REPORTS OF SOCIETIES, - NCBI

rMar3ll1, 1888.THE BRITISH MEDICAL JOURNAL.

REPORTS OF SOCIETIES,ROYAL MFEDICAL AN'D CHIRURGICAL SOCIETY.

TU'ESDAY, MARCH 27TH, 1888.Sir E. 1I. SIivEVEKING, M.D., President, in the Chair.

A Case of ai troversion of the Bladder T'reated by P1reliminary_Dirisonn of the Sacro-Iliac Synchondroes.-Air. G. 11. MAKINI reada paper on this subject. Thle patient was a male child, aged 5.An atttmipt to raise a flap after Thierschl's method had failed threeyeaLrs previously. OnI the second admission a cicatrix on the leftside of the extroverted bladder marked the position of the unsuc-cessiul flap, and prevented any considerable shifting of the skinon that side. On November '2th, 1886, the sacro-iliacsynchon-droses were dlividled on each side, with the result of allowing alp-proximation of the anterior superior iliac spines to the extent ofone inch, with corresponding diminution of the gap existing inthe situation of the symphysis pubis. This gain was maintainedby means of continuous extension. On Jaiiuary 22nd, 1887, aIIattempt was made to unite the opposite boundaries of the bladder,whichl failed, presumably in great part, in consequence of thetension due to the old cicatrix. The bladder was then covered bymeans of a single lateral Thiersch's flap at a later date, the ex-posed surface having been reduced in area from 34 in. x 3.j in. to1., in. x 11 in. by the closure of the symphisial gap. The specialfeatures of the case were discussed, and some of the possible ob-jections to the method were considered, the following advantagesbeing claimed for it:-1. Saving of time. In one of Trendelenberg'scases the whole procedure, excepting the closure of a small fistula,occupied eight weeks only. 2. A perfect mucous lining to theIIew bladder, interrupted only by a median cicatrix, was attained.3. Failure of the primary operation in no way prejudiced subse-quent measures. 4. Should primary lunion fail, mUch smaller flapswere needed than in the usual operations. 5. The superficial areawas not merely lessened, but a gradual backward sinking of thel)ladder-wall accomIpaniied the decrease in diameter. 6. The lasttwo points were of special importance in cases like the one re-lated, whlere cicatrix interfered with the ready fashioning of flaps.7. The closuire of the symphisial gap offered a better suppOrt forthe abdominal visceera.-Mr. THOMAS SMITH had not operated onmany cases of this kind, and, though he was glad that the newoperation had been tried, was afraid that much good would notcome of it.A Case of WVound of the Femoral Artery and Vein; Traumatic

VaricoseAneurysm; Ligature of both Artery and Tein, Recovery;with Remarks on the Treatment of Wffounds of the Femoral Arte)ryandl Vein.-Mr. W. J. WALSHAM read a paper on this subject.R. II. W., aged 19, a medical student, received a punctured wPoundin the upper third of the left thigh. The profuse hcmorrhagethat resulted was controlled by digital pressure and a firm.bandage. On the following afternoon an arterio-venous aneurysm-was detected. Tliree days after, as the tumour was incrensing, itwas explored. The femoral artery and vein in Hunter's canalwere found wounded, and were tied above and below at the in-jured spot. The patient made aii uninterrupted recovery. Thequestion of the treatment of a wounded femoral artery and veinwas discussed uinder the following heads: 1. Immediate simul-taneous ligature of the artery and vein. The author gave twelvecases in wlhichl immediate ligature was applied. In four, andprobably in five, gangrene occurred. It was submitted, however,tlhat, especially as concerned the superficial femoral vessels, thedanger of gangrene had been overrated. 2. Continuous pressuirewithout operation. Out of thirty-six cases so treated, thirty-fiveTesulted in arterio-venous aneurysm. The dangers of treating thisaffection were commented on. The author concluded that pressurealone could not he recommended, and showed that pressure itselfinvolved the danger of slougliing and secondary h.emorrhage. 3.Temporary pressure in order to allow the collateral circulation tobecome established before resorting to ligatuire. The danger ofgangrene after ligature wats reduced to a minimum when the col-iateral circulation had become established. Grillo, of Naples, tiedboth vessels in fifteen cases for aneurysm withouit a single badre-sult. In twenty cases collected by the author, gangrene occurredin five only, andl in fouir of these five cases the gangrene was dueto otlher catuses. 4. Ligatuire of the artery and application of pres-sure to the vein. (ases at St. Blartholomew's Hospital were men-tioned in wlieli the? vein was prieked in tying the artery. Noarftn foll'wed where the ligature was withdrawn and the artery

tied higher up. But where the artery was tiedl at the same spotthrombosis anid blood-poisoning ensued. In all the hNemorrhagefrom the vein ceased on tying the artery or on applying pressure'to the vein. The author considered that in a woutnd of the arteryand vein there was some risk in tying the artery above and belowand leaving the vein untouched, or in trusting to pressure upoII it,and that such treatment should only be uindertaken when tlhewound in the vein was very small, and there was a reasonableprospect of tlhe external wound healing by the first intention.5. The question of the lateral versus the circular ligatuire of veins.In four cases of wounds of large veilns observed by the auithor, itsuse was successful, as it was also in tlhirtetn cases outt of sixteencollected from other sources. The fatal cases occurre(d before thedays of antiseptic surgery. The following concilusions weredrawn: 1. That wlhen the femoral artery and vein 'were in-volved in a punctured wound of the thiglh, the safest course wasto apply pressure for a few days in the way described in the abovecase, in order to allow the collateral circulation to become estab-lished, and then to cut down and tie the proximal andI distal endsof both the artery and vein. 2. That immediate ligature (that is,before the collateral channels have had time to enlarge) of boththe femoral artery and vein, and especially of the common femoralvessels, was liable to be attended witlh gangrene, although thisrisk was probably less than had generally been assumed. 3. Thatligature of both vessels when, in consequience of pressure, as of atumour, the collateral circulation had become established, wasattended witlh muich less risk of gangrene. 4. That when thefemoral artery and vein were wounded, ligature of the artery andpressure on this vein, if the wound of the latter vessel was amere puncture, was a safe treatmenit, provi(le(h that the natuire ofthe injury allowed of reasonable prospects of the external woundbeing kept aseptic and uniting by the first intenition. 5. Thatwhen the wound in the vein wvas too large to permit of treatmentby pressure, the walls might be safely inipped up and a ligaturethrown around them without obliterating the calibre of the vessel;but that this procedure should only be resorted to, as in the formercase, when there was a reasonable prospect of the wound healingby the first intention. 6. That consi(lering the grave risks of gan-grene that attend the sudden obliteration of the common femoralvein, the lateral ligature should in this situation, for all small andmoderate-sized wounds that require immediate ligature, I e thetreatment adopted.-Air. IIULKE congratulated the autlhor on thesuccess of his case, and said that in regard to treatmeiit it wasvery often difficult when haemorrhage was great to diagniosewhether the vein was injured as well as the artery. I-e liadtwice (in cases of cancer) been obliged to ligature both the iliacvessels at the same time, and in both cases the patients had sur-vived a week or ten days, and the ligature had not been followedby gangrene or other bad result. He thought perhaps when botlhvessels were ligatured the risk of gangrene was less. Every caseof arterio-venous aneurysm could not be treated in the same way;much must depend on the nature of the case. Aman came tohim to be treated for slight eczema of the foot, who for years hadbeen treated with elastic bandage for an aneurysmal varix, andhad been able to follow his occupation as a carpenter. Thepatient complained only of the eczema, and did not mention thevarix, which Mr. Hulke discovered accidentally. He thouglhtvarix sometimes followed bruises of vessels, as in cases of bulletspassing between artery and vein, when there couild be no hmmor-rhage at the time of accident.-Mr. IIARRIsON Ci'tii'is referred alsoto difficulty of diagnosing when the vein was injured as well Asthe artery. He thought that pressure ought always to betried first, and recommended the following method: Limb tobe firmly bandaged from bottom to top; wound to beleft exposed; then fire-stick to be applied above, an(dand below wound, and retained by narrow webbing at each end of

Estick. Compresses over the stick, and a Liston's splint to leg.Many cases had probably been cured by pressure treatment thathad not been recorded.-Mr. THOMAS SMITH related a case of a boyxtreated by pressure, who had recovered.-Mr. P'FARCE GouLa;mentioned a case of Mr. Lawson's which had not been improved

I under pressure treatment. He was operated on, and communiea-i tion found between artery and vein. The arterywas tied, but theI vein left alone, andcomplete recovery followed. lie thouglt thata all surgeons who had tried pressure in wounds of the palmar arch

were dissatisfied with the treatment, and would always cut downand tie bleeding points, and that arteries in all parts ought to be

z treated in the same way. Pressure on vessels was probably a,Y dangerous as ligature. He preferred immediate operation aud

696

THE BRITISH MEDICAL JOURNAL.

ligature of bleeding points.-Mr. WALSHIAM replied that the pres-sure in his case was done while Mr. Cripps vwas looking on. hlistreatment gave the patient the chance of recovering with pressureonly. In one case, supposed to have been cured by pressure, ananeurysm appeared after a sudden strain ten years later.

CLINICAL SOCIETY OF LONDON.FRIDAY, MIARChT 23RD, 1888.

W. H. BROADBENT, M.D., F.R.C.P., President, in the Clhair.Iyperpyre.via in Acute J?heumatigm treated by Ice-Pack.-Dr.

WILLIAM M. OID related this case. The patient was a man, aged32, a heavy beer drinker, who had contracted, three weeks beforeadmission to St. Thomas's Ilospital, a sharp attack of acuterheumatism, referred to exposure to cold. On admission he wasfound to have acute inflammation of many joints, marked signsof pericarditis, and slighter signs of endocarditis, with somepleurisy. Ilis temI)erature was 102.40, the respirations were (iiuiek-ened, the urine contained one-sixth of albumen and very littlechloride. He was slightly delirious. Two days later the deliriumhad increased to such a degree that it was necessary to remove himfrom tlhe large ward to a single-bedded ward. Ile was veryviolent, lad hallucinations and delusions, and was with difficultykept in bed. The delirium strongly suggested the existence ofhyperpyrexia, but the temperature was only 101.40. After this thetemperature rose steadily, till at 4 A.m. on the morning of thefourth day from admission it reached 108.40, wlhile the patient hadfallen into a state of restless utnconsciousness, with tremors. Theice-pack was now applied, an(I was maintained for four hours, atthe end of which the temperatuire was 1000, the patient had reco-vered consciousness and spoke sensibly, and the pulse had fallenfrom 160 to 100. During the next few days the temperature, aftera first rise to 103.4', kept between 1000 and 1010. The signs ofpericarditis disappeared, but those of endocarditis remained. Thejoint affection had greatly decreased, and the albumen had disap-peared from the urine. On the seventh day after admission tem-perature again began to rise, and at 2 A.M. on the morning of theeighth day was 105.40, the patient hiaving passed througlh deliriumnto restless unconsciousness. The ice-pack was again applied.By 5 A.M. the temperature was 1000, and the patient had recoveredconsciousness. After this the patient made a steady recovery, andwas discharged six weeks after admission in good general health,and without sign of lung or heart disease. The treatment waseffectively carried outtby D)r. Ord's liouse-physicians, Dr. Wheatonand Mr. Macevoy. Dr. Ord brought the case before the ClinicalSociety, not because it presented anything new or original, butwith the intention of emphasising the value of cold applicationsto the surface of the body in hyperpyrexia. He urged that, not-withstanding the acknowledged value of the various antipyreticdrugs in pyrexia, their use in hyper.pyrexia was comparativelyunsafe, large and frequent doses being required, whereby toxicsymptoms were often produced. He admitted that the batlhtreatment was not of universal applicability, but pointed out thatit involved nio poisoning, and had a remarkable effect, not only inreducing temperature, but in restoring the nervous system to anatural condition. The rapid disappearance of inflammation inthe thoracic viscera and joints was also noteworthy.Two Cases of Hyperpyre.ria Successfully Treate(d by ColdZ.-Dr.

C. J. AknxLE read notes of these cases. Case I.: A.W.GT., aged 27,married, railway clerk, was admitted into University College Hos-pital, September 21st, 1887, with an ordinary attack of rheumatism.His previous health and habits were good. He hiad syphilis ninevears ago. His mother died after an attack of acute rheumatism.Yis'sister was rheumatic. On admission he was treated withlarge doses of salicylate of soda. The night after admission hebecame very delirious, the joint pain disappeared, the skin becamehot and burning, and the temperature was up to 110.40. He wastreated with ice-cold bath for forty minutes. The temperature fellto 970, but ran up four hours later to 107.20, while he was takingantifebrin. The bath was repeated for twenty-five minutes. Thetemperature fell again, and showed no further tendency to run upexcessively. No visceral lesion followed. The patient was ulti-mately discharged cured.-Case II.: E. C., aged 30, a marriedwoman, had rheumatic fever eighteen years ago, but no complica-tions. There was no family history of rheumatism. Present ill-ness: She had been ailing with joint pain for a week before shehad been seen by a medical man. The temperature at midday onOctober 9th, 1887, was 102.50 ; at 10.30 the same night it was 110.40.The patient was violent and delirious. No bath being available,

she was treated with ice-cold packs. The temperature fell onehour later to 1010, and for the next twenty-four hours averaged1030. It then fell to normal under salol and salicylate of soda.The patient was discharged well on October 27th, 1887. She hadbeen readmitted witlh another attack of acute rheumatism andpericar(litis, but was now convalescing. Remarks: These casesshowed the value of the cold bath or pack as antipyretics.Both belonged to the type in which the temperature, after main-taining for one or two (lays a moderate level, suddenly rise.s to anexcessive height. In both cases the temperature was very tract-able, having a little tendency to run up repeatedly. Tlhe casesthrewv no liglht on the etiology: one was a male anid the other a

female; oIIe a first attack and the other a second; both seemedmild uncomplicated attacks. In both there was cessation ofsweating, and in one disappearance of artictilar pain. In boththe delirium accompanied the hyperpyrexin, andl was of thesame violent character. Both patients had marked retrac-tion of the head, and one severe or persistent opistliotonos.-Dr. MACLACAN tlhought all the cases formed a valuable additionto the literature of an imlportant andl somewhlat obscure subject.In the way of criticism he liad nothing to say; lie wouil(d onlyhomologate in its entirety what had been stated by1)oth gentle-men, that the salicyl compounds, all potsnt in rheumatic pyrexia,were of no use in rlheumatic hyperpyrexia. In the treatmient ofthat condition the external application of ejldl was th*e onlyremedy on whielh one could rely, andl it wvas waste of. valuabletime to have recourse to any otlier. lie would try to giv-e someindication as to whiy it was that a remedy wlhiehi rapidly curedrheumatic pyrexia was of no sevnice in rheumatic hyperpyrexia,aild that the one agency on which one depended in rheumatichyperpyrexia one never thought of applying in rheumaticpyrexia. Rheumatic pyrexia and rhefuimatic hyjerpyIrrexia weretwo totally different morbid conditions, essentially distinct intheir pathogenesis. It was because of thli-i that their treatmentwas so essentially different, and that what cured the one was ofno avail in the other. Rheumatic pyrexia was of metabolic origin;rheumatic hyperpyrexia of neurotic origin. In the one the feverwas due to increased metabolism and consequent increased pro-duction of heat; in the other the rise of temperature resulteehfrom paralysis of hleat inhibition. As the subject was not beforethe Society, he did not stay to consider low rheumatic pyrexiawas produced, or how the salicyl compounds cured it. Hyper-pyrexia was not a disease per se, but an incident occurring. in thecourse of various and different ailments. It might occur in anyof the specific fevers. How was it induced. The fever in theseailments was of metabolic origin, due to increased produc-tion ofheat; normally heat production was preventedl from passing duebounds by the lieat-inhibiting function. Increased production oflheat necessarily gave rise to stimulation of this function. Pro-longed stimulation (as in the tetanising of a muscle) might lead to,exhaustion of function. Stimulation of the inhibitory functiom.,might in any fever lead to fatigue, and even paralysis of thatfunction, and consequent rapid rise of temperature. Rheumatiefever was the one in wlhich this was most likely to occur, becausein that fever much metabolism, the chief source of heat produc-tion, was more increased than in any other; as a result,hieat production was greater, heat inhihition more strained,and therefore more like y to be paralysed. But hyperpyrexiadid not consist solely in excessive rise of temperatureany more than pyrexia consisted in increased body heat.That a very higli temperature did not necessarily cause nervoussymptoms was evidenced by what one saw in relapsing fever, inwhich it was not ulncommon to have a temperature of 1060, 107°,or even 1080 withlout the patient presenting any other symptomby wlhich his case could be distinguished from that of the man inthe next bed, wlhose temperature might be only 102' or 1030.The condition to which wats applied the term hyperpyrexia essen-

tially consisted in paralysis of inhibition of the functions of organiclife, heat inhibition bemg only one of them. Ilow did cold pro-duce its curative action in this condition? Not by lowering thetemperature, for to say that would be equivalent to saying thatthe hiighl temperature was the cause of the distuirbance. More-over, cold actually removed the whole morbid condition and curedthe patient. It could not do this simply by a refrigerating action.The physiological effect of long exposure to cold was to producea sense of drowsiness and a tendency to sleep, which, if notresisted, gradually deepened into fatal coma. Cold was evidentlya powerful agency, experiencing a sedative action so great thatit might prove fatal by coma; but, like other sedatives, it might

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698 THE BRiTiSH MEDiCAL JOURNAL. [March 31, 1888.

be used in moderation, and have its quieting action turned togood account. Ile would illustrate whlat lie believed to be itsmode of action in hiyperpyrexia by it reference to the action ofdigitalis in heart dlisease. Stimtulationi by the cardiac inhlibitorynerve, tlhe vagus, slowed the heart's atctioni. When, as oftenhappened in nmitral disegase, the heart's action was excite(d anlddisturbed, one dlid not try to allay the disturbance by soothing tlleexcito-motor nerve of the lheart, blut by giving digitalis, and stimu-lating thle inhilbitory nerve. To stimulate inhibition was thephysiological and scientific way of allaying excessive funcetionalactivity. It was thlus that coldl acted in hyperpyrexia. That con-dition essentially conisisted in paralysis of ihliibitioin. Cold stimu-lated inhibition and cured the patient. Its mo(l of applicationwas a matter of detail and conveniience. Ice or cold water werethe two meanis of ap)plying it. Care must only be takeii tllatinhibition was Inot over stimulated, for complete inliibitioia oforganic life meant (leath. Cold acte(d in hryperpyrexia not by

lowering the temperature, but by causiiig such periplheral excita-tion of the cutaneous nerves as resulted ill stimulation of theinhibiting centres. It was only by recogniisinig that rheuimaticpyrexia and rheuimatic hyperpyrexia were different morbid con-ditions, totally dist.inct in thieir pathiogeniesis, that oIIe could ex-

plain why it was that the treatment suiitable in the one was iniap-plicable in the other. Dr. COUPLAND thlolught that althlouglh Dr.Maclagan lhad clearly differentiatetd between pyrexia and liyper-pyrexia, they were b;oth equally due to (list urbance of the nervoussystem, and that cold was equally a menns of reducingpyrexia as of loweriiig lyTerpyrexia. Dr. AlacAlister's argu-ment in his lectures oII fever was based on the neuroticorigin of fever, of pyrexia as of hzyperpyrexia. The cases relatedwere all good examples of the benetit p)roduce(l by the treatmentby cold in hyperpyrexia. I)r. Ord's patient had well-mnarkednervous disturbance before the hyperpyrexia set in, andtl this,fortunately, was often the case; so tlhat, by watching the pa-tient in wlhom these symptoms arose, and takingr hiis tempera-ture, one miglht anticipate and prevenit the lhyperpyrexi. A

committee appoinited by the Society some years siince hiad foundthat the cases had marke(d prodromata, tl;e chief of which werein the nervous system. If, when the temperatuire rose to 105°,the bath was always used, the patieiit would probably be cuired.In Dr. Arkle's patients there were no prodonmata mentioned.Dr. H. TiomipsoII hlnd years ago advised to look ahead in thesecases, aiid treat them carefully, so as to avoid the sad fatalitywhich awaited the lpatients uniless treatment was prompt.-ThePRESIDENT tilougllt the cases were all of extreme interest, butthe fact that in Dr. Ord's case there was cerebral disturbancebefore the hyperpyrexia was noted was of far-reachiing import-ance. Whatever the explanation, it was clear that the deliriumand subsequent coma were not altogether due to the rise oftemperature. The nervous element in the case came first; thedisturbance was probably of the whole nervous system, not ofthe inhibitory heat centre. In failure on the part of the ner-vous system the trouble seemed to commence. In relapsingfever, with a temperature of 1079, the patient 'was sometimesfuriously delirious. In two cases lie hiad seeni the peculiar de-lirium mentioned by Dr. Ord; no higlh temperature followed ineither case; both patients were under the influence of salicylateof soda, and both proved fatal. Possibly the cold treatmentmight have averted the fatal result. Two factors were at workin the cold treatment; one was the abstraction of heat; theother was that that treatment enabled the nervous system toreassert its control over the body, and thils led to the cure ofthe patient.-Dr. BASIL MORISON cited the case of an infanit, 14days old, whose pulse, consequent on over-feeding, fell to 30 perminute, the skin becoming cold. A drachm of tincture of bella-donna was injected into the rectum, whereupon the pullse rose to180 and the temperature to 1300. In fact, the child's life appearedto be in danger. Ice was applied, and the temperature cooleddowrn-to such an extent, indeed, that the heart stopped for a fewbeats. The child, lhowever, recovered with artificial respiration.He thought the case might serve to illustrate the action of cold.-Dr. ANGEL MONEY remarked that in Dr. Arkle's first case, wlhenthe man recovered from the coma, his first remark was " Isn'tthis marvellous?" Ile thought the use of this expression wellillustrated Dr. Ilighlings Jackson's theory that the centre inthe brain, which was well used (for this was an ordinary expres-sion with that patient) was the first to act.-Dr. BARLOW hadtreated a case of acute rheumatism in a delicate woman whccould not be removed from her bed to a bath when it was neces

sary to apply the cold. The patient was stripped, except at thewaist, and the bed tipped at the head so that cold water whichwvas poured over lher ran away at tlhe foot. The water was usedseveral times, and slhe was rubbed dry after each application.This simple procedure reduced the temperature from 1070 to 1000.This was a good substitute for a cold bath wvhere the latter couldnot be applied. The constant application of cold in sliglht pyrexiaproduced (lepression and rigor, and made a patient look q(uiteblue. It was really a powerful remedy. Ile cited also the caseof a barman, witlh furious deliriumn at the beginning of pneumonia,whose temperature wafs lowered by similar treatment.-Dr. O)tiremarked that Dr. Maclagan's theory of hyperpyrexia being (lueto paralysis of the centres of organic life, of wlhich heat vaIs one,was partly corrohorate(l by D)r. Buzzard's views that rheumaticfever miglht be dlute to an affection of the cerelwllum, in which theheat-inlhibition centre seemed to be situatedl. He (the speaker)also tliought that the effect of cold was not simply mechanical, aswas evidenced by some experiments performed upon ca(latvera.hlaving heated them to a heiglht in warm baths, lie treated themby a cold bathlwithout reducing the temperatutre in anythinlg likethe proportion to wlhich a cold bath reduced the temperature of alhyperpyrexial patient. Ilis patient, wlho wvns before deliriousbecame quite clear, and slept; his pleurisy disappeared, and theperi- and endocarditis both thenceforward diminishled. Ilyper-pyrexia was a fever outt of proportion to the local symptoms. Forits treattment one must look to prevention in cases of rheuimaticfever; and if the temperatuire rose over 105° he hlad rconirse totlhe cold treattnent. It was said that pericarditis was usuallyaccompanied )y (lelirium. This lie had not found in hiis eases;but it was a sign of rising temperature. lie thoulght a graduatedbath was preferable to the ice-pack.-Dr. AnKLE said that possiblyin hiis second case prodromal symptoms were present before thelbyperpyrexia. In the flrst case the patient was a little deaf andlight-lheaded-symptoms that frequently occurred when the sali-cylate treatment was pushed. That man ha(l taken 240 grains inthe day preceding his hyperpyrexial symptoms.

Gall-.stones exciting 8 )puration: Operation: Recovery.-Mr.PEARCE Gou.D described this case. The patient was a gentle-man, aged 38, who had symptoms of gall-stones two years beforehe consulted M1r. Gtould for an abscess in the abdominal wall atthe junction of the epigastrium anid riglht lhypochlondrium. Theabscess was opened, and 140 small biliary calculi were removed,together with pus. The sinus that was left was long in healing.No bile was discharged tlhrough it at any time. Many of the cal-culi sliowed evidence of spontaneous fracture of a larger calculus.Mr. Gould mentioned that he had found reference to tliirty-fiveotlher cases of gall-stones making their way tlhrough the abdo-minal wall, but this was the only one in wlichl the diagnosis ap-peared to have been made prior to the abscess bursting. Theabscesses had pointed at various places in the abdominal wall,most often above and to the right of the umbilicus. As a rule nobile had escaped wit.h the stones, and these latter had generallybeen numerous. There appeared to be lacking any satisfactoryexplanation of the very different results of biliary calculi in di-ferent cases.-Dr. ORD said that the disintegration of urinary cal-

Lculi had much interested him, buit as to that of biliary calculi heki-new nothing. The disintegrationi of urinary calculi miglht be theresult of either of man different causes; the shrinkage of theouter layer, or of the inner portion, in consequence of the dif-ferent composition of the layers. Biliary calculi were composed

iof a mixture of cholesterine and biliary pigment, and the bilermight act on one or other of these constituents alone.-Dr. MAC-[LAGANN mentioned the case of a woman who died from peritonitis,

and in whom post mor-tem 180(small calculi were found in the peri-toneum, and of which twenty or thirty were disintegrated. Hethought that possibly the squeezing of small calculi against one

Ianother by the contraction of the walls of the gall-blad(lder, whenIit became distended, might produce disintegration.-The PRESI-,DENT thouglht tlhe explanation offered by Dr. Ord seemed very

reasonable. Calculi being formed of heterogeneous materials, andthen exposed in a medium of a different charaeter from that in

iwhich they were originally formed, would be liable to suffer dis-tintegration. Ile remarked that unless the cystic duct were closed1 no abscess would form externally.-Mr. GoVLD thought it remark-aable that, considering the variations to which calculi were exposed, in the intestine, more of them were not found broken up. As tod Dr. Maclagan's explanation, he thought that, if it were correct, oneowould expect to find after biliary spasm thiat the stones voided

wwere broken up biy the contracting gall-bladder andl ducts, but

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THE BRITISH MEDICAL JOURNAL

such stones were Inot found disintegrated. lie tlhought that thesharp angles of these disintegrated calculi might, perhaps, havedetermined the abscess in his case. The specimens in the variousLondon museums were of facetted stones, quite unlike the frag-ments he had handed round.

MIEDICAL SOCIETY OF LONDON.MONDAY, MnARCH 26TH, 1888.

J. KNOWSLEY THORNTON, M1.B., C.AM., Vice-President, in the Chair.CLINICAL EVENING.

Lupus of the Mouth, Pharynx, and Laryn.-Dr. ORWIN slhoweda Frl, aged 1l,who came to him in 1886 with lupus of thie nose.There was then no disease of pharynx or larynx, but she returnedin March, 1888, with lupus of the guims and soft palate, pharynx,and larynx. In this case the lupus had spread througlh the noseto the palate by lymphatic channels. Mr. L,ENNOX 1BnOWNF. saidhe had recorded eleven cases of lupus of the larynx. He lhad neverseen lupus of the posterior wall of the pharynx, and he did notagree with Dr. Orwin's view as to the path followed by the lupus.A distinguislhing point between lupus aild tertiary sypliilis wasthat the latter often attacked the palate, both soft and hard, byextension from the nasal mucous membrane, whereas lupusalways extended by the buccal mucous membrane.-Dr. ORwIN, inreply, said that there wa9s no history of syphilis.injury to Lower flpiphy.sis of Ulna.-Mlr. EDMUNr) OWEN

showed a girl, aged 18, who, sixteen years previously, hlad beenunder his care at St. Mlary's Hospital for an incised wound ofthe left wrist. The blade liad passed through thle ulna, justabove its articulation with the lesser sigmoid cavity; that jointwas not opened, but the lesser sigmoid cavity was sliced from theradius, and the wrist-joint was laid widely open. The tendon ofthe flexor carpi ulnaris, the ulnar nerve and artery, and some ofthe adjacent flexor tendons were cleanly severed; circulation andcutaneous sensibility were ultimately restored along the inner sideof the hand, and thouiglh inflammation attacked tle surroundingtissues and an abscess formed on the back of the hand, the powerof movement became in due course as free as ever. Indeed, thechild was left-handed; as slhe grew up slhe easily used her knife inthat hand; ultimately she became a useful domestic servant. Butthe ulna had ceasedl to be developed, and bent the growing radiusover to its side. In September, 1887, the girl fell upon the innerside of the damaged wrist, and immediately afterwards (accordingto her accouint) sensation became diminished along the inner sideof the hand, and the member became uiseless. Ilow far the casemight be influenced by hysteria Mr. Owen could not say, but itwas evident that the ball of the little flnger and the web of thethumb were wasted; probably the nerve was injured. Thc chiefinterest consisted in the apparent overgrowth of the radius; actu-ally, however, that bone was half an inch shorter than the oppositeone, whilst it was bowed in its lower two-thirds towards the ulna,which latter bone was three inches and a half shorter than itsfellow on the right side. The case showed how largely the ulnadepended on the integrity of its lower extremity for growth inlength. The upper epiplhysis was of comparatively little import-ance in that respect. Reference was briefly made to cases reportedby Mr. Augustus Clay and Mr. Walter Brown, of Leeds. Inthese cases the radius had been injured, but the deformity lhadnot been so great because the radius was less dependent forits growth on the lower epiphysis than was the ulna. He thenmade some remarks as to the best method of treatment.-Mr. WM. RosFE alluded to the case of a boy with fracture of theleg above the internal malleolus. The boy subsequently returnedto the hlospital with marked deformity in consequence of thegrowth of the fibula and the arrest of growth of the tibia. lie re-moved an inclh and a lhalf of the fibula, and thus restored thesymmetry of the limb.-Dr. DAVIES-COLLEY spoke of a case offractured tibia involving the epiphysis, which gave rise to seriousdeformity, which he treated in much the same way as Mr. Rosehad done.-Mr. WALTER lPYF said that he did not think the sym-ptoms were due to damage of the ulnar nerve at the date of acci-dent, as the wasting had been far too rapid.-Mr. KNOWSLEYTHORNTON asked whether it was not advisable in such cases toawait the full development of the bones.

Paralysis of the Ocular Mluscles.-Dr. S. WEST showed a woman,aged 62, addicted at one time to drinking, who had suffered fromheadache. This returned about two months before admission,chiefly at night. It rapidly got worse, and was most marked inthe left temporal region. On getting up one morning five weeks

ago she saw double, and the eyelid dropped a few days later. Noother symptoms were noticed, no vomiting nor giddiness. Eye-sight began to fail on Marchl 19th, an(l she coul(d then hardl'y seeat all. No changes were visible on examination of the disc. Shehad lost flesh, but lhad picked up more recently. There was nohiistory of gout, rlheumatism, or syphilis. There was completeparalysis of all the recti and the iniferior oblique, and ptosis. Noother nerves were affected.

G;unshot Injury of itiyht Knee-Joint.-Mr. Wmt. ROSE related acase of gunshot injury of the riglht knee treated by opening upthe joint, an(I cleansing with solutions of carbolic acid andsublimate. A ftill rep)rt of this case will slhortly be published.

Threphinny for Middle Meningeal IIoimnorrhaye.-l r. DAVIES-COLLEY showed a man whio hIad sustained an injury to the headfrom a fall. lie lost consciousness, anid on recovery there wasslight paralysis of the left arm, anld great bruising over the, tem-poral region on the right side. The paralysis afterwards becamecomplete, and extended to the left side of the face. Ile passed hisurine and motions involuntarily, and his temperature wvent downto 970. On the eleventh day Mlr. Davies-Colley trephined, andfound a clot three inches long by seven-eighths of an inch thick,which lie scooped away, washlinig out the cavity. The patientrapidly an(I completely recoveredl. Mr. Davies-Colley observedthat very few such cases were on record.

Charcot'S Duease of the Shoulder-Joint.-Dr. BEEvon showed aman with symptoms of ataxia who had suddenly developed sym-ptoms of ('harcot's disease of the left shoulder-joint. No historyof previous injury; no pain.

Obliterative Arteritifromn Crutch Pressure.-MSr. WALTFR PYBshowed a man whio had been obliged to use a crutch sincethe age of 8. A year ago he lhad noticed some loss of sensation inhis fingers, and ultimately the artery from the axilla (lownwardslhad solidified. The circulation had since returiled to some slightextent.-Mr. IHADDEN said that he lhad seen tlhree cases resemblingthe above, and thought that there was a class of cases in whichplastic effusion into the arteries gave rise to thrombosis.

Thierach-rould's Operationfor7I?ernoval of Penis.-Dr. PURCELLshowed a man, aged 45, who had been operated on several timesfor cancer of penis, the first time in March. 1886, and the last inJanuary last. He had operated according to the method describedby Mir. Gould. The testicles were not removed, and thepatient had complete control over his bladder. He was now com-paratively well. The second case was not well enough to leavethe hospital. Ile was operated upon on February 21st last. Ilewas 68 years of age. Epithelioma of penis began last year, but noglands were enlarged.

Carcinoma en G'uirasse.-Mr. MORGAN showed a woman, aged52, who presented a typical example of the disease named anddescribed by Velpean as carcinoma en cuirasse. Last summer in-duration and swelling of the right mamma began, and wasfollowed very shortly by a similar condition in the oppositebreast, and this by hardness of the skin of the chest over thewhole surface above and between the maminT. Wlhen sent tothe hospital in October, there was a hard wedematous condition ofthe whole of the skin of the chest, whiichl was red and even ontlle surface, presentiing almnost perfect symmetry, and so hiard asto obsenre the exact condition of the mammae. The skin of theaxilloe were little if at all enlarged. Since October, little changein this condition had taken place, except some ulceration of theskin around the margin of the right breast. Both nipples weresurrounded by tlhick crusts of pigmented epithelium.

IROYAL ACADEMY OF MEDICINE IN IRELAND.SECTION OF MEDICINE.

FRIDAY, 31ARCH 9TH, 1888.JAMBS LITTLE, M.D., President, in the Chair.

Case of Pneumothorax.-Dr. WALTER G. SEITH exhibited apatient suffering from pneumothorax.Etiology and Classification of the Anemia of Puberty.-Dr. E.

MACDOWEL COSGRAvE read a paper, which is published in thisday's JOUNAL, p. 688.-Mr. Cox said his treatment was, first of all,absolute rest in bed for a fortnight, then purgation by sulphate ofmagnesium, then iron. He combined the iron with tincture ofdigitalis or of nux vomica, and sometimes used a combinationcontaining ferrum redactum in 2-grain doses, with 1-graim of thearseniate of iron.-Dr. C. J. NIXoN said he could not understandany distinction between the anwmia of puberty and chlorosis.Why not as well speak of the anrmia of dentition or of diarrhce,a?

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March 31, 18N.j

7TIE BRITISH MEDICAL JOURNAL.

The object was to determine the origin of aniemia-whether itwas essential or symptomatic. The essential forms were of threeclasses: First, the constitutional, whiclh had its origin from birth;that was a form of which tlley knew nothing, whet1 er as regardsits being due to a deficiency in the manufacture of the elementsof blood, or to an increased amount of the destruction of thoseelements. The second class was the anaimia of puberty,ordinarily spoken of as chlorosis. The third class was the formknown under the name of pernicious anaumia, the certainty of theexistence of wlhich they on y arrived at because the patient died.When the pathiological principles as to the basis came to beinvestigated, they recognised all forms of anremia as standingon the same level wlth regard to the condition of the blood-cells,in simple aniemia as in cases of chlorosis, or in tlle most profouindforms of pernicious anremia. Chlorosis appliedl not on y to thefemale, wlien special calls were made on the vascular system inpuberty, but to the male also. The reason the female was moresubject to the disease was because the red blood-cells were nor-mally fewer in number; and certainly, from the condition of thegenerative system-ovulation and menstruation-there was moredisturbance in the blood-forming process in the female than inthe male.-Dr. WRIGHT said the only way to cure the patient wasto recommend her, the moment she felt lher lhealtlh fail, to putherself under treatment and commence taking iron. AlthioughSir Andrew Clark had recently claimed the credit of being thefirst to indicate fiecal aecumulations as a cause of the (lisense, hewell remembered that the late Mr. Richardson taught his classyears ago that hie could cure as many cases by using aloes as byusing iron.-Mr. Foy mentioned a case of five dauglhters and twosons, the offspring of an early marriage, of whiom the girlsbecame anaemic; the boys escaped.-Dr. J. W.M.oonT said thatseason exercised an influence on the occurrence of an.tmia orchlorosis in young adult life; for instance, there was a greaterprevalence of the disease in winter than in summer.-ThePRESIDENT thought it would be a very dangerous thIiing to makea diagnosis of anvimia in any case where there was loss of weiglhtaccompanying it. Where he saw a girl who became breathlessand had palpitation on exertion and had got white, if she did notincrease in weight, he would fear he had to deal with tuberculosisand not with anaemia. There were cases where anmmia had beenset going by shock; for instance, that of a young lady who acci-dentally killed her father by giving him a poisonous linimentThen there were affairs of the heart and otlher exciting causes,suggesting that annamia was due to some influence oIn the nervoussystem.-Dr. COSURAVF, replied.

Gastric ESpilepsy.-Dr. A. W. FOOT made a communication ongastric epilepsy. A lad aged 17 had a series of epileptic attacksfor two years, induced by eating rich and indigestible things, oiordinary food in a rapid manner. His attacks occurred at meah;and in the dining-room almost exclusively. lie was seen b3Dr. Brown-S6quard, and, after persevering in his treatment fo'five years, the seizures ceased to occur.-Dr. FINNY meintioneethe case of a young student who, crossing the. Chlannel,hadhsupper of bee?steak about 3 o'clock in the morning on board thisteamer. After breakfast he became the victim of a very severattack of epilepsy. The cause proved to be the undigested beefsteak, and there was no return of the disease. lie had experiencof another case of a young man who had, when a child, suffere(from scarlet fever. That youth, whenever the large bowel becamiloaded with animal food, became liable to epileptic seizures.-DYC. J. NixoN said Dr. Foot's case was one of extreme interest, i:view of the important fact that an epileptic of live years had gocompletely well. It was not sufficient to direct attenition to thperipheral irritation alone. A healthy person would not get a:attack from a mass of undigested food in the bowels. Thermust be a peculiar condition of the cortex of the brain whicifrom irritation, set up the epileptic condition; and the speciedanger was that, once it was developed, it was apt to continue.-Mr. Cox made some remarks, and the PRESIDENT said there weitwo factors at work. Besides the irritation, there was the mobilexcitable condition of some portion of the brain, which madeliable to discharge itself on slight provocation. Some twentyears ago he saw a boy. aged R or 9, whose case left a great inpression on his mind. The boy had had a succession of epileptseizures. His father and mother were first cousins, and he hafive uncles and aunts confirmed epileptics. Still it occurred Ihim that the boy might have worms. Means were taken that dilodged a vast quantity of round worms. From that time to tlpresent the patient, who was now thirty years of age, had never hi

a recurrence of the epileptic seizure. If the worms had beenallowed to remain some time longer, until the epileptic habit hadbeen established, he would hiave I een, like his uncles and aunts, aconfirmed epileptic.-Dr. FOOT replie(d.

LEEDS AND WEST RIDING MEDICO-CHIRLTRGICALISOCIETY.

FRIDAY, MARCH 16TH, 188.J. SPOrTIswNOODE CAMERON, M.D., Vice-lresident, in the Chair.Cystic Kidney.-Dr. CUFF showed a kidney in an advanced state

of cystic degeneration; weight, 10 ozs. The other kidney weighed7- ozs., being healthy.

Abces.s ofBrain.--This was shown for Dr. EDDISON. Therewasa large collection of very fcetid pus in the substance of the rightlhemisphere. There was no bone or tubercular disease discovered.0Specimens.-Mr. JEssoP showed the following. 1. Lipoma nasi.

2. Adenoid tumour of kidney (successful nephrectomy). 3. Sarcomaof femur (amputation). 4. Large, round-celled, alveolar sarcoma,from popliteal space. 5. Haimatoma of arm.-Dr. AI.LAN showed:1. P'rimary cancer of bladder. The symptoms had existed for sixmonths. 2. Spleen, greatly enlarged, from case of leucocythaemia.The intestine, also, was shown. The latter showed pearly nodules,ann( the mesenteric glands were enlarged, but there were no

nodules in the spleen. 3. Cancer of stomach and liver. 4. Viscera.from a syphilitic infant. 5. A collection of gall-stones. 6. Twinchickens, united by the thorax.Knee-joint.-Mr. TEALE showed a knee-joint from a man,

who on two occasions had received injury by strain or wrenchfollowed by pain and swelling. A loose body could befelt, and the joint was opened for its removal. It wasthen found that besides partial detachment and great thicken-ing of the synovial fringes, there was destruction of the carti-lage on the inner side, and the surface of the bone had beenworn into a deep groove, with a sharp edge, as if a piece had beenremoved by two saw cuts at riglht angles to each other. Severalloose pieces of bone and cartilage were also removed. In a secondoperation the knee-joint was excised, but the patient died fromacute septicemia. Mir. Teale thought a piece of bone and articularcartilage had been broken off by the injury, which had worn thegroove in the opposing surfaces of femur and tibia.-Dr. JACOB,Dr. BAURS, and Mr. LITTLEWOOD made some remarks.

Pelvic Cysts.-Mr. MAYO RoBsoN showed a series of prepara-stions illustrating the origin of pelvic cysts. le shiowed speci-

mens of hydrosalpinx, pyosalpinx, parovarian and broad ligamentncysts, dermoid, unilocular, multilocular, and papillomatoussovarian cysts, and fibro-cystic tumour of the uterus, demonstrat-r ing by means of diagrams the seat of origin of the variouss tumours. lie remarked on the frequent gonorrlhwal origin ofytubal disease; and, aftershowing specimens of follicular degenera-or tion of the ovary, said that such disease, though forming no,d tumour, was frequently a cause of intense pelvic distress, incap-a able of relief except by removal of the appendages. In all thee cases shown the patient lhad recovered from the operation.,e Ankylosis of Atlas and OcMiput.-Dr. WAIRDUtoP GRIFFITH- showed a specimen of ankylosis o atlas and occiput. There wasWe a history of suppuration about the neck in childhood. There wasd a thickening of the bone at the origin of the trapezius.e Cirrhosis of Liver.-Dr. GRIFFITH also showed a specimen ofr. this condition. There was a very large vein, in the position ofn the fcetal umbilical vein, passing from the portal vein to the um-3t bilicus, providing collateral circulation. This perhaps was theie reason that ascites had not recurred after the patient had beenLn tapped.re liver Disease in Cat.-Dr. GRI1FITH also showed the liver of ah, cat studded with large nodules, presenting somewhat the appear-al ance of a human syphilitic liver.-Dr. 1AtARts and Dr. JACOB_ thought the condition a congenital abnormality, and not patho-re logical.le %apillary Growvths.-Dr. JACOB showed on a screen, by means ofit a Lewis Wright's lantern mieroscope, a number of preparationsty illustrating papillary forms of growing epithelium from variousn- inflammatory and neoplastic growths, including papillomata ofic the tongue, coccidium nodules from rabbit's liver, and adenoidad growths from the kidney and prostate.to Miscellaneous Specimens.-Mr. MAYO showed a specimen ofis- Tubercular Arthritis of Knee. Specimens of Abnormalities ofhe Arteries, from the Anatomical Department of the Yorkshiread College, mounted by Dr. OLIvEm, were shown, as weU as a number

LMarch 31 p 1888.700

Mach 31, 1888.] THE BRITISH MEDICAL JOURNAL 701

of ophthalmic and other preparations recently added to the York-shire College Museum.-Mr. LrrrLEwooD shlowed sections of hardchancre (excised on the sixth day) and pigmented moles. In theformer a characteristic induration had appeared at the edges of thewound. -Mr. LIrrTLEWOOD, for Mr. Bnowix, showed Median andUlnar Nerves, becoming bulbous and adherent to the stump ofthe forearm.

SOCIETY OF MEDICAL OFFICERS OF HEALTII.FRIDAY, MARCH 16TH, 1888.

ALFRED HILL, M.D., President, in the Chair.Death-Rates as Tests ofHlealthine8s.-Dr. Louis PARKEs read

a paper in which the fa acies arising from a faulty enumera-tion of the population on which deatlh-rates were founded werepointed out, and it was shown that in the ten years interveningbetween two censuses, it was in many cases impossible to arriveat even an approximate enumeration by any method at presentknown. The only effectual remedy would be a quinquennialinstead of a decennial census. The author next pointed out thefallacies which might arise from disregard of the different age andsex distributions of different populations, when their death-rateswere used for the purposes of comparison and as tests of healthand sanitary condition. It was urged that no public statement ofdeath-rates should be made, which had not been corrected for ageand sex distribution on the basis of the proportions found to existin the country generally at the date of the last census. Themethod employedl by the Registrar-General in the case of thetwenty-eight large towns of E^ngland and Wales was simple andefficient, and witlh no great labour might be applied to every com-munity of persons throughout the country. The influence ofbirth-rate upon death-rate was considered, and the late Dr.Letheby's views upon the relations which should subsist betweena high birth-rate and a high death-rate were alluded to. Thefundamental distinctions between mean age at death and meanduration of life were insisted upon, and it was shown that themean duration of life was one of the best tests of the healthiness ofa population. In conclusion, the author brought under notice thehigh death-rates wlhich had distinguished for so many yearssome of the northern manufacturing towns, and urged that thisexcessive mortality, whiclh was largely confined to the earliestperiods of life, was due to causes which could be brought undercontrol, and that an autlhoritative inquiry into all its aspects wasdemand ed. Such an inquiry would bring public opinion to bearupon acondition of things which should not be allowed to existany longer.-In the discussion which followed, the PRnE8SDENT,Drs. BATE, SYKES, SAUNDERS, and SEATON, and Messrs. BUTTmn-FIELD, BLYTH, NOEL HuMpjH1auYs, LoVErT and SHIRLEY MURPHYtook part, and Dr. PARKEs replied.

REVIEWS AND NOTICES,A TREATISE ON CHEMISTRY. By Sir HI. RoscoE, F.R.S., and C.SCHORLEMMER, F.R.S. Vol. III, Organic Chemistry. Part 1V.Messrs. Macmillan and Co.

Tim present volume, consisting of 544 pages medium octavo, formsa further instalment of the well-known textbook on chemistry,both inorganic and organic, with which the names of theseauthors are associated. This part is devoted to a description ofthe aromatic compounds containing seven atoms of carbon, in-cluding the toluene, benzyl, benzoyl, and hydrobenzyl groups, aswell as the xylene group of tlle compounds containing eightatoms of carbon. The volume is a worthy successor to thosewhich have preceded it, and is characternsed by the lucid andcomprehensive manner in which the extremely uilwieldy mass offacts composing modern organic chemistry is presented to thereader. Of particular value are the historical retrospects givenin introducing the more important compounds, and which serveto indicate the progress and development of the various branchesof organic cliemistry. It is these passages which make thissomething more than a mere work of reference, and render alarge part of the volume suitable for continuous reading.As a work of reference, the treatise of the authors cannot, ofcourse, compete with the exhaustive compilation of Beilstein,Handbuch der Organischen Chenie, in which the avowed aim ofthe author has been to refer to every organic substance the com-position of which has been determined by analysis. But there can

be no doubt that the work, as far as it hias progressed, is not onlywithout a rival as a treatise on organic chemistry, but is also Un-equalled as a book of reference in the English language. The re-sent part is not one whicih contains much that is of speciain-terest to medical men generally, althiotigh there is a very clear ac-count of the relationshil) between benzoic and hippuric acidsand of the causes to wl -ichi the appearance of tIlese substances inthe urine of man arid of the lower animals is due. The descrip-tion of the preparation and properties of salicylic acid, as well asof some of the products of oxidation of the opium alkaloids be-longing to the 8-carbon-atom group will also be read withinterest.

THE CURABILITY OF INSANITY. By Joinr- S. BUTLER, M.D.,hiartford, Connecticut. M1essrs. I'utnam. l887.

AT first sight one is prejudiced against this v-erv small work onsuch a very large sulbject, and but for I)erson;al knowledge weshould have suppose'1 that it was the first effort of a y-oung manwho was starting on the path of authorshil). As it hiappens itis the summing uip of the experience of an oldl man who has seenmuch, and probably discovered into how small a space all our realknowledge can be put.

Dr. BUTLER begins by (discussing the proportion of patients tomedical men in asylums, in the past and in the pre-sent. lie is astrong advocate for the separation of the curable from the incur-ably insane, and for the individualised treatmcnt of the former.Why should it be necessary to state this proposition that the in-sane must be treated as in(lividuals? Ilut s;o it is an(d so it willremain as long as medical superintendents are exp)ected to be medi-cal stewards, or are men appointed for social rather than medicalfitness. We do not know of a single Englisl asylum or hospitalfor the insane wlicll is sufficiently oflicered if there is to bethorouglh medical supervision of the cases. No general physician,even with a staff of clinical clerks, would pretend to be respon-sible for the diagnosis and treatment of two or three hundred cases;and yet in the best hospitals for the acutely insane this is what isexpected. Skilled an(l experienced general physicians, with specialtraining, slhould be at the head of asylums, and they should be freefrom mere administrative work, and have every assistance in pro-viding suitable companions and attenidants.

Dr. Butler points out how many cases of functional mental dis-order require special treatment, and nowadays one must admit thatin asylums ladynursesandlady companions have replacedthe "Mrs.Camps" of former days, yet here in England there is still muchto be desired. The general hospital nursing is in advance of thatof our asylums, and even this is much better than the nursingprovided for those cases wlhich are treated at home. Individuatreatment, such as that recommended in this little book, impliesthorough knowledge of the conditions under which the disorderhas arisen, and a proper exertion of force to counteract the evils.It is surprising that so little has been written on the functionalcure of functional disorders, for there is plenty of room for theexercise of this kind of treatment among the insane.The majority of medical men seem to have three courses open

to them in treating the insane. Either they narcotise them, sendthem to an asylum, or send them abroad. Any one of these formsof treatment may be abused, but we think that the sending of aperson of unsound mind abroad without having fully consideredwhat he is going away for is unreasonable and may be danferous.The mind is at least as much influenced byrestas the organs ofsense,and rushing over the Continent is not rest. Rest in bed and carefulwatching may be much better than railway or even ocean travel.The advice given by our author is sound, his examples are in-teresting, and his authorities are the best in lunacy. He exhibitsthe old man's love of quotation, and his quotations will be foundto be correct and apposite.

A TIEATISE ON ASTIGMATISM. By SWAN BURNETT, M.D.St. Louis, Missouri: J. II. Chambers and Co.

NOTwrITISTANDIN` the author's preface, we much doubt the wis-dom of writing a book on astigmatism alone. It appears to us to(be both theoretically unsound and practically inconvenient todivorce the consideration of one form of ametropia from that ofothers, and the book before us could have been only completehad it formed part of a larger work.The theoretical parts are, we think, the best. The nature of a

bi-axial and a tri-axial ellipsoid is well explained, and the effectof spherical and ellipsoid surfaces in causing spherical aberra-