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obstruction ; (b) all cases which have relapsed afterone course of thorough medical treatment ; (c) allcases with a history extending over many years ;(d) all cases with large ulcers adherent to surroundingstructures ; (e) practically all cases in which a testmeal is retained in the stomach for more than sixhours; and (f) all cases whose economic positionmakes prolonged medical treatment impossible.

It is surprising how large is the class of patients whomust be placed in this last group. There can be noescape from the conclusion that the medical treatmentof gastric ulcer is a difficult and protracted procedure.In the cases remaining for medical treatment, theapparent source of infection having been removed, themain lines of treatment recommended are as follows :(a) Secure true physiological rest for the stomach bykeeping the patient in bed, by feeding him with liquidfoods which will neither irritate the ulcer nor promoteperistalsis, or, should he be a suitable subject, bydirect duodenal feeding ; (b) secure neutralisation ofhyperacidity by means of atropin and alkalis ; (c) con-tinue treatment for a sufficient time to procuregenuine firm healing of the ulcer, and control thisopinion by radiographic examination ; and (d) protectthe patient against relapse by warnings againstsubsequent indiscretions, whether dietary or otherwise.

GONORRHŒAL MENINGITIS.

IN view of the rarity of authentic cases of gonor-rhoeal meningitis, not a little interest attaches to thecase recently described by Dr. L. Lindenfeld,l of thePathological Institute of the Wieden Hospital inVienna. The patient was a man aged 53 with nohistory of venereal disease, who suddenly developeda septicsemic attack of unknown origin and died afterseven weeks’ illness. The autopsy showed a purulentspinal meningitis decreasing in intensity from abovedownwards, purulent inflammation of the cerebralmeninges, suppuration in the left seminal vesicle,and a scar in the left epididymis. Smears of thepus from the seminal vesicle and the spinal meningesshowed the characteristic intracellular diplococciwhich were also found in the scanty exudatein the cerebral meninges. Cultures on ascitic agarremained sterile. On a study of the literature,Dr. Lindenfeld was able to find 17 cases of gonorrhoealinvolvement of the central nervous system, consistingof 8 cases of myelitis and 9 of meningitis or meningo-myelitis. Of these 9 cases, 4 were fatal, but in only 1,which was reported by Prochaska, was a careful autopsymade, corresponding in all essential respects to thatof the present case. The clinical course of gonorrhoealmeningitis shows nothing characteristic to distinguishit from meningitis due to other causes. Occasionally,as in the present case, erythemata have been described,which have been classified by Buschke into four groups :(1) Simple erythemata and scarlatiniform eruptions ;(2) urticaria and erythema nodosum ; (3) haemorrhagicand bullous exanthemas ; and (4) hyperkeratosis, whichis characteristic of gonorrhoea. The histologicalfindings in gonorrhoeal meningitis are not specific,although there may be several differences of detail todistinguish it from meningitis due to other causes.Thus, in the present case, the exudate was not nearlyso rich in fibrin as s the exudate in pneumococcalmeningitis, and was of a denser consistency than theexudate in streptococcal meningitis.

INTERNATIONAL EXCHANGE OF LECTURERS.

THE friendly relations already existing betweenleaders of medical thought and practice of differentnationalities are likely to be still further developed bythe exchange of lectures delivered by distinguishedforeigners in Paris and in London next month. Inthe grand amphitheatre of the Faculty of Medicine ofParis the following lectures will be delivered in English:The Circulatory Effects of Mitral Stenosis and AorticRegurgitation, by Sir Sydney Russell-Wells, on

1 Medizinische Klinik, Feb. 5th, 1922.

May 6th ; Trench Fever, by Sir Wilmot Herringham,on May llth ; Lymphatic Pathology, with SpecialReference to Malignant Disease, by Mr. SampsonHandley, on May 13th ; The Mechanism of Com-pensation in the Heart, by Prof. E. H. Starling, onMay 18th ; Acute Pancreatitis, its Diagnosis andSurgical Treatment, by Mr. H. J. Waring, on May 20th ;and on Stereoscopic Vision and the Evolution of Man,by Prof. G. Elliot Smith on May 27th. In London onMay 22nd, 25th, and 31st respectively, at 5 P.M., thefollowing lectures by Professors in the Faculty ofMedicine of the University of Paris will be given at theHouse of the Royal Society of Medicine, 1, Wimpole-street, London, W. 1 : Anti-anaphylaxie, by Prof. F.Widal, Lord Dawson of Penn presiding ; De 1’Ery-thrémie (Maladie deVaquez-Osler), SirWilmot Herring-ham presiding : Des Reflexes de Défense, by Pro;. J.Babinski, Sir James Purves Stewart presiding. Theselectures will be delivered in French. The undermen-tioned lectures by Dutch professors will be given inEnglish at the same place. On May 3rd Prof. C.Winkler, professor of clinical psychiatry in theUniversity of Utrecht, will speak on the HumanNeo-Cerebellum, Sir Frederick Mott, F.R.S., presiding;on June 12th Dr. Murk Jansen, professor of ortho-paedics in the University of Leiden, will speak onInjurious Agents and Growths, Prof. G. Elliot Smith,F.R.S., presiding; and on June 21st Prof. Hijmans VanDen Bergh, professor of pathology in the University ofUtrecht, will discuss the Pathology of Haemoglobin,when Sir Frederick Andrewes, F.R.S., will take thechair. Since the courses have been arranged in con-nexion with the University of London it may be hopedthat students as well as qualified men may availthemselves of the opportunity of hearing of originalwork from its source.

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BLOOD OR GUM.

DURING the war, when blood transfusion was calledfor on the grand scale as a life-saving operation, greatefforts were made by many surgeons to carry itout, often under the most difficult conditions. Butthe process demanded sometimes impossibilities, andit was evident that an efficient substitute for bloodwas greatly to be desired. The introduction of theuse of a solution of gum acacia during 1917 was there-fore hailed as a great advance, and some surgeonsbelieved that the great claims made for gum as ablood substitute were fully justified. Others, how-ever, remained sceptical, and their scepticismseems to be justified by the publication ofreports such as that by R. Charles and A. F.Sladden,l who showed that in two series ofparallel cases the results with gum infusion were

inferior to those obtained with blood, although thelatter series included on the whole more desperatecases than the former. This has tended to be confirmedby laboratory experiments, F. C. Mann showing thatshock produced in animals was more successfully com-bated by blood transfusion than by gum. More recentlygum infusion has often been used in treating surgicalshock in hospitals and elsewhere, and good resultshave been reported. Nevertheless evidence to thediscredit of gum continues to accumulate. During thelast three years several investigators 3 have shown thata gum solution may have a deleterious effect inseveral ways. It may produce agglutination bothintravenously and outside the body. It may causepulmonary emboli and thrombi, accompanied bysymptoms resembling those of anaphylaxis. It may,on the other hand, interfere with the normalcoagulation of the blood, and so be harmfulby discouraging haemostasis. At least one deathhas been recorded which was definitely to be attri-buted to the use of gum. 4 Finally, in a recentpaper, 5 Y. Henderson and H. W. Haggard have sought1 Brit. Med. Jour., 1919, i., 402. 2 Amer. Jour. Phys., 1919, 86.

3 Kruse : Amer. Jour. Phys., 1919, xlix., 137 ; P. J. Hanzlik andH. T. Karsner : Jour. Pharmac. and Exp. Therap., 1920, xiv.,379, &c.; Foster and Whipple : Amer. Jour. Phys., 1922, lviii., 393.

4 H. Olivecrona : Acta Chir. Scand., 1921, xlv., 1.5 Jour. Amer. Med. Assoc., 1922, lxxviii., 698.

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to show that the most important factor in a case ofserious haemorrhage is the acapnia produced by adeficiency in the number of blood corpuscles ratherthan the fall of blood pressure following decrease inblood volume. This theoretical explanation of theeffects of haemorrhage introduces many complexproblems, but at least the experimental findings ofthese observers are clear in their implications. It wasfound that after animals had been subjected to astandard haemorrhage, an intravenous infusion of gumacacia was " distinctly superior " to normal saltsolution ; but the animals receiving it were usuallydead on the next morning! Replacement of theblood with gum did not relieve the air-hunger and itsattendant muscular exertion and over-ventilation.Life was therefore only prolonged and not preserved.It rests with the advocates of gum infusion to bringforward more evidence of the clinical efficacy of thissubstitute for the physiological remedy.

VENTILATION OF PLACES OF ENTERTAINMENT:

PROPOSED L,C.C. POWERS.

IN February, 1920, the London County Councilrepresented to the Minister of Health that regulationsshould be made to secure the " more effectual per-flation and ventilation " of places of public enter-tainment and the exclusion of children as a pre-cautionary measure against the spread of epidemic,endemic, or infectious diseases, and that the Councilshould be empowered to enforce the regulations. Atthat time the Minister of Health was not satisfied asto the desirability of reimposing the Public Health(Influenza) Regulations of 1918 in any form. TheTheatres Committee of the Council, having furtherconsidered the matter, are of opinion that the onlyefficient means of securing satisfactory atmosphericconditions in a place of public entertainment is theinstallation of an adequate system of mechanicalventilation, combined with a system of heating underwhich fresh air is warmed before entering the building.In new and reconstructed premises they have alreadyrequired such an installation to be provided. In thecase of premises, however, in which the ventilationarrangements are not up to the modern standard, theCommittee consider the Council should have somepower. in times of epidemic, to close such places asthev may deem unsatisfactory " for short intervals."or to take " such action as may appear to the Councilto be expedient." The Minister of Health is beingasked to grant this power to the Council.

RENAL GLYCOSURIA.

IT is now well established that a patient who hasdextrose present in the urine in considerable amountmay not be suffering from diabetes mellitus. Ourknowledge of this subject has steadily progressed sinceKlemperer originally drew attention to the conditionin 1896, and the group of cases has now been studiedby many observers in Germany, Austria, the UnitedStates, as well as in this country. In the Practit-ionerfor February Dr. O. Leyton gives his own views ofthe condition, based upon 18 cases which he hashimself observed. He disapproves of the alternative ename of diabetes innocens, which was used bySalomon who described 10 cases in 1914, on theground that although the disease is undoubtedlyinnocent there is no polyuria and therefore no diabetes.He also disapproves of the name renal glycosuria,which is used by nearly all the other observers on theground that it is not proven that the kidney is at fault.The recent work of Hamburger, however, on thevariations of the threshold of the frog’s kidney is sosuggestive that it is difficult to avoid the conclusionthat the kidney is at fault. Leyton has suggestedthe name of negligible glycosuria. But while theglycosuria is certainly negligible when the diagnosis ismade, no care should be neglected to establish thediagnosis. It is not sufficient, as Dr. Leyton seems

to imply, to make an isolated estimation of the bloodsugar some time after a carbohydrate meal, as a

patient with a mild diabetes may have a normal bloodsugar after a meal if he has ceased to pass sugar.It is advisable to estimate the blood sugar beforegiving a dose of dextrose, and to repeat the estimation15, 30, 60, and again 120 minutes after the dose. Theurine should be collected at the end of each hour andthe sugar estimated. The amount of sugar to begiven must be selected with care in a doubtful case asa large dose of sugar may do some damage to thepatient. A dose of 10 g., sufficient in some cases as apreliminary dose, should, if well tolerated, be followedby 25 g. and 50 g. of dextrose. An obvious case maysafely be given 50 g. for the first test. The sugaralways rises in the blood after a carbohydrate meal,but different observers do not agree as to what per-centage is pathological. Dr. Leyton thinks that theblood sugar should not rise above 0-15 per cent.,whereas some observers think that it may rise to 0-18or 0-19 per cent. At all events the blood sugar shouldnot rise above the normal limits after the dose of sugar.If’the patient passes this test he should then be givenincreasing amounts of carbohydrates in the diet andthe total of sugar should be estimated. This test willshow that the amount of sugar excreted is very nearlyindependent of the amount of carbohydrate eaten.The diagnosis should not be made unless such testshave been carried out, for if the patient comesthrough them, he may then eat an ordinary diet.A mistake in the diagnosis is fraught with dire con-sequences for the patient if he really has got diabetesmellitus. Dr. Leyton speaks of the glycosuria as"

adietetic," since it is always present in the urine.This is not quite so, for even in these cases thegreatest amount of sugar is usually post-prandial,and in some cases there is no sugar except after themeal.

INDUSTRY IN RELATION TO ALCOHOL.

THE influence of alcohol on the efficiency of indus-trial workers is a subject of great practical importance,and one in which we are all of us certain to take anincreasing interest in the future, when we get morereliable information than is at present available as tothe effects of prohibition in America. We thereforewelcome the lectures on the subject which haverecently been given by Sir Thomas Oliver before theSociety of Arts and by Prof. E. L. Collis before theSociety for the Study of Inebriety, abstracts of whichappear elsewbere-in our columns. These lectures notonly summarise much of the existing information onthe subject, but bring forward a number of fresh facts,collected from employers of labour and others. Bothlecturers adopted a thoroughly scientific and unbiasedattitude, and did not hesitate to point out the goodqualities of alcoholic beverages, and the very naturaltendency of the worker to indulge in them, not onlybecause they slake the thirst created by many hours oflaborious work in what is frequently a hot or a dustyatmosphere, but because they act as a direct sedativeto fatigue. At the same time it must be admittedthat the balance of the evidence they adduce is verystrongly against indulgence in alcohol, and much of itpoints to the advantages of rigid abstinence. We readof one engineering firm who found that their employeeslost so much time from their work that they madetotal abstinence a condition of employment. In con-sequence, the average time lost fell to 0-5 per cent.,instead of the 10 per cent. usually met with in theengineering trade. Again, the trainer of the NewcastleUnited Football Club informed Sir Thomas Oliver thatwhilst most of the players of his club lose their valueafter 10 to 15 years’ service, some of them still play anexcellent game at the age of 40, and the majority ofthese men are total abstainers. Again, many of themen employed in Scottish glass works drink large quan-tities of beer, but Sir Thomas Oliver was informed thatafter 15 or 2 0 years’ service these men could not competein physical fitness with the abstainers. The menthemselves recognised the fact. and as a result some of