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influence of these rays on lupus he attributed to their burn-

ing action. No good effect resulted unless the treatment was.accompanied by at least some symptoms of burning. Hedid not think that the Roentgen rays afforded any markedsuperiority over the best of the old-fashioned methods of

treating lupus. The x rays were in the majority of casesinferior to the arc lamp rays in the treatment of lupus.-The PRESIDENT, Dr. ALEXANDER, and Mr. G. P. NEWBOLT

.spoke, and Dr. TAYLOR replied.

ROYAL ACADEMY OF MEDICINE INIRELAND.

SURGICAL SECTION.

Synovitis. -Pylorecto7ny. --Exhibition of Cases.A MEETING of this section was held cn Jan. 17th, Mr.

THOMAS MYLES, the President, being in the chair.Mr. R. L. SWAN read a paper on the Surgical Treatment

- of Chronic Synovitis. In cases of primary tuberculoussynovitis he recommended that the joint should be opened, thefluid evacuated, the synovial membrane irrigated and thenthoroughly sterilised with pure carbolic acid, again irrigatedwith sterilised water, and closed. With proper aseptic pre--cautions he looked on the operation as the best treatment for,chronic hydrops articuli of the knee. Rightly carried outthe operation placed the synovial membrane in a conditionto return to its normal functional activity and the patient’recovered a useful limb. He illustrated his paper by thehistory of two successful cases. He had not found carbolicacid the dangerous bactericide that some said it was. He inno way wished to be understood as advocating the operationfor disease of the joint complicated with disease of theosseous tissues or cartilage. The operation was intendedto place the synovial membrane of the joint in a con-

- dition favourable for its recovery.-The PRESIDENT saidthat in the majority of cases the pathological lesion,consisted in pedunculated growths commencing from the,alar ligaments. If on opening the joint, especially in’children, he found the synovial membranes to be tuber-

culous, he recommended that they should be dissected out,.a procedure which he believed led to recovery.-Mr. E. H.TAYLOR thought that free swabbing with strong carbolic.acid devitalised the synovial membranes and the cartilage.and left them a prey to the tubercle bacilli in their vicinity.He looked on the method suggested as one not well calcu-lated to give good results in hydrops articuli ; the woundhealed, but after a little time the limb became shorter and.often flexed. There was not true ankylosis. He recommendedthat the hyaline cartilage should be shaved off the bone and theraw osseous surfaces joined, ensuring a sound limb.-Mr.JOHNSON said that he had under his care a man with hydropsarticuli which was benefited for a time under the treatment by,rest, but the swelling did not wholly disappear. He openedthe joint, irrigated it, and closed it. The fluid removed-about 18 ounces-was highly albuminous. The synovialmembrane contained bacilli in large numbers. The incisions,one on each side of, and parallel to, the patellar tendon,healed quickly and well ; but they broke down in a week,and not long afterwards the patient developed tuberculousmeningitis from which he died.-Mr. H. G. CROLY, Mr. R. F.TOBIN, Dr. W. S. HAUGHTON, and others also took part in the’discussion.

Mr. T. E. GORDON read a paper on a successful case ofPylorectomy. The patient, who was 43 years of age, wasadmitted to the Adelaide Hospital for an abdominal tumour,and on April 2nd, 1901, Mr. Gordon performed the first stepin a Roux’s operation. The patient made a good recoverywith little or no shock. 25 days afterwards the second stageof the operation was completed by the removal of the pylorusand about half of the stomach. The intestinal and gastricwounds were sutured with silk, a gauze drain was left in thearea of operation, and the wound was closed. The operationoccupied one and three-quarter hours. The growth wasfound to be a columnar-celled cancer. For some days thepatient remained in a precarious condition, with a tempera-ture of 102° F. and a pulse of 160. At the end of a week thefood was increased in amount and the patient made a goodand quick recovery. Mr. Gordon afterwards considered the

legitimacy of the operation of pylorectomy, and con-

cluded that in a favourable subject Roux’s operationwas called for. - The PRESIDENT congratulated Mr.

Gordon on the first successful pylorectomy performed inDublin. In one of his cases he cut down on the stomachwith the intention of performing a pylorectomy, but foundso much thickening of the gastric walls with what he andhis friends thought was cancer that he returned the stomachunopened to the abdomen, and the woman is to-day, aftersome years, alive and well.-Mr. SWAN also congratulatedMr. Gordon on his great success.

Mr. CROLY showed a case of Amputation at the Hip-joint and a case of Ligation of the External Iliac Artery forIlio-femoral Aneurysm.

Mr. TOBIN showed a patient, aged 80 years, from whomthe Prostate was removed by Enucleation.

SOCIETY FOR THE STUDY OF DISEASE INCHILDREN.-A meeting of this society was held on Jan.19th, Mr. A. H. Tubby being in the chair.-Dr. GeorgeCarpenter showed a case of Paroxysmal Hæmoglobinuria ina female child, aged three years. An infant sister had beentreated at the hospital for congenital syphilis, but the

patient showed no signs of that disorder.-Dr. CharlesMacalister (Liverpool) suggested that absorption from thenasal discharge, from which the child suffered, might beresponsible for the condition.-Dr. G. A. Sutherland calledattention to the presence of oxalates in the urine of suchcases.-Dr. L. G. Guthrie spoke of two sisters who developedhæmoglobinuria and who were undoubtedly syphilitic. -Dr.Carpenter, in reply, remarked on experiments showing theimmediate destructive action of cold on the red blood cor-puscles of such cases when topically applied.-Dr. Carpenterread notes of a case of Suprarenal Sarcoma in a boy, agedtwo and a half years, in which the organs were demon-strated by Dr. D. N. Nabarro who had conducted the necropsy.The right kidney was invaded secondarily by the new growthand the left had become hydronephrotic from pressure on’its ureter. The mesenteric and pelvic glands were secondarilyinvaded and some glands under the sterno-mastoid sub-

sequently. The case in its clinical aspect was not unliketuberculous peritonitis, but the injection of tuberculin gavenegative results and confirmed the original opinion.-Mr.Tubby and Mr. Clement Lucas drew attention to the hope-lessness of surgical interference in the large majority ofcases of renal sarcoma.-Dr. E. Cautley looked upon it as acase of extra-renal sarcoma, with secondary renal attachment,and inquired as to secondary deposits in the skin.-Dr.

Carpenter, in reply, said there were no secondary cutaneousdeposits. He did not consider it a case for operation, andthat opinion was borne out by the post-mortem examination.- Mr. Clement Lucas showed a case of Traumatic Chorea andMusculo-Spiral Paralysis complicating a fracture of the

upper third of the humerus in a girl, aged 11 years. Thechorea developed within half an hour of the injury andwas not associated with heart disease or a rheumatic history.The musculo-spiral paralysis was believed to be caused bythe callus resulting from movement during repair, and it wasproposed to cut down on the seat of fracture and relieve thenerve from pressure. Another interesting point in the casewas an abnormal growth of hair on the lower third of thearm and dorsal aspect of the forearm corresponding to theskin supplied by the injured nerve.-Dr. Frederick Taylorasked whether a recent attack of any infectious disordercould be negatived and whether it was certain that therewere no choreic movements prior to the accident. Hereferred to the obscurity surrounding the relationship ofchorea to the emotions and shock. How did the traumatism

operate ? ‘! Through the central nervous system, the nerveof the limb, or by the production of shock ?-Mr. G.Pernet, Mr. F. Jaffrey, and Dr. Carpenter joined in thediscussion and Mr. Clement Lucas replied.-Mr. Tubbyshowed several cases of Paralytic Talipes Calcaneo-valgus,Equino-valgus, and Equino-varus which had been treated bymuscle-grafting. In some of the cases, especially those of

calcaneo-valgus, the results were good, also in two of thecases of equino-varus. But the cases of equino-valgus werenot so striking, although the improvement was very con-siderable. In his remarks on the operative procedures whichhad been alluded to Mr. Tubby said that .paralytic casesmight be divided for purposes of treatment into three classes :(1) those in which a single muscle or a single group of muscleswere affected, and these were capable of satisfactory treat-ment by tenotomy ; (2) those in which at least two groups ofmuscles, were paralysed, and these were fit subjects formuscle-grafting ; and (3) those severe cases in which all

378

the muscles around a limb were useless, and for thesearthrodesis was recommended. After speaking of thelimitations of muscle-grafting and indicating its scope,and pointing out that as there was a diminution of

power applicable to a given joint the best results couldnot be perfect, Mr. Tubby yet thought that muscle-

grafting was a scientific and practical procedure, for itdistributed what voluntary power was left around an

articulation and so it became well-balanced, although toooften weak. The indications and methods of operating inarthrodesis were then alluded to and three cases were

shown. A case of infantile spastic paralysis affecting theupper extremity was brought forward in which considerableimprovement had been obtained by converting the pronatorradii teres into a supinator, and by section of the flexor

carpi radialis the patient now had the power of voluntarybut partial supination of the forearm. The method adoptedwas fully described in the British Medical Journal of

Sept. 7th, 1901, and from an experience of six cases Mr.Tubby thought the operation promised well.-Mr. ClementLucas and Dr. A. E. Sansom spoke of the value of Mr. Tubby’ssuggestions, and Mr. Tubby replied.-Mr. Walter Edmundsand Dr. Carpenter showed a case of Myositis Ossificans in afemale, aged four years, one of a family of eight. The dis-order had been noticed six months and recently had rapidlyadvanced. The affected muscles were in parts infiltratedand in others displayed bony plates. There was fusion oftwo phalanges of the great toes, a condition which had beenrecognised as occurring in these cases. Microscopicalexamination of a portion of an infiltrated muscle showed fibro-nuclear tissue alone.-Dr. W. A. Milligan read notes on a caseof Contracted Granular Kidney in a boy, aged seven years.The chief symptoms were pallor, wasting, headache, and

polyuria. The heart was slightly hypertrophied, the skin wasbronzed, and the urine was of low specific gravity and albu-minous. Later the patient developed albuminuric retinitis, andepistaxis and cutaneous hsemorrhages occurred. Four weeksbefore death the heart began to fail, the extremities becamedropsical, giving place to general anasarca with anuria, andthe child died comatose. The kidneys, macroscopical andmicroscopical, were typical of the condition.-Dr. Carpenterinquired as to a history of syphilis in the case and said thathe had not yet detected albuminuric retinitis in cases of con-tracted granular kidney in children ; but he had seen thatcondition in a child, aged eight years, who suffered from a largewhite kidney which was verified post mortem.-Dr. Sansomregarded it as one of typical interstitial nephritis, but thoughtthat acute parenchymatous nephritis had been grafted onit.-Mr. Sydney Stephenson thought it quite possible thatretinitis might be as common in interstitial nephritis inchildren as it was relatively in that disorder in adults. Hisown experience had furnished him with two such instances,the latter of them two days since.-Mr. Stephenson read (forDr. Lewis Marshall of Nottingham) notes on a case of

Thyroid Dislocation of the Hip in a child, aged nine years,of four months’ duration, confirmed by x rays. There weretwo points worthy of note : a previous synovitis of the hip-joint had existed and reduction was quite easily effected bymanipulation.BRADFORD MEDICO-CHIRURGICAL SOCIETY.-A

meeting of this society was held on Jan. 21st, Mr. P. E.Miall being in the chair.-Cases and specimens were showrby Mr. R. Me cer, Dr. H. J. Campbell, Dr. B. H Slater, ancDr. R. H. Crowley.-Dr. Nicholson Dobie read notes on a cacaof Distension and Hernia of the Gall-bladder. The patieniwas a woman, aged 60 years, who for two years had com.plained of pain in the umbilical region when she was movineabout. There was no pain when she was at rest in bedFor about 12 months she had noticed a lump in the bodyThere was no history of jaundice. Examination of th<abdomen showed a large ventral hernia in the middleline below the umbilicus. The hernia was reducible easilyand it contained a tumour which when returned to the abdominal cavity could be moved about freely. The tumou:was tense and fluctuating and was of about the siz<of a fcetal head at full term. On the right side o

the tumour was a hard projection one and a half inches

long and of the size of three fingers. On Dec. 4th, 1901the abdomen ’was opened in the middle line below thlumbilicus. The tumour was found to be a greatly distendeEgall-bladder with thickened and congested walls. Therwas no adhesion. In a pouch on the right side was

large gall-stone cylindrical in shape and weighing eighand a half drachms. The gall-bladder was opened

the stone was removed, and the gall-bladder was thenstitched to the upper end of the abdominal incisionand the rest of the wound closed. The wound healedby first intention except for the biliary fistula. OnDec. 27th the patient had an attack of right hemiplegiawith complete loss of speech.-Mr. Mercer read the noteson a case of Pyloric Obstruction-Gastro-jejunostomy. The

patient was a woman, aged 45 years. In March, 1899,oophorectomy had been performed for dysmenorrhoea andovarian neuralgia. In September, 1899, symptoms of

gastric disturbance began with pain and vomiting. Bloodwas present in the vomit on one occasion. Notwithstandingtreatment by rest in bed, dieting, and gastric lavage, reliefwas never more than temporary, and as she was becomingmore and more emaciated and weak operative measures wereadvised. She was admitted to a hospital and the abdomen wasopened in January, 1901. A band was found stretching fromthe greater curvature of the stomach near the pylorus to thescar of the previous operation. This was divided and inaddition the pylorus was stretched by the fingers, the stomachwall being invaginated into it. For three months the patientdid well but then the old symptoms began to return, and byAugust she had fallen back to much the same condition asbefore and appeared to be dying slowly from starvation. Atthe patient’s request a further operation was undertaken byMr. Mercer at home in October, 1901. On opening theabdominal cavity the transverse colon was found to beadherent to the scar and the intestines were matted together;after some difficulty the jejunum was brought up intothe wound and united to the posterior portion of thestomach. The pylorus was embedded in a mass of adherentintestines and was not seen. The shock after the operationwas not severe, but there was very persistent vomiting whichwas stercoraceous on the morning of the third day. Thestomach was washed out with permanganate of potash solu-tion and a turpentine enema administered. The vomitingnow ceased and the patient was able to take nourishment.A month after the operation she was taking solid food andwas rapidly regaining her strength and weight. She did wellfor a time, but recently (January, 1902) the old symptoms ofpain and vomiting had returned.-Dr. C. F. M. Althorp readnotes on three cases of New Growth in. the Large Intestine.-Mr. J. Basil Hall read a paper entitled " Some Observationson Dilatation of the Stomach and a Modification of PosteriorGastro-jejunostomy," illustrated by five cases.

, CLINICAL SOCIETY OF MANCHESTER.-A meeting

of this society was held on Jan. 21st, Dr. A. Wahltuchbeing in the chair.-Mr. J. Howson Ray related a case ofStrangulated Femoral Hernia occurring in a man, aged 53

years, where the sac was found to contain about three

drachms of foul-smelling pus and a gangrenous loop of

small intestine which had already given way. The symptomswere masked by alcoholic mania. The patient was sent into,the Salford Royal Hospital by Mr. J. Cantley of HigherBroughton, and was operated upon by Mr. Ray about half

an hour after admission. The gangrenous bowel-about

three and a half inches long-was excised and the endsof the gut were united by continuous catgut sutures,including all the coats of the intestine, whilst Lembert’ssutures of fine silk were used in two layers outside.No button or bobbin was employed. The sac was re-

moved and a gauze drain was left for a few days withda small-sized drainage-tube just entering the peritoneum.

&deg; Feeding was entirely per rectum for the first week. On theLt eighth day there was some fsecal matter noticed about theI- wound and for a week longer fseces discharged at the groinas well as per rectum. In the course of the fifth week the. wound had entirely healed and the patient’s mind wasr. practically clear. He left the hospital quite well eights weeks after admission. The patient was shown to thes meeting, as also the specimen removed.-Mr. J. E. PlattYgave a demonstration on Diseases of the Tongue and showed’’ cases of smoker’s patches, leukoplakia, atrophy of papillag,ir erythema migrans, lichen planus, secondary and tertiarys syphilitic affections, tuberculous ulcer, dental ulcer, nsevoid’I papilloma, and epithelioma. He advocated the use of oint-s ments with a basis of vaseline and lanolin, as recommended’ by Mr. H. T. Butlin, for the treatment of certain affectionss of the tongue, several of the cases having derived great benefitd from their application.e

a MIDLAND MEDICAL SOCIETY.-A meeting ofLt this society was held on Jan. 22nd, Mr. Arthur Oakes, theL, President, being in the chair.-Mr. W. F. Haslam showed

379

a woman, aged 37 years, the subject of Diffuse Symmetrical IScleroderma. It affected the skin of the face, neck, thorax, [,.and to a less extent the upper extremities. It came on aboutsix months ago and reached its maximum intensity in five

months, since which time it had improved.-Mr. F. Marshshowed a case of Carcinoma of the Sigmoid Flexure in a boy,aged 15 years, who was admitted into the Queen’s Hospital,Birmingham, on June 26th, 1901, for pain in the epigastriumand passing of blood with the faeces. The passing ofblood began six months prior to his admission. The pain,which was intermittent and referred to the epigastrium,only commenced a month before. Per rectum an in-distinct fulness could be felt to the left in therecto-vesical pouch. Blood and mucus followed the with-drawal of the finger. On July 5th a median incision wasmade and a growth was found in the lower three inches ofthe sigmoid. The growth was excised with a margin ofhealthy bowel, some enlarged mesenteric glands were re-

moved, and with considerable difficulty the two ends of theintestine, the middle of the sigmoid, and the upper end ofthe rectum were joined as accurately as the position of theparts would allow with Lembert sutures. A good recoverywas made, the bowels acted regularly without difficulty, andthe boy went home well on August 7th. Microscopical exami-nation showed that the growth was a columnar carcinoma. Thesubsequent history, however, pointed to recurrence, as thebrother of the boy reported some four months after the

operation that there was a return of blood in the fasces, butMr. Marsh had not had an opportunity of examining him.-Mr. Christopher Martin showed a Kidney removed on

Feb. llth for Calculous Pyonephrosis from a woman, aged40 years. The patient bore the operation well and made anuninterrupted recovery.-Mr. J. F. Hall-Edwards read a

paper, illustrated by lantern slides, on Experiences with theImperial Yeomanry Hospital in South Africa.

Reviews and Notices of Books.The Healing of Nerves. By OHARLES A. BALLANCE, 12.5.

Lond., F. R. C. S. Eng., Assistant Surgeon to St. Thomas’s

Hospital; and PURVES STEWART, M.A., 11LD. Edin.,Assistant Physician to the Westminster Hospital. Illus-trated by 16 Plates and one Figure in the Text. London :Macmillan and Co., Limited. 1902. 4to, pp. 112.Price 12s. 6d.

IN the preface to this treatise the authors state that mostof the work was completed by the end of 1899, but the absenceof Mr. Ballance at the South African war for more than a

year has delayed its publication until the present date.The subject of the volume is one of great interest and hasattracted the attention of many observers. The experimentsrequired are not difficult to perform, and they can be prac-tised whilst the animal is under chloroform ; but the subse-quent microscopical investigation demands a thorough know-ledge of the modern methods of staining and mounting, andMr. Ballance has been fortunate, as he himself points out, inobtaining the assistance of so able a coadjutor as Dr.J. Purves Stewart. The animals on which experiments weremade were monkeys, dogs, and cats, and the points whichthe authors proposed to investigate were the following -theprocess of degeneration in a peripheral nerve after injuryboth without and with immediate suture of the two ends ;the process of regeneration in a divided nerve-trunk whichhas been divided and reunited by suture ; the process of re-generation, if any, in the distal segment of a divided nerve,the cut ends of which have not been reunited by suture ;and lastly, the changes which occur in nerve grafts. The

literature of the regeneration of nerves after injury and agood historical r&eacute;s1t1ll&eacute; and bibliography will be found

appended to an article published in 1892 by Professor W. H.Howell and Dr. G. C. Huber, in the J01lrnal of Physiology,and to articles by Galeotti and Levi in " Ziegler’s Beitrage

"

for 1895 and by Dr. Kennedy in the " Philosophical Tran sac-tions " for 1897. On the strength of statements made by Dr. IWaller, Professor Ranvier, Professor Kolliker, and Professor li

His, it has been generally accepted that after division

of a nerve new axis cylinders are developed in the formof outgrowths from the axis cylinders in the central segmentwhich, inclosing the medullary sheaths of the distal segment,replace the old axis cylinders which have undergonedegeneration. Another view, however, has been advancedwhich the authors term the ’’ ‘ peripheral theory and towhich they give their entire adhesion. According to this

the peripheral segments of the cut fibres undergo completedegeneration whilst new fibres in the distal segment-axiscylinders, medullary sheaths, and neurilemmata alike-are

formed from pre-existing cells in the distal segment itself,and after their formation become attached to those of thecentral segment, thereby restoring the conductivity of thenerve-fibre. A small portion of the proximal segments of thecut fibres undergoes degeneration, but this process doesnot extend to any considerable distance up the nerves

towards the cells which form their trophic centres.

The successive changes that take place in the processof degeneration have been very carefully worked out bythe authors and constitute an interesting history. Withinsix hours after the initial blood extravasation consequenton the cut an invasion of leucocytes takes place, reachingits maximum about the eighteenth hour. After three daysthe leucocytes are gradually and largely replaced by con-nective-tissue cells. These begin to proliferate and on thefourth day indent the fatty substance of the myelin sheathsand then absorb both sheaths and axis cylinders, the wholeprocess occupying several weeks. In the meanwhile, com-

mencing about the second day, the neurilemma cells pro-liferate, the young cells sending forth fine protoplasmicprocesses from their extremities in the direction of the

original nerve. The smaller nerves resist the degenerativeprocess longer than the larger ones. In the process of

regeneration the proximal extremity of the cut nerves ex-

hibits at a very early period-that is to say, within 24 hours-a primitive end-bulb, produced by the curling up of the

loose ends of the divided fibres. This acts as a scaffold

on which the permanent end-bulb is deposited. The

earliest signs of regeneration in the distal segments ofthe cut nerves occur at the end of three weeks ;numerous longitudinal spider cells" appear in the distalsegment and in the intermediate scar tissue which shoot out

young beaded axis cyclinders from their opposite poles.These are new axons which overlap and coalesce with oneanother. New medullary sheaths then appear inclosing theaxons about the fourth week, and gradually the regenerationbecomes complete and the cut nerve functionally active.

The regeneration of a cut nerve is not therefore affected bythe growth of the proximal extremities of the axis cylinders,but is accomplished by the development from longitudinalchains of cells of axons which fuse together and becomeinclosed in medullary sheaths. The treatise, though short,is well deserving of attentive study.

Text-bonk of Pharmacology and Therapelltics. Edited byW. HALE WHITE, M.D., F.R.C.P. Lond., Physician to,and Lecturer on Medicine at, Guy’s Hospital, London.London and Edinburgh: Young J. Pentland. 1901.Pp. viii.-1040.THE title of this work accurately describes what manner of

book it is and implies what it is not. Here we find no phar-macopoeia or materia medica and no description of universal,but only of medical, therapeutics-no book for students pre-paring for examination, but a standard work of reference forthe library of the practitioner. Handicapped as pharmacyin England still is by reason of the lack of a universal

system of weights and measures, it has been found necessaryto use the English system for clinical descriptions anddirections while the laboratory details are given in the

decimal system.