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of arsenic. As to elimination without symptoms Dr. Mannhad found in some surgical patients who drank beer that

’

a considerable amount of arsenic was eliminated by theurine as though no symptoms of arsenical poisoning werepresent.

Dr. JUDSON S. BURY (Manchester) thought that thenature of cases of slight pigmentation must now be moreclosely investigated. He believed that he had seen peri-pheral neuritis in spirit-drinkers. There was in his expe-rience no outbreak similar to the recent one. He had neverbefore seen such severe hyperæsthesia in the limbs. The

hyperassthesia was very persistent, remaining months afterthe keratosis or the paralysis. In some cases pain andeffusion of the joints and tenderness of the bones wereobserved. He thought the paralysis was more widespreadin the arsenical than in most other forms of peripheralneuritis. In the hand the paralysis of extension was markedand it led to a curved shape of the fingers. -

Dr. NATHAN RAW (Liverpool) said that the outbreak didnot appear to have been so extensive in Liverpool as inManchester. During the last three years out of 12,623patients admitted to the Mill-road Infirmary 226 had alcoholicneuritis; of these 147 presented symptoms attributable toarsenic. Of the 226 patients 51 died from cardiac failureand general asthenia. From his statistics he concludedthat the contamination of beer commenced in May, 1900.Beer and porter appeared to be the usual vehicles. Hehad observed very little peripheral neuritis in Scotland.The serious lesions, he thought, were due rather to con-tinued drinking of moderate quantities than to sudden out-bursts of deep drinking. Among the symptoms markedpyrexia was present in three cases. He found arsenic inthe urine in five cases out of 33 examined, but in no casewas he able to find it later than 10 days after admission.Dr. Raw referred to the observation made by Osler to theeffect that liquor arsenicalis when given in brandy had moreeffect than when given in water alone.

Dr. T. N. KELYNACK showed illustrations, photographs,and casts of numerous cases. The casts showed the lateeffects. He believed that the alcoholic "vehicle" " in theform of beer accentuated the toxic effect of arsenic. Hehad observed cases in infants at the breast, and this pointedto elimination in milk. He thought the presence of As2O3in glucose was associated with an acid reaction. The amountpresent in different samples of beer varied. In one instancethere were 14 grains of As203 in the gallon.

Sir LAUDER BRUNTON referred to John Hunter’s experi-ments on dogs. Hunter found that when dogs were poisonedby placing arsenious acid in a wound they died just as surelyas when the poison was swallowed, and after death there wasevidence of inflammation of the stomach in both cases, butit was more marked when the poison was absorbed from awound than when it was taken by the mouth.

Dr. A. P. LUFF had for some years taught that where

peripheral neuritis of doubtful origin was present arsenicwas to be suspected. The elimination of arsenic in ponder-able quantities as described by Dr. Dixon Mann was really anew fact. In one case he (Dr. Luff) had given an adultfive minims of arsenical solution three times a day for ashort time when suddenly peripheral neuritis set in. Itthen transpired that the patient was an alcoholic subject.He took notes in 40 cases in Manchester and found thatthere had been vomiting and colic in only 36 per cent., andthese were cases where large quantities had been consumed,so that possibly these symptoms were due to gastric catarrh.He had classified the symptoms in 91 cases, and had foundthat pain and tingling in the feet and the calves of the legswere a prominent and fairly constant symptoms.

Dr. F. W. TUNNICLIFFE, whilst agreeing that arsenic inthe beer accounted for the chief symptoms, thought its actionmight have been modified by the presence of selenium,which he had found in sulphuric acid, glucose, and beer.

Dr. FREDERICK TAYLOR could not quite agree that

peripheral neuritis with marked tenderness of the calvesof the legs was practically limited to cases of alcoholic orarsenical poisoning or to beri-beri. He had observed itafter typhoid fever and diphtheria and in other conditions.

Dr. SYDNEY RINGER thought that the general action ofarsenic was akin to that of the potassium salts, whichaffected the muscles both of the skeleton and of the heart.

Sir DYCE DUCKWORTH said that in his experience thetherapeutic use of even large doses of arsenic was practicallyfree from serious consequences as in the cases before themeeting.

Dr. REYNOLDS, in reply, said that some difficulty of

separating cases of peripheral neuritis into etiological groupswas caused by the fact that many spirit-drinkers took largequantities of beer.

MEDICAL SOCIETY OF LONDON.

Exhibition of Cases.I A CLINICAL meeting of this society was held on Feb. llth,Mr. J. H. MORGAN, the President, being in the chair.

Dr. C. E. BEEVOR showed two cases of Paralysis of theSerratus Magnus and the Lower Half of the Trapeziusoccurring in joiners (occupation paralysis). The two caseswere identical. One man, aged 27 years, had severe pain inAugust last in the right supra spinous fossa ; two months afterhe noticed difficulty in raising the arm and two weeks later thedeformity of the scapula was observed. The other patient,a man, aged 18 years, had severe pain behind the rightshoulder-blade and along the axilla ; two weeks after he wasunable to raise the arm above the horizontal line and amonth later it was observed that he had complete loss ofpower of the right serratus magnus and of the lower half ofthe trapezius. In both cases there was inability to advancethe arm and carry it upwards beyond the horizontal line,and in this attempt the scapula was drawn upwards and itsposterior border projected backwards owing to the serratusmagnus being absent. The wasting of the trapezius belowthe level of a horizontal line from the second dorsal spineto the spine of the scapula was well shown by makingthe patient carry the arm horizontally backwards againstresistance. It was pointed out that " winging

" ofthe scapula might be produced by absence of theserratus or of the lower fibres of the trapezius; inthe former the deformity increased as the arm was

advanced to the horizontal position, beyond which the

patient could not raise it, while in paralysis of the trapeziuswithout the serratus the deformity increased till the armreached the horizontal line, but above this point the armcould be raised and the deformity disappeared. In the

present cases both muscles were affected, but in the first casethe serratus had partially recovered and the deformitydiminished after the arm passed the horizontal line. Theaffected muscles gave no reaction with the faradaic currentand only a slight slow reaction with the constant current.There was no anaesthesia. Both patients were joiners andthe muscles affected were those of the right arm, whichwould be most used in planing. It seemed probable that thelesion was a neuritis affecting the intra-muscular motor andsensory nerves and that the character of the work was adetermining cause and the cases might be looked upon asthose of occupation paralysis. In both cases only the fibresof the trapezius below the level of the second dorsal spinewere affected and in several other cases Dr. Beevor hadfound that this was the level of the lower border of theunaffected fibres, where the lower half of the trapezius wasparalysed. The reason of this might be due either to thedistance of the lowest end of the spinal accessory nervefrom its trophic centre in the cervical cord or to the part ofthe muscle which escaped being the fibres which are suppliedby the third and fourth cervical roots as well as by the spinalaccessory nerve.-Mr. A. E. BARKER and Mr. EDMUNDOWEN discussed the case.

Mr. F. C. WALLis showed a young woman who had Con-genital Synostosis of the Upper Ends of Both Radii andUlnæ and on one side Ischæmic Paralysis (Volkmann) whichsupervened on using Esmarch’s band during an operation forthe relief of the congenital disability.

Mr. WALLIS also presented a second patient who sufferedfrom Pressure Paralysis the result of Tight Splinting forBackward Displacement of the Upper End of the Ulna. The

. patient showed atrophy of the muscles of the hand supplied! by the ulnar nerve.

Mr. H. BARNARD showed two patients-a boy, aged three: years, and a girl, aged four years-with Typical Ischæmic

Contraction of the Forearm in each case. The deformity’ was removed by splitting and elongating the flexor tendonsi through a longitudinal incision above the wrist and

the power of supination was restored by elongating thepronator radii teres and detaching the pronator quadratus

r from its ulnar attachment.-Mr. WALLIS, in reply,; said that in cases where no power had returned

in the contracted muscles he doubted whether much

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improvement would be obtained by tendon elongation.-Mr.OWEN congratulated Mr. Barnard on the good results whichhe had obtained.-Mr. WALLIS stated the opinion that inischasmic paralysis operations should not be undertakenuntil a fair amount of power had returned in the affectedmuscles.Mr. MARMADUKE SHEILD showed a boy in whom after

failure of the ordinary means he had Removed a Halfpennywhich had Lodged Opposite the Upper Edge of the Sternum.The œsophagus, which at the site of operation was coveredwith indurated inflammatory tissue and glands, was incisedlongitudinally and the body grasped with long forceps andremoved. From the facts that some force had to be usedbefore it was dislodged and that the escape of some pusfollowed its removal there was no doubt that the body hadcaused ulceration. The wound was left open and closedslowly in spite of the septic conditions.-The PRESIDENTsaid that it would be interesting to watch the patient witha view of ascertaining whether the operation was followedby any stenosis of the œsophagus.—Mr. KELLOCK observedthat the seat of lodgment of the coin in Mr. Sheild’s casewas the favourite one and that usually the "coin-catcher" "was efficacious.-Mr. WALLIS and Mr. BARKER had alsoexperience of similar cases in which removal was effectedby the "coin-catcher."—Mr. SHEILD, in reply, said that hehad removed coins, and also a tooth-plate, withh the " coin-catcher," and in this case he had tried the same means butwithout avail.Mr. SHEILD also showed a woman after Anterior Gastro-

enterostomy for Pyloric Obstruction. The pylorus was foundto be thickened and knobby. Murphy’s button was used toeffect the anastomosis. The patient made a rapid recoveryand had put on two stones in weight when she left thehospital.

Mr. SHEILD also showed a man on whom he had operatedfor a large intermuscular tuberculous abscess of the thigh.An incision 24 inches long was made and the large cavitywas allowed to heal by granulation.Mr. STANLEY BOYD showed a man, aged 47 years, who

eight or nine years ago had Severe Pain in the Chest andAbdomen after Food. Vomiting began six years ago inattacks lasting from one to three weeks, with intervals offrom four to six weeks, and had continued up to admission.Vomiting usually occurred after lying down at night; aboutthree pints of frothy matter were usually brought up. Therewas no hæmatemesis but much flatulence. The stomachusually felt distended. Vomiting relieved the distension andpain. He was admitted on December, 1900, under the care ofDr. Abercrombie after a month of daily vomiting. He wastransferred to Mr. Boyd’s care on Dec. 27th. Even after a

fortnight’s rest and treatment, which arrested the vomiting,the patient was very thin, pale, and feeble. Abdomen:stomach formed a visible tumour in the left hypochondriacand lumbar, the epigastric, and umbilical regions. Notumour or hard mass could be felt. Splashing was obtained.,Capacity was nearly two quarts. There was no sarcinse inthe contents. On Dec. 29th posterior gastro-enterostomy wasperformed. The opening was from one and a half to two incheslong between the stomach and first loop of jejunum, and theedges were secured by three continuous lines of fine silk sutureon either side of it. The most external held the sero-muscularcoats, the second the cut edges of the same coats, and theinnermost united the edges of the cut mucosæ. With regardto the after course the patient vomited once only. Peptonisedmilk was given by the mouth soon after and was continuedin increasing quantity. Nutrient enemata were also given fortwo days. Minced meat and-bread were given on Jan. 5th,and the quantity was quickly increased, the appetite beinghearty. The wound healed perfectly. The temperature was100° F. on the second evening, 101° on the 3rd and 4th, andthen practically normal. As to the patient’s weight, ninedays before operation it was 7 st. 12 lb. ; 12 days after theoperation it was 7 st. 71b. ; 26 days after operation it was8 st. 7 lb. ; and 40 days after operation it was 9 st. 2 lb.-The PRESIDENT had operated both by the anterior method-i.e., by bringing the small intestine up in front of the colonto the anterior surface of the stomach and using a button-and by the posterior method-i.e., by bringing up thesmall intestine through an opening made in the transversemeso-colon and making a communication with the posterioraspect of the stomach by means of stitches.-Mr. BARKERsaid that rapid improvement after gastroenterostomy couldnot be taken to mean that the case was not one of cancer.For some years past he had adopted the posterior operation

and it had not proved to be much more difficult than theanterior method. With practice the operation could be donewith suturing almost as rapidly as with Murphy’s button.-Mr. WALLIS said that in some cases the patient did betterif placed in the sitting position after operation.-Mr. OWENhad found it advantageous to turn the patient face down-wards after meals when the anterior operation had beenused.-Mr. SHEILD stated that he allowed patients to liein the position they found most comfortable.

Dr. W. HUNTER showed a case of Pernicious Ansemia.The patient was a man, aged 37 years, who had enjoyedgood health till two years ago when pallor (lemon colour), withpain in the mouth and stomach came on ; an inflammatorycondition of the tongue was present and was relieved bythe removal of three very bad teeth. The gastric pains andanæmia increased, so that he became extremely anasmic, withurobilinuria. The blood corpuscles were 27 per cent. andhaemoglobin 35 per cent. of normal. Suppuration of thegums, which had been present for five years, continued.The treatment consisted of oral and intestinal antisepsiswith injections of antistreptococcic serum. In six weeks hesteadily improved and gained 7 lb. in weight. Liquorarsenicalis was then added to the treatment and five weekslater he had gained an additional stone in weight and wasdischarged as cured.-Dr. J. F. H. BROADBENT referred totwo cases in which the symptoms of pernicious anæmia hadbeen closely simulated by anaemia secondary to other causes.The first was a case of septic anæmia and was successfullytreated by injections of cacodylate of soda, and the secondwas a case of contracted kidney in which there had been noclinical evidence of the condition.

Dr. STCLAIR THOMSON exhibited two cases to show thedesirability in certain cases of Removing the Tonsils byEnucleation. The first patient was a woman, aged 38 years. ,_In 1894 she was in close attendance on her husband who wasvery ill with tonsillitis and a foul discharge from his throat.Soon after she noticed in her tonsils cheesy collections, ofoffensive taste and foetid odour. The local conditions werevery similar to those presented by her son who was thesecond case shown at the same time. For this condition shewas under continuous treatment for three years. During twoyears she attended Dr. Thomson’s clinic and was activelytreated with gargles, paints, lozenges, caustics, the galvano-cautery, and incisions la)ing open the tonsillar crypts. Atthe same time attention was given to her digestion andgeneral health. She remained unrelieved. Accordingly, twoyears ago the imbedded. tonsillar stumps were enucleatedunder chloroform and she had since been quite free of thechronic fœtid follicular tonsillitis which had been such a

persistent nuisance. There had been some regeneration oflymphoid tissue between the pillars of the fauces, but therewere no crypts in which these cheesy septic concretionscould form. The patient found that her voice had not inany way been injured, but rather improved, fc singing.The second patient was the son of the former one. He wasa boy, aged 10i years. When four years old his tonsilswere noticed to be enlarged and they were removedat the Throat Hospital. He was not again troubledwith them until after scarlet fever, at the age ofsix years, when they were again enlarged and were

removed with the guillotine at the Throat Hospital by Dr.StClair Thomson. A few months later cheesy collectionswere noticed in the crypts of the tonsils, and these had sincecontinued almost without intermission. He was undertreatment from September to December last. The chiefcomplaint was of his foul breath, which was said to be mostmarked in the morning, but was perceptible when he wasasleep with his mouth closed. The tonsil stumps were seento be deeply imbedded between the faucial pillars. Theywere riddled with crypts, some of which were half an inchdeep. From these crypts dirty white, foetid, cheesy matterswere easily extruded. There were no adenoids. It wasseen that it was impossible to thread these tonsillar stumpsinto the ring of the guillotine. In the previous case allattempts to obliterate the crypts failed. The choice oftreatment, therefore, seemed to lie between punching outthe remains of the tonsil by morcellement or enucleation, asin the former case. The mother of the boy was so gratifiedwith the result in her own case that she was anxious for himto have the same treatment. The operation was performedunder a general anaesthetic, chiefly by a pair of curvedscissors and the fingers.

Dr. J. L. BuNCH showed a case of Localised AbdominalSwelling. The patient was a child, aged three years, who

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was strong and healthy up to five months ago, when she hadbronchitis and was in consequence kept in bed for a fort-night. When she got about again she seemed rather weakand ailing at first. Soon afterwards her mother noticed aswelling of the right side of the abdomen, and during thelast three months this had gradually increased in size. Theswelling was said never to become appreciably smaller, butthe mother thought that it was sometimes a little "softer"first thing in the morning or after the child had been lyingdown for a considerable time. The child had never been outof England. There was now an elastic swelling of about thesize of a cricket ball in the right hypochondriac and upperpart of the right lumbar regions, which formed a definiteprominence when the child stood up. The percussion noteover the swelling varied. No thrill could be made out. Thechild was apparently in good health. The urine was normal.-The PRESIDENT thought that the swelling was due to alocal weakness of muscle rather than to a definite tumour.-Dr. EDMUND OAUTLEY had under his care a similar caseand regarded it as being due to muscular defect.

CLINICAL SOCIETY OF LONDON.

Address of Condolence to His Majesty King Edward VII.-Leucocythæmia.-Instantaneous Radiography.

A MEETING of this society was held on Feb. 8th, Sir R.DOUGLAS PowELL, Bart., the President, being in the chair.The proceedings opened with an address of condolence to

His Majesty King Edward VII. in respect of the death ofHer Majesty the late Queen and of congratulation on hisaccession to the throne.

Dr. D. N. NABARRO read notes of a case of PronouncedSpleno-myelogenic Leucocythæmia subsequent to an attackof Malarial Fever. The patient, a man, aged 23 years, con-sulted Dr. Thin on account of enlarged spleen on March 28th,1900, at the recommendation of Dr. C. H. Perram of Bed-ford. He went to Vancouver in 1899 and considered him-self to be then in good health. During April andMay of that year, which were wet and cold months,he felt very tired. In July he was attacked by.. chills." The rigors came on about midday, lasting anhour, then for an hour he felt hot in the head, with afinal stage of perspiration. He was confined to bed forfour days. Not regaining his strength he returned to Englandin October of the same year. He had noticed that he wasgetting corpulent towards the end of August and thought hewas getting fat. The abdominal enlargement, however, wasfound to be due to enlarged spleen when the patient wasfirst examined by Dr. Perram on Dec. 13th. Dr. Thin wroteto Mr. J. A. Pybus for further information regarding the originof the illness, and was informed by him that the patient firstconsulted him on July 5th, 1899, and he was asked to seehim again on July llth. He then complained of feeling ill,had a quick pulse and a furred tongue, with a temperatureof 104° F. Under treatment, antipyretics and quinine, thetemperature sank to 99.5°, and on July 26th he was con-sidered cured. During August and September he wassubject to sensations of chilliness but had no rise of

temperature. When he left for home on Sept. 26thhe seemed to Mr. Pybus to be suffering from some

"pernicious toxæmia." He told Mr. Pybus that while atManitoba, about April 2nd, he stayed two days in a low,swampy place, and from July 20th to 27th he campedbeside a small creek where there were swarms of mosquitoes.Mr. Pybus informed Dr. Thin that he saw three other casesof fever in a house two miles distant from that in whichthe patient under notice lived. These cases were similar innature and were characterised by high temperature, 104° inone case and 106° in a second. The attack in these caseslasted 10, 16, and 20 days respectively, and all the patientsmade good recoveries. Mr. Pybus stated that " thesewere the only cases of fever in the district during the10 years he had been in practice there and were believedto be of a typho-malarial character." On Dec. 13ththe spleen was found definitely to be the cause ofthe abdominal enlargement. On March 28th, 1900, Dr. Thinfound the patient to be very pale and anæmic and with a " verylarge spleen, which descended to the groin on the left sideand crossed nearly to the ilium on the right side." Nomalarial parasites or pigmented leucocytes were discoveredon careful examination, but the white corpuscles were greatly

increased in number. On May 25th, by the kindness of Dr.Thin, the patient was seen by Dr. Nabarro and a completeblood examination was made. The spleen was then as largeas it had been found to be in March and was slightly tenderabout the notch. There was no enlargement of the liver orof any lymphatic glands. In September another differentialcount of the leucocytes was made and on Nov. 16th thepatient was again seen at Dr. Thin’s house and a completeblood examination was again made. (The conditions thatwere found at the different examinations are shown in thesubjoined table.)

Many transitional forms between large lymphocytes, poly-morphonuclear leucocytes, and myelocytes were seen, Thefilms were fixed by immersion in alcohol and ether andstained by eosin and hæmatoxylin and by the Ehrlich-Biondi triple stain. In November the patient was feelingso much better that he was desirous of taking up someoccupation. The spleen was as large as ever but causing noinconvenience beyond a feeling of weight when the patientwas tired. Treatment had brought about but little benefitas regards the condition of the blood or of the spleen. Thepatient had had at various times arsenic, iron, quinine, andpreparations of hsemoglobin and bone marrow. There werea few interesting points in the case—(1) the antecedenthistory of malaria, almost certainly indicated by the"chills "described; (2) the great size of the spleen beforeattention was drawn to it and the slight inconveniencecaused by it; (3) the condition of the blood showed a greatdiminution in the percentage of lymphocytes (from 20 to23 per cent.) and a corresponding increase in the number ofmyelocytes (from 28 to 42 per cent.) between March andNovember, 1900; and (4) in spite of the marked anaemiaand the large number of white cells in the blood the patientwas apparently in good general health and was anxious andable to follow an occupation.

Mr. E. W. SHENTON displayed a large number of radio-grams taken with very short exposures, examples of so-calledInstantaneous Radiography. He explained that the word" instantaneous merely conveyed the idea that the exposurehad been reduced to reasonable limits-i.e., from a fractionof a second to a maximum of 30 seconds. This he hadbeen enabled to accomplish by the aid of x ray tubes oflarger size, whereby not only was the exposure materiallyreduced, but the deeper parts of the body could be readilyseen on a screen. He described the advantages of thesetubes in the detection of renal calculus, in the treatment offracture, and in the rapid localisation and extraction offoreign bodies. Mr. Shenton then demonstrated a very

simple and effective method of ascertaining the exactposition of a foreign object inside the body. When the

shadows of the body and foreign object were thrown uponthe screen, on the tube being moved from side to side it was

! seen that the rate of movement of the two was differentowing to their different distance from the tube. If a

probe were placed behind the screen at a distance atE which its movements approximated those of the foreigni body, that would be the distance of the latter, and by, repeating this proceeding in different positions the where-s abouts of the foreign body could be ascertained to a

nicety. (This was demonstrated by the aid of a lime-1 light projection in a perfectly satisfactory manner.)-The PRESIDENT said that although Mr. Shenton had not