180

1030-1040 in the evening : there were signs of bronchitis,and over a small area above the liver, where he complainedof pain, a pleural rub and, later, tubular breathing wereheard. On the fourth and sixth days hsemoptyses of half apint occurred, but osdema did not appear until the end ofthe next week, during which time occasional vomiting andslight hsemoptyses took place ; the measure of urine beganto decrease, but specimens remained free of albumin ; thepulse was small, rapid, and regular. The following days,which preceded death, were marked by irregular pyrexia-probably due to the bronchitis and pneumonic condition-and by a gradual stasis of the systemic circulation, pro-gressive cedema of extremities and scrotum, ascites. andgreat engorgement of the liver.

Post mortem, there was an excess of fluid in the peri-cardium, but no adhesions ; the right auricle and ventriclewere very much dilated and hypertrophied. occupying thewhole front of the heart ; the left auricle widely dilated,the left ventricle small, with healthy muscle (microscopicalexamination showed no evidence of myocarditis). Themitral valve showed extreme stenosis (scarcely admittingthe tip of the little finger), the flaps were adherent to eachother, a mass of fibrous tissue, and the chordae tendinesemuch shortened. Recent vegetations were seen on themargin of the narrowed mitral orifice, on the dilated tricuspid,and on the aortic cusps, but, apart from the mitral, therewere no signs of old valvular disease. In the lungs the rightmiddle lobe showed pneumonic consolidatioit elsewherethere were numerous areas of collapse, and a few doubtfulinfarctions of small size, but no signs of recent or old pleurisy.There were no infarctions in the spleen or kidneys.

The cause of death in cardiac disease duringchildhood is usuallv identified with failure of the leftventricle, due to myocarditis or mechanical defectfrom adherent pericardium, aortic or mitral regurgita-tion, &c. In this case, however, the fault appearedto lie in the inability of the rest of the heart to supplythe left ventricle with enough blood to maintain thecirculation ; this was due to a degree of stenosis inthe mitral valve which would have been remarkableeven in an adult heart, and was evidenced clinicallyby the persistently small, rapid pulse, and by the grossembarrassment of the pulmonary circulation (theboy coughed up more than half a pint of blood onthree separate occasions within one week, at a timewhen signs of stasis in the systemic circulation werelacking).My thanks are due to Dr. G. A. Sutherland, whose

case it was, for the opportunity of recording it.

TWO UNUSUAL CASES OF

INTESTINAL OBSTRUCTION.

BY CECIL P. G. WAKELEY, F.R.C.S. ENG.,ASSISTANT SURGEON AND TEACHER OF CLINICAL SURGERY,

KING’S COLLEGE HOSPITAL.

AXIAL rotation, or torsion of the pedicle, of anovarian cyst occurs in about 2 per cent. of cases whichcome to operation, and this phenomenon takes placemore commonly with cystic than with solid tumours.Axial rotation is met with most frequently duringpregnancy and in the puerperium, but rarely givesrise to intestinal obstruction.

CASE 1.—Patient, aged 72, was admitted to King’s CollegeHospital, June 21st, 1923. with signs of intestinal obstruction.The patient stated that two days before admission tohospital she was seized with acute pain in the abdomenand vomited several times. On admission, to hospital hertemperature was 98°-l F.. pulse 72, and respirations 24. Theabdomen was very distended, except in the andvisible peristalsis was evident. A hard painful tumour couldbe palpated in the right iliac fossa. The obstruction wasthought to be due to the tumour pressing on the lower partof the ileum. as the signs all pointed to an obstruction iii thesmall intestine.

Opo’<to-.&mdash;Laparotomy was performed through a rightparamedial incision. The small intestine was very distended.The obstruction, was found to be due to a twisted ovariancyst which was almost black in colour, adherent to themedial side of the caecum and completely occluding the ileo-caecal valve. The cyst. which was the size of a large orange,was carefully dissected off the caecum and removed, togetherwith the right Fallopian tube. which was also very congested.

IAs soon as the obstruction to the ileo-csecal valve wasremoved, the gaseous intestinal contents moved into thecaecum and ascending colon.

The wound healed well, and the patient left hospitalten days after the operation. The cyst on microscopicalexamination proved to be teratoma.CASE 2.&mdash;Patient, aged 73, was admitted to King’s College

Hospital, Xov. 20th, 1!)23, with the following history.Three day,:. earlier she was seized with acute pain in the lowerpart of the abdomen, which was followed by vomiting on twooccasions. Previously she had enjoyed good health. Onadmission the temperature was 97.6c F., pulse 100, andrespirations 28. The abdomen was clistended ; there wano rigidity, but there was some tenderness in the right iliacfossa. A bilateral swelling was found in the hypogastriumbigger on the left side than on the right. The swellings weredistinct and well defined. There was no free fluid in theabdomen. Per vaginam the swelling on the left side wasfound to be fixed in the pelvis.

Opeya<MM.&mdash;Laparotomy was performed through a para-medial incision ; two ovarian cysts were found. ThatariSing from the left ovary was a pseudo-mucinous cyst,the pedicle of which was twisted through two and a half turns;it was found to be impacted in the pelvis. With difficultythe cyst was elevated from the pelvis and removed. Thecyst of the right ovary was a dermoid ; it had undergoneaxial rotation and was very congested and adherent to themedial aspect of the caecum, causing obstruction to theileo-csecal valve. It was removed with the right Fallopiantube. The abdomen was closed without drainage. Thedermoid cyst on section contained pus.The patient made excellent progress for the first week,

but then died sudctenly from pulmonary embolism.It will be noticed that in both the cases recorded

the patients were over 70 years of age. and in eachcase the intestinal obstruction was caused throughadhesions between a twisted teratomatous ovariancyst and the caecum.

Medical Societies.ROYAL SOCIETY OF MEDICINE.

CTRDI_1’G OF THE POPULATION FRO.M THE POIXT OFVIEW OF PHYSICAL FITXESS.

A SPECIAL meeting of this Society was held on,Tan. 21st at 1. Wimpole-street, W., Sir WILLIAMHALE-WHITE. the President, in the chair.

Air-C’ommodore DAVID MLTRO, in opening a dis-cussion on this subject, said it was complex and far-reaching, being mixed up with fundamental, social,economic, and political problems, some of which hadbeen subjected to close studv by the best brains inthe medical profession. The late war had shownthe physical state of our manhood to be far belowwhat the average man thought it to be. The war-time pronouncement of a well-known politician, whodeclared ’’ We are a C 3 people." was untrue forcertain classes of the population, but for other classesit was pretty well agreed to be true. Thus. whileminers and agricultural labourers were found to havea high index of physical fitness, as judged by Keith’sstandard, those engaged in sedentary industrialoccupations were found to have a low index. Thereport issued by the Ministry of rational Serviceupon the physical examination of men of militaryage by National Service Medical Boards was themost comprehensive survey that had yet beenattempted on the health and physique of a large portionof the population. Records of some 2- millionexaminations carried out on men between the agesof 18 to 45 were analysed. To quote the words ofthe report :-

..

As the result of this analvsis the cunolusions come to werethat of every nine men of military age in Great Britain outhe average three were perfectly tit and healthy ; tu:o wereupon a definitely infirm plane of health and strength whetherfrom some disability or from some failure in development :three were incapable of undergoing xnore than a very moderatedegree of physical exertion and could almost in view oftheir age-with justice be described a physical wrecks, andthe remaining man was a chronic luvatid with a precarioushold on life.

As matters had existed in the past only the stressof a great national struggle could have brought intoexistence, and caused to function. the machinery for

181

conducting such a number of medical examinations, 1and for analysing their results, and it might well bewondered what practical possibility there was in

peace-time of obtaining records to show the state of IIphysical fitness of any large section of the populationand, if obtained, to what practical use they couldbe put,. He would endeavour to give a sketch of

(a) the value of such records, if obtained ; (b) theamount of information necessarv to be recorded -,(r) the possible method of obtaining and recording it.

1 ’allte of I’ ecoi-d8 and Amount Required.The picture presented would indicate the directions

in which efforts should be made to improve healthgenerally, and as such the figures would be of greatvalue to the Ministry of Health.To the physical culture teachers these figures

would be of value in giving them a picture of thedifferent classes. Figures of this kind, giving infor-mation of the fit classes of the population, wouldundoubtedly be useful in the future in the considera-tion of eugenic problems, for one could not forecastwhat influence Malthusian and neo-Malthusia.ndoctrines might have on future policies. Informationof value to industrial psychologists would be obtained.Physical fitness was a quality not capable of precisemeasurement. There were, it was true, certain

qualities capable of exact measurement, such as

Iheight, weight, and girth of chest. Sir Arthur Keith’sstandard. as he (the speaker) understood it, was Ibased on such measurements-in fact, on height measurements. But while physical qualities lentthemselves to exact measurement physical disabilitiesunfortunately did not. To refer again to words inthe report already quoted :-To give an exact percentage value to every known

disability would present insuperable difficulties in practice.The health of individuals and of each of their componentstructures and organs shades off gradually, and often almostinsensibly, into disease, which in its turn exhibits varyingdegrees of intensity which are not sharply defined from eachother, and react differently on different individuals. Themedical interpretation of objective clinical phenomena doesnot, and cannot, led itself to expression in figures.The borderland of disease was still largely

unexplored. What, then, was it necessary to do inthe way of getting data about physical fitness ? Hebelieved that certain of the tests in use in the RoyalAir Force, for assessment of the physical fitness of airpilots, gave results capable of numerical expression,and yielding extensive information as to the state ofhealth of the individual tested. According to theperiodic results of these tests, supplemented by arecord of observed physical disabilities, he felt thatindividuals might be classified from a health point ofview. The tests he would describe gave no resultsindicating in the subjects any special aptitude forspecial employments, and therefore, from the pointof view of the industrial psychologist, they wouldbe valuable in picking out the man who was physicallyand mentally fit for arduous work, but not the manlikely to become a skilled manipulator. For theseaccessory tests-such as reaction-time tests-wouldneed be employed. He would prefer to use thewords " physical and mental endurance rather than..

physical fitness "-meaning that state of healthwhich made a man able to perform an act of physicalexertion not once or for a short time but repeatedlyover a long period of time without undue physicalor nervous stress This was a state of health whichrequired personal care and preparation with a view tothat end. Even then, every man had his breaking-point, and the fit man was the man whose breaking-point takes longest to supervene. These particulartests were originated after examination of men whohad manifested such endurance-viz., star-turnpilots. The tests which he would suggest were

(1) the endurance" or mercury 1 r-tube test, and(2) the response of pulse to exercise, or exercise-tolerance test.tolerance 1’he Eudururtce Test.

This test was performed as follows. With thenose clipped, the subject was asked to empty the

lungs completely, inhale fully. blow the mercury inthis tube to 40 mm., and maintain it there withoutbreathing for as long as possible, the pulse beingcounted in periods of five seconds during the perform-ance of the test. The average time of holding up themercury in a large number of cases tested was between50 and 00 seconds. The pulse-rate should remainsteady or rise gradually according to the time thebreath was held. A marked rise was unsatisfactory,and a still more unsatisfactory sign of cardio-motorinstability was a marked rise during the second orthird period of five seconds, followed by a dying awayto normal or below normal. For the detailedphysiological explanation of the phenomena of thitest he would refer them to its inventor, Group-Captain Martin Flack. The factors involved were, ashe understood them, (1) the state of oxygenationof the patient’s blood ; (2) the state of his respiratoryefficiency ; (3) the tone of his blood-vessels. Whateverwas the actual physiological machinery functioningin this test, empirically it had proved of great valueto the R.A.F. as an indication of a man’s capabilityfor physical endurance. So far it had only been usedfor testing flying personnel, but he anticipated itsgeneral use in recruiting centres for all personnel atno very distant date. He also anticipated that aU-tube manometer would in the future be as much apart of the equipment of a general practitioner as is astethoscope.

Response of Pulse to Exei-eise Test.The pulse-rate was taken with the subject sitting

down and the total number of beats in 60 secondsrecorded. If the pulse was unsteady it was countedin periods of five seconds until the minimum constantrate was obtained. The subject was then directed tostand up, and the number of beats recorded in thefirst. five seconds multiplied by 12 was recorded asthe rate per minute for the standing-up pulse. Withthe subject still standing the examiner then recordedthe lowest steady rate to which the pulse fell.Regulated exercise was then carried out by the subjectplacing one foot on a chair and standing alternatelyon the floor and on the chair five times in 15 seconds,the speed being regulated by the examiner raising andlowering the subject’s wrist in every three seconds.At the end of the 15 seconds the pulse was counted inperiods of five seconds-the time which it required tofall to its steady rate being recorded in addition tothe rate per minute in the first five seconds afterexercise. A typical numerical record of this test in afit man would be (a) sitting 72, standing 84-72, afterexercise 96 ; (b) time of return to normal standingrate, 20 seconds. This test was made five times upand down only on the chair because at the timeseveral hundred men were being examined each day.A pulse which rose rapidly on standing and tooksome time&mdash;e.g., 1-2 minutes-to return to its loweststeady rate indicated probably poor splanchnic vaso-motor control-in such cases the pulse maintained itsquicker rate during standing. If the time of returnto normal after exercise exceeds 30 seconds it wassuggestive of cardiovascular insufficiency or of nervousinstability. Further, this test tended to differentiatebetween true and false tachycardias and to throwlight on various disordered actions of the heart, ofwhich one heard so much during the war. Possibly,also, it would assist in assessing the seriousness orotherwise of valvular lesions as expressed in terms of" bruits." To sum up-these two tests were simplein application ; their results could be expressednumerically and used for health classification pur-poses ; they could also be easily codified for statisticalpurposes; apart from gross disabilities and specialqualifications such as vision, they gave a goodindication of general neuro-muscular and constitutional

tone at the time of examination. The standards of

fitness in the R.A.F. were set by the examination ofindividuals who had successfully withstood con-

siderable physical and nervous strain in contra-distinction to those who had broken down ; the

psychological element in the endurance test was, hethought, of real value as a measure of the mental

182

" make up " (the report of the Shell Shock Committee

brought out very clearly the previous lack of attentionto mental standards in the course of medical examina-tions) ; the tests would be valuable as a comparativetest of fitness employed periodically, and he wouldsuggest their use to safeguard the public in thoseoccupations in which the element of public safety isinvolved-e.g., motor drivers, tram drivers, loco-motive engine drivers, railway signalmen, factorymachine operators. mercantile marine navigators,civilian air pilots ; lastly, where employed up todate on a small scale they have given consistentresults. The chief disadvantage of the tests was thattemporary toxaemias upset them&mdash;mild influenza oreven a heavy cold was sufficient to cause remarkabledeterioration in results-hence the value of successiverecords. Also, of course, they gave no informationabout specific disabilities.Possible Methods of Obtaining and Recording Data. In the Services the obtaining of information was

easy. If medical information was asked for, thestatistics compiled from the forms rendered con-

stituted the basis of future medical policy-thoughno one who filled up the forms ever believed it. Ifthe filling up of forms was resented in the Services,in civil life it was hardly even tolerated ; it would bequite impracticable to attempt to conduct anyexaminations annually on every man, woman, and child of the population-not only because of thedifficulty in _ setting up the agency but also from thepont of view of expense. Whatever agency wereemployed the cooperation of the Medical ResearchCouncil would be essential. However it might bedone, he felt that some time or other some system ofhealth classification of the population would beestablished.

_

The Government Commission.Sir ARTHUR KEITH dated his own interest in the

question of the physical fitness of the populationfrom the appointment, in 1903 or 1904, of a Govern-ment Commission to inquire into it. The Anthro-pological Society had at that time suggested machineryfor such an inquiry. Later, during the war, he becamea member of the Committee appointed to advise theMinistry of National Service concerning the gradingof recruits. With regard to the percentage of thereally fit in any normal population, he did not use thedata quite as had been stated. An infinite number offactors had to be considered, but it was found thatof a thousand men from a part of the country witha good physical standard, 700 could be placed ingrade 1, 200 in grade 2, and the remainder left over ;in other parts of the country the figures were verydifferent. The standard they had suggested hadbeen formulated for the guidance of medical officers.At present it was no longer a matter of compulsoryservice, and recruits could be chosen by more exactingstandards. Formerly the standard was purely thatof physical appearance, weight, &c. ; but thesefactors might fail. He considered that Group CaptainFlack’s work marked a great advance in methods ofexamination upon anything hitherto done in anycountry. We were seeing an extension of the movementperhaps introduced by Sir James Mackenzie-namely,the consideration of the manner in which an organworked, the physiological method of classifying men.

Sir DUNCAN RHIND, speaking from the layman’spoint of view, recalled his experiences in gatheringthe statistics upon which the report of the Ministryof National Service was based. It was sometimessaid that the National Service examinations carriedout during the last year of the war were not indicativeof the true state of the national health, but the factremained that year by year there was a very largenumber of men called up and found unfit for anyform of service. The percentage of the unfit, extendingto the youths of 18, was much greater than it shouldhave been. It would be verv difficult to introducetest-,, on which estimates of man power could bebased, but if it were possible, such tests as had beendescribed were what was required.

The Examination of Recruits.Dr. WILLIAM FITZGERALD said that he could perhaps

speak with some little force on the question underdiscussion, for during the war he had been engagedsolely in the examination of recruits at Liverpool.Under the Ministry of National Service alone hismedical board had dealt with some 30,000 recruits,and he had previously served on the much-ma,lignedWar Office boards ; even the latter, when left alone,could only find some 30 per cent. of recruits fit forgeneral service. To a certain extent they were

dealing with a residual population under the Ministryof National Service ; the boys of 18 were particularlydisappointing, in a great measure because they were..suffering from conditions of the feet, tonsils, ears,nose, &c., which if treated earlier in life would havebeen remediable. The tests described by Air-Commodore Munro were most valuable ; they couldnot replace sound clinical examination, but formed auseful adjunct. He failed to see how such medicalexaminations could be brought into being in thiscountry, and referred to an instance in one of ourColonies showing how organised labour would objectto them. Practically nothing had been done to

remedy the state of affairs disclosed by the reportof the Ministry of National Service. He had visitedthe slums of Liverpool on Saturdays and Sundaysduring the war, and had learned what they meantfrom the point of view of national health.

Group-Captain MARTIN FLACK explained that thetests referred to were designed solely as adjunctsto general physical examination. They were perhapsempirical, being set on subjects who had enduredstress, but they seemed to show the importance ofthe efficiency of the controlling centres of respirationand circulation. A man who lacked good respiratoryefficiency, and whose blood was not well arterialised,would quickly show signs of discomfort when breath-ing into a bag, giving up in under two minutes,whilst a healthier man might go on for five minutesor more. The unfit were hypersensitive to lack ofoxygen. Marked respiratory inefficiency tended tobe associated with laxity of the trunk muscles andpooling in the venous reservoirs, rendering thesubject unable to respond to effort as the fit man wasable to do.

The Tests of Efficiency.Sir THOMAS LEWIS said that he had been out of

touch with the questions under discussion since 1919.and had been particularly interested to hear about thetests of efficiency. He agreed that if they were uspdto test the fitness of large numbers of people, thosechosen for the purpose would soon object. Examina-tion was, however, possible in the case of men whoclaimed pensions. Exercise tests could not replaceor be replaced by clinical examination. Men withvalvular heart trouble were frequently found totolerate exercise well ; again, others who showed nosigns of such trouble had poor tolerance of exercise.The tests must approximate to the forms of exercisethey were intended to represent : many persons whocould pass the chair test would fail if exercise werepressed further. The chair test was originally putout with some emphasis on the resulting pulse-rate.and there had arisen a tendency on the part of officersof medical boards to rely almost wholly on the reactionof the rate of the heart. It became almost a rule ofthumb method, and was then misleading, since manymen who showed a normal heart reaction soon

displayed respiratory distress. Again, exhaustionmight soon develop, the subject becoming unsteadyon his feet. &c. The only really crucial test was thething itself-to put men into the front line and seehow they stood it. The individual test. again, mightsuit one man much better than another ; a man

should be put to his own work. He suggested aprobational period for recruits, which, if not necessarynow, might be useful in event of another problemlike that of 1914. He wished to know if the mercurytest had been employed mainly on young men or onmen in the ’forties, who could not be expected togive the same reactions to the test.

183

Sir ARTHUR KEITH interpolated a few words to the &egrave;effect that he had supported the idea of a probational period of a rnonth or two months for recruits duringthe. war.

Dr. F. W. COLLINGWOOD asked whether it would notbe possible to include some test of character whenexamining recruits. In medical examinations forthe Navy years before he had found men who passedall the tests and later showed an inability to submitto reasonable discipline.

Dr. G. H. HUNT wished to know the relative

importance attached by Air-Commodore Munro tothe mercury and exercise-tolerance tests. He hadhimself had experience with students, and had foundthe mercury test open to misinterpretation. He hadalso found the vital capacity test extremely fallacious ;a very poor reaction had been given by a Rugby international player.

Colonel SYLVESTER BRADLEY said he had come tothe conclusion that the exercise test was of value notas showing the amount of exercise the individual couldperform, but as indicative of the latter’s nervous

stability. He pointed out that the period spent bythe recruit at a dep&ocirc;t was a probationary period.Recruiting statistics were of interest as showing thealteration of incidence of various conditions such asvaricose veins, which were apparently decreasing, andconditions apparently on the increase, such as flat-foot and middle-ear disease. The PRESIDENT, speaking of his experience on the

I

Appeal Board during the war, and as officer in chargeof a hospital, remarked on the light-hearted way inwhich many recruiting officers treated nervous

instability, particularly epilepsy, and on the harmand waste of public money this occasioned.

Reply.Air-Commodore MUNRO, replying, said that the

discussion had not developed as he had intended ;he had approached it with a civil rather than a mili-tary mind. He had hoped for enlightenment as tothe machinery by which examination of the popula-tion might be undertaken. He agreed that the pointof the tests must be-does the man do the job ?The tests he had instanced were used for flying,where the man could not be put to the work beforeexamination. In answer to Sir Thomas Lewis’squestion, the tests were performed chiefly on young men, but also on every R.A.F. officer once a year,and before he was sent overseas. No marked deteriora-tion with increasing age had been observed, but theexaminations had not been carried out for a sufficientnumber of years for an answer to be given withconfidence.

In answer to Dr. Hunt, he would point out thatin any case the tests only provided bits of evidence,and could not be relied upon to the exclusion ofgeneral examination.

EDINBURGH MEDICO-CHIRURGICALSOCIETY.

A MEETING of this Society was held on Jan. 16th,Sir DAVID WALLACE, the President, being in thechair.

Dr..T. S. FRASER gave a communication on

Seytic Otitic I’hrontbosis of the Cranial Blood Sinusesand Jugular Bitlb,

being an analysis of 28 consecutive cases operatedon between 1907 and 1923 inclusive. He said thatseptic sinus thrombosis was relatively more commonin acute than in chronic cases of middle-ear disease.As regards sex- and age-incidence, males were morenumerous than females, and 19 of the 28 cases

occurred in the first two decades. A history of auraldischarge commencing after measles or scarlet feverwas obtained in seven cases. Only one of the caseswas operated on in private practice. Dr. Fraserregarded rigors as the most important symptomfrom the point of view of differential diagnosis. A

rigor might occur in the initial stages of brain abscessor meningitis, but recurring rigors were only foundin septic venous thrombosis. The hectic temperaturewas typical; that of meningitis being continuous,whilst in cases of brain abscess after the initial rigor itwas usually subnormal. In all cases of middle-ear sup-puration associated with evening pyrexia he held thatthe sinus should be exposed and examined. Incontrast with cases of brain abscess and meningitis,the patient usually was mentally bright and feltwell. Vomiting and giddiness were present in abouthalf the chronic cases, but in these there were com-plications, such as labyrinthitis, meningitis, or brainabscess. Mastoid tenderness was by no means con-stant. Otoscopy was usually rendered difficult bydischarges and cholesteatoma. A dry tongue, show-ing brownish fur in the centre, was frequently noticed.Blood cultures had not proved of great diagnosticservice. Dr. Fraser went on to speak of the findingsat operation in the seven acute cases. Pus in theantrum and cells was present in all. Four cases

showed bacteriologically a pure growth; two ofstreptococcus, one of diphtheroid bacillus, and one ofan organism closely resembling B. influenz&oelig;. In theremaining three the infection was mixed. An extra-dural peri-sinus abscess was present in only three.A peri-sinus abscess alone may cause evening pyrexia.In deciding whether to open the sinus, the conditionof the wall is important. If this shows reddishpurple, so-called " healthy " granulations, drainingof the abscess may suffice ; otherwise the sinus mustbe opened and the clot turned out. In only one casewas there intracranial complication-purulent men-ingitis. Metastatic abscesses occurred in three of theseven cases, five recovered, and two died. Only onehad an uninterrupted recoverv. Both of the fatalcases developed empyema. in the 21 chronic casescholesteatoma with or without pus was present in 15.Of 15 investigated bacteriologically seven showedpure cultures, eight mixed infection. Peri-sinusabscess was present in 14. Complications were morefrequent in these cases. Eight cases had labyrinthitis,four had purulent meningitis on admission, fivedeveloped it later ; four cases had brain abscess. Inseveral cases more than one complication was present.Only four showed metastatic abscesses. Of the11 uncomplicated cases nine recovered and twodied. Of the ten complicated cases four recoveredand six died. Only four of the successful cases

showed uninterrupted recovery. In the eight fatalcases septic thrombosis beyond the point of opera-tion was found. In these cases septic infarcts in thelung with empyema were present. In only one casewas there septic infarction with empyema in whichthe blood sinuses seemed healthy. In one case

death was caused by meningitis alone, and in twothere was, in addition, abscess of the temporal lobe.The paper was followed by a lantern demonstration.

In the subsequent discussion the PRESIDENT, Dr.LOGAN TURNER, Dr. D. J. GUTHRIE, Dr. G. E.MARTIN, Prof. EDWIN BRAMWELL, and Dr. W. T.GARDINER took part.

Dr. CHALMERS WATSON gave a communication on

Alin2entccry Sepsis from the Practitioner’s Pointof Vietv.

He referred to the work of Metchnikoff, J. G. Adami,Arbuthnot Lane, and others, spoke of the r&ocirc;le of

alimentary sepsis in present-day surgery, and dis-

cussed the possibility of the aaiological importanceof intestinal subinfection, as suggested by Adami andothers, in many common diseases. He regretted thenomenclature used in many diseases, stigmatising asmere labels many of the terms used. So-calledanatomical diagnoses were often very misleading.He dwelt on the importance of two aetiologicalfactors in disease-heredity and strain or stress. Inthe term strain he included the different forms ofmedical sepsis, as revealed clinically by (a) oralsepsis, (b) the condition of the urine, and (c) the stateof the bowels, as determined by simple clinicalmethods of examination. With these three points in