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With regard to the normal position of the hepatic 1flexure, most books said it was at the tip of the Ieleventh costal cartilage, but in over 75 per cent. of inormal healthy people he had found it to be, withthe persons standing up, just at the crest of theilium.

Mr. J. P. LOCKHART-MuMMERY spoke of the greatimprovement which had taken place in the diagnosisof colon disease in the last 12 years. An importantquestion was as to how carcinoma of the colon wasto be diagnosed when there was neither a palpabletumour nor obstruction ; this was now accomplishedin many cases in which neither of those helps waspresent. If diagnosed early, there were no moresatisfactory operations for carcinoma than on thosegrowths in the colon. He placed a higher value onthe sigmoidoscope than did Dr. Hurst; if a patienthad been properly prepared, his experience was thatin the majority of cancer cases blood, or traces ofit, could be found high up in the sigmoid, if therewas no such condition as ulcerative colitis. Heattached considerable importance to the history.X rays were a distinct help in the localisation of thegrowth, and he thought there would be increasedaccuracy in this in the future. Negative X rayevidence was useless. It was very important torepeat the opaque enema, to lessen the chance oferror. By this means also diverticulitis could beeither confirmed or excluded, a very importantadvance in the diagnosis of colon conditions.

Dr. W. H. COLDWELL considered that there wasstill much to be said in favour of the barium mealas a diagnostic aid in conjunction with the opaqueenema in colon conditions, though the enema wasthe more valuable. He had a word to say aboutthe inefficiency of some wash-outs before-making anX ray examination, and the errors which the shadowof faeces left behind might give rise to. For detectingdiverticulitis, of which he threw some skiagrams onthe screen, he thought the opaque meal was as usefulas the enema, and most patients preferred the meal,owing to its greater convenience.

Dr. S. C. SHANKS, speaking of the barium enemamethod, pointed out that there were certain " silentareas." The first was in the sigmoid. One loop ofthe sigmoid might be superimposed on another loop,and in that way the symptoms might be obscured.Another silent area was in the splenic flexure. Andin the middle of the transverse colon there was oftenan area which an enema did not fill, it was thehighest part, and the enema fell to the more depen-dent portions. Thus the part which looped over theridge formed by the spinal column was not filled.He had seen such cases in which the skiagraphicpicture resembled that of carcinoma. The barium-

imeal method was very valuable for investigatingcases of chronic constipation ; a large mass in therectum settled the question. In 196 examinationshe had made by barium enemata, he found 14 definitecases of diverticulitis (or 7 per cent.) and five doubtfulones. On separating hospital from private cases hefound that in the former out of 150 examinationsthere were three cases of diverticulitis, or 2 per cent.,while in 46 examinations of private patients therewere 11 of diverticulitis, 24 per cent. That seemedto show that well-to-do people were more pronethan others to this condition.

Mr. ASLETT BALDWIN related a case in which aman said he felt some inconvenience in the left sideof the abdomen, and had some trouble with defaeca-tion. Examination with the sigmoidoscope did notdisclose blood or mucus, and the X ray report wasthat there was no filling defect nor obstruction.The man was put upon paraffin, with hopes for thebest. Six weeks later he said he felt certain therewas something abnormal present. Mr. Baldwinthought he could feel a lump, and some distensionof the large intestine. He operated, and found acarcinoma in that situation. Another case he describedwas that of a man who had constipation for a weekand had been treated with enemas. When seen, hecomplained of pain in the upper part of the abdomen

on the left side, which was tender. A large masscould be felt on the right side of the abdomen.Washing out was done for a week, bringing awaylarge flakes of lymph and mucus, and the sigmoido-scope showed streaks of blood. X ray examinationshowed the large intestine and transverse colon downin the pelvis, forming a very acute kink on the leftside, and another on the right. There was no signof any filling defect. The man was told to continuewith paraffin, and though that was 14 years agothere was nothing further to report.

LONDON ASSOCIATION OF THE MEDICALWOMEN’S FEDERATION.

A MEETING of this Association was held on May 8th,at the London School of Medicine for Women, toentertain the council members of the Medical Women’sFederation. Demonstrations were given by variousmembers of the staff of the School. In the physiologydepartment Prof. Winifred Cullis demonstrated onthe isolated mammalian heart, the action of certaindrugs, and the production of arrhythmia by sectionof the A.-V. bundle. Miss M. Bond, M.Sc., com-

municated the results of her feeding experimentsas to the content of vitamin A in bacon-fat, experi-ments undertaken in view of the fact that this fatis largely used in the dietary of children. Miss D.Woodman, M.Sc., showed slides, indicating that thefeeding of rats with parathyroid exerts an inhibitoryaction on the thyroid. Mrs. Pillman Williams,M.B., demonstrated the methods of blood-groupdeterminations. Microscopic preparations of fcetaltissues, demonstrated by Prof. M. F. Lucas Keeneand Miss E. E. Hewer, D.Sc., were set oat. Theseillustrated some of the points that have emergedin the course of their investigations regarding thecorrelation between the structural changes in the organsof the foetus with physiological activity. Miss M.Waller, B.Sc., demonstrated emotive response tostimulation.A demonstration was given by the National

Institute of Industrial Psychology on various applica-tions of psychological tests. Examples were shownof the best known varieties of both linguistic andperformance-i.e., non-linguistic—intelligence te sts.Some of the tests which are being used for vocationalguidance and selection were also demonstrated.Specimens were shown of tests for the selection ofengineers, weavers, clerks, and packers, all of whichtests had been devised by the Institute at the requestof various industrial firms. Some examples wereon view of general tests for " manual dexterity "and " mechanical ability " which are being used inconnexion with research into the best methods ofvocational guidance.

II The meeting was largely attended, over 150 membersbeing present. ___ __ __

BRIGHTON AND SUSSEX MEDICO-CHIRURGICAL SOCIETY.

A MEETING of this Society was held on May 7th,Dr. E. F. MAYNARD, the President, being in the chair,when Mr. M. FITZMAURICE-KELLY read a paper on

Some Abdominal Emergencies in Children.He remarked that the mortality associated withthese conditions was to a great degree preventable,and that improvement in results was to be lookedfor mainly in the direction of earlier diagnosis andtreatment. Dealing first with appendicitis, attentionwas called to the fact that, early in the attack, painwas often not localised, but was complained of acrossthe abdomen. The importance of a band of hyper-eesthesia above Poupart’s ligament, as evidencethat perforation had not yet taken place, and theinformation to be derived from rectal examination,were especially emphasised. Treatment consisted in

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immediate operation, delay being dangerous in youngchildren. The right paramedian incision with internaldisplacement of the rectus was preferred in mostcases ; in those with definite localisation to the rightiliac fossa, Mr. Fitzmaurice-Kelly preferred Battle’sincision, closing it again with drainage of the rectussheath and providing stab-drainage elsewhere ifnecessary. In the matter of drainage the surgeonwas guided chiefly by his judgment in the individualcase as to whether the peritoneum was capable ofdealing with the exudate, but as a general ruledrainage was more frequently required in diffuseperitonitis in children than in adults. In post-operative ileus the value of pituitary extract andeserine, in combination, was mentioned-in theworst cases jejunostomy was the only hope and shouldnot be unduly delayed. Acute inflammation ofMeckel’s diverticulum was briefly mentioned, andthe value of a paramedian incision in dealing with itpointed out. Pneumococcal peritonitis was not veryrare among young girls of the poorer class. Manycases were mistaken for appendicitis ; suggestivesymptoms were the onset with symptoms of pelvicirritation-loose stools, painful and frequent micturi-tion-and in acute cases severe toxaemia, with dis-proportionate increase of the respiration-rate. Theacute cases did best with drainage, and the valueof blood transfusion, as recommended by Fraser andMcCartney, was mentioned. Referring to intus-susception, Mr. Fitzmaurice-Kelly laid stress on theextreme gravity of the condition and the seriousmortality-about 30 per cent.-associated with it.This was almost entirely due to a failure to recognisethe urgency of the case at the outset. The clinicalpicture was very definite and strikingly uniform,and it was a serious error to delay treatment becausea tumour could not be felt, or no blood was passedwhen the symptoms were otherwise suggestive. Threerecent fatal cases were detailed, illustrating the sourcesand the dangers of delay. Pyloric stenosis in infantswas, in the light of recent improvements in technique,claimed as a surgical emergency. The early diagnosis,and especially the differentiation of stenosis frompylorospasm, was discussed and Rammstedt’s opera-tion was described. In view of the fact that themortality of cases operated on by this method was ofthe order of 30 per cent. against 80 per cent. in thosetreated medically, Mr. Fitzmaurice-Kelly contendedthat surgery should be invoked at the earliest possiblemoment after the diagnosis was definitely established.

Discussion and Reply.The PRESIDENT recalled the days when appendicitis

was a battle-ground between the physician and thesurgeon. While conceding that the results were nowbetter, he did not think that, as a result of surgicalexperience, we had advanced in certainty of diagnosis. IHe agreed that in pyloric stenosis in infants Ioperation should be the rule. ’,Mr. L. A. PARRY recalled a case of intussusception

in which pain had been absent throughout and thesymptoms were otherwise obscure. He did not findcutaneous hyperaesthesia of much value in practice,and regarded the physical signs of rigidity and tender-ness on pressure as of more value than symptoms.He called attention to the difficulty of diagnosisbetween appendicitis and certain cases of ileo-ceecaltuberculosis, and was strongly in favour of immediateoperation in appendicitis in children.Mr. H. NETHERSOLE FLETCHER called attention to

the virulence of cases of appendicitis starting withdiarrhoea. In the matter of drainage he thought norisk should be taken, and that in cases of doubt atube should be left in. He discussed the diagnosis ofintussusception from gastro-intestinal catarrh withbloody stools in infants, and emphasised particularlythe intermittency of the symptoms in the former.

Dr. H. M. GALT stated in regard to blood trans-fusion that, in such cases as he had tested, he hadalways found the blood of a parent and childcompatible-but he recommended that the bloodsshould be tested in every case.

Mr. J. R. GRIFFITH advocated a transverse incisionoutside the linea semilunaris, splitting the rectumsheath if more room were required, in cases of acuteappendicitis. He mentioned a case of intestinalobstruction by a band following operation by theparamedian incision.

Mr. FiTZMAURIcE-KELLY, in reply, agreed that thediagnosis of appendicitis had not grown more exact,but contended that, in the presence of acute symptoms,an early exploration was the safest course, and theattempt to arrive at certitude might lead to a fataldelay. The same argument applied, with even greaterforce, to the case of intussusception, and he had neverseen any harm come of a negative exploration.

EDINBURGH MEDICO-CHIRURGICALSOCIETY.

A MEETING of this Society was held on May 6th,Sir DAVID WALLACE, the President, being in the chair.A communication was read by Dr. J. STEWART

FOWLER onj5’7M’<yd!ettMt.

Erythroedema, he said, also known as the pink diseaseand in America as acrodynia, was a rare affection ofinfancy and early childhood. He had seen only fourcases, but doubtless as the condition became betterknown it would be found more frequently. Thesymptoms were disconnected and cases might wellbe overlooked. The disease appeared to be morecommon in Australia and was originally describedand named by Swift in 1911 ; later Jeffreys Wood,of Melbourne, published a further series of cases.

Following on this the disease was described in America,by Bilderback and Weston, who called it acrodynia,and shortly after Byfield reported it under the titleof " a polyneuritic syndrome resembling pellagraacrodynia in very young children." In 1922 a fewcases were recorded in England by Thursfield, ParkesWeber, and Patterson, while Feer, of Zurich, unawarethat the disease had already been described, gave whatis the most plausible explanation of the pathologywhen he named it " a peculiar neurosis of the vegeta-tive nervous system in very young children." He alsodemonstrated the high blood pressure in the disease.

Dr. Fowler gave a description of four cases. All ofthese had been perfectly healthy up to the time ofthe onset of the disease and no hint to throw anylight on the cause could be obtained.The first case was of a girl, aged 2, who suddenly had an

attack of feverishness with vomiting. Subsequently shehad become cross and sleepless and had developed an itchyrash all over the body ; the fingers and toes had becomethickened, red and clammy. She was wasted, could notwalk, and fell forward on her face when sitting in bed. Onadmission the child, who was very unhappy, was moderatelynourished ; the cheeks and nose were bright red. She laywith her face buried in a pillow and over her body werescattered patches of punctate erythema resembling a sweatrash. The hands and feet were swollen and livid red withthickened fingers and toes covered with sodden desquamatedskin with a clammy feeling. They did not pit on pressureand the discoloration reached to an ill-defined marginjust above the wrist. There was a leucocytosis of 12,000.An interesting point was great muscular hypotonia withoutany paralysis, the knee-jerks were diminished and sensibilityto pin-pricks impaired, sleeplessness was a very prominentsymptom, the appetite was poor and the child wasted ;there was a good deal of cutaneous irritation, especially ofthe scalp, with the consequence that lumps of hair werepulled out. The temperature was not raised, but the pulsewas always rapid, running from 120 to 150 ; the blocdpressure was from 100 to 120. Soon after admission someteeth dropped out without previous change in the gums,but followed by a persistent stomatitis. After eight weeksin hospital she developed first an infection of a finger-nailand later a fatal general septicemia.The second case, similar to the first, occurred in a boy,

aged 2, who was sent into hospital by his doctor on accountof stomatitis and loss of teeth. The patient was markedlyirritable, but sleeplessness was not a prominent symptom.The hands and feet were the same as in the last case, asalso was the irritable skin rash with consequent loss of hair.The patient died a few hours after admission.