861

effects as well as the fallacy of frequent inoculation, for it wasimpossible to produce a progressively cumulative and lastingpositive phase in a patient’s blood. Dr. Ritchie had found,on the other hand, that with a suitable dose, if each successiveone were given only as the effects of the previous one werepassing off, the treatment might be continued for months oryears without incurring the risk of a prolonged negativephase. In this procedure the index was maintained verysteadily above the normal. If this could be secured theywould probably succeed in preventing extension of diseasein chronic cases which demanded long-continued treatment.He had not found it necessary to exceed a dose of 1/1000th ofa milligramme with any bacterium with which he hadworked and the results had been as satisfactory as withdoses a hundred times larger such as were commonlygiven. Subcultures should be avoided. A simple schemefor treating a chronic condition in an adult wouldbe to give doses of 1/1000th of a milligramme at in-tervals of two, then three, then four weeks, continuing atthat rate for six months. Later, it would probably not benecessary to inoculate oftener than once in six weeks andfinally, perhaps, in two months. In chronic affections,especially tubercle, inoculation should be practised long afterrecovery is assumed to prevent relapses. Staphylococcalinfections, so common in surgical work, offered a large fieldfor treatment. Abscess formation might in its early stagesbe prevented ; if already developed its healing was greatlyhastened. Boils could be aborted. If a slough had formedit usually separated in from two to four days after inocula-tion and healing followed rapidly. Relief of pain wasprompt. Recurrent crops of boils could be entirely obviatedand treatment should be prolonged after apparent recovery.In streptococcal infections he had seen more strikinglygood results than in any others. The diseases inducedby these organisms might be highly acute or in-

tractably chronic, but all were amenable to treatment.In the case of wounds a dose might be given consisting of1/4000th or 1/1000th of a milligramme each of staphylococcusaureus and streptococcus pyogenes and also bacillus coli, ifin the region of a mucous tract. Most eventualities wouldas a rule be covered as other infections were, as a rule,secondary. In all operation cases he had given such withsatisfactory results. In accident wounds also suppurationcould be controlled and even entirely prevented. This methodof treatment had proved very valuable in aiding the con-servative treatment of lacerated wounds, in primary skingrafting, and generally in all cases where complete wound dis-infection was difficult to insure. If this method were

employed the use of chemical antiseptics in the tissues wascontra-indicated as they inhibited phagocytosis which wasthe means of final disinfection which was relied upon afterthe necessary mechanical cleansing.

ROYAL ACADEMY OF MEDICINE INIRELAND.

SECTION OF SURGERY.

Gall-stones.-Exophthalmic Goitre.A MEETING of this section was held on Feb. 28th, Mr.

SETON S. PRINGLE being in the chair.Mr. KENNEDY read a paper on Gall-stones, laying stress

on the fact that the only available treatment was by opera-tion. He mentioned three cases of obstruction of the

common bile duct upon which he had successfully operated ;in one of them the obstruction was present for three and ahalf years and was caused by a single calculus weighing50 grains. In another case there were six calculi removedfrom the common bile duct ; this patient had had perforationof the gall-bladder and peritonitis about six months pre-viously for which Mr. Kennedy had also operated. Thethird patient was an old woman who had apparentlyobstruction to the common bile duct produced bychronic inflammatory trouble in the pancreas. Mr.Kennedy also gave a short account of two cases in which hehad performed cholecystectomy. In both cases the cysticduct was obstructed by a calculus, and numbers of calculiwere present in the gall-bladder.-Mr. A. J. BLAYNEYsaid that he shared Mr. Kennedy’s opinion that it wasno more safe to leave a gall-stone in the gall-bladderthan to leave a suppurating appendix inside the abdomen.Recently he had removed gall-bladders more often than

formerly, as he had had experience of a recurrence of

gall stones in some gall-bladders which he had openedand drained.

Mr. WILLIAM TAYLOR read the notes of a case of Exoph-thalmic Goitre treated by removal of the right laterallobe and isthmus of the thyroid gland. The patientwas a woman, aged 24 years, who had been sufferingfrom the disease for six years. Both eyes were veryprominent, the heart’s action was rapid, and palpitations werevery distressing on the slightest exertion ; muscular tremorswere well marked, and her nervousness was so bad that shecould scarcely speak intelligibly. The thyroid gland wasenlarged, especially on the right side. After admission intothe Meath Hospital in Dublin, under Mr. Taylor’s care, shewas kept quiet in bed for three weeks prior to operation.During that time her pulse-rate varied from 120 to 136.Under chloroform anaesthesia preceded by a hypodermicinjection of 1/6th of a grain of morphine and 1/100th of agrain of atropine the right lobe and isthmus of the thyroidgland were removed. The operation presented no unusualfeature of interest. There was very little blood lost and theoperation was well borne. The pulse-rate during the sub-sequent 24 hours varied from 120 to 140, and the tem-perature rose to 101’ 40 F. On the second day the

temperature fell to normal and the pulse-rate averaged 120.The drainage-tube was removed on the third day and thesuture on the sixth day. The pulse gradually fell in frequencytill the tenth day, when the rate was 78. On examination20 months after the operation the patient’s condition was inevery respect quite satisfactory. Her nervousness had dis-appeared, there were no muscular tremors, she never had anyattacks of palpitation, her pulse-rate averaged 80, and theexophthalmos, though still present, was much less marked.She expressed herself as quite well in every respect, save forthe slight prominence of her eyes, and she was workingdaily as a dressmaker. Mr. Taylor said that when opera-tive treatment was undertaken in an early stage, before theheart became disorganised and degenerated, the mortalityattending it was but little in excess of that of partialthyroidectomy for simple colloid goitre. An entire lobe andthe isthmus should be removed.Mr. K. E. L. G. GuNN read a note on the Surgical Treat-

ment of Exophthalmic Goitre, dealing mainly with thepathology of the disease. He said that in his opinion theparathyroids were primarily affected and that the enlarge-ment of the thyroid followed. The microscopic appearancesof the gland in the early stages of the disease were notdistinguishable from those of simple goitre, whereas in thelater stage of the disease the appearance of the exophthalmicgoitre under the microscope was unmistakeable. Mr. Gunnthen briefly related three cases of Graves’s disease in whichpartial thyroidectomies had been done. Two of these hadbeen most successful, but the third died from subacutethyroidism ten days after the operation.-Mr. KENNEDYsaid that he attributed considerable importance to the posi-tion of the patient during the operation. He believed thatmany deaths had occurred through interference with therecurrent laryngeal nerve. The danger of thyroidism wasgreater the more gland was left. To get a good resultit was necessary to remove practically the whole ofthe gland. The central lobe would be quite sufficient forthe needs of the patient afterwards. If the surgeongot the case before pathological changes had occurredin other organs the cure of the disease could be practicallyassured.

BRISTOL MEDICO-CHIRURGICAL SOCIETY.-Ameeting of this society was held on March 11th, Dr. H.Waldo, the President, being in the chair.-Dr. Carey F.Coombs showed specimens from the Myocardium in AcuteRheumatism. He drew attention to the nodules occurringu the neighbourhood of arterioles composed of aggrega-tions of large spindle-shaped polynuclear cells and pointed)ut that they were chiefly met with in the muscle ofthe left ventricle near the apex. He was inclined to

’egard them as the result of a fibroblastic reaction

peculiar perhaps) to the rheumatic virus.-Dr. W. S. V.tock read notes of a case of Carcinoma of the Breastn which metastasis occurred after an interval of 24 years.The breast had been amputated 24 years previously toMay, 1907, when the patient noticed a lump in the rightliac fossa which Sir Thomas Smith (who had performedhe first operation) and Mr. A. A. Bowlby diagnosed as a

862

growth in the right ovary but regarded as inoperable; (

the growth increased rapidly and nodules appeared above above the clavicle, on the sternum, and ultimately in many 1other situations either in glands or subcutaneous tissues. 4

Some glands were removed from the groin, which I

under the miscroscope showed clear evidences of beingcarcinoma secondary to a primary mammary growth. Ulti-mately the patient died (eight months after first noticingthe mass in the pelvis) with symptoms of cerebral meta-stasis. The reasons for the long period of quiescence andthe ipossible channels of transmission were considered atsome length.-Mr. C. B. Goulden read a paper on LacrymalObstruction. After briefly reviewing the anatomy and phy-siology of the lacrymal sac and nasal duct he went on todeal with the causes of obstruction, most of which were dueprimarily to diseases in the nasal mucosa or to caries ofthe nasal and lacrymal bones from tuberculosis or syphilis.The treatment advocated for epiphora without mucoceleconsisted in bringing the puncta into correct apposition withthe globe either by slitting the canaliculus or better by pro-ducing with the actual cautery a scar between the innercanthus and punctum which by contraction would restore thelatter to its true position ; for mucocele he advised treatmentof the nose if required and syringing of the sac, but unlessthis proved successful in six weeks excision of the sac mustbe resorted to. For dacryocystitis the sac should invariablybe excised ; the use of probes and styles he utterly con-demned.-The paper was discussed with interest.-Dr. A.Fells read notes of a case of Urobilinuria associated withPolycythsemia occurring in a woman, aged 37 years, who hadbeen long resident in India and had suffered from sunstrokeand many attacks of fever. In 1901 she returned to Englandand first began to complain of shivering fits and attacks ofpain in the left side which radiated down the leg. In1906 she became liable to attacks of fainting, with ex-

treme irritability and restlessness ; she had then inter-mittent pyuria with pyrexia. The right kidney was

explored and being found moveable but otherwise healthywas fixed by suturing. Subsequently headache, neuralgia,insomnia, constipation, and profound muscular weaknesssuccessively developed and the urine became of a clear

port-wine colour; the blood count showed an increase oferythrocytes (6,500,000) without leucocytosis. Eventuallythe patient died with increasing myasthenia and paralysisextending gradually from the extremities to the respiratorycentres. The urine had been examined and was reported tocontain "urobilin." The case was probably one of auto-intoxication from the alimentary tract. The patient hadtaken sulphonal but not to excess.-Dr. J. 0. Symes con-sidered that a case showing such persistent and long-con-tinued urobilinuria was probably unique ; he agreed with Dr.Fells’s suggestion of toxaemia as the explanation.-Dr. F. H.Edgeworth said he felt no doubt that the specimen of urineshown contained hasmatoporphyrin and that the case wasone of sulphonal poisoning ending, as such cases frequentlydid, in peripheral neuritis.-The President detailed a casewhich he had treated of a man who had died from chronicsulphonal poisoning with hoematoporphyrinuria. Thesimilarity in the course of the disease to that of Dr. Fells’scase was striking, and he could not help thinking that

probably ha3tnatoporphyrin was present in this instancealso.-A small subcommittee was asked to examine theurine and to report on its composition to the society at somelater date.

MANCHESTER MEDICAL SOCIETY.-A meeting ofthis society was held on March 4th, Dr. A. T. Wilkinson, thePresident, being in the chair.-A discussion took place onthe question of Gastro-jejunostomy.-Dr. F. Craven Moorehaving dealt with the medical aspect, Mr. E. Stanmore

Bishop said that gastro-enterostomy, which was first per-formed by Woelfler in 1881 as an alternative for pylorectomyor as an adjunct to partial gastrectomy where the amountof tissue removed rendered reunion of the stomach andduodenum specially hazardous, had lately been far morefrequently employed as a remedy for gastric or duodenalulceration. In sich cases its good effects appeared to bedue, first, to its action as a drain, at least at first, so pro-ducing rest for the a’ea implicated ; secondly, because suchrest permitted the coating over by mucus of the ulceratedpatch, and consequently of its protection from irritatingmaterials, thi9 protection being favoured by the folds intcwhich the gastric walls fall ; thirdly, to the avoidance oialternate stretching and contraction of the gastric walls andthe elimination of pyloric spasm ; and fourthly, to the

decreased acidity of the stomach conten’s preference wasmade to the observations of Wertheimer and Pdwlow uponthe results of acid in the jejunum and to Paterson’sestimate of 5 per cent. regurgitation of intestinal contents).The reasons for believing that drainage was the primaryresult were based upon observations made by Mr. Bishophimself and Dr. A. E. Barclay of the passage of food afteroperation at successive periods with the aid of radioscopy ;later the opening appeared to act more as a safety valve.Three illustrative cases taken from many of its effect ingastric and duodenal ulceration were detailed. Mr. Bishopreferred to several visits paid to the clinics of noted Englishabdominal surgeons and to the lessons learnt from them ; healso showed some appliances for assistance in the work. Ashort review of the stages through which methods of in-testinal union had passed was followed by a description ofthe operation as at present performed. The question of"vicious circle " vomiting was discussed and the reasonswere given for believing that this had ceased to be a

serious factor in gastro-enterostomy. Finally he referredto the small and decreasing mortality and to the strikinglygood symptomatic results obtainable by this operation.-Dr. Barclay read a paper on X Ray Examination of theStomach, making special reference to gastro-jejunostomy.He stated that he always used the upright position in hisexaminations, which were entirely carried out by means oftracings made on the screen from shadows cast by a mealof bismuth carbonate with porridge (four ounces to one pint).The average healthy stomach in normal circumstances variedin shape. Solid foods did not mix and he found in one caseevidence of "churning," though fluids taken after a mealpassed all round the walls of the organ right down to thepylorus in a few seconds. This he demonstrated after themeeting. He agreed with Dr. Leven and Dr. Barrett thatthe healthy stomach maintained a level for its contents andthat increased capacity was obtained by lateral expansionand not by filling from below upwards. If this latter wasnoted there was atony of the walls, but this need give rise tono symptoms unless there was inefficient peristaltic action.Motor efficiency could be tested by watching the passage ofbismuth porridge out of the stomach and the presence of freeHCl demonstrated by observations with capsules of bismuthmade with goldbeaters’ skin which should be digested andthe bismuth dispersed in two and a half hours. Carcinomasometimes led to irregularities of outline that helped in thediagnosis. He had examined some cases in which Mr.Bishop had performed gastro-jejunostomy and had foundthat the stomach was utilised in them all although peristalticaction was directed towards the pylorus. In only one casedid food pass through this orifice. Shortly after operationfood-stuffs passed through much more rapidly than later-say three months-when their passage was more or less

normal, the stomach moreover retaining proteins and fat

longer than carbohydrates.GLASGOW MEDICO-CHIRURGICAL SOCIETY.-A

meeting of this society was held on Feb. 2lst, Dr. J. WalkerDownie, the President, being in the chair.-Dr. J. Crawford

’ Renton showed, or read notes on, a number of surgical cases,among which were: 1. Excisions of the Elbow-joint for

’ injury or disease. The movements in all cases were very’ satisfactory, even in one severe case where 5t inches of boneI had been removed. 2. Two cases of Rupture of the Spleen.’ One recovered. 3. Four cases of Intussusception, with three

recoveries. 4. Notes on 12 cases of Gastro-enterostomyf done by Mayo’s method. There was no trouble with vomiting.-Dr. A. McLennan reported a case of Tumouri of an Accessory Thyroid and also read a paper upon3 the Function of the Thymus Gland with special refer-3 ence to the results of thymusectomy. The result of the- investigation was as follows :-1. The recovery of the animalswas rapid. The animals operated upon showed more vigourt and had larger appetites ; their weights increased more rapidly1 than the controls, though the latter were selected to begine with, because of their larger size. 2. Slides were put on the,1 screen to show the changes in the epiphyseal cartilages. Ite was found that the epiphyseal lines were thickened in the- thymus less ; there were a greater number of cells between11 cartilage and bone ; there was evidence of increased rate ofd growth. 3. The thyroid was reduced in size, was paler, andgon section there was seen reduction in the size of the glando spaces; the connective-tissue cells were more numerous inIf the thymusless. 4. After thyroidectomy the thymus wasd found to atrophy in some cases completely. 5. Three

e cases of thymusectomy in children were mentioned

863

in connexion with the relationship of the thymus tothe status lymphaticus. The connexion with marasmus,rickets, sudden death, &c., was shortly discussed.-Dr. William MacLennan reported an unusual case ofMediastinal Tumour. The case was that of a young woman,-aged 28 years, who was sent into a surgical ward of theWestern Infirmary " suffering from an abscess at the root ofthe neck." The case was transferred to a medical wardafter a diagnosis of a tumour of the anterior mediastinumhad been made. When a girl, aged 15 years, she had hadremoved from the front of her neck a small tumour, whichfrom the position of the scar was clearly connected with, orclose to, the thyroid gland. Unfortunately, no histologicalexamination of this growth was made, but its occur-

rence was a very interesting antecedent and probably hadmore than a casual relation to the present tumour.The differential diagnosis of the three likely conditions-abscess, aneurysm, and tumour-was made and the pro-gress of the case was related. The disease ran a rapidcourse, the entire illness, from the earliest complaint tilldeath, only occupying a period of ten weeks. The pointsof interest in this case were :-1. Was the tumour removedat an earlier date an aberrant or accessory thyroid ? It waswell known that these growths were prone to take on amalignant action. Might the adeno-carcinoma, of which thistumour was partially composed, have taken origin in suchan accessory thyroid or in some portion of embryonic tissueimbedded in, or lying near to, the tissue of the thyroid?2. Rare at all times, such primary tumours were specially soin the thyroid gland. It was composed of sarcoma and ofadeno-carcinoma. The primary tumour was probably anadeno-carcinoma, which acting as a chronic irritant, set up amore malignant and rapidly growing sarcoma whichultimately dominated the entire growth. In most of suchtumours this was the usual course of development. 3. Withthe exception of the neighbouring lymphatic glands in theneck, which showed both varieties of tumour, all the othersecondary growths examined were entirely composed ofsarcomatous tissue-showing again the greater malignancyand tendency to metastasis of the latter.

BRITISH BALNEOLOGICAL AND CLIMATOLOGICALSOCIETY.-A meeting of this society was held on March 5th,Dr. W. J. Tyson, the President, being in the chair.-Dr.George Carpenter read a paper entitled seaside Treat-ment for Sick Children." " In the course of the paperhe briefly reviewed various ailments for which seasidetreatment was beneficial, chief among them being tuber-culous diseases of the bones, joints, the lymph glands

and peritoneum, and early pulmonary tuberculosis. Hesaid that as a tonic after surgical operations and afterrecovery from the exanthemata sea air was most valuable,and that cases well-nigh moribund from summer diarrhoeaand entero-colitis derived the greatest benefit from it,and that for rickets it was a most helpful adjunct.He then passed in review the different seaside climateswithin a moderate train journey of London. He consideredthat the physicians practising at the seaside did notmake the best use of the natural advantages of theirtowns-viz., the sea-water; in this respect they were behindtheir continental brethren. He advocated the study of theeffects of hot and cold sea-water baths and douches on thesecretions and metabolic processes of children, and of thetherapeutic effects of such remedies on their complaints. Hethought that medical men residing at the seashore resortsshould give more information to physicians residing in otherparts as to the peculiarities of the climates of their townsand more information concerning the class of cases whichwould receive benefit.-The President thought that there wasno scientific reason for sending children to the seaside or toinland resorts, but his experience was that they did well atthe seaside. He discussed the possibilities of the effect ofthe climates of Margate and Ramsgate, and had never beenable himself to make out scientifically or clinically whyMargate occupied its high position in the minds of the

profession and of the public, as compared with some otherplaces. He would not send children with anaemia to a bracingseaside resort. Cases of insomnia and rheumatism did not dowell at the seaside. Patients who benefited were thoserequiring a stringent treatment-those suffering fromleucorrhoea, nasal affections, and congestive conditions of thethroat and ear. Skin cases did well at the seaside, butdermatologists never sent them there. With regard to eyecases the only point against them was possibly the glare. He

thought that many children and adults who went for sea-bathing actually did badly as a result. The seaside phy-sician was willing to treat cases scientifically, but thepatients frequently treated themselves as far as the sea-

bathing was concerned. He used sea-water for garglesand injections. He found excellent results from theearly treatment of tuberculous cases.-Dr. F. Bagshawefully endorsed the opinion of Dr. Carpenter on the import-ance of giving delicate children the great advantageof seaside treatment, especially after the occurrence ofacute illness. Several large institutions existed at Hastingswhich gave ample proof of their usefulness among thechildren of the poor working-classes. He had found thebenefit of seaside treatment especially marked in tubercu-losis, in bronchitis and asthma, and in chronic heart diseases.- Dr. Leonard Williams said that he was entirely at one withDr. Carpenter in his complaint that seaside places of thiscountry did nothing to use sea-water as a natural mineralwater in the same sense as spas used their natural mineralwater in this country. The only English place which he knewwhere the water was used in the form of baths and doucheswas at Sidmouth. Sea-water might be an exceedingly goodthing, but it ought to be used in dosage, temperature, andamount just as any other powerful therapeutic agent.-Otherspeakers described the advantages of other seaside resorts.

ABERDEEN MEDICO-CHIRURGICAL SOCIETY.-Ameeting of this society was held on Feb. 20th, Dr. GeorgeWilliamson, the President, being in the chair.-Dr. A. W.Mackintosh exhibited a case of Narcolepsy. The patientwas a man, aged 41 years. Since May, 1907, he had suf-fered from continual desire to sleep. The attacks of sleepwould come on suddenly and last for a few minutes. He fell

asleep when driving or at meals. The sleep was apparentlyquite natural and the patient could be roused from it quiteeasily by touching him and sometimes merely by speakingto him. The attack was sometimes preceded by a " heavyfeeling " at the back of the head. He was nervous andirritable and his knee-jerks were hypersensitive, but other-wise nothing further could be detected. There was a

history of syphilis 20 years previously and of alcoholismsome years back but not recently. From the lightness ofthe sleep Dr. Mackintosh did not consider the attacks to beof an epileptic nature. He suggested that they might be theprecursor of syphilitic brain changes.-Dr. T. C. Mackenziequoted a somewhat similar case in a schoolboy, aged tenyears, who was admitted to an asylum owing to the develop-ment of mental changes and hallucinations of hearing. For18 months previously to admission he had exhibited markedattacks of a narcoleptic character.-Dr. A. R. Gallowaydescribed five cases of serious Visual Deficiency affectingresponsible employees in the marine and railway services. Twoof his cases were engine-drivers, one suffering from compoundmyopic astigmatism and the other from hypermetropia. The

remaining cases were trawl fishermen, all of whom hadtaken an active part in the navigation of vessels. The firstof these, who showed myopic astigmatism with vision (botheyes) 1f61f, had acted as the mate of a trawler. Theother two cases were completely colour-blind.-Dr. JohnInnes read notes of a case of Atonic Dilatation of theStomach which was successfully treated by lavage.-Dr.F. Kelly gave the history of a case showing unusual mani-festations of Lues. The patient was a house painter whowas in the habit of holding his paint brushes between hislips. He developed a circinate and depressed ulcer of theright side of the pharynx, which appeared to be the primarysyphilitic lesion. This was followed by the appearance uponthe face and extensor aspects of both thighs and legs of aneruption, at first papular, later molluscoid or frambcesia-like.As the patient exhibited a very marked idiosyncrasy towardsboth mercury and iodides the skin lesions were scraped.They healed rapidly, leaving white scars. Several monthslater the old scars broke out again, forming painful serpi-ginous ulcers covered with lichen-like crusts. These werescraped, with a successful result, and the patient is at

present in excellent health.

BRIGHTON AND SUSSEX MEDICO-CHIRURGICALSOCIETY.—A meeting of this society was held on March 5th,Mr. H. H. Taylor, the President, being in the chair.-Mr.J. A. Rooth showed a case of Conjoined Twins (Pygopagus).The mother was a primipara ; her father was a twin and hada family of four pairs of twins. These twins are joined bya partly bony and cartilaginous union of the pelves; they

864

8na.re a commuu It:Cl1Ulll nuu auu/; uuD blie VuLve4z: rere LUHnuub

and well formed. The first was born with vertex presenta-tion, the second by evolution, legs first; there was very littledelay at birth and no laceration. The twins are a monthold and weigh 13 pounds. The first born has a better diges-tion and cries less than the second.-Dr. C. F. Bailey showeda skiagraph of the twins.-Mr. J. Howell Evans read a paper,illustrated by lantern slides, on Twins and Monstrosities.-Dr. D. G. Hall showed the father of the twins, who had con-genital morbus cordis, having a loud systolic murmur overthe whole cardiac area, audible also at the back of the chest,

the point of greatest intensity being in the pulmonary areawhere a thrill could be felt. There was neither cyanosis norclubbing of the fingers.-Dr. A. W. Williams showed a caseof Symmetrical Tertiary Syphilitic Ulceration in the regionof the Elbows.-Mr. Willoughby Furner read a shortcommunication on the Recent Improvement in Operatingfor the Cure of Femoral Hernia. He advocated the appli-cation of Bassini’s method for inguinal to the femoralvariety. The incision parallel with and splitting the fibresof Poupart’s ligament allowed of easy approach to thefemoral ring by pushing up the arched fibres of the internaloblique and transversalis muscles. These muscles were thensutured to Cooper’s ligament, closing the femoral ring. Thisroute to the femoral ring came first under his notice in 1903,when division of an abnormal obturator artery during anoperation for femoral hernia rendered ligature necessary.He had performed this operation on four occasions. Furtherinquiry informed him that this operation had been the

typical one in use in von Hacher’s clinic since 1898.T. E. Gordon of Dublin and R. H. Parry of Glasgow hadalso advocated the same method in 1900. The advantagesclaimed were that the site of stricture was exposed to viewand that injury to important parts might be avoided. Theclosure of the upper part of the femoral canal by unitingmuscle to ligaments was preferable to closing the lower endby ligament to ligament.HUNTERIAN SOCIETY. - A meeting of this

society was held at the North-Eastern Hospital for Childrenon March llth, Mr. F. Rowland Humphreys, the President,being in the chair.-Dr. J. Porter Parkinson showed : 1. Aboy, aged five years, who had developed Fibrosis of the Lung,with Bronchiectasis as a sequel of pneumonia three and ahalf years ago. At the left base the movement of the chestwas deficient ; there were dulness, cavernous breathing, andx6,les. The x rays showed nothing abnormal, the diaphragmmoving well. 2. A girl, aged nine years, who was admittedfor fever of unknown causation of one and a half years’duration. The spleen was enlarged and below this theleft kidney was felt to be enlarged considerably. Theright kidney was also large and palpable. The urine wasdiminished in amount ; it contained pus and tuberclebacilli had been found in it. The blood showed thecharacters of a secondary ansemia with a moderate leuco-cytosis.-Mr. Douglas Drew showed a series of cases inwhich the Hip had been successfully Excised for TuberculousDisease. He said that his practice in these cases was onlyto operate when there was an abscess or when the child wasgoing downhill. He never operated in early cases but, onthe other hand, if an abscess were present he never simplyscraped the abscess out but excised as much of the joint aswas affected through a posterior incision. -Mr. J. P. LockhartMummery showed : (1) A case of Hemihypertrophy in a smallboy; (2) Dupuytren’s Contraction in a girl ; and (3) a caseof Congenital Absence of the Fibula.-Dr. Taylor showed: a(1) A case of Disseminated Sclerosis in a girl, aged fiveyears; and (2) a Cerebellar Tumour in a girl, aged tenyears.-Dr. Carpenter showed a Microcephalic Infant withCongenital Heart Disease, probably due to a patent septumventriculorum.

,

]ROYAL SANITARY INSTITUTE. - A provincialsessional meeting of this Institute will be held in theCouncil Chamber, Town Hall, Hull, on Saturday, April 4th,at 11 A. at., when a discussion will take place on Diphtheriain Elementary Schools and its Prevention. The discussionwill be opened by Dr. J. Wright Mason. The chair will betaken at 11 A.M. by Colonel J. Lane Notter, R.A.M.C.,deputy-chairman of the council of the Institute. Tickets foradmission of visitors may be had on application to Dr.

Wright Mason, medical officer of health, Town Hall, Hull,who is acting as the local honorary secretary of the

meeting, and from Mr. E. White Wallis, Secretary, RoyalSanitary Institute, Margaret-street, London, W.

Reviews and Notices of Books.The Principles of the Treatment of o2ct. By ALFRED NN.

SiKES, M.D.,D.Sc.Lond. London: Ballantyne and Co.1907. Pp, 11’7.IN this work Dr. Sikes has given a brief account of the

present state of knowledge with regard to the treatment ofarticular gout and of those irregular conditions which areprobably the result of metabolic perversion in the otherorgans of the body. We agree with Dr. Sikes in his viewthat the conception of the nature of gout will vary with thelines of research in the regions of chemical physiology andpathology, and as a result the opinions of various observersmay for some time naturally differ in reference to the

pathogeny of the disease.Dr. Sikes touches very briefly on the etiology of gout,

confining himself almost entirely to considerations of the

therapeutics of the disease. He premises that gout is due

to a general change in the whole protein metabolism of thebody, the chief seats of the derangement being those tissuesand organs which are usually the site of the greatestchemical activity-viz., the muscles and the liver. He is of

opinion, and probably rightly so, that this condition is

primarily brought about by gastro-intestinal derangement,either due to alterations in the digestive ferments or defectsin the process of absorption. In either case he thinksthat abnormal chemical products enter the circulationand cause, after the lapse of time, a permanent changein the protein metabolism. There is usually an excess

of purins in the blood and they are present in some condi-tion differing from the normal so that they cannot leavethe system in the usual way. Dr. Sikes suggests that theexcess is possibly due to changes in the liver. He

therefore naturally lays stress on the importance of dietbut his directions on this subject are not characterised bynarrowness or by any inclination to insist on one sort offood only. He rightly maintains that no diet will be suitableunless general nutrition is maintained. He recommends as.

simple a diet as possible, with good cooking and thoroughmastication of the food. With the majority of individualshe considers that a moderate amount of proteins, carbo-

hydrates, and fats is advisable. He also gives directions as tothe kind and the amount of fluid food that should be taken.-With regard to drugs he considers that the most importantis undoubtedly colchicum and he believes that there has.

useful some misconception as to its dangerous properties.A good account is given of i"the treatment of irregulargout.There is little that is new in this volume but it contains a

useful summary of the views at present held with regard tothe therapeutics of gout, and the practitioner by reference toits contents will obtain hints and suggestions likely to be of-value to him in his practical work.

Studies in Pathology. Written by Alumni to celebrate theQuatercentenary of the University of Aberdeen and theQuartercentenary of the Chair of Pathology therein.Edited by WILLIAM BuLLOC, Bacteriologist to theLondon Hospital. Aberdeen. 1906.

THIS excellent volume opens with an appreciation ofProfessor D. J. Hamilton, the first occupant of the chair ofPathology at the University of Aberdeen, and there is also anaccount of the establishment by Sir Erasmus Wilson of that-post. The other papers included in this volume comprise anumber of monographs on subjects of pathological andpractical interest by Professor Hamilton and his former

pupils. The first of these, on the Alimentary Canal as aSource of Contagion, is by Professor Hamilton himself andcontains a large amount of original and suggestive work onthe subject illustrated by his own observations on a group of