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any doubtful case, and especially those cases in which thepatients were still comparatively young. He did not thinkthat all cases of chronic enlargement of the head of thepancreas did well, and he referred to one case of a man whoat the time of operation was thought to be the subject ofmalignant disease, but at the necropsy the head of thepancreas was found to be the seat of chronic inflammation.He did nut think that it was possible in many cases to pusha gall-stone back along the common duct into the gall-bladder.

Mr. A. E. BARKER said that from time to time cases weremet with which were believed to be cancer and in whichthe patients made good recoveries. He referred to the caseof a woman in whom he had explored the abdomen and hadfound what he considered to be cancer and accordingly hadgiven a grave prognosis. The patient made a good recoveryand was well a year after the operation. He thought thatcelerity in operating and protection to the patient fromcold did most to eliminate shock.

Mr. W. G. SPENCER suggested that the duration of thedisease was an important factor in the diagnosis, for in thosecases which ran a rapid course the disease was commonlysituated in the head of the pancreas, whereas in those of morechronic course the growth might be secondary to the irrita-tion caused by gall-stones. He suggested that some casesmight be due to the occurrence of gumma of the liver anddeprecated operation in such cases.

Mr. J. HUTCHINSON, jun., did not consider that rapidityof operation was so important as Mr. Mayo Robson considered,for in operations on the lower abdomen the most successfulresults were obtained by the slower operators. In comparingcases of intestinal obstruction in which a Murphy’s buttonhad been used with those which had been sutured, the mor-tality was less in those sutured (although a longer operation)than it was in those in which a Murphy’s button was used.He asked if in the treatment of cases of ascites stitching theomentum to the abdominal wall had been shown to be of anyservice. With regard to those cases in which cancer wasseen at the time of the operation and yet the patientrecovered he said that he did not believe that it was the effectof the operation, and he mentioned the case of a man withascites, jaundice, and lumps in the liver who recoveredwithout any operation.

Dr. A. F. VOELCKER asked what dose of calcium chloridehad been used in these cases.

Mr. MAYO ROBSON, in reply, said that he gave 30 grains ofcalcium chloride three times a day for from two tothree days before operating and one-drachm doses with.saline solution per rectum subsequently to the operation.He mentioned a case in which chloride of calcium had provedof good service in arresting hæmorrhage. He was convincedthat it was inadvisable to operate in cases of cancer of thehead of the pancreas.

CLINICAL SOCIETY OF LONDON.

The Radical Treatment of Chronic Tuberculosis of the In- testine. -A Case of Hair Ball removed from theStomack of a Child, aged Nine Years.

A MEETING of this society was held on Jan. 10th,Mr. HOWARD MARSH, the President, being in the chair.

Mr. A. W. MAYO ROBSON (Leeds) read a paper on theRadical Treatment of Chronic Intestinal Tuberculosis, inwhich he observed that whatever might be their views

regarding the treatment of acute intestinal ulceration surgicaltreatment was generally advisable in chronic intestinal tuber-culosis. He related seven cases (one male and six females)in which he had operated with only one death, andremarked that while in the first and seventh of hiscases the adhesions to adjoining parts were very in-timate in the other cases the affected part of the bowelwas quite free, thus rendering operative measures easyand simple. In the first, second, third, and fifth of hiscases he bad employed a decalcified bone bobbin as a tem-porary splint over which to apply sutures, a method whichhe had described on numerous occasions and which he stillemployed and advocated as being simple and efficient. The

physiological rest to the diseased parts secured by short-circuiting, as in his third case, and by colotomy, as in his sixthcase, seemed to answer so well that where the radical opera-tion of excision involved serious difficulties or the patientwas not in a condition to bear it he would not hesitate in

future to be content with similar procedures and then totrust to general treatment and hygienic surroundings toassist in the cure. If in the future operative treatmentshould be thought advisable in acute cases he anticipatedthat short-circuiting the diseased area would be found tobe the more useful procedure, as it was the easier andsafer method to pursue, but experience alone would showwhether the suggestions would prove of as much servicein acute as they were in chronic cases. It was

interesting to note that in his first and seventhcases, in which a condition of tuberculous peritonitiscoexisted with tuberculous ulceration of the intestine,the mere exploratory operation had not cured or even arrestedthe tuberculous process, but that the radical operation ofremoving the principal focus of disease or, as in his thirdcase, the short-circuiting and so setting at rest the diseasedbowel, was in all three cases effectual in putting a stop to thetuberculous peritonitis and, so far as could be seen withoutthe parts being exposed, in curing the more diffusedisease. All surgeons must have had the experience of

curing tuberculous peritonitis by simple abdominal section,with or without drainage, and probably many of them hadalso experienced disappointment in other cases where theeffusion had returned after a longer or shorter interval. He

suggested that the explanation of these recurrent cases lay inthe fact that the original focus of disease in the ovaries,Fallopian tubes, or bowel, had not been removed and had againbeen the starting-point for a further effusion of the tuberclethroughout the peritoneal cavity. If that were the correctexplanation the remedy was quite clear-viz., that whereverthe original disease might be it should be removed, if thatwere possible without adding seriously to the risk of opera-tion.-Dr. W. EWART asked what were the early symptomswhich led to the diagnosis of tuberculous ulceration of theintestine and what were the indications for operation. Healso asked if tuberculin had been used as a means

of diagnosis.—Mr. CHARTERS J. SYMONDS pointed outthat the symptom which in the cases recorded hadled to operation was obstruction and that operationhad been performed rather for the relief of obstruc-tion than for the treatment of ulceration of the intestine.He quoted the case of a female, aged 25 years, who hadrecurring attacks of mild appendicitis. The appendix hadbeen removed and a faecal fistula had formed when she firstcame under observation. The cæcum was excised and anend-to-end union of the intestine was made. At the time ofthe operation tuberculous ulceration of the intestine wasseen to be present. He mentioned two other cases of

possibly tuberculous stricture of the small intestine in men.One of these patients had been subject to symptoms ofobstruction for 20 years. In this case two feet of enor-

mously distended intestine were excised. In the other casea man, aged 40 years, was too ill to stand the excisionof the intestine but the gut was short-circuited. He

thought that Mr. Mayo Robson’s suggestion of removingthe localised focus of tubercles was a good one.--Mr. W. WATSON CHEYNE said that there were two im-

portant points for discussion : the first was the treatmentof tuberculous ulceration by excision or short-circuiting, andthe second was whether the focus of the tuberculous diseaseshould be searched for and removed. He quoted the case ofan infant with extensive tuberculous disease of the peri-toneum with symptoms of obstruction. In this case he short-circuited the intestine and at the time of the operationtubercles were seen all over the peritoneum. Thechild made an excellent recovery. He was convincedthat the treatment of tuberculous ulceration of theintestine by short-circuiting was sound practice, but heconsidered it debateable whether the searching for andremoval of the original focus were advisable, though,of course, where the disease was strictly limited-as, for

instance, to the Fallopian tubes-these should be re-

moved. In diffuse tuberculous peritonitis it was in-advisable to search for the focus as the patient couldseldom stand the prolonged operation.-Dr. G. NEWTONPITT thought that the operation in the cases recordedwas performed rather for obstruction than for ulcera-tion of the intestine. He considered it inadvisable tointerfere with cases in which there was "matting" of theintestines. Although tuberculous affections of the appendixwere not uncommon at post-mortem examinations he

thought that tuberculous appendicitis was decidedly rare.-Mr. A. E. BARKER said that he had removed a tuberculousmass f i o m 1 he abdomen of a little girl in the region of the

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appendix and the child had made a good recovery. He considered that it was inadvisable to interfere with thosecases in which there was " matting" of the intestines and in such of these cases on which he had operated he had alwaysregretted it, as the wound had opened up and faecal Ifistulæ had formed, the final condition of the patient thereby being rendered very distressing. The cases most ’

suitable for operation were those with a considerable amountof fluid. He did not think that tuberculous disease ofthe appendix was of common occurrence. He then enteredon the question of how much of the intestine might besafely removed and mentioned a case in which the

cæcum, the ascending, the transverse, and the descend-

ing colon had all been successively removed for tuber-culous ulceration and the patient after the final operationremained in excellent health.-Mr. C. R. B. KEETLEY

thought that it was important in all cases of tuber-culous peritonitis to find the point from which thedisease had arisen. He classified the cases under threeheadings-the first, cases in which a tumour could be felt(this, he said, was always glandular) ; the second, cases inwhich there was a tuberculous appendicitis ; and the third,<cases in which there was diffuse tuberculous peritonitis. He

quoted a case in which he had removed some suppuratingglands in the mesentery and the patient had made a goodrecovery and he considered that the presence of enlarged glandsin the mesentery was a valuable indication of the seat of the

disease and should always be looked for at the time of theoperation. He considered that patients with abdominal tuber-culosis usually stood the severe abdominal operation verywell.-Dr. NORMAN DALTON mentioned the case of a girl,aged 12 years, who was taken acutely ill with symptoms ofappendicitis. The abdomen was opened and the peritoneumwas seen to be thickly studded with tubercles. The girlmade a goodrecovery.-Dr. PERCY KIDD referred to the diffi-culties of diagnosing ulceration in early cases of the disease.He thought that in most cases there was also disease of thelungs. Multiple ulcers of the intestine were generally foundand these were more common in the c&aelig;cum than in theileum, and it was curious that tuberculous appendicitis wasnot more common considering how frequently this region wasthe seat of tuberculous ulceration.-Mr. MAYO ROBSON, inreply, said that out of some 300 cases of appendicitis inwhich he had operated five had been tuberculous. He con-sidered that loss of flesh, diarrhoea, abdominal pains, andnight sweats were the symptoms upon which he had reliedfor the diagnosis of ulceration of the intestine. He believedthat the removal of the focus of the disease was mostimportant.

Dr. E. PERCY PATON read a paper on a case of Hair Ballin the Stomach of a Child, aged Nine Years, which was suc-cessfully removed. The patient was an intelligent girl inwhom a lump was accidentally found in the epigastricregion. As she was known to have eaten hair and othersimilar substances since she was three years old and had

only been broken of the habit recently a hair ball wasdiagnosed. There were no gastric symptoms. On openingthe stomach a mass, consisting chiefly of the child’s ownhair, seven inches long, weighing seven and a quarterounces, and having the general shape of the stomach, wasextracted. The child recovered without a bad symptom.

OBSTETRICAL SOCIETY OF LONDON.

Chorio-epithelioma with Pulmonary Metastases.-Pneumo-coccic Meningitis.-Exhibition of Specimens.

A MEETING of this society was held on Jan. 1st, Dr. PETERHOREOCKS, the President, being in the chair.

Dr. CUTHBERT LOCKYER read a paper on a case of Chorio-

epithelioma with Pulmonary Metastases, in which the evi-dence of an abortion lay in the fact that the patient lostblood freely four months before admission, the loss con-

tinuing until she was sent to hospital. The patient was 42years of age. She had given birth to seven children. Thelast confinement took place three and a half years beforeadmission into the Samaritan Hospital. Three abortionswere recorded, the last being 13 years before the patient wassent to the above hospital. She was admitted with evidentuterine enlargement and in a condition which prohibitedoperative interference. The uterus was perforated by a newgrowth in its walls and secondary deposits were found in thelungs. The pathological characters of the primary andsecondary growths were described, pathological proof of the

occurrence of chorio-epithelioma following immediately onthe removal of hydatidiform mole was given, and the paperwas followed by a lantern demonstration on the closeassociation between vesicular mole and chorio-epithelioma.-The PRESIDENT remarked that it was quite impossible toprove definitely whether these malignant growths were ofmaternal or of foetal origin. Even if it could be shown that

they were developed from the outer epithelial layer of thevilli of the chorion, that would not settle the question,because it was still disputed whether that layer was maternalor foetal. It was for this reason that he had named his own

specimen, shown at the society some months ago,"deciduoma malignum," the name given by Sanger whofirst described the condition. He could not help leaning tothe view that it was foetal in origin, and he did not see howthosewho believed in its maternal origin could get over thefact that it so often followed upon hydatidiform mole. The

point raised by Dr. Lockyer that there were two sorts, onewithout syncytial elements, probably maternal in origin, towhich the term deciduoma malignum " would be appro-priate, and one with syncytial elements of foetal origin, towhich the term "chorio-epithelioma" would be better

applied, was no doubt very important. But it had to be

proved. Could, for instance, Dr. Lockyer say that in allcases of this malignant growth which had followed vesicularmole there had been syncytial elements ? In every instanceof this malignant growth it was very desirable to investigatethoroughly the question of a recent pregnancy, miscarriage,or parturition. In his own case this had been verydifficult to ascertain. The woman was 48 years of age andhad had a child two or three years previously. The growthwas typical and contained syncytial elements.-Mr. ALBANDORAN stated that when the patient was admitted into hiswards she was too ill for any operation. At first sightsloughing fibroid seemed probable, but on further examina-tion extensive malignant disease was evident. It was

remarkable that she lived so long. Dr. Lockyer was to becongratulated upon his excellent report of the pathology ofthis case. Many similar cases must have been overlooked ormisinterpreted.-Dr. HERBERT SPENCER said that while heagreed with Dr. Lockyer’s views in the main, he thought itwould for the present be better to use the term deciduomamalignum

" until a little more was known about the patho-genesis of the disease. There was no doubt that two distinctclasses of growth had been described under this name.

But Klebs, who was, he thought, the first pathologist toinvestigate the disease, had hesitated whether to describe itas a cancer or a sarcoma, and the late Dr. Kanthack hadstated his decided opinion that his (Dr. Spencer’s) case,which showed large masses of typical syncytium, was asarcoma. He thought therefore that it was a little prematureto style it a "chorio-epithelioma," though personally he wasinclined to regard the syncytial growth as of that nature.-Dr. LOCKYER, in reply, stated that the patient’s historyafforded no proof of a period of amenorrhoea prior to theonset of haemorrhage which began suddenly in June andcontinued until November, 1900. He thought that the

syncytial masses were of chorionic origin and if a chorionicvillus was entirely foetal it followed that any neoplasmarising therefrom must likewise be of foetal origin. He

adopted this nomenclature of I chorio-epithelioma " for his

specimen, believing that the syncytial envelope of a

chorionic’ villus was an epiblastic foetal structure. Theterm syncytial carcinoma " would be equally applicable inthe case of these new growths. ,

Dr. THOMAS WILSON (Birmingham) read a short com-

munication on a fatal case of Primary PneumococcicMeningitis simulating Puerperal Eclampsia, in which therewas 1 -5 per cent. of sugar in the urine but only a cloud ofalbumin.

Dr. A. H. N. LEWERS showed two specimens of Cancerof the Body of the Uterus removed by abdominal pan-hysterectomy.

EDINBURGH OBSTETRICAL SOCIETY.

Exhibition of Specimens.-The Movements of the Pelvic Bonesduring Symphysiotomy.-Full-term Intact Extra-peritonealGestation.-Expulsion of a Dermoitl Ovarian Cyst per

’ Vaginam during Labour.’

A MEETING of this society was held on Jan. 8th, Dr. JAMESRITCHIIE, the President, being in the chair., Dr. N. T. BREWIS showed: (1) A Cyst of the Kidneyweighing 48 pounds and measuring 48 inches in circum-