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he bad observed in another case. He urged, then, that thegeneral phenomena of the disease, which were probably dueto lesion of the central nervous system, had been overlookedin the study of the local manifestations.

Dr. SAVAGE said that his experience led him to believethat ordinary goitre and exophthalmic goitre very rarelyoccurred together, nor did he accept on purely theo-retical grounds the idea that it was due to peripheralneuritis. Most of them were of a general rather than ofa, local neurotic origin. It was very rarely associated withinsanity. In one type of recurrent insanity there was anassociated prominence of eyes, enlargement of throat andincreased pulsation during an attack, and it was noticed thatthe remedies which benefited exophthalmic goitre relievedthe recurrent mania,. In a very few cases of general paralysisbe had seen some or all of the symptoms of exophthalmicgoitre.

Dr. HEBON had noticed two associations with this disease-namely, that the thyroid gland was always more or lessenlarged and that patients usually had one of two kinds ofbad temper, either an almost insane fury or a kind of sullensavageness. Such persons in these states might lapse intocrime, and then a medico-legal question of responsibilitymight arise.

Dr. MURRAY (Newcastle) said that the thyroid gland wasnearly always affected. It was a, secreting gland, and if it wasremoved in a monkey the cachexia strumapriva developed,but the glycerine extract of thyroid gland would removethese symptoms, and the same thing occurred in the treat-ment of myxoedema. If the gland underwent enlargementhyper-secretion might take place, and this might help toproduce the symptoms of Graves’ disease; and if this were soany measures which tended to diminish the secretion shouldtend to improve the symptoms of that malady. In practice thisoccurred, for inunction of the red iodide of mercury, which ’’,tended to diminish the size of the thyroid gland, was accom- I

panied by a beneficial effect on the affection ; belladonna, by I,checking secretion, also was of use. In like manner pilo- ’,carpine was beneficial in myxœdema because it promotedover-secretion of the small portion of thyroid gland left. Iftoo large a dose of thyroid gland extract was given in ’Imyxoedema the pulse-rate was raised, and it was accom-panied by tremor of the hands and sweating of the skin, andin larger doses muscular wasting and weakness followed. Ifthe symptoms of Graves’ disease and of myxœdema were compared they for the most part were in contrast.

Mr. BERRY showed specimens from two cases of Graves’disease under the microscope to demonstrate the completeabsence of all colloid secretion from sections of thyroidgland, and he showed two other sections from ordinaryparenchymatous goitre showing a large excess of colloid inthe alveoli. The thyroid gland in Graves’ disease was muchmore homogeneous on section.

Dr. ORD did not regard exophthalmic goitre as more com-mon than formerly, but thought that it was more observed.He was inclined to agree with Mr. Maude as to the relationsbetween exophthalmic goitre and myxoedema ; in the formermalady there was too much vascularity and too great a pro-liferation of the secreting structure, which led to a destruc-tion of the gland. He had seen the gland too rapidlyreduced by treatment, and the symptoms of myxoedemaproduced.

Dr. GUTHRIE held that there was increased vascularisationin the early stages of Graves’ disease, and quoted instancesto show how the gland might vary in size. He believed thatpulsating aorta was often associated with an abdominal formof Graves’ disease.

Dr. HECTOR MACKENZIE insisted on the necessity for pro-longed observation in these cases, and he was not convincedthat the disease was due to change connected with thethyroid gland. The relation between goitre and Graves’disease required collective investigation. He had given largedoses of thyroid gland extract in cases of Graves’ disease,and no bad result followed; this was against the change inthe thyroid being at the root of the disease, which tendedgradually to subside of itself.

Mr. MAUDE, in reply, said he had found that the questionof altitude had no bearing on the etiology of the affection,in which the liability to crime was, he considered, the sameas that of any neurosis producing a tendency to acute mania.He had applied a cold coil over the thyroid gland with advan-tage. He had noticed a variation in the size of the thyroidgland in early cases of myxcedema. He thought that no reliableconclusion as to the secretion could be drawn from microscopic

sections. The malady was very chronic in its duration, anda larger series of cases must be awaited before the effectof operation could be properly appreciated.

CLINICAL SOCIETY OF LONDON.

Presidential Address.-Abdominal Section for Pyloric Adhe-sions.-Excision of Malignant Turmour from LargeIntestine.

THE first ordinary meeting of this Society for the presentsession took place on Oct. 13th.Mr. HULKE, the newly-elected President, on taking the

chair for the first time, delivered his inaugural address. He

began with a historical sketch of the progress of the Society,and recalled some impressions of its first President, SirThomas Watson, whose election he held to be a happy auguryof future success. During the twenty-six years that hadelapsed since the foundation of the Society in 1867 manyadvances in surgery and medicine had been made-advancesin which the Clinical Society had ever been found in the fore-most marching rank. He mentioned the flourishing conditionof the Society at the present time from the numerical pointof view, and he then approached the subject of his addressby referring to communications in the first volume of theSociety’s Transactions from Mr. Durham and the late Mr.Campbell de Morgan in illustration of the value of anti-

septics in surgery, which value was at that time much dis-cussed and even questioned. He gave some reminiscencesof his own early work to show that strict asepsis was imper-fectly understood in those days by a few and completelyignored by most surgeons. As an example of the defects inhospital construction, then so common, he gave a graphicaccount of the insanitary condition of the old hospital inCarey-street-formerly a workhouse, but which in his studentdays was attached to King’s College-where a charnelhouse existed under the male accident ward and the sametheatre was used for operations and necropsies. He held thatfor the attainment and maintenance of asepsis a strictattention to method and a scrupulous observance of detailwere of nearly as great moment as the selection of the agentemployed. In the last few volumes issued by the Societythere was recorded a series of notable instances of the

adoption of surgical measures for treating certain disordersand injuries of the digestive canal which would well repayattentive study. The heavy mortality attending some of theseoperations, and especially of those for relieving a slowly pro-gressive narrowing of some part of the digestive canal, was toooften due to the fact that the malady was allowed to reachsuch a stage that the greatly lessened strength of the patientmaterially diminished the prospect of obtaining relief fromoperation. Referring to cases in which excision of the vermi-form appendix was practised, he held that in many instancesit was better not to attempt a methodical excision of theappendix, but to be content with freely opening, emptying,and draining the abscess. He thought, in conclusion, thatthe chief progress of medicine had been in the direction ofexact diagnosis, rather than in that of treatment, and hequoted the disorders of the nervous system as being aptillustrations of this lagging of medical therapeutics behinddiagnosis. Though the physician appreciated an exact dia-gnosis, this did not satisfy the patient, who craved for aremedy, and pharmacological research was doing somethingtowards supplying this great want. In this connexion -helaid much stress on the value of the reports which were fromtime to time issued by specially appointed committees of theClinical Society.Mr. MAYO ROBSON read a paper on Dilatation of theStomach and Severe Pain dependent on Pyloric Adhesions,treated by abdominal section and separation of abnormalattachments, with general remarks on visceral adhesions as acause of obscure abdominal pain. Two cases had been sentto him for operative treatment on account of extreme emacia-tion dependent on dilatation of the stomach and severe painin the epigastrium and right hypochondrium. Medicaltreatment had been previously tried without affording relief.In both cases the same treatment-namely, separation ofadhesions of the stomach and pylorus-was carried out

successfully, the original cause of the adhesions being inthe one case gall-stones and in the other ulceration ofthe stomach. The cases were brought forward because,although it was known that simple adhesions might produce

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- erious symptoms, it was not generally recognised thatdilatation of the stomach might be cured by their separa-tion. After relating the cases in detail, Mr. Mayo Robsonremarked that in many instances of severe abdominal pain,.often spoken of as neuroses, the vermiform appendix was dis-torted and fixed in an abnormal position ; the ovaries or Fal-lopian tubes, or both, were displaced and fixed ; and last, butnot least, omental adhesions of great variety were present,producing visceral distortion ; all of which were curable orrelievable by a carefully planned and skilfully performedlaparotomy, and that without any mutilation of viscera. Hefarther remarked that although it was difficult to lay downany hard-and-fast rules, yet, personally, he should feel it wisein cases of obscure abdominal pain, after medical treatment ’,bad been fully tried and failed, to open the abdomen in orderto clear up the diagnosis, and then to adopt that line of treat-ment which seemed to be indicated. He thought that theoases were of interest, not only from a diagnostic and an etio-logical point of view, but also from that of treatment. for ifsome cases of dilated stomach, depending on pyloric dis-tortion, could be cured by simply separating adhesions, thiswould be manifestly a safer and more satisfactory methodthan that of dilating the pylorus or performing pyloroplastyor gastro-enterostomy, in all of which the stomach had tobe opened. He was afraid that it would appear as ifhe had included two distinct subjects in one paper-viz.,..lilatation of the stomach and obscure abdominal paindependent on adhesion ; but he wished to lay specialstress on adhesions producing visceral disability, and theircapability of cure by operation, and if he had succeededin showing that adhesions were not as harmless as someobservers would lead one to suppose his purpose had been- erved.—The PRESIDENT congratulated Mr. Mayo Robson onhis cases. He remarked that if the adhesions had been theresult of ulceration within the stomach they might have beenthe only barrier to perforation. If the adhesions were broad’;hey could scarcely fail to become re-attached after separa-tion, though if they were mere threads this was not likely tooccur.-Dr. FREDERICK ROBERTS said that he had for manyyears urged the importance of recognising internal adhesionsas the cause of obscure abdominal pain, and he had known oftwo or three cases of dilated stomach produced by adhesionsin the neighbourhood of the pylorus. It was remarkablethat, although in some cases nothing was found to accountfor the symptoms when the abdomen had been opened, thepatients were relieved by the operation.-Dr. HALE WHITEreferred to a case in which there was dilatation of thestomach which was thought to be associated with malignantdisease. At the necropsy the gall-bladder was found to beadherent to the pylorus, and the latter was thickened by.chronic inflammation. Though there had been no jaundice,,the trouble seemed to have been produced by a gall-ston,which had ulcerated its way through the pylorus. Such a case,

:.if treated early on Mr. Mayo Robson’s plan, would have been.a great success. In another case, after an attack of typhlitis,,-,t woman complained of pain at the menses, referred to theregion of the cæcum. It was thought that the vermiformappendix had become adherent to the right ovary, and onoperation this was found to be the case. The ovary wasremoved, together with the vermiform appendix, and’there had been no further pain. Dr. GLOVER inquiredwhether there had been any record of pyrexia.-Mr. PEARCE’GOULD asked whether it was easy to determine that there’was no narrowing of the pylorus itself. In such a case asthat which Dr. White had related breaking down ofthe adhesions alone would not have effected a cure.-

llr. MAYO ROBSON, in reply, said that peritonitis had occurredin both cases. In many cases when adhesions were separatedthe viscera would return to their proper positions, and freshadhesions were not likely to form. It was his impression ingall-stone cases that more benefit accrued from separation ofadhesions than from removal of stones. The good done bysome abdominal explorations was inexplicable.Mr. W. EDMUNDS related two cases of Excision of Malignant

Tumour from the Large Intestine. The first patient, a managed fifty, was admitted to hospital suffering from a lump inthe right hypogastric region. There was a history of hæmor-rhage in considerable quantity from the bowel, but not ofobstruction. Laparotomy was performed, a tumour involvingthe caecum was found and brought out, the portion of thebowel involved was excised, and the two ends of the bowelwere brought together externally. The patient recoveredand was now, four years after the operation, in good health.o attempt to re-establish the continuity of the bowel had

been made. The second case was that of a man agedfifty-four, suffering from incomplete obstruction. By amedian incision a malignant growth in the sigmoid flexurewas found and brought out externally, a glass tube beingpassed beneath it. On the fourth day the portion of thebowel involved in the tumour was excised and the dividedends were sutured together. The bowels acted normally,but a fascal fistula formed, through which in time the

greater portion of the faeces escaped. Subsequently theopening was closed and the continuity of the intestinewas re-established, the bowels acting normally. Now,fifteen months after the first operation, the patient waswell, there only remaining a minute fistula leading tothe.bowel. It was remarked that in similar cases, when-ever possible, it was desirable to excise the growth andnot to be content with a palliative operation. The reason

why the growth was not at once excised and the bowel re-sutured in the second case was from fear of peritonitisfrom leakage, a danger which, it was hoped, would beavoided by having the line of sutures shut off from theperitoneum.-The PRESIDENT asked what was the conditionof the motion voided from the opening in the ileum.-Mr.GOULD referred to a case in which he had opened the ccccum ;the patient was quite comfortable, there being a dailyevacuation after breakfast and no excoriation after it.Instances like the second case related by Mr. W. Edmundshad been recorded by Allingham, Bryant, Treves andothers.-Mr. MAYO ROBSON said that in the Leeds Infirmarythe rule followed was that where the symptoms were acuteand the gut distended an artificial anus was made, butwhere there was no special distension and no obstructionexcision with suture was practised.-Mr. EDMUNDS, in reply,said that there was considerable excoriation of the skin atfirst, but this healed later, though the liquid discharge con-tinued. The function of the large intestine was probably toconvert liquid into solid fseces. He admitted that it was

right treatment to perform immediate suture where there wasno distension.

PATHOLOGICAL SOCIETY OF LONDON.

The President’s Address. - Congenital Deformity of Lip. -Pyo-nephrosis of Kidney with Double Ureter.-Abnormalities ofIntestinal Tract.THE first ordinary meeting of this Society for the present

session was held on Oct. 17th, Dr. PAVY, the new President,taking the chair.

Dr. P A V Y delivered the inaugural address. He hoped thatthe Society would endeavour, even more ardently than it haddone, to advance the knowledge of chemical pathology, whichhe was sure would yield a fruitful harvest to those who wouldengage in the research. Protoplasm, he said, had three funda-mental properties belonging to it. It started from previouslyexisting matter; under suitable conditions it was endowedwith power to shape itself into some determinate form ; and itcould bring about chemical changes in matter in its neighbour-hood. Modifications of the surroundings of the protoplasmbrought about deviations which came within the province ofpathology. He then proceeded to deal with a problem offaulty chemistry. In diabetes mellitus there was an elimi-nation of sugar from the kidney in a manner that ought not tooccur. Carbohydrate matter taken into the system was undernormal conditions lost sight of, but the carbohydrate mattersimilarly taken in diabetes passed off with the urine in

proportion to the amount of carbohydrate matter ingested.It was a matter of common belief that glycogen passed fromthe liver to the systemic capillaries and was there used up,and that in the absence of carbohydrate food glycogen wasproduced by the liver. There was a functional transport ofsugar from the liver to the capillaries for destruction, anddiabetes might result either from deficient destruction orfrom excessive entry of sugar into the blood. But a beliefin the conveyance of sugar to the capillaries for destructionled us into darkness, and the present accepted physiologywas untenable. Many years’ study and recent experimentalresearch had convinced him that the glycogenic doctrine waswrong. The liver, instead of being usually charged with sugar,possessed no more than existed in other parts of the system,and even not so much as some parts. Blood flowing from theliver was not more charged with sugar than that flowing toit ; indeed, after ingestion of food the portal venous blood wasricher in sugar than that in the hepatic vein. There was afixed condition of the constitutional blood as regarded sugar