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operation was not only justifiable but desirable, for it wasfound that even trephining relieves the symptoms of cerebraltumour, and more especially has an influence on the

optic neuritis. One question of great importance arose inreference to those cases-viz., should trephining be done inindefinite cases or even in cases in which it was known or

suspected beforehand that the growth was not capable ofbeing completely removed ? The decision of this difficult ques-tion must, he thought, depend upon the particular case and itwas perhaps better to put the responsibility of deciding uponthe patient after explaining to him and his friends all therisks of the proceeding. In reference to cerebellar tumours,which were regarded by some as indefinite in their symptomsand undefinable in their position, he was of opinion thatthe risks of operation had been somewhat exaggerated, forexperiments show that extensive interference experimentallywith the cerebellum was not attended with any fatal effect.On the whole it could be shown that operative interferencewas followed in a certain number of cases by what mightbe regarded as complete recovery-i.e., immunity fromsymptoms for at least a year after operation-and in anotherclass of cases by much relief to all the serious symptomseven if permanent cure did not ensue. Operation wasprobably to be recommended in a large number of cases.The relief of symptoms by medicinal measures must alsobe kept in mind and it was now recognised that iodide ofpotassium and mercury often relieved the symptoms andpresumably influenced the growth of tumours which werenon-specific and might be even malignant.

Dr. DERCUM (Philadelphia) agreed with Dr. Ferrier inhis statement that tumours other than syphilitic, especiallygliomata, were, as had been some years ago pointed out bySeguin, very manifestly influenced as regards their symptomsby anti-syphilitic treatment. In reference to the possibilityof influencing the growth of brain tumours he related arecent unsuccessful attempt of his own to influence by meansof tuberculin the symptoms apparently arising from a

tumour of the brain associated with otorrhoea of manyyears’ standing. A large tuberculous mass was afterwardsfound present in the brain, apparently due to infection fromthe middle ear and erosion of the temporal bone. He quiteagreed with Dr. Ferrier’s views as to the great relief affordedin many cases of indefinite or non-localisable tumour bysimply trephining the skull.

Dr. COLLiNS (New York) expressed surprise and gratifi-cation at the large percentage of cases in which not onlyrelief but actual recovery had followed in Dr. Ferrier’s casesand associated these results with the matchless surgical skillof Mr. Horsley. He was in the heartiest accord with Dr.Ferrier as to the relief afforded by operation and as to theaccessibility to operation of some cerebellar tumours. Hestrongly advocated lumbar puncture, even carried out daily,for the purpose of relieving optic neuritis (choked discs), andhe thought that the use of toxins such as Coley’s fluid, &c.,in cases of intracranial tumour offered prospects of reliefwhich were by no means small. But many tumours mustremain, for some time at least, unlocalisable. These, hethought, should be operated upon-i.e., trephining should becarried out in the hope of obtaining at least relief, perhapseven arrest of the symptoms. And although every syphiliticcase should be energetically treated with mercury and iodideof potassium delay in operating in any case in which thistreatment was ineffective or inadmissable was almostcriminal.

Sir WILLIAM BROADBENT (London) remarked that his

experience was small and not very favourable of opera-tion in cases of intracranial growth, but he was ofcourse delighted to have the more sanguine view ofDr. Ferrier, and looking back on the early difficultieswhich he could remember associated with ovarian opera-tions, &c., he was not inclined to despair of cerebral

surgery. His experience was that in cases of intra-cranial tumour the neuritis was greater on the side oppositethe tumour. As regards the effect of iodide of potassium hehad many years ago treated a patient in whom there was anegative history of syphilis and who had all the symptomsof cerebral tumour with iodide of potassium, relieving all hissymptoms. Quite recently he had again seen him with arecurrence of his symptoms and he mentioned this as a caseof intracranial tumour, almost certainly non-syphilitic, inwhich anti-syphilitic treatment had relieved the symptoms.

Dr. JOHN M. MACCORMAC (Belfast) said he was inclinedto be optimistic, although results now only indicated hopein the future. He found phenacetin useful for the head-ache and hyoscin for the vomiting of cerebral tumour.

Dr. BEEVOR (London) mentioned four cases upon whichhe had operated which were now alive after two years or

more. He was in favour of operation for palliation of thesymptoms in cases of non-localisable or non-removabletumours. In such cases if no relief followed trephining hewould advise puncture of the ventricles.Mr. WATERHOUSE (London) had trephined in ten cases"

four of them cases of infiltrating growth. In three of these,all symptoms-headache, vomiting, &c.-disappeared at

once ; in the other case occasional headache persisted, butwas easily relieved. Optic neuritis also disappeared in thesecases, so that much relief was afforded.Dr. E. F. TREVELYAN (Leeds) doubted whether tuber-

culous tumours so frequently became obsolescent as wassupposed and in his experience such tumours were usuallymultiple.

Dr. MiCHELTj CLARK (Bristol) thought that hardenedgummata not removed by anti-syphilitic treatment were

usually found in cases in which the anti-syphilitic treatment,had not been adopted in the early stage and he called.attention to a class of case of cerebral tumour in whichspontaneous recovery occurs.Mr. J. PAUL BUSH (Bristol) spoke of the difficulty of the

surgeon had in deciding at an operation whether he had todeal at the margin of a growth with healthy brain tissue ormorbid growth.Mr. COTTERILL (Edinburgh) thought that in spite of

success operative treatment of cerebral tumours was notsatisfactory. Yet exploration and removal of pressure.seemed important and desirable and he detailed various.

important points as to the technique of operation.The PRESIDENT cordially endorsed Dr. Ferrier’s view and

gave details of his own cases. Out of 123 of his caseshowever, examined post mortem only 5 could have beensuccessfully treated by removal of the tumour. He referred.to the spontaneous subsidence of symptoms in certain casesand expressed the view that such cases were possibly notcases of tumour but of hydrocephalus associated probablywith meningitis. He expressed surprise at the favourable-results furnished by Dr. Ferrier’s cases and attributed them.to the careful consideration of cases, by which certaincases were not submitted to operation, and to the care andskill with which the operations were conducted. He had notbeen so much impressed as some speakers apparently werewith the palliative results of operation.

Dr. FERRIER, in reply, said that in his experience opticneuritis as a result of frontal tumour most often occurred onthe same side as the growth, and he hesitated to express adefinite opinion on the efficacy of lumbar puncture. His

views, of course, as to ..

recovery " were necessarily modifiedby the fact that he regarded cases living a year after opera-tion as cases of recovery, and also he regarded cases asrecovered even if paralysis remained-paralysis the result ofdestruction caused by the growth before the operation haclbeen undertaken.

THURSDAY, JULY 28TH.Dr. BUZZARD (London) opened a discussion on

The Influence of Micro-organisms and Toxins on the Produc-tion of Disease of the Cerebral and Peripheral Nervous

System.He began by stating that he could not expect to do morewith such a subject to discuss than throw out fragmentarysuggestions which might be useful to other workers at thishighly interesting aspect of neurology. Micro-organismsprobably acted in two different ways-directly by theactual effect of the organisms themselves on the nervoustissues and indirectly through the agency of chemicalsubstances produced by the action of the micro-organ--isms on the blood or other tissues of the body. Diph-theritic paralysis was probably the most striking andundoubted condition showing the effect of a chemicalsubstance probably resulting from the action of thebacilli. The ordinary acute anterior poliomyelitis hadalways seemed to him to be a disease of infective character,and the fact that as a rule cases occurred sporadi-cally did not seem to him to militate against sucha view. Basic meningitis had lately been distinctly shownby Still to be microbic in origin, yet all the cases in theHospital for Sick Children during the last ten years had beensporadic cases. So the fact that infantile paralysis usuallyoccurred in isolated cases was evidently no argument againstits bacterial origin. Further, it was not uncommon to find-that in a family in which a case of infantile paralysisoccurred one or more of the other children were ill with

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similar symptoms, their illness, however, not resulting inparalysis. He also referred to epidemics of the diseasewhich had been described by several observers. The poisonusually falls with greatest force on the anterior nerve cells,but is not always confined to them, for convulsions occa-sionally occur, pains in the limbs are not infrequent,and spasticity may result. He then referred to anotherdisease-insular sclerosis-and said the view enunciatedby Pierre Marie was apparently gaining ground-viz.,that this disease is really an infectious one. Patchesof myelitis undoubtedly do occur as a sequel to in-fective fevers. But while not claiming that this wasthe same condition he thought that the periods ofremission in disseminated sclerosis, so similar to thoseoccurring in constitutional syphilis, indicated the infectiveoharacter of the disease. Tabes was another disease theclose connexion of which with syphilis no one could doubt.It was an interesting question how far tabes was a resultof specific infection and he suggested that not syphilismerely but also chancroids might be the infection precedingtabes. We know that neuritis may follow different kindsof microbic infection and probably myelitis also may dothe same. There seems no reason why tabes should notsimilarly follow different kinds of microbic infection.

Dr. DERCUM (Philadelphia), after thanking Dr. Buzzard forhis suggestive address, remarked that the action of toxinswas probably a general one on all the tissues, with a localexpression at some very susceptible part.

Dr. JOSEPH COLLINS (New York) had found in the exami-nation of cases from the Vermont epidemic that the nervoussystem generally was affected. yet no specific organism wasfound. He did not agree with the view that disseminatedsclerosis is infective. He thought a more probable explana-tion was that it was a result of congenital abnormalities.The nutritional balance of the cells of the nervous systemwas also of much importance in reference to nervous disease.

Dr. F. J. SMITH (London) related two cases of apparentlysome infective nervous affection after a septic wound andsuggested that in such cases where the symptoms pointed toperipheral rather than central affection the transference ofsymptoms from one side to the other should be regarded asthe result of nerve influence.

Dr. JOHN M. MAC CORMAC (Belfast) remarked on thegreat divergence of opinion as to the connexion betweentabes and syphilis and expressed the opinion that the

changes in the nervous system in disease are chemico-physical in nature.

Dr. J. A. ORMEROD (London) thought that in tabesthere must be more than mere microbic infection, probablypersonal susceptibility. For it is well known that tabesoccurs ever so much more frequently in men than in womenand cases of Friedreich’s ataxy became much worse after anillness. Indeed, in some cases the illness seems to evokethe first symptoms and he would be inclined to think theElicrobic origin of disseminated sclerosis and even ofinfantile paralysis was " not proven."

Dr. R. A. FLEMING (Edinburgh) thought that in peri-pheral neuritis the vaso-motor nerves probably suffer and sothere is exudation into the sheaths with pain and paralysis.

Dr. MOTT (London), in detailing the changes which hehad found in two cases of beri-beri, remarked on the direct- effect apparently exerted on the cardiac muscles by thepoison of this disease and on the severity of the clinicalsymptoms as compared with the amount of change foundia the nervous system.

Dr. FERRIER (London) remarked on the great suggestive-ness of Dr. Buzzard’s address, but was inclined to regard theinfective theory of the origin of disseminated sclerosis asseductive but not proven. Of the close connexion betweensyphilis and tabes dorsalis and also general paralysis of theinsane he had no doubt.

Dr. ALEXANDER BRUCE (Edinburgh) had found in a casehe had examined recently, in fresh foci of disseminatedsclerosis, a blood-vessel in the centre and he thought thatthe change probably spread from this vessel and was causedby some toxic substance which had the effect of dissolvingthe myelin. The change occurred symmetrically round thevessel and evidently spread from it.

Dr. E. F. TREVELYAN (Leeeds) described a condition ofdisseminated myelitis found by him in dogs which died aftercanine chorea and distemper and he described a case inwhich death occurred eighteen days after exposure to cold.There was suppuration in the back muscles, empyema, andmyelitis.

The PRESIDENT thought that toxins in many instances gaverise to changes, but he thought that toxins were not always ofmicrobic origin but were produced sometimes inside the

body. He referred to the fact that second attacks of infantileparalysis were practically unknown as evidence of infectivecharacter. He thought herpes zoster was probably microbicand facial paralysis seasonal. He referred to muscular

atrophy (myopathy) with little change in the nervous systemas occurring as a sequel to sprue and he was inclined toregard disseminated sclerosis as a result of intoxication.

Dr. BuzzARD replied on various points raised, and thePRESIDENT, in conclusion, thanked him for his introductoryaddress.

Dr. BEEVOR (London) read a paper onThe Action of the Latissimus Dorsi in Hemiplegia.

He said that this muscle had three different actions-in

moving the arm, in coughing voluntarily, and in coughingreflexly. In hemiplegia the voluntary action in moving thearm was usually lost on the paralysed side, the voluntaryaction and the reflex action in coughing both usually remain-ing. Sometimes, however, the voluntary action in coughingwas also lost but the reflex action remained. He remarked onthe possible usefulness of the condition as a diagnosticsign.

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PATHOLOGY.

WEDNESDAY, JULY 27TH.Dr. G. SIMS WOODHEAD (London) read a paper on

Post-Diphtheritic Paralysis.He began by quoting statistics from a large number of

cases of diphtheria or suspected diphtheria in which abacteriological examination had been made at the ConjointLaboratories, with the object of showing the large propor-tion of cases in which paralytic phenomena developed. Thedistribution of the primary paralysis was as follows. Out of494 cases 185 were primary paralysis of the fauces, 197 ofthe oculo-motor muscles, 10 of other muscles, and 102 ofprimary paralytic heart failure. In regard to the time ofonset important observations were made. Of the paralysesof the palate the great majority occurred between the fifthand fifteenth days ; none before the fourth. Of the oculo-motor paralyses the bulk occurred between the fourth andseventeenth days ; none before the fourth. Of the paralysesof other muscles about one-half occurred between the tenthand fourteenth days ; none earlier than the tenth. Of thecardiac paralyses the bulk occurred between the fifth andtenth days, and in a few instances as early as the secondday. In each of these groups the onset of the paralyticsymptoms might be delayed for many days. It was

obvious, however, that in the human subject the bulkof the paralyses occurred at a comparatively early dateand cardiac paralyses earliest of all. The fact thatthe heart might be affected so much earlier than the othermuscles appeared to indicate that the primary lesion pro-bably occurred in the nerve-cells. These lesions were easilyoverlooked, because the changes were transient except inthose cells which were completely degenerated. SidneyMartin, Meyer, and others had described segmentaldegeneration of the motor nerves, but in all probabilitysuch changes were of a Wallerian type. The toxin actedprimarily on the nerve-cells which either degenerated or

recovered at an early date ; later the nerves for which thesecells acted as trophic centres showed secondary degenerativechanges, and only then was the paralysis revealed. Afterexperimental inoculations of guinea-pigs for the purposeof testing antitoxins, paralyses occurred more frequently thanbefore, probably owing to the larger doses of toxin and anti-toxin now employed. Madsen, who used the original methodof testing-i.e., neutralising with one-tenth of an antitoxinunit-found that most of the cases of paralysis inguinea-pigs developed at the end of the third week.He pointed out that the paralysis, when it did occur,followed the local infiltration which resulted from the injec-tion of an incompletely neutralised dose of toxin. It beganin the posterior part of the trunk and in the hind limbs.Later the symptoms became mor ; pronounced and the

paralysis gradually extended forwards to involve the forelimbs also. The muscles of the head and neck were the last

to be affected. In spite of the extreme muscular weaknessthe animals were still very lively and continued to eat as -

long as there was food within . ach. Ehrlich, on the