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abdominal wound which had united perfectly. There wasnever a sign of anything wrong in connexion with theuterine or abdominal wound. A few clots came awayper vaginam on the third day which were non-offensive incharacter. Beyond this there was no discharge, either lochialor from the cancer, until three weeks after the operationwhen the cancerous discharge re-appeared. The measuresadopted for the resuscitation of the child were successfuland it appeared to be doing well at first, but on the thirdday it began to waste away rapidly and died on the fourthday from marasmus.

lle11larks by Captain EARLE.-The chief points about thiscase are the weak state of the patient prior to operation andthe extreme and persistent collapse following it from whichshe finally rallied. The benefit of intra-cellular salineinjections is also apparent. It will be seen, too, that theadministration of considerable quantities of nourishment bythe mouth (necessitated in this case by the collapse andinability of the rectum to retain nutrient enemata) after

opening the peritoneal cavity is not incompatible with

recovery. No attempt was made to remove the uterus asthe disease involved the surrounding tissues to a very con-siderable extent, and therefore could not possibly have beencompletely extirpated. I am indebted to Lieutenant-ColonelJoubert, I.M.S., for permission to publish this case.

Medical Societies.ROYAL MEDICAL AND CHIRURGICAL

SOCIETY.

The Open-air Treatment of T1lberculvsis.A MEETING of this society was held on Nov. 14th, Mr.

THOMAS BRYANT, the President, being in the chair.Dr. KINGSTON FOWLER opened a discussion on the Open-

air Treatment of Tuberculosis. He thought that a fairtrial should be given to the system which had elsewherebeen employed with success. He deprecated enthusiasm inmatters of therapeutics, but the proposal to acclimatise i

this method should not be viewed with prejudice bornof past experience of the failure of other systems. Thediscussion would serve a useful purpose in elicitingimpressions already formed and in guiding professionalopinion on matters both of principle and detail in connexionwith the application of the system to this country. Referencewas then made to his previous attempts to substitute theterm pulmonary tuberculosis " for phthisis or consumptionas a name for the disease. The former diagnosis might beaccompanied by the assurance that the disease frequentlyunderwent arrest. Reasons were also given for preferringthe term "sanatorium treatment" to that of "open-airtreatment." Fresh air was only one of several factors inthe treatment. Brehmer was the first to systematise themethod which consisted in (1) the residence of the patientin a sanatorium under constant medical supervision ;(2) complete freedom from excitement of all kinds ;(3) a life spent in the open air; (4) rest during periods ofthe disease attended by fever ; (5) methodical hill-climbingas an exercise when fever was absent; (6) an abundant andvaried dietary in which vegetables occupied an importantplace ; and (7) various hydro-therapeutic measures. Brehmer’ssystem had since been modified in many respects, but hedid not regard any of these changes as improvements.Dettweiler had substituted to a considerable extent rest in" Liegehalle" for bill-climbing, but the latter was an import-ant means of strengthening the muscular force of theheart. A patient who was stuffed with food and keptat rest might become enormously stout but at the sametime flabby and incapable of exertion, and it byno means followed that the disease was arrested. Anaccount was given of some of the recently establishedsanatoria on the Continent, which were described as hugehotels. In many of these the so-called "open-air" partof the treatment was not really carried out and no care

was taken to see that the patients took the necessaryquantity of food. In this country there were already signsthat the movement might develop upon the same degeneratelines. Dr. Otto Walther’s sanatorium at Nordrach in theBaden Black Forest was mentioned as an honourable excep-

- tion to this condemnation of the continental sanatoria for

paying patients. The object of treatment in all cases shouldbe to obtain not only arrest of the disease but an obsolete con-dition of the lesions. For this in many cases a very long timewas stated to be necessary. The chief factors of themethod were considered in the next place. In the first

place as regards life in a sanatorium. The necessity for amuch stricter supervision of tuberculous patients than hadhitherto obtained was insisted upon. This could in mostcases only be obtained in a sanatorium. It was at first fearedthat the independence of the British character would resentthe discipline necessary, but experience showed that Englishpatients readily submitted to sanatorium restrictions. Thosewho were making progress did not complain of the life asbeing dull. As to the site of the sanatorium, a valley at ahigh elevation, say, 1600 feet, surrounded by tree-covered hillsand sheltered from the north and east was the ideal site;but it was quite possible that experience would show that themethod could be carried out at one of the high-altitudestations or at a much lower level than that just stated. Hehad not observed in the cases successfully treated at thehigh altitudes such a remarkable gain of weight and com-plete physical change in the patient as in those treated atNordrach. In his opinion treatment in a sanatorium con-ducted on Brehmer’s lines was more likely to lead toarrest of the disease than climatic treatment unaccom-panied by proper medical supervision, but he depre-cated the view that climate was of no importance. Turn-ing next to the open-air life, he said that they were dealingwith pulmonary tuberculosis, and not " phthisis "-a diseasebelieved to be due to catarrhal inflammation the effect of"catching cold." The object in view, therefore, being todevelop by every means the resisting power of the body, anopen-air life was a natural mode of treatment. It was observedthat visitors to the Scotch hills could get wet through and runother risks without fear of taking cold. Ordinary catarrhwas probably an infectious malady; at any rate, experienceshowed that tuberculous patients living an open-air life insome place remote from crowded habitations did not catchcold. The importance of making careful observations on thebody temperature in all cases of pulmonary tuberculosis wasemphasised. Dr. Fowler then referred to a paper whichhe had published in 1893, showing that the degree offever present was an exact measure of the activity of thedisease. The temperature charts of a case recently treated inthe Middlesex Hospital were exhibited and showed that therectal temperature might be 0’5°, 1°, or even 2°F. above thatof the mouth. The rectal temperature was the best guide,and it was essential that temperature observations should befrequent and accurate, as the important question of rest orexercise depended upon the presence or absence of fever.The practical indications derived from temperature observa-tions were then given in detail. For patients whose diurnalrecord exceeded 100’50 F. rest should be enjoined. Prefer-ence was expressed for the I I separate system" in vogueat Nordrach over the "Liegehalle" system, at anyrate for patients who required to be at rest. Inmost patients it was desirable to maintain a more

absolutely quiet condition of the nervous system thanthat incidental to the latter method. As regards exercise,slow up-hill walking, as advised by Brehmer, was to bepreferred to any other fessa of exercise until the lesions hadbecome obsolete. The importance of exercise as an integralpart of the treatment was insisted upon. Brehmer’smethod was described as a system of training, and for thisexercise was as important as fresh air and plenty of food.Turning to the question of diet, one of the chief differ-ences observed to follow the employment of thissystem was the much greater gain of weight, dueto the larger quantity of food assimilated. It was,however, pointed out that the greaÜr the amount of foodtaken the less nas the significance to be attached to a gain of7icight as evidence of arrest of the disease. Mention wasmade of a case in which the patient had gained three stonesin weight although the disease had not undergone arrest.The importance of restricting the number of patients in asanatorium to 45 or 50 was in no respect so obvious as in theopportunity it gave to the physician to personally super-intend the patient’s meals and to insist on each one eatingthe quantity of food prescribed for him. Reference was thenmade to cases treated at Nordrach which had come underDr. Fowler’s observation and in general terms the resultshad been all good. Nordrach should be the model for sana-toria in this country. As regarded administration, the viewthat everything depended on "the man was erroneous. On

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the contrary, if the right system was adopted there would beno lack of men capable of carrying it out. All methods of i

treatment must have limitations and this was no exception.The earlier the case came under treatment the better, butthis method was by no means limited in his belief to theearly stages, for he had known cases with cavities improve.He believed that, whatever the future had in store in thematter of therapeutic discovery, a system which aimed at I

increasing by every means the resisting power of the bodymust always find a place amongst the means to be employed I

in combating tuberculosis of the lungs.Sir WILLIAM BROADBENT said that he was prepared

to accept almost the whole of the statements of the

opener of the discussion. He should not, however, like to dis-card the term "open-air" altogether, for this indicated theprime factor of the method. The placing in a sanatorium un-doubtedly played an important part, for it isolated the patientfrom the public and the public from the patient. It was avery important matter to avoid secondary infections of allkinds. The importation of influenza, for instance, intosome of the foreign sanatoria had been attended byvery disastrous results. Friends should be received inthe open air and under precautions which would excludeall kinds of infection. The closer study of the diseasewas another advantage accruing from treatment by sanatoria.One very important point in the establishment of sanatoriawas that they should be conducted not on commercialbut on scientific lines. The earning of dividends shouldnot be introduced into the question. The temperature in themouth he thought was nearly as good a guide as that inthe rectum, at least, he did not attach so much importanceto the latter as some did. The feeding must be modifiedaccording to the individual needs of the patient and nohard-and-fast routine should be adopted in this respect.

Professor R. W. BOYCE said he would direct his remarksto the construction of sanatoria and would refer to severalforeign institutions which he had visited. Referring first tothe curative action of sanatoria he would insist on the abso-lute necessity of having in every sanatorium all the requisitemeans for diagnosis of tuberculosis by every clinical andlaboratory method possible. They must also be providedwith the maximum amount of air, light, and food, and thelife should be made as cheerful and attractive as possible.The milk-supply and water-supply must be perfect and theother details of administration of the best kind. As to pre-vention it was necessary to teach the patient how to preventthe spread of his own disease. Sputum receptacles must beprovided and the patients should be taught to cleansethese themselves. He would illustrate his remarks bylantern slides of the different foreign sanatoria whichhe had visited. First of all there was Nordrach, whichwas extolled so much in England ; but, curiouslyenough, he had met with many German physicianswho had never even heard of that institution. Personally,he did not think it the ideal sanatorium which some regardedit. He discussed the merits of the cottage system of con-struction, such as that of Dr. Troudeau at Adirondacks,New York State. This system had the merits of greaterfreedom of air and more homeliness. The block system wascheaper. Some preferred the buildings to be arrangedin the form of a crescent bending round to thesouth, with the dining-room at the end facing the south.The ground plan of the sanatorium of Edmundsthall,Hamburg, was in the form of the letter H. This gave asecond frontage one behind the other, and this was an

objection, but the only one, and it was a cheaper system.Perhaps the best was a modified H ground plan, such as thatof Alland, Vienna, the largest sanatorium in Europe. Thisinstitution had a magnificent laboratory attached to it as

part of the electric light installation building away from themain block. Professor Boyce wished particularly to insiston the necessity of all sanatoria having well-equipped labora-tories, for without these neither the investigation ofthe cases nor their treatment could be properlycarried out, and without these none of those re-

searches, still so necessary, could be prosecuted. Therules of the establishment, he thought, should not be tooSpartan. People should be gradually educated up to thenecessary standard, else they would be disgusted at the out-set. The verandah of the building should not interfere withthe light and air of the living rooms. The number of bedsto each ward should not be too numerous ; many of theGerman sanatoria were faulty in this respect. Some did notthink there was any need to have any living rooms, but

Professor Boyce regarded them as necessary. There shouldilways be three rooms-one for men, one for women, andme for both sexes. The sexes should meet so as to promote;heerfulness. The milk question was often neglected in

Germany but it was most important, and the cows shouldilways be tested with tuberculin.Dr. F. W. BURTON-FANNING had been studying the

luestion of sanatoria for tuberculosis for four and a halfyears-at first in only a small way; but he had graduallysvolved a proper sanatorium. The cases of absolute curewere comparatively rare because they were so often in quite1n advanced stage when first brought under treatment. Forcertain success the cases must be selected and thetreatment must be carried on long enough. If admittedwith infiltration and softening only and if the treat-ment was carried on long enough a patient would certainlyrecover. The first sign of improvement was evidentin the weight and the symptoms. The shortest time in whicha patient had lost all signs had been three months.As regards the rectal -2ersns the oral temperature he hadbeen in the habit of taking both. After a very short walk(say, half an hour) the rectal temperature might be to higherthan the oral and it would subsequently go down. But as arule there was very little difference between the two, andthat a constant one. Another objection to rectal observationwas that the patients had to go to their rooms. Dr. Burton-

Fanning agreed with those who laid great stress on thenervous factor. These patients got tremulous and nervousand their temperature went up very readily.

Dr. THURNAM declared himself to be an " apostle " ofNordrach. Referring to the "Liegehalle" principle thequestion was, Should patients be kept separately or together ?He had come to the conclusion that the less number of

patients were allowed to be together the better forthem, within certain limitations. He thought thenervous element was an extremely important one.

He did not see the necessity of "Liegehallen" " andpatients should not be allowed to get into groups. As

regards the verandahs, they were also objectionable, partlyon the same principle, because they not only kept outlight and air, but patients carried on conversations out-side the windows. Turning to the question of rectal andoral temperatures he declared his preference for the rectal,which was much the easiest to take, and he thought it wasmuch the best and most sensitive. The range was muchwider and, he thought, truer. Turning to the question ofdiscipline he mentioned an instance of a revolt of thepatients in a sanatorium because the medical man persistedin having the dining-room windows open. But he could nothelp thinking that such occurrences might be prevented.

Professor CLIFFORD ALLBUTT in visiting sanatoria hadnoticed a considerable difference between " open-air "’treatment and treatment by " draughts." For instance,with pavilions on the H plan the dining-room was placednorth and south. When the windows were all open itwas virtually a portico and the wind would blow rightthrough it like a passage. He thought that system was awrong one. In small bedrooms the same thing happenedand there were a lot of circular draughts. This raised theimportant principle of ventilation. But the defect to whichhe referred resulted in a lot of cold-catching. Headmitted that a "cold" was an infectious disease, butsuch catarrhs brought about a great loss of energy.Camping out in the fresh air was preferable to this systemof treatment by " draughts." It was said that patientsdid not complain, but they became anaesthetic to thesedisagreeable conditions if told it was good for them.He had seen patients with cyanotic faces and livid hands,and in such conditions the vital powers were undoubtedlydepressed by draughts. As regards verandahs, if only fromfour to six feet broad and eight or ten feet high they didnot keep out sun during most of the year, and he thoughtthat they were not quite such a drawback as some seemedto imagine. Turning to the mental condition of patients,the disciplinary treatment in some circumstances was cer-tainly most trying. Why should not the patient be keptcheerful? If they were not to read any book whichimplied any degree of mental exercise or to speak to a

friend, surely enforced imbecility would be the result. He

agreed with the opener in his statement that a patientmight go on increasing in weight and yet the disease mightprogress, and therefore the food, both in quantity and quality,should have relation to exercise. High feeding required dis-cretion and modification in individual cases. And, again, too

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many meals were not advantageous. In regard to the use ofthe word "cure" this must be a relative term. But if apatient had returned for one year to his ordinary work andremained well all the time, that, he thought, would be a pro-visional definition of "cure," and without this cases shouldnot be spoken of as cured or recovered. He wished toempbasise Professor Boyce’s remarks about the necessity ofproviding the means of research in all sanatoria, bothhygienic and bacteriological.The debate was then adjourned to the next meeting of the

society on Nov. 28th.

MEDICAL SOCIETY OF LONDON.

Ex7tibition of Cases.A MEETING of this society was held on Nov. 13th, Dr.

F. T. ROBERTS, President, being in the chair.Dr. E. CAUTLEY exhibited two cases. The first was a case

of Aphasia in a man, aged 71 years. The patient had a fiton April 18th, during which he had convulsive movementson the right side and was unconscious for three-quarters ofan hour. Partial paralysis of the right side and aphasiaresulted. When seen on May 23rd he showed no trace ofparalysis but was suffering from motor aphasia and agraphia.His urine contained a trace of albumin, and its specificgravity was 1012. His present condition was one of

partial motor aphasia. The agraphia had been com-

pletely recovered from and his intelligence was now

unimpaired. The diagnosis made was that of a limitedhaemorrhage into the second and third left frontal con-volutions anterior to the arm centre, pressing on, andpartially damaging, the speech centre. The second casewas one of Congenital Heart Disease, probably an AorticLesion. The patient, a boy, aged 14 years, was verysmall for his age and rather high coloured but with notrace of cyanosis. He was the second of seven children,all living, and there was no family or past history ofrheumatism. As an infant he exhibited no sign of the idisease in the shape of lividity, but though ’’ a fine baby iborn " he soon wasted. He had a fit at the age of two years.Measles occurred during infancy and diphtheria at nineyears, otherwise he had been healthy and he only cameunder treatment for diarrhoea. His heart was relatively relatively small ; the apex was in the fifth space in the nipple line.Over the chest, above the level of the fourth rib, was a well-marked systolic thrill extending to the neck on both sides, 1

best marked in the first right interspace. A systolic murmurcorresponding to the thrill could be heard over the back, iat the apex, in the axilla, and even on the top of the 4

head. There was no evidence of hypertrophy of the rightventricle but the dulness was slightly extended on the Ileft side. The pulse was 72 per minute. The absence iof hypertrophy on the right side and the distribution of 1the murmur and thrill pointed to the lesion being aortic.- iThe PRESIDENT thought that the size of the heart could be Jaccounted for by the nature of the cardiac lesion, for there Iwere distinct signs of aortic mischief, but of what kind i

there was some doubt. He asked if there was any syphilitic vtaint in the family history.-Dr. C. W. CHAPMAN thought he Ihad heard a mitral bruit distinct from that of aortic origin.- 1Dr. H. A. CALEY referred to the loudness of the murmur. (

He asked whether it might not be a constriction of the (

conus arteriosus rather than a stenosis of aortic valves.- ]Dr. J. CALVERT remarked that there seemed to be ia good deal of hypertrophy of the left ventricle. iThis and the smallness of the pulse suggested a 1considerable amount of stenosis. He thought that a 1

sphygmographic tracing might throw a good deal of light own athe case.-Dr. W. EwART drew attention to the weakness of Ithe second aortic sound, although the murmur itself was (

very loud. He thought the lesion might be a permanently 3open ductus arteriosus. In his experience this lesion 1produced very loud murmurs, and there were other 1features confirming the idea in this case. though a double 1

murmur, which was most characteristic, was not present.- 1Dr. WALTER CARR also asked if it might not be possible that Ia small communication existed between the aorta and the t

pulmonary artery.-Dr. CAUTLEY, in reply, said there was no t

suspicion of syphilis. The nature of the lesion was a matter lof speculation, but very likely it was aortic stenosis. This (

would account for the small size of the child, the absence of fcyanosis, and his good general health. 1

Dr. WILLIAM EWART exhibited a case of Pigmentationsimulating Addison’s Disease in an asphalt worker withhepatic and splenic enlargement. The patient was a man,aged 42 years, an Italian born in England. He had beenout of health since last spring when he was laid up for sevenweeks with a severe attack of "influenza," followed bygreat loss of weight and of strength. On admission hepresented marked brownish discolouration of the skin with.out any staining of the buccal mucous membrane,slight pyrexia, some dulness and a few râles at the rightapex, and considerable depression. The liver was moderatelyenlarged and the spleen was much increased in size. Thediagnosis of Addison’s disease was made on the strengthof the pigmentation, of the feebleness of the pulse, ofthe muscular weakness, and of the clinical history of pro.gressive emaciation since the 11 influenza," and the brownishdiscolouration of the distal portions of the nails was

regarded as an unusual feature of the affection. On furtherinquiry, however, it was ascertained that the discolourationof the skin had existed for upwards of 20 years and that thepatient had been constantly exposed to the smoke of heatedasphalt. These circumstances and the total absence ofpigment from the proximal ends of the nails both in thehands and in the feet led to the abandonment of the originaldiagnosis, although the patient had greatly improved undertreatment by suprarenal extract. The association of a

glandular swelling with a marked splenic enlargement hadsuggested the unlikely view that the case might be one ofHodgkin’s disease. The patient had had an attack ofjaundice at the age of 15 years, but no recent symptoms ofhepatic disease. Examination of the blood showed a markeddecrease in the number of red cells with moderate leucocy-tosis, and the eosinophile cells were slightly increased innumber. He had lost four stones in weight in the last two years.- Dr. CHAPMAN asked if there was a history of any malarialtaint and Dr. EwART replied that the patient had formerlytravelled as ship’s cabin-boy. When laid up with influenzahe had had " chilly fits," but there had been no definiteattack of malaria or dysentery. The question of his beingan asphalter was interesting and he would like to ask ifasphalt was capable of producing any toxic symptoms.-Dr.J. G. GARSON referred to the fact that all the Mediterraneanraces were much darker than those of northern Europe.-Dr. A. G. AULD suggested that the condition might bemalarial in origin.

Dr. EwART also exhibited a case of Persistent Lockjaw inan Edentulous Subject relieved by incising a tender portion ofthe gum. The patient, a man, aged 47 years, moderatelyaddicted to alcohol, was suffering from an extensive chroniculcer of the right leg. His illness began with a "severecold" three weeks before his admission into St. George’sHospital on Sept. 20th, 1899. The lockjaw set in quitesuddenly during the night a week later, when he awoke in afit of suffocation due to the closure of his lips unsupportedby teeth. The same nocturnal attacks continued to occur inthe hospital for five weeks. The rigidity of the jaws, of thefloor of the mouth, of the platysma of the neck, and of theabdominal muscles was intensified by excitement, but therewas neither opisthotonos nor any spasm of the limbs.Speech, respiration, and alimentation were much impeded,leading to loss of flesh and weakness. There was t

tender and slightly swollen spot on the gum and thecase was diagnosed from the first as one of reflex spasmdue to periosteal irritation and tenderness at the left

posterior extremity of the upper jaw, and local treatment wasrecommended. This was finally resorted to, after variousremedies bad proved ineffectual, at the end of October, andthe symptoms rapidly disappeared after the tender gum hadbeen freely incised. Dr. Ewart remarked that the case wasa good illustration of the reflex tetanoid symptoms occasion-ally induced by irritation of the dental nerves. These casesdid not present the complete symptoms of traumatic tetanusnor did they end fatally. They could invariably be cured bythe removal of the offending cause. The few cases of fataltetanus which had been observed after operations on theteeth were probably cases of accidental infection with thebacillus. The case exhibited was also a perfect instance ofa purely reflex causation, due to nerve irritation, since, owingto the absolutely edentulous and clean condition of the gums,the mouth contained no source of septic infection.-Mr. ARTHUR BARKER asked what were the details of theoperation which had been done.-Dr. EWART, in replying,said that he had suspected a loose piece of bone just underthe gum, but there was no abscess there ; no pus, only blood