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met with but trifling success.-Mr. CLARKE, in reply, saidhe had carefully selected his cases. He agreed that, incases of middle lobe or of irregular enlargement, if anytreatment beyond catheterism were indicated, then thesupra-pubic operation should be done; but he had not ofcourse advocated’Bottini’s method for these. One could notexpect to get a good resulb unless the bladder were healthy,and he doubted if the operation were more dangerous thanlithotrity in skilful hands. He admitted that an instru-ment requiring a lighter battery power could be constructed,and would be more convenient; but that did not touch thequestion of applicability of the method. He held that thequestion of frequency should not be decided by an appealto mmeum specimens; the only statistics of value werethose of the post-mortem room.

CLINICAL SOCIETY OF LONDON

Gout of Penis.—Trephining for Hœmorrhage from MiddleMeningeal Artery. - Gastro- enterostomy and Jejunostomy.AN ordinary meeting of the Society was held on Jan. 8th,

the President, Sir Dyce Duckworth, in the chair.The PRESIDENT first alluded in a few touching words to

the loss the Society and the profession had sustained by thecomparatively sudden decease of Mr. Berkeley Hill.The reporb of the committee appointed to ascertain the

period of incubation of various diseases was then presentedand received.

Sir DYCE DUCKWORTH gave the clinical history of a caseof Gout of the Penis. A man aged forty-two, a glasscutter, was admitted into St. Bartholomew’s Hospital withgouty arthritis, involving several joints, including those ofthe great toes. There was moderate pyrexia. The patienthad been discharged from a cavalry regiment twentyyears previously on account of hernia. Since then hehad led a sedentary life, and drank about two pintsof beer daily. Sixteen years ago he suffered from leadcolic, and was in St. bartholomew’s Hospital for treat-ment. He was occasionally subject to attacks of arti-cular gout, and inherited the disease from his father.Five days before admission he was awakened by suddenpain in the righb wrist and right great toe-joint. Thefollowing day he awoke with pain in, and firm erectionof, the penis. This continued up to the time of admission.Three days later the left great toe-joint was attacked bygout. The various thoracic and abdominal organs werefound healthy. The urine was acid, sp. gr. 1022, and voidof albumen. The penis was erect and tense, distressinglypainful and turgid. No points of hardness were found in itscourse. The testes were natural. There was no pain orswelling in the perineum. There was pyrexia, with atemperature varying from 99° to 102’. Aperients andsalines with colchicum were administered, and a lightdiet. The priapism persisted steadily, uninfluenced byinternal treatment, by sedative suppositories or leadand opium lotion. A cage had to be placed over

the abdomen to nrevent imnact of the bedclothes.Micturition was painful, and soft catheters had to bepassed. From time to time fresh articular attacks oigout occurred in various joints with slight rises of tem-perature. Priapism persisted for twenty-one days with-out intermission, and gradually subsided with generalamendment of all the symptoms. The noteworthy pointsin the case were-first, the gouty inheribance; secondly,enforced sedentary habits, with exposure to lead impregna-tion, and the habitual drinking of beer. The extreme rarityof the case was commented on. While acute gouty inflamma-tion was shown to be not infrequent in the bladder, prostategland, and testes, gout of the body of the penis in thisacute form was practically unknown, and the author hadnever heard of a similar case. The pathology was believedto be thrombosis of veins in the corpora cavernosa, with someinflammatory condition of the trabecular structure, returnof blood being mechanically prevented during the blockedcondition of the parts. Smaller thromboses of this naturehad been previously noted, but not leading to painful per-sistent priapism, and entailing the presence of small knotsreadily perceptible in the body of the penis, which slowly orimperfectly disappeared. Priapism was sometimes metwith in elderly men as the result of a very acid condition ofbhe urine, and was readily removed by alkaline treatment.The author classified the condition described as amongst the

rarer forms of gout, of which gouty parotitis was anotherexample.—Dr. ORD thanked the author for the record ofsuch a rare clinical condition, which in an acute form h&had never met with.Mr. BLAND SUTTON read notes of a cage of Fracture of

the Skull complicated with Haemorrhage from the MiddleMeningeal Artery in which trephining led to a successfulresult. The patient was conveyed to the Middlesex Hos.pital in an insensible condition, due to falling upon thepavement and striking his head when drunk. Soon afteradmission the right arm and leg became completely paralysed..From the history of the case Mr. Sutton came to the con.clusion that there was an extravasation of the blood dueto injury of the middle meningeal artery. Acting on thisopinion, the left side of the skull was trephined. A verylarge clot of blood was found between the dura and thebone. In order to secure the torn artery it was necessaryto remove bone freely. By means of an electric searchlight a fissure in the bone was found to run from theleft limb of the lambdoid suture downwards into thetympanum and across the petrous portion of the tem.

poral bone. At this spot the dura was laceratedand the sub-dural space opened. After the operationmotor power returned in the paralysed limbs, cerebro spinalfluid escaped during four days, but the patient quicklybecame conscious, and made an uneventful recovery.-Mr. CHARTERS SYMONDS said he had performed opera-tions on three of these cases. The first of these had beenalready published in the Transactions, and was similar to.that described in that the bleeding came from a deep sourcefar forwards, necessitating the removal of much bone; thehaemorrhage was controlled by fixing forceps on the bleedingpoint. The case proved fatal from a limited meningitis.round the site of operation, which he thought was due to.prolonged exposure and to the use of the spray. Both his,other cases terminated successfully. In one the patient, aman, was knocked down by the blow of a crane. He was.at first quite conscious, and complained of intense intra-cranial pain. In an hour and a half he became unconscious,and had universal convulsions. He recovered after tre-phining. The last case was that of a boy who was broughtinto the hospital after an accident to the head. He was.quite sensible, but in the course of two hours became’unconscious, and almost dead. Artificial respiration was.carried on, the skull being trephined meanwhile. Hesoon rallied, and afterwards made a good recovery. Duringthe operation compression of the carotid was practised, andcontinued for four hours afterwards; this materiallychecked the hœmorrhage.—Mr. GODLEE said he had operatedon three or more cases, and he had seen several. None ofthose he had dealt with had been successful and the reason’for this was that they were usually left so long before opera-tion that the cerebral tissue had lost its power of expansionafter removal of the clot. His opinion was that instancesof this lesion were not very rare.—Mr. SUTTON, in reply,said that when he removed the clot the dura and brain werenearly an inch and a half from the surface, but twelve hoursafterwards complete expansion had taken place.Mr. BOWREMAN JESSETT gave the details of five cases on

which he had performed Gastro-enterostomy for pyloric car-cinoma, and two cases of Jejunostomy on patients who weresuffering from carcinoma of the cardiac end of the stomach.Of the five cases of gastro-enterostomv, three had recovered,One case which was shown at the Society in April, 1891,and on whom the operation had been performed in April,1890, was well at the date of reading the paper, and able to’eat and digest ordinary food. A second case which had’been operated on fifteen months ago was also well. In neitherof these cases had the disease materially increased in size.The third case died nine months after the operation, havinglived in comparative comfort until the time of herdeath. Of the two cases which had died, one succumbedbecause feeding had not been begun early enough, thepatient dying of exhaustion ; the other died of septicperitonitis. Since the writing of this paper, Mr. Jessettreported that he had operated on the two other cases, onedying from collapse after the operation, never having ralliedfrom its effects, and the second was a case of combined*pylorectomy with gastro-enterostomy, which was shown,at the Society in October, having been operated on in the-previous July. The patient reported himself now as being:well and in the enjoyment of fairly good health. In allthese cases the operation was performed by means of de-calcified bone-plates. The two cases of jejunostomy were

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both performed in men who were in a tprrible state of col-lapse, pain, and emaciation at the time of operation. Both

operations were successful, one man living in comparativeease for nine months, during which time he was free frompain and able to feed himself through the nstulous open-Ing. The other man, although the operation pcr sc wassuccessful, succumbed six weeks after from ertiaustion.These two operations were performed by a novel methodstiggpsted by the author, which was fully described.-Dr. BURNEY YEO said that these cases were very interestingto physicians. It should be remembered that some cases ofscirrhus of the pylorus ran a prolonged course under suit.able treatment, living in tolerable comfort for many years,and this should make physicians hesitate before recommend-ing operation. In one instance from the commencement ofsymptoms to the termination of the case seventeen yearselapsed, and in another twenty-two years. Success dependedon suitable feeding, nothing being given but what thestomach could readily absorb, and under these conditionsthe patients would often rapidly rally. He held that thestomach rather than the rectum should be trusted fornutrition in these cases. He had seen the greatest benefitresult from the persistent administration of creasote, andalso from courses of Carlsbad water.-The PRESIDENT con- ’curred in the value of palliative medical treatment in suchcases. But if it were found that in spite of careful feedingthe patient was losing ground, there could be no doubt thatoperation should be done at once. It was remarkablehow varying was the susceptibility to cancer of variousindividuals, some being particularly vulnerable, whileothers apparently possessed the power of resisting itsincursions. He asked if in the fatal cases the diagnosis ofcancer was confirmed post mortem, and what operation theauthor would do in a case of closure by malignant growthof the lower part of the œsophagus -Mr. JESSETT, in reply,said he had never seen a case of pyloric cancer last so longas some of those quoted. He strongly suspected that thediagnosis might be in error, and that they were instancesof pyloric fibrous stricture which afterwards underwentmalignant degeneration. He agreed a, to the value ofsuitable diet in preserving strength and nutrition. Threeof the cases he had related had been under treatment for along time, and had been going steadily down hill ; the last,indeed, never rallied from the operation, which had beenpostponed too long. He advocated early operation, as thenthere was a chance of not only doing gastro-enterostomybut pylorectomy as well, if the case should prove onesuitable for extirpation of the growth. One of his fatalcases proved to be non-malignant fibrous stricture. In acase of cancer at the lower end of the oesophagus he woulddo gastrostomy, with the use of Senn’s plates.

Reviews and Notices of Books.Surgery. By C. W. MANSELL MOULLIN, M.A., M D. Oxon.,

F.R.CS. Surgeon and Lecturer on Physiology to theLondon Hospital; formerly Radcliffe Travelling Fellowand Fellow of Pembroke College, Oxford. London:J. & A. Churchill. 1891.

IT is impossible to read this work without realising thatcertain circumstances may tend to raise a prejudice againstit. A volume of over 1400 pages is of necessity verycumbrous, and the reading has been made di1fi:mIt by thedisproportionate margin to the text. This cannot fail to ,,act unfavourably on the mind of a reviewer and to dampthe ardour, of a student. Of a total of 495 illustrations

only 152 are original, while 132 are Mr. Bryant’s and 63 areFergusson’s. In a new edition of the list of illustrationsthe source of the borrowed illustrations is given, but it isnot. indicated in the text as it ought to have been. Wecannot help feeling that to rely so largely as this upon thework of others, and particularly to use for one surgicaltext-book woodcuts prepared for a previous one, is mostundesirable.The work is designed as a text-book for students, and as

such is an ambitious attempt to rival or surpass those of

Krichacn, Bryant, and Holmes. The author has displayedgreat courage in undertaking such a tagk, for it must:.

be confessed that he is lieavily handicapped in thecontest. The writers we have named had all bad a.

large experience in the practice and in the Leachingof surgery when they published their works, while it isMr. Mansell Moullin’s good fortune to be in a positionto anticipate such an experience. And it must be con.fessed that experience is the highest of all qualifications.for the writer of a text-book, and we cannot say that wefind evidence in the book before us that other excellent

qualities can compensate for its want. Mr. MansellMoullin has shown great industry, has made good useof surgical literature, and has utilised the researches,writings, and experience of others. The teaching of thebook is in general harmony with that of British surgeons,and students will find it a safe guide. The writer’s objectappears to have been to give an epitome of general surgicalknowledge, and not to advance original or the most novelteachings, and in that he has been well advised.

The Book of Climates. By D. H. CULLIMORE, M.D.,.M.R.C.P. Lond. and Dab. London: Baillière, Tindall,and Cox. 1890.

THE object of this work, we are informed in the preface,is "to give a concise, clear, and useful account, and onewhich will be acceptable alike to the profession and thepublic, of the climates of the different countries of the

globe, their salubrity, health resorts, mineral springs, andprevailing diseases." In attempting to accomplish theseobjects within the limits of a small volume of 2GG pages, theauthor has essayed a practically impossible task, and hascondemned himself to inevitable incompleteness and super-ficiality. He seems conscious of this himself, remarkingthat " the greatest difficulty encountered has been to keepit within the limits prescribed by the publishers and theneeds and purchasing capacity of the profession ana thepublic, and to render the descriptions at the same time

interesting, intelligible, and useful." Nevertheless, as a

slight sketch of the great topic of the world’s climates andtheir influence on health and disease, Dr. Cullimore’s-work possesses some considerable merits. A very largeamount of information is packed into the narrow limitsof space allotted to the author. There is no verbiageor padding, and the writer presents his facts in the mainaccurately and in a readable form. We have, however,noted some curious errors. Thus at page 197 we find theextraordinary statement that "at Cairo, which is a dirty,.crowded, low-lying city, the death-rate is about 30 percent. " (sic) !The actual death -rate of Ciiro during the,last seven years, including one cholera year, has been21-8 perlCOO among Europeans and 46-5 per 1000 amongthe natives. At page 18 we are informed that "in Switzer-

land, Austria, and the south of France places ...... above.4000 feet are generally exciting, and often wet, variable, dis-agreeable, and harsh." This statement requires much qualifi-cation. Suchstatementsasthat "Penzance possesses the mostequable climate in the world" (p. 61), and that "Homburgis perhaps the most popular and amusing bath in Europe’"(p. 126), are certainly at least open to serious question.Such errors or questionable statements are, however, ex.ceptional, and though calling for correction or modification,do not seriously detract from the general accuracy of theinformation presented by Dr. Cullimore.

It will be eeen that the author aims at giving a bird’s-eyeview of all the climates of the world without regard to thespecial merits which some of them possess as sanatoria. Thepoint of view thus assumed is that of the physical geo-grapher rather than of the physician and medical climato-