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.-seventeenth day basal pneumonia occurred, which con-

tinued until the twenty-ninth day, when the temperature.came down and she began to improve. But on the thirty-first day she vomited suddenly 6 oz. of blood and died within.an hour. Permission for a necropsy was refused. Mr.Wallis remarked on the cause of death by haemorrhagethirty-one days after the operation as being unusual andunfortunate. He suggested that it might be advisable inmany cases to enlarge the opening sufficiently so that an

< examination of the interior of the stomach might be made.and that a small electric lamp would be of great service insuch cases. The fact that, although the peritoneum was onlywiped clean and not irrigated, there was no peritonitis wasin keeping with the now well-known resisting powers of theperitoneum. Mr. Wallis had been led to adopt this method on

’.account of the frequent occurrence of subphrenic abscesses.after irrigation. The second case was that of a young woman,:a patient under the care of Dr. Fincastle Clarke, who was.seen first in July, 1896. The history dated from December,1882, when she had an attack of gastro-enteritis whichrecurred repeatedly until November, 1895, when on gettingout of bed she was suddenly seized with the typical signs of

. a perforated gastric ulcer. From this she recovered but’.from that time until the operation she was unable on accountof pain to take any exercise and was only able to take fluidfood in small quantities at a time. On examining the patient,-she was seen to be extremely emaciated and weak and the.abdomen was tender when manipulated, especially above andto the right of the umbilicus, where there was a distinctsense of resistance. Dr. Abercrombie and Dr. Clarke saw thepatient with Mr. Wallis and it was agreed that an exploratorylaparotomy should be done. At the operation a strong bandin. broad and 1&frac14; in. long was found issuing from the pyloric’.end of the stomach to the abdominal wall. This was removed.The patient made a complete recovery after a long conva-lescence and was now able to enjoy life after fourteen years’of invalidism. The pain bad never returned and she hadput on flesh and was able to take exercise, and as it was nowtwo years since the operation there were fair grounds’for believing that the benefits would be permanent.-Dr. FRANCIS HAWKINS (Reading) related the case of a youngwoman suffering from gastric ulcer with masked symptoms.’Signs of perforation suddenly developed and she was operated.on and recovered. He did not feel certain that laparotomy-should be performed at once in all cases as he recalled twocases in which the evidence appeared to show that perforation- had occurred but in which spontaneous recovery took place.-Dr. KINGSTON FOWLER also thought that rarely patientsmight recover without operation and mentioned the,case of an ex-soldier who had long been sufferingfrom symptoms of gastric ulcer and one day became’collapsed with symptoms of perforation. The next dayhe had abdominal distension with disappearance of liver’dulness. Operation was proposed but he refused to

aubmit, and to Dr. Fowler’s surprise he recovered, the liver,dulness gradually returning to normal. Notwithstanding’the fortunate result in this instance, however, he thought- that in such grave cases operation should be advised.-Dr.SIDNEY PHILLIPS had had a series of cases of gastric ulcers’under his care during the last few months. In two he believed-that perforation occurred and both recovered without opera-tion. In a third case laparotomy was successfully performed.;In the first case there were the usual symptoms of perfora-tion and disappearance of the liver dulness. The patient wasfed by the rectum for some time and improved, but as soon-as food was given by the mouth the symptoms recurred.-and the liver dulness again disappeared, but ultimately:she got well. The ulcer was probably in the posterior wall.In another case, occurring in a girl eighteen years of age,’the pain was so acute at first that he thought that it couldnot be due to perforation, especially as the liver dulness wasnormal. Two days later there was evidence of local peri-’tonitis and the liver dulness disappeared. As the pulse wasgood and there was no acute vomiting he had not advisedoperation and she was now recovering.-Mr. W. G. SPENCER- suggested that in some cases the disappearance of liver’dulness was due to distension of the colon, and men-

tioned a case in which there was marked distension ofthe colon, which was found after death to have been dueto a kink caused by an adhesion connected with a duo-’denal ulcer. He had recently met with another instanceduring an operation for pyloric obstruction. A fibrousband extended from the pylorus to the colon and causedthe distension. Unless the disappearance of hepatic dulness

was accompanied by a very rapid pulse he did not thinkit was of much importance. In cases of perforation thepulse-rate was rarely below 120.-Dr. LuCAS BENHAMrelated the case of a middle-aged stout woman who wastaken suddenly ill with diarrhoea and intense abdominal

pain. She improved for a time but soon relapsed, the stoolscontaining mucus and pus. She ultimately died and at thenecropsy it was found that an ulcer of the size of a shillingon the posterior wall of the stomach had ruptured.-Dr. TOOGOOD mentioned a case in which disappearanceof the liver dulness was noticed without perforation occur-ring. The patient was a blacksmith who had been undertreatment for gastric ulcer. After dinner one day he wasseized with acute abdominal pain and vomiting and wasadmitted into the Lewisham Infirmary in a state of collapse.As the liver dulness had entirely disappeared Dr. Toogoodcut down on the stomach, but finding that its contents hadnot escaped he stitched up the wound. At the necropsy hefound a very small aneurysm of the arch of the aorta whichhad ruptured. The pulse-rate was between 130 and 140. Hecould not give any explanation of the disappearance of theliver dulness.-Mr. CHARTERS SYMONDS narrated the caseof a woman, sixty years of age, who had suffered fortwenty-five years from symptoms suggestive of gall-stones, but there were also symptoms of obstruction atthe pylorus with dilatation of the stomach. On ex-

ploration he found a very large stomach with a thick massin the posterior wall narrowing the stomach into two, parts.As this was taken to be malignant he united the cardiacportion to the small intestine by direct suture. On the fifthday she died suddenly, and at the necropsy the stomach wasfound to be filled with blood coming from an old gastriculcer, of which the thick mass was the heaped-up border.On the posterior wall of the stomach there was an open-ing 5 in. wide leading into a large cavity. In a secondcase, that of a man forty-six years of age, there hadbeen attacks of abdominal pain attributed to gall-stonesfor. thirty years. On exploration the gall-bladder wasfound to be healthy, but there were many adhesions inthe neighbourhood. Later there were symptoms of gastricdilatation and adhesions were found all round the

pylorus and duodenum. In dilating it he ruptured it

right through to the peritoneum. He sewed up the rentand closed the wound. In a third case, that of a girl, therewas a history pointing to perforation of a gastric ulcer.There was a mesial swelling, and an incision gave vent tomuch foul-smelling pus from a cavity which reached up tothe diaphragm. A large, thickened stomach was exposed,which he accidentally ruptured for a length of 3 in. This hesewed up and the patient recovered. With regard to thedesirability of operating in every case it must be borne inmind that the diagnosis was not always perfectly clear. Inone case the operation was postponed for a day, and the painand vomiting were found to be connected with the onset of anattack of acute pneumonia, and in one which was operated onthe stomach was found to be perfectly healthy, the vomitingbeing apparently hysterical. He did not quite agree withMr. Spencer’s views as to the pulse-rate. It was not neces-sarily rapid in perforation: in his first case it was 60, andcases had been recorded in which it was only 30.-Mr.WALLIS, in reply, observed that while it might possibly notbe advisable to operate in every case there was no doubtthat many patients died for want of timely operation, andthe risk of the operation was slight as compared with thatof an untreated perforated ulcer.

HARVEIAN SOCIETY OF LONDON.

Functional Dysphagia.A MEETING of this society was held on Nov. 17th, the

President, Dr. J. F. GOODHART, being in the chair.Dr. STCLAIR THOMSON read a paper on Functional

Dysphagia which will be found in full at p. 1463 of our

present issue.Dr. C. S. JAFFE remarked that dysphagia of neurotic

origin and not associated with other symptoms of hysteriawas as common in men as in women.

Dr. DUNDAS GRANT complimented Dr. StClair Thomsonand stated that in his cases of functional dysphagia paralysisof the oesophagus was relatively more frequent than itappeared to have been in Dr. Thomson’s. He (Dr. Grant)

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diagnosed it by the abnormal ease with which a verylarge indiarubber cesophageal tube could be passed.He referred also to cases of reflex spasm of the ceso-

phagus simulating malignant disease and arising eitherfrom malignant disease in the abdominal organs or fromdefective dentition. In reference to electricity he hadlearnt from Dr. de Watteville how to bring about forcedmovements of swallowing by the continuous current, thepositive pole being placed on the nape of the neck andthe negative one being drawn gently down the side ofthe neck between the sterno-mastoid muscle and thetrachea. Before introducing the bougie he made it a ruleto assure himself that the cardiac apex beat was in itsnormal position. In the passage of a bougie in the middleline the cricoid cartilages sometimes acted as an obstruction,and in such cases the instrument could often be passed withease if introduced to one side or other of the middle line.This was more readily done with a round than with a flatbougie, and he found in some cases a large bougie with aradish-shaped end preferable to a flat one.

Dr. CLIFFORD BEALE referred to three cases of functionaldysphagia where the patients appeared to be almost unableto swallow in the presence of an onlooker but could takefood without difficulty in solitude. The sensation of con-striction of the gullet sometimes led to the suspicion andeven to the diagnosis of cancer, but the passage of a largeoesophageal bougie by demonstrating the absence of anystoppage not unfrequently caused the disappearance of thesensation. A very small inflammation of a follicle in the

pharynx might produce a very considerable dysphagia, andhe suggested the possibility that some cases of transient

dysphagia might be due to a similar cause situated in theoesophagus itself.The PRESIDENT alluded to the not uncommon inability of

children to swallow solids. Sometimes this inability per-sisted up to the age of two or three years. In some cases it

might be due to adenoids, but he believed that it was usuallydependent on some functional neurosis. He mentioned acase in which dysphagia was caused by phlegmons 01 theoesophagus. He had met with an instance in which aman had been unable for many years to swallow except withgreat slowness and in small sips. Possibly congenitalnarrowing of the lower part of the oesophagus existed here,but he inclined to the view that the inability was functional.Functional dysphagia was occasionally mistaken for thatcaused by cancerous stricture, but the converse error hadbeen known to occur. He regarded aneurysm as an ex-tremely rare cause of dysphagia. He attached great valueto auscultation as a means of diagnosing cesophagealstricture.

Dr. G. A. SUTHERLAND thought the passage of an &oelig;so-

phageal bougie was of value in some cases of functionaldysphagia. He recalled one case in which a patient wasunable to swallow owing to the presence, as he believed, of apill in his throat. The passage of a bougie was immediatelyfollowed by the disappearance of the dysphagia. He agreedwith Dr. StClair Thomson in the importance of making athorough examination of the naso-pharynx and larynx bothvisually and digitally. In the case of a small foreign bodysuch as a fish bone he had found by experience that afterlocalising the part by the patient’s sensations a carefulexamination of that region with a probe would probablyreveal a point of extreme tenderness where the foreign bodywould be found.

After some remarks by Dr. H. J. MACEVOY,Dr. STCLAIR THOMSON, in reply, said he was much

gratified at the reception of his paper, for, as he mentionedin his introductory remarks, he had no new facts or ideas tosubmit. The paper had been the result of an effort in hisown mind to get a clear conception of this affection. In

doing this he feared he had talked all round the subject andhad defined it chiefly by a process of exclusion. The debatehad shown the protean features of hysteria. In his own

experience the majority of patients had been females. Ahollow bougie was doubtless much more comfortable for thepatient and easier to pass, but the rigid tube for diagnosticpurposes gave a good deal more information. If surroundedwith every precaution doubtless the oesophageal bougie couldbe passed without danger, but there could be no doubt thatdangerous accidents with it had happened in the hands ofsome of the most experienced and expert practitioners. Thedysphagia associated with anaesthesia of the larynx, thepharyngismus associated with defective teeth, and the aphagia,described by the President as occurring in infants and aden(id

I subjects, might, he thought, be classified under the headingof reflex dysphagia.

BRADFORD MEDICO-CHIRURGICALSOCIETY.

Exhibition of Cases and Specimens.- Grave An&aelig;mia.-Effects of Frequent and Infrequent Feeding.

A MEETING of this society was held at the Royal Infirmary,Bradford, on Nov. 15th, the President, Dr. BEERY, being inthe chair.

Dr. ROBSON gave a Microscopical Demonstration.Dr. MAJOR showed a series of photographs of a Cretin

under Treatment by Thyroid Extract.Dr. CAMPBELL showed a Liver weighing 109 oz., a very

marked instance of fatty and fibrous degeneration.Dr. KERR showed (1) a specimen of Malignant Disease of

the Larynx removed by Laryngectomy ; and (2) a specimenfrom a case of Lateral Sinus Thrombosis.

Dr. GLADSTONE showed a patient and read notes on acase of Grave An&aelig;mia which had been successfully treatedwith arsenic and general massage. The patient was a boy"thirteen years of age, a newspaper-seller, who had sufferedmuch from privation and neglect. He was admittedto hospital on Oct. 6th, 1897, complaining of shortness ofbreath, cough, and abdominal pain. Examination of thechest showed that the heart’s apex was displaced slightlyoutwards and there was a soft systolic murmur over thewhole cardiac area. The lungs showed nothing abnormal.The urine contained a trace of albumin but no casts.The fundus oculi was normal. At the end of a fortnightthe an&aelig;mia was extreme; h&aelig;moglobin 30 per cent. Fourteendays later the patient was extremely weak and could hardlysit up in bed and his face was white and puffy. The bloodwas examined and was found to contain (Nov. 13th) 990,000red discs per cubic millimetre and there were noticednumerous irregular-sbaped discs. Neuro-retinitis was nowdiscovered. During the preceding three weeks the patienthad been taking iron with small doses of arsenic. This wasnow omitted and salol was given with a view to intestinalantiseptic treatment.’ After a slight inprovement in theblood-count, he again became much worse and on

Dec. 6th was apparently moribund. Blood discs, 624,000;h&aelig;moglobin, 10 per cent. All food was returned.Rectal feeding was now begun. Ten minims of arsenicalsolution were given three times daily, together with generalmassage for twenty minutes daily. On Dec. 13th the patientwas much better and was able to take food. Haemoglobin,20 per cent. ; blood discs, 1,520,000. Retinal h&aelig;morrhageswere observed on Dec. 18th. On Dec. 22nd he had an attackof capillary bronchitis and he became very ill again. lje

steadily improved after. This complication had passed awayand on March 5th, 1898, he was sent to a convalescent home.H&aelig;moglobin, 50 per cent. ; blood discs, 3,090,000. By amistake the patient walked all the way (about five miles) andwas taken in much exhausted ; he soon recovered however.When seen in June the boy had a good colour. Haemoglobin,80 per cent. ; blood discs, 4,600,000, no irregular discs beingseen. There was still a cloud of albumin in the urine. Whenshown to the medical society the patient was apparentlyquite well. The massage had been continued with someintermissions up to Feb. 21st, 1898, when it was no longerthought to be necessary. Dr. Gladstone remarked that afterthe massage the boy seemed to feel comfortable and to berefreshed. It appeared to induce sleep.

Dr. RABAGLIATI read a paper entitled " Some Effects ofFrequent and Infrequent Feeding." He said that he hadhad a considerable amount of experience now in treatingpatients by recommending them to eat twice a dayonly in place of the three, four, five, or even six timesfrequently adopted. He believed that with a few exceptions,due to alcohol, syphilis, heredity, and the like, the mainpredisposing cause of nearly all the illnesses he had been inthe habit of seeing for the last thirty years was too frequentand too abundant feeding. Death from starvation pure andsimple no doubt could occur, and no doubt did occur, but heremembered only one case of it-in a neglected infant. Hereferred then to the exciting causes of disease, the ultimatedifference between them and the predisposing causes con-sisting, he thought, in frequency, as distinguished frominfrequency, of action. Next he referred to the proximatecauses of disease which he would rather call "states" than"causes." There were two, and two only-shrinking and