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showed a little opacity on the left side, as of a pleuraleffusion. The patient became drowsy and apathetic, onlyoccasionally crying out with pain. By the 18th over thedull area tubular breathing and bronchophony were presentfrom the third to the eighth space on the left side, andbelow the eighth interspace there were signs of fluid effusionas before. During the next few days her general conditionbecame worse, a chronic deafness became more complete,and the pain in the left shoulder was severe, her tem-perature varying between 102° and 104’ 4°. Cough appearedon the evening of March 22nd and became frequent anddistressing, but there was no expectoration. The pulsewas feeble (140) and the respirations were 40. At last,on March 23rd, in the early morning, the patient suddenlybrought up, by combined coughing and vomiting, over

a pint of fluid. This was chiefly foul pus, with some

stomach contents intermixed. At the same time the

temperature fell from 102° to 97’ 4° and the patient wascollapsed, with cold sweat, thready pulse (132), and re-

spirations 52 to the minute. Stimulants were freely used andfive minims of solution of strychnine were injected hypo-dermically every four hours. During the next few days thepatient continued to cough up foul pus and this did not endfor nearly eight days after the rupture of the abscess. The

cough was frequent and distressing and great effort pro-duced only slight expectoration. Pain on being moved wasacute. On the 25th (two days after rupture of the abscess)signs of pneumonic consolidation appeared at the right base,with pleural frictions, and great pain was felt in the rightside. Her general condition was very bad and stimulantswere freely administered, combined henceforth with largedoses of tincture of perchloride of iron. In view of

apparent inability to cough up the pus, &c., emesis wasinduced with 30 grains of sulphate of zinc, but the result wasnot satisfactory. By the 29th in very slow stages the

patient’s condition had improved ; the pyrexia, though veryirregular, was less ; and the condition of the lungs hadimproved, the right side resolving first. Cough continuedvery troublesome but expectoration became gradually merelybronchial mucus. Improvement slowly but steadily followed,only interrupted by a thrombosis of the left femoral veinwhich showed itself in pain and slight swelling of the limband engorgement of the superficial veins of the leg and thethigh. The temperature did not become normal until so

late as May lst and it has continued so. At first duringconvalescence the heart’s apex moved to the left and therewere no normal breath sounds in the left lower lobe. The

progress to normal sounds and rapidity of recovery ofexpansion of the left lung were more rapid than in casesof ordinary pleurisy. The measurement of the left chest isone and a quarter inches less than the right chest. The

patient left the hospital practically quite well.Remarks by Sir HUGH BEEVOR.-In the early days of this

illness the symptoms pointed to a subdiaphragmatic abscessas much as a lung abscess, the diaphragm being evidentlythe site of inflammation. When the Roentgen rays localisedthe extension of the suppuration as being above the

diaphragm any operation was precluded by the presence ofserous effusion in the left pleura. In such conditions pneumo-thorax might have been expected to arise and cause moreevil than any benefit to be gained by opening the abscesswith such a complication added. But the chief interest inthis case lies in the speed and thoroughness of recoverywhere the abscess was long in penetrating to a bronchus,where secondary pneumonia developed in the other lung, andwhere the patient was of poor physique. In the face ofunsatisfactory results reported in many cases operated uponfor pulmonary abscess the experience of this patient seemsworthy of notice.

MIDDLESEX COUNTY LUNATIC ASYLUM.-OnJune 3rd Sir C. Francis Cory-Wright, Bart., D.L., formallyopened the new asylum at Napsbury, near St. Albans,Herts. The buildings, which will accommodate about1200, have been erected under the direction of the architect,Mr. Rowland Plumbe, and it is hoped that the needs ofthe county will be met for some years. The buildingshave, however, been so designed as to allow of future

development. It is almost needless to say that great atten-tion has been paid to the sanitary arrangements of the

asylum and that everything which could add to the well-being and comfort of the patients has been carefully thoughtout and supplied.

Medical Societies.EDINBURGH MEDICO-CHIRURGICAL

SOCIETY.

Exhibition of Cases.-We Onset of Fear and the Onset of Painin Cardiac Disturbance.-Acute Cerebro-spinal Fever andIntoxication.

A MEETING of this society was held on June 7th, ProfessorJOHN CHIENE, the President, being in the chair.

Mr. ALEXANDER MILES showed four patients after opera-tion for Acute Generalised Peritonitis resulting from

Gangrenous Appendicitis. The patients were boys, agedrespectively 9, 13, 16, and 16 years, and were all in thewards of Leith Hospital at the same time during Marchand April of this year. The cases illustrated the benefitwhich resulted from washing out the abdominal cavity withsaline solution in general peritonitis. Mr. Miles had operatedon 45 cases of acute generalised peritonitis associated withgangrenous appendicitis; of these 25 ended fatally and 20recovered and in all the latter the abdomen had been washedout. Mr. Miles also exhibited a Spleen removed for TraumaticRupture. The man is now following his usual occupation.

Mr. F. M. CAIRD showed a man after Trephining forExtradural Haemorrhage. The patient had been foundlying unconscious at the foot of a stair. There was only aslight bleeding from the ear and the case seemed to be oneof cerebral laceration. A subnormal temperature lasted forthree days and suggested a suppurative condition of thebrain. The size of the pupils varied from day to day.Seven days after the accident the muscles of the face on theleft side commenced to twitch and this soon extended to thearm and leg of the same side. On trephining over the fissureof Rolando on the right side a large, hard, cake-like blood clot,weighing four ounces, was found. Consciousness was regainedalmost immediately after the operation and though theability to speak was at first poor it soon regained the normalamount. The patient recollected everything that had

happened up to the moment of entering the passage leadingto the stairs.

Mr. ALEXIS THOMSON showed a man who had sufferedfrom Tropical Abscess in the Right Lobe of the Liver whichhad been treated by syphon drainage after the method ofSir Patrick Manson. The exploring needle having shown thepresence of pus a large trocar was passed into the cavity inthe arterior axillary line and at the seventh interspace andthe pus was allowed to escape. A large catheter was thenintroduced and fixed in, while a tube attached dipped belowinto a vessel containing boric solution. This form of syphondrainage was established for three weeks, allowing the

escape of much thick brown pus. The result was absolutelysatisfactory.

Dr. GEORGE A. GIBSON showed a male patient sufferingfrom Ophthalmoplegia Externa et Interna. The affectioncommenced five years previously in a slight drooping of theright eyelid and had progressively become worse. Therewas absolutely no movement in the right eye and in theleft the superior oblique muscle had alone escaped. Therewas no alteration in the field of vision; all the cutaneousreflexes were exaggerated. Such cases had been describedas superior tabes dorsalis. The disease consisted in a specificaffection of the nuclei controlling the nerves of the eyeball.

Dr. GEORGE R. WILSON read a paper entitled "TheOnset of Fear and the Onset of Pain in Cardiac Disturbance."The fears referred to were paroxysmal and transient andfor the most part nocturnal-such as fear of suicide, fear ofdisgrace, fear of poisoning someone, fear of mis-signing acheque, and so on. These symptoms were common inpatients suffering from abuse of alcohol and tobacco. Theoccasion of the dread was probably a transient bradycardia.None of these dreads were of long enough duration toconstitute an obsession. With these might be comparedthe night-terrors of children, nightmare, and the sinkingsensation, and the referred pains of cardiac disease. Head’sexplanation of referred pains was convincing so far as itrelated to the sympathetic and dorsal mechanism. The

primary symptom in all the above experiences was a generaland more or less acute sense of uneasiness. Then followed aquick conscious effort at localisation. Both these phases andthe subsequent result-a pain or a fear-should be discussed

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not only as mental processes but as a continuous nervemovement and as dependent upon nerve distribution.With regard to such symptoms as had been mentioned itmight be safely inferred that there was a cortical mechanismfor them having well-defined connexions with the bulbar,sympathetic, and spinal mechanisms. There could be nodoubt, for instance, that in the normal man there was awell-established mechanism to represent a sense of dangerand that it was closely associated with the mechanism ofgeneral uneasiness which was stimulated so frequently inbodily diseases. In certain cases the route of the impulsesfrom the cardiac plexus would be through the sympatheticfibres to the dorsal segment, thence to the medulla, thenceto the cortex. From the mechanism for general uneasinessthe route would be in some cases back to an overstimu-lated spinal segment where it was intercepted andsent back again to the cortical mechanism represent-ing, say, the left arm, and there occurred in the intel-

ligence a "referred pain" in the arm. In other cases a

similar impulse from the cardiac plexus, after leaving themechanism of general uneasiness, was reflected, not to ahyperæsthetic dorsal, but to a hyperassthetic corticalmechanism and was again reflected to the mechanism of

judgment and there occurred in the intelligence a "referredfear." (The term "irrelevant" might be preferable.) Inboth groups of cases the perversion of the impulse hadbeen determined by a "tender" mechanism-in the onecase by a dorsal mechanism which represented a "tender"

"

surface area and in the other case by a cortical mechanismwhich represented a "tender" place in the mind; for, inthe cases of transient fear before mentioned, the fear referredto some subject of almost constant anxiety. It was not

suggested that cardiac disturbance was always the primefactor in these cases of transient terror.-Dr. T. S.CLOUSTON said that all heart pain was not attendedwith fear ; some emotional instability was also required.When both occurred together sudden spasmodic action mightresult. The brain might be the originator of the heart pain.He called attention to the intimate relationship betweenmelancholia and vascular disease. The cerebral cells mightbe poisoned and so might originate the heart pain.-Dr.GIBSON said that in his experience fear was generally absentin cases of heart disease.-Dr. JAMES RITCHIE said that hecould recall many cases of fear, morbid anxiety, &c., inwhich there was no affection of the heart whatever.

Dr. ALEXANDER JAMES read a paper entitled, ’’ Notes otCases of Acute Cerebro-spinal Fever and Intoxicationoccurring recently in Edinburgh and in the SurroundingDistrict Clinically Resembling Forms of Epidemic Cerebro-spinal Meningitis." He said that during the past 15 yearshe had seen serious and often fatal cases of cerebro-spinalintoxication and fever in which the ordinary causes of suchsymptoms could be apparently excluded and for the explana-tion of which some less ordinary infective or toxic agencyhad to be thought of. Within the past few months he hadseen in the Royal Infirmary of Edinburgh and elsewhere amuch larger proportion of such cases than usual. He then

proceeded to sketch out the most prominent features in a fewof the more interesting cases which had come under hisobservation. One of the patients was a boy, aged 13 years,who was found lying under a tree in a state of unconscious-ness from which he could not be roused. He was pale,the pupils were dilated, the pulse was 80 per minuteand feeble, his temperature was normal, and there wasno paralysis. He had complained of headache previously.A few hours later twitchings of the facial muscles com-menced with retraction of the head and death soon

supervened. The post-mortem examination revealed merelysome hyperasmia of the grey matter of the pons andmedulla; all the other organs were quite healthy. Another

patient was a male, aged 18 years, who previously tohis admission to the Royal Infirmary had suffered frombroncho- or catarrhal pneumonia for 14 days. There wasalso a suspicion that he suffered from typhoid fever but noWidal reaction was obtainable. Examination of the sputumshowed many cocci and diplococci but no typical pneumo-cocci. On admission he could hardly be roused to answerquestions ; his pupils were equal, slightly dilated, andreacted to light, though slowly. On the day after hisadmission his temperature was 101’6° F. and his pulse andrespiration were respectively 110 and 36 per minute.Attacks resembling the opisthotonos of tetanus now showedthemselves about every 20 minutes, with intervals ofincomplete relaxation. In these intervals he complained of

great pain in the head, neck, and epigastrium, due

probably to cramp. Kernig’s sign was markedly present;tickling the soles of the feet produced active drawingup of the legs, though knee-jerks could not be elicited.Priapism was present. Lumbar puncture was performedand 15 cubic centimetres of cerebro-spinal fluid escapedreadily, indicating high tension. Marked improvementfollowed, the spasmodic attacks ceased, the patient’s mentalcondition became clearer, and he was able to leavethe hospital five weeks after his admission. The fluidobtained by puncture was quite clear and contained no

organisms. Another patient was a woman, aged 24 years,who, when admitted to the infirmary, complained of greatheadache and was only semi-conscious ; her temperature was101.4°, her pulse rate was 124, and her respiration rate was24. Both eyes were slightly prominent, with slight ptosis onthe left side. Kernig’s sign was absent, knee-jerks werepresent, and the pupils were equal and active. Lumbar punc-ture was performed and 22 cubic centimetres of fluid spurtedout with great relief to the patient’s symptoms. She madean excellent recovery. The fluid showed no excess of cellsand no organisms. Another patient was a boy, aged eightyears, who suddenly fell to the ground, complained ofgreat pain on the right side of his head, and draggedhis left leg on walking. He became dazed and partlyunconscious and seemed paretic on the whole of the leftside ; his pupils were dilated and only slightly reacted tolight. The plantar reflex was more marked on the left sidethan on the right and knee-jerks were absent on both sides.Four days after his seizure lumbar puncture was performedand nine cubic centimetres of fluid were withdrawn. Fromthis time he gradually improved. The fluid contained

staphylococcus albus and either staphylococcus aureus orcitreus. Two forms of bacilli were also present, the oneresembling pseudo-diphtheria organisms and the other beinga short bacillus with rounded ends; no diplococci were

present.

DERMATOLOGICAL SOCIETY OF LONDON. - Ameeting of this society was held on June 14th, Dr.J. J. Pringle being in the chair.-Dr. H. RadcliffeCrocker showed a case for diagnosis of a FollicularEruption occupying the thighs and knees of a woman

aged 51 years. The condition had persisted for sixmonths. Over the knees the skin was much thickened,reddened, and scaly, and this condition, together with thefollicular eruption on the legs and thighs, inclined Dr.Crocker to suggest the diagnosis of pityriasis rubra pilaris.-Dr. Pringle considered the case to be more probably lichenplanus.-No other suggestions were offered.-Dr. Pringleshowed another case for diagnosis of a Follicular Eruptioncovering the back and front of the trunk of -a girl,aged 20 years, who gave the history of the eruption havinglasted for five years ; it was increasing in extent and wasitchy. There was no evidence of seborrhoea or of excessivesweating.-Dr. Crocker, however, considered that it mightnevertheless be of the nature of a sweat eruption.-Dr.J. H. Sequeira showed a case of Keratosis Follicularis(Darier’s disease) of remarkable extent and severity in awoman who claimed to be of Welsh nationality. Theeruption was particularly copious and pronounced upon theupper and inner surface of the thighs, upon the flexor aspectof the forearms and arms, and upon the neck and the abdo-men. She had had the disease for from eight to ten years. Asection from the affected skin was shown and the charac-teristic dilatation of the orifice of the pilo-sebaceous folliclesby plugs of horny material was well marked. This case

being only the second example of this rare disease whichhad been recorded in this country excited a great deal ofinterest.-Dr. Arthur Whitfield showed a case of MyomaCutis in a man about 40 years of age. Numerous smalltumours were grouped, somewhat like herpes, in thecourse of the cutaneous division of the right supra-orbital nerve. They were entirely painless, were found onlyin the position named, and had persisted for five years. Itwas a moot point whether they had appeared in the siteof a previous eruption of herpes, a supposition supportedby a history of original " blisters " in this position and bythe very anomalous arrangement of the lesions. A sectionfrom one of the tumours was shown at the meeting anddemonstrated that the tumour was undoubtedly composedof unstriped muscular tissue.-Dr. E. G. Graham Little alsoshowed a case of Myoma Cutis in a woman, aged 45 years,

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who had small tumours of the size of a pea upon the neckwhere they had appeared in the first instance, upon the leftarm and forearm, and upon the back of the shoulder. Shehad noticed the earliest of these about six months ago. Theywere perfectly painless and she suffered no inconveniencewhatever from them, but they appeared to be getting largerand some fresh ones were still coming out. A microscopicalsection from a tumour on the neck showed characteristicmuscle fibres in the deeper parts of the corium, massedtogether and constituting the greater part of the swelling.Mr. George Pernet showed a microscopical specimen ofStreptothrix which had been derived from a patch ofActinomycosis of the Skin from a case under the care ofDr. Crocker who explained that the patient had been anengineer who had possibly contracted the disease in WestAfrica where he had also contracted malaria.

MEDICO-LEGAL SOCIETY.-The terminal meetingfor the session of this society was held on June 6th,Dr. F. J. Smith being in the chair.-Dr. W. Wynn Westcottread a communication on Suicide. Inquest juries onlyfound about 1 per cent. of suicides guilty of felo de se, ;cases where no evidence was obtained as to the mentalcondition were regarded as temporarily insane. Patientswere often prematurely discharged from asylums andthe exigencies of home life led them to slay themselves.Alcoholism was the most common predisposing cause,then the presence of disease. An additional grievance or

an overmastering passion was usually the proximate causeof the fatal act. The relation of the sexes was very con-sistent, three men to every woman. The rate of suicide per1,000,000 of the population was constantly increasing thusit was in 1861, 66 ; in 1881, 77 ; in 1891, 85 r in 1901, 96 ; andin 1903, 105.-Dr. F. S. Toogood had never witnessedthe fear of death in patients dying in the Lewisham

Infirmary. Alcoholism, love affairs in the case of women,and the delirium of acute disease were responsiblefor most attempts at suicide.-Dr. S. B. Atkinsoninstanced Sir Samuel Romilly as a case where an effec-tive blood-letting led to speedy regret at the act of self-

slaughter.-Dr. James Scott stated that few of those whocame under him in Brixton Gaol for attempting to commitsuicide could be regarded as insane. He had found thatfewest of these cases were entered in February and most inJuly or August.-Mr. A. E. C. Franklin of the FederatedMalay States instanced cases where pity, ennui, and even adesire to annoy had led Tamils and Chinese respectively toslay themselves.-Miss E. L. C. Appel, M.B., then read a paperon Feeling and Emotion, their Bearing upon Crime and In-sanity. Self-responsibility was a purely human characteristic ;to regard criminals as irresponsible robbed them of theirmanhood. Sensation was the function of the central nervoussystem; feeling of the sympathetic system. In man evolutionespecially concerned nerve structures which were influencedby the environment; hence remedial homes of detention werepreferable to prisons for criminals. Further, in states ofnervous fatigue, ill-health, and even sleep, acts might beperformed which would be reprehensible at other times;the actors were not insane but were acting subconsciously.Attendants at public institutions should be chosen withgreat care, with a view both to watch the behaviourand to influence those committed to their charge.-Dr. Albert Wilson held the view that there was no suchthing as free will; a man’s impulses and desires weresummed up by his intellect and called his will.-Mrs.Saunders Jacobs, B.A., distinguished the semi-conscious

ifrom the subconscious state ; the brute creation at times Imanifested a sense of responsibility. Sensation was at ’,the root of every faculty of the mind.-Miss Appel, in reply,said that our wills were bound by our past and to that extentwere not free : we should try to improve the mental machineas it was being made in the young.

SAMARITAN FREE HOSPITAL FOR WOMEN,LONDON.-The new out-patients’ department and nurses’bedrooms at this hospital were opened on June 14th by LordLeigh, the president of the hospital, in the absence of LordPortman, who was to have done so but who had been calledto Windsor. It was now desired to instal the electric lightand to erect a modern theatre to complete the hospital anda special appeal fund has been organised which will be gladto receive subscriptions. Communications should be addressedto Miss D. Royde-Smith, secretary of the Special AppealFund, at the hospital, Marylebone-road, N.W.

Reviews and Notices of Books.Modern Methods of Treatment: The Open-Air Treatment of

Pulmonary Tuberculosis. By F. W. BURTON-FANNING,M.D. Cantab., Physician to the Norfolk and Norwich

Hospital ; Honorary Visiting Physician to the KellingOpen-Air Sanatorium. London, Paris, New York, andMelbourne: Cassell and Co., Limited. 1905. Pp. 176.Price 5s.

THE benefits of the open-air treatment are now generallyrecognised. Although there are certain advantages, bothfrom a curative and an educational point of view, to beobtained by residence in a regularly constituted sanatorium,nevertheless the treatment can be perfectly well carried outin private houses. In agreement with some other authoritiesDr. Burton-Fanning maintains that the conditions which areabsolutely necessary for the satisfactory adoption of the

open-air system are to be found almost everywhere outsideour cities. We regard this statement as rather too sweeping.The site of the building in which the treatment is to be

carried out has to be selected carefully in regard to shelterfrom prevalent winds and a dry soil is obviously better thana moist one.The early chapters of this book are occupied with certain

etiological and clinical considerations and allusion is made tothe differences in tractability to treatment which distinguishthe various forms and stages of pulmonary tuberculosis.The importance of the early recognition of the disease is

duly insisted on, for the success of the treatment is more

dependent on the case being taken in hand at the verycommencement of the malady than on any other one point.The remarks on this subject are well worthy of perusal. Ifthere are found the assemblage of signs and progression ofsymptoms characteristic of pulmonary tuberculosis no diffi-culty will be experienced in arriving at a diagnosis, butcertain symptoms may precede the physical signs or the lattermay be anomalous and then grave doubts may arise whichwill be the cause of considerable anxiety to the practitioner.

In the chapters devoted to a consideration of the detailsof the open-air treatment the routine generally adopted inthe case of a patient who is just embarking on such a courseis first described. One of the principal points discussed is,Should the patient be wholly confined to bed or should hebe allowed up for the whole or part of the day in the bedroomor out of doors ? The answer to this question is chieflysupplied by the observation of the patient’s temperature, butother points have also to be observed, more especially therate of the pulse and the condition of the digestive system.Dr. Burton-Fanning’s observations on these and other

matters afford much valuable information and will greatlyhelp those practitioners who have had no practical expe-rience of sanatorium life. The treatment of the con-

valescent patient is equally well discussed and the dailyroutine is carefully laid down. The chapter on diet in thetreatment of pulmonary tuberculosis is also a valuable one.Dr. Burton-Fanning objects to the " over-feeding " whichwas once in vogue. In this opposition we believe he is right.Success in sanatorium treatment depends largely on " indi-vidualisation "-that is to say, each patient must be studiedseparately and " is a law unto himself." Particularly is thisthe case in regard to diet ; we agree with the author whenhe says : " Our object in the dietetic treatment of pulmonarytuberculosis is to bring the patient’s nutrition up to a stan-dard which is judged to be consistent with the highest levelof general health and at the same time to improve diges-tion and assimilation." This can only be done by placingeach patient on such a diet as he can properly digest andassimilate.

Another matter that has been too much lost sight of in thepast is rightly emphasised in this work-namely, that the