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4case appeared to him to fall under the general heading ofmalarial disease. He had seen a large number of cases in theEastern Soudan which, in their symptoms, length ofillness, and post-mortem appearances, resembled that underdiscussion. He pointed out that ulceration of the smallintestine was not uncommon in many malarial affections,and he had several times noted the presence of small ulcerswith haemorrhages and patches of congestion in this part ofthe digestive tracb.-Dr. THIN, in reply, said that therewas no reason to believe that the patient had had food and-drink other than that taken by the majority of Europeansliving in the north of China. He was inclined to thinkthat the affection was not malarial, and Dr. Manson hadconfessed that in his experience the case was perfectlyunique. It was worthy ot note that it was only late in thecourse of the disease that the symptomatic fever set in.A paper by Dr. G. NEWTON PITT and Mr. W. H. A.

JACOBSON on a case of Pancreatic Cyst successfully treatedby Laparotomy and Drainage was then read. The patient,a man aged twenty-one, was kicked in the abdomen in1886, since which he had been liable to attacks of abdo-minal pain. He was admitted in May, 1889, withjaundice and severe abdominal pain and vomiting. Onexamination, a _globular tumour was discovered in theepigastric region, over part of which the note on per-cussion was dull ; but this area of dulness was vari-able. In June the tumour was aspirated, and half a

pint of alkaline, opaque, greenish fluid, of sp. gr. 1015,and containing albumen, was drawn off. The jaundicediminished and the patient improved sufficiently to be ableto go home. At the end of July the patient was readmitted,the pain, the jaundice, and the tumour having all recurred.The globular tumour now occupied the umbilical and epi-gastric regions, extending rather to the left of the middle’line, moving with respiration, and lying behind the stomach,.as shown by the varying note on percussion, and by thedisappearance of the dulness when the stomach was dis-tended artificially with gas. On Aug. 17th the tumour wasagain aspirated, and eight ounces of alkaline fluid, sage-greenin colour, were removed. This contained 11 grm. of albumenper litre, a large amount of tyrosin crystals, no copper-reducing substance, and no bile. It was therefore clearthat the tumour was a pancreatic cyst. The patientwas very emaciated, the cyst rapidly refilled, and thepatient’s condition became so critical that Mr. Jacobsonperformed laparotomy on the 22nd. An incision three incheslong was made over the tumour one and a half inches to theleft of the middle line. The stomach was with some diffi-culty pushed up under cover of the liver, the greater portionof the omentum was pulled out and removed, and the restwas sutured round the edges of the wound. The two layersimmediately below the stomach were scraped through, and ’,-a very thin tense cyst was exposed. Thirty-six hours later ithe patient’s pulse was very rapid and feeble, and hiscondition most precarious, owing to haemorrhage into the I,cyst, which made it so tense that it was necessary to lay itfreely open. He steadily improved from this time, and wasable to get up a month later, being discharged cured. Withthe exception of Annandale’s case, this was the first instancein Great Britain in which the correct diagnosis had beenmade previous to operation. Senn’s papers in 1886 andi887 were the foundation of all our knowledge about these- cysts. The symptoms of these cases were discussed, some.surgical points of interest were noted, and a résuméwas given of the cases published since Senn’s papers.-Mr. PEARCE GOULD said that he had had under his caretwo cases of pancreatic cyst. In the first the cyst wassituated near the head of the pancreas, and in June, 1887,he opened it and stitched it to the abdominal wall. Thefistula which resulted had never closed, and at the presenttime a malignant growth was forming round the track ofthe fistula. In the second case the cyst was situated in thetail of the organ, and the patient suffered so much painthat, though she had been recently confined, it was con- ’,sidered desirable to operate. The transverse colon andomentum were turned up and the cyst presented belowthem, a large vein crossing its surface. This latter wastied and divided, and the cyst then aspirated. The punc-ture was enlarged, and a finger passed in could be made to,project below the left twelfth rib, behind where a counter-opening was made and a drainage-tube introduced. The- pa-tient ultimately made a good recovery, and she wasexhibited to the Society.—Mr. JACOBSON, in the course ofa brief reply, expressed his indebtedness to Professor Senn

of Milwaukee, without whose able and original workon Lhe subject he would probably have been unable toattack this case successfully.Mr. ALFRED PARKIN contributed a paper on the Causa-

tion and Mode of Production of Pes Cavus. This deformity,by no means uncommon, was described as consisting of anincreased height of the plantar arch, corresponding con-vexity of the dorsum, and shortening in the length of thefoot of from half an inch to one inch and a half. Associatedconditions were: (1) Contraction of plantar fascia; (2) pro-minence of the balls of the toes ; (3) deformity of the toes;(4) projection of the dorsal tendons; (5) contraction of thetendo Achillis, apparently a constant feature. The litera-ture of the subject was sparse and of little value. The fol-lowing had been the suggestions offered as to causation:(1) Paralysis of the interossei muscles (Dachenne) ;(2) weakness of the peronei muscles (Mr. Golding-Bird) ; (3) wearing of tight boots; (4) combined pullof tendo Achillis and extensor longus digitorum; (5) con-traction of plantar fascia. These, considered seriatim,all showed a want of accuracy, and did not explain thecondition at all. Consideration of the normal foot whensupporting weight of the body led to the following con-clusions : The weight of the body was supported by thearch of the foot in contact with the ground at the heel andat the metatarso-phalangeal joints, so that the weight ofthe body was split up into two oblique components, ofwhich the posterior or heel portion was the greater. Incases of talipes equinus the weight of the body was trans-mitted along the anterior part of the arch only, and theposterior portion of the force was free to act, and wascounteracted only by the tarsal ligaments, dorsal and inter-osseous, and adapted shape of the bones ; hence there wasa tendency to curving of the longitudinal pedal arch. Thegreater the talipes equinus the less was thetendencytocurva-ture of the arch, and conversely. Hence the mechanism wascompensatory, tending to bring down the heel and restoreequilibrium as soon as talipes equinus had developed. Iri

position of rest there was no tendency to production ofcavus, only in active positions. Displacement of the toeswas due primarily to position of talipes equinus; then whensubluxation had taken place, the interossei could not act,or acted only in the reverse direction from displacement oftheir lines of action. The position was secured by altera.tion of joint surfaces and adaptation of muscles and liga-ments. Contraction of tibials and plantar fascia wassecondary to these changes-adaptive measures. The fol-lowing statistics from the Guy’s Hospital Surgical Reportssupported these views:-Of 53 cases of talipes equino-varuswith or without pes cavus, 38 were acquired, 15 were con-genital. Congenital cases: 11 of talipes equino-varus belowthree years of age; 3 of talipes equino-varus with pes cavusaged seven, twelve, thirteen years ; 1 of talipes equino-varuswithout pes cavus aged seven, but in this the presence ofequinus was very doubtful indeed. Acquired cases: 4 oftalipes equino-varus below four years of age; 1 of extremetalipes equinus, hence no pes cavus ; 2 of pes cavus simply,with special mention of contracted tendo Achillis in one ;16 of talipes equino-varus with pes cavus, the ages of whichwere : Four and a half years, 2 ; six years, 2 ; seven years,1 ; eight years, 3 ; twelve years, 2 ; fifteen years, 2; abovefifteen years, 4. Conclusions : (1) Pes cavus was a

secondary deformity engrafted upon talipes equinus or

equino-varus ; (2) pes cavus was not congenital, though itmight follow on congenital talipes equinus or equino-varus ;(3) that it was the direct result of transmission of bodyweight through a foot in the equine position ; (4) that thechanges in the soft parts and toes were adaptive or

consecutive.

THE ANATOMICAL SOCIETY OF GREATBRITAIN AND IRELAND.

A MEETING of this Society was held on May 25th, SirWilliam Turner, President, in the chair.

Professor THANE showed two Abnormal Muscles in theLeg.-Mr. LAWRENCE showed Abnormalities of the Aorticand Pulmonary Valves.-The PRESIDENT read a paper onthe relations of the Dentary Arcades in the Crania ofAustralian Aborigines, pointing out that in these skullsthe upper teeth, instead of overlapping the lower, fittedaccurately upon them. This feature is the rule in thehigher apes, but is not present iu the higher races of man.-

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The SECRETARY for Professor Cleland read a paper on theValue of Burial in Sand for Cleaning Bones of the Fat whichfills the Cancellous Tissue.-Dr. HERBERT SPENCER read apaper on Ossification in the Head of the Humerus at Birth,showing that this was not by any means so rare an occur-rence as was generally thought, and that many differentdates were ascribed by different anatomists to the appear-ance of this nucleus.-Dr. WARDROP GRIFFITH read adetailed account of a case of Transposition of Viscera, withmany Abnormalities in the Heart and Great Vessels.-Mr. LOCKWOOD and Dr. ROLLESTON showed specimens ofAbnormal Vermiform Appendix, and read a statisticalaccount of the position of the organ in a hundred con-

secutive cases in which no evidence existed of disease inthat region, showing that, while in most cases it lay to theleft of the caecum, it was found in others under, over, or tothe right of this viscus, and with various degrees of freedomor attachment to it and to the surrounding peritoneum.

Reviews and Notices of Books.Atlas of Clinical Medicine. By BYROM BRAMWELL, M.D.,

F. R. C, P. Edin., F.R.S.Edin., Assistant Physician to theEdinburgh Royal Infirmary. Vol. i., Part 1. Edinburgh:T. and A. Constable. 1891.

THERE are many things to admire in this the first part ofwhat promises to be one of the most important and mostvaluable of modern contributions to the study of clinicalmedicine. Attention is at once attracted by the style, noless than by the matter. Dr. Bramwell has conceived theidea that clinical instruction may be conveyed usefully bya series of well-executed coloured plates, lithographs,and wood-blocks, and in carrying out this idea he has

spared no expense, and has been equally lavish withwealth of material. This part deals with myxoedema,sporadic cretinism, and Friedreich’s ataxia ; the first isillustrated by three coloured portraits, two of the threecases having been under Dr. Byrom Bramwell’s care, thethird having been contributed by Dr. Donaldson of London-derry. In the accompanying text a very full account ofmyxoedema is given ; this is based upon a brief report ofthe first case, from which the author glides by easy andalmost imperceptible stages into a valuable account of thehistory of this disease. He notes that although myxcedemawas first publicly described by Sir William Gull in 1873, andsubsequently elaborately studied both by Dr. Ord and by acommittee of the Clinical Society, it had nevertheless beenrecognised by many different physicians before that date.Then taking the most obvious and striking features of thedisease, and drawing largely from the account given byDrs. Hun and Prudden in the International Journal of theMedical Sciences, the clinical picture is rendered more

complete. Due stress is laid upon the impaired activity ofthe cerebral and probably of all the nervous tissues, whichin great part accounts for so many of the puzding symptomsfrequently noted. The association of this disease with degene-rative atrophy of the thyroid gland is treated with moderation,even though at the outset the author declares his convictionthat the myxœdematous condition is the result of theabolition of the function of the thyroid gland. Still it isadmitted that uncertainty shrouds the exact manner inwhich this abolition of function produces myxoedema,since the physiological work of the healthy gland isstill a matter of conjecture and dispute. What is saidof treatment is not encouraging; the author admits thathe has no practical experience of his own to offer, andhe points out that the condition or conditions which

produce, or help to produce, the thyroid lesion have

yet to be found. The three coloured plates which illustratemyxœdema are extremely well executed. Without refer-ence to the text it is perfectly eay to pick out the case

with renal changes, even though Dr. Byrom Bramwellmakes a point of the difference from the pallor whichcharacterises the swollen face in Bright’s disease. The

colouring is faithful, and the pictures are not overdrawn.There is no undue insistance upon special charac-

teristics, although it is perfectly clear that the artistwas guided somewhat in his indications of the par-ticular features of the disease. In each case he

appears to have drawn from the patient before him,.without attempting to beautify in the style of the modernportrait painter, and at the same time without exaggera.tion, which so readily passes into caricature. The platesare followed by a description giving the clinical history ofeach case. The further study of this most interestingdisease will be facilitated by the valuable suggestionsoffered on page 16.

Sporadic cretinism, the infantile form of myxcedema, isnext passed under review. It is curious to note that this

disease, which is rare, was first described more than twentyyears before Sir William Gull wrote of myxoedema. Thework of Fagge receives due credit, his paper on "SporadicCretinism," in 1871, being regarded as having paved theway for the discovery of myxoedema. The congenitalabsence or arrested development of the thyroid gland ismentioned as an almost invariable feature; and as regardsetiology, Langdon Down’s view of " alcoholic conception "is carefully investigated, though it is fel b that the balanceof probability is against it. The figures in the two platesillustrating sporadic cretinism are from various sources?some being already familiar, but they well bear reproduc-tion in this connexion. The contrast between the symptomsof myxcedema and those of exophthalmic goitre is extremelyinteresting, though the ultimate pathology, the primarycause, is equally obscure.The article on Friedreich’s ataxia is based upon remarks

made at the author’s clinique, and the arrangement ofmaterial is somewhat different. The matter is cast in theform of a clinical lecture, and the notes seem to have beentaken in shorthand at the time of delivery; still there isno difficulty in realising the clinical picture of the case,"the living illustration of the text," though it may bequestioned whether any particular advantage is gained byprinting in full the suggestions made by students. Dr.

Byrom Bramwell certainly has, however, the leading factsconnected with this disease at his " finger-ends," and hemakes good use of all that has recently been written upon it.His range of reading has been extensive, and he annexesfreely the figures of Riitmeyer and others, supplementingthem by original figures. This article is extremely full andvery well written ; an able summary at the end gives dueprominence to the more important facts, and the clinica)aspect is rendered more complete by notes of threeadditional cases of Friedreich’s ataxia.

Dr. Byrom Bramwell has commenced a work involvingimmense labour and considerable expense. This first instal-ment is in every wayso praiseworthy that little anxiety needbe felt about the remainder. We have been favoured withadvance copies of many of the coloured plates, and the vastmajority are as carefully executed as those belonging to thefirst part. The Atlas of Clinical Medicine will, it is safe topredict, take a very prominent place in the annals of medi-cine. It is luxurious in appearance, but its intrinsic valuerenders its acquisition a necessity rather than a luxury.

Bakteriologische Diagnostik. Von JAnES EISENBERG.Hamburg und Leipzig : Leopold Voss. 1891.

DR. EISENBERG’S bacteriological tables are now so wellknown that, under ordinary circumstances, a review of thethird edition would resolve itself into the mere mention of