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of air ; if now aspiration be applied to the upperchamber, bubbles of air will escape from the lowerand, when the aspiration ceases, a correspondingamount of fluid will be drawn into the lower cavity ;if this process be repeated sufficiently, the cavitywill be completely filled. To apply this processto the sinuses, the patient lies on the back withthe head extended so that the chin is vertically overthe external auditory meatus, two cubic centimetresof the fluid are introduced into one nostril and theother firmly closed, while the patient breathes

through the open mouth to raise the palate. Inter-mittent suction is then applied for three minutes

by means of a rubber ball and a closely fitting nozzle,to which Dr. Le Mee has added a manometer; the

negative pressure should be equal to 180 mm. of

mercury. The skiagrams are taken immediatelyin an erect posture, and the method is of value in

revealing thickening and abnormalities of the mucousmembrane as well as anatomical aberrations. The

sphenoidal and posterior ethmoidal sinuses are

the more easily filled by this method but, in anysinus which is infected, occlusion of the ostium mayprevent entrance of the fluid; in the opinion ofLe Mee and Bouchet, the non-entry of lipiodol showsthat the sinus is severely affected and must be treatedsurgically and, on the other hand, every sinus whichadmits the entrance of the fluid has a good prospectof recovery and should not be submitted to operation,even though the usual rules would appear to indicate it.They lay great stress on the value of this sign, whichit would be interesting to see confirmed in other

quarters. The time of evacuation of a sinus mayalso be studied by this method ; according to theseauthors, half the liquid has normally disappearedin 24 hours, two-thirds by the following day, andno trace remains after four days. For treatment

they claim good results from a 1 per cent. solutionof argyrol; the method is very applicable to childrenin whom the sinuses are small but their ostia large,and it is especially useful in the treatment of theposterior sinuses, which are the more easily reached,in contradistinction to other methods by whichthese cavities are particularly inaccessible.

PHYSICAL SIGNS OF BUNDLE-BRANCH BLOCK.IF there are physical signs of bundle-branch block I

which may be elicited by ordinary clinical methodsand without the aid of the electrocardiograph, thesewill obviously be of value. Attempts have beenmade to establish a connexion between this condi-tion and certain signs discoverable at or near thecardiac apex on inspection palpation and ausculta-tion, but the relation can hardly yet be consideredproved. Dr. Maurice Campbell and Dr. S. S. Suzmanin our last issue reported the case of a patient withhypertension, paroxysmal dyspnoea, bundle-branchblock, and gallop rhythm. At a later date both theblock and the gallop rhythm had disappeared.However, both block of this type and gallop rhythmare common findings in a heart whose reserve isseriously impaired, and the two signs may occurindependently of one another. They may arisefrom a common cause-namely, the functionalinsufficiency of the heart muscle. Moreover, thecommoner form of gallop rhythm is produced bythe addition in early diastole of a third heart sound,while if bundle block be a cause of gallop rhythmone would expect the third sound to be located inearly systole. In Campbell and Suzman’s case theelectrocardiogram, taken after the disappearanceof the characteristic bundle-block curve, presents

changes which have been repeatedly observed to

precede, and in the event of its disappearance, tosucceed bundle-branch block. These consist of a

well developed ventricular predominance, with a tallR wave and inverted T wave in lead I. This picturehas usually been taken as indicating a severe degreeof ventricular predominance, but from its frequentappearance as a stage in the development or recessionof bundle-branch block, is considered by some to

represent a mild grade of this form of block. J. T.

King and D. MeEachern are of opinion that bundle-branch block can usually be recognised from physicalsigns. They find, in a series of 50 cases, a visibleand palpable reduplication of the apex-beat in about80 per cent. and a reduplication of the first soundin about 50 per cent. They have demonstrated abifid apex-beat by photographing the movementsof a straw attached to the apex directly on to a plate-a method which we owe to Parkinson-an electro-

cardiogram being taken at the same time. These

tracings carry conviction, and it may be that withthe cultivation of clinical technique a new sign ofsome value may be elicited by inspection and palpationof the cardiac apex. -

MANIPULATIVE SURGERY.

THE medical profession on the whole is broad-minded and does not shrink from acquiring informa-tion from any source provided that source can producescientific evidence for its contentions. The practicesof bone-setters have aroused the enthusiasm ofcertain sections of the public, who are unwearied intwitting medical men for refusing to learn from them.But what the public does not wholly realise is thatthere exist within the ranks of the profession ortho-paedic surgeons who make a special and profoundstudy of bone and joint diseases, who are wellversed in the presumed mysteries of manipulativetreatment and who, on account of their bettertraining, more varied experience, wider outlook, andgreater facilities do, in fact, practise bone-settingbetter and more safely than bone-setters themselves.The reason why, in spite of the existence of ortho-paedic speciKalists, unqualified practitioners continueto thrive, is because orthopaedic surgery has onlycomparatively recently become recognised as an

important specialty ; so that a large proportionof general practitioners have not had the advantageof serving their apprenticeship in the orthopaedicdepartment of their teaching hospital during theirstudent days. These practitioners are apt not to

recognise cases that would benefit by manipulation,and the patients are obliged to take the treatment intheir own hands, when they seek the advice of bone-setters, whose services can be advertised in the laypress in a way that is not open to registered doctors.The remedy for this state of affairs will come onlywhen every student is obliged to serve as dresserin an orthopaedic department before being allowedto sit for any qualifying examination. Practitionerswho have missed this valuable experience need not,however, remain without expert guidance in thisbranch of orthopaedics. Some seven years ago wehad occasion to notice favourably a book on Mani-pulative Surgery, by Mr. Timbrell Fishes,2 and onanother page of this issue will be found an apprecia-tion of a recent work by Mr. Blundell Bankart onthe same subject. Such books are useful, for it is

necessary to emphasise more strongly than hashitherto been done that orthopaedics as a specialty-is concerned not only with the prevention and

1 Amer. Jour. Med. Sci., April, 1932, p. 445.2 THE LANCET, 1925, ii., 1286.