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cedented, in obstetric experience of "posthumous labour." "The incident, however, has attracted notice beyond the Man-tuan province, and medico-legal discussion on its details isyetfar from being exhausted. It is asked, not unnaturally, if thewoman Merli had really ceased to live, how the coffin lidcame to be even partially raised ? She is not by any meansthe only patient, in catalepsy our 11 nona," who in quiterecent Italian experience has been certified as dead andtreated accordingly; and the anti-cremationists, makingthe most of such cases, are warning the public how stillmore slender, in " apparent death," would be the chances ofescape for Merli and her like, if, instead of the coffin, shehad been consigned to the crematorium.

THE FIRST ABDOMINAL NEPHRECTOMYIN CUBA.

THE Revista de Ciencias Médicas publishes an account ofthe first operation for the extirpation of a kidney whichhas been performed in Cuba. The operator was Dr. E.Menocal of Havana, and the patient a young married ladywho had had one child. She suffered from a tumour thesize of the fcetal head, occupying the right hypochondriacand lumbar regions. In the lower part of it fluctuationcould be made out. There was pus in the urine, and allthe physical signs pointed to the existence of a diseasedkidney. This it was decided to remove by means of anincision along the outer border of the external rectus,cutting through the peritoneum twice. There were adhesionsbetween the diseased kidney and the peritoneum, and inseparating them an abscess was opened which gave vent toa quantity of very fetid pus. The opening, however, wasclosed by means of bulldog forceps, and no further

difficulty was met with. The pedicle and the ureterwere ligatured with silk soaked in perchloride of mer-

cury. The cavity was washed out with hot sterilisedwater. A silk suture in the form of a crown was

applied between the edges of the posterior and anterior

layers of the peritoneum, and two large drainage-tubes in-serted, going to the bottom of the cavity, which was com-pletely separated from the rest of the abdominal peritoneum.The external wound was sutured both deeply and super-ficially by metallic sutures, and an iodoform dressing puton. The bladder was washed out with a boracic acid solu-tion. The whole operation occupied only twenty minutes.No serious complications occurred, and the wound was

completely healed and the patient well in forty-six days.On examination, the tumour, which weighed about sevenounces, was found to contain eight abscesses, the cause ofwhich was the blocking up of the ureter by an oxalate oflime calculus situated in the pelvis, and weighing twenty-four grains. "

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THE LAW AS TO FEES UNDER THENOTIFICATION ACT.

IT has been a question under the Notification Act whetherevery practitioner who is called to a case requiring notifica-tion is entitled to the fee for notifying, or only the medicalman who first sees and notifies the case. Such a questionarose in connexion with a case seen for Mr. W. H. Kesteven

by Dr. Watson. Dr. Watson notified and charged. Mr.

Kesteven, acting as he thought under the requirementsof the law, also notified and also charged. The vestryof Islington courteously declined to pay his fee. Mr.Kesteven entered into a long correspondence with themand with the sanitary committee on the point. He

firmly maintained his claim, and told the vestry that

he was confirmed in his view by THE LANCET andother medical authorities. The correspondence extendedfrom January to May, and would have exhausted the

patience of a man less clear-headed and tenacious of h’s

rights. The vestry, fortified by their solicitor’s opinion,adhered to the view that when more than one certificate isreceived notifying the same case of infectious disease, thefirst only can be paid for. Nothing daunted, Mr. Kestevenappealed to the Local Government Board, and, after wait.ing a month, wrote again. The Board replied that theywere in correspondence with the vestry. On July 9th hereceived a note from Mr. Provis, the assistant-secretary ofthe Local Government Board, enclosing a copy of the fol.lowing letter to the Islington vestry :-

[COPY.]Local Government Board, Whitehall, S.W., July 9tli, 1890.

SIR,-I am directed by the Local Government Board to acknowledgethe receipt of your letter of the 27th ult., with reference to a certain ,

certificate under the Infectious Diseases (Notification) Act, which wasforwarded to the vestry of the parish of St. Mary, Islington, by Mr. W. H.Kesteven, of 23, Finsbury-circus, E.C.With reference to the last paragraph of your letter, the Board desire

me to point out that Sec. 3 (1.) (b.) of the Act requires that "everymedical practitioner attending on or called on to visit the patient shallforthwith, on becoming aware that the patient is suffering from aninfectious disease to which this Act applies, send to the medical officer ofhealth for the district a certificate" stating certain particulars of the case;and I am to inform you that the Board are advised that if more than onemedical practitioner is attending on or called in to visit the patient,each practitioner is bound to send a certificate, and is entitled to theprescribed fee. I am, &c., n r - __-_..

(Signed)To W. F. Dewey, Esq., Vestry Clerk, Vestry

Hall, Upper-street, Islington, N.

S. B. PROVIS,Assistant Secretary.

Mr. Kesteven deserves the thanks of the profession for sostoutly vindicating its rights. The decision of theLocal Government Board accords with common sense as

well as with law. It is evident that the framers of the

Act, if they did not draw their clause carelessly, meant tosecure notification, even complete and confirmed, by exact.ing under it notification from every medical practitionerattending on or called in to visit the patient. Suchexactions imply corresponding debts on the part of thesanitary authority, and we are glad that the point has beendiscussed so ably and settled so authoritatively.

ACUTE TUBERCLE OF JOINTS.

MILIARY tubercle of the synovial membrane of joints isof fairly common occurrence, but as a solitary affection isvery rare. In the Centralblatt fiir Chirurgie, No. 22

(abstract), Chamarro describes this condition under theterm " acute tubercular hydrarthrosis." He defines it as aneruption of miliary tubercles, accompanied by a copiousserous effusion, in the synovial membrane of a joint hithertohealthy, but in a tubercular subject. This complaint wasfirst described by Laveran in 1876, but has not been gene.rally recognised. Konig, however, and some other writers,have described a similar affection in the course of acute

pulmonary or general tuberculosis, in which the synovialmembrane of one or more joints is attacked, causing con-siderable serous effusion, and in which after death well-marked miliary tubercles are found in the membrane, butinflammatory tissue changes are absent or only very slight.Chamarro has collected nine cases of the complaint hedescribes, and forms his conclusions upon them. The

symptoms and course are generally as follows : The patientis always the subject of tuberculosis, although this may beobscure, being occasionally situated in the urinary tract,as in a case described by Mr. H. Alexis Thomsonin the laboratory reports issued by the Royal Collegeof Physicians of Edinburgh. A joint, generally theknee (very rarely more than one joint), which has hithertobeen healthy becomes swollen without any apparent cause.The swelling appears very quickly, rising within a fewhours, very often in the course of a night. There is generallya considerable amount of pain, especially if the effusion beconsiderable. The signs of fluid are well marked, and thereis often an cedematous condition of the cutaneous coverings.Pressure on the capsule of the joint causes great pain, butnone is produced by pressing the articular surfaces together, ,

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thus distinguishing it from a tubercular affection of thebones. Absorption of the fluid occurs in from ten to thirtydays, and a complete cure may follow ; usually, however, apermanent thickening remains, not to be distinguishedfrom "white swelling," or "gelatinous" or "pulpydegeneration." In the cases described by Chamarro, tworecovered and two lapsed into a chronic state ; the life ofone of these patients was saved by amputation through thethigh, the other eventually died. The remaining five patientsdied, shortly after the acute joint affection set in, oftuberculosis of the lungs or meningitis. In all these fivecases at the necropsies there was pronounced miliary tuber-culosis of the synovial membrane of the joint affected ; butthere were no, or very slight, inflammatory changes in thesubsynovial tissues, and the cartilages and bones wereentirely unaffected. Giant cells were never found. The

recognition of this condition Chamarro rightly thinks is ofgreat importance, for such swelling may be diagnosed asgonorrhceal or due to acute rheumatism ; the discovery of atubercular affection in the lungs or elsewhere would correctthis error. The thickening of the capsule occurs early, andmust be carefully watched for. The pain is not usually sogreat as in other joint affections. As regards the treat-ment, Chamarro recommends rest, leeches to the affectedjoint, and painting with iodine, and blisters. He suggeststhat the capsule might be punctured and the joint washedout with antiseptic fluids. -

CHELSEA PHYSIC GARDEN.

THE proposed sale of the Physic Garden on the ChelseaEmbankment by the Apothecaries’ Company, however

profitable to its present owners, must, if carried out, beregarded as a public loss. It may be that the Company nolonger see their way to preserving it as provided by the willof Sir Hans Sloane, its founder in 1721, for instruction inbotany, but this need not imply its summary disposal toany purchaser. As a garden, it might still be utilised, ashas been proposed, by one of the polytechnics or othereducational bodies within the metropolis. The provisionalready made for such teaching as it affords is by no meansexcessive, and the project suggested is therefore not un-worthy of consideration. At all events, we should be

sorry to find its other important function, that of a citybreathing space, overlooked. This happily is not the

case, and Lord Meath, as representing the Public Gardens’Association, presided at a meeting convened in the TownHall, King’s-road, Chelsea, on the 16th inst., to take stepsif necessary to secure the space in question for public use.In an atmosphere like that of London, already chargedwith a variety of gaseous and suspended impurities, everyopen area of the kind redeemed from the hammer is adefinite gain on the side of healthy existence. We there-fore wish Lord Meath and his helpers all success in theircommendable endeavour.

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BLEACHING TEETH.

A DIRTY-LOOKING blue tinged tooth in the front of themouth is so disfiguring to the appearance that the subjectseeks the aid of the dental surgeon. Such teeth are toooften recklessly and ruthlessly excised, and an aitificialcrown attached to the root. The result is brilliant as far as

appearance is concerned, and does not call for any greatamount of labour on the part of the operator, but, at thesame time, it is a question whether the true conservativetreatment would not rather be to render the tooth present-able by bleaching and subsequent filling, which is prac-ticable in a large number of cases. The most commoncause of staining is the death of the pulp and the infiltra-tion of the dentinal tubules with the products of its decom-position. Another cause, which is much more common

than it should be, is the insertion of amalgam stoppings,especially those containing copper, and this stain unfortu-nately appears to be indelible. Two general classes ofsubstances have been introduced for bleaching teeth-

oxidising agents, such as chlorine compounds and peroxideof hydrogen, and reducing agents, as sulphurous acid. Thetreatment by means of peroxide of hydrogen is extremelysimple, and gives good results; but it appears from recentexperiments by Dr. Miller of Berlin that this preparationacts upon the dentine, removing the organic matter.

Sulphurous acid is also open to a similar objection, in thatits prolonged use will dissolve out the lime salts. Generallythe chief chemical used for bleaching teeth is chlorine orsome of its compounds. Where chlorine is used steelinstruments are inadmissible, as the salts of iron whichwould be formed would rapidly discolour the teeth. Theinstruments must be constructed of gold, platinum, or

ivory. In order to prevent the chlorine from passing throughthe foramen at the end of the root, which would probablycause acute periostitis, the apical third of the pulp canal issolidly filled with gold. The tooth is isolated at the gums,the soft parts being protected by the adjustment of therubber dam, and the tooth thoroughly dried by means of awarm air syringe. The pulp cavity is then washed thoroughlywith ether to remove any fatty material. Various prepara-tions of chlorine have been recommended, but perhaps thesimplest is freshly made chlorine water, as suggested by Dr.Wright, of Richmond, U.S.A., which is forced into the

pulp chamber by means of a syringe. Three or four sittingsof an hour each are usually sufficient to remove the dis-colouration, when the tooth can be filled in the ordinaryway. -----

THE MORPHOLOGY OF HUMAN MILK.

DR. IVANOFF has published in the form of a graduationthesis in the Military Medical Academy of St. Petersburgan elaborate research on the subject of the morphology ofhuman milk and its capacity for the nourishment of thechild. The materials for the investigation were obtained invarious lying-in, foundling, and other institutions. Theconclusions to which his investigations led him may bestated as follows. The colostrum corpuscles are epithelialin character ; they are more rapidly transformed into milkin the case of multipart than in primiparse; the time atwhich they cease depends on the number of labours thewoman has had, the more numerous these have beenthe sooner do they cease; bad general health and puer-peral affections have also a considerable effect in retard-ing their disappearance. At the commencement of in-volution in the gland after the tenth month of lactationthey reappeared in half the subjects examined. At certain

stages minute hyaline masses exist as normal constituentsof milk, some of them being free, others connected with fatglobules. As a rule, the number of fat globules isfound to stand in a direct relation to their size.

Healthy, young, and well-nourished wet nurses give milkcontaining the largest number of fat globules, these havinga large mean size ; the same, only in a less degree, is true ofthe cellular elements. The later portions drawn by thechild are poorer in fat globules than the earlier portions,and the globules themselves are smaller. The best guidewe have as to the nutritive value of milk is the number ofthe fat globules ; other though somewhat less importantsigns are the size of the globules, the number of the cellularelements, and, lastly, the number of granules. When milkcontains the largest number of fat globules it is less wellborne by very young infants than that with a mediumnumber. A large size of the fat globules lowers the nutri-tive value, especially when there is a large quantity of fat,because it is not well borne. The daily increase in the