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sodium iodide solution were employed on the left sidein making this film and no further distension wasattempted as the diagnosis was thereby established.Had more fluid been used it might have had the effectof provoking an attack of retention in the hydro-nephrosis with undesirable consequences. An X raytaken three days after this one showed the sac to beclear of sodium iodide. Large sacs can generally beadequately recognised without fully distending themand it is better to avoid such distension. Fig. 5 showsa stone in a horse-shoe kidney. This discovery ofthe kidney deformity was invaluable as it forthwithbecame evident that the kidney could not be elevatedon to the loin. The plate shows a low-lying, mis-shapen, dilated pelvis, situated abnormally close to themid-line and showing calyces facing inwards. Theureter crosses the lowest calyx. These features areall characteristic of this deformity. Calyces lying tothe inner side of the ureter always suggest a horse-shoe kidney.

Duplication of the Ureter and Renal Pell’is.Fig. 6 shows duplication of the ureter and

renal pelvis. Catheters occupy each ureter. Thispelvis is true to the invariable rule that the upperpelvis is smaller, often rudimentary, and has fewcalyces, whilst the lower is more complete, larger, andhas better formed calyces. Congenitally ill-formedorgans are quite common; they occur in about 3 percent. of bodies. They are, however, found with unduefrequency in urological practice as their abnormalityappears to render them disproportionately susceptibleto disease.

Renal Neoplasm.In Fig. 7 a large renal neoplasm has developed

in the upper pole of the kidney. The pelvisoccupies a position opposite to the iliac crest, havingbeen displaced downwards by the overlying growth.The upper and middle calyces and the upper part ofthe pelvis have been occupied by the neoplasm and aremissing on the pyelogram. Deformity in renal growthsvaries according to the site of the growth, for instance,if the lower pole is involved it is the lower calyx whichfirst disappears. The kidney then retains its normalposition, but the ureter may be displaced inwards bythe tumour.

Congenital Cystic Disease.In congenital cystic disease (Fig. 8) the pyelo-

graphic deformity has much in common with thatcaused by renal growth and the two may easily beconfounded. The former disease, however, is alwaysbilateral, so that cases of difficulty may be resolved bya double pyelogram, as also by renal function tests.In this figure, as in Fig. 6, a great enlargement ofthe upper pole, this time by cyst formation, hasdepressed the pelvis to the level of the iliac crest.Note how it has been deformed by the encroach-ments of cysts on its cavity and that one limb stretchesout beyond its recognised bounds to serve parenchyma

which has been dislocated by the cysts.

Conclusion.For years we have been able to study separate renal

function by various excretion tests and to collect theurine from each individual kidnev and examine itsorganic and inorganic content. It is odd that theanatomical study of the pelvis of the kidney shouldhave lagged behind these physiological and patho-logical studies, but now by pyelography we have madegood the defect. The renal function and chemicaltests will tell that a kidney is wholly or in part outof action but may omit to say why. The latter notinfrequently rectifies this omission. Renal functiontesting and pyelography are mutually inter-dependent ; they are sister examinations and of thesethe younger bids fair to win a place’not less importantthan that held honourably through many years bythe elder.

J. B. MACALPINE, F.R.C.S. Eng.,Honorary Surgeon, Salford Royal Hospital.

Special Articles.INTER-STATE POST-GRADUATE

ASSEMBLY OF NORTH AMERICA.VISIT TO LONDON, MAY 27TH-29TH, 1929.

INAUGURAL ADDRESS.

THE session on Monday, May 27th, was opened bySir JOHN BLAND-SUTTON who gave a short addressof welcome to the delegates at the house of theRoyal Society of Medicine.

It is ordained, he said, that I should welcome themembers of this Assembly. In the autumn of 1927I was present at the meeting in Kansas City, tookpart in the proceedings, and realised the importanceof this great organisation. There never was a timewhen it was so necessary for medical men in activepractice to keep themselves informed of the progressin the arts and sciences ancillary to medicine. Theproud position of surgery is a consequence of dis-coveries in chemistry which supplied the means forinducing anaesthesia-the conquest of pain, whichwas the starting-point of modern surgery. Theconquest of sepsis followed and helped to raisesurgery from a craft to a beneficent art.Improvements in the microscope enabled men to

see the minute organisms which provoke diseasein plants and animals, and revealed the astonishingfact that germs of disease and death lie hid in thesmallest of living things and are conveyed to plantsand animals by unsuspected carriers. The inventionof clever instruments laid the foundation of specialties.Two of them were invented by non-medical men: thelaryngoscope by a singer, Manuel Garcia ; and theophthalmoscope by a physiologist, Helmholtz. Itis recorded that when von Graefe saw the fundus ofthe living human eye with its optic disc and blood-vessels, he flushed with excitement and exclaimed" Helmholtz has unfolded for us a new world." Ispent a session in Arlt’s eye klinik at Vienna in 1881to acquire facility in using the ophthalmoscope.I foresaw that it would render valuable aid in thediagnosis of disease elsewhere than in the eye.The incandescent lamp is a most useful clinical

instrument. Any hollow organ in man’s body can beilluminated by it. When watching a colleague rescuesome false teeth from a woman’s gullet with the aidof an cesophagoscope I suggested to him that theinstrument required to be used by a surgeon withthe instinct of a sword swallower and the eye of ahawk! The incandescent lamp was followed byX rays which render living bodies diaphanous andtransformed the methods of dealing with brokenbones. No surgeon who values his reputation andthe patient’s welfare trusts to tactile impressions inthe detection of fractures. An X ray picture revealssuch injuries to patients, friends, and solicitors aswell as to doctors !

Our debt to optical glass is very great ; photographyrequires flawless lenses. The progress of radiographyleads us to believe that it may become possible tomake cell-elements visible in human bodies as in thefamiliar experiment of watching red corpuscleswhirling through the capillaries in the web of a

frog’s foot. When I was a boy microscopists wrangledabout the shape of these corpuscles. To-day clinicalobservers describe almost as many varieties oferythrocytes as there are races of men.

Metchnikoff, a Russian biologist, discovered thedefensive powers of leucocytes. His wife hasdescribed the simple way in which this discovery wasmade. Metchnikoff was at Messina and had beenwatching the mobile cells in the body of transparentstar-fish larva, and the idea occurred to him that suchcells might serve in the defence of the organismagainst intruders. To test this idea he took some-thorns from a rose tree and introduced them at night

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under the skin of some beautiful star-fish larvse—theselarvas are as transparent as water. " In the morningthe thorns were surrounded by mobile cells as is tobe observed in a man who runs a splinter in hisfinger." This simple experiment laid the foundation ofphagocytosis, a theory to the development of whichMetchnikoff devoted 25 years of his life. His firstpaper on phagocytosis was written in Odessa in 1883.He propounded his theory to Claus and other col-leagues at Vienna, and asked a Greek equivalent fordevouring cells. The name phagocyte was suggested,and adopted.

In 1886 at the Royal College of Surgeons of EnglandI delivered a lecture on Inflammation as a ZoologicalProcess, and in the light of Metchnikoff’s discoveryI ventured to describe the action of leucocytes inrelation to bacteria as amoebic warfare. In this rooma year ago Dr. Canti showed an astounding film, acombat between phagocytes and bacteria. We mayhope some day, with the help of X rays and themicroscope, to detect the exotic fauna of the bloodin living patients and watch trypanosomes, spiro-chsetes, fiarrie, and the like disporting in the bloodstream, jostling erythrocytes like minnows andtadpoles in a brook. Young guinea-worms have beendetected migrating through the subcutaneous tissuelike eels wriggling in the grass seeking a pond.

It is an advantage, Sir John concluded, to meetannually and hear masters of the craft expound theirmethods. Operative procedures change so rapidlythat text-books on surgery become like railway time-tables, useful only for a season. The meeting of theInter-State Assembly keeps its members in touchwith the almost kaleidoscope changes in everydepartment of practice.

Dr. JAMES COLLIER then gave an address on

EPILEPSY.

A number of conditions, such as rickets and cranialinjury, might, he said, give rise to a lifelong epilepsyindistinguishable from true epilepsy and manifestingevery known phenomenon of epilepsy proper. Not Ione of these causes, however, invariably producedthese convulsions, so that ’there must be some otherdetermining factor. This was connected with thechemical processes of the body ; all epilepsy was adisease of metabolism. The metabolic error mightexist in birds, in all mammals and in man. There werethree classes of individuals : (1) those in whom no sortof aggravation would cause epileptic manifestations ;(2) those who would develop them more or less readilyfrom any of the known causes, the potentially epileptic;and (3) those who developed epileptic manifestationsspontaneously. The error was most likely to developin infancy and childhood and least likely at the zenithof life ; it might be now present, now absent, andcould be removed by the metabolism of a secondindividual, as when the epileptic woman had noseizures during her pregnancy. It was very difficultindeed to make an animal or man epileptic by injuringthe brain unless the individual were potentiallyepileptic to begin with. Only 4-10 per cent. of severecerebral injuries during the war had resulted inepilepsy. Recent experiments had shown that one-seventh of the dose of wormwood oil required to causeconvulsions in normal cats was sufficient to producethem in cats whose brains had previously been damaged,and that a minimal dose would produce strictlylocalised convulsions corresponding with a cerebralinjury. There had been six cases of pre-frontal tumourat the National Hospital, Queen-square, ending instatus epilepticus as sole symptom.

The stability of the hydrogen-hydroxyl ratio variedin different people, and convulsions had long beenknown to result from alkalosis. Occasionally patientsbeing treated with alkalis would pass suddenly intostatus epilepticus with very high blood-urea but withnormal chloride content of the cerebro-spinal fluid, thusexcluding ursemia. Severe tetany-which was closely- allied to epilepsy-might also occur in the course of- alkali treatment. Epilepsy therefore might be pro-

duced by alkalosis, and if alkalosis were artificiallyinduced in a series of epileptics of all kinds by hyper-ventilation, 60-80 per cent. of them would in half aminute have a convulsion, probably a severe one.Thus even temporary alkalosis was a potent excitingcause. In the same way tetany could be provoked atwill by hyper-ventilation in some subjects. At themoment of onset of the fit the brain became blanched,flushing again with the convulsion. This must meana sudden drop in blood pressure followed by a rise.The initial drop might account for the swiftness of theonset. These facts being established, the convulsiveelement might be regarded as a response to the gravethreat to the organism constituted by alkalosis andfall of blood pressure ; it offered a powerful check toboth, and if it failed it was repeated. If even statusepilepticus was unavailing, Nature abandoned thestruggle and the patient, though free from convulsionsand perfectly conscious, slowly died with increasingpulse, temperature, and blood-urea.

Migraine was also very like and might alternatewith epilepsy, and intermediate conditions occurred.Syncope was a most mysterious and interesting event;and there was a sudden or slow drop in blood pressureassociated with a real convulsion, however small. Themost valuable treatments, both for migraine andsyncope, were those used in epilepsy. Dr Collierdescribed a case he had recently seen which hadconvinced him that the epileptic attack might beinitiated in other parts of the brain besides the cortex.Epileptic manifestations were nowadays regarded fromthe point of view of loss of function ; the " gunpowderand match " theory was gone for ever. The besttreatment was a perfectly normal life ; education,work, and pleasure should never be stopped. The" epileptic diet" might do more harm than good.Extensive biochemical research was needed.

Mr. VICTOR BONNEY spoke onGY1VCOLOGY.

He advocated myomectomy for fibroids, emphasisingthe reasons why the uterus should be spared ifpossible. The number of fibroids did not matter atall, but those on the front were much easier to dealwith than those on the posterior wall. It wasessential that the incision should be single and anterior.Posterior fibroids could be removed through an

anterior incision by sidetracking through the muscleor via the cavity. Often the capsule of a largeposterior one could be pulled right over the funduslike a hood and sutured anteriorly. The reason forthe anterior scar was the grave risk of adhesion tointestine. Oozing into the utero-vesical pouch didnot matter. If a posterior wound was unavoidable,the risk might be lessened by stitching the colon or themesosalpinx lightly to the wound. No two cases wereexactly the same and each called for ingenuity.The great danger of the past—haemorrhage—had beenobviated by the special clamp he had devised toencircle both urine arteries above the broad ligaments.

In speaking of carcinoma of the cervix, Mr. Bonneyreferred to the report of his paper published in THELANCET last week (p. 1090), and emphasised the factthat more lives would be saved by surgery combinedwith radium than by radium alone, provided theoperation were properly performed. It was a specialistoperation, but any surgeon could learn to do it.When investigating sterility, he said, he never

inflated tubes in the consulting-room, partly because ofthe possibility of error when the patient was consciousand restless, and partly because he thought a womanshould not be told she had closed tubes unless some-thing could be done about it. He was not sufficientlyconvinced that inflation alone would promote concep-tion. He demonstrated the apparatus he used, whichhad never failed him. If one squeeze of the bulbfailed to pass air through the tubes he packed the tubein the cervix with gauze and opened the abdomen.A nurse then squeezed the bulb and he watched howfar the air went. Air could also be blown throughthe abdominal ostium, and if it passed down into the

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uterus the manometer on the cervical tube wouldrecord it even if it were inaudible. Retroversion onlycaused sterility through kinking the tubes ; kinksmight be very hard to find. If the abdominal ostiumonly were closed he slit it up, avoiding ligatures ifpossible. If the uterine ostium were blocked he cut thetube right off, snipped away until air would passthrough, and then split the uterus across its fundusand sewed the tube in. It was not possible to passanything into the uterus from the abdominal ostiumand be sure of avoiding a false channel.For salpingitis he advocated immediate operation

and had never lost an acute case. Delay might meaninvolvement of the ovaries and an indefinite period ofillness, as well as the danger of delaying an acuteappendix or carcinoma through mistaken diagnosis. Anacute appendix was operated upon immediately, whynot a tube ? He found that the people who opposedoperation had never tried it. If the tube were knottywith blobs of pus on it, it should be removed ; if softand oozing a little pus only it should be drained andperhaps the ostium slit up. Only a small proportionof uteri gave subsequent trouble, and it was timeenough to do a hysterectomy when the need arose.The less that was done in the acute stage the better.He disapproved of a purely vaginal operation, andthought a vaginal drain in addition to an abdominalone was superfluous.

Dr. H. C. SEMON spoke onSOME PATHS OF PROGRESS IN DERMATOLOGY.

The jungle of eczema, he said, had undergoneconsiderable clearance. The exogenous type was

usually weeping ; the superficial epidermal cells onlywere activated. When the irritant was endogenousevery element in the cutaneous structure became abattlefield between the antigen and the specificcutaneous antibodies, and all the appendages of theskin might be involved. The difficulty usually lay inlocalising the septic focus. In erythema multiformeand nodosum it was usually a haemolytic streptococcus iin the buccal cavity, and apical abscesses associated Iwith intestinal stasis were the most common cause ofacne varioliformis and chronic furunculosis. X rays-especially negative reports-should not be trusted toomuch in suspected dental abscess. The possibilitiesof the tonsil, sinuses, and intestines should not beforgotten. Urticaria usually arose from an alteredbacterial content of the intestine, and might be asymptom of grave metabolic disturbance, as mightalso pruritus.X rays as a form of treatment were a two-edged

sword, only to be used by a skilled technician underthe constant observation of the dermatologist. Theresults of over-dosage were grave. While theindications were still somewhat vague, the contra-indications were now fairly definite. X rays shouldnever be used in lupus, psoriasis, or hypertrichosis. andwith the greatest caution only in pruritus of the geni-tals. There was no individual idiosyncrasy to X rays. Insunlight and its artificial substitutes we had an aidwhich had no real dangers except for the possibility oflighting up a hidden tuberculous focus-and in whichthe patient was the best judge of overdosage. Lupusvulgaris melted like the proverbial snow beforeproper heliotherapy in the Swiss Alps, but even thelamp substitutes available in this country had excellentresults in all kinds of tuberculides, many septic lesions,including acne, boils, and carbuncles, and in chronicintractable sycosis. Vaccines were disappointing,and non-specific protein therapy, especially milkpreparations, were just as useful as streptococcalvaccines or sera and were quite harmless. Chronicurticaria and dermatitis herpetiformis respondedparticularly well to autohaemotherapy, which wasalso useful for boils, pruritus, and obstinate eczema.For resistant cases more violent shock therapy in thefrom of TAB vaccine could be tried. Septic or

allergising foci should always be removed beforevaccines were used. Intravenous sanocrysin or othergold salts had proved a valuable new weapon for lupus

erythematosus ; the patient should be watched fortoxic effects. In psoriasis there had been no advancesince the days of Hebra, and Dr. Semon, after tryingall the treatments advocated, had returned toinunctions of chrysarobin. Psoriasis was the mostformidable problem and most outstanding reproach ofmodern dermatology. For extensive seborrhaeiceruptions, psoriasis, and eczema, for which no causecould be found, the elimination treatment was use-ful, especially for stout middle-aged men who werefond of their port. Dermatology was tending moreand more to return to the fold of general medicine.

On May 28th the chair was taken by Sir JoHNBROADBENT, and Mr. J. E. H. ROBERTS spoke on

INTRATHORACIC SURGERY.

Collapse of the lung in bronchiectasis and pulmonarytuberculosis, he said, could be procured in two stages 1. By division of the phrenic nerve in the neck. Thiswas always done before a thoracoplasty as it improvedthe patient’s condition and gave an idea of what theeffects of collapse would be. The diaphragm roseabout two and a half inches and compressed thelower lobe very considerably. 2. By extrapleuralparavertebral thoracoplasty, in which the ribs shouldbe removed from the tip of the transverse processes.Partial thoracoplasty had been given up. Collapsewas produced in three ways : the anterior part of theribs was pushed back when the posterior part wasremoved, the anterior ends of the upper ribs droppedand the lowered ribs buckled down. Local anaesthesia.was not advisable.for injecting the nerves caused ratherthan prevented post-operative pain, and shock couldbe obviated by attention to haemostasis, carefulpreparation (including administration of salines,glucose, and morphine), and above all by carefulhandling. There was no need to hurry the operationunder nitrous oxide and oxygen ; 25 minutes was anaverage time. Mr. Roberts showed a series of X raysand photographs of illustrative cases, many of themshowing how mistaken diagnoses might be made, andthe importance of a preliminary bronchoscopy to makesure that the lung was not bound down by granulationtissue. -Bronchoscopy, creosote chamber, and inversionmake all palliatives and should always be tried beforecollapse therapy.

In Mr. Roberts’s view collapse therapy was used toolittle and too late, The phrenic nerve should bedivided as soon as bronchiectasis was diagnosed in onelobe. Abdominal surgery had reached its highstandard of results because the surgeon operated inthe early stages.

Intrathoracic tumours often went undiagnosed.An accurate history was the first essential, followed bythorough physical examination, including search forglands and for the effects of pressure on nerves. Thenext process was radiography in antero-posterior, truelateral, and oblique positions, with screen examination.Sputum tests came fourth and blood tests fifthin importance. The hydatid skin reaction andbronchoscopy followed, and when an artificialpneumothorax had been induced thoracoscopy mightteach a good deal. Biopsy and exploratory operationcompleted the list. Mr. Roberts then showed slidesillustrating these points. X rays, he pointed out, byno means always gave the correct diagnosis. Fibroticcalcified breasts, subpleural tuberculous abscess,haematoma, and tumours of the ribs projecting inwardsmight all simulate intrathoracic tumour under X rays.Fibromas consisted of fibrous tissue and a littleunstriped muscle ; they caused death by pressure andwere removable. Dermoids might be mistaken fortuberculosis ; their usual position was in the anterioror middle mediastinum. Mr. Roberts had had five casesof traumatic inclusion dermoid-pieces of metal or bonedriven into the lung by war wounds had been enclosedin a capsule lined by squamous epithelium. In thediagnosis of hydatid cyst eosinophilia was unreliable ;tests for a specific antigen were helpful but uncertain.Fifty per cent. of aneurysms did not pulsate whenwatched on the screen. The operative chances in

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intrathoracic malignant growths were very poor;the future lay with radium therapy.

Sir WILLIAM WILLCOx spoke onCHRONIC RHEUMATISM AND THE TOXaeMIC FACTOR.

It was generally admitted, he said, that most formsof rheumatism were caused by toxaemia. Physicianswere constantly dealing with diseases of which thecause was still to seek, and he had been trying tofind the toxeemic cause of several common conditions." Focal sepsis " was not a satisfactory term, becausethe infection might be more widespread than a focus ;it was often a " surface sepsis " of an entire mucousmembrane. He attached great importance to sepsisand believed in starting treatment with a cleanslate. Every patient should be systematicallysearched. The mouth should be X rayed, as an

unerupted tooth might be septic. He showed a

series of photographs illustrating the various con-

ditions that might affect the teeth and jaws. An

expert should investigate the tonsils, glands, andsinuses. The frequency of infection of nasal sinusesin patients with no localising symptoms was onlyjust becoming recognised. An X ray was essential,since transillumination sometimes failed to revealthe disorder. In doubtful cases puncture could beperformed without any risk. Infected antra wereparticularly common in diabetics. The bowel, gall-bladder, appendix, and urogenital tract should alsobe investigated bacteriologically and radiologicallyin obscure cases. The treatment of disease wasreally a problem in immunity which was a verydelicate balance. Removal of a focus of infectiondid not produce immediate cure because the infectionhad usually spread beyond it. Symbiosis played animportant part, especially in recurrent boils. If apatient with phthisis had septic teeth his phthisiswas not likely to improve. Sir William Willcox thenrecounted some cases showing how systematicsearch for infection repaid the physician in difficultcases. A para-enteric infection (i.e., by one of theless common organisms of the typhoid group) was ,,not uncommon in arthritis. In early cases of diabetesremoval of the sepsis caused remarkable improve-ment and the patients could go back to practicallynormal diet; in long-standing cases there would beonly an improvement in the carbohydrate tolerance.

In the course of the morning Dr. R. G. CANTI

Ishowed his cinematograph film.

MEDICINE AND THE LAW.

Patient in Public .Ward: Successful Claim forOperation Fee.

IF a patient occupies a bed in the public ward of ahospital, can the honorary physician to the hospitalclaim a fee for performing an operation on the patient ?His honour Judge Crawford, before whom thequestion came on May 13th in the Watford CountyCourt, answered it in the affirmative in the followingcircumstances. Dr. John Alexander McKinnon, ofPark-drive, Wembley, sued Mr. Thomas Cox for25 guineas for professional services rendered. Dr.McKinnon stated in evidence that he had been calledin by Dr. Elizabeth Jenkins to give his opinion on thecondition of Mrs. Cox who was suffering from aninternal complaint; he found an operation to benecessary ; the patient was taken to the WembleyCottage Hospital, and the operation-a matter of lifeand death-was entirely successful. Dr. McKinnonexplained that, owing to the existence of a septic casein the private ward, it was necessary to place Mrs. Coxin the public ward ; he gave his services gratuitouslyto the sick poor in the public ward, but he did notregard Mrs. Cox as a person needing charity. Headded that when he discussed the question of feeswith Mr. Cox, the latter said that, although not a rich

man, he did not want charity. Mr. Cox, the defendant,.said he was a railway employee and a member of the-railway hospital fund, which entitled his wife andhimself to free hospital treatment. He denied that-he ever engaged the services of Dr. McKinnon, orthat he had ever seen him before. The Secretary ofthe Wembley Hospital gave evidence that Mrs. Coxwas throughout regarded as a public patient, andthat the hospital received two guineas a week inrespect of her treatment. Dr. R. H. Martin, chairmanof the medical committee of the hospital, said that-the rule of the hospital provided that a patient in thepublic ward should receive free treatment. Thejudge had presumably to address himself to the"question of contract. Had Mr. Cox employed Dr.-McKinnon ? If so, was there any reason to excludethe ordinary principle of law that a professional manexercises his skill for reasonable reward ? His honour,accepting (it would seem) the plaintiff’s rather thanthe defendant’s evidence on the question of employ--ment, decided that Mr. Cox had employed DrMcKinnon. Judgment was given accordingly for theplaintiff for the amount claimed and costs. Thejudge observed that he thought Dr. McKinnon had,broken the hospital rules by charging a fee, but thiswas a matter for the hospital authorities to settle.

"Neurasthenic" in Poor-law Infirmary.A Coroner’s jury at the Steyning Union Poor-law

institution, on May 24th, in recording its verdict of.suicide while temporarily insane, expressed theopinion that the union infirmary was not a suitableplace for a typical neurasthenic case where constantobservation was necessary. The jury had been called.by the coroner, Mr. F. W. Butler, because he thoughtthe circumstances rather unusual. A man, aged 25, a..market garden labourer, of Sompting, was taken tothe infirmary in June of last year, suffering fromneurasthenia. Unhappy with his surroundings hewent home after ten days, and was afterwards more--or less an invalid. In February this year he was.repeatedly asking his mother to end his life, and ashe became beyond control it was proposed to again.take him to the infirmary. He declared he would-never go there, and taking a clothes-line, barricaded-himself in his bedroom. The police were telephoned.for, and when the young man saw them approaching.the cottage he jumped out of the window with theend of the rope attached to his neck. The police cuthim down, and he was charged at Worthing police--court with attempted suicide, and was bound over oncondition that he entered the Steyning Union infir--mary. He was readmitted to the institution on Maylstand for a time had a special day and night attendant.He soon became normal, and was allowed in the-general ward. On May 21st he died from injuriescaused by falling from a balcony. Dr. G. F. L.Mitcheson said the man was neurasthenic, but in, Lorder to certify him he would have had to be able toput down queer things he had seen or done that he(Dr. Mitcheson) had himself witnessed. It was notsufficient for him to be told anything. The coroner" You did not feel you could certify him as insane ?

,,-

Dr. Mitcheson : " The Commissioners would notaccept it." Dr. Mitcheson said in his opinion the-infirmary was not a fit and proper place to send a case.of this description. It was often done, but the con--ditions were not ideal at all. Acute medical casesshould not be mixed up with neurasthenics. Dr.Mitcheson agreed that it would have been better tohave sent the man to Portsmouth on remand, and tohave asked the prison doctor to keep him underobservation. The coroner said it always seemed tohim that if a man attempted his life once and wasstill ill, he might do so again. It was very questionableif an institution, such as a poor-law infirmary, whichwas not a lunatic asylum-although he believed theyhad a considerable number of mental defectives there-was a suitable place for the care of such a case asthey had been inquiring into, where they had notthe means, in fact, to take care and look afterssuch cases.