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optic neuritis (Case 2). anomalous ataxia case (Case 28),and tuberculous meningitis (very early stage) (Case 29).

8. Hence, I think that lumbar puncture should be tried asa therapeutic effort in a variety of cerebral conditions whichare not hopeless but which are stationary or retrocedentunder ordinary treatment. Also that the cerebro-spinalpressure should be measured n every case of lumbar

puncture for the present.This investigation would have been impossible without the

kindness of the honorary and resident staff of the Hull

Royal Infirmary. My sincere thanks are therefore due toDr. G. F. Elliott, Dr. Frank Nicholson, Dr. E. 0. Daly, Mr.E. H. Howlett, Dr. D. Lowsor, Dr. Rockliffe, Mr. E.Harrison, Mr. A. G. Francis, Mr. Guy B. Nicholson, andMr. Carter ; also to Sir Victor Horsley.Hull.

Medical Societies.CLINICAL SOCIETY OF LONDON.

Malarial Affection of a Joint.-Intermittent Hydrops of theJoints.-Hydronephrosis due to Moveable Kidney.

A MEETING of this society was held on April 14th, Dr.’FREDERICK TAYLOR, the President, being in the chair.

Professor HOWARD MARSH communicated a case of’Affection of a Joint possibly due to Malaria. The patientwas a man, aged 38 years, in whom there was a history ofsyphilis and who had lived abroad and contracted malaria.In April, 1903, his knee became the seat of severe pain butwithout swelling or loss of movement. When first seen inDecember, 1903, the joint appeared natural but the muscleswere very much wasted and were so weak that he was unableto raise his heel from the bed. He complained of agonisingpain from his hip to his ankle. Every evening the jointbecame considerably swollen and measured one and a halfinches more than the other, the swelling having a remark-ably globular appearance. There was no fluid in the jointand the swelling seemed due to vascular turgescence ofthe synovial membrane. The patient stated that the jointswelled up in this manner every evening and then graduallyreturned to its natural size. After the administration of

quinine in ten-grain doses twice a day for four days theattacks of swelling had disappeared and the patient recoveredmuscular power in the limb so rapidly that in three weekshe was able to walk three or four miles without any badresult. Six months later he had a patch of swelling coveredby overwarm and hypermsthetic skin just over the internalmalleolus, worse at night, which was similarly relieved byquinine. The blood was examined by Major Ronald Ross andno parasites were found, but on account of the periodicityof the swelling of the knee recurring at intervals of 24 hours,and that it was attended with severe neuralgic pain andrelieved by quinine, Professor Marsh believed it was possiblethat these symptoms were due to malaria and referred tothe "brow ague," neuralgioe, and other symptoms occurringin malarial subjects.-Sir PATRICK MANSON remarkedthat Professor Marsh’s case had again raised a questionwhich had been often discussed but never settled-namely,the position of certain irregular manifestations of malaria.There were two ways in which these manifestations might berelated to malaria-first, as a direct symptom of the diseaseand, secondlv, as a condition due to the lowered vitalitycaused by the malaria. Thus syphilitic or other poisonsproduced a greater effect in a person who had had malariathan in a healthy person. In Professor Marsh’s case he couldsee no reason for supposing that the condition of the joint wasdue to malaria, as the patient presented no symptoms whichwere pathognomonic of that disease. The periodicity wasquotidian, a periodicity which was common to many con-ditions and was usual in all septic fevers. In malaria the

periodicity would be typically tertian or quartan. Moreover,in this case the exacerbation of symptoms had been in theevening, which was a common event in syphilis butrare in malaria; the typical feature of malarial symptomswas their occurrence before midday. There were no othermanifestations of malaria, such as fever and enlargement ofthe spleen. He paid less attention to the absence of themalarial parasite from the blood, for quinine had beenpreviously administered ; it would have been more useful toexamine the blood before this administration. He would

like to know how recently the patient had been exposed 10 omalarial infection, for in his experience no active evidencesof malaria ever occurred after three years at the utmost fromsuch possible infection. He referred to various conditionsthat had been termed irregular malaria, notably periodicnervous, cutaneous, and gastric symptoms. He did notknow of any that had had the two great malarial testsapplied to them-namely, finding of the parasite andobservance of the malarial periodicity, though he referred totwo cases of urticaria which were probably malarial onaccount of their clinical features. The malarial parasite un-doubtedly had a predilection for certain organs but hedoubted if the joints should be included amona them.-Lieutenant-Colonel T. R. MULRONEY, I.M.S., had seen manycases of malaria complicated by syphilis, the manifestationsof which were more decided than in non-malarious subjectsand were often temporarily relieved by quinine. But iodideof potassium was necessary to cure them permanently as ina case which he quoted of affection of the ankle-joint.-Professor MARSH replied and stated that over three years hadelapsed since the man had been abroad.

Professor MARSH also made a communication on threecases of Intermittent Hydrops of the Joints occurring in awoman aged 28 years, a man aged 42 years, and a boy aged12 years. These three cases were in all their essentialfeatures very similar to each other. The effusion in the joints returned with remarkable periodicity : in two every 14 daysand in one every 12 days. In all the local condition--mereincrease of synovial fluid-was the same. In all, the jointsin the intervals seemed normal. These cases were typicalinstances of the usual form of intermittent hydrops of thejoints and they closely resembled those which were observedor recorded by Dr. E. J. Brackett and Dr. F. I. Cotton.’In these examples the periodicity was always marked 1utthe interval between the attacks varied in differentindividuals from three or four days to 30 days or more, themost frequent interval being 14 days. In several instancesthe attacks continued for three, four, or even more years.Some cases after showing definite periodicity lost thisfeature and the attacks became irregular both as to thetime of their recurrence and their severity. The pathologyof this affection was not known. It might be that underthe influence of some cause not yet recognised a vaso-motordisturbance led to synovial effusion of a periodic character.In regard to treatment, arsenic was the only agent whichappeared to be useful. These cases were not only interest-ing on their own account but because they might lead toerrors in practice, for the recurring effusion might verywell suggest the presence of a loose cartilage or a synovialfringe for which a useless operation might be performed.- Mr. F. C. WALLIS expressed the belief that sl1chcases as those now described by Professor Marsh were dueto some micro-organism or its toxin and thought it wouldbe interesting to know the results of a series of culturestaken from the fluid in the joint. He had opened and washedout the affected joint in one case with advantage.-Dr. F. J.POYNTON pointed out that micro-organisms in affections ofthe joints were commonly confined to the subendotheliallayer and were rarely found in the fluid. He was not ofopinion that the cases described were of microbic origin butrather of the nature of an oedema or an urticaria. It was,however, well known that the subcutaneous injection ofcertain toxic and antitoxic sera, such as those of diphtheriaand tetanus, could produce synovial effusion. Had urticarialor erythematous lesions been observed in Professor March’scases.-Dr. F. W. FoRBES-Ross thought that the effusionwas probably a serous hsemorrhage into the joint, dueto a diminution in the coagulability of the blood. Malariawas known to predispose to this condition and oedemaoften occurred in such subjects after the administrationof mercury.-The PRESIDENT asked on what groundsarsenic had been given.-Professor MARSH said thatthose who had seen many of these cases recommendedarsenic but some cases did not improve with it, whereasmost cases spontaneously improved. He did not think thatthe condition was of infective origin, for there was no

structural alteration of the joints, even after repeatedattacks. He had not examined the synovial fluid or theblood in his cases. Dr. A. E. Garrod had told him of threecases which he had seen, two of which were the directsequelae of gonorrhoeal rheumatism.

Mr. F. J. STEWARD communicated two cases of Hydro-nephrosis due to Moveable Kidney. These two cases were

1 Boston Medical and Surgical Journal, vol. exlv., 1901.

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brought forward on account of the marked degree of hydro-nephrosis caused solely by the undue mobility of the kidneywhich resulted in the formation of a sharp kink in the

upper part of the ureter, as described by Gigon in 1856.The first case was that of a young woman, aged 20 years,who had had attacks of pain in the right loin for eightweeks before admission to Guy’s Hospital in February, 1900.A large, freely moveable, fluctuating tumour was foundin the right loin. The tumour varied somewhat in tense-ness but never disappeared, the pain being worse whenthe tumour was most tense. The tumour was exploredthrough a lumbar incision and found to be a large hydro-nephrosis caused by a sharp bend in the upper part of theureter which was easily straightened out by pushing thekidney up into its normal position. The kidney was fixedby silk sutures to the parietes and the wound was closed.The patient had no further pain and the average dailyexcretion of urea increased from 167 grains to 277 grains.On examination nine months later the tumonr was found tobe markedly smaller but it had not disappeared. Thesecond case was that of a girl, aged 18 years, who wasadmitted into Guy’s Hospital 16 weeks after a right-sidedhydronephrosis had been opened and drained. The causeof the condition was found, as in Case 1, to be a kinkof the’ upper part of the ureter which was straightenedout by pushing the kidney upwards. The kidney andthe upper part of the ureter were fixed to the parietesand a catheter was passed down the ureter from the olddrainage opening in the convex border of the kidney.Six months later there was no return of the hydronephrosisand the kidney remained firmly fixed in its normal position.-Mr. K CLEMETT LLTCAS referred to four cases which he hadrecorded at the meeting of the British Medical Associationin 1891, in all of which a moveable kidney had terminated inhydronephrosis. In all there had been intermittent attacksof very severe pain from time to time and these symptomsindicated a kinking and blocking of the ureter. Sometimesthe conditions could be cured by fixing the kidney in itsproper position but in one case he had watched the gradualdestruction of the kidney. In another case the conditionwas cured for some years by a pregnancy but some yearslater considerable trouble arose from the formation of pyo-nephrosis. The kidney often became fixed in the wrongsituation, with the result that recurrence took place.-Mr. WILLIAM TURNER related the details of a similar caseon which he had operated recently. He speculated as to themode of infection that converted a hydronephrosis into apyonephrosis.-Dr. FoRBES-Ross pointed out the importanceof the direction in which the kidney subsequently shrank.As they could not foretell this direction would it not bebetter to examine the opposite kidney by laparotomy andthen remove the hydronephrotic kidney if the other washealthy?-Mr. STEWARD replied.

LIVERPOOL MEDICAL INSTITUTION.

Aspiration of the Chest.-Paranayoclonus Multiplex.-Haemorrhage due to High Arterial Tension.-FloatingKidney.- Prognosis in Pulmonary Ticberc2closis.A MEETING of this society was held on April 13th, Dr.

JAMES BARR, the President, being in the chair.Dr. WILLIAM WILLIAMS demonstrated an improved method

of Aspiration of the Chest.Dr. J. C. M. GIVEN related a case of Paramyoclonus

Multiplex occurring in a man, aged 21 years. The con-tractions were unilateral in distribution, affecting mainlythe muscles of the forearm, the leg, and the abdomen on theleft side. The patient’s mother had suffered from chorea

gravidarum whilst pregnant with this child. He had hadtwo severe accidents at long intervals to which he attributedthe commencement and the increase of the disease. Theadministration of of a grain of hyoscine hydrobromatetwice daily had been followed by distinct improvement.-The PRESIDENT, Dr. T. R. GLYNN, and Mr. R. C. DUN dis-cussed the case.

Dr. A. C. WiLSON related five cases of Hsemorrhageapparently due to High Arterial Tension. Case 1 was thatof a youth, 20 years of age, who from early childhood hadbeen subject to bleedings from the nose. During one weekhe had two severe attacks of hasmatemesis. The radial pulsedemoted high arterial tension and there was no pain or

tenderness over the epigastrium suggestive of gastric ulcer.The patient quickly improved on taking large doses of per-chloride of iron. Case 2 was that of an elderly woman the

subject of arterio-sclerosis. She was suddenly seized withdizziness and her congested face and slow high-tension pulsethreatened an attack of apoplexy. Fortunately this wasaverted by profuse bleeding from the nose. Case 3 was oneof cerebral haemorrhage which occurred in a man, 38 years ofage. There were aphasia and paralysis of the right side. Hegradually made a complete recovery. Case 4 was that of afemale, 45 years of age, who for the last 17 years had hadattacks of haemoptysis, at one time thought to be due topulmonary tuberculosis. Her general health was excellent;the sputum did not contain tubercle bacilli. Case 5 alsowas a case of haemoptysis. The patient, a man, 48 yearsof age, had for six years been subject to slight attacksof bleeding. There were no physical signs of pulmonarytuberculosis and the sputum did not contain tuberclebacilli.-The cases were discussed by Dr. GIVEN, Mr.RUSHTON PARKER, Dr. GLYNN, and Dr. JOHN HAY.

Dr. CHARLES PINKERTON related a case of FloatingKidney in which the symptoms closely resembled those dueto gall-stones. The patient was a married woman, 38 yearsof age, who during the last 18 months had 12 attacks ofgreat pain in the right side with sickness followed byjaundice. She had lost four stones in weight during thattime. Physical examination revealed a floating kidney anda dilated stomach. A belt for the kidney was ordered butbefore it arrived she had another attack, a typical Dietl’scrisis, attended, however, by jaundice. After wearing thebelt she rapidly gained in health and weight and hadremained perfectly free from all attacks since.-Dr. T. R.BRADSHAW referred to a case the converse of this in which awoman had a freely moveable kidney and hepatic pains but anoperation for the removal of gall-stones completely cured her.

Dr. R. J. M. BUCHANAN read a paper on the Prognosisin Pulmonary Tuberculosis. The pulmonary infection waspeculiar, affecting as it did organs which lent themselves,by structure, vascularity, mobility, and communication withthe exterior, to easy dissemination and secondary infections.The difficulties of prognosis were very great and the clinicalcourse of the disease was full of i-urprises. It was pointed outhow dangerous it, was to relate closely the pathological andclinical stages in forming a prognosis and reference wasmade to the post-mortem proofs of the spontaneous curabilityof pulmonary tuberculosis. The question of predisposition,acquired or hereditary, was discussed. In reference tothe latter it was considered that evidence was graduallyaccruing in support of a less gloomy view being taken ofthe prognosis in such cases and that an inherited predis-position was general rather than specific to tubercle. Thevalue of physical signs was fully considered-cough, hemo-ptysis, mixed infections, and complications. The value ofconstitutional symptoms as prognostic factors was discussedat length, with special reference to the temperature, nutri-

tion, and circulation. In reference to the duration andcourse of the disease difficulties arose in obtaining the exactdate of incidence. In conclusion, he advocated that theprognosis in pulmonary tuberculosis should be based upon acareful study and estimation of (1) the general constitutionalcondition of the patient ; (2) the effects of the disease uponthe body temperature, nutrition, and circulation; (3) a re-cognition of the extent of the lung involved and the abilityof that left to carry on the respiratory process ; and he said(4) that the above were the important factors and in com-parison with them physical signs as they interpreted localpathological 11 stages " of the morbid process occupied a sub-ordinate position. Valuable as might be their diagnosticimportance they formed an untrustworthy basis for pro-gnosis.-Dr. NATHAN RAW said that the virulence of theinfection and the resisting power of the tissues decided thefate of the person attacked. A predisposition to tubercu-losis often made the prognosis unfavourable. Treatmentcommenced early and maintained under proper surround-ings would of course favour arrest of the disease.-Dr.HAY said that an opinion based upon the physical signsalways under-estimated the extent of the lesion. In form-ing an opinion as to the prognosis due consideration shouldalways be given to the result of previous treatment.-Dr.W. B. WARRINGTON, Dr. J. HILL ABRAM, Dr. WILSON, Mr.W. B. BENNETT, and Mr. 0. BOWEN also took part in thediscussion.

FORFARSHIRE MEDICAL ASSOCIATION.-A meetingof this society was held on April 7th in the Schoolof Medicine, Dundee, Dr. James Orr (Tayport) being in

the chair.-Dr. R. C. Buist read notes on three cases

of Icterus Gravis or Grave Jaundice-terms which he used