27ROYAL SOCIETY OF MEDICINE: OBSTETRICAL SECTION.

definite could be made out. When I saw her a couple ofhours later she complained of intermittent cramp-like feelingsin the lower abdomen (uterine contractions). The abdominalmuscles were still rigid; per vaginam beyond some slightincreased resistance in Douglas’s pouch nothing definitecould be made out ; there was no vaginal discharge. On thenext morning when I called the patient said that she feltbetter. The colic, as she called it, had ceased, andshe had come on unwell; clots had also been passed. On

examining them I came across the decidual membrane. Thiswith the history of amenorrhoea helped towards a definitediagnosis of extra-uterine gestation. As the patient feltbetter she would not hear of an operation. I, however, kepther in bed, and all went well till the tenth day, when againstmy wishes she got up and did some washing. She again feltas if something had given way inside her, followed byexcruciating pain. I was out when this occurred and sawher an hour later, when I had her removed to the local

hospital, where she was operated upon. On opening theabdomen it was full of blood due to recent haemorrhage. Onremoving it. clots of former haemorrhage were found, chieflyfilling the right iliac fossa, and among them was an embryoattached by cord to the Fallopian tube of the left side. The

patient died from collapse on the third day after the

operation. - . - - --

CASE 2.-The patient was a multipara, aged 45 years,and came under my care two months after the date of fallingill. In the meantime she had been under the care of another medical man, who had applied linseed-meal poultices assidu-ously for that time. She was supposed to be suffering frominflammation of the womb. When called in the temperaturewas 102° F., the pulse was 110, and the respirations were 19per minute. The abdomen was tender and rigid ; per vaginama hard mass could be felt in Douglas’s pouch. There was a

history of five months’ amenorrhcea, which the patient lookedupon as being due to the change of life till she fell ill, whenshe passed some clots. I made an incision into Douglas’spouch and removed clots and a macerated foetus of from twoto three months’ gestation. The pouch was packed withiodoform gauze, which I removed on the second day. Thepatient made an uneventful recovery.CASE 3.-The patient was a multipara, aged 30 years, and

felt something give way inside her whilst she was coughing.She had missed one period. There were tenderness andrigidity over the whole abdomen, being most marked in theright iliac fossa and over the umbilicus. The pulse was 115 ;the respirations were 18 and thoracic ; she complained thatshe could not breathe. On the next day she came on unwelland passed clots and membrane; the temperature roseto 102° F., the pulse was 120, and the respirationswere 18. Operation was refused.. This patient has graduallyimproved, though there is fulness over the hypogastric regionand a definite bulging in Douglas’s pouch and the rightlateral fornix. As she says she has passed membranes atother times when unwell, diagnosis in this case cannot bedefinite. But if correct, rest in her case is proving curative;it also did so in the first case till the patient got up to wash,and in the second case the patient had nothing done to hertill two months after taking ill.

This brings up the question, Should cases of extra-uterinegestation be operated upon at once, or should rest be triedand abdominal section done when the acute stage has passed? American gynaecologists, I believe, hold the latter view.

Personally, I believe immediate operation would save morelives than a waiting policy.

Dorchester. .

SURGERY AT THE BRUSSELS EXHIBITION.—Theexhibit of British.surgical instruments at Brussels comparesin the most gratifying manner with anything shown by othernations. It is that of only one firm, but it is sufficientlyrepresentative and attracts a good deal of attention. TheGerman surgical exhibit contains, no doubt, ingenious andpractical instruments, but what makes the evident superiorityof the British installation is the high finish and the com-parative lightness of the appliances which admit of moredelicate manipulation. At the Brussels Exhibition GreatBritain is worthily represented and the section attractscultured visitors of every sort. Members, of the professionwho have friends abroad should certainly urge them to seethe exhibit of Messrs. Down Bros. ’

Medical Societies.ROYAL SOCIETY OF MEDICINE.

OBSTETRICAL SECTION.Pelvic Conditions resvclting from the Slighter Forms of

Puerperal Sepsis.A MEETING of this section was held on June 9th, Dr.

H. MACNAUGHTON-JONES, the President, being in the chair.Sir WILLIAM JAPP SINCLAIR read a paper upon the Pelvic

Conditions resulting from the Slighter Forms of PuerperalSepsis and their Treatment, which appears in full on p. 16of our present issue. -

Dr. HERBERT R. SPENCER said that there was no mysteryabout hysteropexy or Sir William Sinclair’s method of perform-ing it. It was a useful operation in certain cases of retro-flexion, but, as was shown by Dr. H. Russell Andrews andothers, it did not always give good results, and was some-times followed by disaster. He had known pain to followthe operation in cases performed by himself and others. He

thought on the whole that the results of shortening theround ligaments by the abdomen were preferable to stitchingup the uterus, although he had known pain also after thatoperation. He had operated by shortening the round liga-ments in a case where conception occurred a few weeksafter the operation, and the pregnancy and labour pursued anormal course, and the subsequent health of the patient wasexcellent. He protested against the statement that "incontrast with private practice, it is alleged that morbidityis unknown in some of our lying-in hospitals." He askedSir William Sinclair for the source of that statement, whichhe (the speaker) had never come across in any work he hadever read. Then, again, what was the meaning of " ovariesare dragged off their shelves "? Could Sir William Sinclair

give any authority for the implication that normal ovarieswere ever on shelves in the living body ? Then, again, " Nonoteworthy new knowledge has been added to obstetricscience and practice since the middle of the eighteenthcentury." He did not see the slightest use in discussing state-ments of this kind.

Sir F. H. CHAMPNEYS said that Sir William Sinclair’s pre-liminary remarks apologising for the character of his paperalmost disarmed criticism. He would only speak to one ortwo points. In the first place, he did not think that SirWilliam Sinclair was correct in saying that it was the habit inLondon to treat cases of sapræmia lightly. He believed thatall teachers taught that at the onset it was impossible tobe sure that a case of puerperal pyrexia was nothing butsapræmia. The point was to make certain that nothinggross was left inside the uterus, and in severe cases toremove anything remaining. If symptoms ceased on pro-viding for the thorough evacuation of the uterus the casewas one of sapræmia. Sir William Sinclair had re-

ferred to the Central Midwives Board (of which he wasan original member) and to the great drawback from thesurvival of so many bonâ-fide midwives. It was not thefault of that Board that these women were on the roll; but,indeed, it was an act of justice that they should be put uponthe roll, and this was in accordance with the practice of thelegislature in such cases. Now this class of midwife doubt-less included many who were highly undesirable, and suchwomen were giving up practice, dying, and being eliminatedby the Board in its penal sittings ; but it also includedwomen who were of great utility, and of whom local super-vising authorities spoke highly. They had, it is true, tomake bricks without much straw, but the bricks which theymade were often uncommonly good. Sir William Sinclairhad spoken rather despondingly of the progress which wasbeing made in the care of the poor mothers of the kingdom.In this respect it might interest the section if he quotedfrom the Registrar. General’s reports figures showing that thelives of more than 621 women were saved in 1907 whichwould have been lost in 1902.

Dr. E. MALINS traversed the remarks made by Sir WilliamSinclair as to the present lack of intelligent appreciation oftheir duties by midwives and nurses. He said that the con-

trary was his direct experience, for that since the formationof the Central Midwives Board he had noticed, both from

A 3

28 MEDICO-CHIRURGICAL SOCIETY OF GLASGOW. -

observation and experience as an examiner, a vast improve-ment.

Dr. LEWERS said that Sir William Sinclair had spoken ofcases of so-called one child sterility " associated with retro-flexion. These he claimed to have cured by ventral fixation ofthe uterus. He had incidentally mentioned that in these casesseparation of adhesions was necessary in order to restore theuterus to its normal position. Dr. Lewers thought that inthe class of cases mentioned it was the adhesions more orless completely occluding the fimbriated ends of the

Fallopian tubes that were the cause of the sterility ratherthan the retroflexion. He considered that if pregnancyfollowed the performance of ventral fixation in the circum-stances mentioned it was to be ascribed to the separa-tion of the adhesions interfering with the patency of

Fallopian tubes rather than to the alteration of the uterusitself.

Dr. T. W. EDEN said he understood the main point of thepaper to be that a great many cases of chronic pelvic inflamma-tion and of uterine displacement were due to slight septic in-fection during the puerperium which had not been recognisedor treated. He was quite in agreement with this view, whichhad been impressed upon him by his experience of gyneeco-logical out-patient practice. But with the explanationoffered by Sir William Sinclair he could not entirely agree. Sofar from thinking that the distinction between sapræmia andsepticaemia was a source of danger, he regarded it as of greatpractical usefulness. And further, he thought that the workof Bumm with regard to septic endometritis in the puer-perium marked a great advance in our knowledge, andjustified the clinical distinction of the two varieties of uterineinfection.

The PRESIDENT said that with the general trend ofthe conclusions come to by Sir William Sinclair as to theoccurrence of certain preventable complications arising outof labour he quite agreed, but both as regards nurses

and practitioners Sir William Sinclair appeared to havehad a very unfortunate experience. He could not conceivethat Sir William Sinclair was speaking seriously whenhe said that the art of midwifery had not advanced since1750. Since that date it had been elevated into a scientificart, worthy of the place it occupied in medicine generally.They were indebted to Sir William Sinclair for havingbrought these practical matters before them for discussion,while he had afforded an opportunity for expression ofopinion on the points that he had raised.

MEDICO-CHIRURGICAL SOCIETY OF GLASGOW.-Ameeting of this society was held on May 6th, Professor R.Muir, the President, being in the chair.-Sir George T.Beatson, in showing two cases illustrating the treatment ofOperable and Inoperable Cancer of the Mamma, referred tothe work done in the study of the mamma and its lymphaticsby Heidenheim, Stiles, Handley, and others, and to the

operative measures thereby shown to be necessary for theadequate removal of the gland. Case 1: A female, aged45 years, was admitted to Western Infirmary, on June 17th,1909, with extensive mammary scirrhus. As there seemed to beno regional or metastatic deposits, the mamma (left) wasremoved. Pathological report showed scirrhus carcinomawith marked involvement of lymphatic glands. The

patient made a good recovery; there was no recurrence

up to March, 1910, and she had very satisfactory powerof movement of the left arm. Case 2: A female,aged 46 years, had her left mamma with all the axillaryglands removed in February, 1907, for scirrhus. By May,1908, small recurrences had taken place alongside the scarand the axillary glands were again involved. In June theserecurrences and glands were removed. The wound healed

completely. In December there was found recurrence in the

portion of the pectoral muscle left after the previous opera-tion-a mass about the size of a walnut. Above and belowthe clavicle were enlarged glands, and in the skin on eachside of the scar were small whitish nodules. No furtherlocal treatment was considered advisable, and on Jan. 28tb,1909, both ovaries were removed. By Feb. 16th therewas a marked difference in the appearance and sizeof the hard mass in the pectoral, and the nodules inthe skin had disappeared. On March 30th the hardmass could not be felt, the scar tissue had become

pliant and freely moveable, and no glandular enlarge,ments could be made out. Examination of the patientat the meeting on May 6th showed no apparent disease.In Sir George Beatson’s opinion oöphorectomy or thyroidtreatment and oophorectomy combined do not influencevisceral deposits in metastasis, but undoubtedly do so inother tissues, such as lymphatic glands. It was not main-tained by him that these procedures were cures, but that incertain cases they favourably controlled the disease.-Dr.J. Shaw Dunn showed Preparations from two cases of AcuteLeukaemia. Case 1: A female, aged 22 years, was admitted tothe Western Infirmary in June, 1907, whose chief symptomswere weakness and breathlessness, which dated from loss ofblood following extraction of a tooth six months before, menor.rhagia, a purpuric rash, ulceration of the gums, and diarrhcaa.Temperature 99°-101° F.; spleen slightly enlarged ; lymphaticglands in neck, axilla, and groin just palpable. Bloodexamination showed: red blood cells, 1,288,000 per cubicmillimetre ; haemoglobin, 15 per cent. ; colour index, 0 5 ;nucleated red blood cells, about 7000 per cubic millimetre(about half of which were megaloblasts and many of veryembryonic type) ; leucocytes, 198,000 per cubic millimetre.Differential count : neutrophile polymorphs, 0’ 5 per cent. ;neutrophile myelocytes, 1.5 per cent. ; small lymphocytes,2-5 per cent. ; large mononuclear cells with basophileprotoplasm, 95-5 per cent. Thee last, in their lack of

neutropbile granules and in their possession of markedlybasophile protoplasm and very indistinct nucleoli, re-

sembled the cells described by Schulze and Pappen-heim as occurring in acute myeloid leukaemia-the myelo-blasts of Naegeli. The presence of these cells and of thelarge number of nucleated red blood cells pointed to acutemyeloid leukæmia, but no necropsy could be obtained. Case 2 :A male, aged 22 years, was admitted to Glasgow Royal In-firmary on May 12th, 1908, with a history of illness beginningsix weeks before with shivering, and marked by weakness,headache, failure of vision, deafness, and, later, delirium ; nohaemorrhages or stomatitis. Blood examination showed redblood cells, 2,953,000 per cubic millimetre ; haemoglobin, 30per cent. ; colour index, 0.5 ; leucocytes, 984,000 per cubicmillimetre ; nucleated red blood cells, scanty ; a few megalo-blasts. Differential count of leucocytes : neutrophile poly-morphs, 0’4 per cent. ; neutrophile myelocytes, 0,5 5 percent. ; eosinophiles, 0’05 per cent. ; small lymphocytes, 0’4per cent. ; large mononuclear cells with basophile protoplasm,99 -1 per cent. These last corresponded in all respects withthe classical description of large lymphocytes, possessingfrom one to three very distinct nucleoli and no granulations.Post-mortem examination pointed to acute myeloid leukaemia,though the blood picture suggested the lymphatic form.-Dr.Dunn showed also a specimen of Rupture of the Diaphragm,with Hernia of the Stomach and Transverse Colon, and readnotes of a case of similar Rupture of the Diaphragm, withHernia of the Liver.-Mr. Archibald Young showed speci-mens (with microscopic sections by Dr. Dunn) fromtwo cases of Sarcoma. 1. Left tibia of a male, aged60 years. At the first operation, in November, 1908,a tumour was enucleated from the tibia, microscopicexamination having indicated a perithelioma, which was

judged unlikely to give off metastatic tumours. The cavityfilled up satisfactorily and the patient was well and able togo about freely till June, 1909, when pain, tenderness, andpulsation returned at the seat of operation and radiographsshowed more extensive absorption of bone. On June 23rd aLister-Carden amputation was performed. The patient re-mained well till January, 1910, when he had a haemoptysisand was ill for several weeks. Since April he had suffered frompain in the right hip and flexion contracture of the knee, andthere is now evidence that a fresh tumour is developing inthe lower end of the femur, and at least a suspicion of somepelvic deposit. Microscopic sections showed that the tumourtissue in many respects resembled that of a hypernephroma.2. Right femur of a male, aged 19 years. The first operationwas exploratory and revealed a tumour of the lower end ofthe femur, which on microscopic examination proved to be achondrosarcoma. Disarticulation at the hip was performedon April 4th, 1910, and the patient was allowed up 25 dayslater. The tumour was of the epiphyseal type, and probablya development from a cartilaginous rest.-Dr. David Dickieshowed three drawings illustrative of his new method oftreating pus-tubes, and showed various water-colour drawingsof this condition.

29MEDICO-LEGAL SOCIETY.-OXFORD MEDICAL SOCIETY.

MEDICO-LEGAL SOCIETY.—A meeting of thissociety was held on June 21st, Sir John Tweedy, thePresident, being in the chair.-Dr. C. A. Mercier read a paperon the Lunacy Certificate and the Liberty of the Subject.When the lunacy certificate was first instituted, he said, in1819, the chief motive of those who prescribed its form wasto safeguard the liberty of the subject. The scandal of themadhouses at that time had become notorious, and it waswell-known that sane persons were detained in them whowere obnoxious to their relatives. The last great reform ofthe Lunacy Laws in 1890 proceeded from the same motive, andwas evoked by the series of actions brought by Mrs. Weldonin the early I I eighties " which resulted in her obtaining heavydamages against the various defendants concerned. It wouldseem that that result was substantial vindication of the

efficiency of the law as it then stood, but the publicmind was so sensitive to any attempt to infringe the liberty ofthe subject that a great outcry arose for a modification of thelaw, and the 1890 Act was accordingly passed. Since thosedays a remarkable change had taken place in public senti-ment on the subject. The difficulty now was not to getpeople under control, but to preserve some modicum of

liberty. The character of amusements was settled byauthority, the conditions of work in factories, in workshops,and on the farm, the age at which a public-house might beentered, and projects were continually being brought forwardfor restricting liberty in various directions. Habitualcriminals were sentenced as such, compulsory detention ofinebriates would soon be enforced, and restrictions on marriagewere urged. He did not know whether this was beneficial ornot, but he drew attention to the remarkable change of

public sentiment which permitted restrictions on libertyseriously to be considered which less than a generation agowould have been beyond the realm of discussion. The

particular point on which Mrs. Weldon gained her verdictagainst the two medical men who certified that she was insanewas their non-compliance with the statutory require-ment that the examination of each medical man shouldbe made separately from the other. It was a littledifficult to understand what was in the minds of thosewho inserted this provision in the Act. Presumablyit was to prevent collusion between the practitionersor to prevent one of them from biassing the mind ofthe other in favour of the insanity of the patient. Ifthat was the object a more futile provision was never

enacted. It could only be attained by providing that thecertifying practitioners should hold no communication withone another previous to certifying. It was not the practiceto argue the expediency of certifying a patient in his

presence, and there was nothing in the Act to preventargument and persuasion taking place to any extent betweenthe medical men, provided they did not make their examina-tions in the presence of each other. As a means of prevent-ing collusion the provision was worthless. Also, it was notto be forgotten that if it were effectual in preventing themind of one practitioner being influenced in favour of

certifying, it would be equally effectual in influencing hismind against this course. In practice the provision is

extremely inconvenient, and if it were now adhered to withthe strictness required by the decision in the Weldoncase it would work great injustice to the patient whomit was presumably intended to protect. When medical

practitioners examined a patient they did not set themselvesthe problem, as the law seemed to assume, as to how theycould best get the patient certified, they set themselves theproblem of ascertaining what was the best thing to do forhim. A patient had the right to the best examination andadvice available in the circumstances. Now when one

practitioner was called in by another to examine a patientthe consultant was entitled to a full and complete accountof the case and the patient to a full and complete considera-tion cf his case. It was a commonplace of medical experi-ence that such an account and such consideration could notbe given unless the two practitioners conducted the examina-tion together. Then the important question also arose as towhat was meant by an examination conducted separatelyfrom another practitioner. If it was to be separate in thesense required by the decision in the Weldon case, where Ithe two practitioners were never in Mrs. Weldon’s ’,presence together for a moment, but drove to thehouse together and left together, then he said withconfidence that the law was continually being broken.

The consultant was always introduced, and, he submitted,might always be introduced to the patient by the practi-tioner in charge of the case. But was it necessary in orderthat an examination should be conducted separately from anyother practitioner that no other practitioner should be in thehouse during the time that the examination was beingmade, for that was what the judgment in the Weldon caseamounted to ? Suppose the patient was the wife or child ofa medical man, was the husband or father to leave the houseduring the examination ? If the patient himself was a medicalman how was the examination to be conducted separatelyfrom him? If, as the judgment in the Weldon case asserted,no other practitioner was to be present in the house while anexamination was proceeding, what was to be done in thecase of a nat ? If in such a case another practitioner mightbe in the same building without infringing the Act, thenwhy might he not be in the same house ? and if inthe same house, why not in the same room, pro-vided he took no part in the examination ? Hesubmitted that if he examined a patient at the Poly-clinic in the presence of 30 or 40 medical practitionersthat examination was conducted separately from anyother practitioner if he alone performed the examination.If the Act were interpreted in that sense then there was noharm in it, but that was the utmost that could be said for itin any case; and as that particular enactment could notin any circumstances be of the slightest value to anyone,and was often productive of inconvenience, expense, and dis-advantage to the patient it was presumably designed tobenefit, it ought to be abolished altogether.OXFORD MEDICAL SOCIETY. - The annual

meeting of this society was held in the Radcliffe Infirmary onJune 17th, Dr. James Neil, the President, being in the chair.- Mr. C. A. Coventon exhibited a young man whom he had

previously shown to the society. The patient had had tuber-culous abscesses from early youth and had practically neverbeen free from discharging sinuses. A large number of opera-tions had been performed in order to rid him of the infectingfoci. In Mr. Coventon’s hands the patient had been treatedwith vaccines of staphylococcus and streptococcus andwith tuberculin T. R. This treatment had been continuedfor three years, and for the last six months he had been

entirely free from any discharge and had been able to leadan ordinary life.-Mr. A. P. Dodds-Parker related a case thathad been sent into the Radcliffe Infirmary as one of gastriculcer. From a child the patient, a young woman, had hardlyever been free from pain in the abdomen, which at times wasso bad as to make her vomit. The diagnosis was not certain,but at the urgent wish of the patient an operation was under-taken. The first thing discovered was the presence of coils ofsmall intestine in the lesser sac of the peritoneum ; a com-plete examination of the whole of the contents of theabdominal cavity revealed a hernia of a large portion of thesmall intestine through a hole in the transverse meso-coloninto the lesser sac. The hernia was reduced, the hole inthe meso-colon was sewn up, and the abdomen closed. The

patient made an uninterrupted recovery and has remainedwell ever since.-Dr. H. T. Gillett read a paper on

Diet in Training, in which he said: The majority ofOxford rowing men consume on the average at least169 grammes of protein daily. This is only a rough estimate,but they probably exceed Atwater’s standard of 150 grammesdaily for those doing severe muscular work. Liebig taughtthat the oxidation of proteins was the sole source of mus-cular energy : hence the diet formerly consisted largely offlesh, but now carbohydrates and fats are recognised assources of energy, so that a high protein diet is unnecessaryand possibly harmful. Atwater and Bryant in their dietarystudies in University boat crews estimated that the averageamount of protein consumed daily was 155 grammes. Theydo not show that it is necessary to take so much, but theysay that the diet best suited to training has not been decidedupon, and varies according to the ideas of special trainers.Chittenden, on the other hand, does not follow the ideas oftrainers or tradition, but proves that athletes can keep ingood condition and compete favourably with others on aslittle as 55 grammes of protein daily for a man weighing 69’ 2kilogrammes. These figures are the average for his athletes.In order to ensure nitrogenous equilibrium it may be safer toallow 1 gramme of protein for each kilogramme of body-weight. Any excess of protein is broken down in the liningmembrane of the gut ; the carbonate of ammonia passes to

30-

REVIEWS AND NOTICES OF BOOKS.

the liver, where it is changed to urea and so excreted.Excess of protein must mean unnecessary work for thedigestion, liver, and kidneys. The purins may cause sym-ptoms of general malaise and irritability and throw extrawork on the organs of excretion. Toxaemia may result fromdecomposition of protein and cause a high blood pressureand consequent strain on the heart in addition to the straindue to rowing. Atwater and Bryant mention the beneficialeffects of fairly large quantities of sugar in training.

Reviews and Notices of Books.A Text-book of Medical Treatment. (Alphabetically arranged.)

By WILLIAM CALWELL, M.A., M.D. R.U.I., Physician,Royal Victoria Hospital, Belfast; University ClinicalLecturer on Medicine, Queen’s University, Belfast; Con-sulting Physician, Ulster Hospital for Women and

Children, the County Antrim Infirmary, the Throne

Consumptive Hospital, Belfast, the Old CharitableInstitute, Belfast, &c. London : Edward Arnold. 1910.

Pp. 630. Price 16s. net.

THIS book is a practical work of reference on the subjectof the medical treatment of disease, and Dr. Calwell, in his

preface, states that it is the outcome" of 20 years’ experiencein teaching the principles as well as the application of

modern therapeutical knowledge." It bears the stamp of awide practical experience in treatment, and althoughnumerous authorities are quoted and references made tospecial forms of treatment, it is the personal note whichrenders this book a useful and practical work of reference.The author acknowledges his indebtedness to Dr. William

Graham for the articles on insanity, to Dr. Thomas Houstonfor the article on vaccine therapy, to Dr. Campbell Rankinfor that on electrical therapeutics, and to Mr. H. NormanBarnett for that on inebriety and State treatment for

inebriates. Dr. Robert J. Ferguson has assisted in systema-tising the articles and in revision, but with these exceptionsDr. Calwell is responsible for the book. There is thus a

continuity of character about the recommendations givenwhich is often lacking in works of similar character but

produced by the collaboration of many authors.In spite of the title given to the book, it is rather a

dictionary of treatment than a text-book, since the alpha-betical arrangement precludes the systematic exposition ofthe principles of treatment except in so far as the diseases ofa given organ or system are classed together, which is fre-quently done, but not invariably. The individual articles varyconsiderably in length, and repetition is avoided by copiouscross references. The general plan adopted is to discuss pre-ventive measures where these are practicable, to outline thegeneral regimen and method of treatment, including diet aswell as medicinal measures, and to give details of the latterincluding as a rule actual prescriptions. Where different

forms of treatment are practised for the same malady theseare indicated, and the names of authorities recommendingthem are often given. As a general rule the author giveshis own experience, and frequently his practical hints

are good and useful. Where drug treatment’ is necessarythe doses of the various substances advised are given, andthe most satisfactory way of administering them is described.The treatment of the ordinary forms of poisoning is con-

sidered, but the accounts given are often meagre and not ofthe same detailed character as those of most of the other

conditions dealt with. To the treatment of skin lesionsDr. Calwell devotes considerable attention, and longdescriptions with several alternative methods of treat-

ment are given for many of them ; these should be veryuseful to the practitioner using the book for purposesof reference. The treatment of general nutritional diseases,

such as gout, diabetes, and obesity, is dealt with very fullyand special directions in-regard to diet are given. These are

in all instances explicit and definite. Pulmonary tuber-culosis is considered at some length and the use of tuberculinis discussed. The recent work upon the value of graduatedlabour in the treatment of this condition is not referred to,although the importance of rest and exercise for patientssuffering from this condition is recognised. The sympto-matic treatment of pulmonary tuberculosis is also fullydiscussed. The various common parasites are considered,and the appropriate treatment for their removal and for therelief of the effects produced by them is given.The articles on the treatment of insanity by Dr. Graham

give a useful account of the general principles involvedin the management of insane patients. In regard to the

prevention of mental disease, Dr. Graham states that mostauthorities would agree that if we could destroy alcoholismand syphilis about 50 per cent. of insanity would dis-

appear with them, and he urges the importance of educatingpublic opinion in regard to these two matters. He is

also strongly in favour of the establishment of out-door

departments in connexion with asylums or hospitals for thetreatment of patients capable of remaining at their own

homes. He gives useful directions in regard to feedinginsane patients, including the methods of forcible feeding,and he discusses at some length the use of hypnotic drugs.The questions of occupation, restraint, and psychic treat-

ment are also dealt with, and brief descriptions are given oftreatment appropriate to the various common forms of

insanity.Mr. Barnett’s article on inebriety and the State treatment

for inebriates gives a résumé of the various Inebriates

Acts, and discusses the value of the treatment in reforma-tories. The subject of alcoholism in its various forms is

dealt with by Dr. Calwell, and he gives careful directions inregard to the management of delirium tremens, chronic alco-holism, and dipsomania. Dr. Rankin’s article on electrical

therapeutics gives a short description of the various forms inwhich electricity is employed in treatment, with the indica-tions for their use. An interesting description of the generalprinciples of vaccine therapy is contributed by Dr. Houston.He closely follows the recommendations given by Sir AlmrothWright and emphasises the importance of commencing withsmall doses of vaccines and controlling by determination ofthe opsonic index. The manner of preparing the commonervaccines is given.

Dr. Calwell’s book should prove helpful to the practitionerand we can recommend it because of its practical andcommon-sense character. There seem to be very few

omissions, though we miss mention of the medical treatmentof cystitis. A few errors, such as "spinal chord" and

" folie du doubts " have escaped correction, and mixable "

is an inelegant substitute for miscible.

A System of Operative Surgery by Various Authors. Edited byF. F. BURGHARD, M.S. Lond., F R.C.S. Eng., Teacherof Operative Surgery in King’s College, London ; Surgeonto King’s College Hospital, &c. In four volumes.Vol. III., pp. 764. London: Henry Frowde and Hodderand Stoughton. 1909. Price 36s. net per volume, or ,E6 6for set of four volumes.

THIS the third volume of this System deals with the

surgery of the ductless glands, the bile passages and thepancreas, the central nervous system, the genito-urinaryorgans, and the thorax and its contents, so it is seen that

many and various parts of operative surgery are dealt with.Mr. Harold J. Stiles has written on the operations for

tuberculous diseases of the lymphatic glands, and he espe-cially refers to the structures that might be possibly injured