has a fair margin of error. The accurate but more elaborate method described by Kay\" might be of use in such cases. Further, the final phosphatase figure depends to some extent on the initial figure before the onset of jaundice, so that a low initial phosphatase and a trifling obstructive jaundice might leave the figure within normal limits. This, however, is not the class of case in which the type of jaundice is of great practical importance, whilst it is clear that the method is capable of differentiating correctly most of the cases ordinarily met with. On this account it seemed worth while reporting it at this stage, in order that it might be applied and further tested by others interested in the subject.

Abstract: Undoubtedly, however, there is just now an unprecedented multiplicity of institutions and agencies dealing with children, and we all know that \" too many cooks spoil the broth.\" An attitude of observant neglect towards a child Nk ritost certainly an important and necessary feature in healthy development when coupled with what our farseeing American ambassador in London told us the other day was the strongest Anglo-American bond of unionnarmely, a rich supply of common sense. The existence of facilities for assistance through manifold agencies encourages a tendency not only to lack ct discrimination and a loss of focused view on the part of parents, but also, not infrequently, acts as direct incitement to wander from one possible source of aid to others. Departmental medical work has extended from routine advisory examination to the treatment of disease, and there has been great development in the notification, segregation, and care of large groups of case s in connexion with controlled institutions. Thus has arisen in some respects overlapping, and even competition, i n supervision, and so far as medical instruction is concerned some degree of difficulty. The present time is, of course, a period of transition, and it is essential that in future the voluntary and the controlled hospitals should mutually co-operate and ultimately form a complementary whole, subserving the interests and needs of all classes of society. Such would form a co-ordination within what may be termed pure medicine, but beyond this is growing the recognition of need for a wider co-ordination in the completion of medical work. There is fortunately an everincreasing spirit and practice of harmonious co-operation between medicine and education-the two are becoming closer and closer linked.

Abstract: of the to1:al male population of their age. On the other The Alvarez Lecture hand, if t-he subsequent history of the hundred could on be traced, from what is known of the incidence of these THE UNITY OF GASTRIC DISORDERS * diseases about 11.5 per cent. would develop one or other BY of them, and almost all of these would be among the BYTHUR . M.A., M.OxoN RCP constitutional hyperchlorhydrias and hypochlorhydrias. ARTHUR F. HURST, M.A., ,I.D.OXO , F.R.C.P. Consequently a large group comprising healthy people SEN-IOR P'HYSICIAN' TO GUY S H{OSP'ITASL of all ages, such as that investigated by Vanzant, Alvarez, and their colleagues (1932), is a selected group from which I. THE HYPERSTHENIC AND IIYPOSTHENIC many of the individuals with the hypersthenic and hypoGASTRIC CONSTITUTIONS sthenic gastric constitutions are excluded, and an inaccuInvestigations on the anatomy and physiology of the rate picture of their incidenice is obtained, quite apart from stomach of healthy young adults of both sexes show the fact that owing to the effect of long-continued gastritis that considerable variations from the average occur under the number of people with acquired low acidity makes perfectly normal conditions. In about 80 per cent. these it impossible to estimate the true incidence of constituvariations fall within comparatively narrow limits. This tional hypochlorhydria. is shown, for example, in the results obtained by Bennett The secretion of mucus is the normal response of every and Ryle (1921) with a fractional gruel test meal in a healthy mucous membrane to chemical, thermal, and hundred healthy male students -who had never suffered mechanical irritants. The presence of mucus in the ordifrom any form -of indigestion: the curves of free hydronary fractional test meal is, however, an indication that chloric acid in eighty of them fell within the shaded area gastritis is present, because nothing could be less irritating shown in Figs. 1, 3, and 4. The anatomy and phvsiology than the gruel meal. But it is a matter of common experiof the stomach in these 80 per cent. of healthy people ence that mucus is rarely present in much excess, except

Abstract: patients-cured of their colic-indigestion, flatulence, and occasional subcostal aching remain. Recurrence of stone occurs in at least 7 per cent., and malignant disease may supervene as in two of my cases. After cholecystc'tomy the results are good in 70 per cent. of cases. In general terms it may be stated that the grosser the pathology the better the result after operation. The most gratifying results of all are found after cholecystectomy for subacute obstructive cholecystitis. Over 90 per cent. of patients in this group express themselves as cured. Flatulence and an intolerance of cooked fats remain after operation in approximately 20 per cent. of patients. A few patients complain of occasional attacks of diarrhoea. Improvement in general health and energy, and freedom from former rheumatic pains, are the common tribute of the majority of patients. The most striking improvement occurs in patients from whom stones have been removed from the common bile duct. From a life of semi-invalidism they are usually restored to robust health. However, in a few cases, where a subacute pancreatitis is present or where cirrhotic changes in the liver have developed, improvement after operation is slow, incomplete, and disappointing. I shall refer but briefly to the reconstructive surgery of the common bile duct, as my experience of it has been relatively small. It is a tribute to biliary surgery in this country that I have had to deal with only three cases of fistula from, or stenosis of, the common duct due to operative trauma. In all three cases the first operation had obviously been performed through an inadequate incision, and the cystic duct must have been clamped blindly. The moral is that unless the surgeon is prepared to expose the parts fully and to assess and deal with the whole pathology present he had better not embark on biliary operations.

Abstract: become infected cannot be stated with certainty at PUERPERAL FEV-ER: ITS AETIOLOGY present, but it is probable that the cocci are devoid of AND) PREVENTION * I the capacity for infecting human tissues. My colleague Dr. Hare is investigating this question just now. The BY only -direct evidence we have at present as to whether LEONARD COLEBROOK, M.B., B.S. the haemolytic streptococci causing puerperal infections (From the Bernhaard B3iron MI,rinorial Research Laboratories, QuTeen had been present in the mother's vagina before delivery Charlotte's Hlospital, London. Mlenlmer of the Scientific is that of the Elsie Inglis Hospital (personal communicaStaiff of the Mledical Research Council) tion from Dr. Rose). In a group of eighteen cases of puerperal infection by haemolytic streptococci thirteen The Final Report of the Departmental Committee on (62 per cent.) had been found to be free from that Maternal Mortality and Morbidity (1932) showed that orgainism (vaginal swab) during labour. In view of the nearly 20 per cent. of all the deaths due to child-bearing findings of Taylor and Wright it would be rash to assume, follow normal labours. What is the significance of this? without confirmatory serological evidence, that the If it can, be proved, as I think it will, that most of these remaining five cases were actually infected by the streptofatal infections are due to the transfer of haemolytic cocci which had been isolated from the vagina during streptococci to .the genital tract of the woman in labour labour. Lastly, there is no bacteriological support for from some outside source, it means that these infections the idea that the nion-haemolytic streptococci which are are preventable. Since the labours are normal we cannot so often present in the normal vagina become transformed h.ope to prevent these disasters to any appreciable exten..t into the haemolytic variety after labour. by improvements in ante-natal services or in the better teaching of obstetric manceuvres, but we can hope to avert them by excluding the dangerous type of The Mother's Respiratory Tract streptococci from the woman in labour. How can this In my opinion all thiis evidence, although not absolutely be done? conclusive, warrants the tentative conclusion that in the Up till now the preventive measures adopted have been majority of cases the Streptococcus pyogenes causing largely founded on guesswork. We have assumed that puerperal infection was not present in the genital tract the infecting cocci *either are derived from the mother's at the time of labour. If that conclusion is correct we -vagina or are transferred to it by the doctor or nurse a.re obliged to assume that they reached it from outsidefrom another septic case. Occasionally the circumstances that is, either from -some other part of the mother's body suggest such a transfer ; more often they do not. In the or from another source. What evidence is there about future we must frame our preventive measures on definite these possible sources? As to the transfer from some other knowledge as to where the dacger lies. And so we come part of the mother's body we may say this: careful back to the central problem of puerperal sepsis: Why do bacteriological surveys have shown that these or-ganisms the women become infected with haemolytic streptococci? are rarely found in any part of the body except the Is it because they are particularly susceptible to infection respiratory tract. On the normal skin of the hands they by that organism by lack of an immunity which other cannot persist for any length of time (Colebrook, 1930), women possess, or by reason of some particular dietetic b4t the'yr are sometimes found in very trivial foci of deficiency? Such deficientcies may play a part in allowinfection on the fingers. They have been isolated from ing the infection to occur in certain cases, and probably faeces, but so seldom as to mak-e it very improbable that they do affect the course of the disease in many, but I transfer from the rectum can be a frequent source of think the evidence available does not suggest that these genital infection. (It is., however, possible that future xactors usually decide the issue of infection or no infection. refinements of bacteriological technique may necessitate More probable is it that that issue is usually decided by some modification of this view.) Streptococcus pyogenes the chance encounter of the mother, during or after is found in the throat, nose, or gums in about 5 to 30 per labour, with a streptococcuis which happens to have at cent. of adults in England chosen at random. It may that moment the capacity for infecting human tissues, be assumed, therefore, that not less than 5 per cent. of or, to put it in another way, the capacity for repelling parturient women-and probably more-have these cocci the defensive mechanisms of the human body. It will be at the time of their confinement. The figure actually profitable now to review what progress has been made in found among 3,774 wcomenexamined in Edinburgh (Rose, tracking down to their origins these streptococci which 1.933} was 10 per cent. infect puerperal fever cases. | That haemolytic streptococci will be conveyed from the

Abstract: NORMAN C. LAKE, MI.D., M.S., D.Sc. F.R.C.S., obtained, on account of the drawing together of the NOR..S , .R.C.S. edges of the aperture) to some extent compensates for SENIOR SURGEON, CHARING CROSS HOSPITAL a short oesophagus. Indeed, in bad operative risks While the essential factors in the cure of herniae in phrenicotomy may be adopted as the sole treatment: it general are well established, defects of the diaphragm prevents spasm with incarceration of the stomach, which present a special problem to the surgeon for several usually is the only abdominal viscus involved in this reasons, the chief of which are: difficulty of access, type. In the case now to be described another method congenital shortage of tissue (rendering approximation of of overcoming these difficulties was adopted, and it proved the edges of the \" ring \" without tension almost impossible entirely successful. In a short report there is no need in some cases), and the continual movements of the to elaborate the pros and cons of the method, most of diaphragm. When to these primary difficulties are added which, in any case, are self-evident. those of adhesioLn of contents to the sac and, in certain cases, the congenitally high position of the diaphragm, CASE HISTORY shortening of the oesophagus, and \" thoracic stomach,\" H. P., a well-developed man of 51, sought advice for a the operation may become really formidable and fraught feeling of ill-defined discomfort under the left cestal margin with considerable risk. In the case recorded here some cominig on a few minutes after a meal had been taken. The of these problems were solved in a rather unusual manner. history extended back for two years, and started with As over four vears have elapsed since the performance occasional attacks of sudden dysphagia at long intervals. Of the operation without any recurrence of symptoms Recently, however, the attacks had increased in frequency, o operation any symptoms and now occurred with every meal. The sensation was the method may claim to be considered satisfactory. described as a \"pain having a character akin to obstruction to the gullet.\" Eructation brought relief, buit was invariably CLASSIFICATION accompanied by small quantities of fluid and food recently S. W. Harrington, in reviewing forty-five cases of taken. He had developed a real fear of food, and had d:iaphragmatic hernia dealt with at the Mayo Clinic, reduced his intake to two small feeds daily. Nevertheless adopted the following classification: there was no loss of weight, nor had blood or slime been observed in the vomit. The alarm and distress occasioned Through foramen of Bochdalek by the taking of food resembled that of an anginal attack, Through dome and afforded an explanation of the wrong diagnosis of angina (Congenital (usually Through oesophageal opening pectoris sometimes made in these cases. The only other without sac) Through foramnen of Morgagni a ~~~~Through the gap left by thepotofntrs ntehsrywetv icdtshn absence of the left half of the the intra-abdominal pressure may have been unduly raised: Non-trauimaticdiaphragm five years previously, after a severe cold and violent coughing,

Abstract: The two latter are considered by some authorities to constitute \" closed \" tuberculosis, but the term does not appear to be quite accurate, as the pelvis is so extensively involved. It is difficult to place this particular specimen in the groups mentioned. If placed in Group 3 almost complete destruction of the whole kidney would be implied, and this is far from being the case. Such a specimen might be rightly considered as one of \" closed renal tuberculosis,\" and be placed accordingly in a final and fifth group under that heading. The term \" closed \" could then be considered inadmissible in cases falling into Groups 3 and 4.

Abstract: In the diagnosis of heart disease we rely on symptoms and signs. While symptoms retain the high regard of physi cians, some physical signs have depreciated and are being revalued because they do not conform to the modern standards exacted by the sphygmomanometer, the electro cardiograph, and x rays. Such instruments represent the current demand for precision, even at the expense of simplicity. An instrumental method eliminates many fallacies inherent in the personal factor. For example, hypertension may be suspected (or not) from palpation of the pulse, but the sphygmomanometer gives us reliable information as to its presence and degree. Similarly, the electrocardiograph excels in the recognition of abnormal heart rhythms, not to mention certain myocardial defects which nothing else can reveal. X rays now claim a place in cardiac diagnosis because they furnish us with detailed evidence beyond the reach of percussion. Should any dislike this development, I would have them accept it as a modern application of a traditional method in medicine. It is inspection by #-ray sight (radioscopy), with an extension and permanent record of the visual picture (radiography). Percussion

Abstract: It is not only because head injuries are such common occurrences, but also because skilful treatment of the right kind, and at the correct time, mav make so much difference to the result that they are a fruitful subject for discussion on such an occasion as this. Few subjects can boast a more voluminous literature, reflecting the mutations in theory which time has brought and the alterations in practice which logic demanded. Nor is opinion

Abstract: Effects on Chorea.-After each bout of pyrexia there was a definite decrease in the spontaneous movements and an increased facility, in performing voluntary movements. It is noteworthy that this improvement did not reach its maximum till the second day after the pyrexia. During the ten days' interval betwveen the second and third injections not only was there no further improvement after the second day, but towards the end of this period a slight relapse set in. This was probably attributable to a visit of the child's parents. Two days after the final injection involuntary spontaneous movements had disappeared, except for an occasional twitching of the angles of the month, and of the tongue when protruded. Control of voluiltary movements was normal. The child could write legibly, and do up buttons with one hand. The effect of the treatment on the paresis was much less obvious than on the movements. There was still weakness of the legs, and the knee-jerks were still absent.

Abstract: subsided. Sputum negative for tubercle bacilli. Dry cough, and had failure to gain weight between these attacks. Signs . Undernourished, and dullness, with weak breath sounds and crepitations at right base, and weak breath sounds and crepitations at left base. Radiograph: Tubular bronchiectasis of the right lower bronchi (Fig. 4). Resuilt : Bronchitis rapidly subsided. Discharged to convalescent home, with persistent slight dry cough. No change in physical signs.