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eliminated under healthy conditions by the lungs in the

expired air. The non-volatile toxins were eliminated for themost part by the cells of the liver. If for any reason theeliminating function of one of these organs was interferedwith, the toxins over the fate of which the lungs or the liverrespectively presided would not be sufficiently eliminated andwould accumulate in the blood. This gave an explanationof the almost constant association of pulmonary disease andosteo-arthropathy. If the liver was for any reason unable to

carry on its detoxicating work the other organs, such as

the spleen were capable of taking its place. If, on theother hand, anything interfered with the amount of respira-tory surface available in the lungs the volatile toxins had noother way of escape and they therefore accumulated in theblood. If these conclusions were correct the presence of atoxic focus in the lungs was not essential for the productionof osteopathy. What was essential was the co-existence of atoxic focus somewhere in the body with a condition of thelungs which interfered with normal respiratory inter-

change-e.g., a fibrosis, or even a chronic congestiononly.

Dr. C. THEODORE WILLIAMS, after congratulating Dr.Symes-Thompson on his paper, said that he had not seenany large number of cases of hypertrophic pulmonary osteo-arthropathy. On the other hand, he had seen a very largenumber of cases of bronchiectasis but had very seldomseen hypertrophic pulmonary osteo-arthropathy follow thatdisease. Dr. Symes-Thompson had shown that as the pul-monary discharge varied the condition of the bones alsovaried. It wa3, however, difficult to see how such varia-tion could take place if there was an actual thickening ofbones. Dr. Symes-Thompson had attributed the disease toa toxin and had also stated that the disease occurred incongenital heart disease ; it was difficult to conceive whattoxin could be produced in congenital heart disease whichwould give rise to osteo-arthropathy.

Dr. PERCY KIDD mentioned four cases which he hadrecently seen. In one there were tuberculosis of the sternumand but little affection of the lung. He thought that theimportant change in most cases was an arthritic change andnot an osteo-arthritic. In one of his cases there had beenmarked pain and there was marked thickening around thejoint. In one of the cases examined after death there wasno change in the joint but marked thickening around thejoint. He referred to a case in which there was hypertrophicpulmonary arthropathy but without any physical signs ofdisease of the lungs. Some time later signs of growth inthe lung occurred and the patient died. The joint symptomshad then been in existence for two years. He was of opinionthat the growth was not the cause of the osteopathy in thiscase. This patient had developed hair on the face and othermale characteristics which suggested some altered meta-bolism. He quite agreed with Dr. Symes-Thompson that thedisease was due to a toxin. In the earliest stage of thedisease it rather closely resembled rheumatoid arthritis.

Dr. R. MAGUIRE said that the theory which regarded thelung as a "gland" " was one which was too often neglected.Some of the acute attacks of dyspnoea which occurred with-out there being any signs of disease in the lung were attri-butable to some altered function in the "gland." Hementioned the case of a boy, aged 16 years, who sufferedfrom bronchiectasis with a cavity at the base of the lung.The temperature was very irregular and this was probably dueto absorption of toxic material. There was a considerableamount of foetid sputum. Swelling of the tissues around thejoints and effusion into the joints were present. Intravenousinjections of formaldehyde were given, the temperaturebecame more regular, and the joints less swollen, and at thesame time the amount of sputum was also diminished. Thisresult was the exact reverse of that obtained in the casesmentioned by Dr. Symes-Thompson for in them as theamount of expectoration increased the joint trouble began toimprove. He was of opinion that the joint trouble was dueto invasion by a micro-organism.

Mr. W. G. SPENCER said that he considered this affectionrather one of the joints than of the bones, but that it wasdifficult to draw a sharp line between the early stages of thisdisease and chronic pyaemia. He did not think that thetoxic theory could alone explain the condition but thatvenous congestion might play a very important part in its

production. He referred to the joint affection whichoccurred in "mother-of-pearl" workers who were for themos’i part young girls. This disease appeared to be due tothe irritation of the lung by dust. He was of opinion that

the question of the cause of the disease was a more com-plicated one than could be explained by the presence of atoxin only but that venous congestion played an importantpart.

Dr. G. NEWTON PIT’l’ referred to the fact that in theadvanced cases there might be thickening of the bones,clubbing of the fingers, and affection of joints, but that inthe earlier cases only one of these might be present andthis might render the diagnosis difficult. He suggested thatit was important to examine the medulla of other than thelong bones so as to show if any inflammatory conditionsoccurred in them also.

Dr. S. RussELL WELLS suggested that in the human body,as in the laboratory, organisms grew best on certain mediaand thus the disease tended to affect certain tissues. As thedisease affected cartilage and fibrous tissue in the lung, so inthe same way it affected those parts of the body in whichfibrous tissue and cartilage occurred-viz., the joints.

Dr. SYMES-THOMPSON replied.

MEDICAL SOCIETY OF LONDON.

The Use of Serum and Other Inooulations in PyoyenicInfections.

A MEETING of this society was held on Jan. llth, Dr. F.DE HAVILLAND HALL, the President, being in the chair.

Mr. W. G. SPENCER opened a discussion on the Use ofSerum and Other Inoculations in Pyogenic Infections byreading a paper on the Use of Antistreptococcic Serum.Streptococcus infection presented itself clinically undermany forms-e.g., erysipelas, septic inoculation of the ex-tremities, septic pharyngitis, scarlet fever, puerperal fever,endocarditis, pneumonia, or pleurisy. Any one of theseforms might take such a virulent course that the indirectmethods of treatment available to the physician provedinadequate. A generalised streptococcal infection was

diagnosed by finding streptococci in the blood and nodefinite proof of the value of antistreptococcic serum

could be deduced from any case in which the strepto-coccus has not been found in the blood beforehand.The blood should certainly be examined repeatedly in allcases in which the antistreptococcic serum was beingadministered, but difficulties and delays in carrying outbacteriological examinations were often inevitable and timewas an essential factor in the commencement of thetreatment. However, apart from the examination of theblood, clinical observation went far to establish strepto-coccal infection in many of its varieties. The difficultiesof producing a satisfactory antistreptococcic serum werethen referred to. It was very probable that manyreported cases of failure might have been due to theserum never having been standardised or to its havingsubsequently become inert. The essential requirementsfor the successful use of the serum were as follows:(1) evidences of a general infection by streptococci ; (2) astandard antitoxin ; (3) early administration after onset ofthe fever ; (4) subcutaneous injection, and, perhaps, in

very severe cases, intravenous injection ; the administrationby the mouth or rectum might be rejected and summarilydismissed ; and (5) the administration of full doses everythree or four hours until relief. Failure to comply with theserequirements might explain many possible sources of failure.Reference was then made to the clinical varieties of strepto-coccus infection. 1. In acute septic pharyngitis the bestresults had followed the administration of streptococcalantitoxin. 2. In cutaneous erysipelas, especially of the faceand head, the indication for the serum treatment in thisclass of case was limited. 3. In cellulo- cutaneous ery-sipelas there was for the most part local suppuration duevery often to a mixed infection with staphylococci ; hencethe issue was confused. 4. Scarlet fever Dr. Klein hadfor many years connected with a variety of streptococcusand this view of the pathology of the disease appearedto be generally accepted. Certain cases of malignantscarlet fever had been successfully treated by the serum.5. In puerperal fever they reached the most importantsection of the subject. The chief cause of fatal puerperalfever mainly consisted of streptococcal infection. It was,however, erroneous to infer that puerperal fever was in-

variably streptococcal in origin. Staphylococci and gono-cocci might cause the infection, even the diphtheria andcolon bacillus had been found in the lochia. 6. Cases of

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endocarditis and pericarditis were either secondary to somelocal lesion or, when arising primarily, were diagnosed byfinding streptococci in the blood. In primary cases it wasessential to find streptococci in the blood beforehand and tonote their disappearance after the administration. 7. Incases of septic pneumonia and empyema the serum hadbeen administered but with very doubtful benefit. Inconclusion, Mr. Spencer expressed the belief that there wereabundant reasons for the proper use of antistreptococcicserum. There should be available for the practitioner anabundant supply of active standardised serum of the specialkind required for use at the shortest notice.

Dr. A, E. WRIGHT communicated a paper on Inoculationin cases of Staphylococcal Infection. He remarked that hewould confine his attention to that kind of immunisationwhich was developed within the patient, such as could beaccomplished in chronic or recurrent suppurative disorders,acne, boils, sycosis, and other suppurative conditions in theskin, and chronic generalised pyogenic conditions. Refer-ence was made to a man who infected his finger, theinfection from which spread up the arm and became

generalised and chronic for ten years, the general staphy-loc:)ccal infection taking the form of repeated crops ofboils and suppurative lesions in various parts. Dr. Wrighthad administered staphylococcal vaccine prepared fromdead cultures and the patient had rapidly recovered. Fiveother cases were treated with like success. 1 15 more cases(making a total of 21) of chronic recurrent suppurativeconditions had been successfully treated in this way.Cases did best if treated by the vaccine derived from theirown staphylococcus. Cases required watching and thetreatment adapted from day to day. The phagocytic re-

action might vary considerably and in a negative phase godown to 0 of normal. Similarly the serum of immunisedanimals might vary and that was why the sera on the marketwere untrustworthy.

Sir FELIX SEMON, referring to the treatment of acute in-toxications-Ludwig’s angina, for instance-remarked thatthey were not necessarily of streptococcal origin, they mightbe due to any of the pyogenic group of organisms. The treat-ment to be of any use must be extremely prompt. The seraon the market were better than nothing. ,

Dr. E W. GOODALL thought they had not advanced verymuch in the last four years in their knowledge of thesubject. In regard to scarlet fever Marmorek’s serum hadentirely failed. He did not agree that the streptococcusagglomeratus was the organism of scarlet fever, thoughno doubt the pyogenic complications might be due to

streptococci, and reference was made to a case of severe

angina in which recovery very rapidly took place under theserum treatment. ,

Dr. CYRIL OGLE had collected records of 110 cases treatedby antistreptococcic serum. The results of his analysisshowed some very hopeful results.

Dr. W. J. Gow referred to puerperal fever and expressed thebelief that no real good had been accomplished in puerperalcases. The uncertainty of the serum on the market was agrave objection. Results would necessarily be fallacious, formany puerperal women incurred considerable temporaryelevations of temperature which subsided spontaneously orunder simple local measures.

Dr. F. J. PoYNTON remarked that no one knew the natureof the several pyogenic cocci. The difficulty of preparingthe sera was very great. The sera on the market were anti-bactericidal, which property was very easily and rapidlylost. Evil results arising from their use had been recorded,such ag multiple arthritis and enlargement of the spleen.The PRESIDENT thought that in desperate cases the use of

these sera was justified. He had recently treated five cases ;two were severe cases of erysipelas, one was a case ofmalignant endocarditis, one of Ludwig’s angina, and oneof septic pneumonia. Early administration was very im-portant. Other precautions should not be neglected. Severalextraordinary recoveries had been recorded when the sera hadbeen admini-tered by the mouth or the rectum.Mr, SPENCER and Dr WRIGHT replied.

CLINICAL SOCIETY OF LONDON.

Pneumococcal Peritonitis.A MEETING of this society was held on Jan. 8th, Dr.

FREDERICK TAYLOR, the President, being in the chair.

1 THE LANCET, March 29th, 1902, p. 874.

Sir DYCE DuCKWORTH and Professor HOWARD MARSH com-municated a paper on a case of Pneumococcal Peritonitis.The patient, a woman, aged 27 years, was seized with head-ache, generalised pains, and a rigor on Feb. 26th, 1903. Thetemperature was found to be 104 ’2° F. on the following dayand symptoms of general peritonitis followed. Widal’s re-action was negative and a large polynuclear leucocytosis waspresent. On March 2nd Professor Manh and Mr. A. A.Bowlby saw the case and a diagnosis of typhlitis withsome general peritonitis was made. Professor Marsh

operated and signs of inflammation were seen inthe peritoneum and the large intestine. The appendixwas found to be constricted at the base, dilated, andfull of mucus above ; it was ligatured and removed.There was some thin, turbid, and dark-coloured fluid in theperitoneal cavity but no adhesions were found nor was thereany evidence of the perforation of a viscus. A culture ofthe fluid showed pure specimens of the pneumococcus, thepresence of which was confirmed by an inoculation test.Three days later hiccough and abdominal pain supervenedand ten cubic centimetres of No. 1 antipneumococcic serumwere injected. On March 6th the injection was repeated.Signs of fluid in the left pleura appeared and on the 20th puswas found on exploration. Resection of part of the ninthrib was performed on the next day, when 12 ounces of sour-smelling pus were evacuated. The further progress of thecase, though slow, was uneventful. The sudden onset andthe rapid and grave development of the peritonitis closelycorresponded with that which is observed in pneumococcalinflammations in the joints and elsewhere.The PRESIDENT also communicated a case of Pneumo-

coccal Peritonitis. The patient was a girl, aged eight years,who was admitted under his care into Guy’s Hospital onNov. 19th, 1903. On the 10th abdominal pain set in,followed by a rigor, and two days later signs of pneumoniadeveloped. On admission the abdomen was distended andtender, moving very little on respiration, while physical signsof pulmonary consolidation at both bases were present.Some herpetic vesicles were seen at the base of the nose.Mr. R. Clement Lucas performed laparotomy and a quantityof odourless pus together with masses of lymph was re-moved. The cavity was irrigated with hot saline solutionand drained. The pneumonia on the right side cleared upbut on the left side physical signs of empyema manifestedthemselves and on the 27th six ounces of pus were-

withdrawn resection of a portion of rib being performedfour days later when more pus was evacuated. Cultivations.,made by Dr. J. W. H. Eyre from the peritoneal pus gave a.pure growth of the pneumococcus ; those taken from asecond collection in the left iliac fossa which was incisedon Dec. llth gave a growth of pneumococcus associatedwith the staphylococcus aureus. Cultivations from the pus..aspirated from the chest were sterile but under the micro-scope showed badly staining diplococci and empty capsules.characteristic of a pneumococcal empyema. The child was..making good progress. The President discussed the questionof the seat of primary infection which he thought was shownby the sequence of events to be the lung; the peritonitis and .-empyema he considered were secondary.

Mr. STANLEY BOYD referred to the case of a woman, aged26 years, upon whom he had operated for symptoms of’peritonitis, three pints of odourless pus being evacuated fromwhich pure cultures of the pneumococcus were obtained.The abdomen was distended in a peculiar fashion and moved’with surprising ease. No information was forthcoming at.the time of operation as to the primary origin of the disease:but the possibility of infection through the pelvic organs.might be considered.

Dr. J. H. BRYANT alluded to three cases of pneumococcalperitonitis which he had published in 1901 in which theprimary point of infection was the peritoneum. He con.sidered that an alimentary origin was not at all improbable,especially as the pneumococcus might be found in the throatsot healthy individuals. He called attention to the fact thatabdominal pain was frequently complained of in pneumo,coccal pneumonia and he thought that the adhesions some-times found post mortem between the lung and the;

diaphragm might account for this. Pneumococcal peritonitis was rare; of 162 cases of pneumococcal infectionreported by Dr. Netter of Paris, in only two had the peri-toneum become infected.

Dr. J. FAWCETT stated that in 182 fatal cases of lobarpneumonia which had occurred in Guy’s Hospital during thelast five years and in which necropsies had been made fiveonly showed any evidence of infection of the peritoneum and