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ambidextrous were also classified under this heading.No connexion could be found between left-handednessand mental inferiority, although in the schools contain-ing none but backward children 12-4 per cent. wereleft-handed. It was sometimes stated that theleft-handed children learned to talk later than others.Stammering or stuttering was found no oftener amongthe left-handed than amongst the right-handed.As regards heredity, the mothers of left-handedchildren were often " latent left-handers " themselves.Genealogical studies relating to private patients hadconvinced Dr. Neurath that transmission fromparents or grandparents is frequent, and mostly onthe female side. The left-handed, he believed, werenot degenerate ; they were merely variations, a littlehandicapped by their condition, because of the pre-valence, in present times, of right-hand instruments,customs, and work. The aetiology of left-handednessis a subject for much speculation. It was not yetknown. Dr. Neurath stated, whether intra-uterinepressure, pre-natal or post-natal effects of posture,or variations of brain circulation may be heldresponsible for the condition. From an educationalstandpoint it was inadvisable to promote an ambi-dextrous habit ; a child should be educated to makeuse of the right hand in the customary way, althoughthe left hand should not, of course, be neglected.

Vienna Summer Health Report, 1922.The recently-published quarterly report of the

Board of Health shows that normal health conditionsare gradually being regained. No case of hungeroedema has been recorded for six months. The

number of tuberculous children is constantly diminish-ing, although the figure is still above the pre-war level.Whilst from 1917 to 1919 the chief increase in mor-tality was among infants and children, as well as of theaged, infantile, and child mortality, in spite of theregular summer rise of the death-rate due to enteritis,now constitutes a much smaller percentage of thetotal of deaths. The death-rate of aged people(70 and above) also shows a decline. The summer of1922 (till the end of September) was remarkable for itslow morbidity. Although the weather was not verybright there was an excess of rainfall of over 27per cent. over the average-general health conditiorswere quite satisfactory ; summer diarrhoea was

scarce, and September was one of the healthiestmonths on record during the past ten years. In fact,were it not for a marked frequency of tonsillitis,it would have been the healthiest of all. But a marked, although slow, increase of pathological conditions ofthe circulatory system is observed all over the country,especially amongst males, whilst there is also an

increase in diseases of the nervous system. Affectionsof the respiratory tract still constitute the largestpercentage of total morbidity.

Deaths in the Medical Profession.The medical faculty of Vienna has recently lost two

of its oldest members, of whom one at least was wellknown all over the world-namely, Prof. HeinrichObersteiner, the learned neurologist, who was born in1847 in Vienna, and soon after completing his studiesturned his attention to the problems of the nerve-tissues. When 20 years old he published his firstpaper on the pathology of nerves, and every year sincethat time he continued to contribute one or moreimportant works to the subject. In 1882 he founded,at his own expense, the Vienna Neurological Institute,which served as a model for numerous similar insti-tutions in many countries. Obersteiner was the firstto define the pathology and aetiology of tabes. Hisopinions on concussion of the medulla and on generalparalysis of the insane, and his studies on heredity innervous diseases are still pre-eminent. His namebecame best known through his text-book on neuro-logy (1896), which was translated into French,English, Italian, Russian, and Japanese. Prof.

. Obersteiner was always prepared to assist any of hisstudents in all their personal or professional difficulties;he gave his great library of over 50,000 volumes tothe Neurological Institute, and endowed the latter

with capital sufficient to ensure its permanent working.The other death was that of Prof. Albert Bing, anaural surgeon, well known in former days. Bingwas one of the pioneers of otology, and with Gruber.Pollitzer, and Urbantschitsch he taught and practisedhis specialty in Vienna at a time when in othercountries this part of medical knowledge was scarcelynoticed. His text-book on this subject was at onetime an important manual.

Decrease of School-Children zya 1921.

The Vienna magistrates have lately published areport on the number of school-children attending the(compulsory) public schools in the city in 1921.On Oct. 15th of that year there were 171,174pupils (84,296 boys, 86,878 girls), or 6 per cent. lessthan in 1920. There were 119,246 younger than10 years, and 51,928 between 10 and 14. They weredistributed in 5046 classes, so that on an average aclass contained 34 children ; no class contained morethan 45. On the same date of this year (1922) asimilar census was taken. The drop in numbers waseven more marked. being 12 per cent. less than in1921 ; the decreased numbers were especially markedin the lowest standards (children 6 and 7 years of age).In some districts no more than 10 or 15 childrenwere sent into these lower forms, so that some classeshad to be united in order to provide reasonable workfor the teachers. This is the first year in whichthe full effect of the war has been felt in the schools ;in 1915, of course, a large proportion of the malepopulation was already on active service.

The Services.INDIAN MEDICAL SERVICE.

THE Secretary of State for India announces that appoint-ments of Europeans, to the number of not more than 30,are to be made in the immediate future to commissions inthe Indian Medical Service on special terms, which includethe right to retire on a gratuity of £1000, with free returnI passages, on the completion of five years’ service, if theofficer no longer desires to remain in the Service. Candidatesmust be under 32 years of age.

Service as an officer during the war counts for pay, pro-motion, and pension purposes, under the ordinary conditions,but not for gratuity. Officers will receive on appointmentfree passages to India for themselves and their families.Full particulars may be had on application to the Secretary,Military Department, India Office, Whitehall, S.W., andenvelopes should be marked

" Medical Recruitment."

ROYAL NAVAL MEDICAL SERVICE.

Surg. Lt.-Cmdr. G. F. B. Page is allowed to withdraw,with a gratuity.

Surg. Lt. F. H. Vey to be Surg. Lt.-Cmdr.

ROYAL ARMY MEDICAL CORPS.Lt.-Col. R. McK. Skinner retires on ret. pay.Capt. J. H. Ward retires, receiving a gratuity, and is

granted the rank of Lt.-Col.Temp. Capts. R. W. Harper and J. B. Taylor (retain the

rank of Capt.) relinquish their tempy. comnins.ARMY DENTAL CORPS.

Temp. Capt. J. S. Smith, Dental Surg., from Spec. List,to be Capt.

ARMY RESERVE OF OFFICERS.

Lt.-Col. E. A. Bourke ceases to belong to the Res. of Off.on account of physical unfitness.

Capt. A. L. Urquhart resigns his commn.Army Dental Corps.-The undermentioned Capts., late

Spec. List, to be Capts. : D. Gilmour, E. B. Armitage, T. B.Place, R. M. Wormald, J. Harris, B. J. T. Bennette, V. R.Dvke, R. A. Gunn, J. Stevens, and R. V. Kingham.Lt. F. E. S. Brailsford, late Spec. List, to be Lt.

MILITIA.

Capt. W’. R. Gardner to be Maj.Capt. C. Shaw-Crisp relinquishes his commn. and retains

the rank of Capt.TERRITORIAL ARMY.

Maj. C. S. Wink, from T.A. Res., to be Capt., and relin-quishes the rank of Maj.

I Maj. A. Milne-Thomson, having attained the age limit,is retired, and is granted the rank of Col.

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Capt. C. R. Crowther, having attained the age limit, isretired. and retains the rank of Capt.Capt. C. G. Teall resigns his commn. and retains the

rank of Capt.The undermentioned offrs. relinquish their commns. and

retain their rank, except where otherwise stated : Maj.G. E. St. C. Stockwell, Capts. I. C. Marshall (granted therank of Maj.), H. W. Robinson, and W. Combe.

Lt. 0. G. Misquith resigns his commn. and retains therank of Lt.

TERRITORIAL ARMY RESERVE.

Lt.-Col. S. G. Barling, from General List, to be Lt.-Col.Capts. T. C. Clarke and W. Sneddon, from General List,

to be Majs. -

Capt. H. W. Fethestone, from General List, to be Capt.The undermentioned offrs., having attained the age

limit, are retired, and retain their rank except where other-wise stated : Capts. J. W. Dale and J. O’Sullivan (grantedthe rank of Maj.), J. R. Holmes, J. Buckner, F. G. Bennett,G. Dick, and R. J. Isaac. -

ROYAL AIR FORCE.

Squadron Leader J. F. Carruthers relinquishes his tem-porary commission on account of ill-health contracted inthe Service.

_________________

Correspondence.

THE DRAWBACKS OF CÆCOSTOMY WITHOUTGENERAL EXPLORATION.

"Audi alteram partem."

To the Editor of THE LANCET.Srrt,-It is, I suppose, a good thing for us all to have

our cherished beliefs seriously challenged by com-petent authority from time to time. A new considera-tion of old experience may confirm us in our opinionsor persuade us reluctantly to change them. One ofthe opinions I hold most confidently asserts that indeclared cases of acute obstruction of the largeintestine (other cases are not now under discussion),a general exploration of the abdomen is both needlessand disastrous. Such exploration is needless becausein the very large majority of cases it is not difficult to discover with sufficient accuracy for the purpose oftreatment where the obstruction lies. The history ofthe case is very helpful. When a growth is on theright side diarrhoea, in the earlier stages, is the rule,and complete obstruction infrequently occurs ; whenthe growth is on the left side, obstinate and increasingconstipation is the rule, and obstruction frequentlyoccurs. Probability is the very guide of life. In casesof acute and complete obstruction of the colon theprobability is that the growth is in the left half of thecolon. A careful examination of the abdomen is veryhelpful. One may prontably spend 15 or 20 minuteswith the hand gently passing over the surface of theabdomen ; distended intestine may be felt to hardenand relax and the site of the growth in that way bedisclosed. And a stethoscope is not without its use.To explore the abdomen in the very great majority ofcases is therefore quite needless. In a small numberof cases it is true the obstruction may be due tocauses other than growth : to volvulus of the rightcolon, or of the sigmoid flexure. Of the latter I haverecently had two cases ; in both the abdomen wasopened by an incision displacing the left rectusoutwards. The anamnesis and the physical examina-tion will rarely fail to clear up any doubt in thediagnosis of such conditions. A general exploration,moreover, is apt to prove disastrous. The patientsare often very ill and suffer always from toxæmia.An obstruction in the colon does not cause serioussymptoms in its earlier stages, and in consequencedelay in resorting to surgical treatment is rarelyavoided. When the colon has been completely blockedfor many days a general exploration is attended bydifficulties which tax the skill of the surgeon and thestrength of the patient to the uttermost. The bowelis enormous, the growth often small, the patientperhaps obese. A deep degree of anaesthesia is

inadvisable, and a satisfactory examination withoutit may be impracticable. If a growth is found in thesplenic flexure, let us say, what happens ? To mobilisethe growth and perform Paul’s operation, which attimes is extremely useful, is probably out of the ques-tion in some subacute cases, and is certainly not to beconsidered if the obstruction is acute. The practicewould probably be to stitch up the exploratoryincision and to perform cæcostomy. Time wouldhave been wasted and no one would be the better.What should have been done first is done last. Iconsider that such a procedure would certainly expressitself in a heavily increased mortality. Is it notpandering to untimely curiosity ?

Prof. Pannett in TI-IE LANCET of Dec. 2nd tells usthat to make the procedure of cæcostomy withoutgeneral exploration or routine will " land us oftenin rather an unfortunate predicament."

" Old experience doth attainTo something like prophetic strain."

The prophecy in this statement has not yet beenfulfilled in my own case, nor in that of others withwhich I am very familiar. The procedure on thecontrary has relieved my anxieties on many occasions,and, in my judgment, has saved the lives of largenumbers of patients who would have died if more thanthis had been done to them. Prof. Pannett alsosuggests that there may be difficulties at the secondaryoperation if " blind csecostomy

" has been performedat the first ; the incision may be made on the leftside when the growth is in the hepatic flexure and.4 unnecessary mutilation " take place, if colectomy isperformed through the wound then made. If there issuch a fear why not stitch up the first wound and makea second exactly where it is wished to have it ? Ifit presents " few difficulties

" when the case is acuteit will present none when the time for operation ischosen in a tranquil period by the surgeon. It issurely better to do this occasionally, in a deliberateoperation quietly performed upon an unobstructedpatient, than to have to do it always or often in anobstructed patient who is gravely ill. Perhaps I have ehad a little luck in having found it necessary to changefrom one incision to another once only in the casesI am now reviewing, and the word " mutilation,’’whether necessary or unnecessary, is one which makesme shudder, and revolts my sense of the artistrywithout which the craft of surgery is nothing. lIymost profound and confident belief in connexion withthis phase of intestinal disease is that our immediateand paramount duty is to relieve the obstruction, andbeyond that to do nothing. Anxiety to know wherethe growth is, whether it can be removed, whetherthere are secondary growths in the liver or elsewhere,or indeed to know anything more of the intra-abdominalconditions than that there is obstruction to be relieved,is not permissible. When the obstruction has passedaway, and the patient is duly prepared for a secondoperation, then all the time that is needed may beexpended in this kind of research. The challenge tothis opinion leaves me more than ever sincerelyconvinced of its accuracy.

I am- Sir. vours faithfullv.

I Leeds, Dec. 3rd, 1922. --,

BERKELEY MOYNIHAN.

To the Editor of THE LANCET.SIR,-Prof. C. A. Pannett in his letter on this

subject in your issue of Dec. 2nd gives a very ablecriticism of my paper published in the previous issue,and as the subject is one that naturally lends itselfto criticism, indeed invites it, I trust you will give mespace to briefly reply to his remarks.

Prof. Pannett’s chief objection to the performanceof cæcostomy in cases of acute obstruction due togrowth in the colon without a preliminary explorationis that it leaves the surgeon in the dark as to the exactposition of the growth, and that our means of diagnos-ing the situation of the lesion by means of X rays,&c., are often unsatisfactory. With this, of course,I agree, but on the other hand he will agree with methat when the patient is suffering from acute obstruc-