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Sir WILLJAM WHEELER, in reply, said that in makingthe diagnosis embolism was discussed, but was notseriously entertained. In the first place, obstructionfrom an embolus might produce the symptomsdescribed in a young man, but if the limb survivedthe first few days the collateral circulation wouldbe rapidly established, and all anxiety would havedisappeared within the first fortnight. As a matterof fact, the circulation in Case 2 became moreprecarious daily for three weeks, until gangrenefinally appeared. In the second place, there was nodiscoverable lesion from which an embolus wouldcome. The pathological examinations later provedthe correctness of this point of view, and establishedthe fact that a true thrombo-angiitis obliteransexisted. Raynaud’s disease was difficult to excludeas a possible explanation in Case 1. Nevertheless,Raynaud’s disease commencing in the toes, in a

strong man of 25 years of age, was exceptional, andthe patient was the exact reverse of the type ofindividual in which the Raynaud syndrome was to befound. No pathological examinations were made,and he did not definitely exclude the possibility ofRaynaud’s disease. In Case 2 the diagnosis ofthrombo-angiitis obliterans was certain. It was

made before operation, and the pathological examina-tions were conclusive. He had had a fairly largeexperience of the Leriche operation. It producedmany of the effects claimed, but the physiologicalreasoning on which the operation was based wasopen to criticism.Mr. MAUNSELL showed a teratoma removed from

the transverse colon of a girl of 17, and a specimen of

Diffuse Hcema7agiorrzcc of the Liver.The patient was a man, aged 26, who had come to hospital

stating that two days previously, while at a fair, he hadgot weak, and had gone into a friend’s house, where hebecame weaker and had abdominal pain. He was seen bya doctor, who thought he was suffering from perforation,possibly of a gastric ulcer. When seen by Mr. Maunsell hewas absolutely blanched ; the abdomen was distended,and seemed to have fluid in it. When it was opened thisfluid was found to be pure blood. A bleeding point waslooked for unsuccessfully, but the blood seemed to becoming down from the liver. Next day blood transfusionwas done, and the patient did well. After a slow conva-lescence he was allowed up, but he never had a perfectlynormal temperature. One day, while up, he again feltfaint, and was put back to bed, and from that time onwardshe ran a higher temperature. A radiograph showed thatthe diaphragm was higher on the right side than on the left ;a needle was inserted, and bloody fluid found. A rib wasthen resected, and only blood escaped. A tube was inserted ;the patient apparently bled internally and died.

LIVERPOOL MEDICAL INSTITUTION.

AT a meeting held on Nov. 25th Dr. H. S.PEMBERTON read a paper on

Arthritis Deformans : Its etiology and Treatmentin which he gave an account of investigations carriedout by Dr. L. S. Ashcroft, Dr. L. Cunningham,Mr. T. P. McMurray and himself. After referringto the difficulty of diagnosing the condition fromother forms of arthritis, with the exception ofmonoarticular and menopausal forms, which wereincluded, Dr. Pemberton said, that 64 cases hadbeen studied, from the clinical, the bacteriological, themetabolic, and the therapeutic standpoint. It hadbeen found clinically that cardiovascular changes wererelatively infrequent. Little or no change had beendiscovered in the rate of intestinal passage, nor wasthere any evidence of renal inefficiency. The degreeof hepatic efficiency was doubtful as, although therehad been no excess of urobilinuria, the blood-lasvulosecurves had indicated abnormality ; sulphur excretionwas definitely increased ; 65 per cent. of the fractionaltest-meals had shown hypochlorhydria (50 per cent.of these being achlorhydria), and the glucose tolerancehad been found impaired in practically every case.The basal metabolic rate varied very little. Dr.

Pemberton showed illustrations comparing blood-glucose curves in arthritis with those in normaldiabetes, and in pancreatic disease, and said thatthe latter were found to resemble most closely thecurve in arthritis. He also showed pictures of bon3and joint changes in diabetes mellitus. On thetherapeutic side, he said, the aim had been to makegood or counteract deficiencies which the investigationhad shown to exist-i.e., deficient gastric secretion,diminished glucose tolerance, and increased sulphurloss. This had been done by giving as a routine :(1) large quantities of 0-4 per cent. pure hydrochloricacid ; (2) a carbohydrate-free diet of low calorificvalue, increased later by the addition of more fats,proteins, and some of the 5 per cent. carbohydratefoods ; (3) collosol sulphur ; (4) massage and thenexercises. Dr. Pemberton referred to the difficultyof taking a carbohydrate-free diet over a long period.By the results, which had proved very encouragingin some 60 to 70 per cent. of the cases, and sometimeswithin so short a period as three weeks, it was feltthat such therapy was distinctly valuable.

Mr. C. 0. DAvIES read a note on

Recurrirzg Acute Ifttacssusceptionin which he described the main features of a casewhich had recently come under his care. A malechild, 5 months old, was operated on twice within12 weeks. On the first occasion an ileocaecalintussusception was reduced, whilst on the secondthere was an ileocolic invagination. From a studyof 32 cases reported in the literature, Mr. Davieshad reached the following conclusions : (1) recurrenceof acute intussusception in childhood is rare, at themost amounting to less than 4 per cent. of cases ;(2) the usual interval between the recurrences variesfrom two and a half to ten months, though he hadmet with a few cases in which the interval was aslong as two years ; (3) there does not appear to beany necessity for trying to prevent recurrence, noris there any reliable method for doing so. He laidstress on the importance of warning parents thatrecurrence is possible, although unlikely, and urgedthe necessity for immediate reoperation.

CARDIFF MEDICAL SOCIETY.

A MEETING of this Society was held on Nov. 23rd,when Dr. ALFRED HOWELL took the chair and Mr.J. BERRv HAYCBABT read a paper on the

Diagnoss and Treatment of Gastric and DuodenalUlcers.

He described the routine method of examination ofcases in the surgical unit, which consisted of clinical’history, physical examination, X ray examination,fractional test-meal, examination of stools for occultblood, blood count of red cells, blood compatibilityin case of transfusion, and Wassermann reaction.He laid stress on the importance of taking an accurateclinical history of the symptoms of the disease fromits commencement, and described in detail thesymptoms and methods of questioning the patients.A good history was the most important means ofdiagnosis. X ray examination should be conductedby the radiologist and the surgeon together, andscreen examinations gave a better indication ofthe nature of the lesion than films. The fractionaltest-meal had been of value in confirming the diagnosisin only half the cases, but the detection of occultblood in the faeces had made it certain in manydoubtful cases.

>

In considering what type of operation was of mostvalue, Mr. Haycraft emphasised especially the needfor early diagnosis, which, as a rule, rendered operationsimpler and less dangerous. Speaking generally,duodenal ulcers and simple ulcers close to the pyloruscould be cured by the operation of gastro-jejunostomy,but ulcers on the lesser curve and those adherent tothe liver or pancreas required some form of excisionor partial gastrectomy to get a satisfactory result

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It was in these old-standing adherent cases thatpartial gastrectomy was often very difficult and themortality was higher than that of gastro-jejunostomy,but by earlier diagnosis and treatment some of thesemore severe operations could be avoided. Sleeve re-section was not a good operation unless combined withgastro-jejunostomy. Two cases of hour-glass stomachwhere gastrectomy was not feasible had done wellwith gastro-gastrostomy combined with gastro-jejunostomy. Careful pre-operative treatment wasmost important, particularly the rectal administrationof glucose and, if necessary, one or more transfusionsof blood. Similar measures were indicated to combatshock after operation.

EDINBURGH MEDICO-CHIRURGICAL SOCIETY.

A MEETING of this Society was held on Dec. 8th,Prof. WILLIAM R-USSELL, the President, in the chair.

Mr. N. M. DoTT read a communication on a

Simple Method of Intestinal Anastomosi8.He had been led to adopt this method, he said, byits simplicity and its usefulness in otherwise awkwardsituations. It was founded on the technique of Eck’svenous anastomoses and was applicable to lateraland end-to-side union, but not end-to-end anastomosis.In lateral union the two lines of viscera were laidtogether and the posterior seromuscular layerstitched in the usual manner, the proposed opening ineach viscus then being outlined by an incision whichdivided the seromuscular layers and laid bare thesubmucous tissue. The cut posterior edges were

firmly joined by sutures, anchoring the exposedmucous membrane, and including in the stitchesblood-vessels of any size. The novelty of the methodlay in the next step. A long needle, carrying No. 60commercial linen thread, was passed through theexposed mucous membrane to the lumen at one endof one of the incisions ; it was then passed along thelumen and brought out at the other end of the incision.Next this same needle was passed along the lumen ofthe other viscus in a similar way but in the oppositedirection, and thus the two layers of mucous membranewhich were to form a septum when anastomosis wascomplete were encircled by the thread. Next theanterior part of the incision was stitched up in thesame way as the posterior, but the last stitch of theinverting seromuscular suture was left uncompleted.The linen thread was now used in the manner of theGigli saw and the layers of the mucous membranewhich it included were easily and rapidly dividedand the continuity of the lumina thus established,after which the final stitch was completed.The advantages of this method, said Mr. Dott,

were (1) its relative asepsis ; (2) the accurate appositionof the submucous surfaces; (3) it could be carried outin any reasonable situation; (4) clamps were notrequired, the only instruments needed being sutureneedles. Hsemostasis was assured since all the vesselsexcept the capillaries of the inner surface of the mucousmembrane were secured. By modifying the methodend-to-side anastomosis could be carried out, thoughthis necessitated open exposure of one end of gut anda controlling clamp. The method was exceptionallyuseful in ileocolic anastomoses where the colon wasfixed and difficult to approach with clamps, and itminimised the danger of severe sepsis from a stagnantcolon.

Mr. W. A. COCHRANE read a paper on

Bac7mche from the Orthopcedic 8tanilpoint,in which he began by discussing industrial injuriesof the back. The first thing to be noted, he said,was that people might engage in industries for whichthey were physically unsuited. The slender, small,and delicate type of anatomical structure was inappro-priate for bearing heavy weights. Secondly, backstrain might arise during either light or heavy workin persons using their body at mechanical disadvantage.Incorrect bodily mechanics paved the way for strainof the dorso-lumbar, lumbo-sacral, and sacro-iliac

regions. In the examination of cases a radiogrammight show no evidence of an intrinsic lesion, and insuch an event a detailed physical examination wasof the first importance. It was wrong to take up theattitude that because X rays revealed nothing thepatient could have nothing the matter. In point offact, however, careful stereoscopic films would oftensupply the evidence sought for. A further problemwhich merited attention was that arising from thechance discovery, after radiography of the spinein cases of alleged trauma, of a definite lesion, suchas osteoarthritis or compression fracture. In suchcases the question of compensation might lead toendless argument in the midst of which the patienttoo often got no definite treatment. In considering therelationship of the common anatomical abnormalitiesin the lumbo-sacral and sacro-iliac regions to allegedinjury, Mr. Cochrane took up the view that they wereto be regarded as potentially contributory in thedetermination of the onset and persistence of sym-ptoms. Malingering presented a difficult problem.Two factors must be discounted before concludingthat the patient was malingering ; first, his probablemisconception of the setiology of his condition, andsecondly, his apprehension that, even in the genuinelypainful back, he had no tangible and visible evidenceto produce. Mr. Cochrane believed that as more waslearnt about the proper methods for conducting asystematic routine examination it would be found thatthe real malingerer was not common.The varieties of strain in the back, continued Mr.

Cochrane, might suitably be classified as (1) acutetraumatic; (2) general postural; (3) lumbo-sacral;(4) sacro-iliac ; and (5) combined pelvic joint strain.In acute traumatic strain the lesion represented a ruptureof muscular and aponeurotic fibres with all thephenomena of acute injury. These cases were capableof getting well if early treatment of heat, massage,and recumbency, followed by graduated exercises,was enforced. The late cases were due to the persist-ence of the muscle spasm and to myositis. Theycomprised the large number of such cases which wereon compensation in industry. They could not becured by perfunctory treatment. tieneral posturalstrain was a condition of general muscular andligamentous fatigue without definite localisation ofsymptoms. It occurred in slender individuals withpoor postures who required adequate support andpostural re-education. In lacmbo-sacral strain the painwas localised to the lumbo-sacral’region and sciaticawas a frequent symptom. One form occurred in theheavy individual with relaxed abdomen. The clinicalfeatures of sacro-iliac strain were quite definite.Treatment was by a suitable support and posturalre-education. In resistant cases manipulation underan anaesthetic was required, and in selected cases anarthrodesis operation. By combined pelrir joint strainwas meant that in cases of semi-sacralisation of thefifth lumbar vertebra secondary strain of the sacro-

iliac joint could and did occur.In conclusion, Mr. Cochrane said that injury of

the back was often only one factor in a compensationproblem, and treatment must have regard to the otherfactors. To make diagnosis more accurate, a routinemethod of careful physical examination must beemployed, based upon an appreciation of the anatomyand statics concerned. The chronic cases wouldcontinue to be unsatisfactory under present con-

ditions since they have to be treated very largelyas out-patients.

Dr. FREDERICK PORTER opened a discussion onthe sphygmometer in general practice, which will becontinued at a later meeting.

ROYAL INSTITUTION OF GREAT BRITAIN.—Afternoonlectures of the juvenile course will be given on Tuesday,Thursday, and Saturday of next week at 3 P.M., by Prof.A. V. Hill, F.R.S. The subject of the course is Serves andMuscles : How We Feel and Move ; and the titles of thelectures are Nerves and the Messages they Carry (Dec. 28th) ;Muscles and How they Move (Dec. 30th) ; and the Heartand Some Other Muscles (Jan. 1st). The address of theRoyal Institution is 21, Albemarle-street, London, W. 1.