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be regarded as the real value of such methods

seeing they are confessedly uncertain ? Their value lies inthe aid they afford to the prosecution of further inquiry ;also in the suggestions ard associations of ideas which areawakened in the mind when the attention is directed to

particular points in an investigation. Granting this, dothese so-called object-lessons in disease not more properlybelong to the period in professional life when sufficient ex-perience has been gathered to utilise them ? This is onlypartly true. These phenomena are open to observation andthe exercise of this faculty, which lies at the foundation ofall clinical progress, cannot be begun too early. Assuredlyit may be cultivated by all, notwithstanding the fact thatit comes easier to some than to others. It is at

no time an entirely easy matter, seeing that it includesa great deal more than mere perception. It hasbeen affirmed of some eminent literary characters that

they possessed the power of being able to find out all thatwas in a book by merely glancing over a few pages hereand there. The book of disease, as set forth in the individual,is not to’be read to any good purpose in this fashion, butevery page, every sentence, every word must be studied andweighed if we are truly to interpret its contents. As onewho has, over a long series of years up to the present time,enjoyed the privilege of engaging in clinical teachingmight I venture with all respect to suggest to mybrethren in the work the importance of keeping beforethe student the fact that nature has object-lessons toteach regarding many-perhaps nearly all-diseases, if

only we can find them out and read them ? " [The Presidentnext considered Clinical Impressions, about which he said :]"The careful prosecution and the mental registrationof observations in disease lead in process of time to theexperience of what, for want of a better term, I wouldventure to call clinical impressions. By that is meant theview that is conveyed to the mind, when brought in contactwith any case of disease, as to the patient’s condition andhis prospects. This, whatever may be thought of it, has longappeared to me to be one of the most valuable assets in the i

practitioner’s possessions, which, moreover, may oftentimes Ibe turned to practical account in his efforts at treatment.For confirmation of this my appeal must of course be mademostly to my senior brethren. Is it not the case that in nota few instances there comes to one an impression or anadmonition which could not find expression in words butwhich yet gives a view of the patient’s state that often

proves to be true and which may indicate at the same timea line of treatment that might otherwise have been over-looked ? One advantage which this acquisition possessesconsists in the power it sometimes gives us of inspiring hopein circumstances where appearances might indicate the con-trary. No doubt such impressions as I have referred to mayoccasionally be ill founded or erroneous, and certainly theyare never to be put in competition with, still less made tosubstitute, the most detailed and exhaustive examination pDS-sible, but yet that there is on the whole a substantial prac-tical value in them cannot, I think, be seriously disputed."[The third point discussed by the President was the PsychicalFactor and its Relation to the Practitioner, about which hesaid:] "It is never to be forgotten that when called to dealwith any case of illness we are dealing not merely withpathological phenomena but with the man or woman or childwho is the subject of them. And just as certainly as that fewdiseases are not attended with some more or less observableoutward and visible sign, so there are few where the mental- or psychical elements of the nature are left wholly un-touched ; and their influence and reaction upon eachother form oftentimes an important and difficult problem.Sometimes the mental outweighs the physical and has tobe reckoned with and treated before the health can berestored. But probably more often the reverse holds good."[The President, after quoting a story of Sydenham’spractical recognition of the psychical factor in treatment,proceeded to emphasise the importance of the mentalattitude of the patient towards his disease as seriouslyaffecting its issues, and continued :] "This reckoning withthe patient’s mental condition, alike for diagnosis and treat-ment, may impose demands upon the forbearance and charityof the practitioner but the output of these virtues will inthe long run seldom be in vain. I have directed attention tothe importance of the scrutiny of the face in disease. Butit is ever to be remembered that there is another aspect ofthe matter and that is the scrutiny of the practitioner’s faceby the patient. It is surprising with what penetration and

accuracy some sufferers will read into the thoughts andviews, the hopes or fears, of their medical attendants. It iswell if the patient can read in the physician’s face thatwhich inspires confidence and brings hope and courage. Itis better if, in addition, he recognises that divine quality ofsympathy which seems to lighten and to bear away some ofthe heavy burden of sickness and gives strength and solace,even in the presence of the last enemy." [After these wordsthe President devoted an eloquent peroration to thanking thesociety for having elected him two years ago to the officewhich he was bringing to an end and testified stronglyto the value of the work of the society. ]

Mr. GEORGE L. CHIENE read a Preliminary Note on a SimpleOperation for Uncomplicated Inguinal Hernia in YoungAdults. The hypotheses on which he based the operationwere : (1) That oblique inguinal hernias in young adults weredue to a pre-formed sac ; (2) that the muscles in the regionof the inguinal canal would soon regain their normal action ifthe sac was obliterated at the internal ring ; and (3) that itwas quite unnecessary to dissect out the sac if the neck wasobliterated. The operation which he suggested was onewhich attacked the internal ring by making an incisiondirectly over it, exposing the neck of the sac, ligaturing itafter division at the internal ring, and then suturing theexternal oblique by the overlapping method. The internaloblique muscle, the transversalis muscle, and the remainderof the sac were in no way interfered with. Mr. Chienebrought evidence to show that oblique inguinal hernia inadults was probably congenital, and, further, that removal ofthe sac was unnecessary if it were efficiently dealt with atthe internal ring. He quoted cases which had been operatedon during the last 18 months with satisfactory results andstated that ligation of the neck of the sac in children hadbeen proved to be efficient. If it was admitted that thesame cause gave rise to oblique inguinal hernia in youngadults, then the operation he suggested was the simplestpossible. He further pointed out that it was an operationthat could easily be performed with a local anaesthetic.—Mr. CHARLES WATSON MAcGILLIVRAY, while agreeingwith most of the suggestions which Mr. Chiene hadmade, thought that inguinal hernia was probably acquiredin old age from the long-continued intra-abdominalpressure induced it might be by prostatic hypertrophy,chronic bronchitis, &c.-Mr. E. W. SCOTT CARMICHAELthought that it was not sufficient merely to ligature the neckof the sac in young children where it was already thickened.- Mr. J. W. DowDEN said that the great essential was tosee that the abdominal muscles were strengthened by judi-cious exercise.-Mr. J. W. STRUTHERS and Mr. COTTERILLalso took part in the discussion and Mr. CHIENE replied.

Mr. COTTERILL exhibited the following- specimens: (1)From a case of Panhysterectomy for Fibroids and OvarianDermoids ; (2) Pyosalpinx complicating Appendicitis; (3)Spindle-celled Sarcoma of the Foot; (4) Hydatids of theLiver ; and (5) Tumour of the Cerebellum, successfullyremoved.The following gentlemen were elected office-bearers for the

session 1907-08: -President : Dr. James Ritchie. Vice-President : Mr. C. W. MacGillivray. Councillors : ProfessorH. Harvey Littlejohn, Dr. W. G. Aitchison Robertson, Dr. G.Keppie Paterson, Mr. W. Guy, Dr. J. 0. Aflleck, Mr. GeorgeA. Berry, Dr. G. Lovell Galland, and Dr. Claude B. Ker.Treasurer : Mr. J. W. Dowden. Secretaries: Mr. DavidWallace and Dr. F. D. Boyd. Editor of Transactions: Dr.William Craig.

ROYAL ACADEMY OF MEDICINE INIRELAND.

SECTION OF SURGERY.

Some Unvas2cal Abdominal Cases.-Ligature of the InnominateArtery.

A MEETING of this section was held on Nov. lst, SirHENRY R. SWANZY, the President, being in the chair.

Mr. GRAVES STOKER read a paper in which he gave theclinical history of a number of interesting Abdominal Cases.In one of these, a woman, who had suff ared for a number ofyears from almost incessant vomiting and extreme emacia-tion and who had been diagnosed by a late distinguishedsurgeon as having malignant disease of the stomach,obtained complete relief from her symptoms after an explora-tory laparotomy in which the stomach was found to be quite

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normal. In another case, apparently of hydronephrosip, thepatient, a woman, had the power of emptying the sac,the capacity of which was several pints, more or less atwill.-Dr. W. 1. DE C. WHEELER said that all the casesshowed points of interest and spoke with approval of theresults obtained through the adoption of the method ofcontinual saline injection as practised by Murphy ofChicago. The theory advanced by Murphy to explain thegreat improvement in his results was that the lymphaticcirculation in the abdomen was reversed and the salinepouring in prevented the toxins of pus going the other way.

Sir THOMAS MYLES read a communication on a case of Liga-ture of the Innominate Artery. In the course of a veryinteresting paper he described the symptoms and signs pre-sented by a male patient, aged 29 years, who suffered from aright subclavian aneurysm. He gave the reasons why he wasled to reject treatment by Syme’s method of opening thesac, followed by ligature of the artery on the proximal anddistal sides, and also the treatment by distal ligature alone infavour of ligature of the innominate artery. The chief ofthese was that the most frequent cause of failure in previousattempts-namely, secondary heemorrhaize induced by sepsis-could now almost certainly be prevented. Most of these

operations had been carried out in the pre-antiseptic era,while Mr. C. Coppinger’s case, which was brilliantlysuccessful, was performed with strict antiseptic precautions.He then discussed the methods of approach to the artery,finally selecting a median incision in the lower partof the neck, the ligature being accomplished withoutdivision of the sterno mastoid, resection of the inner endof the clavicle, or trephining the sternum. In additionto securing the innominate he placed a double ligatureon the right common carotid dividing the artery between.He expressed the opinion that in carrying out this step heleft too short a distance between the two ligatures and thatto this the failure of the operation was due. He thendetailed the subsequent progress of the case, which was atfirst very favourable. The wound healed by the first

intention, the pain caused by the aneurysm disappeared, andthe patient felt very well. The pulsation in the aneurysm,however, persisted. About ten days after the operation a largesubcutaneous haemorrhage occurred, which was treated byreopening the wound and securing the bleeding vessel whichcould not be identified. Subsequent haemorrhages, how-ever, took place necessitating further operations whichfor a time checked the bleeding. The wound now

began to suppurate, the haemorrhages continued to takeplace, and, finally, the patient died about a month afterthe first operation. The post-mortem examination showedthat the source of haemorrhage was the carotid artery fromwhich one of the ligatures had slipped.-Mr. WILLIAMTAYLOR said there were, after all, only two reasons whysuccess should not attend the effort to ligature the innomi-nate artery-first, failure in the establishment of the anasto-motic circulation of the brain ; and, secondly, sepsis. The

surgeon ought to be able to control the latter, and thereforeshould be able to control the secondary haemorrhage. Yetthey all knew how possible it was for some septc infectionto creep in, and in Sir Thomas Myles’s case it was justpossible that there might have been some source of infectionin the bottom of the wound in the deep structures. Barwellhad drawn attention to the fact that death in such casesalmost invariably arose from secondary haemorrhage and hadstated that if ever he came to ligature the innominate arteryhe would ligature the vertebral artery as well as the in-nominate and carotid -Sir THOMAS MYLES, in reply,

Istated his belief that the cause of failure was that the liga-ture on the common carotid had slipp d.

GLASGOW MEDICO-CHIRURGICAL SOCIETY.-Ameeting of this society was held on Nov. 1st, Dr. J.Walker Downie, the President, being in the chair.-Dr.G. Barnside Buchanan showed an infant who had beenoperated on for relief of an Imperforate Anus whentwo days old. There were no signs of intestinal obstruc-tion. The child was small and the skin was dry andwrinkled. There was an anal dimple a quarter of aninch deep. The blind end of the anus was found one inch

deep. There was no cord of denser tissue between it andthe skin. The rectum had to be separated for three inchesfrom the perineal surface before the end could be broughtdown to the edge of the wound. Eight weeks after opera-tion the child was very well.-Dr. A. J. Ballantyne showed :1. A case of Syringomyelia with Eye Symptoms, chiefly

unilateral. The general symptoms began in the left armand were still more marked on that side. There were

drooping of the upper lid, contraction of the pupil, andexophthalmos on the left side. The left pupil did not dilatein the shade, on sensory stimulation, or on the application ofcocaine. Both optie discs were pale, especially the left, andthere was well-marked contraction of the visual fields forwhite and colours. Nystagmus was present in the lefteye. 2 A case of Albuminuric Retinitis with VascularChanges in a man, aged 36 years. The man had a contractedwhite kidney. There were four small globular aneurysmsin the course of the retinal arteries which disappeared infour or five months. Blood pressure was persistently high.-Dr. T. K. Monro reported a case in which degeneration in thespinal cord was associated with profound anaemia. The

patient, aged 28 years, was a compositor, and after rheumaticpains in the knees his legs became so stiff and weak that hefrequently fell. He then suffered from pains in the stomachand blood corpuscles were found in the stools but therewas no other sign of gastric ulcer. The knee-jerks werelost and there was marked ataxia. Sensation was un.

impaired. An examination of the blood gave red bloodcorpuscles, 2,042,000 per cubic millimetre; white bloodcorpuscles, 6400 per cubic millimetre ; hemoglobin, 15 percent.; colour index. 0’ 3; differential count-polymorpbo-nuclears, 77’ 6 per cent. ; small mononuclears, 18 -1 per cent. ;transitional, 1 - 8 per cent. ; eosinophiles, 1 - 8 per cent. ; onenormoblast was seen. The temperature was irregularlyfebrile. Treatment by iron, arsenic, and calcium improvedthe blood condition but the general condition failed and deathtook place. A post-mortem examination revealed atheroma ofthe aorta, hypertrophy of the left ventricle, pyasmic abscessesin the kidneys, and a large chronic ulcer in the stomach(about the centre of the small curvature). Microscopicexamination showed sclerosis of the posterior columns ofthe cord, most marked in the lumbar region, and slightsclerosis of the pyramidal tracts. Dr. Monro consideredthe degeneration of the cord and largely also theanaemia, to be aue to a toxin evolved or absorbedin connexion with the chronic ulcer of the stomach.-Dr. A. Bankier Sloan read notes of an interesting case ofSevere Diphtheritic Paralysis. The points of special interestwere : first, the case was one of very severe infection, thefauces and nose being extensively involved ; over and abovethis profuse epistaxis and hasmorrhagic ecchymosis were bothpresent ; the child received in all 72,000 units of antitoxin.Secondly, the paralysis was severe and dangerous, the heart,pharyngeal muscles, larynx, palate, and probably also facialand some skeletal muscles being involved. On account ofthe pharyngeal palsy the child was artificially fed for 39days, being fed solely by the rectum for 22 days, and for afurther 17 days nasal feeding had to be used. The third

point of special interest was the occurrence of very severealbuminuria accompanied by general cedema. The child’scomplete recovery, notwithstanding the severe infection, thedangerous paralysis, and the kidney involvement was, as Dr.Sloan stated, matter for gratification. In closing, Dr. Sloaninsisted, in oppo-ition to the usual teaching, on the muchgreater frequency of paralysis after severe initial attacks indiphtheria than after mild. He also pointed out that severeparalysis is much commoner after severe attacks than aftermild. In support of these contentions he showed twostatistical tables which strongly bore out his remarks, oneof these referring to a consecutive series of 166 cases underhis own care in London and the other to a series of 495 casesreported by Dr. J. D. Rolleston of London.WINDSOR AND DISTRICT MEDICAL SOCIETY.-A

meeting of this society was held on Oct. 30th, Mr.W. A. U. Thomson being in the chair.-Mr. V. Warren Lowread a paper entitled " The Modern Treatment of SurgicalTuberculosis." Mr. Low began by pointing out thatgreat advances in the treatment of surgical tuberculosis hadcome from the pathological side recently and outlined themain features of Wright’s work on opsonins in their relationto the treatment of the disease. In this respect he pro-ceeded. The terms "negative phase " and " positive phase

"

were applied by Wright respectively to the initial loweringand subsequent elevation of the opsonic index followingon a dose of tuberculin. (Mr. Low here showed charts toillustrate his meaning.) The possibility of causing a cumula-tion in the direction of the negative phase doubtlessaccounted for the disappointing results which so oftenformerly followed the use of tuberculin when uncon-

trolled by the estimation of the opsonic index. Another

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most important use of this power was to obtain informa-tion of the amount of auto-inoculation taking placefrom a tuberculous focus, often too small in the case

of localised tubercle and in excess in systemic infections.In localised tuberculosis, therefore, therapeutic inoculationwas indicated, whereas in systemic cases it might be contra-indicated and efforts should rather be made to limit thecirculation through the diseased foci, the therapeutic valueof rest being at once obvious and equally so the need ofavoiding operation during the negative phase. Not onlyhad they to raise the opsonic value of the circulatingfluids but also to insure their ready access to the affectedarea; in fact, the guiding principle for their operativemeasures should be the removal of surrounding inert materialso that the diseased parts might be flushed with healthylymph, whether such obstruction be fluid free in theabdomen in a case of tuberculous peritonitis or the

pus of a psoas abscess or the hard caseous material oftenmet with in glands of the neck. After reviewing thesurgical treatment of tuberculosis during the last 20 yearsMr. Low said that the modern surgeon relied rather on thereaction of the organism for good results and his operationswere directed to the removal of inert material in order toallow the free circulation in the diseased area of fluids ofhigh bactericidal value. Above all, he must avoid sepsis, forthe tissues being already the seat of microbic invasion hada less resistance than normal. Under the influence of sepsisthe tuberculous process became more malignant locally anddissemination was markedly accelerated. Sinuses, therefore,were to be avoided. The risk from these caused by drainage-tubes could in most eases be obviated by using sterilisednormal saline solution in the place of irritating chemicalswhen any fluid was required. Operations must be timed tocorrespond with a high opsonic index. Abscesses, psoas andothers, were opened so far as practicable from the spot wherethey might be pointing, gently wiped out with sterile gauze,and the wound was then sewn up in layers; if the cavityrefilled the old scar must be avoided at the second operation.In joint disease where operation was unavoidable arthrectomyhad replaced excision and amputation was but rarely called for.An operation, however, was not always necessary to effect asufficient flushing of a tuberculous focus. In earlier stagesof the disease the result might be obtained by such means asfomentations, iodine, Scott’s dressing, the Finsen light, andBier’s treatment of passive hypersemia, due control beingexercised by the opsonic index. Klapp’s suction apparatusmight also be mentioned. Mr. Low proceeded to pointout the value of fresh air and sunshine in whatever localityas an adjuvant in the treatment of surgical tuberculosis andshowed some photographs of light airy canvas living rooms,and suggested that such special hospitals for cases of

surgical tuberculosis should be formed in the country asextension of the city hospitals, thereby freeing from 10to 15 per cent. of their surgical beds. He concluded byshowing a skiagram of a tuberculous femur in illustratingthe value of x rays in the early diagnosis of surgicaltuberculosis.WEST LONDON MEDICO-CHIRURGICAL SOCIETY.-

A meeting of this society was held on Nov. lst, Mr. RichardLake, the President, being in the chair.-Dr. E. ArthurSaunders showed a boy, aged six years, with Chronic Dis-seminated Myelitis. The patient was attacked with scarletfever a year ago ; this was followed a fortnight later by theonset of paraplegia with anaesthesia of the legs and lowerpart of the trunk. His condition had remained practicallystationary since that time.-Dr. F. S. Palmer showeda boy, aged 15 years, with Primary Progressive Myopathyof the Facio-scapulo-humeral Type. There was no nervousdisease in the family. He had five brothers and two sistersliving and well. The patient was quite well until 18 monthsago, when he first complained of fatigue and weakness in thearms and the shoulders; at the same time it was noticed thatthe facial muscles were weak. The wasting and weakness hadbeen steadily progressive.-Mr. Blair showed: 1. A youth withCongenital Absence of the Iris. In the right eye the iris wasentirely absent and the lens was deficient at its lower edgeand had a small anterior pyramidal cataract. The left eyehad practically the same defects. His father and sister hadsomewhat similar congenital anomalies of the iris. 2. Acase of Misplaced Pupils.-Dr. Seymour Taylor showed aman, aged 34 years, with Perforation of the Aortic Valve.The patient had lead colic on two occasions and had atypical blue line on the gums. While lifting a heavy weighthe experienced severe pain in the upper zone of the chest, a

choking sensation in the throat, and faintness. There wasa diastolic thrill all over the front of the chest and a louddiastolic musical murmur was heard all over the chest, backand front, also over the upper half of each humerus.-Mr.W. McAdam Eccles showed a man, aged 45 years, withCharcot’s Disease of the left knee. He had had signs oflocomotor ataxy for three years; the pupil reaction was onlypresent on the left side. The joint became largely distendedwith fluid in three days and without pain. 15 ouncesof fluid were aspirated from the joint and a plaster caseapplied. While this was on no re-collection of fluid tookplace but on its removal the joint became distended in thesame time as before.-Mr. Aslett Baldwin showed : 1. Awoman, aged 29 years. This was a case of Excision of theRectum for Carcinoma by an abdomino-anal method. Thepatient was admitted into hospital with complete intestinalobstruction of ten days’ duration. Colotomy was performed.Later the abdomen was reopened and the attachments ofthe rectum were divided as high as the sigmoid flexure. Theanus was dilated and the bowel and growth were forced outthrough the anus forming an intussusception. This was cutoff externally and the bowel was united by circular sutureand returned. The sigmoid flexure was attached a shortdistance above the anus. The patient had perfect controland normal action of the bowels. 2. A man, with

Lengthening of the Left Leg and extensive Naavus ofthe Left Half of the Body. A venous nsevus occupied theleft side of the trunk and most of the left thigh, leg, andfoot. The left leg was two and a half inches longer than theright and the left foot was half an inch longer, but the leftcalf measured eleven and a half inches in circumference,whereas the right measured thirteen inches. Varicoseveins were also present in the left leg. 3. A man, aged30 year?, with Carcinoma of the Right Breast. The patientnoticed the lump about ten months ago, which had beenulcerated about a month. There were two secondary growthsin the skin near the primary one and numerous hard enlargedglands in the axilla. A microscopical section of one of thesecondary growths showed typical scirrhous carcinoma. 4. A

girl, aged four years, with Tumour of the Scapula, &c. The

enlargement of the right scapula was noticed two monthsago. The lower end of the right fibula was markedlythickened and nodules could be felt on the metacarpalbones and phalanges of the right hand. There appeared tobe no pain or tenderness.NOTTINGHAM MEDICO-CHIRURGICAL SOCIETY.--

A meeting of this society was held on Nov. 6th, when Dr.L. W. Marshall read his presidential address on " Children’sWork in Medicine.’ After a brief historical survey he pointedout that children’s ailments need be made no specialty inthe "popular and evil sense of the word." The work did notdeal with an organ but with the entire organism at its mostinteresting period of development. Arguing from this factand the universal lament of the student that the medicalschools did not provide at all adequately for his instruction inthis topic, so that he was left to search for knowledge own hisown after qualifying, Dr. Marshall urged strongly thatattendance on the practice of a children’s hospital should becompulsory for every student and that children’s diseasesshould be taught in every medical school by someone who byhis earnestness and enthusiasm was fitted for the task-not byone who was asked to sandwich it in between other subjectswhich were to him of more interest and with which he wasmore at home. The student should begin his clinical work inthe children’s ward, for there was no better training-groundfor adult work, and the man who had children’s work at hisfingers’ ends started with the best possible equipment for thedifficulties of general medicine and general practice. Itmust not be assumed that children were miniature menand women ; their ailments had been well called "the

grammar of disease" and should be studied first, forchild-life was exempt from none of the diseases ofadult life, though it did modify them in proportionto the stage of development reached. To view lifeas one great entity of which the infant was the stepping-stone was to give to children’s work new force, as wellas more interest and much pleasure to the worker. The

nutrition, feeding, and hygiene of child life were also veryimportant with the object of avoiding disease and acquiringa sound constitution. Possessing no intuitive knowledge thehuman parent needed guidance as to the care of her offspringand such instruction ought to come from the general practi-tioner rather than lady visitors who obtained their knowledgeonly from pamphlets. Nursery hygiene did not begin and

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end with feeding and those who had to teach others mustthemselves have some practical knowledge of the subject.If therefore medical men were to teach others they mustfirst of all be instructed efficiently themselves. In all

things they must seek to follow Nature rather than forestallher and education in the technical sense should not beginbefore the seventh year. The commoner neuroses of child-hood were attributable more to errors in rearing than toheredity, and teething had primarily very little to do withconvulsions. The malnutrition often spoken of contemptu-ously as "only rickets" was, directly and indirectly,responsible for more deaths than any other cause and henceshould claim their serious attention. The widespread exist-ence of this scourge might well be attributable in part totheir own apathy and indifference in the study of infant lifeand its requirements.

MEDICO-PSYCHOLOG1CAL ASSOCIATION OF GREATBRITAIN AND IRELAND -A meeting of the Northern andMidland division of this society was held at the Sunder-land Borough Asylum, Rybope, on Oct. 17th, Dr. JamesMiddlemass being in the chair.-Dr. Middlemass related thecases of two brothers admitted to the Sunderland Asylum in I

February, 19C6. The interest of the cases lay in the I,combination of unusual nervous symptoms with a graduallyprogressive dementia. The elder brother, aged 31 years, 13years before had an accidental fall which gave him a greatfright but produced no immediate physical symptoms.About two years later symptoms of difficulty in walkingmade their appearance and gradually became more

pronounced. These symptoms consisted in marked in-coordination of muscular movements, with a spasticcondition of the muscles of the legs. These then appearedin the muscles concerned with speech, then in the arms, and,finally, in the head and neck. But at no time was there anynystagmus. The mental faculties underwent a gradualprocess of deterioration ending in profound dementia. Hedied in January, 1907. The younger brother, aged 27 years,first began to show the same symptoms seven years pre-viously. He had no accident but he bad been in the habitof sleeping in all weathers in the town park and had

frequently been chilled and soaked. The symptoms in hiscase took the same line of progress and promise the sameresult. The muscles generally are in a spastic condition,there is marked incoördination on voluntary movement, thedeep reflexes are much increased, and there is slight mus-cular weakness but no atrophy as yet. His speech is verypoor and he is a facile, contented dement. These symptomswere demonstrated in the patient. The examination of thespinal cord of the elder brother made by Dr. E. Bramwell ofEdinburgh showed the absence of disseminated sclerosis, towhich disease the symptoms are most nearly related. Theyappear, on the whole, to belong to that group named byWestphal "pseudo-sclerosis."—Dr. Colin F. F. Macdowall(Newcastle) read a paper on Three Cases of Juvenile GeneralParalysis.-An informal discussion followed on Some of theLessons of Experience.

Reviews and Notices of Books.A System of Medicine by Eminent Aitthorities in Great

Britain, the United States, and the Continent. Edited byWILLIAM OSLER, M.D. Oxon. and McGill, F.R.S., RegiusProfessor of Medicine in the University of Oxford, &c.Assisted by THOMAS MCORAE, M.D., F.R.C.P.Lond.,Associate Profpssor of Medicine and Clinical Therapeuticsin the Johns Hopkins University, Baltimore. Vol. II.,Infectious Diseases. London : Henry Frowde and Hodderand Stoughton. 1907. Pp. 828. Price, in sets of sevenvols., 24s. net each ; single volumes 30s. net each.THE second volume of Professor Osler’s "System" is

devoted to the infectious diseases. It opens with a generalstudy of infection written by Dr. Ludvig Hektoen, in whichan excellent account is given of the modes of action of

pathogenic organisms and of the resistance offered to themby the body, including a discussion of recent work on

opsonins, agglutinins, and similar substances. The assistant

editor, Dr. McCrae, writes on Typhoid Fever, to which over150 pages are devoted, the whole constituting a complete

monograph on the disease. It is in all respects worthy ofthe great reputation which its author has already gained forhimself and illustrates the special attention paid to this

malady in the Johns Hopkins Hospital. Dr. McCrae alsocontributes chapters on Typhus and Relapsing Fevers-

Small-pox is intrusted to Dr. William T. Councilman,whose researches on the causal organism of the disease arewell known. Some good illustrations of the different stages

of the disease in an unvaccinated person are given and

may be commended to the attention of antivaccinationists.Vaccination itself is dealt with by Dr. George Dock. Avaluable study of Scarlet Fever is furnished by Dr. John H.McCollom ; we may note that the author is inclined toadmit a much longer incubation period than is usuallyassigned to scarlet fever in medical text-books. He does.not believe in the existence of a "fourth disease."

Dr. John Ruhtah writes on Measles, Whooping-cough,and Mumps; he states that desquamation occurs in

nearly every case of the first-mentioned malady, a factthat is not always recognised. He also lays stress uponthe serious nature of the affection as indicated by its

alarming death-rate, as opposed to the popular notion thatit is of trivial importance, and this is a lesson which we inthis country are trying to bring before the public. Dr.McCollom writes on Diphtheria’ and commends intubationrather than tracheotomy for hospital patients. The subjectof the prophylactic use of antitoxic serum is rather scantilytreated, and the chapter on Influenza by Dr. Frederick T.Lord might also perhaps have gained by greater fulness.Dr. Thomas D. Coleman writes on Dengue and Dr. HenryKoplik on Epidemic Cerebro-spinal Meningitis. Posteriorbasic meningitis, which is also due to the meningococcus, isincluded in this article. Dr. James M. Anders writes on

Erysipelas, for which he finds iron and quinine the mostefficient remedies ; he notes the disappointing resultsobtained from the use of Marmorek’s serum.Three chapters are devoted to Lobar Pneumonia; we

are not sure of the advantage derived from divisionof a single subject into separate chapters, when the

use of central headings in dark type throughout the

work sufficiently breaks up the subject matter. The

study is based on very full statistical material and is verycomplete. The authors, Dr. John H. Musser and Dr. GeorgeWilliam Norris, approve of the use of alcohol in suitable

cases ; they also advise the use of plentiful draughtsof water as a beverage, from 4 to 8 ounces every hour

or two. A chapter on Toxaemia, Septicaemia, and Pysemiaby Dr. Richard M. Pearce deals with these conditions.from the bacteriologist’s point of view rather than from

the surgeon’s ; the author includes among septicaemiasall instances of organisms which multiply in the blood,and among toxaemias all bacterial poisonings, and the

account necessarily overlaps other chapters to some extentand also presents the matters dealt with somewhatbriefly. Rheumatic Fever is intrusted to Dr. F. J. Poyntonwho gives a very impartial account of the bacteriologicalinvestigation of the disease in which he has taken a

leading part. Asiatic Cholera is described by Dr. W. P.Dunbar and Yellow Fever by Dr. James Carroll, whosename is well known in connexion with the work of the com-mission of investigation sent out from the United States

during the occupation of Cuba. Dr. W. J. Calvert dealswith Bubonic Plague and Dr. K. Shiga with BacillaryDysentery, in which good results have been obtained fromthe use of a polyvalent serum. In the former article itseems a mistake to speak of Haffkine’s prophylactic as aserum ; in the latter there seems to be a misprint in the doseof castor oil employed, 15 cubic centimetres being equivalentto half an ounce, not to half a drachm, as stated. Misprintsare, indeed, not infrequent throughout the book; amongthem we would fain include the use of 11 flagellm for