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Mr. N. BISHOP HARMAN read a paper on the cognatesubject of the Education of Children with Defective Vision.The claims of the Montessori system were compared withthe scheme of myope classes which had been working inthis country and America for seven years. In Italy theMontessori system had one great advantage over the currentmodes of education, in that it allowed for the per-sonality of the child, and it had proved of great value formental defectives. But the spirit of England was againstanything in the nature of drill-sergeant education, personalityhaving always been fully recognised ; moreover, in itstechnical methods the Montessori system had nothing newto offer, and it had been claimed that a substitution of

feeling for sight was a reversion to a lower order of things.If the claim were substantiated that by the Montessorisystem a child learned to read two years earlier than by theordinary methods, it effectively condemned the system forchildren with defective vision ; it placed the child too earlyinto the unreal world of books, and there was an absence ofchildish questioning for information. The myope class hada natural origin, numbers of short-sighted children had tobe dealt with. The scheme resolved itself into three

parts: (1) Oral teaching with normal children ; (2) literarywork in the special class where all the work was doneon blackboards; and (3) handicraft work, which hadboth utilitarian and expressional" " value, and to thiswork were attached the practice of history, arithmetic,geography, and so on. Despite the regulation forbiddingwork necessitating stooping and the use of rules and scales,the handicraft work had been highly developed. It was

working as a full scheme in elementary schools for childrenaged from 7 to 14 years, and was also used, with modifica-tions, in the teaching of children in well-known public schoolswith equal success.The papers were discussed by Mr. CHARLES WRAY and

Dr. G. E. SHUTTLEWORTH, and Mr. PATON and Mr. BISHOPHARMAN replied.The following clinical cases were shown :-Mr. A. C. HUDSON : Two cases of Couching of the Lens.Mr. STEPHEN MAYOU : Glaucoma in a boy aged 17 years.Mr. G. W. ROLL: (1) Bullet Wound of Orbit; and

(2) Proptosis.Mr. RAYNER BATTEN : Vascular Keratitis of Upper Third

of Cornea, with Terminal Perivascular Deposits.Mr. WRAY : Conical Cornea.

ROUEN MEDICAL SOCIETY (ROYAL ARMYMEDICAL CORPS).

Typhoid -FeverA MEETING of this society was held at No. 11 Stationary

Hospital, Rouen, on Feb. 13th, Colonel B. M. SKINNER beingin the chair.The following committee was appointed to conduct the

affairs of the society, the A.D.M.S., Rouen, consultingphysicians and surgeons, and honorary general secretary tobe ex-officio members of the committee Lieutenant-ColonelC. B. Lawson, Major A. J. Hull, Major Adye-Curran,Lieutenant Struthers, and Lieutenant Harold Wiltshire.Lieutenant Beckwith Whitehouse was elected to undertakethe duties of honorary secretary and treasurer.

Colonel SKINNER announced that a large consignment ofmedical and surgical books had been received from Messrs.W. B. Saunders Company for the use of members of thesociety, and these had been placed in a room at the Hotelde la Poste, kindly placed at the disposal of members byColonel Sir Berkeley Moynihan.

Colonel Sir BERTRAND DAWSON, in opening a discussionon Typhoid Fever, said that he proposed to treat the subjectunder the following headings: (1) Early diagnosis ; (2) atypicalcases ; (3) the results of inoculation; and (4) the coexistenceof typhoid and paratyphoid. The most important points inthe early recognition of the disease are headache, fever, alow pulse-rate, and cough. If typhoid is rife and a patientpresents himself with a temperature of 1030 F., pulse90-100, and headache cultures should be made at onceand a dose of vaccine administered. In about 30 percent. of cases epistaxis occurs as well, and must benoted in relation with the above symptoms. Mistakes are

most likely to occur in relation with meningitis, influenza,

and measles. Measles is usually quite evident by the-fourth day. The slowness of the pulse in relation to tempera-ture is most striking and helpful. It is not uncommon tofind fever of 1020 and 1030 associated with a pulse wellunder 100. Furthermore, the pulse-rate may frequently beregarded as of prophetic value. Thus, a pulse consistentlybelow 100 indicates spontaneous recovery. On the otherhand, a rising and high pulse-rate means a severe infection.Frequently the rate will increase to 105 or 110 long before-other symptoms arise. It is advisable to chart the pulse-readings as well :as the temperature, for reference. If the

pulse line remains below the temperature all is well ; if it.

mingles with the latter complications may be expected ; if,.on the other hand, the tracing wanders above the temperatureline danger is foreboded. The speaker illustrated theseremarks by a series of charts. As regards the diagnosis.between typhoid and meningitis and influenza some diffi-

culty may arise, owing to the fact that both diseaseshave a slow pulse in relation to temperature. In.

meningitis pain and stiffness of the neck and the initialvomiting are important diagnostic points. The banishedabdominal reflex does not help much, as it is sometimescommon to both diseases. Kernig’s sign and absence ofknee-jerks have also been noted in typhoid. Lumbar

puncture may b3 performed in doubtful cases, but only whenother diagnostic signs have failed. Influenza more frequentlygives rise to mistakes in diagnosis. In both typhoid andinfluenza headache is present, and in both a sore throatmay exist. Influenza, however, always presents physicalsigns by the fourth day of the disease. The most importantof these is fine bronchitic signs and blocking of the lungbases. This may occur in typhoid also, but the clinicalpicture is totally different. The influenza patient underthese conditions is restless and excitable, whereas thetyphoid individual is somnolent and apathetic. Swabs

may be taken from the throat, but it must beremembered that the influenza bacillus is easily missed.As regards a blood count, typhoid is undoubtedly one

of the fevers that give a leucopenia; but with influenzait is not uncommon also. In discussing paratyphoid SirBertrand Dawson observed that paratyphoid A is hardlyknown in England, although of common occurrence in India.Paratyphoid B, on the other hand, occurs not infrequently,and he thought that many cases are probably being missedat the present time and not reaching the base hospitals.Clinically, the disease is often indistinguishable fromtyphoid, exhibiting the characteristic splenic enlargement,spots, bronchitis, &c. The cases recover more quickly,however, and relapses are less frequent. He did notremember a single case in which perforation had occurred.As regards the temperature, the fever is remittent from thefirst and subsides about the sixteenth day. Considerable

difficulty arises in the diagnosis of the slight cases. The

patients are usually seen at too late a stage to get a bloodculture, and the temperature only lasts for three or fourdays. In a series of 6 cases of slight fever recently investi-gated 2 proved to be paratyphoid. With regard to the

question of antityphoid prophylactic inoculation, he hadinvestigated a series of 27 cases of paratyphoid B. Of these,21 had been inoculated. He suggested that if the incidenceof paratyphoid increases the prophylactic vaccine should bea mixed one and include strains of paratyphoid B. Thedisease is communicated probably by carriers and directcontact. Discussing the relation of prophylactic inoculationand true typhoid, Sir Bertrand Dawson noted that in 61recent severe cases 14 only had been previously inoculatedand 47 untreated. Of 37 mild cases, 28 had received vaccinepreviously and 9 had not. The proportion in each is there-fore about 3 to 1. No death had occurred in the inocu-lated cases, although there had been two narrow shaves.Referring to the Widal test, the speaker observed that it hasthe disadvantage of not being available during the first week.Also it is always present after inoculation, and although thedilution increases during the progress of the disease theinformation given is necessarily late. Furthermore, the test.is eccentric. He cited various instances in support of this.fact. In one case the blood was positive to typhoid, but theWidal was negative throughout. In another case the testwas positive one day, negative the next, and positive againthe next. In yet another patient the Widal was negative twadays before death and positive in blood taken post mortem.People are apt, therefore, to put too much reliance upon the

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test. From a clinician’s point of view nothing comes up to ablood count. With regard to blood cultures it is curious howin some cases they are always negative. Does this mean thatthe bacilli are absent from the blood or present in very minute Inumbers or is the culture medium not correct ? It is knownthat the B organisms are present in plenty in the spleen, andthe speaker asked if it was possible to obtain the blood forculture from such an organ or perhaps the liver. Punctureof the latter organ may easily be performed between the

.eighth and ninth ribs, and if a medium-sized needle is

.employed sufficient blood withdrawn for culture purposes.Examination of the stools becomes of increasing importanceowing to the failure of the Widal test due to inoculation.With regard to therapeutics, most interest centres round

specific treatment. It is very difficult to maintain an openmind on this matter, and to designate between post hoc andpropter koe. On the one hand is the man who sees very little

good derived from vaccines, and on the other is the manwho lauds them to the skies. Whilst it is easy to estimatecorrectly the value of vaccines in the chronic lesions, it is-difficult to judge success in the acute conditions. The onlycriteria upon which to base deductions are (1) statistics, and(2) clinical data. With regard to the former, it must beremembered that statistics are ever unreliable. It is

important, for example, to know if a specific epidemic issevere or not. The mild cases get well whether vaccines are.employed or not, as do also paratyphoids. Concerning theclinical facts the important points are : (a) Does the patienthave more resistance under specific treatment? (b) Does herelapse less ? To obtain these facts each observer must statehis own views, and this introduces a fallacy due to thepersonal element. Illustrating the mistakes that may arise,the speaker referred to a case in which the temperature fellafter each dose of typhoid vaccine and yet the bacterio-

logists report the case to be one of paratyphoid. Sir.Bertrand Dawson’s view with regard to vaccines was thatthey are valuable if used with caution. Inoculation mustbe commenced early and in larger doses than are usually ’administered. 750 million should be given rather than theusual 200 million, increasing every second day until.500 million are reached. It is preferable to employ the ilarger dose in the hope of overtaking the disease, and no ],harm will result from the larger doses. The heterogenous heterogenous

army vaccine should be used, although some people prefer ran autogenous vaccine. The latter is open to the objection }that it may not possess the same immunising power as a 1

beterogenous preparation of proved value. Living cultures (

tave been tried in some quarters, and it is claimed that tisaocess has followed their employment. It is, however, a t

dangerous question and one which requires more thorough Binvestigation. The number of typhoid carriers, for example, r

may be thus increased. In the complications of typhoid fever tvaccines undoubtedlydo good. This is particularly the case in I

periostitis. With regard to diet, all kinds of views prevail a

from the advocates of starvation to those who advise u

solid food. Concerning the latter it appears almost im- s

possible to give solids to an individual who has no appetite pand whose mouth is exceedingly dry and foul. In the few Foases, however, where these measures have been employed c

perforation has not followed. Starvation also cannot be n

recommended unless distinct advantages are gained A

thereby. The ideal diet is milk. used as a basis, and h

.supplemented by Benger’s or Mellin’s food, and beef o

juice. Chocolate may be given with advantage, and supplies s]the necessary amount of carbohydrate. When the tem- h

.perature is approaching normal the amount of food gshould be increased. On the continent treatment by baths tihas a very wide application. Unless it can be proved, w

however, that it really materially improves the symptoms, hit is a method which appears to have more disadvantages ojthan advantage. The constant moving disturbs the patient, irand unless the circumstances are such that the whole bed b<-can be immersed in the bath it is better to employ other treat- tlment. A continuous warm bath of 100&deg; is good in cases htassociated with muttering delirium, but even in the best con- 01- ditions of civil practice it is difficult to arrange. As regards n(

the empoya ent of alcohol. in an ordinary straightforward ar

case it is not required. With a high pulse-rate, however, bEand toxasmia it is valuable, and should be given. Strych- tl;nine is useful if abdominal distension is marked and ell i.the pulse not good. l’ltuitrin is also well worthy I W&laquo;t’ trial. The speaker concluded by discussirg the in

symptoms and treatment of typhoid perforation. Thisaccident should be suspected if (a) acute pain suddenlydevelops in the abdomen, followed by distension, rigidity,and a rising pulse ; or (b) if the pulse is rising and thepatient is exceedingly clear in mind. In the latter case

pain may be little and distension absent. Two such caseshad occurred at Wimereux. As regards treatment, if a

surgeon is available it is best to operate. If, however, thesite of perforation cannot be reached quickly the propercourse is to leave the patient alone and administer morphia.It does not follow that all such patients die. Severalinstances are on record where the perforation has been closedby local adhesions.

Colonel Sir WILLIAM LEISHMAN, continuing the discussion,observed that during the six months the war had lasted only605 cases of typhoid fever had occurred in the Britishtroops and 25 in the Indian. In other words, ab:ut only halfa battalion had been incapacitated from this cause. Of505 of these cases 72 had been iully protected by inoculation(two doses of vaccine within two years), 113 partially pro-tected, and 320 uninoculated. These figures proved onceand for all the value of protection. It was impossible, forobvious reasons, to publish the total number of men that hadbeen inoculated, but he could say with conviction that from80 to 90 per cent. of the army were now protected. Withregard to the question of mortality no death had occurred inthe fully protected patients, one only in the partly protected,and 45 in the uninoculated cases. The influence of inocula-tion upon the severity of the case was also made evident bythe figures obtained during the last six months. Theavailable material might be classed as follows:&mdash;

furning to the question of vaccine treatment, the speakeradmitted that nothing was harder to answer as to whethervaccine treatment in typhoid was a success or not. In aseries of 146 cases 94 had been treated by vaccines. The:esults might be given as follows : Good, 28; doubtful, 30 ;10 benefit, 17 ; too early to judge 19 ; total, 94.rhe large majority of cases have not had a fair chance ofDroving the value of vaccines. They are seen too late, veryarge numbers not being treated until the end of the second)r well into the third week. Also, many of the patients,reated by typhoid vaccines have later proved to be para-yphoid infections. Furthermore, the cases treated by’accine are usually the most severe, the milder conditionsecovering without resort to these measures. As a result ofhis no controls are available. With regard to Sir Bertrand)awson’s suggestions on the use of mixed vaccines of typhoidnd paratyphoid he (the speaker) said that the matter had beennder consideration, but personally he had been against theame on two grounds-(l) increased danger; and (2) thepossibility of damaging the typhoid element in the vaccine.eferring to paratyphoid B he agreed that many mildases of this type were undoubtedly being missed. The

iajority of them remained in stationary or clearing hospitals..s Sir Bertrand Dawson had remarked, paratyphoid B hadhemorrhages and relapsed, but perforation very rarelyscurred, if at all. Concerning Widal’s reaction, theweaker said that if the bacteriologist had the time atis disposal to apply the test thoroughly, it was capable ofliving very valuable information. The anomalies that fromme to time occurred could be explained. For example,ith regard to fluctuation, it must be remembered that theeight of agglutination is only a rough index of the amount: protective substances in the blood. These substances varyL cases of severe infection-e.g., agglutinins disappear justfore death. It is therefore not to the discredit of the testiat these variations occur. He (the speaker) was glad to3ar Sir Bertrand Dawson lay stress upon the importance’ blood cultures. As a matter of fact, all cases are

)w being dealt with systematically on these lines,id the number of occasions upon which bacteria have;en found in the cultures has been considerable. ProbablyLe number of organisms present in the blood varies onfferent days of the disease, as is the case with plague.’ith regard to the previous speaker’s suggestions of obtain-g blood from the spleen or liver, French physicians had

604

made investigations concerning the former organ but hadsince abandoned the method, which was hardly justifiable.It was not difficult, all the same, to obtain blood from thespleen, and in kala-azar from 200 to 300 cases had been in-vestigated without danger or mishap. Hepatic puncturewould probably be of little use owing to the difficnltyof obtaining hepatic blood. Unless the tissue is definitelybroken up the blood obtained would be that circulating andnot true hepatic. In conclusion, Colonel Leishman referredto the value of autogenous versus heterogenous vaccines in thecase of typhoid fever. He agreed that so far the ideal vaccinehas not been reached. The army vaccine has given verygood results in the past, and he preferred to employ a pre-paration of proved value than one of uncertain worth.Rawling’s vaccine was as good as any, and when a goodantigen was known it was inadvisable to waste timein using a possibly inferior strain. The question ofemploying living cultures was undoubtedly an importantone. Lieutenant Rowlands, at No. 10 Stationary Hos-

pital, had used living cultures upon four occasions andthe attacks seemed to have been aborted. Further trialswere needed before a dennite reply upon this matter couldbe given.Lieutenant HAROLD WILTSHIRE said that owing to the

very short period he had been in charge of the typhoidcases in Rouen he was unable to speak at length. AtNo. 12 General Hospital 68 cases of enteric fever hadbeen treated, and of these 10 had died. With regardto the value of preventive inoculation, the figures fromRouen had been included in Sir.William Leishman’s report.It was a matter of extreme difficulty to ascertain in manyinstances whether a man had been inoculated or not. The

army pay book was not always available, and in someinstances men said that they had been inoculated when thereverse was the case. The effect of inoculation upon theWidal reaction urgently requires investigation. In practicethe test is only pushed to the degree of diagnosis and not toits highest dilution. Blood cultures had been taken in 35cases. The method was a very useful one, and was now theroutine. In discussing the points of diagnosis, LieutenantWiltshire laid special stress upon the slow pulse, the greathelp derived from the tongue, the slightly full and tym-panitic abdomen, and a gurgle in the right iliacfossa. As illustrative of the difficulties of diagnosis hereferred to the abortive and ambulatory types of the diseaseand quoted cases which were only proved by conducting abacteriological investigation of the fasces. He suggested thatpossibly the clinical aspect of the disease is modified byinoculation, since so many of the cases resembled influenza.He was inclined to the belief that, as a rule, when an inocu-lated patient gets typhoid he was a mild but typical case.As regards vaccine treatment, out of 68 cases, 48 had beentreated by vaccines, and of the latter 45 had been hetero-genous and of the ’’ stock variety. In 21 no improvementwas noted and in 24 it did good. The dosage had been125 million, working up to 500 -million. No ill effecthad been seen from larger doses. Late in the diseasevaccines may give an increased possibility to hoemorrhage,bat as a rule in practice this symptom occurs so

late that vaccines are not required. The time forvaccine treatment is undoubtedly the first fortnight, and thespeaker suggested that it should be combined with anti-endotoxic serum. The vaccine will kill the bacteria andthe serum will neutralise the toxin. Concerning drugs, ,,urotropine in large doses had been tried, but so far noimprovement had been noted. Salol and other antisepticsalso appeared to be useless. In order to prevent the foulcondition of the mouth Lieutenant Wiltshire recommendedthe employment of chewing gum. He was accustomed tc

prescribe it in every case where nutrient enemata wereindicated.Major A. B. SMALLMAN said that case mortality is th<

true test of the value of vaccine treatment and this had beer

amply proved by the figures laid before the meeting. H(referred to a series of 235 cases treated in South Africa, som<by heterogenous and some by autogenous vaccines, but hboth the total case mortality was very low. With regard tthe risks of haemorrhage from vaccine treatment data wer,required as to the dosage employed. It was possible to overload a patient. As regards local conditions the value ovaccine treatment was very striking if full-strength dosewere employed. _

WEST LONDON MEDICO-CHIRURGICALSOCIETY.

X Ray Appearances of Some Common Disorders of the S’tomach.A MEETING of this society was held at the West London

Hospital on March 5th, Dr. F. S. PALMER, past President,being in the chair.

Dr. REGINALD MoRTOrr read a paper on the X RayAppearances of Some Common Disorders of the Stomach,which was illustrated with a number of lantern slides. He

emphasised the necessity for keeping all the conditionsduring an X ray examination of the digestive organs as

nearly normal as possible. The patient should be preparedby giving a laxative the second night before the examina-tion, and the opaque meal was to take the place of the usualbreakfast. This meal should be of some ordinary food suchas porridge or bread-and-milk, and the substance used to.make it opaque to the X rays quite inert and free from anypossible chemical or physiological action, the two bestmaterials being bismuth oxychloride and barium sulphate.Bismuth carbonate neutralised the gastric juice and shouldnot be used. After indicating possible sources of error inobservation, Dr. Morton first showed the appearances of anormal stomach, antero-posteriorly and laterally, in a younghealthy adult, and explained how the appearances of thisdiffered from our original ideas of the size and shapeof the stomach-the absence of muscular tone being thechief factor on the operation table and post mortem.He then demonstrated how easily the form and position ofthe organ were influenced by mechanical, reflex, and sensoryimpressions, proving it to be a very sensitive part of thedigestive system. Turning to the pathological stomach, heshowed instances of atony, one of the most common abnor-malities, sometimes existing alone, but most often inassociation with gastric ulcer or pyloric obstruction or both.The spasmodic constriction of the circular fibres commonlyassociated with gastric ulcer was shown in several cases andthe method of distinguishing the spasmodic from the organiccontractions explained. One case in particular showed thetruth of the epigram which says, ’’ The most frequent seatof gastric ulcer is in the right iliac fossa." The stomachshowed the presence of at least two ulcers as well as somedegree of pyloric obstruction. Suspicion rested on the

appendix, which was found to be catarrhal and was removedby Mr. Aslett Baldwin. A radiogram made five monthslater showed a normal stomach. Cases exhibiting differentstages in the development of the condition of hour glassstomach were shown, those of the organic type being bothvarious and striking. Of these the X ray examination gavea large amount of information as to the relative size ofthe two sacs and their condition-an important pointin the matter of operative procedure. In most cases

gastro-enterostomy was the only possible operation,but where the lower sac was seen to be acting fairlywell and no indication of pyloric obstruction, as some-

times happens, the question of joining the two sacs bya gastro gastrostomy should be considered. An effortshould be made to preserve the gastric digestion where thecircumstances made this possible. Dr. Morton suggestedthis as a suitable subject for discussion, and he hoped someevidence as to the condition of patients who had undergonegastro-enterostomy several years previously might be’forth-

I coming. In conclusion, he explained how any paper dealing; with one part of the digestive system was bound to be incom-, plete, so intimately were the various parts linked togetherL through their nervous mechanism ; it was impossible to studyI the disorders of one part while ignoring the others. His object was to help those who were not radiologists more

accuratelv to visualise the various disorders of the stomachas they occur under the ordinary conditions of everyday

iexistence, and he hoped he had met with at least, some small degree of success.s Dr. PALMER, after speaking of the interesting character ofi the paper and the clearness of the radiographs shown, went3 on to say how important had become the X ray method ine the diagnosis and treatment of gastric affections, and gave- instances where it had proved the existence of disease quitef different from what the clinical signs and symptomss indicated. He would like to ask Dr. Morton if it was not the

case that barium gave a better shadow than bismuth.