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age-groups, and TANNER has seen it even at 91 ; itseems certain that this diagnosis is often overlooked.For the old patient with ulcer, gastrojejunostomy isBsufficient, for the mucosa is usually degenerative andulceration does not recur. The stomach growth, ofcourse, does require partial gastrectomy, and it is

amazing how well the aged withstand this procedure.TANNER records a successful total gastrectomy in apatient of 74, and WAUGH and GIFFIN 9 one in apatient of 72. In such patients preliminary splanchnicblock may be dangerous, for, especially with theanterior approach, pressure on the aorta may fracturesome of the atheromatous plaques usually present.Resection of oesophageal growths is now being success-fully performed even in old patients, and the risks areworth taking. The pharyngeal pouch quite commonin the aged is being dealt with under local anaesthesiaby first transplanting the pouch to a higher level andat a second operation coring out the mucosa. Growthsof the colon can be expeditiously dealt with by Paul’soperation, and even if there are secondaries in theliver an attempt should be made to remove the localgrowth. Patients with secondaries in the liver oftenlive for two or three years in fair comfort and removalwill spare them the misery and pain of the local

spread. The aged do not always need the full abdomino-perineal resection ; where the growth is at the

pelvirectal junction, or high in the rectum, the simpleroperation of leaving a distal blind rectal stump(Hartman’s operation) is ample. CUTHBERT DuKES,loand GLOVER and W AUGH,l1 have shown that distalretrograde spread is slow, and that it only occurs in1% of cases, and then usually only when the normalupward channels have been blocked. Section of thebowel an inch below the palpable edge of the lesionwill satisfy pathological requirements. The breastcarcinoma usually needs but a local amputation toavoid the local ulcerating mass, and to remove whatthe patient knows perfectly well is slowly whittlingaway her life. Admittedly, such carcinomas are oftenextremely slow growing, but, with the ever-extendingpropaganda on cancer of the breast, no patient candismiss it lightly from her mind. Minor operations,even circumcisions, are often necessary in old peopleand should not be shirked. Haemorrhoidectomy caneasily be performed under local anaesthesia. The frailold lady withstands well an operation for procidentia,and it will give her comfort. As HowELL astutelyremarks, " trifling matters often distress the agedmore than great ones."The possibility of a vascular catastrophe alway

hovers over the old patient. Embolism of a mesentericor peripheral vessel is a condition amenable to

surgery, and has to be borne in mind. The peripheralembolus is too often overlooked till too late for

surgery ; numbness and loss of power, rather than

pain, may be the chief symptoms. The limb with a

peripheral embolus, if operated on early (usually underlocal anaesthesia), does well. Arteriosclerotic gangreneis now being treated by more conservative methods ;gangrene of a single toe often ends with no more thanloss of the superficial skin. Reflex vasodilatation,12by heating the body or immersing the opposite limb

9. Waugh, J. M., Giffin, L. A. Proc. Mayo Clin. 1941, 16, 363.10. Dukes, C. E. J. Path. Bact. 1940, 50, 527 ; Proc. R. Soc. Med.

1941, 34, 571.11. Glover, R. P., Waugh, J. M. Surg. Gynec. Obstet. 1946, 82, 433.12. Learmonth, J. R. Edinb. med. J. 1943, 50, 140.

in water at H0° F, is probably the best way of

encouraging the collateral circulation ; it does as

much as a sympathectomy and certainly more thanvasodilator drugs. For the frail patient, particularlywith spreading gangrene, amputation under iceanaesthesia has a place. The results of surgery in the" old man’s illness "-prostatic obstruction-havebeen much improved ; Millin’s retropubic operationhas largely justified the original optimism. The otherold person’s disease, trigeminal neuralgia, is beingincreasingly operated on early, and these patientswithstand the operation remarkably well. Fracturedneck of femur, which was the harbinger of death formany of the aged in the past, is now almost routinelytreated with the trifin nail-a procedure which eventhe very old withstand well. Aseptic necrosis andextrusion of the pin have rather damped initial hopes,but a good result can usually be anticipated in at least50% of cases ; where this fails McMurray’s osteotomyis extremely valuable.One example of the success being attained must

suffice. CARP 13 has collected figures from a variety ofsources covering 2558 patients submitted to operationat ages over 60 ; these show an average operativemortality of 13’1 %-a gratifying result. It doesindeed seem that the age of the " lean and slipperedpantaloon " may become a less formidable problemto the surgeon than that of the " fair round bellywith good capon lined."

Annotations

DENTAL CONTROVERSY

THE dispute between the dental profession and theMinister of National Insurance raises an importantpoint of principle. Negotiations for a new scale of feesfor dental work done for insured persons began as longago as January of this year, when the Dental BenefitCouncil set up a negotiating committee consisting ofthree dentists, representatives of three approved societies,and a number of Government members. This committeeissued a questionary to more than 1000 dentists engagedin N.H.I. practice to ascertain (a) to what extent the costof running a practice had risen owing to the war, and(b) what were the private fees charged to non-insuredpatients in the same walk of life as those treated underN.H.I. The committee issued a unanimous report andsubmitted a scale of fees which represented an averageincrease of about 100 % over the pre-war scale. This scaleof fees has now been rejected by the Minister of NationalInsurance. The dental profession feels that havingexhausted what it regards as the normal negotiatingmachinery it has no alternative but to abstain from

participating in the service. The dental profession fearsthat if the present Minister is prepared to disregardnegotiating machinery in connexion with dental benefitin this way, and to rate the value of a dentist’s servicesso low, there can be no hope of any better treatment ina scheme applying to the whole nation.The scale which the Minister proposes to adopt from

Sept. 30 will yield an average net increase of 50% overpre-war, according to the Ministry’s letter circulatedto dentists on Sept. 12, but the rise is not uniform.Thus the fee for full upper and lower dentures,which unfortunately is the form of treatment mostnecessary for working-class patients, is jE7 15s. Whenthe scheme started in 1926 this fee was 6 ; the presentfee is .E6 7s. 6d. ; and the dentists were prepared toaccept 9 guineas. The dentists contend that they cannot

13. Carp, L. Ann. Surg. 1946, 123, 110.

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guarantee a satisfactory service for insured persons atany scale below that which the Minister rejected, andthe Joint Advisory Dental Council recommends dentiststo refuse to undertake N.H.I. work unless the higherscale is adopted.

PERCEPTION

THERE are many subjects of common interest to

philosophy and medicine : but if he is a physician theManson lecturer, required by the terms of his appoint-ment to consider some such subject, may well doubt hisability to reach the standard of subtle and reconditeprofundity manifest in philosophical writings. Dr.Russell Brain has, however, succeeded in illuminatinga problem of basic importance for the philosopher-the nature of perception, especially in its causal aspects.Neurologists, he points out, usually adopt physiologicalidealism as their epistemological theory : for them the

only independently necessary condition for the awarenessof sense-data is an event in the cerebral cortex. But,besides the familiar arguments against idealism, it is

possible to object to this, as Russell Brain does, that thepeculiar phenomena of cortical representation duringvisual perception make simple " projection " of cerebralevents an inadequate explanation : " when we perceivea two-dimensional circle we do so by means of an activityin the brain which is halved, reduplicated, transposed,inverted, distorted and three-dimensional." But realismtoo has its difficulties, implicit in Brain’s (probablyrhetorical) hope that a realist philosopher will give anaccount of the " ontological status of a black sense-datumwhen it is not being perceived and, in particular, its

relationship to its non-existent substratum in the

physical world."By way of hallucinations and the phenomenon of

phantom limb," which further illustrate this crux,Brain passes to the role of the body in perception, andinstances a number of observations hard to reconcilewith any variety of critical realism. Awareness of

externality is clearly the cardinal problem : and spatialrelations, upon which this depends, are primarily per-ceived in a somatocentric way. The body is well adaptedto the task of spatial discrimination, through its apparatusfor the integration of impulses conveyed from differentsense-organs to the cerebral cortex. Russell Brain holdsthat the most likely explanation of the relationshipbetween sense-data and the nervous system is that asense-datum is a neural event which is conducted fromthe surface of the body to the surface of the brain butwhich carries with it some characteristic of the physicalstimulus which excited it. In his conclusion, which takesaccount of the ; successiveness " of the stimulus event,he adopts a realist position in so far as he denies thateven secondary qualities are generated by our brainsor minds : in sensing them we are perceiving the four-dimensional texture of the external world." This is a

thoughtful and stimulating essay which shows howsignificant for the philosopher can be the observationsand reflections of the neurologist.

DEATH AFTER CURARE

AN inquest was held at Hammersmith on Sept. 9on a patient who died after an operation in which curarewas employed. A woman of 70 years had been admittedto hospital two days after the onset of symptoms ofacnte appendicitis. An hour after receiving morphinegr. 1/,; and atropine gr. she was anaesthetised with’ Pentothal ’ 1 g. and was given ’ Intocostrin ’ 9 c.cm.

Oxygen was administered during the operation, whichrevealed-an acutely inflamed but unruptured appendix,with much induration of the surrounding tissues and asmall adjacent collection of pus. The appendix wasremoved, the pus mopped out, and the wound closed in

1. Neurological Approach to the Problem of Perception. Philosophy,July, 1946, p. 133.

layers. The first alarming signs-cyanosis and shallowrespiration-appeared after the end of the operation,which had taken 43 minutes. The patient recoveredsomewhat with oxygen and carbon dioxide, but relapsedand, despite the injection of ’ Coramine’ 1 c.cm. and’Veritol’ 1 c.cm., died 35 minutes later. Necropsyconfirmed the presence of early peritonitis, which wasmost pronounced in the right iliac fossa ; there wassome dilatation of the terminal loops of the ileum,suggesting early paralytic ileus. The left lung was almostcompletely collapsed and there was considerable collapseof the posterior halves of the right upper and lower lobes ;there were one or two adhesions in both pleural cavitiesand the lungs showed pronounced terminal congestion.The heart muscle was a little friable, but only earlyatheromatous changes were found, and there was novalvular disease. Early toxic changes were seen in thespleen and liver. The kidneys were remarkably healthyfor a patient of this age, although albumin had beenfound in the urine before operation. The pathologistconsidered that death was due to toxaemia and had beenaccelerated by respiratory failure due to curare. Averdict of death by misadventure was returned.

PENICILLIN IN WOUNDS

THE topical application of sulphonamides to woundshas proved a disappointment, and, though there is notunanimous opinion on this point, it is widely held thatthe presence of a sulphonamide powder in a flesh woundmay actually delay healing. In sharp contrast to this,there has never been a doubt that penicillin as a topicalapplication is of great value, for it has the advantagesover the sulphonamides that it acts in the presence ofpus, that its effect is not weakened by large numbers ofbacteria, that it is a much more powerful bacteriostaticagent than any sulphonamide, and that it is very solublein tissue fluids. In the early stages of its use, penicillinwas recommended as a topical application because thismethod was more economical than systemic adminis-tration at a time when supplies were short ; and manysurgeons believed that, valuable as it was used thus, itseffects would be greater still when easement in the

supply position permitted free systemic administration.This belief has not been borne out in practice, and thepaper by Florey, Turton, and Duthie in this issue givesscientific foundation for the clinical impression that

locally applied penicillin is as effective in preventingwound infection as it is when given parenterally.

Florey and her colleagues collected samples of woundexudates after penicillin had been given either by localapplication or by injection. The difficulties they encoun-tered in the assay of the penicillin content of theseexudates and the methods they used to overcome themneed not detain us here. It was shown that whereas100,000 units of penicillin injected intramuscularlyyielded for a minimum of 8 hours a wound exudatewhich inhibited the test organism, a similar dose

implanted in the wound yielded exudates with inhibitoryconcentrations for at least 48 hours. -It might be arguedfrom this observation that locally implanted penicillinremained in the wound cavity but might fail to reachorganisms lying in the wall, but this argument is defeatedby observations on the duration of inhibitory activityin the blood and urine. There was little difference in thetime over which inhibitory levels were maintained in theblood whether penicillin was given locally or parenterally,but in the urine inhibition persisted in half the casesfor twice as long after local application as it did afterintramuscular injection. Penicillin is therefore readilyabsorbed from wounds and must traverse the walls ofwounds (inhibiting meanwhile organisms lying in its

path) to gain access to the blood and urine.All this is of great importance in its practical application

to wound treatment. Locally implanted penicillin is of