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of information, and said that it should awaken the nation to ithe existence of its mental defectives and should promote Ilegislation for their proper care and control.

Dr. SHUTTLEWORTH (London) referred to the history ofthe Education Act of 1899, which was legislation for de-fectives not to be graded under the Idiots Act. It failed,however, as being permissive only and not compulsory, andthe result was that probably only one-third of the cases weredealt with by the authorities. Moreover, the defectives onreaching the age of 16 years had no authority to care for them.He objected to classing cases of feeble-mindedness of a mildcharacter under the general heading of mental defectives,which in its modern connotation was to include lunatics.He thought it might prevent parents from consulting theirmedical attendants from fear of official interference. Healso mentioned that many children, although subnormal atthe age of six years from immature development, were quitenormal at the age of eight years, and that they would

needlessly be classed with mental defectives.Dr. W. J. MAGUIRE (Belfast) said that speaking from the

physician’s point of view he hoped that wards would be setapart for mental cases in the general hospitals. There wasat present only one institution for imbeciles in Ireland---

namely, the Stewart Institution, with 100 beds. Placeswere needed where mental defectives could earn their livingunder supervision.

Mr. P. J. FAGAN (Dublin) said that he spoke as one of theinspectors of reformatories in Ireland, having under his

cognisance about 8000 children, taken from the waifs andstrays of society. He referred in terms of approval to theGovernment offer to increase the grant from 5s. to 7s. perweek for mental defectives, which would enable the managersof schools to deal with the whole group adequately. Manycases, coming as they did from a miserable environment,required practical training rather than book knowledge andwere improved thereby.

Dr. E. C. BIGGER (Dublin) said that his experience as aPoor-law inspector taught him that Ireland was behindhandin the care of the feeble-minded. Many, he considered, mightbecome good citizens if properly looked after in early life.While so much was being done in asylums, too little wasdone in preventive measures.

Dr. CALDECOTT spoke of the work achieved at the asylumfor idiots at Earlswood during the past 60 years. All typesof feeble-mindedness from the minor to the deeper gradeswere received at that institution. He considered that its

special schools and shops were even better than those of theLondon School Board. He deprecated certain of the recom-mendations as tending to curtail voluntary effort and he

thought that the financial considerations had been greatlyunder-estimated.

Mr. C. S. MORRISON (Hereford) expressed a hope thatwhat was at present voluntary in the Education Act fordefectives should with future legislation become compulsory.

Dr. J. M. MACCORMAC (Belfast) stated that he saw manycases of incipient insanity at the hospital for nervous

diseases, and he considered that many cases might be savedif taken proper care of in early childhood.The PRESIDENT commented on the difficulty experienced

in providing for the large group of the uncertified mentalcases and regretted that no proposals had been submittedby the Royal Commission for dealing with the ordinaryinebriate, who was commonly regarded as sane yet wasincapable of taking care of himself.

Dr. DAWSON, in his reply, estimated that there were about10,000 mentally defective children in Ireland for whom atpresent there was no provision.The PRESIDENT, in terminating the proceedings, expressed

the gratification of the section at the presence in it of LadyAberdeen, who had done such good work in connexion withtuberculosis amongst the poor in Ireland, and he trusted thatshe would extend her sympathetic help in the alleviation andbetter care of the mentally defective, which was a questionof national importance.

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LARYNGOLOGY, OTOLOGY, AND RHINOLOGY.THURSDAY, JULY 29TH.

President, Dr. STCLAIR THOMSON (London).Dr. P. WATSON WILLIAMS (Bristol) gave a demonstration

on the cadaver of his modification of Killian’s radical opera-tion on the frontal sinus and ethmoid cells. He showed thedifferent stages of the operation and demonstrated the steps I

as he proceeded, pointing out the dangers of entering thecranium through the olfactory plate, and the means ofavoiding them, which his operation afforded, by giving afull view of the whole field and by keeping external to themiddle turbinate. The operation consisted in the formation ofan osteoplastic flap which was turned outwards to enable theinterior of the nasal passage to be seen and treated accordingly.The ethmoidal cells could be removed and no pockets wereleft without inspection, as in the case of Killian’s method ;there was also practically no deformity as a result. Thefirst step was to take a radiograph of the frontal sinuses tosee their extent, as they were entered from the anterior wall.The first incision was made over the previously shavedeyebrow, the inner end curving slightly downwards to thecentre of the root of the nose. The incision should not gothrough the periosteum. This cut was subsequently pro-longed vertically downwards in the middle line to thelower end of the nasal bones. The soft tissues wereretracted and the periosteum incised and reflected as muchas necessary to gain entrance to the frontal sinus at its innerand anterior aspect. As much as required of the anteriorwall and floor of the sinus was then removed. The sub-

sequent prolongation downwards of the incision at its innerend was then made, the knife being here carried right throughthe periosteum to the bone, and at its lower end was pushedthrough into the affected side of the nose just external tothe septum and made to cut upwards as far as it would

go, the remainder being severed with a specially bentaw right into the sinus. A slightly curved incision ofabout half an inch in length was then made through thetissues down to the bone beneath the lower orbital margin ofthe same side, its inner end commencing just in front of theanterior lacrymal crest, the lacrymal sac being turned out-wards and an opening made here into the nose. By meansof a bent probe-pointed saw or a Gigli this opening was con-nected with the fronto-nasal duct subcutaneously, the nasalprocess of the superior maxilla was then divided sub-

cutaneously in a similar manner, the bent saw being passedfrom the opening in the region of the lacrymal sac into theanterior nares. This then freed the osteoplastic flap,consisting of the nasal bone, the nasal process of thefrontal and superior maxillary bones, together with thatsmall piece of the frontal which joined the superiormaxillary nasal process. The facial artery was leftintact. The flap was then turned outwards, and theinterior of the nose and the anterior ethmoidal cells

brought into view. These latter could be removed, also theposterior cells, and the sphenoidal sinus made visible ifnecessary. The important point in these further procedureswas to keep external to the middle turbinal, a small portionof which should be left as a guide. The flap was thenreplaced and the operation concluded. A good foreheadillumination was essential.Dr. G. WILLIAM HILL (London) also gave an interesting

demonstration, illustrated by photographs and diagrams,copies of which were given to members present, of his methodof operating upon the larynx and the application of radiumto these parts through a Bruning’s tube by direct vision.

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Dr. BRYSON DELAVAN (New York) also demonstrated Hay’spharyngoscope for the examination of the posterior nares andlarynx. The instrument was based upon the principle of acystoscope and consisted of a vertical shaft which served as ahandle and a horizontal portion which served as a tongue

depressor, the distal portion of which contained a small lensand electric lamp, the light being conducted along this to asuitably arranged eye-piece in the manner of the cystoscope.The small lens could be rotated so that any portion of thenaso-pharynx or larynx could be examined. It was most useful

for cases where the mouth could not be opened or when thepatient was lying in bed. Of course, it was of no use foroperative putposes. It was made by the Wappler ElectricController Company, New York. The Section then joined with the Section of Hygiene andPublic Health to discussLatent Infeotíons of the DiphthefJ’ia Bacillus and Administra-

tive Measzures requiredfor dealing with Contaots.This discussion is reported under the proceedings of theSection of Hygiene.

FRIDAY, JULY 30TH. Mr. H. LAMBERT LACK (London) read a paper oni 27ee Treatment of Cicat’l’ieial Stenosis of the Larynx.He said at the outset that he would confine his remarks

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mainly to those cases of cicatricial stenosis of the larynx inchildren which occurred after diphtheria when tracheotomyhad been performed, as in most of them the tracheotomytube had been inserted in or near the larynx. He consideredthat diphtheria had no direct connexion with the stenosis,but that it was secondary to the irritation and injury caused bythe high tracheotomy. Personally, he had never seen stenosisfollow a tracheotomy lower down. The amount of stenosisvaried from a slight fibrous thickening to an impermeablestricture. The treatment he adopted was to do a lowtracheotomy and to remove the other tube, allowing thiswound to close, and, if the original tracheotomy had beenperformed within a few weeks, the probability was that thelaryngeal condition would, quickly recover without furthertreatment. The tube in the trachea should then be blockedfor longer and longer periods until the child breathed easily,when it should be blocked night and day. This might takefrom one to three months. He had previously tried a com-bination of dilatation of the larynx together with a lowtracheotomy, and for this purpose he used T-shaped tubesfor the upper opening, but it was found impossible to keepthem clean, and he came to the conclusion that the improve-ment was due to the low tracheotomy, which was the onlytreatment he now adopted for such cases. Of course, recovery iwould not occur in cases attended with extensive sloughingor with necrosis of cartilage. He had since tried intuba-tion, but had not obtained any benefit from it. With refer-ence to almost impermeable strictures, he had hitherto

regarded them as hopeless and that such patients were

condemned to wear a tube all their lives, but he lookedforward to the subsequent speakers for help in this direction.The PRESIDENT remarked that the subject was one of the

most interesting that had been brought before the section,and that hitherto its treatment had been one of the mostdifficult problems of the laryngologist. They had just heardthe opinion of one of the foremost British laryngologists,and he was to be followed by Dr. Delavan, who would givethem the latest experiences of intubation, which method hadbeen, except in fever hospitals, neglected in Great Britain.Finally, they would have the benefit of hearing the views ofDr. Delsaux, than whom none was more capable of describingtracheo-laryngostomy, and, finally, they would hear Dr.

Mayer, of the land of O’Dwyer.Mr. LACK, in reply, said that he had generally been able

to remove the tube in from one to three months. He passedround for inspection one of the plugs which he used in hisearlier methods. He had found that an intubation tubeintroduced from below was more comfortable than one

inserted from above ; he also gave illustrative cases of treat-ment in this respect.

Dr. BRYSON DELAVAN (New York) then read a paper onThe 1 fJ’eatment of Cicatricia7 Stenosis of the Larynx by the

Methods of 0’-DYvytr and Rogers.He said that, in his opinion, three ’things were essential inthe successful management of these cases-namely, relief ofthe stricture, permanence of such relief, and as little injuryto the parts as possible. He referred to methods previousto O’Dwyer, whose character and attainments he consideredworthy of the highest regard. He thought that O’Dwyer’smethod comprised all the advantages, and none of the dis-advantages, of the previous forms of treatment, and this hadbeen shown abundantly by the brilliant series of cases re-ported by Dr. John Rogers. He referred to certain anatomicalfactors upon which the principles of intubation were based,and believed that cutting operations would only result inultimate failure, because of resulting adhesions, even afterlong-continued dilatation and supposing that cicatrices werealso excised. He stated that scar tissue in general whensubjected to long-continued stretching would finally lose its

resiliency, and it was upon this fact that intubation wasbased. For this purpose each case should have its own tube

specially modified to suit the individual requirements, andthe instrument should exert steady and continuous pressureupon the contracted tissues for at least one year. Therewere various normal" " tubes designed by O’Dwyer fromcasts to fit average larynges somewhat loosely, and thesemust be modified to suit the individual larynx, when theacute period had passed away, by passing under generalanaesthesia different sizes until one was obtained which theoperator considered would effect the desired result withoutcausing sloughing. Then a special tube was made of asuitable length and with a retaining swell, which

occupied the space at and below the cricoid car-

tilage, of the same size as in the trial tube. Theneck of this special tube, which pressed upon the

hypertrophied intra-laryngeal tissues, should have itstransverse diameter 3 inch smaller than the retainingswell or it would be coughed out, while the head, whichrested on and in the aryteno-epiglottic folds, must have adiameter -..rB inch greater than that of the retaining swell,otherwise the tube would slip into the larynx. These measure-ments applied to hard rubber tubes, but with metal ones thehead should be still a little larger. Occasionally a trache-otomy was essential when there was danger of the tube beingcoughed out, as occurred at times with hypertrophic laryn-gitis. Various tubes were here passed round for inspection,including a plugged or clamped tube which consisted of aremoveable right-angled piece passing through the tracheo-tomy wound and screwing into the one already described,which effectually prevented its being coughed out. Tracheo-tomy should only be performed if absolutely necessary.Vulcanised rubber was an ideal material for a tube, andshould first be tried, but occasionally metal was better. Hereferred to several clinical cases in which recovery requiredfrom one month to a few years, two years being perhaps afair average, and he contended that no other method had yetbeen tried for a sufficiently long period of time to enable anydefinite conclusions to be drawn from it. He referred to atemporary spasm of the adductors after removal of the tubewhich might lead the surgeon to think that the conditionwas unchanged, but general aumsthesia would determinewhether the dyspnoea was due to fibrous stricture or to

spasm.Dr. DELSAUX (Brussels) read a paper on

TfJ’aelteo-lafJ’yngost01ny in the Treatment of OicatriciaZ Stenosisof the La’J’ynx and Trachea.

He defined it as a large opening of the larynx and superiorpart of the trachea made permanently or at least for a longperiod. He excluded cases of tubercle and lupus, and

thought that bronchial catarrh was a contra-indication,but considered it possible in all other cases of cicatricialstenosis of the larnygo-tracheal tube. He referred to thecare required in preparing for the operation and to disinfec-tion of the mouth and teeth. The operation could be per-formed under either general or local anaesthesia. The headshould be held by an assistant in Rose’s position duringthe whole of the operation. He indicated the instru-ments required and emphasised the importance of a goodfrontal mirror. He divided the operation into the fol-

lowing six stages: 1. The preliminary incision extendingfrom the previous tracheotomy wound to the upper marginof the thyroid cartilage. 2. The longitudinal division of thetrachea and the cricoid and thyroid cartilages, together withthe thyroid isthmus. 3. The suturing of the mucous mem-brane of the larynx to the skin. 4. Excision of the scartissue. 5. Introduction of a dilator and cannula, the latterhaving, of course, an opening at its upper part. The dilatorwas a rubber tube which should exceed the diameter of thetrachea. Fournier introduced his cannula through a hole inthe dilator. Some preferred gauze for the dilating materialduring the first few days, afterwards inserting a rubber tube,so that the patient could learn to breathe again through thenatural passages. 6. Dressing of the wound and of thecannula to keep it in position. The inner cannula should be

frequently cleansed and boiled and the dressings removed asoften as necessary. The mouth must be frequently cleansed.The epidermis soon commenced to grow along the granula-tions which lined the new laryngo-tracheal conduit. The dila-tation should be continued for a period varying from a fewmonths to a year or longer, and when all the raw areawas covered with epidermis the upper part of the woundmight be allowed to heal, and later a plastic operationwould of course be necessary and should be done at oncewithout any safety opening, when the patient could breatheeasily through the nose and was not out of breath whenrunning. The methods that could be used in closing thisaperture were next described, either with square Saps ofskin or flaps elliptic in shape sutured in the median line withthe skin turned inwards. A synopsis of the results of 36 caseswas then given.

Dr. EMIL MAYER (New York) read a paper on theTreatnteitt of Cicatricial Stenosis of the Larynx.

In this paper he instanced three unusual cases in whichtracheotomy had been performed. He used intubation and

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exhibited a special hollow handle so designed that the tubes Icould be passed slowly, the patient breathing through thehandle all the time-one case required two minutes for its Iinsertion. The introducer, which was here passed round for I,inspection, was an excellent one for the purpose. Hereferred to the right-angled screw attachment of Dr. Rogersof New York, previously described by Dr. Delavan, and

passed one round for inspection, emphasising the importanceof carefully arranging that it should be fixed in the correctposition in the intubation tube, so that there should be notension upon the tracheotomy wound. Dr. Mayer’s first casewas due to a bullet which entered the temple, passing down-wards through the soft palate into the thyroid gland andthen into the ceosophagus; it dropped into the patient’sstomach and was finally passed per rectum. The second casewas due to post-typhoid perichondritis, and the third casewas one of granuloma of the larynx, which had been pre-viously operated upon. These were both successfully treatedby intubation.

Dr. HILL described a laryngeal splint which he haddevised for preventing transverse webs and cicatricial bandsin the larynx from being reproduced after removal, instancinga case. The patient had satisfactorily worn it for aboutthree weeks. The splint was passed round for nspection.

In the discussion Dr. A. LOGAN TURNER (Edinburgh)referred to the difference between the American treatmentby intubation and the European by the knife. An objectionto the former was the prolonged period necessary in somecases for using the tube. He had had trouble in one of his

laryngo-tracheoscopy cases from cesophageal fistula, whichhad interfered with the maintenance of the lumen of thetrachea. In case of post-operative stenosis following laryngo-fissure he thought that fibrolysin used locally might be ofservice.

Mr. H. S. BARWELL (London) referred to Schrotter’smethod of intermittent dilatation which had been successfulin his hands. One reason why he had avoided intubationwas his idea that the tubes required frequent removal andre-insertion.The PRESIDENT said that in his opinion one lesson to be

learned from the papers was the sufficiency in certain casesof a low tracheotomy in curing, and better still in preven-ing, the post-diphtheritic cases. Another lesson was thedeath knell of Schrotter’s tubes, for those of O’Dwyerwould do all that Schrotter’s tubes could do and even more.Another lesson was the promise held out by laryngo-tracheos-tomy. He laid stress upon the benefit which the successfultreatment of such conditions would confer on society,instancing the case of a little girl whose social life was

being sacrificed due to want of laryngeal function.Dr. DELAVAN briefly replied, and showed a concealed knife

for the division of cicatricial bands in the anterior com-missure. He stated that intubation could not be masteredin a few days, and that he thought it better for one or two

specialists in large centres of population to become pro-ficient, so that they might send such cases to them.

Dr. DELSAUx, in his reply, said he thought that the

epidermis took up the character of mucous membrane. Hehad had no good results from fibrolysin. To prevent anysecondary stenosis a piece of cartilage might be insertedprior to performing the plastic operation.

Dr. R. H. SCANES SPICER (London) read a paper upon the

- Be’MAp of Cancer of the lxroat to Abdominal andThoracae Breathing,

which depended, amongst other things, upon posture anddistension of abdomen. He illustrated his remarks upon amodel made for the purpose.

Dr. R. H. WOODS (Dublin) showed a patient whose larynx hehad extirpated, and exhibited a method which he had adoptedfor enabling the patient to speak. For this purpose a reedwas introduced into the distal end of a tube which wascarried from the tracheal opening through the nose into thepharynx, by this means reinforcing the resonance of thatcavity for vowel sounds.A short paper by Dr. J. HARDIE NEIL (New Zealand) was

read by Mr. G. A. BARTON (London), on the

Surgical Anatomy of the Tonsils,in which the author differed from Dr. D. R. Paterson as tothe downward extent and relationships of the supra-tonsillarfossa.A vote of thanks to the President concluded the work of

the section.

NAVY, ARMY, AND AMBULANCE.

WEDNESDAY, JULY 28TH.President. Fleet-Surgeon J. LLOYD THOMAS. R.N.

The PRESIDENT delivered an address of welcome to themembers of this section. "

" :

Colonel H. E. R. JAMES, R.A.M.C., communicated a

paper entitled - ’

;An Aco01tnt of the OjfioefJ’s’ Training Corps, with Special

Reference !*0 its Medical Branch."He said that for reasons of expediency it was obviously un-necessary to maintain the medical establishment of the armyat war strength during times of peace, and upon the out-break of war upon a large scale a call would be made uponthe civil medical profession for the completion of the medicalestablishment of the expeditionary force. About 50 percent. of its medical complement would consist of medicalmen not of the regular army medical service, andthe existing reserve was totally inadequate to providethis number. A "special reserve of officers was designedto meet the case, but under the most favourable condi-tions it was unlikely to produce the large body of officersrequired, as many men were loth to bind themselves toundertake war service in prospective, while it was alsoobvious that a man knowing nothing of the medical servicemust be at a great disadvantage under conditions of fieldservice. Therefore the giving of a free hand to schools anduniversities without binding the recipients to service was ameasure which promised well, even if it should not fill the

special reserve and the Territorial Force as was hoped. That

, was the origin of the officers’ training corps. The generalobject of the organisation was to provide officers for the

regular army, for the special reserve of officers, and for theTerritorial Force, and its method of working was to give astandardised measure of military training to boys and youngmen of the educated classes at schools and universities. The

university contingents formed the senior and the school

contingents the junior division of the officers’ training corps.No physical examination was imposed, the only regulationbeing that the cadet shall be able’ to perform his duties to thesatisfaction of his commanding officer.

Lieutenant-Colonel R. PORTER. R.A.M.C., read a paper on

Physieal Training of Reerzcits in the Army.He said that the object of physical training should be toincrease intelligence, quickness of movement, power ofendurance, and keenness for work ; in other words, physicaltraining meant the gradual training of the heart and lungs toaccommodate themselves to the demands of muscular exer-tion, and the undertaking of fatiguing exercises withoutundue distress. The recruit on joining the army at theage of 18 years was not physically fit to undertake theduties of a soldier without considerable preparation, andit was by this system of physical training that he wasprepared for the strenuous and active life which was

: now required of a soldier. In carrying out these exer-

cises his body was gradually and harmoniously developed,faulty postures were corrected, and at the end of his traininghis standard of physical fitness was enormously increased.All this was done without any undue strain to the body, andin practice it was found that generally recruits after three orfour months’training improved in weight, chest capacity, andthe harmonious working of heart and lungs was well seen intheir power of running one mile without distress, as shownby their respiration and pulse-rate. The methods by which

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this training was carried out were based on the Swedishsystem, which had been introduced into the British armywithin the last few years, and differed entirely from anysystem of physical training previously employed in England.The methods in vogue in the army a few years ago, andindeed in the universities and schools, were very unscientific

’

and opposed to all physiological laws. They tended to pro-duce a state of abnormal muscular development. What was

. aimed at now was the harmonious development of the wholebody without strain to muscular, respiratory, or circulatorysystems. Great care was taken to avoid hurry in physicaltraining. It was impossible to obtain good results by cram-ming more work into the same or less time. The object

aimed at in these physical exercises, particularly of the armsand legs, was not exactly the development of the differentmuscles engaged, but their’increased efficiency and power ofresisting fatigue. Generally speaking, in all recruits the