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obstruction ; (b) all cases which have relapsed afterone course of thorough medical treatment ; (c) allcases with a history extending over many years ;(d) all cases with large ulcers adherent to surroundingstructures ; (e) practically all cases in which a testmeal is retained in the stomach for more than sixhours; and (f) all cases whose economic positionmakes prolonged medical treatment impossible.

It is surprising how large is the class of patients whomust be placed in this last group. There can be noescape from the conclusion that the medical treatmentof gastric ulcer is a difficult and protracted procedure.In the cases remaining for medical treatment, theapparent source of infection having been removed, themain lines of treatment recommended are as follows :(a) Secure true physiological rest for the stomach bykeeping the patient in bed, by feeding him with liquidfoods which will neither irritate the ulcer nor promoteperistalsis, or, should he be a suitable subject, bydirect duodenal feeding ; (b) secure neutralisation ofhyperacidity by means of atropin and alkalis ; (c) con-tinue treatment for a sufficient time to procuregenuine firm healing of the ulcer, and control thisopinion by radiographic examination ; and (d) protectthe patient against relapse by warnings againstsubsequent indiscretions, whether dietary or otherwise.

GONORRHŒAL MENINGITIS.

IN view of the rarity of authentic cases of gonor-rhoeal meningitis, not a little interest attaches to thecase recently described by Dr. L. Lindenfeld,l of thePathological Institute of the Wieden Hospital inVienna. The patient was a man aged 53 with nohistory of venereal disease, who suddenly developeda septicsemic attack of unknown origin and died afterseven weeks’ illness. The autopsy showed a purulentspinal meningitis decreasing in intensity from abovedownwards, purulent inflammation of the cerebralmeninges, suppuration in the left seminal vesicle,and a scar in the left epididymis. Smears of thepus from the seminal vesicle and the spinal meningesshowed the characteristic intracellular diplococciwhich were also found in the scanty exudatein the cerebral meninges. Cultures on ascitic agarremained sterile. On a study of the literature,Dr. Lindenfeld was able to find 17 cases of gonorrhoealinvolvement of the central nervous system, consistingof 8 cases of myelitis and 9 of meningitis or meningo-myelitis. Of these 9 cases, 4 were fatal, but in only 1,which was reported by Prochaska, was a careful autopsymade, corresponding in all essential respects to thatof the present case. The clinical course of gonorrhoealmeningitis shows nothing characteristic to distinguishit from meningitis due to other causes. Occasionally,as in the present case, erythemata have been described,which have been classified by Buschke into four groups :(1) Simple erythemata and scarlatiniform eruptions ;(2) urticaria and erythema nodosum ; (3) haemorrhagicand bullous exanthemas ; and (4) hyperkeratosis, whichis characteristic of gonorrhoea. The histologicalfindings in gonorrhoeal meningitis are not specific,although there may be several differences of detail todistinguish it from meningitis due to other causes.Thus, in the present case, the exudate was not nearlyso rich in fibrin as s the exudate in pneumococcalmeningitis, and was of a denser consistency than theexudate in streptococcal meningitis.

INTERNATIONAL EXCHANGE OF LECTURERS.

THE friendly relations already existing betweenleaders of medical thought and practice of differentnationalities are likely to be still further developed bythe exchange of lectures delivered by distinguishedforeigners in Paris and in London next month. Inthe grand amphitheatre of the Faculty of Medicine ofParis the following lectures will be delivered in English:The Circulatory Effects of Mitral Stenosis and AorticRegurgitation, by Sir Sydney Russell-Wells, on

1 Medizinische Klinik, Feb. 5th, 1922.

May 6th ; Trench Fever, by Sir Wilmot Herringham,on May llth ; Lymphatic Pathology, with SpecialReference to Malignant Disease, by Mr. SampsonHandley, on May 13th ; The Mechanism of Com-pensation in the Heart, by Prof. E. H. Starling, onMay 18th ; Acute Pancreatitis, its Diagnosis andSurgical Treatment, by Mr. H. J. Waring, on May 20th ;and on Stereoscopic Vision and the Evolution of Man,by Prof. G. Elliot Smith on May 27th. In London onMay 22nd, 25th, and 31st respectively, at 5 P.M., thefollowing lectures by Professors in the Faculty ofMedicine of the University of Paris will be given at theHouse of the Royal Society of Medicine, 1, Wimpole-street, London, W. 1 : Anti-anaphylaxie, by Prof. F.Widal, Lord Dawson of Penn presiding ; De 1’Ery-thrémie (Maladie deVaquez-Osler), SirWilmot Herring-ham presiding : Des Reflexes de Défense, by Pro;. J.Babinski, Sir James Purves Stewart presiding. Theselectures will be delivered in French. The undermen-tioned lectures by Dutch professors will be given inEnglish at the same place. On May 3rd Prof. C.Winkler, professor of clinical psychiatry in theUniversity of Utrecht, will speak on the HumanNeo-Cerebellum, Sir Frederick Mott, F.R.S., presiding;on June 12th Dr. Murk Jansen, professor of ortho-paedics in the University of Leiden, will speak onInjurious Agents and Growths, Prof. G. Elliot Smith,F.R.S., presiding; and on June 21st Prof. Hijmans VanDen Bergh, professor of pathology in the University ofUtrecht, will discuss the Pathology of Haemoglobin,when Sir Frederick Andrewes, F.R.S., will take thechair. Since the courses have been arranged in con-nexion with the University of London it may be hopedthat students as well as qualified men may availthemselves of the opportunity of hearing of originalwork from its source.

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BLOOD OR GUM.

DURING the war, when blood transfusion was calledfor on the grand scale as a life-saving operation, greatefforts were made by many surgeons to carry itout, often under the most difficult conditions. Butthe process demanded sometimes impossibilities, andit was evident that an efficient substitute for bloodwas greatly to be desired. The introduction of theuse of a solution of gum acacia during 1917 was there-fore hailed as a great advance, and some surgeonsbelieved that the great claims made for gum as ablood substitute were fully justified. Others, how-ever, remained sceptical, and their scepticismseems to be justified by the publication ofreports such as that by R. Charles and A. F.Sladden,l who showed that in two series ofparallel cases the results with gum infusion were

inferior to those obtained with blood, although thelatter series included on the whole more desperatecases than the former. This has tended to be confirmedby laboratory experiments, F. C. Mann showing thatshock produced in animals was more successfully com-bated by blood transfusion than by gum. More recentlygum infusion has often been used in treating surgicalshock in hospitals and elsewhere, and good resultshave been reported. Nevertheless evidence to thediscredit of gum continues to accumulate. During thelast three years several investigators 3 have shown thata gum solution may have a deleterious effect inseveral ways. It may produce agglutination bothintravenously and outside the body. It may causepulmonary emboli and thrombi, accompanied bysymptoms resembling those of anaphylaxis. It may,on the other hand, interfere with the normalcoagulation of the blood, and so be harmfulby discouraging haemostasis. At least one deathhas been recorded which was definitely to be attri-buted to the use of gum. 4 Finally, in a recentpaper, 5 Y. Henderson and H. W. Haggard have sought1 Brit. Med. Jour., 1919, i., 402. 2 Amer. Jour. Phys., 1919, 86.

3 Kruse : Amer. Jour. Phys., 1919, xlix., 137 ; P. J. Hanzlik andH. T. Karsner : Jour. Pharmac. and Exp. Therap., 1920, xiv.,379, &c.; Foster and Whipple : Amer. Jour. Phys., 1922, lviii., 393.

4 H. Olivecrona : Acta Chir. Scand., 1921, xlv., 1.5 Jour. Amer. Med. Assoc., 1922, lxxviii., 698.