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recovery would probably be better since there would prob-ably be less scarring : (a) less destruction of brain roundthe clot owing to there being a smaller amount of com-pressed cedematous tissue ; and (b) if the clot was turnedout there was less to absorb and so a shorter convalescence.The risks of pneumonia were less if there was restoration ofnormal breathing. Subtentorial haemorrhage had a very highmortality ; probably many cases could be saved. Numeroussuccesses had been recorded by various authors. It might beurged that there was risk of recurrent haemorrhage. Thesize of the risk was at present unknown. It was present inall cases of cerebral haemorrhage, and haemorrhage mightalso follow thrombosis. In many case of haemorrhagelocalisation of the lesion was difficult; it was probable thatthe site of the decompression was not of much importance.The point was under investigation.

Mr. ROBERTS said that there were a few points which hadnot been brought out by Dr. Hamill, but which appearedfrom their investigations: (1) That the effects of haemor-rhage were due to compression and not to the injury itself ;(2) that artificial (respiration should be readily obtainable ;and (3) that the application of decompression to the

meningeal haemorrhages of the newly born was advisableand had been successfully performed.

Mr. C. A. BALLANCE said that he thought the time wasnot far off when all varieties of intracranial haemorrhagewould be considered as clearly surgical as were other formsof haemorrhage. It had long been recognised that fractureof the cranial vault, when accompanied by cerebral

symptoms, should be treated by operation whether therewas or was not any obvious depression of bone, but thesame practice was by no means so generally followedin the treatment of fractures of the base of the skull,notwithstanding that these fractures were liable to beinfected by the openings of the nose, the ear, and the

pharynx. The effused blood, which induced an increasedsecretion of the cerebro-spinal fluid and oedema of thebrain, must be evacuated whether it was within or

without the dura or intracerebral in location. Effusion ofblood within the cranial cavity might occur from injury insuch amount that life was immediately threatened, andwould be destroyed if the pressure was not promptly relieved.Intradural haemorrhage might be complicated by injury toa sinus. Such cases demanded immediate operation. Intra-dural haemorrhage did not always call for immediate opera-tion, and it was only in the later stages that such cases cameinto the surgeon’s hands. Hæmorrhage also occurred intothe subarachnoid space and into the brain itself in injurieswhich lacerated the brain, even when no fracture of theskull had occurred. Referring to apoplexy, he said that thechief difficulty in the study by operation of these cases wasthat acute apoplexy was seldom seen in hospital practice,and in operation for chronic apoplexy the best results couldnot be obtained. In conclusion, he would urge that opera-tion was the rational treatment in all the types of casesmentioned, especially in fracture of the base and in acuteapoplexy, which had, until now, seldom been considered as

, urgently demanding surgical intervention.Mr. W. G. SPENCER said that he preferred the suboccipital

site for decompression when the site of the lesion was

unknown, and by that means often came down upon thehaemorrhage. There were certain difficulties in the way ofsubtemporal decompression. He always trephined cases ofcompression as far as he was able if the patients were goingdownhill. He narrated certain cases in which decompres-sion had been performed with advantage, and one of

apoplexy in which the heart improved promptly after theoperation. Referring to the experimental evidence, he didnot think that the results could be transferred from the catto the human being. There were difficulties in connexionwith the stimulation of the dura and cortex, which mightfollow the procedure employed by Dr. Hamill and Mr.Roberts, and he suggested that the dog and monkey wouldbe the better animals for the purpose.The PRESIDENT spoke with regard to the advisability of

operation in cases of apoplexy. There were many questionsto be answered. Which were the suitable cases ? How longshould one wait ? Was there any great risk from damage tothe brain ? There were many things other than pressure tobe considered in such cases. Might not another burst ofhaemorrhage be produced by the operation ? He said hewould be very guarded in recommending the operation forspontaneous apoplexy.

HARVEIAN SOCIETY OF LONDON.

Discussion on Oral Sepsis in its Medical and Surgical Aspects.A MEETING of this society was held on Feb. 12th, Mr. J.

JACKSON CLARKE, the President, being in the chair.Dr. WILLIAM HUNTER opened a discussion on Oral Sepsis

in its Medical and Surgical Aspects. He referred to thefrequency with which oral sepsis was met and the far-

reaching character of its effects. Its seriousness lay not somuch in its mere presence as in its association with openwounds in the mouth. The peculiar anatomical dispositionof the teeth made the proximity of sepsis a particularlydangerous one. He spoke of the frequency of tonsillitis andchronic inflammatory conditions of the naso-pharynx whenoral sepsis was present. Septic gastritis was a common com-plication. Septic anaemia arising from this source was

frequently superadded to other diseases such as phthisis,nephritis, and specific fevers, and might constitute a seriousdisease in itself. He regarded pernicious anasmia as a diseasesui generis but intensified by anæmia of septic origin, andtreatment devoted to this factor had greatly improved theprognosis. He did not advocate such wholesale extractionof the teeth as was sometimes performed. What was neededwas the advent of an era of antiseptic medicine comparableto that of antiseptic surgery.

Mr. W. H. DOLAMORE spoke from the point of view of thedental surgeon. He did not think that wholesale removalof the teeth was justifiable except in comparatively rarecases where severe systemic disorders followed.

Dr. C. BUTTAR said that he would like to ask the whole-sale extractors and the vaccinists what proportion of theircases could be described as cures ? and did the percentagejustify the pain, the disappointment, and the distress of anedentulous lower jaw caused in those who were not benefitedby the treatment ? In his own practice, amongst ten patientstreated by different specialists, only one professed to berelieved of his symptoms. He narrated several cases inwhich extreme measures had been far from satisfactory, andurged enthusiasts to consider carefully whether they werenot doing rather more harm than good by this form oftreatment.

Mr. G. COATS thought it was very questionable whetherchronic irido-cyclitis was connected with oral sepsis. Post-

operative inflammation might be due to it and therefore

septic teeth should be removed before intra-orbital

operations.Mr. D. C. L. FITZWILLIAMS corroborated Dr. Hunter’s

view that tuberculosis of glands was engrafted on adenitisarising from oral sepsis, and agreed with him as to the

importance of septic teeth in causing tonsillitis.

MANCHESTER PATHOLOGICAL SOCIETY.

Leucocytic Reaction after Repeated Serum Injections.-Per-forating Ulcer of tlte Aorta.-Acute Perforating Diver-tdceclitis of the Pelvic Colon.-Congenital Heart Disease.-Exhibition of Specimens.A MEETING of this society was held on Feb. llth, Dr. A.

BROWN being in the chair.Dr. J. S. C. DOUGLAS read a paper on the Leucocytic

Reaction after Repeated Serum Injections. In an experi-ment on man a leucocytosis followed the subcutaneous

injection of normal horse serum and also of diphtheriaantitoxin given a few days later, but when antistreptococcicserum was subsequently introduced none was observed.This failure of leucocytosis in the third experimental periodwas discussed, and with the aid of experiments on rabbits itwas shown that neither the presence of antibody in theserum nor the induction of the anaphylactic disease wouldserve as an explanation, but that it was possibly due to somefailure of the leucocytic system to respond to the repeatedserum injections similar to that found by Jorgensen in theformation of agglutinin after repeated doses of antigen.The possible bearing of this observation on the treatment ofpatients with repeated injections of serums was pointed out.

Dr. P. R. COOPER described a case of Perforating Ulcerof the Aorta which had caused fatal hsemothorax. The

patient, a man, aged 45, had complained of pain in the leftside and upper dorsal region for two or three months. He

537

was distinctly anasmic. There was no evidence of syphilisor injury, but there was a probable history of influenza

shortly before the commencement of symptoms. There wasabsence of any confirmatory signs or symptoms pointing tospinal disease, aneurysm and gastric or duodenal ulcer orcancer. At the necropsy the left pleural cavity was filledwith blood clot, and the lung and pleura were adherent tothe spine at the sides of the fifth and sixth dorsal vertebras.The aorta and oesophagus were involved in this adhesion, andit was through a rent in the adhesion that blood had

evidently escaped from the aorta. In the aorta was a roundhole with well-defined margin about 1 inch in diameter,perforating all the coats ; the rest of the aorta was normalexcept for some small patches of atheroma. The adjacentbodies of the fifth and sixth dorsal vertebræ were partiallyeroded. It was suggested that the condition might havebeen due to a circumscribed aortitis, probably influenzal inorigin.Mr. JOHN MoRLEY described a case of Acute Perforating

Diverticulitis of the Pelvic Colon. The patient was a man,aged 50, who was sent into Ancoats Hospital as a case ofretention of urine. There was a history of pain in the leftlower abdomen for a week, much worse the last two daysbefore admission, attended with constant painful desire tomicturate and great difficulty in the act. A silver catheterwas passed without difficulty, and the urine, beyond con-taining some albumin, was not abnormal. There was

frequent vomiting and absolute constipation in spite ofenemata. The abdomen was generally distended and tenderand somewhat rigid, but chiefly so in the left iliac fossa.There was shifting dulness in the left flank. Diagnosis laybetween peritonitis due to a misplaced appendix, acute

perforating diverticulitis, or thrombosis of the inferiormesenteric vessels. Operation under spinal anæsthesiarevealed general peritonitis. The appendix was normal,but the pelvic colon was thickened and adherent to thebladder. In spite of peritoneal toilet and drainage the

patient died five hours later. Post mortem, a necroticperforation was found in the pelvic colon of the sizeof a threepenny piece. Round this, projecting into thebases of the appendices epiploicas, were several smalldiverticula or herniæ mucosas. It seemed plain thatfæcal impaction in one of these pouches had led to gangreneof the pouch and perforation. Diverticula of the pelviccolon were found in elderly subjects with chronic constipa-tion. The complications which might give rise to symptomswere as follows : (1) chronic thickening of the pelvic colonand plastic adhesions (peridiverticulitis), producing a massthat simulated cancer; (2) cancer might supervene on

chronic diverticulitis; and (3) acute inflammation due tofæcal impaction might give rise to (a) general peritonitis or(b) a localised abscess. Such an abscess might rupture intothe bladder, producing (e) a vesico-intestinal fistula. Theadhesion to the bladder and intense pain on micturitionshowed that in the case under discussion such a fistula waswithin a little of being produced.

Dr. CHARLES H. MELLAND gave an account of a case of

Congenital Heart Disease in which it was recognised that theheart’s apex beat was to the right and the liver dulness onthe left. At the post-mortem examination (the child was1 year and 3 months old and a patient at the NorthernChildren’s Hospital) complete transposition of all the viscerawas found. The heart showed the usual features of stenosisof the pulmonary orifice, with imperfect ventricular septumand patent ductus arteriosus. In view of the suggestionsthat have been made that congenital heart disease was theresult of fcetal rheumatism, or, more recently, is the resultof congenital syphilis, the occurrence of the widespreaddevelopmental defect with the cardiac lesion stronglysuggested that the congenital heart disease in this case, as hebelieved in all others, was purely a developmental defect andnot in any way due to either of the two other suggestedcauses.

Dr. MELLAND also showed macroscopic and microscopicspecimens from a case of Ilelanotic Sarcoma. The patientwas admitted into Ancoats Hospital with enormous enlarge-ment of the liver and ascites. There was a history that hehad had one of his eyes removed for melanotic sarcoma some12 or 13 years before, and at the post-mortem examinationmelanotic sarcomata were found widely disseminatedthroughout the various organs and tissues of the body. Noother possible primary source was to be detected, and it was

)f much interest to speculate on what was happening in theong period between the removal of the primary growth and;he general dissemination of secondary tumours.Dr. MELLAND also showed specimens from a case of

General Lympho-Sarcomatosis. The boy, aged 12, had hadelands enlarged in the neck and one axilla for six years.rhese had varied in size during that period, occasionallyalmost disappearing under arsenic, in the way so typical)f Hodgkin’s disease. In the end, however, treatment had’ailed, and at the necropsy it was found that extensivelissemination, particularly in the abdominal organs, had)ccurred. The liver, pancreas, abdominal lymph glands,and kidneys were invaded and in some cases almost replacedby lympho-sarcomatous masses. Whether these were truesecondary growths or were evidence of general sarcomatoustransformation of pre-existing lymphoid tissue was difficultto be certain about, but the fact that the Peyer’s patcheswere extensively involved seemed to point to the latter

xplanation as the most likely.

GLASGOW MEDICO-CHIRURGICALSOCIETY.

The Presence of Complement in Infectious Diseases.-Anomalous Forms of Enteric Bacillus.-Excretion of Saltand Nitrogen in Nephritis of Scarlet Fever and Diplt-theria.-Wassermann Reaction in Children from PoorerClasses.A MEETING of this society was held in Ruchill fever

hospital on Jan. 30th, Mr. A. ERNEST MAYLARD, the Presi-dent, being in the chair.

Dr. W. C. GUNN discussed the Presence of Complement inInfectious Diseases. He said that in enteric fever he hadfound complement always present, and as a rule more

abundant throughout the period of pyrexia than duringconvalescence. Diminution in its amount in favourablecases seemed to coincide with the production of immune

body. Severity of the attack bore some relation to theamount of complement present. In patients who were veryill complement as well as immune body might be producedslowly, or only a weak type of complement might be present.In patients moderately ill a relatively small amount ofcomplement seemed to indicate the presence of a consider-able amount of immune body, but not sufficient to terminatethe attack. In the intermediate type of illness, the mostcommon, a large amount of complement was usually found.During relapses complement was increased, and diminishedwhen recovery was taking place. Death from enteric fever

appeared to be due chiefly to absence of immune body.Complement was sometimes very abundant in fatal cases,but at other times only a weak type might be present. Com-

plement and immune body were not produced in any fixedratio to one another. In the majority of cases of erysipelasexamined complement was present in greater amount duringthe acute stage than during convalescence, the diminu-tion apparently coinciding with the production of immunebody. In diphtheria varying results were obtained. In10 severe cases complement was greater in amount duringthe acute stage than during convalescence. In 5 moderatelysevere cases the amount was greater during convalescence.In 4 cases little or no complement was present during thewhole illness, while in 2 cases of fatal diphtheria of thehaemorrhagic type complement was relatively abundant

shortly before death. In 6 mild cases of scarlet fever nodefinite type of variation in the amount of complementoccurred. In 10 more severe cases a diminution wasobserved during the pyretic period, with, in 6 of these, anincrease during convalescence. In 4 cases of scarlatinal

nephritis little or no complement was found. In 2 fatal

malignant cases a large amount of complement was presentat the time of death. In measles the variations of comple-ment were small and seemed to follow no definite rule. In

typhus fever complement seemed to be less in amount duringthe period of illness than during convalescence, while inlobar pneumonia it was present in greater amount duringthe acute stage than during convalescence.

Dr. ADAM PATRICK described some Anomalous Forms ofthe Enteric Bacillus. It was found during the investigationof bacilluria in men suffering from enteric fever that in

6 cases out of 17 the bacilli were not typhoid bacilli, but