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trauma which might thereby be caused. The benignforms of the disease as seen in a series of 90 cases

might be classified thus : hilar flares, 36; epi-tuberculosis, 18 ; pleural effusions, 31 ; chronic

miliary tuberculosis, 5. This classification was based

upon X ray findings, and the series included most ofthe benign cases he had seen in the last ten years,excluding those which only showed the calcified

sequelæ of disease. Of these groups, pleural effusion,the most obviously exudative form, was usuallymild in childhood, and even though copious mightbe entirely symptomless. In chronic miliary tuber-culosis the individual stipples were slightly largerand softer than in the acute variety and often appearedquickly to melt away.The commonest manifestation of pulmonary tuber-

culosis in childhood was the hilar flare-a triangularshadow of more or less uniform density and basedon the hilum, usually on the right side. No arbitrarydivision could be made between this type and epi-tuberculosis. Epituberculosis in process of devolutionbecame a flare, and a flare in process of evolutionmight become epituberculosis. The two might betermed epituberculosis major and minor. Havingsatisfied themselves by history and clinical evidencethat the condition in a given case was tuberculous,the site could best be ascertained by a lateral orsagittal view. The nature of the tuberculous lesionmust be ascertained. The blur might be due to

perifocal reaction round a primary focus near thehilum, or to an area of tuberculous pneumonia,caseous or splenic, but the majority of hilar flares

appeared to follow rather than accompany primaryinfection. The evanescent nature of many of theseshadows, the absence of scarring after resolution, andthe frequent simultaneous appearance of other exuda-tions suggested that a raised tissue sensitiveness

might be causing a reaction of an exudative characteraround the root glands. In the series of post-primarypulmonary tuberculosis, 18 might be classed as

epituberculosis. As in the flares, right-sided lesionspredominated, with a strong tendency to involvethe middle lobe.The epituberculosis picture might be due to one

of three causes : (1) reaction of allergic type arounda tuberculous focus ; (2) a tuberculous pneumoniaof benign type ; (3) atelectasis. The simplest explana-tion of epituberculosis was that it was mainly due topulmonary deflation following bronchial occlusion.The physical signs and clinical course supported thistheory. The condition occurred at a period in thedisease which was particularly associated withenlargement of the bronchial glands, and at an agewhen the bronchi were easily compressible. It wasrare in adolescence and was never seen in later life.Bronchoscopic examination had shown that a caseousgland might ulcerate into a bronchus, block it, andcause atelectasis. The great difficulty in radio-logical investigation of mediastinal glands hadal-ways been their situation in relation to otheropaque organs. Tomography should be- helpfulhere. Mediastinal shift towards the affected side inepituberculosis was not always obvious, possiblybecause the occlusion was sufficiently gradual to

give time for compensatory changes in the otherlobes. It was possible also that the volume of theaffected lobe was influenced by the amount of cedemaand engorgement of the alveoli.

Dr. Burton Wood concluded with a brief summaryof his findings. Epituberculosis, he said, was a mani-festation of post-primary tuberculosis in childhood,occurring in a period characterised by enlargement ofthe bronchial glands and a tendency to exudation. The

chief factor in its production was atelectasis caused bycompression of the bronchial glands, a secondaryfactor probably being exudation into the alveolias a result of lymph stasis and congestion. Tuber-culous allergy also possibly played a part. Ifglandular caseation led to rupture of the wall of abronchus, a caseous bronchitis or broncho-pneumoniamight alter the clinical picture and lead to permanentdamage of the lung. When the bronchial wall

escaped damage, the collapsed lobe might in timereturn to its normal condition. A failure to re-

expand must, in any case, give rise to bronchiectasis,which was a not uncommon result of tuberculousadenitis.

MANCHESTER MEDICAL SOCIETY

AT a meeting of this society on Nov. 2nd Dr.FERGUS R. FERGUSON opened a discussion on

Neuritis

The term, he said, was a very vague one and heproposed to deal particularly with multiple neuritis.The most useful classification of this condition wasinto exogenous and endogenous groups. In the

exogenous group almost all the metals except iron hadgiven rise to polyneuritis, and especially lead, arsenic,mercury, and gold. The lesion caused by lead,however, was probably a myopathy affecting themuscles which were principally used, and not a trueneuritis. Arsenic and mercury polyneuritis were nowrelatively rare, but gold polyneuritis was becomingcommoner because of the therapeutic use of gold.The exogenous group also included non-metalliccauses such as alcohol, apiol, and the substance

producing Jamaica ginger paralysis. Apiol was stillimportant because it was on open sale and might bea possible cause of obscure polyneuritis.Turning to the endogenous group, Dr. Ferguson

said that though neuritis was a very common com-plication of diabetes, diabetic neuritis was rarely veryextensive. It was not known whether the lesion

principally affected the peripheral nerves or the cord.Apparently the condition was never found in youngpeople and there were numerous cases suggestingthat the affection involved the cord rather thanthe peripheral nerves. Again, was the neuritis dueto the hyperglycsemia, arterio-sclerosis, sepsis, or

diminished resistance ? The differential diagnosisbetween polyneuritis due to diphtheria and to serumadministration was important. In diphtheria theneuritis did not appear until about two monthsafter the initial symptoms, whereas serum poly-neuritis showed itself within a few days of the serumsickness.Acute toxic polyneuritis was now the commonest

form of generalised polyneuritis. It was not widelyknown that cranial nerve paralyses were commonfindings in this condition. For example, a patientpresented herself with a Bell’s palsy ; but a weeklater facial paralysis appeared on the opposite side;it was ascertained that paræsthesia had developedin the hands before the facial palsy, and later

generalised weakness of the limbs was noticed.Despite the enthusiasm with which vitamin-B1

therapy of neuritis had been introduced, and theexcellent results recorded in its early days, furtherexperience had been disappointing. It seemed thatthe only patients who would be benefited were thoseshowing diminished vitamin-B content in the blood,such as was found in beri-beri and in the nutritional,gestational, and alcoholic groups. There appeared

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to be no definite improvement in acute toxic poly-neuritis, diabetic neuritis, or subacute combined

degeneration of the cord.Mr. HARRY PLATT, in speaking of sciatica, said

that symptomatic treatment should never be pre-scribed for this condition except as a temporaryemergency measure until an accurate diagnosis hadbeen made. It was essential to approach the problemin a systematic fashion. The first step was to eliminatethe possibility of pelvic visceral lesions ; the next

step, to eliminate bony lesions of the spine andpelvis. This left three main groups of sciatica forconsideration : (1) fibromuscular lesions (fibro-myositis) of the lumbar region, buttocks, and ham-strings ; (2) joint lesions, affecting the lumbar

spine, sacro-iliac, or hip-joint ; and (3) intraspinalnerve lesions, more especially tumours of the caudaequina and the recently discovered condition of

protrusion of an intervertebral disc.Dr. JOHN CowAN thought there was much uncer-

tainty among medical men as to the most suitableform of physiotherapy to be applied in neuritis ;hence the choice of treatment and the dosage wereoften left to a masseuse. The conditions usuallyrequiring treatment were pain, tenderness, loss of

function, and loss of sensation. Pain was oftenreferred to some distant area, and the treatmentwould- then be ineffective if directed to where thepain was felt. The site of a localised inflammationof the nerve could be discovered by applying labilefaradism along the course of the nerve. On passingthe electrode over the affected area the patient gotacute pain. The chief therapeutic agent in the treat-ment of pain was heat-either superficial or deep.For superficial heating, infra-red rays of the externalband were the most suitable, for they were entirelyabsorbed in the skin and superficial fascia. Ultra-violet rays also caused a superficial reaction whichlasted for a considerable time. For heating to thedepth of a few centimetres the internal infra-red raysand luminous heat rays were the most effective as

they were not absorbed until they had penetrated tothat depth. When deep heating was desired, long-wave diathermy or ultra-short wave diathermy wereindicated : the former tended to heat the tissues oflow resistance while the latter heated those that werescreened by high-resistant tissue such as fat. Anodalstabile galvanism was sometimes useful and ionisa-tion (chlorine, iodine, histamine, quinine, salicyl)would sometimes relieve pain by producing vaso-dilatation. In the acute stages of neuritis only thelightest massage (effleurage) and not petrissage ortapotement should be applied. Another valuablebut little-known treatment for tenderness was a fine

high-frequency effleuve ; this required an experiencedoperator, for a coarse effleuve would make the patientworse. Loss of function was associated with disuse

atrophy of muscles and joints, but the wasting ofmuscles could be avoided, except in the severestcases, by applying surged galvanic currents or (betterstill) slow sinusoidal currents with a periodicity ofabout two. These should be applied throughout theillness; as a rule surged faradism could not betolerated. Owing to the patient adopting the positionof ease for long periods, severe stiffness and contrac-tures were likely to develop ; they could often beprevented by massage (petrissage and movements)especially if diathermy was applied first. Free activemovements should be encouraged. Loss of sensation

required stimulation of the sensory nerve-endings-e.g., by applying high-voltage induction shocks witha wire-brush electrode or by a coarse high-frequencyeffleuve.

NEW INVENTIONS

NON-SLIPPING HYSTERECTOMY CLAMPS

THE two main features of these clamps are thatthe blades are deeply grooved longitudinally insteadof transversely and that the groovings articulateaccurately. This longitudinal grooving has beenused before, but the vertical depth of the bladeswas insufficient to prevent distortion when grippingtough tissues, so that the tissue often slipped out,particularly when clamping the vagina.The complete set consists of two angled ovarian

pedicle clamps, two slightly curved uterine-arteryclamps of modified La Foure pattern, two straightcervical-artery clamps, and two very powerful curvedvaginal clamps.The ovarian clamps (Fig. 1) are angled so that the

handles hang down over the edge of the wound outof the surgeon’s way. In section, the blades represent

FiG. 1

Fjc.2 2 F]G.3 3 FIG. 4

I -Ovarian clamp.2-Cervical-artery ciamp.3-Uterine-artery clamp.

4-Vaginal clamp.

an isosceles triangle, the two long sides giving a muchstronger grip on the tissues than the short base ofthe ordinary clamp. The shoulder of the outer bladeprevents the tissues from being cut through, and theedge of the inner blade is finished quite bluntly for thesame reason. Thus, tissue-paper can be held firmly with.out cutting or slipping, as well as the toughest pedicles.The jaws of the straight cervical-artery clamps

(Fig. 2) are of the same design, and produce a mostsatisfactory pedicle to tie in a rather inaccessible anddeep position. The uterine-artery clamps (Fig. 3)are of the same general design as La Foure’s pattern,but with the grooves in the jaws deepened and runninglongitudinally. The powerful vaginal clamps (Fig. 4)are deliberately made heavy enough to avoid anydistortion under load. The curved jaws are deeplygrooved longitudinally and the grooves articulateaccurately. The jaws are also tapered from hinge totip, so that when the two clamps are used, tip totip, across the vagina, and a continuous suture is

applied round them from one side to the other, eachclamp can be withdrawn and the suture pulled tightwithout the vaginal edges opening. In addition totheir special use in gynaecology, it is possible theymay prove useful in general surgery.The clamps have been made for me by Messrs.

Philip Harris and Co. of Birmingham.KENNETH MCMILLAN, F.R.C.S.

Surgeon to Birmingham and Midland Hospitalfor Women and to the Birmingham

Maternity Hospital.