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enlarged. A surgeon who saw the case used a short trocarinserted from the front, and he found no pus. The patient<lied and a small abscess was found in the thick part of theri;htlobe of the liver.-Mr. HULKE, in reply, said that inthe case related in the paper the pus had already burstthrough the pleura. He used the water so hot that he could

just bear his hand in it. Though distilled water was good,some endosmosis of water into the surface cells of the peri-toneum might occur, and a neutral saline solution was,

perhaps, better for this reason.Mr. EDMUND OWEN then read a paper on the Radical

Treatment of severe Talipes Equino-varus in Children. He.’said that the orthodox treatment of severe club-foot by sub-cutaneous division of the tibial tendons and of the plantarfascia, and subsequently of the tendon of Achilles, left muchto be desired. The tendon of Achilles should, in all cases of’congenital talipes, be the first to be divided. In not a few.cases of slight equino-varus its subcutaneous section sufficedin the way of actual operation, and in severe cases the amountof the inversion of the sole could be correctly estimated only.after its section. Though subcutaneous surgery in generalhad doubtless played a useful part, it was at the present daymore or less of an anachronism. It had been entirely super-seded in the operative treatment of reducible inguinal,ernia, and greatly to the advantage of ruptured persons; butsubcutaneous operations were still generally performed forthe cure of congenital club-foot. Operating thus, com-

paratively in anatomical darkness, the surgeon could notknow for certain what structures he was dividing, nor couldone be sure of severing certain important bands, deeply placedin the sole perhaps, which chiefly prevented his obtainingthe perfect and easy rectification of the foot. Moreover, in a:severe case of congenital club-foot, the skin itself offered amost serious impediment to a correction of the deformity.The operation recommended in this paper for adoption insevere cases of club-foot was that introduced by Dr. A. M.Phelps of New York. It consisted in dividing every resistingstructure which was encountered in a free vertical incisionpassing from the dorsum of the foot into the depths ofthe sole over the head of the astragalus, the tendon ofAchilles having been first cut. The improved position ofthe foot was thus obtained by lengthening the inner borderof the foot rather than by shortening the external border,.as was usually accomplished in tarsectomy. It consistedin inserting a broad wedge of space into the astragalo-scaphoid joint. This space was duly filled up with granu-lation tissue, which was eventually converted into a strongand trustworthy cicatricial band between the anterior.and posterior segments of the foot. The treatment of thefoot subsequently to the operation was simple and satis-

factory, and relapse was far less likely to occur than after’the old method of operating. Mr. Owen had for several

years been carrying out this open method of treatment,.and in a considerable number of severe cases of congenitaltalipes he expressed himself as highly pleased with it.

Further, Dr. Phelps wrote to him to the effect that he

(Dr. Phelps) had now carried it out in 200 cases with no’fatal result, and with but a very small proportion of

’relapses.&mdash;Mr. ADAMS regarded the advocacy of the openmethod as a retrograde step. He himself still held tothe method by subcutaneous puncture, which excluded’the air and kept the wound free from after-inflammation.He thought there should be no difficulty in finding.and dividing the various tendons and ligaments. He pre-ferred to divide the Achilles tendon last.-Mr. BRODHURSTagreed in the main with Mr. Adams, and said that aftereperating by the subcutaneous method he had never seen arelapse. He held that the skin did not interfere with thereduction of the deformity, and said he had never seen acase in which the bones were so deformed as to inter-fere with reduction.-Mr. HuLKE pointed out that the sub-cutaneous method was a strictly antiseptic one, and there-fore Mr. Adams’ views were not so opposed to Mr. Owen’sas might at first sight appear. Every surgeon in hospitalpractice must have seen cases of inveterate deformity inpatients of a certain age in which some operation of the kindadvocated on the bony framework of the foot was absolutelynecessary to fit the parts for functional use. Hueter ofGreifswald had proposed division of the neck of the astragalus,and Macewen and others had advocated operations on thebones. So long as these extreme instances of deformity wereto be met with, so long must some method more radical thandivision of the tendons be adopted for treatment of them.-1B11’. OwEN, in reply, said that of course this operation had

Mt been proposed for ordinary cases of club-foot, but onlyFor those in which subcutaneous surgery left so much to belesired. He maintained that the use of plaster was infinitelysuperior to Scarpa’s shoe, and that bony deformity wascommon in cases of severe talipes equino-varus-a statementeasily verified by the study of museum specimens.

MEDICAL SOCIETY OF LONDON.

Syphilis and Nervous Disease in Child7’en.AN ordinary meeting of this Society was held on Nov. 21st,

Mr. Goodsall, Vice-President, in the chair.Dr. W. B. HADDEN read a paper on the Bearings of Syphilis

in respect of the Production of Nervous Diseases in Children.After alluding to the observations of Dr. Barlow and Dr. JudsonBury, 11 that nearly every variety of nervous a:ffection of acquiredsyphilis has its parallel among congenital examples," as inpart true, he passed on to consider the question whethersyphilis was an important agent in the etiology of suchinfantile disorders as hemiplegia, posterior basal meningitisand sclerosis of the convolutions. In the absence of post-mortem proof, clinical evidence, however strong, must bereceived with reserve. He referred to Osler’s work on thecerebral palsies of young children, and remarked that only onecase out of 120 was ascribed to congenital syphilis, whereasAbercrombie mentioned four, if not six, out of a series of fifty.lSachs and Petersen found two such cases out of a series of

eighty-three. He reviewed other statistics of the same kind,and pointed out that the balance of opinion was in favour ofsyphilis being an important and a frequent cause. Therewere not many observations bearing on the condition of thevessels in congenital syphilis, but he thought arterial diseasewas probably less uncommon than was generally supposed.He pointed out that the majority of cases of hemiplegia inyoung children arose without any apparent cause ; that

syphilis was known to predispose to arterial changes in adultsand occasionally also in children, and he insisted that asyphilitic history should be most carefully sought for. Hisown experience in this respect was based on the notes of fortycases, mostly at the Hospital for Sick Children, GreatOrmond-street. Though he had no pathological experienceto offer, his cases possessed a special value on account oftheir having been observed in very early life. He divided hiscases into (1) those with an acute onset and (2) those withouta definite onset. Many of the latter were probably congenitaland dependent on mechanical conditions during pregnancy ordelivery favouring intra-cranial haemorrhage ; others wereprobably associated with sclerosis of the convolutions. Manyof the acute cases followed so closely on certain specificdiseases-measles, diphtheria &c.-that a causal connexionmight be reasonably assumed. In most, however, there wasno apparent cause, the hemiplegia supervening on convulsionsin children in apparent health. The commonest cause beingthrombosis or haemorrhage, the question resolved itself intothe inquiry as to the causation of arterial degeneration. Upto three years of age embolism was rare, but after that itbecame comparatively frequent. In the cases of hemiplegiaunder consideration embolism might be practically excluded.With reference to syphilis he said that in twenty-five cases ofhemiplegia having an acute onset no inquiry was madein three, there was no evidence in nine, in five therewas a bare suspicion, in six there was a strongerhistory, and in two the presence of syphilis was undoubted.In discussing his cases he commented on the fact that inmore than one the symptoms had supervened in childrenpresumably syphilitic during a course of mercury, a factwhich might be adduced as an argument against the specificorigin of the lesions. He concluded by suggesting thefollowing points for discussion : z 1. Was there fair clinicalevidence that infantile hemiplegia was often syphilitic?2. Was arterial degeneration common in children, and whatshare had syphilis in its causation ? ’1 3. What share hadsyphilis in the causation of non-congenital idiocy? 4. Didsyphilis act as a factor in the production of sclerosis of theconvolutions in chronic meningitis ? 5. Was mercury aconstant and infallible therapeutic test in infantile syphilis ?

Dr. ALTHAUS, after referring to the value of the triadof symptoms-the notched teeth, keratitis and medianotitis-in the diagnosis of congenital syphilis, made some

1 Brit. Med. Jour., June 18th, 1887.

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remarks on the differentiation of this variety from theacquired disease in children. Although the hemiplegia mightoccur in children in apparent good health, a prolongedwatching would rarely fail to be rewarded with the discoveryof signs of syphilis. He agreed that mercury alone was oftendisappointing, but combined with iodide of potassium it gaveexceedingly satisfactory results in these cases.

Mr. SHEILD remarked that the deafness in children wasusually not due to otitis media, but a large majority of themhad complete nerve deafness caused by an effusion into thetissues of the labyrinth and auditory nerve.

Dr. LEES said that, looking to the difficulty of proving thepresence of syphilis, that affection might act more largelyas a cause than could be actually demonstrated ; yet, not-

withstanding this, he did not believe that it was to a greatextent provocative of infantile hemiplegia or of posterior basalmeningitis ; the latter might coexist with syphilis withoutbeing actually due to it, and he related a case in which hebelieved that this relation existed between the two. Thefact that many of these cases did better on mercury andiodide of potassium than on any other combination of drugsdid not prove that they were necessarily due to syphilis. Herelated two cases of gummata on the cranial nerves inchildren, one being in a little boy and the other in a girlaged thirteen. He referred to a third case in a boy agedeight, who had a paralytic affection of the lower limbs,and who at first was thought to have spinal caries, but thecase ultimately turned out to be one of syphilitic cerebralfibrosis.

Dr. BARLOW said that he could recall about six cases

of hemiplegia in congenital syphilis, in two of which

necropsies were made. In one, a girl aged nine, whohad been under observation for five years, there were allthe signs of inherited syphilis ; she had a convulsion, fol-lowed later by the development of hemiplegia, first on oneside and then on the other, and she later passed into a stateof hebetude. There was found extensive and typicalsyphilitic disease of all the arteries of the circle of Willis,with marked sclerosis of both hemispheres. He said thatthe rule was to get generalisation of the disease all over thenervous system-first convulsions, local or general, then

hemiplegia, perhaps spasm on one side and palsy on theother, then choroiditis, interstitial keratitis, and finally idiocy.Such was the typical course of cerebro-spinal syphilis. The

prognosis was always bad, though the symptoms might berelieved by iodide of potassium and mercury. The true basisof observation was morbid anatomy, and it should be remem-bered that every kind of lesion found in acquired syphiliswas found also in the congenital affection, though the distri-bution was different.

Dr. WALTER CARR said he had made necropsies in sixcases of posterior basal meningitis and in none of them wasthere evidence of congenital syphilis. He considered thatthe remarkable definiteness of the clinical symptoms and ofthe pathological lesions of that disease pointed to somedefinite but at present unknown etiology.

Dr. WHEATON thought that some of Dr. Hadden’s casesmight be instances of insular sclerosis, either syphilitic ornot. He remarked on the prevalence of gummata in children,which were not generally recognised. He thought that oneof the commonest lesions in children was an osteitis or

necrosis of the bones of the skull. In some cases of hemi-

plegia with Jacksonian convulsions tubercle was found in thesubstance of the brain.

Dr. HADDEN, in a brief reply, admitted the necessity offurther post-mortem evidence, and said that his experience ofthe presence of gummata was very limited. -

Reviews and Notices of Books..Vegetable Parasitical Diseases qf the Skin. By Dr. D. C.y< .P<MVMMe 7)Me p/* i7<6 Low, Marston and Co.DANiELSSEN. London : Sampson Low, Marston and Co.

Bergen : C. Floor. 1892.

THIS is an atlas in large folio consisting of nine plates andseven woodcuts of the vegetable parasitic diseases of the

skin, the text of which is written in Norwegian and English inparallel columns. Although complete in itself as far as thelimited subject of which it treats is concerned, it really formsthe fourth and fifth parts of the atlas of diseases of the skin

commenced, by the author in conjunction with the lateW. Bocck, many years ago ; accordingly, the first plate of thepresent fasciculus is numbered Plate XIV. The plates of theprevious parts represented Norwegian scabies of the palmand sole, psoriasis of the back, herpes ophthalmicus, of

tertiary syphilis (five plates) and anassthetic leprosy (freeplates), and the text was in Norwegian and French. The

present instalment, which we hope will not be the last, iswelcome evidence that Dr. Danielssen’s interest in the sub-

ject of diseases of the skin is unabated.The plates in the present fasciculus comprise favus of the

body with tinea tonsurans ; favus of the limbs ; favus of thescalp, with artificially inoculated favus of the arm in a herpeticform ; tinea, or, as the author calls it, herpes tonsurans ofthe head and artificially inoculated tinea on the forearm;sycosis ; pityriasis versicolor ; very extensive tinea circinata ofthe whole trunk in complicated patterns, which he considersto be the same as the herpes tonsurans maculosus of Hebra.This latter is now generally acknowledged to be the pityriasisrosea of Gibert, while this plate apparently represents a truetinea circinata in concentric circles and of wide extent. Thenext is a plate of eczema impetiginosum traced to the

staphylococcus pyogenes aureus and albus ; and, finally,there is a plate comprising the microscopic appearancesof the organisms previously treated of. The plates them-selves, which have been executed at Bergen, are veryfine specimens of chromo-lithography, and show well theadvances that have been made in that process, since thefirst fasciculi were printed by the same firm some thirtyyears ago.The explanatory letterpress is comprised in eighty pages,

and is no mere perfunctory explanation of the plates, but con-tains a large amount of original matter recording experimentsin inoculation of the various organisms. Among other results ofDr. Danielssen’s observations, those on favus inoculation (whichprimarily produced vesicles, the characteristic favus crusts

appearing later) are specially worth quoting, as he comes tothe conclusion that they point to there being only one kind offavus fungus, in opposition to the cultivation experiments ancldeductions of Quincke, Elsenberg, Frank, Unna and otherswhich he quotes. The text, indeed, is very interesting and .

well worth reading, though, like the bibliophile with the

&eacute;dition de luxe depicted by Du Maurier, owing to the enormoussize of the pages, it is somewhat difficult to decide how to

hold it for perusal. It is, however, well worth the extra

trouble, and we can heartily congratulate both author andpublisher on this handsome contribution to the knowledge olvegetable parasitic diseases.

jPMM M!. CMMM. By JAMES CARMICHAEL, M.D.,Disease in Children. By JAMES CARMICHAEL, M.D.,F. R. C. P. Edin. Edinburgh and London : Young J. Pent-land. 1892.THIS is the latest addition to the series of Pentland’s

"Students’ Manuals." It will be observed that Dr. Car-michael prefers to call his work "Disease in Children"rather than " Diseases of Children, " since he holds that, "witbfew exceptions, and those mainly of a congenital nature(malformations), we are dealing with the same diseases asin adult life, modified as they are by the conditions of growthand development going on in the child. It is not strictlycorrect to talk of diseases of children as we would of women,who suffer from ailments peculiarly their own. Disease i4children must be studied on the same lines and by the samemethods as disease in adults." This seems to us a just andnecessary distinction. The chief difficulty in the way of awriter of a manual on the subject lies in the reception andrejection of material. He feels justified in assuming thatthe reader already possesses a fair acquaintance with someof the ordinary works on practice of medicine, and aimsrather at emphasising those clinical features and therapeutic