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will be inclined to ascribe to other causes the symptomscredited by Mr. LANE to chronic intestinal stasis. It is,however, when we come to treatment that the greatestdivergence of opinion will be found to exist, and it is on

this portion of the subject that the novelty of Mr. LANE’S

opinion mainly rests. He agrees, of course, that surgery

has nothing to say until medical and mechanical methodsof treatment have been tried and have failed. When, how-

ever, all the usual medical and mechanical methods for the

relief of this chronic constipation have been tried Mr. LANEholds that the aid of a surgeon should be invoked, andvarious degrees of operative interference are recommended

by him corresponding to the various degrees of severityof conditions existing. In some cases he has obtained

considerable success by the mere division of constrictingbands, and most surgeons who have had much experience inabdominal surgery will agree that cases do occur, thoughthey are not common, in which a very intractable chronic

constipation has yielded to the division of a constrictingband. When the case is more severe, and mere division of

adhesions will not suffice, Mr. LANE employs one or otherof two more radical measures. The simpler of these is thedivision of the ileum near its attachment to the caecum, and

its transplantation to the sigmoid flexure, so that the

intestinal contents no longer traverse the whole of the largebowel, but take a shorter route and pass only through a por-tion of the sigmoid flexure and the rectum. The more

liquid nature of the fseces is sufficient to prevent any

accumulation, and the previously troublesome constipationdisappears at once, and with it, Mr. LANE tells us, disappearalso all the serious symptoms which resulted from it. The

skin clears and gains its normal colour, the mind of the

patient is relieved from the anxiety and irritability which

formerly interfered with its normal action, and the temper ofthe patient shows definitely the good which the operation hasdone. There are, however, some cases which Mr. LANE con-siders are not adequately treated by this operation of trans-

plantation of the ileum, and in these he considers it necessaryto excise the whole of the large intestine except the sigmoidflexure and the rectum, an operation of no great difficulty initself but one accompanied by a large amount of shock,a matter of especial anxiety in subjects so much debilitatedas most of these patients are. The same beneficial results

follow upon the success of the larger procedure, and inaddition there is no risk of any of the intestinal contents

passing backwards in the cul-de-sac formed by the largebowel.

We cannot doubt the benefits ascribed to these operationsby Mr. LANE, who has shown the medical profession manyof his successful cases, but we think that hardly sufficientstress has been laid on the question of the risk of the

operation itself. We have not been able to find any very

definite statements as to mortality of operation ; but deathshave occurred, and it would be well if we could see at a

glance the exact effects of the operation with regard to mor-

tality. The whole question must depend on whether therisks of persevering with medicinal treatment would be lessthan those of an operation. Are the dangers and discomfortsof chronic intestinal stasis sufficient to justify the recourseto operative procedures in which the risk to life is by no

means slight ? It must be acknowledged that in this countrythe number of those surgeons who accept Mr. LANE’S viewson this matter is comparatively small. Abroad they havemet with more recognition, but in most countries it seems tobe felt that sufficient data are not available for comingto a decision. We are sure of these things-that theevils of chronic intestinal stasis have not been fullyrecognised, and that the condition needs more attention thanit often receives. The mere administration of a purgativeand a few instructions as to diet are often considered

to be sufficient treatment for chronic constipation which

may have lasted many years. This unenterprising policyshould not continue. On the other hand, althoughMr. LANE has done good service in bringing forward themethods he advocates, and has shown extraordinaryperseverance in the face of much opposition in advancingour knowledge of the capability of operation on the largebowel, we doubt if he has yet proved his case as to the

frequency with which such extensive operations as excisionof the large intestine are required. In other words, wewant to know more of the risk of the operation so as todecide how large a number of cases should fall into the classwhere operative procedure is justifiable.

Hospital Sunday, 1909.THE annual collection of the Metropolitan Hospital

Sunday Fund will be made on Sunday, June 13th, and onthe eve of the event we again express the hope that the

appeal in the places of worship of all denominations

in and around London will arouse a free and generous

response. We know that the liberality of many con-

gregations is taxed on frequent occasions, perhaps weekly,on behalf of deserving causes, but we urge the claim

of the hospitals of London as one of paramount im-

portance, worthy to be met by a donation exceedingthe usual weekly offering. As a number of persons leave

London at the end of the week in order to spend Sunday else-where we trust that they will be mindful also of the needs ofthe Fund. Many of them may attend worship on HospitalSunday at places where no collection is made on behalf of

this great distributing agency of London’s charity, but it

will give them little trouble to send their gift direct to theoffice of the Fund at 18, Queen Victoria-street, E.C., if theyhave omitted to entrust it to a friend for addition to the

offertory.In enjoining upon all that they should give generously

and that they should treat Hospital Sunday as a specialoccasion, we are not unconscious that the present year is

likely to be one of exceptional need for our charitable insti-tutions, and that the benevolent coöperation of all will be

required even more than in past seasons in order to maintainthe Fund at its usual high level. THE LANCET holds no

brief for Government or Opposition, and expresses no viewson political questions from a party point of view, but weneed not therefore ignore the fact that the financial pro-

posals of the Chancellor of the Exchequer, whether

justified or not by our needs and our circumstances,must seriously affect our voluntary hospitals. Under

those proposals many , will find their contributions to

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Imperial taxation increased materially, and we do not

shut our ears to statements which have been freelymade that some at least of those affected may have to

recoup themselves by diminishing their contributions to

charity. If they are compelled to do this, and if the

hospitals suffer thereby with other charities, then it behoves

all who are not driven to such an unfortunate pointof penury to put forth an additional effort to make

good the loss involved. We have referred only to those

obliged out of necessity to curtail their generosity. Others

may feel disposed to do so, but we trust that they willclismiss the thought from their minds as an unworthy one.We feel sure that upon reflection they will realise that anyeffort of self-denial, any decision to forego a temporary and

fleeting luxury, or even some much desired pleasure, wouldbe preferable to allowing their personal loss to be transferredto those noble institutions whose cause we are pleading.The hospitals of London, if they crave for aid in their

financial necessities as a visible and substantial token of

public recognition of the great work which they carry on,have no reason to complain that their usefulness is not heldin high esteem. Indeed, the main reason of their perpetualappeals for help lies in the increased and increasing apprecia-tion bestowed upon them and in their desire to prove them-

selves worthy of it. They have to strive to do more each

year because each year more is expected of them. And the

help which they receive should be proportionate to the

growing arduousness of their task.The report of the Royal Commission on the Poor-laws

affords in numerous passages proof of the huge burden cast

upon the rates by the sickness or premature deaths of

parents in the humbler classes of society, to which subjectMr. BURNS also referred in the eulogy of modern medicinewith which he declared the Tuberculosis Exhibition openlast week. We would remind the public that the work donein the hospitals tends, directly and indirectly, to preventand diminish the accumulation of that burden, and thatwhat the public gives in charity is to no small extent

repaid to them by the hospitals and by the unpaid workof their medical staffs. A committee appointed by the

Home Secretary for the purpose recently issued a reportupon the provision of a rapid and effective service of

ambulances throughout the metropolis. In our specialsupplement published on behalf of the MetropolitanHospital Sunday Fund we pointed out that the holdingof this inquiry showed the importance attached to the

work of the hospitals and to the promotion of such a

service, but that its institution in accordance with the

recommendations made would mean no small increase in the

number of cases brought to hospitals of all kinds for

treatment. But already aid to the sick and injured is

supplied in every hospital of the metropolis to the full

extent of its financial power, and we urge upon all that the

supply should be made as nearly equal as may be to a

,demand likely to be augmented considerably. The supplywill never exceed the demand, for the hospitals aim at oneideal- Efficiency"; and efficiency for them is inseparablefrom constant movement forward along that path of scientificprogress, the pioneers of which work in the hospital wards.Medicine desires to place, through the generosity of those

who are wealthy by comparison, the benefits of thera-

peutic and surgical skill and of nursing, all of the highest torder, at the disposal of those whose poverty wculd

otherwise set the boon beyond their reach, leavingthem to die unaided. Therefore, the demand for aid neverlessens, and in urging it on behalf of the MetropolitanHospital Sunday Fund we appeal to all, whatever their

financial circumstances, to give generously, in the assurancethat their gift, whether great or small, will be wisely andeconomically administered, and that it will do its full sharein maintaining those great charities among which the Metro-

politan Hospital Sunday Fund annually distributes its

resources.

Annotations.

THE MODERN TREATMENT OF FRACTURES.

" Ne quid nimis."

WE publish this week an address entitled The Modern Treat-ment of Fractures, delivered by Dr. Lucas-Championniere, thePresident of the International Society of Surgery, before theCardiff Medical Society on Friday last, June 4th. Comparedwith the progress which has been made in most departmentsof surgery, the treatment of fractures has lagged far behind.The rules laid down in the dawn of medicine held good untila very recent date, and as certain of these were based ontheory rather than on practice it is not surprising that the bestresults should be withheld from those practitioners who willnot allow the possibility of modification. It is still taught bymany surgeons, and was until recently universally believed,that the essential principles of the treatment of a fracture arethat the fragments of the bone should be replaced exactly intheir former position, and that they should be there heldfixed for a sufficient time to allow the fragments to becomefirmly united. These are the directions which are found

repeated, the words merely being varied, in nearly every text-book of surgery or treatise on fractures up to the presenttime, and in most cases without addition or qualification.There are, however, considerations which give rise to some

doubt as to the correctness of these generally received prin-ciples. The formation of callus is essential to the union of

a bone, and it is certain that the chief factor in the deter-mination of the amount of callus formed is the amount of

movement of the fragments. Further, it cannot be acceptedas essential that the fragments must be replaced in theiroriginal position with anatomical accuracy. The introduc-

tion of the Roentgen rays produced shocks in the mindsof not a few surgeons, for they found that fractures

which had seemed to be accurately reduced were often

in a by no means perfect position when they were

scrutinised by the new exponent. Various slight displace-ments were seen to be present, and yet the limb was asuseful as its fellow. It cannot be too firmly laid down thatthe true test of the success of the treatment of a fracture is

functional activity. To have the fragments of a bone in

perfect position will not serve unless the utility of the part isalso completely restored, and if the utility of the limb isperfect the precise positional relation of the fragmentsmatters little or nothing, cosmetics apart. The introductionof the x rays has not been wholly beneficial to the operatingsurgeon, for in the first place skiagrams are very liable tomisinterpretation, and secondly, the fact that the fragmentsof a bone are not in perfect apposition may lead the unlearnedto think that the treatment of a fracture has been unsatis-

factory. Dr. Lucas-Championniere’s method of treatment