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The pain is evidently produced by the pressure of the inflam-matory deposits upon the nerve endings.As I believe the infiltration occurs in the panniculus

adiposus I should be inclined to coin a word and call it

"panniculitis." The condition is apparently quite distinctfrom fibro-myositis, although the two are sometimes asso-ciated. In one of my cases the masseuse had to disperse thethickening in the panniculus adiposus before attempting tomassage the indurated muscle immediately underneath onaccount of the tenderness caused by the manipulations.

Dr. W. H. Maxwell Telling,l in a most interesting paperentitled "Nodular Fibro-myositis," does not differentiatebetween panniculitis and induration of the muscles. One ofthe cases he describes (No. 4) was, I think, an example ofpanniculitis. Further, in my experience panniculitis occursmore frequently in gouty than in rheumatic subjects.

Regarding treatment, massage is the only effective remedy.I have tried thyroid extract, but I am not satisfied as to its

therapeutic utility in this affection.Harrogate.

A CASE OF COMPLETE LOSS OF MEMORY—? AFTERINFLUENZA.

BY H. S. GASKELL, M.B., CH.B. EDIN.,HONORARY MEDICAL OFFICER TO THE COBHAM COTTAGE HOSPITAL.

THE following case may, I venture to think, be of interestto readers of THE LANCET.On Jan. 16th I was called to see a young man, aged

2 years. I found him in bed complaining of feeling seedyand having a cough and sore-throat. He lay very still,muffled up in the clothes, and seemed rather depressed. Theduration of the illness had been four days. Up to the 15thhe had been attending to his duties as usual. He had neverhad any illness, and the only medical attention he hadever received had been for measles and chicken-poxin childhood. My examination proved negative. The

temperature was normal and the pulse was of low ten-sion and regular in force and frequency. The fauces anduvula were very slightly, if at all, reddened. The tonguewas very slightly furred at the back. The action of theheart and lungs appeared to be normal. I prescribedcalomel and a mixture containing sulphate of magnesiaand nux vomica. On the 18th I saw the patient again, whenhe was up and dressed. He said he felt better, only a" bit slack." On the 22nd (Monday), although not yetfeeling quite up to the mark, he started out to walk tohis place of employment, a distance of half a mile. Hewalked about 200 yards, and remembers addressing someremark to a boy on the road, and after that hismind became an absolute blank. The next thing heremembered was sitting, in a state of complete exhaustion,on a’seat at Hampton Court, nine miles away. He askedwhere he was, and then having just enough money in his]pocket, he came back by train, went to bed, slept straightoff for 13 hours, and woke up feeling much better. He was

kept in bed for five days, although he felt well, and a fulldiet, with extra milk and eggs, was recommended. He hasnow resumed his duties and appears to be perfectly well.The I I trance " began approximately at 8.45 A. M. and ended

at a.bout 3.45 P.M. The patient stated that on awaking hehad a violent headache, and felt very tired and cold. Hewas so cold that he thought he must have been sitting stillfor some time. The weather at the time was damp andrainy, but not very cold. He had never been near HamptonCourt before. He must have walked along a main road (thePortsmouth road), along which flows a constant stream ofmotor traffic, and must have passed through the congesteddistrict of Kingston-on-Thames, with all its trams and

crossings. It would be interesting to hear of any otherexperiences of the sort.Cobham, Surrey.

1 THE LANCET, Jan. 21st, 1911, p. 154.

MEDICAL SICKNESS AND ACCIDENT SOCIETY.-The twenty-ninth annual general meeting of the above

society will be held at the meeting-place of the MedicalSociety of London, 11, Ohandos-street, Cavendish-sqnare,W., on May 9th, at 4.30 P.M.

Medical Societies.ROYAL SOCIETY OF MEDICINE.

MEDICAL SECTION.

The Vaocine Treatment of Goitre.A MEETING of this section was held on Jan. 23rd, Dr.

FREDERICK TAYLOR, the President, being in the chair.Captain R. MCCARRISON, I.M.S, read a paper entitled,

The Vaccine Treatment of Simple Goitre, which is pub.lished in full on p. 357 of this issue of THE LANCET.

Dr. F. PARKES WEBER asked whether thyroid feeding pro.duced diminution of the goitre in the class of cases whichCaptain McCarrison had treated. One would expect it to doso if the explanation offered were correct.

Dr. FREDERICK LANGMEAD said that anyone who hadfollowed Captain McOarrison’s work on goitre and alliedconditions could have counted beforehand on hearing some-thing of importance and interest that afternoon. The ques-tion which the reader of the paper had introduced, of therelationship between the thyroid gland and toxasmic condi-tions, was a very broad and intricate one. Amongst a largenumber of examples of this relationship he would mentionthree groups of cases in which it occurred : (1) conditionsconnected with uterine and ovarian function; (2) rheu-matoid arthritis ; and (3) tetany. It was generally agreedthat the thyroid gland enlarged at puberty, during preg-nancy, and during the menstrual periods, which could beregarded as minor and abortive pregnancies, and that signsof thyroid incompetence were not uncommon at the

menopause. Evidence was accumulating to show that thisenlargement was not merely associated with ovarian

activity, but was brought about by the presence of an activeagent in the blood. This agent in the case of pregnancywas thought to be actually transferred to the blood of thenewly-born child, in whom it caused mammary secretion,vaginal haemorrhage, or prostatic activity. By Halban itwas believed to be a product of the chorionic villi. Withregard to rheumatoid arthritis, there was considerableevidence to show that it might be produced by absorptionof toxins from the bowel, and the good effect of such drugsas guaiacol was ascribed by some to its antiseptic action onintestinal micro-organisms. Moreover, many cases hadbeen recorded of the association of Graves’s disease andrheumatoid arthritis, and thyroid extract was sometimes

very efficacious in the treatment of the latter. Tetanyhad been mentioned by Captain McCarrison. Now tetany,as it occurred in young children, was almost in-

variably preceded by abnormal loose or offensive motions.In adults it complicated dilatation of the stomach andBouveret and Devic had isolated a toxin which couldproduce tetany from the stomach contents in such cases.

The speaker himself had recorded other cases of tetany inchildren, associated with dilatation of the colon, which

appeared to be analogous. That there was a relationshipbetween tetany and the thyroid gland was well known.These remarks only conveyed a few ideas bearing on the con-nexion between thyroidal enlargement and toxæmia-a verybig subject.

Mr. JAMES BERRY said that he thought the profession wasrapidly coming to the conclusion that all cases of goitre weredue to a toxic influence, and that chemical changes in thewater were not the cause. Whatever the toxic agent was, itwas suspended in the water used for drinking. The treat-ment of parenchymatous goitre was essentially medical, butthere remained other forms to be dealt with by the surgeon.He hoped that vaccines might be another valuable means ofmedical treatment. He was convinced that no surgeon shouldoperate upon simple parenchymatous goitres until they hadbeen efficiently treated by medical means for a considerabletime. It could not be expected that medical treatmentwould benefit patients suffering from adenomata. He didnot agree that hypertrophic and parenchymatous goitre weresynonymous terms. The latter was a condition of atrophyrather than of hypertrophy. The vesicles were filled withsecretion, but it was stagnant and the cells were inactive.He asked whether any diarrhoea was produced by treatment.The PRESIDENT said that, as various medical methods were

365

beneficial in parenchymatous goitre, it was to be expectedthat there was some underlying factor which was common to Cthem all. Had Captain McCarrison thought whether there ’’

was anything in common in the methods of operation of el

arsenic, iodides, thyroid extract, and vaccines ?Dr. ROBERT HUTCHISON said that although no one could tl

deny Captain McCarrison’s therapeutic results he was not so s4

sure about the validity of his explanation of them. He was tl

always rather sceptical about intestinal intoxication and ri

thought that it was too often advanced as an explanation of Iall sorts of obscure conditions. All they knew of the secretion pof the thyroid tended to show that it was a great stimulant of oxidation in the body, and those conditions in which a ri

physiological hypertrophy of the thyroid occurred, such aspregnancy, were perhaps conditions in which there was an Iincreased metabolism and a demand for more thyroid secre- c

tion to meet it. This explanation was quite as likely as that bthere was an increased toxaemia. On the other hand, there s

was much more reason to regard the liver as the organ con- r

cerned with the destruction of poisons passing from the portal system. He would like to know how long the bene- v

ficial effects of vaccine lasted in these cases. a

Dr. F. G. OROOKSHANK asked what kinds of goitre were i

prevalent in Gilgit, and whether they showed any tendency cto spontaneous cure ? Did endemic cretinism occur ?

Captain MCCARRISON, in reply, said that no diarrhœa had ...

occurred in his cases. No recurrence had taken place over a ...

period of two years in some of them. He thought that the s

common factor in the various forms of treatment lay in the truth that they all assisted the thyroid in its antitoxic 1function. Goitre in the Gilgit Valley was like goitre else- i

where. Cretinism was very common there and goitre occurred tin 40 per cent. of the cretins. He had never seen a goitre of any standing disappear spontaneously. 20 per cent. of frecruits imported to that district became goitrous and a few got well without treatment when the enlargement was very i

slight. -

’

SECTION FOR THE STUDY OF DISEASE INCHILDREN. ;

Radical Cure of Inguinal Hernia in Children. -Exhibition ot :Cases and Specimens.

A MEETING of this section was held on Jan. 26th, Dr. G. A. l

SUTHERLAND, the President, being in the chair.Mr. DOUGLAS DREW showed a case illustrating the Late

Result of Muscle-transplantation for the Relief of TalipesValgus. The peroneus brevis had been transplanted to the tibialis posticus by passing it across, beneath the tendo Achillis, and over the other tendons at the inner side of the ankle. The operation had been most successful in remedying the valgus, but a slight degree of varus had supervened.Reference was made to other cases in which a similar resulthad been obtained. i

Dr. THEODORE THOMPSON showed two brothers with

Hæmophilia. The first shown was a poorly nourished boy 10 years old. The symptoms had been present from infancy, and bruising had been usual on very slight trauma; if he 1scratched his hand he would bleed for an hour. Sometimesthere was slight bleeding from the mouth. For several years he had had attacks of pain and swelling in the knees. ]

Coagulation time five minutes. The second boy was aged 5 years, stout, and well nourished. Extensive bruising of the skin and deeper structures occurred on very slightinjury. The only family history of bleeding was on the mother’s side.

Dr. ERIC PRITCHARD and Mr. SYDNEY STEPHENSONexhibited a case of Cerebellar Tumour. Five years ago thepatient had received a blow on the head. Three years ago he had vomited for no apparent cause, and since then he hadbeen subject to intermittent attacks of headache, vertigo,and sickness, which were preceded by optic prodromata,which usually took the form of fortification spectra with abrilliant range of colours. There was slight incoordination inwalking, and Romberg’s sign was present. The pupilsresponded to light, both directly and indirectly. There washippus, especially in the left eye. When the eyes lookedstraight at an object, as, for example, the ophthalmoscopicmirror, they jerked slightly up and down. There were alsojerking movements on looking inwards, outwards, andupwards, and double papilloedema without inflammatory signsor retinitis.

Dr. R. C. JEWESBURY showed a case of Deformity of thebest in a girl aged 12 years. The mother first noticed

something wrong " with the shoulder 10 months ago. Thehild had had a severe fall down 15 stairs when 3 years old,nd was considerably hurt at the time. The upper part ofthe right side of the chest was much flattened, the first and3cond ribs were sunken, and bony thickening was felt onlese ribs below the clavicle. The pectoral muscles on theight side looked wasted, but there was no loss of power.’he radiogram showed a bony outgrowth from the first ribrojecting downwards and articulating with a similar growthrom the second rib. Cervical ribs, well developed on theight side, were present.Dr. JEWESBURY also showed three cases of Hemiplegia.

’he first patient was a boy, aged 4 years, a full-timehild. Labour had been prolonged, but no instraments-had been used. The child had been weak down the rightide from birth, and subject to fits, chiefly affecting theight side, causing twitching, with loss of consciousness.Phere was marked atrophy of the right side of the face, withweakness of the right face, and right arm and leg, the handand foot cold, and shortening of the right leg. The patientn the second case was a girl, aged 7 years, with weaknesslown the left side which had been noticed when she was1 months old. Fits of epileptic type affecting the right sidevere first noticed five months ago. The left arm and legveie much wasted, and there was marked loss of power with;hortening of both arm and leg. In the third case, that ofv boy aged 4 years, loss of use in the right hand and armlad been noticed for about one month. Squint was firstloticed six months ago. There was marked loss of power inihe right hand and arm ; the arm was usually held straightlownwards and kept stiff. The patient walked with the’eet wide apart and kept the right leg stiff. There wasweakness in the right leg. Elbow-jerk and knee-jerk wereincreased if obtained when muscular spasm was relaxed.rhe boy was backward and his speech was difficult to-understand.

Dr. F. PARKES WEBER showed a case of CongenitalPulmonary Stenosis without Cyanosis in a boy 6 years of

ge. The heart was somewhat in excess of the normal size,and over the præcordium was heard a harsh systolic murmur,with its maximum intensity over the pulmonary area, to theleft of the sternum.

Dr. EDMUND CAUTLEY exhibited a case of Lymphatism ina boy aged 6i years. The boy was tall for his age. Therewas an area of dulness over the manubrium sterni extendingmore to the left than the right, with some general enlarge-ment of the lymphatic glands and spleen ; and adenoids andayperplasia of the circumvallate papillæ. The heart-beatwas slow, the pupils were large, the complexion was pale,and the skin was thin, with an excess of subcutaneous fat.

Mr. J. P. LOCKHART MUMMERY showed a case of Shorten-ing of the Left Femur in a boy aged 7½ years. The pre-sentation had been a breech, and at two weeks of age " some-thing wrong " was noticed with the left leg. For two yearsthe boy had worn a high boot, and there did not appear tobe any increase in the shortening in that time. The left leg-was 1½ inches shorter than the right, and this was practicallyentirely in the femur. The angle of the femur was slightlyreduced on the left side. It was considered that the

shortening might be due to an injury to the upper femoralepiphysis at birth.

Dr. CAUTLEY exhibited a specimen of Tuberculous Tumourof the Dura Mater in a child aged 14 months.

Mr. PHILIP TURNER read a paper on the Radical Care of

Inguinal Hernia in Children. The object of the paper was tobring forward a modification of the usual operation for thiscondition, and by the method the least possible damage wasinflicted upon the inguinal canal, and the sac was efficientlyremoved. The operation which Mr. Turner performed is asfollows :-The external oblique aponeurosis is exposed by ashort incision above Poupart’s ligament, external to theexternal abdominal ring. A short inch incision is madethrough the aponeurosis just above the middle of Poupart’sligament ; the internal oblique is retracted, and the cord,covered by the cremaster, exposed just below the internalabdominal ring. By blunt dissection the cord and sac aredrawn through the small incision in the external oblique ; thesac is readily isolated and ligatured at the internal ring andremoved, the small incision in the external oblique aponeurosisbeing closed with a few catgut sutures.

w 3

366

BALNEOLOGICAL AND CLIMATOLOGICAL SECTION. ‘

Bl(bonio Plague. A MEETING of this section was held on Jan. 25th at

15, Cavendish-square, W., Dr. G. H. THOMPSON (Buxton), i

the President, being in the chair. About 20 members andvisitors were present.

Dr. F. M. SANDWITH read a paper entitled "BubonicPlague " (illustrated by the epidiascope).

Dr. P. ABRAHAM remarked that the important role whichthe lower animals played in the spread of disease was one ofthe most notable advances in knowledge in recent times, andhe believed that the number of diseases so spread would berecognised to be greater in the near future. He instancedleprosy, the bacillus of which would probably be found to beidentical with the acid-fast bacilius discovered by Mr. Deansome few years ago in rats. Dr. Bayon was now writingupon this subject, and his observations so far tended to provethe truth of this view.

Dr. S. D. CLIPPINGDALE expressed his grateful apprecia-tion of Dr. Sandwith’s instructive and interesting paper.Referring to the matter mentioned by the President, the out-break of plague at Eyam in 1665, he had visited the place,and was interested to learn that the vicar had not only placeda cordon round the affected area, but outside this cordonhad placed a tank of water into which money was placed topay the people who brought food for the cloistered plague-stricken inhabitants, thus showing on the part of thereverend gentleman a commendable knowledge of therequirements of sanitation.

Mr. W. J. MIDELTON (Bournemouth) said he thought hehad heard Dr. Sand with say that pus organisms killed offplague bacilli in the buboes. If so, did not this raise the

question that pus organisms might be beneficial in certaincircumstances ?

Dr. LIEVEN (Aix-la-Chapelle) mentioned how importantwas the study of zoology for employment in practicalbacteriology, as, for instance, the bacillus typhi murium(mouse typhoid) discovered by Löffler, which attacked onlycertain mice, and it was luckily that species most commonlyfound to which it has a predilection.

Dr. E. SOLLY (Harrogate) and the PRESIDENT also tookpart in the discussion.

ROYAL ACADEMY OF MEDICINE IN

IRELAND.

SECTION OF PATHOLOGY.

Exhibition of Specimens.A MEETING of this section was held on Jan. 12th, Dr.

T. G. MOORHEAD being in the chair.Dr. W. D. O’KELLY exhibited specimens from a case of

General Tuberculosis with some unusual features. Thepatient, a female child, aged 11 years, died with every signbefore death, confirmed post mortem, of generalised tuber-culosis, but Dr. O’Kelly was unable to demonstrate tuberclebacilli in the affected tissues. Numbers of sections werestained by the Ziehl-Neelsen method, especially those fromthe lungs, spleen, and liver, with a negative result. Eventhe anti-formin method was unsuccessful. The dairy fromwhich the girl perhaps became infected may be traced, andtubercle bacilli demonstrated in the milk supplied by it.

Dr. W. G. HARVEY gave a short clinical history, with anaccount of the morbid anatomy of a case of Addison’sDisease, and showed specimens and sections. The patientwas admitted to the Adelaide Hospital under Dr. H. T.Bewley on May 22ad, 1911, complaining of weakness andvomiting. She had never enjoyed very robust health. In1897 her foot had been amputated for tuberculous trouble.Subsequently she began to suffer from pain along her spine,which continued with intermissions until February, 1911,when she became noticeably weak. The weakness increasedfor a couple of months, when the following symptoms super-vened : Insomnia, loss of appetite, with palpitation andbreathlessness on the slightest exertion. Constant pain inthe stomach, uninfluenced by food. Frequent attacks of vomit-ing, usually in the morning, and often followed by fainting.General languor, mental and bodily, and failure of memory.On admission to hospital she appeared excessively weak.She was moderately well nourished, nor was there apparent

anaemia. She lay sunken down in the bed, and answeredquestions drowsily without turning her face or eyes towardsher interrogator. The skin of the face and-hands, and moreespecially that of the axillæ and nipples, were darkly pig-mented. Reflexes normal, slight nystagmus. Temperatureirregular, generally subnormal, but rising to about 100° F.Pulse weak, tension low, rather rapid (100 per minute). Atrace of albumin sometimes present. There was general

tenderness over the abdomen. She gradually sank anddied on June 16th, 1911. At the post-mortem examinationvery little abnormality could be made out by the. naked

eye, save completely caseous suprarenals, the darklypigmented skin, and a markedly flabby heart. The micro-

scopic examination showed the suprarenals to be entirelycaseous, none of their normal structure being discernible.The skin showed dense masses of pigment, mostly situatedin the deep layer of rete Malpighii. The heart muscle showedan extreme degree of " fragmentation." In addition to thisa miliary tuberculosis was present in the lungs and liver, andtubercles were also present in the ovary. It would seem thatthis miliary tuberculosis, which had every appearance ofbeing recent, must have come on shortly before the patient’sdeath. The suprarenals, on the other hand, must have beentuberculous for some considerable time, and the history of thecase would suggest their infection before the foot was

amputated in 1897.Dr. W. BOXWELL showed a specimen of Carcinoma of the

Cardiac End of the Stomach.Dr. K. E. L. G. GUNN showed two specimens from cases of

Disease of the Bladder. He described the first as a typicalwarty carcinoma of the bladder occurring in a patient from

’ whom a villous growth had been removed some years before,! and at the time reported "innocent." Both ureters were

widely dilated and thickened, and both kidneys pyo-nephrotio. The patient from whom the second specimen was

taken had been thought to be suffering from enlargedprostate. He was moribund on admission, and the post.mortem examination proved death to be due to general septici peritonitis. In the bladder were found three calculi, one in

each of two lateral pockets, giving the organ the shape, andto the touch the sensation, of a large prostate gland The

third calculus had caused a perforating ulcer of the fundusand consequent peritonitis. It was the first case of the kindMr. Gunn had seen.

SECTION OF STATE MEDICINE.S’terilisation of the Mentally Unfit.-Causation of Insanity in

Ireland.A MEETING of this section was held on Jan. 19th, Dr.

T. P. 0. KIRKPATRICK being in the chair.Mr. M. J. NOLAN read a paper on the Proposed Sterilisa-

tion of the Mentally Unfit, in which he advanced thecalculation that this line of treatment, when confined to

reproductive cases of reproductive ages, only amounted tosome 7 per cent. of the asylum population on any given date.He invited the attention of his hearers to the probable badeffects of these operations on the mental condition ofthese recoverable cases, and also the probable evil effecton the healthy husband or wife of such recoveredcases. He dwelt on the fact that the lines of mentalinheritance follow no very definite lines, and that thesterilisation of the unfit of one generation was no guaranteefor the degree of fitness in the next. He pointed out thatthis aspect of the question became more involved when theobservations made recently at the Epileptic Village Colonyat Skelman, U.S.A., were taken into account. There it was

, noted that the mating of persons nervously unstable withthose mentally deficient produced 50 per cent. of normaloffspring, so that such paradoxical results would tend to

L reinforce the sound stocks, and that as the natural law wasthe survival of the fittest, nature always kept the degenerates

, in the minority. In conclusion, he held that sterilisation, was a premature proposal, and that much could be done byl legislation touching education, syphilis, drink, marriage of. defective, and pathological research in mental disease, tol accomplish the reduction in the number of the insane, soi much to be desired by all.- Mr. R. R. LEEPER read a note on the Causation of Insanity. in Ireland. He stated that in the course of his experience. he found that in cases of insanity who did not recover, and. in whom recovery was not complete, a hereditary taint wast nearly always present. In Ireland the most potent cause in