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made to interest the patient in his treatment, the" mental effort " on his part being an all-importantfactor. In children the inner side of the sole and heelof the boots should be wedged up, the inner side ofthe " upper

" should be stiffened. In adults electricaltreatment often gave marked relief of pain, but inaddition in these cases " sole-plates " were usuallynecessary. These plates should be made for eachindividual, plaster casts being taken and carved upsuitably after Trethowan’s method, which Mr.Fairbank described and demonstrated in detail. Inchildren contracture of the calf muscles was anoccasional complication. This could be overcome inmilder cases by stretching, while tenotomy of thetendo Achillis might be necessary in the severer

forms. Osteo-chondritis of the heel epiphysis andthat of the tubercle of the navicular were among thecauses of painful flat-foot in children. The pathologyof the condition was similar to that of Schlatter’sknee. Kohler’s disease (isolated disease of the navicu-lar) was another cause of pain in children. Lastly,Mr. Fairbank drew attention to the frequent develop- ’’

ment of flat-foot after convalescence from illnessesnecessitating prolonged confinement to bed, theabsence of reflex postural tone accounting for this.

Mr. W. McADAM EccLES said that all infants wereborn with poorly-developed longitudinal arches, thearch developing as the child grew. Flat-foot in childrenwas, therefore, more often due to non-development ofthe arch than to subsequent flattening. He agreedwith Mr. Fairbank as to the efficacy of electricaltreatment and as to the frequent development of flat-foot during convalescence from long illnesses. He hadseen a number of cases of epiphysitis of the proximalend of the first metatarsal bone in lads about 12 yearsof age, the subjects of flat-foot.

SOUTH-WEST LONDON MEDICAL SOCIETY.

A MEETING of this Society was held at the Boling-broke Hospital on Feb. 15th, Dr. E. J. PRITCHARD,the President, being in the chair, when Mr. W. H. C.ROMANis gave an address on

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’l’he ,5 urical Aspect of Gastric Ulcers.He said that gastric ulcers may be acute and chronic,and these might almost be called the woman’s andthe man’s ulcers. The acute ulcer is rare and isnot as a rule a surgical disease, as it should be curedby efficient medical treatment. Chronic gastriculcer is far more serious and difficult to treat. Itscause was not definitely known, but it was most

probable that in the majority of cases there was aprimary infective focus somewhere, when success intreatment depended on the removal of this primaryfocus in addition to the treatment of the ulcer.Recurrences after medical treatment were frequent

and a recurrence of symptoms with the history of aprevious attack must be regarded as an indication forsurgical measures, as was also a severe haemorrhage.The operation should be performed as soon as thehaemorrhage had stopped, provided the patient wasin a condition to stand it. Haemorrhage from thestomach in a male had a more serious significance thanthe same symptom in a woman. Mr. Romanis saidthat the nature of the operation to be performed mustdepend on the nature and situation of the ulcer. Forulcers in the pylorus or near to it gastro-enterostomywas the operation of election, the risk being negligibleand the results excellent. For ulcers in the centralportion of the stomach and on the lesser curvature,gastro-enterostomy was not so useful, and hereprobably partial gastrectomy gave the best results.The various methods of local excision, though thereis, of course, a very definite mortality attached to it.Those rare ulcers far away to the left-hand side of thestomach were best treated by D. C. Balfour’s operationof excision with the cautery suture and gastro-enterostomy. Adhesions of the ulcer to the neigh-bouring organs, such as the liver and pancreas, were

indications in favour of partial gastrectomy if possible.For the first four months after an operation thepatient had to be strictly dieted, to abstain fromoverwork, and to take great care of the alimentarycanal.

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LONDON ASSOCIATION OF THE MEDICALWOMEN’S FEDERATION.

A MEETING of this Association was held on Feb. 4that the Elizabeth Garrett Anderson Hospital, when thePresident, Dr. LouisA MARTINDALE, was in the chair.

Prof. LOUISE McILROY spoke onSome Complicat-ions of Pregnancy and their Influence

upon Infant Alortaliiy.She pointed out that the spread of antenatal clinicwork has opened up a possibility of dealing with suchcomplications at an early stage ; general medicaltreatment should obviate many of those complica-tions due to toxaemia and similar conditions. Sheregretted the fact that as yet there exists no systemof training midwives in antenatal work, and urgedthat more facilities for obtaining laboratory reports onspecimens should be provided. She then discussed twotypes of complications of pregnancy: (a) contractedpelvis, and (b) toxsemic conditions and their treat-ment. In dealing with the treatment of pelvic con-traction stress was laid upon the necessity for ascer-taining the relationship of the head to the pelvisrather than the dependence upon actual measurementof the pelvis itself. Prof. McIlroy said that inductionwas seldom advisable before the thirty-sixth week inthe interests of the child. Caesarean section was still .

an operation associated with danger to the mother,and should not be lightly undertaken. The future ofobstetrics lay in antenatal supervision, and by thismeans many of the diseases of pregnancy could beprevented, and also much of the operative interferenceat the time of labour. The application of forceps wasassociated with risks to the child’s future welfare,except in cases of flat pelves where the head wasretained in the cavity of the pelvis owing to defectiveexpulsive forces. The toxaemias of pregnancy includedabortions, premature death of the foetus, and hoemor-rhages. Accidental haemorrhage would in time beprevented by careful antenatal supervision; post-partum haemorrhage also owed its origin in some casesto a condition of toxaemia. The early phenomena ofpregnancy, such as vomiting, were not physiologicalconditions, but were due to the retention of toxins andto the upsetting of the balance of the internal secretoryorgans, their adjustment being affected by the newlyintroduced ovurn, which acted temporarily as an internalsecretory organ. More laboratory work was requiredto aid clinical diagnosis and prognosis in cases oftoxaemia.

In the discussion which followed Dr. F. HUXLEY,.Miss M. BASDEN, Miss E. BOLTON, Lady BARRETT, LadyBRISCOE, the PRESIDENT, and others took part.

LIVERPOOL MEDICAL INSTITUTION.

A MEETING was held on Feb. 2nd, with Dr. J. HILLABRAM, the President, in the ’chair.

Dr. C. 0. STALLYBRASS described a case of ExanthernSubitum, drawing attention to the clinical picture andepidemiology.

Dr. H. S. PEMBERTON read a short paper on

Diet w 11%ephritis.He contended that the maintenance of adequatenutrition should always be recognised as one principlein the management of chronic renal disease. Thequestion of diet might be considered from two aspects :receptive and eliminating. There were certain changesin the receptive side (gastro-intestinal mucosa andportal system) often associated with chronic nephritis,and unless these were recognised, the diet might proveinadequate from non-renal causes. Changes on the

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eliminating side were often directly associated withrenal disease, the degree of which might be determinedby clinical or biochemical means. The fate of knowndiets might in part be investigated by means of therenal test-meal, combined with estimations of blood-urea and total nitrogen content of the urino. Manyrenal cases--irrespective of type-were still deprivedof proteins. Those which needed proteins appearedto be: (1) cases of albuminuria without retention ofnitrogen ; (2) cases with or without albuminuria whichretained nitrogen, but did not show an elevation of thenormal blood-urea content ; (3) certain anomalouscases where the amount of protein which could betolerated was only determinable by trial. Proteinswould seem inadvisable in cases which showed highblood-urea concentrations, and hence one of the mostgenerally useful controls on dietetic management wasperiodic estimation of the blood-urea content.

Mr. K. W. MONSARRAT read a paper entitledThe Peptic Ulcer.

He reviewed records of the 48 cases on which hehad operated during 1921, of which 41 were men and7 women. In 34 instances the ulceration was gastric,in 8 duodenal, and in 6 jejunal. 25 of these cases hadbeen treated by partial gastrectomy and to the indica-tions for this operation Mr. Monsarrat particularlydirected attention. There had been no mortalityamong the cases under his care, and he considered thatthe operation was well borne. Certain cases were

suitable for sleeve resection, but for the greater numberof inveterate ulcers the Polya operation was the bestprocedure. He preferred the posterior Polya operationand had not met with the stenosis which had led othersurgeons to prefer the anterior operation. He discussedthe relations between functional disturbances of thepyloric mechanism and the incidence of ulcers. Heconsidered that the basal condition of the aetiologyof ulcer was the disturbance in the normal correlationbetween gastric and pancreatic secretion.

BRISTOL MEDICO-CHIRURGICAL SOCIETY.

A MEETING of this Society was held on Feb. 8th,with Mr. CYRIL H. WALKER, the President, in thechair, when a discussion on the

Treatment of Fractureswas opened by Mr. HEY GROVES, who confined hisremarks chiefly to consideration of the role of X raysin the diagnosis and treatment of fractures, and tothe classification of cases suitable for different types,of treatment. He urged that every case of seriousinjury should be submitted to X ray examination atthe earliest possible moment, in order to detect thepresence of a fracture where it might otherwise beoverlooked, and to recognise the exact nature of thefracture in order to determine both treatment andprognosis. The system in common practice of treatingcases of injury for several weeks without accuratediagnosis by X rays, and of employing the latter onlywhen matters had evidently gone wrong, was stronglycondemned by Mr. Hey Groves on the grounds thatit led to irreparable damage of function, and laid thepractitioner open to serious legal liability. In con-sidering the classification of fractures with a view totreatment he suggested three great classes : first,those in which a very -simple type of treatment wassufficient, this class being made up chiefly of children,and adults with fractures with little or no displace-ment ; secondly, those cases in which a good functionalresult could never be expected-for example, in aged,infirm, or lunatic patients, in whom it was wise to becontent with the simplest methods of treatment; andthirdly, there remained the great class of fractures withmarked displacement in vigorous adults, where a

rapid restoration of function ought to be the objectaimed at. In the attainment of this object the mostuniversally reliable method was some form of traction,and Mr. Hey Groves then proceeded to demonstratehow this could be carried out by means of such con-trivances as Thomas’s splint, Pearson’s bed, and hisown cradle-splints with callipers or transfixion pins.

Mr. R. G. P. LANSDOWN spoke of the advantages ofa special fracture department, on the ground thatsuch a department would raise the general standardof knowledge of the subject. In favour of thisargument he quoted the experience of the war.

which had taught surgeons to segregate their cases offracture for the sake of enhancing the efficiency oftreatment. The ancillary services of massage,electro-therapy, and physical exercise were alsobetter organised if they were coordinated under onedirector. Finally, such concentration made forimprovement in the teaching offered to students.

Dr. J. J. S. LUCAS spoke of the difficulties attendingthe treatment of fractures in general practice. Theview that skiagrams should be taken in every case ofpossible fracture was difficult to apply in practicebecause of the economic factor. He urged someprovision for the middle-class patient who could noteasily pay the full fee for a skiagram, but on the otherhand objected to accepting gratuitous services. Forsuch patients, also, long courses of massage weredifficult to arrange, and he found it advisable to leta skilled masseuse initiate the course, completing itby directing some relative of the patient how tofollow on the treatment.

Mr. HUBERT CHITTY gave some account of fracturesof the lower end of the humerus in children, which,he said, were usually due to a fall on the hand andinvolved a separation of the lower epiphysis of thehumerus. He described the chief clinical featuresand dwelt on the risk of ischaemic paralysis involvedby faulty correction. Massage should be begun early,but movements, both active and passive, deferred tilllater. ’

Mr. CLIFFORD A. MOORE said that cases should beselected for operation with the greatest care, sincethere was a certain inevitable risk of sepsis, partly dueto the forcible manipulations requisite in a majorityof cases. The operative treatment of fractures was amatter for specially skilled surgeons. ,

Mr. W. J. GREER deprecated the use of thefluorescent screen; skiagrams should always betaken. In only about 1 per cent. of fractures of longbones did he find open operation necessary. Hecondemned unreservedly the use of Liston’s splintand plaster-of Paris, and spoke with enthusiasm ofLambotte’s technique.

Mr. HEY GROVES replied.

WEST KENT MEDICO-CHIRURGICAL SOCIETY,

A MEETING of this Society was held in the MillerGeneral Hospital, Greenwich, on Feb. 10th, withDr. C. T. T. COMBER in the chair.

Dr. C. 0. HAWTHORNE gave an address on

Some Pulse-Tracings and Their 1ll eanings.He said that he preferred the terms sphygmometerreadings and sphygmograph tracings to the use ofthe term blood pressure. The sphygmometer gave thepressure required to obliterate the brachial pulse,whilst the sphygmograph showed whether the pressurewas well or ill sustained. He showed tracings frombooks labelled high blood pressure and low bloodpressure, and tracings from his own cases whichcontroverted these ideas, suggesting that the sphygmo-graph does not give proper conception of what thesphygmometer reading will be. He thought the tidalwave, shown in tracings with pressure well sustained,was due to the inertia of the button of the instrument,comparing it to a pea on the inside of a tambourine,which, when nicked, gave a greater excursion than themembrane. He said that if the pressure is sustainedthe button falls on the artery before it has contractedand thus shows a wave. If the artery has contractedearlier, no wave appears. Dr. Hawthorne agreedthat the dicrotic wave was due to the closure of theaortic valves. There was no change in the peripheralcirculation in some cardiac diseases if compensation wasadequate, and so nothing was shown by the sphygmo-graph. In his opinion digitalis did not raise the blood