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.over-exertion following an attack of influenza. Although, as IDr. Goodhart stated, treatment by rest might be overdone, I,he was convinced that in all acute cases it was necessary forat least a month. Gentle and graduated exercise might thenbe prescribed, but athletics and all prolonged or severe

physical exertion should be forbidden to those who had oncesuffered from definite symptoms of cardiac strain anddilatation.

Dr. F. PARKES WEBER having spoken, Dr. GOODHARTreplied, and the meeting concluded.

ROYAL ACADEMY OF MEDICINE INIRELAND.

SECTION OF SURGERY.

T’I’rtaspe’l’itoneal Cystotomy, with Report of a Case.-lJiagnoÛsof Penal CaZauZus.

A MEETING of this section was held on Nov. 18th, Mr.R. H. WOODS, the President, being in the chair.Mr. SETON PRINGLE read a paper on Transperitoneal

Cystotomy for Tumour of the Bladder, with Report of aCase. He gave a history of this operation, and compared theresults obtained by it with those obtained by operating bythe suprapubic route. He advocated this method in allcases of tumour, except those situated at the apex of thebladder. He desctibed the operative technique in detail, andillustrated the various steps by lantern slides. The paper con-cluded with a report of a case of papilloma successfully dealtwith by this route by Mr. Pringle.-Mr. A. J. BLAYNEY saidthat he had used the method twice, and he could confirm whatMr. Pringle had said with regard to the excellent view of thebladder obtained. The after-treatment he had used was todrain the bladder for a few days, and afterwards urine waspassed quite readily.-Mr. JAMESON JOHNSTON said he had notdone the operation, but it appealed to him as being scientific,and based on anatomical principles, and one certain to bevery useful in the future, but he would not use the trans-peritoneal method unless he thought the other method wasnot sufficient.-Mr. C. A. K. BALL said he had attempted to dotransperitoneal cystotomy in the case of a man, aged 56 years,who had a malignant tumour of about the size of a five-shillingpiece involving the left ureter. On opening the abdo-men it was found that there was a mass of secondarygrowth completely adherent to the iliac vessels. The casewas therefore inoperable and the abdomen was closed. Hewas much struck with the splendid access to the bladderthat was obtained. Although in a thin patient it was one ofgreat ease, in a fat person there was difficulty in keeping theintestines back before opening the bladder, but when openedthe tumour was easily removed and the result was satis-

factory. He did not gather whether Mr. Pringle had usedthe valuable aid of the electric head-lamp which had beenbrought to his notice by the President. With the head-lampone was able to work with a smaller incision in the bladder,and the interior was readily illuminated.-Mr. W. I. DE C.WHEELER said that, considering the mortality of the removalof benign tumours, it was time some new methods of techniquewere developed. He had been impressed with Mr. Pringle’swork, and on his advice had used the transperitoneal method.The operation had great advantages over the ordinary supra-pubic method, and he would be inclined to use it in everycase of tumour of the bladder where there was any difficulty inthe removal of the tumour.-Mr. K. E L. G. GUNN asked if Mr.Pringle meant that the operation was to be done in all casesof the bladder or only in carcinoma. He had operated oneight cases of malignant growth in the bladder. In oneof the cases he had not recognised malignancy before theoperation and found the growth too late to do anything.In two cases he did the transperitoneal operation, and inone case had to replant the ureter higher up in thebladder wall. The patient died five years after the opera-tion. The second survived the operation, but died fromrecurrence five months afterwards. In four cases of radical

suprapubic operation, one died 12 months later, one died innine months, one was still alive three years after opera-tion, and another four years. One should adopt whatevermethod was most convenient to get at the growth. Nomatter how carefully they sutured, there was a danger in the

transperitoneal method of leakage of urine.-The PRESIDENTsaid that, in his opinion, no cavity operation could be as welldone without an electric head-lamp as with it, but for thepurpose they must have a theatre that was not too highlylighted. If they had a subdued light sufficient to enablethe assistants to do their work, and others to see what

they wanted to see, and they used a suitable lampwith a large concave reflector that could be varied,he was of opinion that, no matter what the operationwas in a cavity, they would be able to see ever so muchbetter, and they would never go back to the old plan thatcompelled them to put their head between a light and thecavity.—Mr. PRINGLE, in reply, said he did not advocate theoperation for all tumours. He thought it had not been doneoften enough to be quite sure of its mortality. He wasinclined to advocate it in all cases except those of tumoursituated near the apex of the bladder. One would thinkthat with the transperitoneal operation, even with therisk mentioned by Mr. Gunn, they should have a lessmortality than the immediate mortality of 10 per cent.with the supr8:pueie method. One could form a fairidea of malignancy with the cystoscope, but it was not sure,and the transperitoneal method enabled them to deal muchmore radically and rapidly with the tumour. He had goodlight in his case, and he thought the chief point was to getthe patient into a very high Trendelenburg position so thathe was almost vertical, and the light of the theatre windowshining in. He did not personally feel the need of a head-light. As regards the risk of the operation, a great many ofthe 23 cases reported by him, from American literature, wereseptic bladders. Richardson in America had taken out twolarge stones in two cases in which the bladder had tightlycontracted down. He did the transperitoneal operation inboth cases, the bladder being intensely septic, and bothrecovered without peritonitis.

Mr. MAURICE R. J. HAYES in a paper on X Rays in theDiagnosis of Renal Calculus laid special stress on thenecessity for thorough evacuation of the intestines in order toobtain a satisfactory radiogram. A description of a simplemethod of obtaining compression of the kidneys by means ofan ordinary girth was given. The various causes to whicherrors in diagnosis may be due were discussed, and radio-grams illustrative of these were shown. The use of radio-

graphy as the only method of diagnosis of calculi was notrecommended, but taken in conjunction with the ordinarymethods of diagnosis it furnished more valuable informationthan could be obtained in any other way. -Dr. W. S. HAUCIITONsaid he did not think that X rays should be used to replacethe ordinary methods of clinical examination, but rather toconfirm them. He had never known a Roentgen picture tomake a mistake with regard to a stone in the kidney.With regard to controlling the respiratory movement of thekidney, the strap mentioned was an admirable addition tothe work. There were other methods of extreme usefulness.-Sir JOHN LENTAIGNE said the X rays were so valuable a

help that they were tempted to drop the more laboriousmethods of diagnosis.-Mr. HAYES, in reply, said he hadinvested so much in apparatus that he was afraid to

put more money into the Albers-Schonberg compressor.He thought it was a cumbersome and heavy affair, andeverything could be obtained by a contrivance at an expenseof 3s. 6d. He had recently used a rubber air-pillow, andfound that he got the shadow of the air-pillow trans-

versely on the plate. One disadvantage of the air-pillowwas that the position of the patient changed duringexposure. He expressed his thanks to the speakers fortheir kind remarks.

Mr. GUNN read a short paper on the Diagnosis of RenalCalculus, giving briefly the chief symptoms and the relativevalues of such symptoms in diagnosing renal calculus. Mr.Gunn then discussed the question of how far the opinion ofthe radiographer should influence the surgeon in his treatmentof the patient.-Dr. W. G. HARVEY supplemented Mr. Gunn’spaper with a few remarks on the X Ray Diagnosis of RenalCalculi. He agreed with Mr. Gunn that the radiographershould examine the whole urinary tract. In the greatmajority of cases a negative diagnosis was justified by theabsence of a shadow in a sufficiently good negative. Such anegative should show (1) the last ribs ; (2) the tips of thetransverse processes ; (3) the line of the ilio-psoas muscle ; and(4) the outline of the lower pole of the kidney. He thenshowed some lantern slides illustrative of these points.-Dr.

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HAUGHTON said that if there was any doubt they shouldrepeat the photograph some time later. But a quicker andmore satisfactory way was to take a stereoscopic picture byMackenzie Davidson’s method. It was astonishing how tworather indifferent negatives would yield an excellent stereo-scopic result. The question of including the opposite kidneywas most important. He had come across patients in whichthe pain was referred to one side, and there were two largestones in the opposite kidney.-Dr. H. STOKES said they couldget the symptoms of stone from a hypernephroma. Most ofthese were not diagnosed until too late. Cases reportedshowed the surgeon practically certain of stone. If the radio-

grapher took two photographs and found no stone, were theyto sit down and let the patient die ?-Mr. PRIKGLB and Mr.HAYES also spoke.-Mr. GUNN, in reply, said he did not

attempt to deal with the differential diagnosis. What Dr.Stokes said was perfectly true. There were other conditionswhich made it difficult, but time would not permit theirdiscussion.-Dr. HARVEY also replied.

EDINBURGH MEDICO-CHIRURGICALSOCIETY.

-discussion on Blood Pressure.A MEETING of this society was held on Nov. 30th, Dr.

BYROM BRAMWELL, the President, being in the chair.Dr. GEORGE ALEXANDER GIBSON, in introducing a dis-

cussion on Blood Pressure, first gave a definition of theterms employed in studying arterial pressure. The maximal,or systolic presh’l1ll’e was gauged by that which would arrestthe flow in the vessel. The l1Ûnim,al or diastolia pressure wasestimated by the point of greatest lateral oscillation. Themean pressure was that half-way between maximal andminimal, and the pulse pressure was the amount of differencebetween maximal and minimal. But these pressures were

lateral-i.e., exerted on the walls of the vessels-andthe terminal pressure consisted in this pressure plusthe velocity. The lateral pressure in an artery was

usually held to be equal to the terminal of the next

pulse pressurebranch. The -- = co-efficient of pressure ;systolic pressure

thus, in a person in health if the systolic pressure were 120, thediastolic 90, the pulse pressure 30, and the pulse-rate 70, thenP.P. 30 1 1 co-efficient, and P.P. X P.-rate- velocityco- CIent and

= = , or the efficiency of the heart in health.In an instance of heart-block S.P. 270, D.P. 90, P.P. 180,

P.R. 30, . The factors which maintained

the arterial pressure were as follows-: 1. Energy of the heart.2. Access of blood. It had long been known that anyobstruction lessened the distal pressure and increased theproximal, and Dr. Gibson narrated an illustrative case ofobstruction to the subclavian. 3. Elasticity of the vessels.During the systole the vessels became dilated and the

potential energy thus stored up was given out later as kineticenergy in their contraction. 4. Resistance in arterioles ;resistance and pressure were reciprocal. Increased resist-ance was equal to higher pressure, and vice 1,ersd. Re.ist-ance was due to tonus of vessels which resulted fromthe antagonistic action of vaso-constrictor and vaso-

dilator nerves ; the former were always in action, thelatter only when required. 5. Character of the blood.Dr. Gibson had observed that density of blood and pressurewere in direct ratio, and viscosity of blood stood in the samerelation. Chemical impurities, for the most part, increasedpressure. 6. Quantity of blood. It might be expected thatincreased volume would cause increased pressure. This was,however, amply compensated for by vasomotor activity.With regard to the methods of estimating arterial pressure,Br. Gibson narrated the earliest observations made by ascer-taining the height of a column of blood from an artery, andlater by the use of a mercury manometer for the artery anda water manometer for the vein ; while still more recentlythe spring manometer had been introduced. The differentforms of kymograph were alluded to. He spoke of the earlystudies of the pulse and the importance of educating thesense of touch in this relation. He said that the only

accurate instruments were those based on estimation bymeans of a column of mercury. The systolic pressurewas gauged by the amount of external pressure necessaryto overcome arterial resistance ; while diastolic pressurewas estimated by the maximum waves of the columnof mercury. Dr. Gibson described the instruments of

Erlanger and the recording instrument suggested byhimself. As regarded the possible fallacies in the

methods, he alluded to: (1) the instrumental; (2) thepersonal equation ; and (3) the state of the walls-Herring-ham stated that the maximum pressure exerted by these was35 millimetres. Dr. William Russell held that increasedtonus could add to this, but the muscular coat of a largeartery was not so large relatively as a small artery. As tothe clinical results, the cardiac muscle and arterial pressurewere reciprocal, and arteriole contraction and arterial pres-sure were also reciprocal. With high arterial pressure therewas a loud aortic second sound, going on to hypertrophy ;with low pressure there were feeble sounds. Vascular crises(both high and low pressure) of Pal gave changes in theamount of secretion, renal and salivary. Nervous causeslead to high pressure, and worry to this and to sclerosis ;while, on the other hand, from high pressure nervous in-stability in varied forms resulted. Nervous causes could

give low pressure, and in the opposite sense low pressure ledto nerve depression. Abnormal extremes: In interstitialnephritis and arterial degeneration 260 D. ; 300 S. Addi-

sonism, 60 D., 90 S. Greatest pulse pressure in aortic

escape, 70 D., 150 S., and in heart-block 80 D., 270 S.In infective diseases there was an early rise and earlyfall ; this was very marked in typhoid fever. Inlead poisoning the pressure was high throughout until

recovery, and in gouty conditions it was also high. Itwas interesting to note that, apart from aortic disease,valvular lesions had little influence on pressure. In aortic

incompetence the pressure in the arteries of the legs wasmuch higher than in the arteries of the arms. Arterialsclerosis : There was a general consensus of opinion thatretained poisons as well as those from outside caused thisdisease. There might be arterial sclerosis without highpressure, as of 500 cases examined by Groedel in 35 per cent.there was none; Rudolf with Ellis and Robertson found50 per cent. of cases with none : and D. Elliot Dickson foundthick vessels with only moderate pressure in miners. Therelation of high pressure to angina pectoris was discussed.Respiratory diseases : The pressure was high in asthma andlow in phthisis. Glandular diseases : In myxoedema thepressure was high ; in exophthalmic goitre it was usuallylow, but was very variable. In Addisonism, low if the

medullary portion of the gland were affected. Renaldisease : The pressure was usually high from retention ofpoisons, but much depended on previous conditions. Inchronic Bright’s disease it was always high; in amyloidchanges, usually low ; in urasmio poisoning, high. In con-clusion, Dr. Gibson discussed the value of arterial pressurein prognosis and as a guide in therapeutics.

Dr. WILLIAM RUSSELL said that in the time at his dis-posal he could not debate the question before the society.He could only try to define what he considered to be the

essential phenomena in the subject under consideration. Hewould begin at the extreme end and take as an example ofit a patient admitted to hospital with a brachial pressure of295 mm. Hg. Under rest and treatment it fell to 165. Ibrose and kept about 190 to 210, but it would suddenly rise70 to 80 mm. more with symptoms which there was no timeto describe. This patient had thickened vessels, and alongwith the rise in pressure the vessels, including the brachials,underwent hypertonic contraction. 1 Nine years ago he hadmade a communication to the society on arterial hypertonus,in which he pointed out that hypertonus cccurred in normaland in sclerosed radial arteries ; with the advent of themodifications of the Riva Rocci instrument he had carriedhis observations to the brachial artery and found thatit became greatly thickened, and that it could infavourable cases be both felt and seen to diminish

greatly in size and increase greatly in the thicknessof its wall during such hypertonic contraction. When thiscontraction took place the pressure in the aorta was raised-how much there was no means of determining, for there wasa great power

of restoring the balance and relieving the

1 THE LANCET, Dec. 3rd, 1910, p. 1602.