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&bgr;coPYJ but not for aesophagoscopy, and not at all inchildren; morphia is usually given before a first

bronchoscopy, and is sometimes combined with

atropine or hyoscine. It is well known that the

oesophagus is almost insensitive ; the bronchial tree is.now shown to be less sensitive than has been supposed.and doubtless the endoscopist might dispense withanaesthesia more often in this country. But the

temperament of patients is a very variable factor ;in nervous cases, with throats rendered irritable

by tobacco and alcohol, it is sometimes difficult tomake an adequate examination even of the tonsils.We all know the spoilt, undisciplined, frightenedchild of 7 or 8 years old, in whom the simplest examina-tion is very troublesome; and it is hard to understandhow such a child is persuaded to submit quietly tobronchoscopy without the use of any form of anoes-thesia. The highly perfected team-work of the

Philadelphia clinic doubtless makes for great dexterity,but the American, as a race, is not more phlegmaticthan the Briton, and it is probable that the occasionalbronchoscopist will still have to resort to generalanaesthesia, at any rate, for his more nervous andirritable subjects.

THE ARCH OF THE FOOT.

ALTHOUGH the various forms of pes cavus andclaw-foot are common enough in England and arein general adequately treated, not much has beenwritten about them in this country. In some of thelargest and best known works on orthopaedic surgeryin our language the subject is dismissed withoutmuch consideration of details, as though its importancewere small or its cure easy by obvious methods. Yetthis deformity often gives rise to grave disability andpain, and shows itself most obstinately defiant ofmany attempts at cure. In considering pes cavus,as to a lesser degree in considering flat-foot, we aremet at the outset with the difficulty of defining thenormal arch of the foot. At the two ends of thescale of severity it is easy enough to distinguish flat-foot and pes cavus respectively, but the further wego from the extremes the more difficult does definitionbecome. Races of men and individuals differ verywidely in the shape of their foot-soles ; the aristocraticfoot " under which a mouse could run " on the onehand, and the foot with an almost non-existent archon the other, may both be perfectly good feet froma functional point of view, and give no trouble totheir owners. Some years ago an attempt was madeat a large New England hospital to forecast the futureof the feet of some hundreds of nursing probationers.The result was disappointing, for the observers failedto find any constant relation between defects detectedon entry and subsequent breakdowns in training inthe wards of the hospital. In severe and advanced

cases, where radical operations on the bones are

justifiable, treatment may no doubt be simple ifsevere. But in the vast majority of cases in whichsuch mutilating procedures cannot be justified, thecure is often uncertain and the treatment is nearlyalways tedious. Dr. Hackenbroch 1 describes anddiscusses the pathological anatomy of the differentgrades of deformity and their operative treatment,ranging from fasciotomy to tarsectomy, not omittingthe various tendon-transfer operations which havefound favour with some surgeons. In something like30,000 words and with the help of 40 illustrationshe has given us a very full account of the subject,and one which should be of practical use to allsurgeons who may be in doubt as to the best meansof treating this deformity, for in this monograph theymay find recorded most, if not all, of the proceduresthat have been devised for its relief.

1 Der Hohlfuss. Seine Entstehung und Behandlung. VonDr. M. Hackenbroch, Privatdocent, Oberarzt der OrthopädischenKlinik, Köln. Mit 40 Abbildungen. Berlin: Julius Springer.1926. Pp. 83. G.M.6.60

Annotations.

THE MAUDSLEY HOSPITAL.

" Ne quid nimis." ol

PSYCHIATRY, which among primitive peoples is theearliest and most important branch of medicine, is,in civilised countries, only just coming into its own.In the middle of the last century many great physiciansrecognised that the mind had its diseases, and gavethemselves to its study ; then came a sudden expansion of interest in pathology and a dark period duringwhich men declined to believe in the reality of diseasesfor which they could find no physical cause. Fromthis attack of " parallelism " the science of mentaldisease is just rallying. Although it has not yetreached the position it deserves, it has attractedsome of the greatest minds in medicine, and is subduingthe forces of pathology to its own ends. It was onlyto be expected that the swing of the pendulum wouldbring uppermost the opposite view, that all disease,physical and mental, is the result of mental disturb-ance ; the schools of psychology have increased andmultiplied, and signs are not wanting of a tendency toneglect the demonstrable facts of biology and to intro-duce into the study of mental disease an element ofingenious psychological speculation that, while afford-ing great satisfaction to its exponents, is not likelyto contribute much help to the clinician, who is, afterall, the person who matters most. Against this dangerthe Maudsley Hospital is a valuable defence. Thosewho direct its policy are not only psychiatrists ofexperience and skill, but they have a deep respectfor hard work and patient research in pathology,biology, and chemistry. The essence of their attitudeis that mind and body are one, that one cannot becomedisordered without the other, and that the only wayto a full understanding of the secrets of mental diseaseis the proof, step by step, of the accompanying physicalchanges. Everyone knows in what a chaos the scienceof psychiatry is to-day; each author has his ownclassification and his own explanation of its problems,and nearly everything is empirical. But clinicalcertainty can only be built on a basis of pathologicalproof, and the workers in the well-equipped modernlaboratories of the Maudsley Hospital have everychance of building the foundations of a scientificpsychiatry. Their work on metabolism, vaso-motorreactions, hydrogen-ion concentration, and many othersubjects is well-known, and they are fortunate alsoin being connected with a hospital where the nursesare enthusiastic enough to give up their time andcomfort to act as controls, and where the medicalofficers add to their heavy routine work by collaborat-ing in or initiating research work.

It is regrettable that the issue of the report ofthe Maudsley Hospital, in common with many otherofficial publications, is so-tardy. The booklet justpublished only takes the history of the institutionup to Jan. 31st, 1925, and the work reported is alreadyout of date. It serves to remind us, however, thatthis important experiment of the London CountyCouncil is fulfilling the hopes of those who conceivedit and achieving its objects of facilitating researchand teaching in psychological medicine and providingtreatment for voluntary patients suffering from mentaldisorders of all degrees of severity. During its secondyear 1304 patients were treated, an increase of 300over the number in 1923. The preponderance offemale applicants for admission was so unexpectedlylarge that the accommodation had to be rearranged,until finally 96 out of the 144 beds were allotted towomen. The hospital’s policy of admitting mild,severe, and psychophysical cases together has metwith a good deal of criticism, but the results havejustified the innovation. The Maudsley has amplefacilities for treating cases of slight mental disturbanceaccompanying such physical conditions as exoph-thalmic goitre and chorea, for it has the advantageof the cooperation of the consulting staff of King’s

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College Hospital. Moreover, in the present empiricalstate of psychiatric science, it is of the first importanceto study those mental conditions that have a well-defined pathological basis, if the pathology of thosewhich are as yet little understood is ever to be madeclear. To make the Maudsley a clinic for mild casesonly would defeat its end of furthering the study ofmental disease as a whole, and would deprive it ofa unique and valuable characteristic. The work ofthe out-patient department has increased considerablysince the beginning of 1924, and the now insufficientaccommodation is to be extended. The medicalsuperintendent feels that the future success of thedepartment will depend on an adequate supply ofexperienced clinical assistants, who will see most ofthe cases and leave the senior medical officers freeto see new patients and those whose disposal is stilluncertain. For chronic cases out-patient treatmentcan be only palliative, but it is none the less valuablein enabling many to " carry on " who would collapsewithout the periodic encouragement of " therapeuticconversation " and a little bromide, and it is actuallypreferable for watching and stimulating neurotics,who might drift into an asylum to shirk theirdifficulties. The arrangements for treating in-patientsare exemplary. It is possible to keep three-fifths ofthe acute cases in bed in the open air in all weather,and when two bridges are covered in this accommoda-tion will be increased. Massage, remedial exercises,and electrotherapy are extensively used. A special" occupations officer " attends three afternoons a

week to instruct patients in a large number of handi-crafts, at which many display great skill. Practicallyall the patients who are up do some gardening, clericalwork, or tasks in the wards. Singing and dancingclasses, entertainments arranged by the patientsthemselves, parties and picnics keep the patientscheerful and happy. The consultant staff includesa general surgeon, an ophthalmic surgeon, a gynaeco-logist, a surgeon for diseases of the ear, nose, andthroat, and a dental surgeon. !The steadily increasing waiting list and the results

of the treatment are sufficient proof of the need forother hospitals such as this. Systematic investigationinto after-histories is carried out three months afterdischarge and then annually, and these statistics willbecome valuable material later on. The medicalsuperintendent remarks on the party held lastJanuary of about 100 ex-patients, and the almostincredible contrast between the health of the gueststhen and the memory of what it had been at theirworst when they were patients. The most urgentneed now is for an associated convalescent home whererecovering cases can be treated less expensively underthe same general supervision.

THE QUARTERLY REVIEW OF BIOLOGY.THERE are, says Prof. Raymond Pearl in the preface

to the first number of this new paper, about 25,000reputable scientific journals in the world to-day, andthe promoters of Biological Abstracts judge that theywill deal with some 4000 journals devoted to theirsections of natural knowledge. It sounds almosthopeless to expect that more than a fraction of theseprinted researches will ever be assimilated, broughtinto their proper relationships, and made adequateuse of. It seems as if we need a group of students whowill forswear the fun of exploration for laborious livesof reading, contemplation, and synthesis. Till Mr.Rockefeller endows the appropriate colleges we mustget what help we can from such papers as PhysiologicalReviews, Science Progress, Nature, and the presentspecialised biological quarterly. Biology moves fastnowadays, and it is of real importance that medicalmen should have such means as can be provided forkeeping themselves aware of what is being done ;for medicine is a branch of biology, it has much toreceive from general biology, and it has much tocontribute from its own unique experience ; man isstudied on a far greater scale and in much more detailthan any other animal. We welcome, therefore, this

attempt to make some of the modern developments ofbiology available for the ordinary reader. It is editedby Prof. Raymond Pearl and R. W. Hegner, of JohnsHopkins University, the form is tolerably agreeable,and the difficulty of reading the long lines of a quartopage is obviated by printing in double columns. Thearticles in this number deal with the mammaliantestis and scrotum, symbiosis among animals, especi-ally termites, experimental morphogenesis of thenervous system, the influence of the length of daylighton the growth of plants, recent work on the amoeba.and adaptation ; there are as well notices of recentbiological books. ____

HERPETOMONIASIS.

STUDIES 1 carried out by Dr. Jaroslav J. Drbohlavin the Department of Comparative Pathology at theHarvard Medical School serve to clear further theground for the consideration of the probable, andpeculiar, r6le of Phlebotomus species in the trans-mission of human leishmaniasis. Wenyon, investi-gating Oriental sore in Bagdad in 1910, found aherpetomonad in a Phlebotomus, and recent work byothers has, at least, gravely implicated this fly as thevector of kala-azar and Oriental sore. Laveran andFranchini (1913-20) reported the successful inoculationof certain insect and plant flagellates into laboratoryanimals. They concluded that a relationship existedbetween the herpetomonads of insects and leish-maniasis. Fantham and Porter (1914-15) from theirown experiments went further in claiming thatleishmaniasis is herpetomoniasis of almost general-insect origin, and especially that canine kala-azaris herpetomoniasis due to Herpetomonas ctenocephali,a flagellate occurring in the dog-flea. This flea wasclaimed by Basile (1912) to be the specific host ofLeishmania infantum. About 115 species of herpeto-monads have been reported, 96 of them in insectsand arachnids. If the conclusions of Fantham andPorter be accepted, then flagellates from variousinsects should produce infections in mammals similarto, if not identical with, the leishmaniasis thatoccurs spontaneously. A considerable number ofother investigators experimenting with the same

species of flagellates, injecting them in the same wayinto the same or other similar species of animals,obtained negative results. The results of Drbohlav’swork are in entire agreement with these investigators-viz., Wenyon, Novy, Macneal, Torrey, Bruce, Chatton,Delanoe, Rodhain, Pons, V. d. Branden Bequaert,Noller, Tyzzer, Walker, Patton, Sundara Rao,Glaser, and Becker.

I Inoculation of Herpetomonas ctenocephali of the dog-flea, from both old and freshly isolated cultures,into warm- and cold-blooded animals was invariablyunsuccessful in Dr. Drbohlav’s hands. The parasitesrapidly degenerated and diminished in number, fewcould be found after six hours, and none after 24 hours.Up to three hours the parasites could usually berecovered in culture. Crithidia from the water strider,Gerris remigis, inoculated into mice, rats, and frogsgave negative results. The inoculated flagellatesdisappeared in six hours. Herpetomonas mU8carumfrom the gut of Lucilia genus, and from freshlyisolated cultures, inoculated into mice, rats, andfrogs, and the same monkey as that used for(unsuccessful) inoculation of flea flagellates, producedno infection. Several species of plants of genusEuphorbia and a species of Asclepias were all foundfree from flagellates. In hanging-drop preparationsfrom these Euphorbiacese inoculated with Herpeto-monas ctenocephali, H. muscarum, Leishmaniainfantum, and Trypanosoma rotatorium motile formswere present after five days; but there was nomultiplication and all forms degenerated and weredead after six days. The Euphorbise were inoculatedwith different cultures of herpetomonad flagellates,but no forms were found in the latex. In no animal

1 Studies on the Relation of Insect Herpetomonad andCrithidial Flagellates to Leishmaniasis, Amer. Jour. ofHygiene, vol. v., No. 5, September, 1925.