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thyroid has been removed, is often prescribed ; it probablyacts, if it acts at all, in the same way as Moebius’s serum.If the patients are very restless and excitable, it is of theutmost importance that they should be kept quiet, and inextreme cases hyoscine is certainly the best drug for this.I remember seeing a man, aged 30, who had acute ex-

ophthalmic goitre following influenza ; he had great tremor,was extremely restless and sleepless, and so ill that it wasthought he would die. After a subcutaneous injection oftryoscine, 1/100 grain, he slept for the first time for a longwhile, and ultimately got quite well. For less severe cases

paraldehyde is very useful, and for still less severe cases Iusually prescribe bromides. If there is much tachycardiait seems only natural to give digitalis, and sometimes thepatient seems better for it. The ansemia from which patientssuffer usually passes away as they improve.

(Readers who wish for the details of each of the cases herementioned will find them in the Quarterly Journal of Medicine,Tol. iv., No. 13.)

A Post-Graduate ClinicON

RECURRING ARTERIAL HYPERTONUS INGRANULAR KIDNEY AND IN

MIGRAINE.Delivered in the Royal Infirmary, Edinburgh, on Sept. 6th,

1910,

BY WILLIAM RUSSELL, M.D., F.R.C.P.EDIN.,PHYSICIAN AND LECTURER ON CLINICAL MEDICINE, ROYAL

INFIRMARY, EDINBURGH.

GrENTLEMEN,—There are two patients in the adjoiningward whom you will have the opportunity of seeing andexamining for yourselves after I have given you an accountof the clinical phenomena which have been noted in themduring the time they have been in the ward.

GRANULAR KIDNEY.

CASE I.-The patient is 52 years of age. She has had acheckered life, has been in this infirmary and in the work-house hospital on more than one occasion for various ailments,and she frankly acknowledges to having been fond of agood big dram." The details of such a life do not require tobe dwelt upon ; the results of it at 52 years of age areillustrative of a large group of cases, not all, however,presenti-ng a personal and social history of hard work, poverty,ill-treatment, and bad habits. The patient was admitted onJune 10th, 1910. She stated that for some weeks she hadbeen breathless, especially on going upstairs, while latterly itwas continuous ; she also suffered from attacks of dizziness;her legs also at times became weak and shaky, and she haddifficulty with her speech at times-she stammered andcould not get the words out. She sought advice at the

Cowgate Dispensary, was recommended to the infirmary,and was admitted under my care.On admission the pulse was 80, the respirations were 24,

the temperature was 970 F., and the brachial pressure was295 mm. Hg. She was kept in bed, put on milk diet, andwas given a dose of Henry’s solution at night. The radialartery was thickened, but did not give the impression of any-thing like the pressure given by the brachial. The heartdulness at the apex was in the nipple line ; the sounds wereclear and slapping, and there was no murmur. The lungswere emphysematous but otherwise normal. The urine hada specific gravity of 1017, and showed a faint trace ofalbumin. The blood count and the amount of haemoglobinwere normal. The bowels moved once or twice daily. Bythe 14th the pressure had fallen to 185 mm. Hg. She wasthen given 5 grains of potassium iodide three times a day.On the 18th the pressure had fallen to 165 mm. and she wasallowed light diet, which includes chicken and fish.From that date to July 2nd the pressure varied from165 to 210 mm.-the level being somewhat higher afterthe increase in her diet than before that. On theforenoon of July 4th she was not so well, and, when I

saw her, her face was flushed, she was propped up in bed

with pillows, she looked dazed, and when spoken to couldnot articulate ; the pulse was rather over 100, the respirationswere 24 and laboured, and the brachial pressure had risen to268 mm. She was given erythrol at once, and at night had adose of mannitol. She rapidly regained her ordinary condition,had a good night, and next morning the pressure had fallento 190 mm., and she felt in her usual health. On August 12th,with her pressure only at 202 mm., she complained of head-ache, a tingling sensation in the right limbs, right side of thetrunk, and in the corresponding side of the tongue. Thesesensations continued, and she was given erythrol. On the14th the pressure was 186 mm. On the 30th the patientwas noted to be particularly well in the morning, but atabout 6 P.M. she became restless; at 7.30 she com-

plained of violent pain in the head, was breathless, and haddifficulty in articulation ; at 8.15 the pressure was 258 mm.and she was given erythrol ; and at 9.30 the pressure hadfallen to 207 mm., and as she was drowsy she was notdisturbed again, and she soon fell asleep. The followingmorning the pressure had fallen to 175 mm., and since thenshe has been in her usual condition, the pressure keepingabout 200 mm.The course of the pressure may be tabulated thus :-

This patient is suffering from the effects of granularkidney and extensive arterial change, and I bring her casebefore you to illustrate the clinical lessons such a case

supplies, and to impress upon you some points which it isof the first importance for our patients that we shouldunderstand the true significance of and be able to treat

intelligently, and then, happily, successfully up to a certainpoint.You will note that this woman on admission had a vessel

pressure of 295 mm. Hg, one of the highest pressures I havehad in this ward, and that rest in bed, the administration ofa saline purge, milk diet, and later 5 grains of potassiumiodide thrice daily brought the pressure down from100 to 130 mm. During the period she has been in

hospital she has sometimes shown symptoms whichare classed as ursemic, such as restlessness, incoherence,dyspnoea ; at other times, symptoms that are regarded aspremonitory of cerebral haemorrhage or cerebral softeningfrom local anaemia or thrombosis, such as tingling in one-half of the body, confusion of thought, difficulty in articula-tion, even loss of articulate speech. She has had severalminor manifestations in one or other of those directions ; butshe has had two or three graver attacks, in the first of whichI was fortunate enough to see her and at once to recogniseits nature. In all these attacks I ask your attention to thefact that the pressure showed a great rise-a rise whichwould doubtless have risen still higher had it not beenarrested by therapeutic interposition. With such inter-

position, however, the pressure fell, as on July 4th, from 268to 190, and on August 30th from 258 to 175 mm. With the fallof pressure all the urgently alarming symptoms disappeared;in fact, the arrest of its upward movement, and a fall evenof 15 or 20 mm. brought visible relief to the symptoms,and this was effected in a remarkably short space of time.The association of a marked rise in basmomanometer readingwith such symptoms as I have indicated is in my experiencealways to be noted.

Neither the ordinary pressure nor the rise in pressure inthese cases can always be estimated correctly by the fingeron the radial artery. None of you would guess from thispatient’s radial artery that the pressure would be as high asit is ; indeed, those of you who study blood pressure by thefinger will think that it is even lower than normal. I entirelyagree with those of you who may think so. The finger, Ihold, is the only means by which you can estimate true bloodpressure. True blood pressure to the clinician means thepower of the left ventricle, and nothing else, as that can beestimated by the finger on an artery. The basmomanometer

reading, on the other hand, is only in part the result ofblood pressure. The patient we are considering has

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a variation in her hasmomanometer reading from 295to 165-a margin of 130 mm., and certain eminent

persons would ask us to believe that this is the

margin of power in this woman’s left ventricle, a marginwhich no healthy man in this room possesses. But I do not

propose to argue this point : I have done that in other places.I merely state that this great margin of pressure, that thesegreat variations in pressure, indicate to us the condition ofthe arterial wall-the degree of hypertonic contraction, or ofrelaxation of it. The armlet being applied to the upper armgives us the condition of the brachial artery, which every nowand again differs greatly from the bit of radial artery to befelt at the wrist. This observation as to the state of thebrachial artery, added to your examination of the radial

artery and pulse, you will find a great help in estimatingcorrectly the state of the circulation in your patients.Let me repeat that in this patient we had, and will have

again, symptoms of uraemia., and symptoms which presagecerebral softening or haemorrhage ; that when these threaten-ings are present the haemomanometer reading is found tohave risen many millimetres. My contention is that the raisedreading is due to hypertonic contraction of the artery fromwhich the reading is taken. The symptoms are associateddefinitely with this phenomenon, for the moment you arrestthe constrictive action the symptoms begin to disappear,and altogether disappear with the cessation of the hypertonusand the consequent fall in the hsemomanometer reading.To you as graduates in medicine I need not labour to

prove the great value, therefore, of this instrument, if

you use it aright and interpret its readings correctly.I shall only ask you to realise what the phenomena arewhich are commonly recognised as presaging paralysis,hemiplegia being the commonest, associated or not with

aphasia. Very many of these cases are preceded for days orfor longer periods by recurring sensations of numbness or

tingling, by temporary slight loss of power in a hand, anarm, a leg, difficulty in articulation, temporary loss ofspeech, feeling of mental confusion, temporary loss ofmemory, and so on. All these you will find associated witharterial hypertonus and a high baemomanometer reading.The nervous phenomena can only be explained by the par-ticipation of the vessels in varying parts of the brain in a con-striction in which the whole systemic circulation is affected.These local angiospasms in the brain lead to anaemia of theareas involved, the clinical phenomena being referrable tothe areas so affected. The angiospasm in brain areas

favours thrombosis, and its consequent deplorable brain

softening, or leads to haemorrhage on the heart side of theregion of spasm.Now I unhesitatingly assert that if these phenomena are

duly observed, correctly correlated and interpreted, youhave it in your power in many instances to save your patientsfrom disaster, preventing their being deprived of the powerof locomotion, of speech, of mental power, perhaps for yearslonger than would otherwise be the case.The patient who is the text of these remarks is but one of

many similar cases I could describe to you. I am glad thata case of the kind happens to be in the ward at present, sothat you may see the case and note the difference betweenthe radial pulse and the high pressure required to obliteratethe brachial artery, and realise that this simple instrument,the hasmomanometer, is really a great help in your every-daymedical work if you use it as a guide to the state of thevessel wall more than as a guide to blood pressure, althoughin other classes of cases it can even help you in judgingof that.

MIGRAINE.CASE 2.-The second case to which I ask your attention

is also of interest, although not of such urgent importance asthe preceding one. The patient, a woman aged 49 years,was sent to me in May, 1909, by Dr. W. C. McEwan ofPrestonpans as she was suffering from migraine, having anattack almost every week, the attack lasting three or fourdays. At that time the radial artery was small and wiry andthe brachial pressure 150 mm. Hg. The bowels were consti-pated, the tongue coated, the breath offensive, and there was atrace of albumin in the urine, which also showed much indican.I advised that she should have a laxative pill nightly ofcascara, belladonna, and nux vomica, and iodide of potassiumthrice daily. Under this treatment she improved, but as theattacks returned she was again sent to see me and was admittedinto the adjoining ward on August 12th, 1910. On admission

the pressure was 205 mm. She was treated with enematato unload the bowel and got a colocynth and hyoscymus pillto keep the bowels moving. Under this treatment and restin bed the pressure fell and kept between 164 and 172 mm.On August 21st the pressure was 164 mm. On the 23rd, inthe evening, she complained of headache, vomited twice, andshe knew that one of her attacks had begun. She vomitedseveral times during the night. On the 24th her conditionwas unchanged, she vomited twice, and the pressure was192 mm. On the 25th her condition still remained thesame, and the pressure was 194 mm., when she was

given a quarter of a grain of erythrol, the hour being12.25 P. M.; by 12.55 the pressure had fallen to 142 mm. ;.by 1.50 it had risen to 168 mm., and by 7.45 to 179mm.On this date (the 25th) she vomited six times between1.30 P.M. and 9 o’clock, and as her symptoms were

not at all relieved by the fall of pressure produced bythe erythrol the drug was not repeated. On the 26th theheadache was much less and the vomiting had stopped.The attack had lasted part of three days. On the 27th therewas neither headache nor sickness, and the pressure hadfallen to 138. On Sept. 1st the pressure was rerorted asrising steadily and had reached 172. The patient thoughtshe was to have another attack, as she had a feeling of ful-ness in the right arm, a symptom she had noticed previouslyas indicating the approach of an attack. On the 2nd, inthe morning, headache began, and at 10.30 A.M., whenI saw her, the pressure was 203. I ordered 10 grainsof phenacetin every hour for three times. At 1 P.M., the

pressure being still 203 mm., she was given the first dose ; at1.45 the pressure was 187 mum. and the headache was slightlyrelieved ; at 2.30 she was given the second dose, and at2.45 the pressure was 184 mm. and the headache continuedrelieved; at 3.30 she was given the third dose, and at4 o’clock the headache was distinctly better and the pressurewas 178 mm. ; at 7 P. M. the headache was much better and thepressure was 178 mm. There was no vomiting and the patienthad a good night, sleeping soundly. The following morning,Sept. 3rd, she expressed herself as feeling quite well and thepressure had fallen to 158 mm. She has remained well downto the present.The course of the hsemomanometer readings may be

tabulated thus :—

August 24th asd Sept. lst are the dates of two attacks-the firsttreated with erythrol and the second with phenacetin.

j This case raises various questions which cannot at presentbe discussed. Some of these questions are : Are the attacksprimarily of nervous origin, and if so are they neurasthenicor epileptoid ? Are they nervous manifestations of earlycirrhotic kidney ? 7 Or are they the result of a primary auto-intoxication due to some error in metabolism, or to theretention of some product not being regularly excreted ? Weare engaged in the investigation of the urine with a view tothe possible determination of this last question, but mean-while we have not got far enough to entitle me to speak aboutit. I bring the case before you as showing the in’ erest that isattached to hasmomanometer observations, and that the instru-ment is well deserving of a place in ordinary medical work. Inthis patient I have shown that her attacks are associatedwith a marked rise in bsemomanometer readings, but it wouldappear that the mere reduction of pressure, as in the attack

beginning on August 23rd, did not modify the course of theattack in any way. It may be that had the erythrol been

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given sooner and been persevered with the result might havebeen different. However that may be, the difference betweenthat attack and the attack on Sept. 2nd, which was at once’treated with phenacetin, is very striking ; in it the symptomswere promptly arrested and aborted, and along with thatthere was in three hours a fall in pressure of 25 mm. By thefollowing morning a fall of 45 mm. had occurred, accom-panied by the relief of all the symptoms. In this attack head-.ache was arrested and vomiting was prevented by theadministration of phenacetin, the drug above all others that:arrests1migraine.

Since the above was written this patient has left hospital.She left on Oct. 15th, having passed nearly a month withoutan attack, although in that time she had two threatenings ofattacks, which have been designated in the subjoined table- "abortive attacks." These abortive attacks were character-ised by a feeling of drowsiness and by urine changes as

indicated below. The examinations of the urine which were

being carried out as mentioned above have been completed.They are given below and form an interesting contributionto the question of chloride excretion in migraine ; they show;a relationship between the migrainous attack, the occurrenceof polyuria, and the discharge of a large quantity of chlorideIfollowed by a big drop in chloride excretion.

Ámo’llnt of Urane and Chlorides Excreted in relation tn Attacksof Migraine an Case 2.

The’patient left the hospital on Oct. 15th, not having hadany more attacks.

I have to express my indebtedness to my residents, Dr.R.W. Lang Todd, Dr. T. Welsh, and Dr. A. L. Taylor, fortheir watchful interest in these cases.

Bibliography.—Russell: Arterial Hypertonus and Arteriosclerosis,THE LANCET, June 1st, 1901, p. 1519; Arterial Sclerosis and Hypertonusin their Relation to Diet, &c., Brit. Med. Jour., June 4th, 1904; ArterialHypertonus, Sclerosis, and Blood Pressure, Messrs. Green, 1907; TheClinical Estimation of Blood Pressure: The Finger and the Hæmomanometer, Brit. Med. Jour., Oct. 10th, 1908; The Clinical Value ofHæmomanometer Observations, THE LANCET, Feb. 13th, 1909, p. 448;Intermittent Closing of Cerebral Arteries, Brit. Med. Jour., Oct. 16th,1909.

PROPOSED NEW HOSPITAL FOR AXMINSTER.-At the annual meeting of the subscribers of theAxminstet (Devon) Cottage Hospital, which was held on

. Nov. 15th, Mr. W. Langran, honorary surgeon to theinstitution, stated that the hospital was now out of date, andas there was a substantial reserve fund he proposed that anew building fitted up to modern requirements should beerected. After some discussion it was decided to take stepsfor the erection of a new hospital.

An AddressON THE

DIAGNOSIS AND TREATMENT OF CYSTICDISEASE OF THE BREAST.

Delivered before the Harveian Society of London onOct. 27th, 1910,

BY D’ARCY POWER, F.R.C.S. ENG.,SURGEON TO, AND LECTURER ON SURGERY AT, ST. BARTHOLOMEW’S

HOSPITAL.

MR. PRESIDENT AND GENTLEMEN,-When you invited meto select a subject for discussion here to-night I turned overin my mind the various cases which have come under mynotice as a surgeon to one of the large teaching hospitals inLondon. I quickly arrived at the conclusion that cystictumours of the breast often gave me trouble both to diagnoseand to treat, and I was vain enough to think that whatproved difficult to me might have proved equally difficult toothers. I have therefore chosen to bring this subject beforeyou in the hope of obtaining a full discussion. Such casesare not rare, and it is the essence of a good discussion that itshould be upon a topic with which everyone is familiar.

CLASSIFICATION.

The classification of cystic disease of the breast is chaotic,and I would therefore submit the following classification foryour consideration and approval, not because I believe it tobe perfect but in the hope of obtaining some kind oforder :-

(A) NON-INFLAMMATORY CYSTS.(a) Innooent cystic <MoM.&mdash;Everyone recognises the

existence of cystic adenomata as one of the commoner formsof innocent tumour occurring in the breast. The actualstructure differs in different tumours. It is sometimes, but

rarely, pure glandular tissue of an imperfect type held

together by a little areolar tissue, the glandular tissuebeing sometimes chiefly acinous and in other cases chieflytubular. Much more frequently the glandular elements arescattered in a stroma of fibrous connective tissue and thetumour is then called a cystic fibro-adenoma. Here are two

examples of such a tumour, the first of which is almosttypical :-CASE I.-An unmarried woman, aged 21 years, had accidentally

noticed a lump in her breast six months previously. It was small atfirst but had doubled in size before she sought advice. Her breastached a little, but never enough to be troublesome. Examinationshowed that both breast and nipple looked natural. The hand laid flatupon the left breast felt a rounded swelling which measured about aninch in diameter. The swelling was hard and nodular, well defined, andpainless. It floated, that is to say it moved freely, not only beneaththe skin and upon the pectoral fascia, but in the substance of the breastitself. A small incision radiating from the nipple allowed the tumour tobe removed with the greatest ease. The tumour appeared to the nakedeye. as an irregular mass of glandular tissue from the edges of whichprojected small cysts filled with transparent yellowish fluid, Micro-scopically it was a fibro-adenoma consisting of glandular acini in astroma of fibrous tissue.CASE 2.-A married woman, aged 30 years, had first noticed a lump in

her left breast seven months previously, her attention being drawn toit by accident. The swelling had increased a little in size, but shecame for advice because it was beginning to be painful after she hadused her arm. Examination’ of the breast showed that it contained arounded swelling measuring half an inch across and divided into twolobules. The swelling was freely moveable in the breast, and there wasno enlargement either of the axillary or the supraclavicular glands.The tumour was removed by simple incision and proved to be a cysticfibro-adenoma.