419

1030; the discharge soaked through the dressing?, so they wereremoved and the stump redressed. Ib was looking remarkablywell and free from inflammation. On the sixth day it wasagain dressed ; the flaps were found to be uniting well, butthere was still a considerable amount of discharge, and alittle pus oozed from one point. For the next month it,continued to progress favourably, and all healed withthe exception of a short sinus which formed at the’outer corner cf the stump, and continued to discharge.She, however, gradually regained her strength, and a weekbefore leaving hospital was able, with assistance, to attemptto get about on crutches. On Dp. 9th, seven weeks afterthe operation, she was discharged. She has since been-under supervision, and ba made almost uninterruptedprogress. Lately, however, she has at times complained ofrather severe paroxysms of occipital headache lasting for an’hour or so, an occasionally accompanied by vomiting, butshe has no optic neuritis, and the attacks do not saem toaffect her general health. The stump is healthy, the cicatrix-firm, and remains soundly healed. With the aid of iron andcod-liver oil she is putting on flesh, appears brighter, andis, to some extent, able to resume her old occupation as aitailoress.CASE 2.-J. P-, aged forty-seven, a contractor, was

admitted into Stroud Hospibal suffering from an aneurysmof the left popliteal artery. He was a stontlv built, healthylooking man, but inclined to be plethoric. He gave a goodfamily history, none of his relatives having suffered fromany hereditary disease. His own health bad always been,good with the exception of an occasional attack of gout.There was no history of syphilis. He stated that twomonths previously to admission he had strained hisknee in lifting a sack, and this had been followed bypain and stiffness in the joint for about a month,after which he noticed a swelling at the back ofthe knee, which grn.dua.tly increased in size. Onadmission, on July 22dd, 1890, all the signs of a saccu-lated popliteal aneurysm were well marked. The leftpopliteal space was occupied by a circumscribed ovoidtumour about the size of a hen’s egg, pulsating with an- expansile impulse, immediately checked by pressure on

the femoral artery. There was no thrill over it, but a softbruit could be heard on auscultation. The knee was semi-fflexed and movement painful and limited. There was alsoslight oedema around the ankle. The posterior tibialartery could be felt pulsating, but not the anterior. Therewere no signs of an aneurysm anywhere else, and theradials appeared to be normal and free from atheroma.The other organs were healthy, and there was no

- albumen in the urine. A sufficient assistance for con-tinued pressure on the femoral was not obtainable,it was derided to ligature the femoral artery. Thiswas done on July 23rd. The artery was exposed ab

the apex of Scarpa’s triangle by the usual incision, aNo 3 ahromicised catgut ligature passed round it througha small opening in its sheath, and firmly tied. A drainage-tube was inserted, the wound closed, stitched with silverwire and dressed antiseptically ; the whole limb wasthen enveloped in cotton-wool. All pulsation in the- sac was immediately arrested and its size slightlydiminished. After the operation the limb became coldand the foot rather dark calonred, but in about three hoursit began to lose its lividity, to feel warmer, and regain itsnormal appearance. Kexc day the sac felt firmer, and was- entirely free from aU pulsation, The tibial arteries couldnot be felt, bub the limb was warm, though slightly cede-matous. There was very little pain, but there was a feel-ing of numbness and tingling. During the next few daysthe leg, and especially the foot, became very painful, neces-sitating the use of hypodermic injections of morphia. Thesac remained free from the slightest pulsation, and was per-ceptibly contracted and consolidated. No pulse could bedetected in either of the tibials at the ankle. At the end ofa fortnight the operation wound had united by first inten-tion, and was entirely healed. The pain had ceased ; alledema had subsided, but the limb remained stiff andweak On Aug. ]8th the patient left the hospital. Theaneurysmal sac was then very much diminished in size, washard, the limb could be moved without pain, and the patientcould bear some weight on it. He was provided withcrutches, and not a’lowed to put the foot to the ground.In August but, thirteen months after the artery was liga-tured, he was again seen and examined. No sign of theaneurysm could be felt in the popliteal space, nor could

any pulsation be detected in either of the tibial arteries.The movements of the leg were perfect. The man com-plained of occasional numbness and pain about the instep,which at times even kept him awake at night, but other-wise he was as well as ever, and was able to attend to hisbusiness without the slightest inconvenience.CASE 3.-H. H-, aged twenty-eight, a timber hauler,

was assisting to move some timber on March 31st, 1890,when he slipped and fell, falling with his right knee,which was flexed, upon the edge of a triangular iron instru-ment called a " scraper," used for scraping the bark fromtimber. On admission to the hospital a few hours after theaccident the following condition of the joint was found.There was a transverse wound about three inches longrunning across the patella, cutting directly down to the boneand completely opening up the knee-joint. The patella wasfractured into three pieces. The upper fragment consisted ofnearly half the patella itself, the lower part of the bone wasdivided into two fragments, one small piece of bone waslying almost loose, separated from the surrounding tissues,whilst the other fragment and larger portion was stillattached to the ligamentum patellae. The patient wasimmediately put under ether, when Mr. Storry enlargedthe incision transversely right and left, removed altogetherthe smaller loose portion of the lower half of the patella,and, having cleaned and cut off some sharp corner of bone,sutured the remaining upper and lower fragments with two

°

wire sutures, leaving the ends long and outside the skinwound. The portions of bone came into excellent position, butleft a small gp where the loose portion had been removed.Two openings were made into the joint on either side ofthe patella, and drainage-tubes inserted. The joint waswell syringed out with (1 in 20) carbolic solution, whilethe skin wound was brought accurately together withcatgub sutures and dressed with iodoform and boracicwool, and the limb placed on a McIntyre’s splint. There isnothing much to record after the operation, the temperaturenever rose above 100° F., and the joint was dressed for thefirst time four days after the operation, when the drainage-tubes were removed. The leg was dressed once a week forthe next fortnight. Subsequently, when an attempt wasmade to unwind and withdraw the wire sutures from thepatella, the wire in each case broke off short close to the bone,and was consequently left alone. The limb was put up ina pIaater-of-Pans casing, and the patient was allowed outof bed with crutches six weeks atter the operation. InNovember, 1890, eight months after the operation,the patient" was examined by Mr. Storry, who found theknee-joint perfectly useful. Absolute bony union hadoccurred, and scarcely a ridge could be felt where the bonehad become united. The man had been at work for amonth, and declared he could use the joint as well as ever,and had felt no inconvenience from the wire sutures whichwere left in the patella. In February, 1891, he was

again seen, when he was doing his old work of timberhauling, the movements of the joint remained perfect, andhe could even kneel on it without any discomfort.

Medical Societies.PATHOLOGICAL SOCIETY OF LONDON

Discussion on Phagocytosis and Immunity.AT the meeting of the Society on the 16th inst. the

PRESIDENT introduced the subject in a few words. Thediscussion was to show how the blood dealt with morbidmaterial introduced into it. He then called upon Pro-fessor SiMS WOODHEAD, who in his address said thatthe phagocyte theory was closely associated either with"chemiotaxis" or the humoral theory. The latterappeared to be in direct opposition to MebchmkoiTstheory, though there was an attempt now being madeab a reconciliation and combination of the twc. Atpresent he was in favour of the theory of pbagoctosif.Metchnikoff and Buchner must he regarded as theleaders of the two fides in this controversy, though theresult of their work was now being corroborated or dis-proved by others. Metchnik;ffs view was that amoeboidcells, in contact with micro-organisms, retained their activity

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and function, whilst the incorporated germs died and dis-integrated. Many leucocytes appeared to have lost thispower; but as a primitive function of protoplasm it wascapable of bsing stimulated into action when required.Although so much stress had been laid on leucocytesat first, it had been shown later that not all thecells concerned were true leucocytes, but were fixedtissue cells deprived of their processes and occupiedby a large nucleus. These were the microphages or

final phagocytes, and were far more active and aggressivethan the macrophages or leucocytes. Their ordinary func-tion was to remove useless effete matter, but they appearedto combine together in the performance of the more difficulttask of attacking living organisms. The amceboid cellswere limited largely to the removal of innocuous material,organic or inorganic, which was a different form of thephagocytic function. It had been shown that the mesodermcells in sponge were capable of attacking and digesting aliving organism like leptothrix, and it was assumed thatthe scavengering power still remained, but that the attack-ing power had been lost by disuse. Tissue resistance meantpower of reaction of its cells, and cells, which in the firstinstance would be destroyed by invading bacteria, might byacclimatisation acquire the power of resisting them. Hethen referred to Metchnikoffs original experiments withthe Daphnia and the mode of absorption of the Monospora

bicuspidata, and proceeded to discuss the question oferysipelas, in which it was alleged that the streptococciwere outside the zone of leucocytes, so that if the cellsplayed any part it must have been in removing deadorganisms killed by the fluid extruded. With regard tothis, he would say that " what was sauce for the goose wassauce for the gander," and there was no more evidence forthis mode of destruction than for digestion in the firstinstance by the cells. Recently Metchnikoff laid morestress on the action of fixed cells. Anthrax bacilli hadbeen demonstrated within leucocytes, stained by anilinedyes. Inasmuch as bacilli stain when dead, this was no Ievidence of their ingestion, whilst living; but Metchnikoffhad shown that vegetable germs retained the power ofreproduction by isolating three such cells with thecontained organisms and obtaining a pure culture.Although thoroughly degenerated bacilli did not takethe stain, in some cases, where cells were breaking downowing to the bacilli being numerous and getting theupper hand, the organisms stained perfectly. In Frank’sexperiment on rats one only died out of twenty-two;the bacillus anthracis was killed in situ, being localisedby the density of the tissue and the congregation of leuco-cytes. The idea of chemiotaxis was originally suggestedby botanists. Experiments showed that deleteriousmaterials were avoided, whilst nutrient ones were taken upand inert ones were not regarded; but after a time the cellsbecame accustomed to the first variety and approachedthem. Metchnikoff stated that similar phases occurred inthe body, and that with the gradual increase of poison itsparalysing effect was not produced, and it was treated asinert matter. In opposition to this, Emmerich and Matteisuggested the presence of an anti-biotic fluid constitutingthe products of bacteria. They afterwards receded fromthis, and attributed its production to the cells of the host.This condition of " acclimatisation" Buchner pointed outmight be maintained, but was usually soon lost. This pro-cess of chemotaxis and getting rid of devitalised microbeshe looked upon as the cause of recovery and acquirement ofimmunity in acute germ disease. There were instanceswhere the same substance in different degrees of dilutioneither attracted or repelled cells, and it was shown bySchultz that yeast was actually more active in dilutesolutions of corrosive sublimate, iodine, or carbolic acid thanin simple solutions. To demonstrate the difference in actionbetween fluids and cells of the body upon micro-organismspathogenic organisms were enclosed in paper or pith enve-lopes and inserted under the skin of animals. Under theseconditions growth and development continued within, whilstthe animal, though susceptible, did not suffer from thespecific disease. Here fluids had free access, the cells alonebeing excluded. These processes, however, could not beconsidered the sole factors. It would seem as though thereacting and congregating leucocytes constituted the firstline of defence, the epithelium of the capillaries and lymphtracts the second, and when these were broken through theanimal system lay at the mercy of the invading germs. Ithad been suggested that by breaking up the leucocytes

some bactericidal material might be set free, as was suggestedby the action of quinine in certain diseases ; butonexperiment

titi was found that animals inoculated after treatment) in thisway died sooner than the " controls," and it was concludedthat active leucocytes exerted the more powerful resistance.Diphtheria and tetanus were instances of toxemia due todevelopment of bacteria in unhealthy areas of the systemor their introduction in large numbers, and could be resistedby destroying the bacteria before this toxine could be,produced in sufficient quantity to give rise to the charac.teristic symptoms. Immunity could be established by thesystem becoming accustomed to small doses of the poison.It was an extremely difficult thing to account for special-immunities for the several diseases. Many theories had beenproposed and disposed of without a satisfactory explanationbeing arrived at.Dr. BURDON SANDERSON declared that he was an

opponent of the theory of phagocytosis, and said that hewould endeavour to place before the Society the difficultiesthat be and those who thought with him had in acceptingthe theory. He would only touch the question of the actionof the leucocytes. The facts themselves were not in dispute.but the interpretation of them might, he thought, be foundwithout ascribing to leucocytes any other than their knownphysiological properties ; whereas those who believed inphagocytosis allowed to leucocytes an extraordinary powerwhich was not in accordance with the accepted principles of

biology. An organism as a whole, such as a human being,had a certain power of recovering from injuries and ofresisting micro-organisms, which might reasonably be termeda specific power. All were agreed that on the invasion ofthe organism by an exciting cause of disease leucocytescollected at the point of entry. Those who believed inphagocytosis attributed this to a specific power of theleucocyte to counteract the particular disease, and not,to their ordinary physiological properties. These latterwere essentially three: (1) Amoeboid movements; (2) thepower of incorporating solid particles ; and (3) theirsubjection to a kind of allurement or repulsion whichmany substances had over them, known as "chemio.taxis." Whenever an injury happened to the body, pro-vided it was of moderate intensity and capable of producing;ordinary inflammation, a migration of leucocytes towardsthe injured spot set in. The explanation was that so longas the surroundings were normal the leucocytes remainedquiescent, but that as soon as a devitalisation of any partoccurred, a flow of leucocytes from the normal to theabnormal part set in, and that this was a physiological-process was shown from the fact that it occurred during theabsorption of a tadpole’s tail. As the movements ofleucocytes were independent of the nervous system, itwould be as reasonable to attribute to the tadpole’sleucocytes an appreciation of the advantage which wouldaccrue to the frog from an absorption of its tadpole tail asit was to ascribe to the leucocytes the wonderful specificpower of acting differently to the various specific infections.

Professor KLEIN admitted his inability to accept thearguments advanced by the supporters of the phagocytetheory, and in support of his position he stated that thequestion of phagocytosis embraced a very much wider fieldof observation than was included in the views alreadyadvanced. Some investigators included all instances inwhich bacteria were found engulphed in cells. This, hecontended, was the first error, and illustrated his remarkby exhibiting a number of photo-micrographs showing adozen instances of micro-organisms contained in cells whichwere breaking down under their influence, thus reversing;the process described. He said that the influence ofchemiotaxis, as shown in the cells of bile, diiets in whichpsorosperms were growing, was of quite a different natureto that asserted. In the many cases of immunity inwhich inoculation was not followed by disease, werethe bacilli killed by leucocytes or some other agent,or by the two in combination ? He referred to theexperiment of Emmerich and Mattei, in which it was.shown that the micrococcus of swine erysipelas, whichwould kill a rabbit when injected subcutaneously, did notdo so when introduced into the circulation ; and further,that an animal so treated acquired immunity from in-fectability by subsequent inoculation, and that phagocytescannot then be found at its site. Reference was made also,to the observation of Metchnikoff-tbat after forty-eighthours living bacilli can still be found in the blood of animmune animal ; but it was stated that in such cases there

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was not a commensurate number of cells containing themicro. organisms. In the dog, cat, and rat, which wereinsuseepuibleiib was extremely difficult to find any adequateaumber of bacillus- bearing cells after inoculation. In thenext place, he would ask if there were any well-establishedcases in which bacilli were known to have been destroyedby lymph or other juices-and here he alluded to

experiments being carried ou!) by Dr. Frederick Andrewes,and which showed that pus already dead, and even

when twenty-four hours out of the body, had a rapidlynoxious effect upon these organisms. When anthrax was11ntroduced into the dorsal lymph sac of a frog hours elapsedbefore any bacilli were seen enclosed in cells, the lymphitself being capable of destroying them. Professor Kleinhen gave an account of some experiments, in which it wasfound that a rapid diminution in bacilli occurred withintwo hours of their introduction into the body, which wasnot at all in accordance with the time observed in theirgradual approach and engulfment by cells. He thoughtit was much simpler to assume that the juices of the bodywere germicidal, though Buchner’s explanation gives littleaccount of what takes place with regard to the bacilli afterthey are weakened by exposure to them, as to whether theyare then taken up and carried away by cells, acting as

scavengers. That important part of the cell’s duty had yet

to be proved.Mr. KANTHACK said the question at issue was" whether

immunity from infective diseases or lesions was caused byphagocytosis-that is, through the phagocytes alone andthrough nothing else." The chief points are : I. The influ-ence of the body fluids ; II. Chemiotaxis; III. Phago-cytosis. I. Do the living fluids of the body play no part inthe production of immunity ? The serum of many animalshas a marked bactericidal power outside the body, bub we- cannot establish any general law, because there is no

necessary correlation between the natural insusceptibility ofan animal to a disease and the bactericidal power of itsserum over the microbe causing such disease. This has beenput forward as a grave objection to the so-called humoraltheory. But he thought wrongly, for it is impossibleto draw any logical inference as to the artificial- causation of immunity by contrasting a naturally immuneanimal with a naturally susceptible one. In future, experi-ments should be made in such a manner that the bactericidalpower of the serum of a naturally susceptible animal betested (a) before it has been immunised, and (b) after it hasbeen artificially immunised. If, then, any law can be estab-lished, we must expect to find one or more of three con-- ditions&mdash;namely, after the acquisition of immunity theserum should be (1) either more bactericidal, (2) or possessgreater attenuating powers, (3) or possess greater destructivepower over the toxines of the microbes. It is too narrow tojudge by the bactericidal power alone, for it is im-possible to disconnect the bacteria from their metabolicproducts, and it is these which cause the disease. As longas the poison is not neutralised, it matters not whetherthe bacilli are eventually killed or not. To give examples,we find-(l) Under the first heading that (a) the serum ofa guinea-pig after artificial immunisation kills the vibrio’Metchnikovi; (b) theserumof a guinea-pigafterimmunisationhas greater bactericidal power over the bacillus Chauvcei.As an exception, we may mention the serum of a sheepprotected against anthrax. But, on the other hand, Christ-mas succeeded in extracting from the organs of an immunisedrabbit a substance which had greater destructive power overthe anthrax bacillus than a substance similarly extractedfrom the organs of a rabbit not protected against anthrax.According to Bouchard, it has been proved for nine infec.tive processes that the serum of the immunised animal hasgreater bactericidal power than the serum of the sameanimal in the non-immunised condition. These are anthrax,charbon symptomatique, cholera, erysipelas, diphtheria,tetanus, pneumonia, and the lesions caused by the vibrioMetchnikovi and the bacillus pyocyaneus. (2) Under thesecond heading we find that (a) the serum of an immunisedrabbit attenuates the streptococcus of erysipelas; (b) theserum of an immunised rabbit attenuates the bacilluspyocyaneus. (3) Finally, under the third heading, we findthat (a) the serum of an immunised animal neutralises thetetanus toxine; (b and c) the same has been asserted withregard to the toxines of diphtheria and pneumonia.<1) Those who object to test-tube experiments as beingartificial do not hesitate to use little paper bags filled witt.germ?, and place them under the skin of refractory or im.

munised animals. Such experiments are as little natural astest-tube researches, for (a) we thus localise the process byartificial means; (b) the fluid which passes through thepaper may be of an inflammmatory nature, and is not neces-sarily the same as the normal body fluids. In studyingthe artificial production of immunity, the absolute followersof Metchnikoff are prone to neglect the most important partin the causation of infective diseases and lesions-namely,the chemical products of the microbes which undoubtedlycause the phenomena of such diseases. (a) We findthat an animal made immune against a living microbecan also resist the toxine of such microbe to varyingdegrees. Examples are tetanus, pneumonia, diphtheria,vibrio Metchnikovi, pyocyanens, charbon symptomatique,and others. (b) Vice versd, an animal made immune againstthe toxine also resists the living microbe. Therefore theprocesses responsible for these results must assumedly bethe same. Now immunity against toxines cannot in anyway whatever be explained by means of phagocytosis. Heconcludes, therefore, that at the present state of knowledgeit is impossible to assert that the living plasma (or bodyfluids) are of no consequence. 2. Chemiotaxis has of latebeen introduced as a welcome support to the phago-cytic theory. Certain chemical substances, accord-ing to their degree of concentration, attract or repelthe phagocytes, but if the phagocytes are in a mediumalready containing these chemical substances, equally dis-tributed, they will not be attracted on adding more ofthese substances unless they be added in a highly con-centrated condition. Analysing this, we have three pos-sible cases:-(a) The metabolic products of the microbe arepresent in equal quantity in the tissues and at the seat oflesion, therefore no migration of phagocytes can takeplace. (b) If the degree of concentration is higher at theseat of lesion, we shall have a migration of phagocytesthereto. (c) If the degree of concentration is higher in theblood, the phagocytes may migrate back into the blood.This teaches us nothing as to the acquisition of immunity,for (1) if true, it is simply a statement of concomitantfacts ; (2) on such a view our successes in the productionof immunity become merely a matter of chance and goodfortune; (3) it supposes, without the slightest foundation,that in an animal immunised against a microbe, the toxineof such microbe circulates in its vessels ; and, lastly, it

: neglects the fact that, besides diapedesis, we have, as a rule,: hand in hand with positive chemiotaxis, a great general

increase of phagocytes and leucocytes, depending ofnecessity on a stimulation not of the leucocytes and

i phagocytes, but of the elements giving birth to thesei bodies. Hertwig, in his monograph, sums up this theory

in the following manner: "(a) In an immunised organismthe negative chemiotaxis, which the body exhibited

, before being made immune, has been replaced by a chemio-: taxis behaving positively towards the specific virus." If so,.

we ask, Why and how ? We are also told that" the effects. of the metabolic products of microbes show themselves as, positive and negative chemiotropism and also as acquired. irritability (Reiznachwirkung). The existence of positive

chemiotropism explains the localisation of the virus throughthe attraction of leucocytes and subsequent phagocytosis.The existence of negative chemiotropism explains the possi-bility of a general infection by means of a diffusion of themicro organisms. By means of suitable injections of bacil-lary products a negative may be changed into a positivechemiotaxis, and thus a cure be effected." This ismystical and unsatisfactory, and treats of the bodyas though it were a specimen on the microscopic slide.1. By causing fever artificially in a susceptible animal,two or three hours after the temperature has begun to riseconsiderably there is a very great increase of leucocytes, not aonly of the so-called lympho.cytes, but also of the larger ele-ments, and this leucocytosis persists for more than twelvehours. On inoculating the animal when in this conditionwith anthrax it will die just as usual; yet here the army ofphagocytes was increased at least tenfold. 2. Thus the in-creased number of phagocytes per se is not sufficient. Theyrequire also the special training. And here we come to themost unsatisfactory part of the theory. Before an animal isimmunised the phagocytes are more or less inert against aparticular microbe, but as soon as ever a relative immunityis established they are extremely voracious. We must ask,why does phagocytosis appear now or why are the cells sud-denly enabled todestroywhat previously perhaps killed them?3. The occurrence and importance of vaccine fever during

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the process of immunisation points to more general changesthan a mere change of habit of the phagocyte alone.4. That changes occur in all the tissues has been shown byEmmerich, who succeeded in protecting animals by inocu-lating them with the tissue juices of such as had been im-mumsed. 5. Some of the methods of immunisation, as theinjection of so-called antitoxine, or of small repeated dosesof poison, &c., point strongly to general changes in the body,the phagocytes being altered with the rest of the body.6. Lastly, phagocytosis does by no means explain many ofthe phenomena mentioned in the first part of the discourse.

MEDICAL SOCIETY OF LONDON.

On the Cure or Subsidence of Ascites due to Hepatic Disease,&mdash;H&aelig;matemesis, with Special Reference to that Form medwith in Females in Early Adult Life.AN ordinary meeting of this Society was held on Feb. 15th,

the President, Dr. Douglas Powell, in the chair.Dr. J. S. BRISTOWE read- a paper on the Cure or Sub.

sidence of Ascites due to Hepatic Disease. He took as hiatext four cases which were under observation up to thepresent time. 1. A governess, aged forty-four, who cameto St. Thomas’s Hospital in the summer of 1886. She wasdepressed and lacrymose, and suffered from delirium andhallucinations. She had jaundice, ascites, oedema of thelegs, and diarrhoea ; also suffering from bronchitis and anattack of poly-arthritis during her stay of nine months anda half. There was no albuminuria and no enlargementof veins. Five, thirty two, and thirty-four pints of fluidwere removed by paracentesis abdominis on three severaloccasions, and she left greatly improved on May 24th, 1887.She was again admitted on Aug. 29th, 1889. Her com-plexion was sallow, she still had bronchitis, and eighteenand twenty pints of fluid were removed from theabdomen. She left on Jan. l2th, 1890, and has con-

tinued well since except for the bronchitis. Shewas seen last week. The case was a typical one

of chronic alcoholism, as was borne out by themental condition, and an attack of peripheral neuritison the second occasion, and it may be accepted that theascites was due to cirrhosis of the liver which still existed,and was liable to induce a recurrence of the ascites. 2. Agentleman aged thirty-five who had fallen into intemperateand immoral habits in 1878. He was lost sight of tillOct, 8bh, 1882; he was then weak and thin, suffered fromsickness, and for three weeks had had oedema of the feetand ascites. On Nov. 20th he was worse, was irritable andrambling, and had in addition some fluid in the left pleura.On Nov. 22nd he was admitted to Sb. Thomas’s Home, withjaundice and dyspn&oelig;a, the left pleural and the peritonealcavities being full of fluid. A month later he was improvedin all respects. Three pints of fluid had been removed fromthe pleura, and he left on Jan. 24th, 1883, for New Zealand,where he has remained in fairly good health. Here, a.gain,was a very clear alcoholic history; and though the ascitesgot well without tapping, there could be no doubt, from thefact of the development of this form of dropsy and ofjaundice, that his liver was at that time affected withearly cirrhosis. 3. A man in good circumstances, aged forty,who kept an eating-house. He was known to drink manyglasses of spirits daily, and was seen in consultation onOct. 24th, 1888. His complexion for some time had beensallow, and for six weeks there had been enlargement of theabdomen and oedema of the legs. In addition the liver wasenlarged and there was jaundice. He was enjoined to ab-stain from alcohol, to take a tonic and a pill of mercurydigitalis and squill. He was tapped five times; nine,thirteen and a half, nineteen and a half, nineteen, andfifteen pints being removed. On Dec. 28th the liver wassmaller, and he had gained flesh ; four tappings were per-formed since, the quantity of fluid removed being eight tosixteen pints, the last occasion being in August, 1889. Afterthat he went to Vichy, and on his return took cold and waslaid up with bronchitis and pleurisy. He was tapped againon Feb. 5th and March 3rd, and twice since, and has beentaking 1-16th of a grain of iodine off and on. On Feb. 8tb,1892, he was in excellent health and spirits, and carried onhis business with his old energy, going to market three timesa week, but he continued to take gin-and-water. In thiscase paracentesis was performed fourteen times in the

course of a year and ten months, the alcoholic his.tory was indisputable, and that the ascites dependedupon the hepatic disease is shown both by theenlargement of the liver and the temporary jaundice.4. A lady, aged twenty-four, belonging to a respectableand wealthy family, with small and delicate physique, andusually enjoying good health, was seen April 30th, 1890.At the end of the preceding year she had a sudden andprofuse attack of hsematemesis while abroad ; there was a.recurrence on arriving at a seaport in England, andsince reaching home there had been two more, the last on.the dav preceding the consultation. Latterly there hadbeen pain and uneasiness after focd, with loss of appetite.She was ansemic and weak, acd was treated for the ensuingtwelve days as a case of simple ulcer of the stomach, withgreat improvement. The abdomen then filled rapidly inthree days. Eleven pints were removed on May 15th,and by the 28th paracentesis had been performed threetimes, nine pints being withdrawn on each occasion. The1L ver was now found to be enlarged. The general healthhad improved, and the gastric symptoms had disappeared.After another tapping a small nodule could be felt, and theidea of cancer was entertained. In June she was tapped fourtimes, the quantity removed being from four to fifteen pints.Itwas then found out that a brother had been under treatmentfor a congenital syphilitic affection of the eye. This led to!the diagnosis of syphilis, and iodide of potassium was pre. ,

scribed in - ten-grain doses. Later the quantity was in.creased and mercury was added. In August she was tappedfour times, and in September thrice, the quantity being fromfour to seven pints. Altogether paracentesis was per.formed twenty-seven time?, the last occasion being Sept.22nd, 1890. She was now better than she had been foryears. The causes of obstruction were threefcld : 1. Truecirrhosis affecting the small vessels and capillaries. 2. Cancerous and syphilitic growths occupying the transversefissure compressing or involving the portal trunk, andocclusion by thrombi. 3. Obstructive disease of the heartor lungs causing " nutmeg " liver. The first three cases be-longed to the first and the fourth to the second class, With reagard to the mode of recovery in these cases, it was, in the firstplace, amply proved that there is a fairly free communicationbetween the portal vein and the systemic veins, and hencewhen portal obstruction exists there is a tendency for theblood of the portal circulation to be shunted into some ofthese other veins which gradually dilate, so that withoutany beneficial change in the liver itself the ascites may dis-appear. The oesophagus, as shown by Drs. Wilson andRadcliff, has a ring of veins which is largely concerned inthe process, and the consequent varicose condition of thesubmucous veins in this pare and their tendency to ruptureare the source of the profuse haemoptysis and mel&aelig;ria in thelate stages, though the vessels of the stomach and duodenumare the ones affected ab first. Sometimes, however, ther&is no evidence that the anastomosing veins have dilated,and on this supposition alone recurrence of ascites after re-newal of bad habits would be inexplicable. Moreover, in thecase of a chronic inflammatory process dependent on anirritant locally applied, cessation of the influence would belikely to be followed not only by arrest of the disease, butalso by some amelioration in so much of it as had recentlyoccurred and was amenable to treatment. In the nrft threecases there was jaundice, which implied a wider orprofounderchange than that producing ascites, and which subsided.Again, as in Case 4, there are causes of obstruction whichare removable. The tfficacy of treatment depends largelyon the accuracy of diagnosis. Doubtless there ale manycases of visceral syphilis which are misinterpreted to thedetriment of the patient. A simple and fairly successfultreatment is to promote the general health by suitable dietand tonice, to cut off alcohol, to tap from time to time with-out waiting for extreme distension, and to regulate thebowels. Bearing in mind the tendency to spontaneousdiarrhoea,, purgative measures were not to be recommended,and diaphoretics were of little use ; more was to be hopedfor fromdiuretics, especially copaiba in teo-graindosesandthepill of mercury, digitalis, and fquill. There was no objec.tion to the use of mercury and iofiide of potassium in the earlystages.&mdash;The PRESIDENT, referring to cedema of the legs, saidbe should be inclined to attribute it rather to the general con-dition of the heart and circulation, and he thought that restand deprivation of alcohol was to some extent answerable forthe improvement that took place under treatment, apartfrom local considerations.-Dr. HAVILAND HALL suggested