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Medical Societies.

ROYAL SOCIETY OF MEDICINE.

SECTION OF SURGERY.

A PATHOLOGICAL meeting of this Section was heldon Jan. 2nd, Prof. GEORGE GASK presiding.

Sir LENTHAL CHEATLE gave a demonstration oftransillumination as an aid to the diagnosis of breastdiseases, a method which he was first made aware ofby having it demonstrated to him by Dr. Max Cutler,in New York. (See THE LANCET, 1928, i., 38.) Themethod was very simple, and he regarded it as ofdistinct value.

Sir LENTHAL CHEATLE also made a communication on

Sterilisation of Surgical Drvw.He criticised the drum most commonly in use atthe large hospitals, stigmatising it as one of the mostseptic things imaginable. He did not think anybacteriologist would trust a result which was foundedon such so-called sterilisation as was applied in atypical drum shown on the screen. Steam, he said,was used under a pressure of two atmospheres, andcertainly sterilisation of everything in it was attained ;but air also had to be admitted, and, though cotton-wool was used, the portals of entry for the air wereso large, and the passage of steam took place at sucha great pace, that sterilisation in the end was not byany means complete. Any dressings exposed to thisprocess, however thoroughly sterilised at first, wererendered septic again by the passage of air and itscontents. He understood that the makers hadnever thought of testing the efficacy of the machinebacteriologically. His purpose in making the com-munication was to warn surgeons as to the possiblefallacy of claims made for drums. Sometimes thedrums were put into the sterilising apparatus open,sometimes closed, but even when closed the airopenings were not closed; and air entering the

machine for drying purposes was the vehicle forreinfection. The holes, moreover, were large enoughto admit humming birds, humble bees, and grass-hoppers ; even maggots had been discovered indrums. The speaker had been experimenting withthe object of evolving a more efficient sterilisingdrum, and his final result, which he demonstrated,was a tin having two grooves. Cotton-wool put inthe two grooves and the lid on top kept the contentssterile until they were required for use. The diffi-culty was how to get steam into the drum to carryout the sterilisation; this difficulty was obviated byevacuating the steam and the air three times duringthe process, the sterilisation occupying two hours.When this method was employed efficiently thedressings, aprons, masks came out sterile and dry.With the apparatus now in general use he did notthink the results were any better than after theordinary wash.The CHAIRMAN said the communication caused him

to feel a little disturbed, because when, as a student,he was attending the bacteriology class, one of theduties was to examine the drums with the big holes;as described, and students were taught to believethat what came out of them was sterile.

Mr. DUNCAN FITZWILLIAMS said that if one boughtfrom a store a roll of ordinary gauze, and removedthe first three layers, the remainder of the roll wouldbe found to have come from the manufacturer sterile.He referred to a war experience in Roumania in thematter of improvisation, and spoke of Dr. Cathcart’suse of sterile sawdust as a cheap dressing, the centrepith of the wood being torn out and dropped into apit, always being found strictly sterile.

Mr. FITZWILLIAMS showed a series of patients onwhom he had carried out, at various dates,

Partial Removal of Breast for Early Carcinoma.He said that probably the breast was the only

site in the body in which a truly radical operationwas carried out-i.e., in which the growth, thelymph field, and the whole area surrounding it.In cancer of the tongue the operator was not nearlyso radical, being content with removing a portionof the tongue and the neck glands. In the rectum,too, though this was a danger area, the operationusually done was less sweeping than that in the breast.For breast carcinoma Halstead had recommendedthat the glands above the clavicle should be removed,because they were in the lymph field. Many sur-geons, however, now left them untouched. Thespeaker suggested to his colleagues that in earlycases of breast carcinoma much more could safelybe left behind than was usual. The earliest case onwhich he had operated in this partial way was seenby him 23 years ago, and the patient was stillalive; he had had 20 cases with a survivalof one and a half to two years so far ; while thatevening ne showeet patients wno were operated uponfive, three, and two years ago. The theory on whichhe worked was as follows. Cancer was recognisedto be, when it started, a local disease-when itwas the size of a millet seed. At that stage, hecontended, it was successfully removable by a purelylocal operation; it was so small that it was relatedto only the finest radicals and lymphatics.If left longer it ate into larger lymphatics, and soglands in the neighbourhood were involved. Thedifficulty lay in knowing just when it was so strictlylocal. His own working definition of " early carci-noma " was carcinoma without a single distinguishingmalignant attribute. Years ago the teachers at JohnsHopkins school said that the presence of one malignantcharacteristic in diseases of the breast reduced thesurgeon’s chance of success by 25 per cent. ; whileif there were two malignant characteristics the chancewas reduced by a further 25 per cent. That Mr.Fitzwilliams held to be true. When a tiny noduleof the breast was discovered the examiner had noright to tell the woman it was " nothing " ; it oughtto be removed forthwith. He remembered one casein which he could not satisfy himself that there wasa lump ; but in six months the woman came backwith a flaring carcinoma. In a very early case

sections would show several doubtful slides, and onlyone which could be called carcinomatous. He con-tended that a very early case of carcinoma of thebreast could be cured by merely doing this partialoperation. He was sure many cancer cells weredestroyed by natural processes. The first gland tobe infected would be blocked, and so very little orno lymph would pass through ; hence this gland, atthis stage, would not infect other glands. Until oneknew a gland was infected there was no reason whyit should be removed. In 30 cases he had seen

no reason to regret having done only the partialoperation. . , . , _ . , , . , , , _

When, at a distinctly later stage, intected lymphwas flowing elsewhere and nodules were present atdifferent sites, however radical the operation, itwould be of little avail. In the smaller operationone did not find secondary growths all roundthe wound, as in the case of the larger surgicalprocedures.The CHAIRMAN said a partial operation of such

limited extent was contrary to surgical teaching,though it was probably supported by a partial truth.It was, however, preached by his chiefs a long timeago. His own immediate chief sometimes did onlya small operation on the breast, occasionally takingaway glands also, but sometimes not. And othersurgeons, whose opinions he valued, had also done thesmall operation and shown good results. His, thespeaker’s, own trouble was in knowing when therewas present only a small local growth. In someof the cases of carcinoma of the breast which he hadregarded as very early, he found metastatic growthsoccurring quickly afterwards. If a growth could becaught before dissemination and destroyed by meansof the cautery, or radium, or other method, a curewould probably ensue. But how was one to know

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that a case had only reached that stage ? Mr. Fitz-williams instanced in comparison tongue cancer,but in that organ the results were bad.

Sir LENTHAL CHEATLE said he agreed that if a casewere met with early enough, local excision would prob-ably suffice. But there must be malignant disease inthe terminal ducts and acini before any of the cells gotout. His own view was that to adopt the methodof local removal was a retrograde step. He remem-bered several cases in his career, and in the careerof other surgeons, in which the axillary glands wereenormous and yet it was very difficult to detect evena small primary nodule in the breast. In a seriesof cases he examined the vessels and tissues round theaxillary vein before doing the complete operation,and in only one was that area free from carcinoma.

Dr. D. F. CAPELL asked whether, as it was oftenimpossible to find changes in the breast apart fromthe local area, there was not a risk of further develop-ment of carcinoma from some of these other foci.He had examined a series of such cases and hadfound changes bordering on cancer in multiple foci.When only a small part of the breast was removed,was not one leaving behind an area which might laterbecome malignant ?Mr. FITZWILLIAMS, in reply, said the points raised

concerned a wider area than he had opened up. Theidea of merely local removal was not new. The cruxof the matter was, if it was felt that removal of halfor three-fourths of the tongue sufficed for cancerof that body, why should not a like local removalbe enough in very early breast carcinoma ? In theearly cases he was speaking of there were no enlargedglands in the axilla, nor was there a single malignant icharacteristic present. If there were such signs alarger operation must, of course, be done. In pre-cancerous leucoplakia of the tongue it was not thepractice to remove the tongue.

Prof. C. A. PANNETT submitted a communicationon

The Use of the Cautery in Operations on the Stomach.He explained that he was not referring to thecauterising of ulcers. The problem was the follow-ing. Often a patient with gastric disease was thin,emaciated, half-starved, and so was not in a fitcondition to undergo a severe abdominal operation.Hence the conservation of every possible drop ofblood became a prime consideration. The generallyemployed methods of performing gastrectomy didnot always meet the situation in this respect. It waseasy to tie off the lesser omentum and the greateromentum and to proceed, bloodlessly, to a stage atwhich the actual growth or ulcerous area must beexcised. But in the case of a large gastrectomy forhigh gastric ulcer or carcinoma he had frequentlyfound it impossible to use the ordinary haemostaticclamps to control haemorrhages while cutting theviscus across. He had been using a simple procedurefor working without haemostatic clamps. In someclinics, faced with the same situation, the Paquelin i

cautery had been used, but this was a clumsy methodof dividing the stump, and it burned a wide area ofthe viscus and led to a wide cicatricial band. He hadnever seen anybody divide viscera with the ordinaryPaquelin cautery. When using the cautery fordividing the stomach, two things were necessary.First, one must minimise the amount of heat required,which was done by temporarily controlling the circu-lation, which would otherwise act as a cooling stream.Secondly, the clamp used must be massive enoughto conduct away the heat, so that the tissue aroundthe clamp was not burned. He used two forceps,one of them fenestrated. He described the detailsof his procedure by means of illustrations on theepidiascope. The adoption of this procedure, hesaid, had enabled him to operate on people on whomhe would not otherwise have ventured. One patientso dealt with died subsequently from a pulmonarytrouble and there was found to be no differencein the operation site as compared with the ordinaryheemostatic cautery suture.

Specimens and Cases.Mr. C. P. G. WAKELEY showed two specimens.

The first was one of cavernous angioma of the brain,from a woman aged 25 who came to hospitalbecause of the weakness of the left arm and left leg.Beyond some excitement, nothing pointed to a cerebrallesion. Post mortem, cedema was seen round theangioma in the brain, and it had led to secondaryhydrocephalus. The other case was a meningealmyxoma. The man, aged 48, had had fits and someparalysis of the leg. X rays were of great help inlocating the tumour. An osteoplastic flap was

turned down, and as soon as the dura mater wasexposed the growth bulged into the wound, and onincising the dura the tumour spontaneously presented.Shortly after the operation some paralysis of the legoccurred, but that soon cleared up, and the patientgot quite well.

Prof. PANNETT praised the surgery carried out inthis case.!, Mr. GWYNNE WILLIAMS showed a patient on whomhe had carried out partial exclusion of the thoracicaorta for the cure of pain. The man had had aneurysmof the abdominal aorta five years, and came to himfor the relief of his pain. Mr. Williams reduced thepulse in the femoral in the groin by pressure, andpain had now practically ceased. He could not puta wire in as the aneurysm was too extensive.

Other cases were also shown.

SECTION OF THERAPEUTICS AND

PHARMACOLOGY.

A MEETING of this Section was held on Jan. 8thwith Dr. H. H. DALE in the chair. An informal dis.cussion on the treatment of

ESTABLISHED DIABETIC COMA

was opened by Prof. E. C. DOIDD’3, who pointed outthat the subject allotted limited the discussion tomethods of bringing a comatose patient back toconsciousness. At the Middlesex Hospital they reliedfor the insulin dosage on blood-sugar estimations.The blood-sugar estimation took about 15 minutes andthen the first dose of insulin was given, usually about100 units ; thereafter the blood-sugar was watchedand the dosage adjusted accordingly until the patientrecovered. It was possible to work with urine-sugarestimations up to a certain point-about the timewhen the patient began to lose his air-hunger-butthereafter grave risk was run if blood-sugar estima-tions were not made. He disagreed with those whoregarded it as waste of time to administer glucose ;apart from the benefit to metabolism, glucose actedas a barrier against hypoglycaemia. The alkali reservewas worth determining, for it revealed more than didthe blood-sugar estimation or the simple tests foracetone bodies in the urine. The majority of patientstreated in this way recovered, but a certain numberdied. For these deaths three reasons had been putforward : (1) Inability to control the diabetes so thathyperglycaemia and ketosis continued. This occurredchiefly in septic cases and therefore did not come intothe present discussion. (2) Kidney damage, leadingto retention of urea and a uraemic coma very likediabetic coma. Investigation of a series of cases hadshown, however, that high urea and non-proteinnitrogen content in the blood was not unusual indiabetic patients, and that it occurred in those whorecovered from coma as much as in those who died.(3) Failure of the circulatory system. Two patientsat the Middlesex who had died in coma had had lowblood pressure and had appeared to die of circulatoryfailure. The total acetone bodies in their bloods hadbeen below normal, about 3-5 mg. per 100 c.cm. ; inone case the blood had been taken just as the patientdied. The blood pressure was of great prognosticimportance. In these two cases the subcutaneousadministration of ephetonin and pituitrin had failedto save the patients’ lives. -

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An Instructive Case.Dr. GEORGE GRAHAM said that all his patients had

either recovered or had first been treated very late.Four weeks ago, however, he had had a case whichmight be instructive.The patient was a boy of 16 who had been doing well on

diet and insulin for six years and had entered for anexamination. He had felt ill and done his papers badly,and had gone to bed without either food or insulin. At12.30 A.M. he had vomited. At 3.30 A.M., when his mother hadseen him, he had been obviously ill, and she had supposedhim to be suffering from hypoglycaemia and had given himadrenalin and sugar. When the doctor had seen him at6.30 A.M. he had been dazed and had complained of pain inthe right side of the abdomen, for which morphia had beengiven. He had then had more sugar and travelled 30 milesto hospital by car. On arrival he had been very cold witha pulse-rate of 120, a blood-sugar of over 700 mg., and awhite blood cell count of 32,000 ; 100 units of insulin hadthen been given. The possibility of a gangrenous appendixhad led to a laparotomy-the first error in treatment, fornothing abnormal had been found. At 4 P.M. the blood-sugar had again been over 700 mg. and 50 g. of dextroseand 150 units of insulin had been given. He had smeltstrongly of acetone, and the blood had flowed sluggishlywhen withdrawn for testing. He had therefore been orderedsaline infused by gravity, the dextrose and insulin dosesbeing continued. At 10 A.M. the next morning a bloodcount had shown 5,800,000 red cells, 6000 white cells, anda haemoglobin percentage of 108. The blood-sugar haddropped to 240 mg. At 11.30 he had received another100 units of insulin by mistake, and the next 24 hours hadbeen occupied in keeping him out of hypoglycsemia by theadministration of sugar per rectum and per os. At 11 P.M.the blood-sugar had risen to 170 mg. but at 3 A.M. the patienthad become pale and rigid, being restored to normal by theadministration of adrenalin and dextrose. At 8 o’clock nextmorning the blood-sugar had been 40 mg. and adrenalinhad been repeated, followed by 10 units of pituitrin anddextrose intravenously. Next morning he had been better,with a blood-sugar of 370 mg.The urine of this patient had contained granularcasts and pus cells but no red cells, and not until thesixth day had acetone bodies appeared in it; thenthe reaction had been very strong until, on the four-teenth day, there had again been no acetone in theurine. The boy had gone into coma because he hadhad something wrong with his kidneys and they hadbeen unable to excrete acetone bodies. Treatment of I,diabetic coma must be by the administration ofplenty of insulin and plenty of sugar ; it was a mis-take to give insulin without waiting for the blood-sugar estimation. Further, fluid should be givenintravenously ; one patient who had died of circu-latory failure had had a haemoglobin percentage of140 per cent. These patients died from a conditionakin to surgical shock ; they could not keep fluid intheir blood. Therefore fluid must be given them, ifnecessary under pressure. There was often some veinspasm which prevented the entrance of fluid undergravity.

The Administration of Glucose and Alkalis. IDr. R. D. LAWRENCE said that he had not had Imany cases of diabetic coma, as the pre-comatosepatient usually recovered with insulin and glucose.He agreed that the patient was dehydrated, as

judged by the tension of the eye, and should at oncereceive large quantities of intravenous saline. Withthis, where the pulse was collapsed, should be givena drop or two of adrenalin. Difficulty in getting thefluid in could be overcome by the use of a bloodtransfusion syringe. Strophanthin might be given forthe heart, but the effect of adrenalin alone was oftenmiraculous. It lasted for 20 to 40 minutes. Thewhole problem was one of circulatory depression, andthe failure of the kidney to excrete acetone bodieshad nothing to do with the severe condition of thepatient. He did not agree, however, that glucoseshould always be given; its administration wasunnecessary and unphysiological. When the blood-sugar could be watched sugar should not be given atthe outset, but for the patient outside hospital itwas essential from the first, as it was impossible totell how quickly a patient would respond to theinsulin. Improvement usually coincided with lower-

ing of the blood-sugar, but the patient might just aswell recover with a high blood-sugar. The old over-dosage with alkalis was now discarded, but it waswise to give small doses of sodium bicarbonate inthe early stages. He detailed a case illustrating thevery prolonged effect insulin might have once it gotgoing. In this patient it had required large doses ofinsulin to get the blood-sugar down in the first12 hours, and it would never have come down ifglucose had been given as well.

Prof. HUGH MACLEAN said that everybody wasagreed on the general treatment of these cases andthat large doses of insulin should be given. At hishospital it was the custom to give 50 units before theblood estimation and thereafter to regulate the doseby the blood-sugar. He agreed that when the blood-sugar could be watched it was unnecessary andunphysiological to give large amounts of glucose.There was no doubt of the efficacy of cardiac stimu-lation, and camphor might have a marked effect insome cases. It must be remembered that a highblood-sugar in itself did no harm so long as therewas no acidosis, and that it did not really matterwhether the blood-sugar were lowered or not. Theprinciples of treatment must be directed towards

supplying large amounts of insulin and moderateamounts of blood-sugar. It was possible for a patientto be suffering simultaneously from diabetic comaand insulin hypoglycsemia, and a fall in blood-sugardid not necessarily indicate the passing of coma.A patient with a blood-sugar of 0-01 or 0-02 mightpass huge quantities of ketone bodies in his urineand be in coma. For the general practitioner whocould not obtain blood-sugar estimations the problemmight be a very difficult one, and under these circum-stances plenty of glucose should be given, after theinitial dose of insulin. The effect of diabetic coma onthe circulatory system was very severe, and graveadditional risks were run if the blood-sugar wereallowed to get so low that insulin hypoglycaemiamight supervene, for this in itself was very detri-mental to the cardiac mechanism. In angina patientsthe brief periods of hypoglycaemia following adminis-tration of insulin might precipitate an anginoidattack and cause death. It was bad to give largeamounts of bicarbonate ; it had been shown that theadministration of sugar after a period of fastingwould fail to stop the ketonuria if a dose of bicar-bonate were given previously. Small doses, how-ever, were indicated because of the low alkali reserveand the depletion of the alkalis of the body.

Dr. 0. F. LEYTON said that he had not been con-vinced that sugar was harmful. Sugar could notdehydrate the patient if plenty of water were givenwith it. In his experience patients with a low renalthreshold might develop diabetes mellitus, and evenif this were not admitted, the renal threshold was notconstant and might fall very low indeed in diabeticcoma and hypoglycaemia. It was therefore dangerousto conclude that because there was sugar in the urine

; more insulin might be given.

The Time Factor and the Age Factor.Dr. P. J. CAMMiDGB said that error was bound to

occur if it were assumed that all diabetic coma wasone and the same thing. The treatment dependedgreatly on the time that coma had existed and onthe age of the patient. Diabetic coma had first beenascribed to acidosis, then to changes in the hydrogen-ion concentration of the blood, and now it was believedto be due to changes in the osmotic pressure in thecells and between the cells and the plasma : depletionof the fixed bases from the nerve cells led to uncon-sciousness, and from the heart to weakness, fall ofblood pressure, &c. In the early stages patientswould recover rapidly if the acetone and other bodieswhich were combined with the fixed bases could beremoved. Fairly large doses of insulin intravenouslywere all that would be required. Other patients, whohad been unconscious for some time, would not beaffected by any amount of insulin. The patient whorecovered easily was usually young. The elderly

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patient as a rule needed sugar as well as insulin, andeven then the rate of oxidation of the ketone bodiescould not always be speeded up beyond a certainlimit. The only way then was to give alkalies intra-venously in small amounts, along with the insulinand glucose.

Dr. W. W. PAYNF emphasised the fallacy of testingthe urine alone. He quoted a case where the urinehad shown no sugar or acetone bodies and the blood-sugar had been 0-5, but the patient had died in uraexniccoma with a blood-urea of 250 mg. Another patienthad been in coma for two days ; on the first day hehad had acetone bodies in the urine but they hadbeen absent on the second day, although there wasno lack of them in the system.

The Significance of Chlorides and Phosphates.. Dr. C. G. WOLF mentioned the work of Prof. L. Blumand his colleagues at Strassburg on the depletion ofchlorides in the body in diabetic coma. They thoughtthat part of this condition was due to the very lowchloride content of the body. The addition of sodiumchloride to the insulin seemed to have a good effect,one that was not produced by any other sodium salt.

Dr. PHILIP HAMILL pointed out that it was dan-gerous to give repeated doses - of morphia sub-cutaneously for cholera because the drug might remainin the skin while the circulation was poor and betaken up again when the administration of salinehad improved the state of the blood. He suggestedthat the same fate might befall subcutaneous insulinwhen the patient was dehydrated.

Dr. F. B. BYROM referred to his work on thephosphate-content of the blood. In three fatal casesof diabetic coma, he had found the phosphate-contentextremely high, a condition only found in ursemia.This suggested that renal drainage played a largepart in patients with diabetic coma who arrived lateat hospital.

Dr. G. C. LINDER described a patient with diabeticcoma who had come into hospital with 400 mg. ofblood-sugar and a ’carbon dioxide concentration of8 volumes per cent. in the whole blood. He had beengiven 10 g. of bicarbonate intravenously, which hadonly raised the carbon dioxide to 17 volumes percent., although the hyperpnoea had disappeared andthe patient improved. Another 15 g. of bicarbonatehad brought the carbon dioxide content to 39 volumesper cent. without any evidence of overdosage. Thisshowed that large doses of alkali could be given,provided their effects were followed by determina-tions of the carbon dioxide in the blood. The patienthad been under a tremendous handicap owing to hisvery low alkali reserve.The CHAIRMAN said that the suggestion made by

Dr. Hamill had occurred to him, and he thought itmight be wise to begin by administering a smalldose of insulin intravenously rather than a large onesubcutaneously. If a rabbit were given insulin hypo-dermically it would suffer from hypoglycaemia in halfan hour. It could be brought round from this state,but its troubles were not then over, for in anotherhour it would be down again. It had to be treatedrepeatedly for several hours. In cholera hypertonicsaline had been found preferable to normal saline,and it might also be better for the diabetic.

Dr. CAMMIDGE pointed out that Joslin in pre-insulin days had strongly favoured the administrationof sodium chloride to patients with acidosis. because Iit kept the ketone bodies locked up in the tissues. sopreventing them from circulating and doing damage.

Dr. GRAHAM, replying for himself and Prof. Dodds,said that he had simply given saline because theblood was sticky. Prof. Dodds agreed that the salineshould be hypertonic and thought that it would bewrong to leave out sugar as a general rule becauseof the danger of passing too quickly from hyper- tohypoglycaemia.

Dr. LAWRENCE remarked that insulin did not actparticularly in the blood, and that its action was

Iusually protracted. The continued effect of large Idoses could easily be explained without assuming a

delay in the skin. He had tried intravenous injectionin a case where subcutaneous administration hadfailed, but without effect.

Dr. CAMMIDGE said he always began with a smallintravenous dose of insulin, taking some blood awayfor testing at the same time, and went on giving smalldoses until a definite effect was obtained. It waspossible to carry out sugar estimations at the bedsideby the picric acid method, and to obtain comparableresults.

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WAR SECTION.

AT a meeting of this Section on Dec. 10th, withLieut.-General Sir MATTHEW FELL, the President, inthe chair, a paper on

Some Common Problems in Naval Hygienewas read by Surg.-Commander P. M. RivAZ. From whathe said it appears that ventilation by punkah-louvres,which direct the entering air to the point where it isdesired, are highly successful in the Navy, and exhaus-tion of- air is serviceable in galleys, lavatories, andengine-rooms, though not in cabins or mess-decks.Constant vigilance by ventilation committees isneeded to keep the supply of air working well. Fansmust be rested, in cabins and mess-decks by day, inoffices by night. Current opinion is in favour of moretable fans. Clothing must be very light in thetropics ; officers are apt to be too much clothed. Ifstokers working on coal fires wear too little they getscorched ; if too much they get heat-stroke. Defi-ciency diseases and diets suitable for the tropics ar&

under investigation. It is hardly possible, Surg.-Commander Rivaz considers, to compare the preva-lence of tuberculosis in the Services with its prevalencein civil life, where notification is still very uncertain.Every man under 36 in the Navy is weighed once aquarter, and all chests are examined every six months,but the early doubtful case is still a difficulty.

In the discussion following this paper Major-General H. P. W. BARROW said that ventilation andthe reduction of overcrowding had been found of greatimportance in relation to troop transport by sea.With enlarged cubic space, better spacing of hammocks,hospital admissions in troopships had gone down from631 in 1914 to 277 in 1926. Experiments on vitaminsand diet were to be undertaken in the East and muchwas hoped from them, also from the forthcomingreport of the Joint Committee on Tuberculosis.-Fleet-Surgeon W. E. HOME said that overcrowding hadbeen defined by Sir Thomas Fraser as a function ofthe number of persons occupying a space and theefficiency of the ventilation of that space. He (thespeaker) had seen men with only 100 cubic feet of spacedevelop illness from overcrowding in a month.

PATHOLOGICAL SOCIETY OF GREATBRITAIN AND IRELAND.

A MEETING of this Society was held at St. Bartholo-mew’s Hospital, London, on Jan. 4th and 5th, withProf. E. H. KETTLE in the chair.

J. W. McNee (London) discussed the pathologicalclassification of chronic splenomegalies met with inBritain and drew special attention to the commontype starting with haemorrhage round the ellipsoidswith subsequent fibrosis and siderosis, the actual grossenlargement being due to venous obstruction. Heregarded true Banti’s disease as very rare.-J. M.Ross (London) exhibited a specimen of the rare formof splenic enlargement due to overgrowth of theMalpighian bodies (Foix and Roemmele type).-J. S.Young (Leeds) found that salts injected into thepleura stimulated hyperplasia of the alveolar epithe-lium in proportion to the valency of the kation.The cells are refractory to a second dose.-I. Beren-blum (Leeds) obtained a few epithelial tumours in miceby repeatedly freezing the skin with CO snow.Freezing did not increase the carcinogenic efficacy oftar which is actually diminished by mustard gas.-