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and was nearly vertical in the erect position, but becameoblique when the recumbent position was assumed. Theincisura angularis, a well-marked depression on the lessercurvature, separated the body from the pyloric part of thestomach, but there was no definite depression on the greatercurvature marking the separation. The pyloric part con-

sisted of the pyloric vestibule and pyloric canal. Theformer was directed upwards, slightly backwards, and to theright, and it generally reached just beyond the middle line.The pyloric canal was about 3 cm. in length, and was sur-rounded by a great thickening of the circular and longi-tudinal coats. Im the empty condition the upper thirdof the stomach was pear-shaped and contained gas.The rest of the organ passed to the pylorus in the formof a collapsed tube. The greater curvature in theerect position approximately reached the level of theumbilicus. When the stomach was partially filled with astandard bismuth meal half a pint in volume, its body wasalmost uniform in diameter, its axis corresponding in

position with that of the empty organ. The diameter of the

pyloric vestibule became slightly smaller as it approachedthe pyloric canal, which was always closed, except whenchyme was passing through it, although its cavity wasgenerally expanded in post-mortem specimens. In thevertical position the greater curvature reached below theumbilicus and rose about 6 cm. in the horizontal position.The junction between the horizontal and descendingportions of the duodenum was fixed, but the pylorus wasmobile and was lower in the erect than in the recumbentposition. When the stomach was filled with a large mealit expanded chiefly in the direction of the greater curvature,as the intestines offered less resistance than the liver. Theleft dome of the diaphragm, however, was pushed upwards,so that it lay as high as the right dome. The diameters ofthe body and the pyloric vestibule were almost uniform,but the pyloric canal remained closed. The pyloricvestibule moved so far over towards the right that it cameto lie in front of the pyloric canal, which passed almostdirectly backwards.

Professor WRIGHT said that the last word on theform of the normal stomach did not rest with the

anatomists, as their observations were made on post-mortemsubjects, and, further, their specimens were always more orless altered by the preserving agents such as formalin. Inhis opinion one of the chief points of difference was inreference to the so-called pyloric antrum. To him this

always seemed somewhat vague, and he considered thatanatomists might very well give that up. Professor Wrightpaid a very handsome tribute to the work done by radiologistsin the investigation of this very difficult problem. ,

Dr. W. P. GOWLAND (Liverpool) read a note fromProfessor A. M. PATERSON (Liverpool) who suggested thatone factor which was responsible for the very remarkabledifference in the form of the stomach as seen in the

dissecting-room to-day from that presented years agowas the method of injection and preservation. It wascertain that the normal stomach in cases preserved bymeans of formol or carbolic acid presented a differentiationof parts which was rarely seen in the days when corrosive

sublimate was used as the preservative. One was nowaccustomed to find dilatations and constrictions in the wallsof the organ associated with a greater thickness andaccumulation of muscular tissue in the one case, and a

thinning out of the muscular coat in the other. He showed

diagrams of 20 stomachs, taken consecutively from dissect-ing-room subjects, and made remarks upon them in detail.Physiologically there was little doubt that there were twoessential parts of the stomach-the cardia and fundus onthe one hand, and the pyloric portion on the other, and hespeculated upon the anatomical factors which were engagedin producing the varieties seen. The hour-glass stomach,he added, was obviously not of necessity pathological, andwas a form most frequently seen in the dissecting-room.

Professor JoHNsoN SYMINGTON (Belfast) was of opinion thatthe post-mortem changes which took place were, as a lule,much exaggerated, and also that many of the points nowbrought out had been anticipated some 30 years ago. Heshowed a specimen where the gas in the digestive organs hadbeen replaced bit by bit by gelatine so as to preserve the actualposition of the abdominal contents. The stomach was seen tobe bulging forwards to the anterior abdominal wall, and alsoraised and tilted up by gaseous inflation of the transverse

colon and intestines. He considered that radiologists shouldinvestigate the lateral view of the stomach more commonlythan they did, though he understood that this was, technically,a very difficult procedure.

Dr. H. J. STILES (Edinburgh) considered that the X rayappearances of the stomach should be properly taught to

students, and in doing this the differences between thevertical and horizontal positions should be made clear. Thelatter position was very important to the operating surgeon,and they also had to remember that under the anaestheticthe appearances were very like those seen post mortem.Undei the same set of conditions the pyloric canal did notexist, nor did he believe it existed in atony.

Professor A. CAMPBELL GEDDES (Dublin) spoke of thedifference in the shape of the abdominal cavity in activemales and in females, and how this was sure to influencethe shape and position of the contents. In females thestomach was lower down in the abdomen and also in the

pelvis quite frequently.Dr. HERTZ replied.

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ELECTRO-THERAPEUTICS.

FRIDAY, JULY 26TH.

President, Mr. C. THURSTAN HOLLAND (Liverpool).Dr. REGINALD MORTON (London) read a paper on

The X Ray Diagnosis of Some Forms of Arthritis.While other forms of arthritis were referred to and illus-trated, the main object of this paper was to demonstrate theidea that rheumatoid arthritis and osteo-arthritis were twodistinct diseases and not different phases of one pathologicalcondition. He believed the joint changes to be due to achemical substance derived from a micro-organism ; thatthe organism setting up rheumatoid arthritis was different tothat causing osteo-arthritis, though he believed it possibleto have a mixed infection. In the matter of a differentialdiagnosis he considered that at the present time the X raymethod offered the most reliable and accurate means at ourdisposal. Rheumatoid arthritis was most common in femalesand affected a number of the smaller joints, as in the hands, asa rule. The first important change seen radiographically wasa narrowing of the normal spaces between the articular endsof the bones, as a result of absorption of the articular carti-lages. In osteo-arthritis, while there were serious carti-

laginous changes, these were in the nature of fibrillation anddisintegration generally, rather than of absorption, with theresult that the narrowing of the joint spaces was not nearlyso marked, even in cases of comparatively long standing.Erosion of the articular ends of the bones was more

common in rheumatoid arthritis than in osteo-arthritis, andspeaking generally he considered the latter disease the lessdestructive of the two, and that there was more effort atrepair than in rheumatoid arthritis. The evidence of thiswas furnished by the absence of rarefaction of the cancelloustissue in osteo-arthritis, the formation of osteophytes tendingto support the diseased joint, and the condensation, or

eburnation, seen frequently on the articular surfaces as ameans of compensating for the loss of the articular cartilage.The formation of osteophytes was not nearly so common inrheumatoid arthritis, and when present they were small andclose to the articular border. In osteo-arthritis osteophyteswere seen extending well down the shaft of the bone quitecommonly. Those sometimes seen at the articular bordersof the affected joint were due to the calcification offragments of disintegrated articular cartilage that had beenpushed out by pressure from between the bones-they weremost often seen in joints that had to carry much weight,such as the hip and knee. Other points of difference werementioned, and the paper was fully illustrated with a seriesof lantern slides.

Peribronehial Phthisis.Dr. ALFRED C. JORDAN (London) said that in a former

account of peribronchial phthisis he had shown that

phthisis was, in most cases, a disease of the rootsof the lungs in the first instance ; not, as ordinarilysupposed, of the apices. In the Pathological Museumhe was exhibiting a series of skiagrams of 36" healthy" lungs fi om the post-mortem room, at ages from4 to 72 years which showed that few persons above theage of 6 years escaped calcareous deposit in the lungs.The deposits were large in 25 cases, slight in the

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rest ; in many there was a large excess of fibrous tissue

arranged in thick strands around the larger air-tubes. Thecalcareous deposits represented obsolete tuberculosis ; thefibrous tissue, healed tuberculous bronchopneumonia.Microscopical sections of the hilum shadows in some of

these "healthy " lungs could hardly be distinguished fromsections of an ordinary case of very chronic phthisis. Therewere typical tuberculous bronchopneumonic patches withsmall round cells and large endothelioid plates, extensivetracts of dense fibrous tissue, the calcareous patches alreadyreferred to. This might readily account for the fact that apositive tubercle reaction was obtained, by the most delicatetest, in 94 per cent. of all children between the ages of 11and 14, and in most adults. The glands and other struc-tures at the hilum had to deal with a continuoustuberculous invasion throughout life. Those who wereunable to cope with the invasion became the sub-

jects of pulmonary tuberculosis. In at least 40 percent. of cases of phthisis the disease commenced as

definite peribronchial mottling. From the hilum thedisease spread in all directions. Sooner or later it reachedthe apex by the ascending bronchioles; extending rapidlythere, so that very soon the apex appeared clinically to bethe chief seat of the invasion. Very often no physicalsigns were obtained until the apex had become infected, thedisease at the hilum being so deeply placed as to escapedetection from without. In about 20 per cent. of cases of

phthisis the disease reached the apex very early, and

progressed at the apex, while the track of the infection fromthe root healed, leaving only fibrous tissue around the

ascending bronchiole. These were the purely apical casesof phthisis. Under favourable conditions the apical lesionmight heal too. This was very well illustrated by askiagram shown of a healthy man, aged 47, killed by anaccident. Healed tuberculous lesions were visible atthe hilum and at the left apex; arching strands of fibroustissue marked the course from the hilum to the apex. Thesecalcareous deposits were easy to demonstrate in the lungsof healthy living persons. The skiagram of a boy of 11illustrated this. No active tuberculous disease was shown,but there was abundant evidence of old tuberculous infec-tion, which the patient, luckily for himself, had been able tomeet by the formation of fibrous tissue around all the

principal air-tubes and numerous calcareous deposits alongthe course of the bronchioles. The boy had shown sym-ptoms from time to time suggestive of phthisis. In a

former paper the author stated, that "fibroid phthisis,"" chronic fibrosis," and "bronchiectasis " were in realityspecial cases of very chronic peribronchial phthisis, in whichmuch fibrous tissue was formed in the attempt to limit thetuberculous invasion. This had been taken to amount to anassertion that chronic fibrosis was always necessarily due totuberculosis. He realised that there were exceptions tothe rule, as when chronic fibrosis followed on an attackof acute pneumonia in a previously healthy person. In suchcases the distribution of the lesions might be found atypicalon X ray examination. The fact had long been recognisedthat physical signs of phthisis might be very hard to find,although the diagnosis was obvious clinically. The explana-tion of this was that these were cases of peribronchialphthisis. By radiography we could now assess the extent ofthe disease in all cases. To complete the evidence for

peribronchial phthisis so as to satisfy the most ’ exactingcritic, a post-mortem examination of a typical case wasrequired. But patients did not die from peribronchialphthisis in the typical stage. At death the whole ofboth lungs were usually full of tuberculous disease. One

might wait years for an early case, previously diagnosedby the X rays, to be killed by accident. and come to post-mortem examination. An imperfect opportunity had arisen, I

however, in a girl of 12 who died from tuberculous ulcerationof the intestines before the disease in the lungs had pro-gressed beyond recognition. Two skiagrams were obtained,two years and two and a half months before death. Thefirst showed definite peribronchial phthisis on the right side,though there were absolutely no physical signs of disease.The second showed well-advanced double peribronchialphthisis ; the physical signs were still very slight, variable,and puzzling to the end. A complete series of sections

through the whole of each lung (exhibited in the PathologicalMuseum), hardened in formalin, was cut by Mr. Stephen J.Mitchell. Comparing the sections with the skiagram taken

two and a half months previously, every part of thetuberculous lesion was faithfully reproduced in the

skiagram, although the disease had advanced con-

siderably (especially on the left side) in the mean-

time. Thus a well-marked case had been examined

pathologically and histologically, and absolute proof offeredthat an important form of phthisis was that which com-menced at the roots. The apex had hitherto been consideredto be the starting place of the disease because, firstly,physical signs of phthisis were easily detected at the apex,while at the hilum there was a considerable thickness ofhealthy lung over it, in the important early stages ;secondly, the disease, once extended to the apex, advancedvery rapidly in this region, while at the hilum it was farmore apt to undergo cure with the formation of calcareousdeposits and of fibrous tissue around the air-tubes. TheX ray method enabled the disease to be recognised in itsearly stages wherever the situation of the lesions. The

patient could then be placed under appropriate treatment.Finally, the recognition of the nature and meaning of theso-called "normal hilum shadow" rendered the X rayexamination of the lungs rational, and cleared up manydifficulties of interpretation and diagnosis.

Mr. S. GILBERT SCOTT (London) read a paper onCervical Ribs.

He drew a distinction between true and false cervical ribs.though recent investigations tended to show that they wereall of the true variety, but in some the extra rib became-fused to the transverse process of the seventh cervicalvertebra. A "true cervical rib was one that showed anarticulation which gave it at least some freedom of move-ment. He also described the technique to be observed inconducting the examination.

Dr. C. FRED. BAILEY (Brighton) read a paper on

Stereoscopic Radiography as a Routine Method cfExamination.

Dr. Bailey stated that a radiograph pure and simple wasmerely a mixture of shadows of varying opacity. He men-tioned how absence of shadow, or minus shadows, couldobliterate or modify plus shadows. The interpretation of aradiograph, which was in no sense a picture, was simply theresult of reasoning. The difficulties in interpreting anordinary radiograph and the errors into which one mightfall were the result of various factors : (1) That every singleradiograph was not a picture in the true sense, but rather aseries of shadows of differently opaque structures ; (2) thatthese shadows might overlap one another and might diminishor reinforce one another, they might cross one another, or byjuxtaposition quite alter one another’s characteristics ; (3) thattheir size and definition in relation to the structures which pro-duced them might be profoundly modified by conditions, suchas distance from plate or tube and position or compositionof the substance itself ; and (4) that these shadows were allseen as if on one plane (the ordinary radiograph havinglength and breadth only), and that it was solely by ourjudgment that we reasoned out what was the form and sizeof the object producing the shadow and what was thedistance and position of that object itself. The stereoscopic-radiograph automatically released our judgment frompuzzling itself over the majority of these difficulties, for it

gave us a radiograph which, in addition to length andbreadth, had thickness or depth, and this was a real and’great advantage, for the heterogeneous jumble of shadowsand absence of shadows on one plane resolved into some-thing more like the objects which produced them. Hebelieved everybody with two fair eyes could, if he reallytried, obtain the stereoscopic effect. He then gave detailsof a simple method he used for taking stereographs, andshowed a perforated card for the observer to view themwith. and stated that the cost by his method was prac-tically no greater for stereographs than for ordinary radio-graphs. He used a lead-guarded frame with a 10 X 6’opening and took the two stereographs side by side on a12 X 10 plate. Various details were given as to how toobtain true binocular perspective in the side-by-sidenegatives, how the same stereographs could be taken in theupright position, and how used if exposures had to be of one-second or less.

Dr. F. HOWARD HUMPHRlS (London) read a paper on

Electricity itt the Treatment of Obesity.Dr. Humphris, after defining obesity, said that chief amongst

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the ; causes was deficient muscular activity, and hencediminished tissue oxidation. He discussed the dangers ofobesity, concomitant symptoms, and other evidences of

faulty metabolism. In the treatment of obesity he mentionedmassage, Turkish baths, light baths, drugs, diet, and electricaltreatment, and referred to Bergonié’s work during the last12 years. Treatment was based on the axiom that "the

proper use of any organ increases the vitality peculiar tosuch organ, and also influences the vitality of the entire

organisation." The general principle was that of a generalexercise of the muscles stimulated thereto by electricity.The current used was a coarse wire faradic, automaticallyinterrupted. Details were given of apparatus required andthe technique of administration, the necessity for medicalsupervision being insisted on. The effects of the current onthe weight and on the general health and appearance werementioned. The rate of weight reduction should be slow,from 2 to 3t lb. per week. The beneficial action of thistreatment on the heart was pointed out.

Mr. W. HAMPSON (London) read a paper onThe Control of Rapid and Irregular Heccrt Beats by the

Electrical Stimulation of Muscles.He said that the large muscles of the body (back, abdomen,thighs, and calves) were stimulated to make brief contrac-tions simultaneously at short intervals by a faradic currentdistributed to the muscles and interrupted rhythmically.The contractions expelled blood and lymph in thedirection permitted by the valves-viz., towards theheart, and so produced rhythmical pulsations of fluidpressure. The pulsations were arranged to occur witha frequency slightly less than that of the heart beat.The stimulation of the heart due ’to the pressure pulsa-tion in the large veins influenced the heart in such a

way that its beats presently synchronised with thecontractions of the muscles, which thus became secondaryhearts. The contractions were then slowed a little more andthe heart beats shortly afterwards synchronised again at theslower rate. By this means the circulation, and with it thegeneral health, was much improved, while the heart wasrelieved of work. Breathing was rendered less distressful,and a feeling of rest and well-being, frequently with sleep,supervened and lasted for several hours. In time the

improved action of the heart became habitual, and dilatationbecame markedly diminished. The treatment had been

adopted as a substitute for the Nauheim course.

DISEASES OF CHILDREN (INCLUDINGORTHOPÆDICS).

FRIDAY, JULY 26TH.President, Mr. ROBERT JONES (Liverpool).

Mr. G. C. E. SIMPSON (Liverpool) and Mr. N. DUNN

(Liverpool) communicated a paper on

Spasmodic Contraction of the Peroneal Muscles io Flat Foot.Spasm of the peronei, they said, was recognised as a com-plication of flat foot, but no detailed description was given inthe text-books. About 40 cases yearly were operated on inMr. Robert Jones’s clinic: 60 per cent. occurred in males,90 per cent. before the age of 20, and trauma was a factor inone-third. Early cases resembled simple flat foot, but theperoneal contraction prevented inversion. In later cases thefeet were rigid and simulated osseous flat foot, but under ananaesthetic the deformity could be rectified readily. In theworst cases osseous changes were superimposed. A seriesof typical cases was described. These cases were resistantto mechanical treatment unless combined with operativeprocedures, and on this account special attention shouldbe directed to peroneal flat foot by classifying it apartfrom static flat foot.

Mr. T. R. W. ARMOUR (Liverpool) and Mr. DUNN (Liver-pool) communicated a paper on

Operative and Post- Operative Treatment of SpasmodicFlat Foot.

In treating peroneal flat foot, they said it was necessary to

put the peroneal muscles out of action until the arch of thefoot had been restored and strengthened. This might bedone by exsection of a portion of the peroneal tendons byopen operation as suggested by Mr. Robert Jones ; after

operation the foot was forcibly inverted and kept invertedfor six weeks. In seven recent cases the writers had exposed

and crushed the peroneal nerve. The advantage of thisoperation was that voluntary inversion was possible imme-diately, and the patient could walk next day. Peronealfunction returned in about six weeks, and the results hadbeen exceedingly favourable. In obstinate cases trans-

plantation of the peroneus longus to the inner side ofthe foot to aid inversion gave excellent results. Aftercorrection of deformity by wrenching, the tendon was

tenotomised on the cuboid ; it was then drawn outof an incision above the malleolus and passed toan incision over the scaphoid, through a tunnel in thetissues across the front of the ankle. The tendon was suturedto the scaphoid by buried sutures. The peroneus brevis mustbe divided. Inversion was kept np for a long time to ensurea good and firm attachment. After all these operations itwas necessary for the patient to wear some support to thearch ; the Thomas boot, raised on the inner side with anoutside iron, was the best apparatus. Massage and exercisesand a proper system of standing and walking were indis-pensable. Some cases associated with bowed tibise were

particularly obstinate and apt to relapse ; in two of these ithad been necessary to remodel the arch by tarsectomy.

Professor M. JANSEN (Leyden) read a paper on

Physiolagical Scoliosis.He said that the human spine tended to deflect to the rightin the mid-dorsal region, to the left in the upper dorsal anddorsilumbar regions. This tendency was the same in differentraces and must be due to physiological causes-asymmetry offunction or of structure. Analysis of cases showed fourcombinations of curves with marked asymmetry of statistics :(1) left low dorsal; (2) left low dorsal with right mid-dorsal;(3) left low dorsal with right mid-dorsal and left high dorsal;and (4) left total scoliosis were very much commoner thanthe reverse conditions. The left low dorsal was the commonconstant factor, and must be the primary curve due to

asymmetrical physiological causes. The diaphragm was thegreat asymmetrical muscle and constantly in action. The

right crus sent a large bundle to the left crus, and the

larger part of the rest of the fibres had recently been shownto be distributed to the left side of the mesial plane. Theleft half of the diaphragm moved with greater force than theright, as was shown by the greater depth of the sulcus onthe left side in rickets, and by exaggeration of the left lowdorsal curve during inspiration in scoliosis cases. This

asymmetry caused a tendency to a left low dorsal curve.Left high dorsal and right mid-dorsal curves were secodnary effects due to its action and to difference of intrathoracicpressures. In school years an element of left total curve was

added, and the degree of summation depended on the

motility of the spine ; gravity further accentuated deflection.Young children should not be allowed to sit before theycould stand and walk. At first they should be kept on theabdomen and back ; then they should crawl. Finally, theyshould repeat developmental history and attain the erectattitude from all fours. The strengthened muscles wouldthen be sufficient to prevent the development of scoliosis.

Mr. J. S. KELLETT SMITH (Eastbourne) read a paper onS’ome Principles of the Treatment of Lateral Curvature cf the

,Spine by Exercise.He said that lateral curvature was due to muscular weaknessand the curative value of exercises was very great, whetheralone or aided by apparatus. Exercises on all fours best over-came the deformity and fixity of the spine and were usedfirst. In crawling exercises moving forward the right armand leg together gave right dorsal and left lumbar scoliosis,while right arm and left leg together gave left total scoliosis.Combinations of movements were chosen to overcome the

deformity, the corrective movement being made forcibly.Later other exercises were commenced to strengthen the

spine: the trunk or arms were moved while a correctivestrain was kept on the spine. Whether on the back orabdomen or in the erect posture all exercises must be

performed with a level pelvis. Other primary principleswere avoidance of muscular fatigue and of strain from workor study. Reading and rest must be carried out in a goodprone position.

Dr. A. MUMFORD (Manchester) and Mr. R. C. ELMSLIE(London) made a few remarks on these two papers onscoliosis, to which Professor JANSEN and Mr. KELLETTSMITH briefly replied.