sigmoid, may be from five to eight inches in diameter and its capacity correspondingly great. One case containing forty pounds is reported. In this way an emaciated child may not actually have lost weight. The walls of the intestine show marked changes and instead of being thinned out, as would be supposed by the extreme dilatation, they are actually thickened in all their layers, especially the muscular coats, so that a hypertrophy exists as well as the dilatation. The peritoneal coat is also thickened and lacks the normal luster. There may be some staining or pigmentation, and the longitudinal bands are usually obliterated. In the majority of cases there is an enlarged and thickened condition of the mesocolon, with a rich blood and lymphatic supply. The rectum frequently does not share in the process and may even be empty in the lower portion, in which case the lower limits of the hypertrophied part may be felt by the examining finger giving the impression of a spincter-like formation. This was true in the patient from whom this specimen was obtained and which I had the opportunity to examine before operation. The examination resulted in immediate but only temporary relief from the constipation. I have found collected by Phinney nine theories as to the cause of this malformation. I am not going to repeat them all to you, but will only remark that such a number is in itself a pretty good sign that there is no one satisfactory explanation. It is known to be congenital, as cases have exhibited the marked hypertrophy as well as the dilatation at autopsy immediately after birth. It is a fact also that up to the seventh month in the foetus the calibre of the large intestine is the same as the small, the longitudinal bands have not yet appeared, and in the last two months of uterine life marked changes and greater activity of growth take place in the colon, especially in the muscular portions. That the influence which controls growth and provides for symmetry and maintains proportions does not more often miss the mark is always a source of wonder to me, and I am afraid we must be satisfied with the explanation that does not explain, that the condition is due to some perversion of the influences that control development. In this same connection it is interesting to note the similarity of congenital pyloric stenosis to megacolon. Both conditions are present at birth and both consist of hypertrophy of the muscular coats, chiefly the circular one, and both occur with much greater frequency in boys. The diagnosis having been made, corroborated by Roentgenographs and differentiated from the few things that could be mistaken for it, chiefly tuberculous peritonitis, or some chronic mechanical obstruction, we have to consider the prognosis, which is very poor with treatment or without treatment. The younger the patient the more unfavorable the prognosis. Treatment is either medical or surgical and one about as unsatisfactory as the other. Medical treatment consists of cathartics, enemata, rectal tubes, massage, electricity, exercise, diet, but if the condition is well established, it is difficult to see how medical measures can help. Drugs rapidly lose all their power, and enemata are usually retained or returned without effect. The rectal tube is uncertain and can be only a temporary expedient, and if the patient's symptoms are progressing, as they do in spite of the medical treatment, surgery holds out the only remaining hope. Duval gives a mortality of 74 per cent. with medical and 34 per cent. with surgical treatment. Lowenstein collected 59 cases treated medically, with a mortality of 66 per cent., and 44 cases treated surgically, with a mortality of 48 per cent. The ages of these patients were not given. The surgical treatment has been varied. Colostomy as a preliminary step to short-circuiting, or resection of the affected part, has been used a great many times. Appendicostomy has been done and the colon irrigated through the stump of the appendix to relieve the intestinal toxæmia, and this is less severe on a young child than a colostomy. Plication of the colon has appealed to many operators, but the results are disappointing. The ideal form of treatment is the removal of the whole of the affected bowel down to the lowest portion of the rectum, and anastomosis of the ends. In children under three years of age this is a very serious operation either when done at a single sitting or by a two-stage operation. There are many cases of successful operations recorded but they are almost entirely among older children who have suffered with more gradual development of symptoms. I have personally seen three cases, all about a year old, and all three died. The first I saw through the kindness of Dr. Stone of the Children's Hospital about a year ago. This patient was operated first by appendicostomy and by an anastomosis between the lower part of the ileum and the upper part of the rectum. The patient was a year old, a marked case, and recovered from the effects of the operation with marked general improvement for about two months, when just before it was planned to resect the affected portion of the bowel, he developed a pneumococcus peritonitis. Of the other two cases which I have seen, the first was opened in the median line by Dr. Chandler, and the colon was emptied by squeezing out its contents. There seemed to be a stricture in the sigmoid which was not so marked as to make the operator feel warranted in doing any more, but the patient died in a few days. The other case was operated on in September by Dr. Crane by the same method as employed by Dr. Stone but without the appendicostomy. The patient was in very poor condition at the conclusion of the operation, and died within twenty-four hours. Such results are the rule with very young children, but before condemning surgical treatment, the successful cases in older children should be considered, since many single reports of successful operation by different operators are recorded. The most remarkable figures that I have found were a series of five cases in 1912 by Lane, who anastomosed the ileum to the lower portion of the rectum, excising the entire colon at one operation. Only one case died, and in that death was due to the slipping of à ligature at the close of the operation, the patient dying from the shock after two days. If such results are obtained in one series of patients in the face of such hopeless conditions, I feel it is a better plan to risk the high mortality and accept the chance than flatly refuse either to operate or to recommend operation for sufferers of this type, as discouraging experiences have led many surgeons to do. HOW CAN A UNIFORM EXAMINATION BE CONDUCTED AND A UNIFORM RATING BE MADE BY THE REGISTRATION BOARDS OF THIS FEDERATION?* By N. R. PERKINS, M.D., Boston, Mass. Member of the Massachusetts Board of Registration in Medicine The fact that the above subject has been suggested as a topic for discussion at this meeting is an assumption that a more uniform method is wanted, and what little I have to say will simply be in the form of suggestions to start something. Any plan to be uniform must have three factors: uniform questions, uniform rating and uniform percentages. A threelegged stool will stand alone and give the sitter a feeling of security, but if one of the legs is removed only an acrobat can retain his seat. It would be a small matter to arrange for uniform questions for the Boards that have examinations at the same time. A part of the Boards, at least, have regular examinations in *Read at the annual meeting of the New England Federation of Examining and Licensing Boards in May, 1916. Reprinted from the Monthly Bulletin of the Federation of State Medical Boards of the United States, November, 1916. March, July and November on even dates. The time of holding examinations by the other Boards I am unable to state. The following is suggested as a tentative plan: Each examiner to submit five questions to the president and secretary of this Federation; or what might be better to the chairman and secretary of one of the State Boards; the Boards to rotate in alphabetical order. This reference board or committee is to draw ten questions by lot from those submitted in each branch, and these ten questions are to be used by each board having examinations at the same time. Should there be duplicate questions drawn, another drawing is to be made. I would suggest a scheme something like the following: Anatomy, ten questions; surgery, ten; medicine, ten; obstetrics and gynecology, five each; physiology and hygiene, five each; pathology, ten; pediatrics and toxicology, five each; when practical examinations are to be held, the examiner should send with his questions a scheme for practical work; the chairman and secretary (or committee) should decide what practical work is to be used at the examinations. Practical work in the several Boards can be arranged so as to be fairly uniform; urinary examinations, more to test the candidate's technic than anything else; patients to be examined by percussion and auscultation, locating the region where the various heart sounds are heard; microscopic slides and pathological specimens; regional anatomy and dissection; bandaging, instruments, splints and their use; demonstration of the application and use of the obstetric forceps on the manikin; use of the pelvimeter and significance of pelvic measurements; use of nose, throat and ear specula, the head mirror and ophthalmoscope. These and various other means will suggest themselves to the alert examiner. Identification of each applicant by a photograph submitted with his application; to be verified by someone known to the Board or by a notary under seal; this to be kept with his application. With examinations conducted on these or similar lines a reciprocity could be obtained, and the objections now made by many would be obviated. Let me illustrate. The examination books of this conjoined method to be kept on file in the office where the application and examination was first made for a period of years (I would put a limit on this and say that those obtaining over seventy-five on first examination) and any applicant having passed a satisfactory examination with a rating of seventy-five or more on first examination and wishing to locate in another State, may have typewritten copies of his examination papers (certified under oath by the secretary of the Board), court records if there are any, sent to the Board in the State in which he wishes to locate; this Board to pass on his A qualifications the same as if it were an original application. uniform fee should be arranged for this. I would suggest three fourths the original fee. Minor details that are applicable to each Board, either by enactment or rules adopted by different Boards, could easily be arranged for without undue conflict. Under such a plan as outlined each Board would pass on the application and if that is found satisfactory, would rate the examination papers, and if these were found satisfactory according to the standard of that Board, the applicant would be registered. The Board would be relieved from the presence of the applicant; the applicant would be relieved from the added expense and anxiety attendant on taking an additional examination, and also it would tend to make each examiner do better work, for if each one of us felt that our work was to be reviewed by members of other Boards, the incentive would be sufficient to make us extremely careful in our work. With uniform examinations and more uniform ratings applicants will have a better standing in communities where they locate; members of the several Boards will strive to do a more uniform work; individual Boards of the New England Federation will have a standing in the National Board that they only can have when back of them stand the united forces of an association like this. NECESSITAS NON HABET LEGEM* By WESLEY T. Lee, M.D., Boston, Mass. One night, my varied daily tasks performed, How long I thus remained I cannot tell: * Annual Oration delivered before the Mass. Hom. Med. Society, Nov. 1, 1916. |