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not generous, and in my opinion shows a want of professionalgood feeling, to increase his trouble by useless censures.

I am, Sirs, yours faithfully,GEORGE TURNER

Medical Officer of Health, Transvaal; and MedicalSuperintendent of the Pretoria Leper Asylum.

Pretoria, Sept. 18th, 1935.

VARICOCELE—WHAT OF IT?To the Editors of THE LANCET.

SIRS,-It is earnestly to be hoped that the able letters ofColonel F. Howard, Mr. Harrison Cripps, and Mr. Edred M.Corner on the subject of varicocele may have the effect ofcompelling the authorities to take a more just and sensibleview of the question of varicocele as it affects the recruit. Itis one in which I personally have long been interested, sincefor several years I experienced the discomfort of varicocele asa soldier, and am now, like many others in the medical pro-fession, frequently called upon to operate for this conditionin order to satisfy the requirements of the services, a largenumber of recruits coming constantly under the care of my.colleagues and myself in the wards of the DreadnoughtHospital. I may therefore lay claim to have viewed the

question from both of its aspects-viz., the military and themedical. During the period of my service in a horse regi-ment, a matter of four years, I suffered from an unusuallylarge varicocele which appeared at the age of 15 years. Theintermittent aching and sense of dragging in the loin andgroin which the condition caused me were as severe (so faras I have been able to satisfy myself) as is usual in theworst cases. During the whole of the period in question Iwas actively employed in my profession both on mountedand dismounted duty, to say nothing of long days of hunt-ing, polo, &c., and that without the use of any suspender.On no occasion was I off duty on account of my condition ;therefore, if any organic change actually takes place in the ’,testis as the result of persistent varicocele, such changeshould undoubtedly be present in my own person ; yet suchis not the case ; fibrosis is entirely absent and no varicocelehas been present for over ten years. Looking back on theperiod of my service I can recall no single instance of anyman in my regiment being reported unfit for duty on

account of varicocele. My own case is only one of several within my recollection.

Considering the question from the surgical standpoint,I am (it is true with a very much more limited ex-

perience) entirely of Mr. Harrison Cripps’s opinion,that the evils of varicocele have been grossly exag-gerated. Although I have seen and examined a verylarge number of these cases and of cases in which thecondition was once present, I have never seen one inwhich I could satisfy myself that any serious degenerationof the testis had taken place, and certainly none in whichatrophy was present. If this opinion is shared, as I believeit to be by the majority of surgeons, I fail to see why anycomplaint of inability to perform duty on this accountshould be taken seriously in any of the services. If dis-comfort and aching are honestly complained of an efficientsuspender will meet the case ; if after the application ofsuch the complaints persist the bona fides of the patientwho seeks exemption from his duty on this account mustbe open to suspicion. That so many young recruits should be

compelled to submit to an operation so unnecessary andoften so unjustifiable is a matter calling for the serious con-sideration of the profession. As matters stand at present itis useless to refuse operation ; such would condemn a willingrecruit to disappointment and the public service to the lossof a good servant. The hidebound rule in respect to varico-cele, defective teeth, and similar minutias has become afetich of the worst type, alike dishonest to the public, whichit annually robs of thousands of good soldiers and sailors inyears already lean to the recruiting officer, and degrading tothe medical profession which is largely responsible for its continued existence.

I feel sure that if the matter were made, as it certainlyshould be, the subject of investigation by the Royal Collegeof Surgeons of England, the services would be the gainers bythe loss of a miserable rule of thumb and the richer by manythousands of willing servants. Men who are ready to undergooperation for large varicoceles for the privilege of entering thearmy or the navy are little likely to prove malingerers, whilethose who have small ones do not require operation, and inthem malingering cannot be serously considered. Personal

experience has shown me that case after case is sent for opera-tion which is of so trivial a nature as not even to require theapplication of a suspender. That such a flagrant abuse ofsurgery has been allowed to exist so long unchallengedspeaks volumes for our professional apathy.

I am, Sirs, vours faithfully,Mansfield-street, W., Oct. 5tb, 1905. LAWRIE McGAVIN.

To the Editors of THE LANCET.SIRS,-May I through your columns call attention to a

point which has not hitherto been touched upon in the

correspondence re the operation for varicocele—I mean the

probable excision of the nervous supply of the testicle

together with the spermatic veins. I have it, on theauthority of an eminent anatomist, that the nerve-supply ofthe gland runs in close continuity with the spermatic artery,which itself usually lies just behind the anterior group ofspermatic veins. I think I am right in saying that in a largenumber of the operations performed for the relief of varico-cele no attempt is made to dissect the spermatic artery awayfrom the veins, the structure to which most care is directedbeing, very properly, the vas deferens. Along this latterstructure run the artery to the vas and a few filaments fromthe hypogastric nervous plexus, these filaments havingpractically no influence on the nutrition of the testicle itself.I would therefore venture to raise the question as to whetherthe excision of the nerve-supply of the gland is not fre-quently the cause of those fibrotic and atrophic changeswhich are, as has been previously stated in your columns, sooften met with after the operation. There is, as far as Iknow, no other gland in the body the nerve-supply ofwhich can be cut away without its undergoing some

physiological change of an atrophic nature, and I should beglad to know the opinions of others on this which seems tome to be a most important point in the technique of theoperation for varicocele.

I am, Sirs, yours faithfully,C. A. S. RIDOUT, M.S. Lond., F.R.C.S. Eng.

Royal Portsmouth Hospital, Oct. 10th, 1905.

To the Editors of THE LANCET.

SIRS,-I have just returned from a lengthened stay abroadand the correspondence under the above heading which hasappeared in THE LANCET, beginning with Colonel F. Howard’sletter of Sept. 23rd, has been brought to my not:ce. MayI trespass briefly on your valuable space to say that I served3 years in the army and for ten years was divisional staff

surgeon in important districts and during that time I neveronce saw an officer incapacitated for duty from varicocele.I feel quite certain that the practice of operating in thesecases is altogether unjustifiable. It must be rememberedthat the operation is performed at the age when the sexualfunction is springing into activity in youths whose vascularsystems are relaxed from the sedentary habits which hardstudy involves. The disastrous consequences in manycases of this operation are notorious and need not be dweltupon. In my opinion greater latitude should be given tomedical boards and their discretion should not be so

fettered. Slight varicocele should not disqualify. In anycase medical boards should cease recommending the opera-tion as essential for the acceptance of candidates. A youthis either fit or unfit and with these recommendationsmedical boards should cease to have anything to do ; theyare ultrcc vires As to varicocele in the private soldier, thatis another matter ; it is no doubt a valuable asset to a soldierwho wishes to shirk a hard day’s work.

I am, Sirs, yours faithfully, WILLIAM HILL CLIMO, M.D. R.U.I.,

Lieutenant-Colonel, Army Medical Staff (retired).

I Earl’s Court, S.W., Oct. 9th, 1905.

CHRONIC PARALYSIS OF THE INTER-COSTAL MUSCLES AS A PRIMARY

CAUSE OF DROPSY.To the -Editors of THE LANCET.

SIRS,-The case published by Dr. Goldwin W. Howland inTHE LANCET of Oct. 7th, p. 1035, under the above title is ofconsiderable interest as showing the important part whichthe respiratory muscles take in maintaining the normal cir-culation. The patient is a lad, aged 17 years, who, as the

1140

result of damage to the lower cervical cord, has been com-pelled for the last four years to rely upon the diaphragmalone for carrying on the movements of respiration, and thisrespiratory paralysis has so far interfered with the circula-tion that within the last few months dropsy, first in the

legs and then more generally, has made its appearance, anevent which Dr. Howland attributes to venous obstructionconsequent upon "diminished expansion in the upper lobesof both lungs," adding that it may partly also be due to " adiminution in the negative intrathoracic pressure."

Dr. Howland apparently assumes that the paralysis of ribbreathing has led to deficient expansion in the upper part ofthe lungs only. Are we not, however, safe in postulating ageneral shrinkage of the lungs in this case ? for when thecostal elevators are paralysed all the ribs, and not the upperones only, tend, especially if the subject be young, to drop,thus causing a flattening of the thorax sagittally throughoutits entire length. It has further to be remembered that,owing to the free mobility of the lungs within the chest,diaphragmatic breathing tends to cause them to expandequally in all their parts. I should therefore expect to findin this patient a generalised pulmonary shrinkage. Suchshrinkage, whether we assume it to be partial or general,augments, as Dr. Howland observes, the resistance in thepulmonary circuit, this resistance being in inverse ratio-to the degree of pulmonary expansion-i.e., it is greatestin full expiration and least in full inspiration. Whileadmitting, however, that in the patient under discussionthe augmented pulmonary resistance tends to obstruct thevenous circulation, I am doubtful whether it has playedany large part in the production of the dropsy. For this Ishould regard the second factor to which Dr. Howland refersas chiefly responsible.With the pulmonary shrinkage resulting from the paralysis

of the costal elevators the stretched pulmonary tissue relaxesand there occurs a fall-probably to the point of extinction- in the suction which the lungs normally exercise on theinterior of the thoracic walls and on the mediastinal contents,including that very important organ the heart. The stretchedcondition of the lungs which results in "negative intra-thoracic pressure," or, as we may more briefly term it,"pulmonary suction," depends, in fact, upon the properaction of the inspiratory muscles. I have elsewhere arguedthat the essential purport of this pulmonary suction is toaid the diastole of the heart, notably of the auricles, and theright one in particular, and in this way to promote the flowof blood into the heart; and if such is the case it followsthat the inspiratory muscles play a highly important partin aiding the circulation. These muscles are, I submit, fromthe beginning to the end of life ever on the watch tomaintain suction action on the heart so that this organshall always 7vork in a partial vaC1lU1I1. Directly they fail inthis the heart must work at a great disadvantage, and when,as has apparently happened in Dr. Howland’s patient,pulmonary suction is permanently done away with gravedisturbance of the circulation is bound to follow.So far as I am able to judge the view that the respiratory

movements of the lungs aid the circulation of the bloodrests on no solid foundation. These movements do, however,promote the flow of lymph in the pulmonary lymphaticsowing to the fact that these vessels are provided withvalves. Hence deficient movement of the lungs favours thestagnation of the pulmonary lymph flow, and this may havepredisposed to dropsy in the patient in question.The great disadvantage under which the diaphragm acts

in this case may constitute another factor in the pro-duction of the disturbed circulation ; for while the rhythmicmovements of the lungs do not aid the flow of blood, therhythmic descent of the diaphragm, by compressing theintra-abdominal veins, normally promotes the return ofblood along the inferior cava ; but in order that the

diaphragm may effectively perform this function, it mustnot only be able to contract vigorously (to which end otherrespiratory muscles must simultaneously contract) but mustbe duly opposed by firmly contracted abdominal muscles soas to insure the necessary increment in intra-abdominal

pressure ; and neither of these requirements obtains in Dr.Howland’s patient.

In conclusion, I would urge that the influence on thecirculation of respiratory paralysis deserves closer study thanit has yet received. In children suffering from idiopathicmuscle palsy the respiratory muscles are generally sooner orlater paralysed, the lungs shrinking in consequence ; and inall cases of this kind which I have had the opportunity of

studying the heart has been manifestly embarrassed—cir-cumstance which I have been in the habit of attributing,rightly or wrongly, to diminution, if not actual extinction,of pulmonary suction. Cases like Dr. Howland’s, in whichthe spinal cord is blocked just below the origin of’thephrenic nerves, are also of great interest in this connexion.His case, from its unusual duration and the ultimatesupervention of dropsy, deserves, I would suggest, tobe recorded in detail, more especially in regard to the

cyrtometric tracings at different levels of the chestand the exact condition of the individual respiratorymuscles. On the strength of the author’s assertion that

’’ respiration has during the last four years been carriedionentirely by the diaphragm," I have assumed all of thesemuscles, with the exception of the last, to be paralysed. Onthe other hand, he attributes the occurrence of the dropsy to" chronic paralysis of the intercostal muscles," which ratherleads one to question whether he regards all the respiratorymuscles other than the diaphragm as being completelyparalysed. It seems, indeed, hardly possible for respirationto be carried on for a number of years under such adverseconditions. I am, Sirs, yours faithfully,Wimpole-street, W., Oct. 8th, 1905. MARRY CAMPBELL.

NEXT YEAR’S ELECTION OF DIRECT RE-PRESENTATIVES TO THE GENERAL

MEDICAL COUNCIL.

I To the Editors of THE LANCET.

SIRS,-The British Medical Jo2cr7aal of Saturday last statesthat the medical secretary of the British Medical Associationhas sent a communication to the honorary secretaries of thevarious divisions of the Association in England and Wales,calling upon them to make arrangements for the selection oftwo candidates to be supported by the Association at nextyear’s election of Direct Representatives to the GeneralMedical Council. Under the scheme of the Association eachsuppliant for the support of the Association will be called uponto sign a "declaration" to the effect that if not selected bythe Association for nomination, he will not allow himself" to be nominated as a candidate in opposition to any can-didate so selected." Further, he has to agree, if elected, todo as he is bid by the bodies constitutionally authorised toinstruct him on behalf of the Association 1 In no circum-stances could I sign such a declaration and therefore myname will not be submitted to the divisions of the BritishMedical Association as a candidate. It is, however, myintention when the proper time arrives again to solicit the

support of my brother practitioners as an independent can-didate. Trusting to your courtesy to publish this announce-ment and thanking you in anticipation,

I am, Sirs, yours faithfully,GEORGE BROWN ,

A Direct Representative for England and Waleson the General Medical Council

I Callington, Cornwall, Oct. llth, 1905. --"’W’ ...._..._.

THE RADICAL CURE OF HERNIA.To the Editors of THE LANCET.

SIRS,-My attention has just been called to the numberof cases of radical cure of hernia mentioned in a paper ofmine which appeared in THE LANCET of August 26th, 1905,p. 594. In that paper, owing to a misprint, the number ofinguinal cases is given as 6 ; comparison with the totalnumber will, of course, show that this should be 76, the firstfigure having been omitted. May I ask you to correct this inyour next issue.-I am, Sirs, yours faithfully,

-

Manchester, Oct. 11th, 1905. E. STANMORE BISHOP.

THE PRESENT STATE OF MEDICALPRACTICE IN THE RHONDDA

VALLEY.lo the Editors of THE LANCET.

SIRS,-I have read with interest the article in THE LANCETof Oct. 7th, p. 1065, entitled " The Present State of MedicalPractice in the Rhondda Valley" and I wish to say that Ithoroughly endorse the statements and opinions contained