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When seen at the morning visit at 10 A.M. he was rationaland seemed comfortable. After this he seemed quite comfort-able, except for some embarrassment of respiration, such asone might expect from a double pneumo- and hsemo-thorax.The pulse varied from 116 to 148, the respirations from 30 to50, and the temperature from 990 to 103° during the fivefollowing days. About 4 A.M. on the fifth day he appeared tohave a faint, from which he rallied. Later, about 6 P.M., heagain collapsed and died suddenly.Post-mortem examination.-All the wounds seemed to be healing

naturally. Both pleural cavities contained blood-stained fluid, recentpleurisy on each side; left lung largely collapsed. Both bases werecongested and almost airless, though each seemed to have escapeddirect injury. The right lung contained a suppurating infarct. Peri-carditis was present; excess of fluid ; whole surface covered withlymph. On separating the lymph from the heart the wound with itssutures was seen. On opening the heart the left ventricle was foundto have been penetrated. A small clot occupied the bases of the musculipapillares, which were themselves partly cut through. On removingthe sutures a blade of the scissors could be passed through the heartwound into the ventricle. The basilar and carotid arteries wereoccupied by white thrombus, but no embolism could be found.

-Reviar7eg.-It is, perhaps, not surprising that the patientdied after such injuries, but for four days at least recoveryseemed quite hopeful. Contraction of the heart muscle musthave accounted for preventing immediate death, while

clotting round the bases of the papillary muscles must havealso prevented any further escape of blood. The bleedingfrom the heart as described was not alarming, and theopinion that it came from a branch of the coronary arteryseemed natural. The heart beat made no appreciable differ-ence to it. The fact that the patient was found lying on hisface may, by pressure on the external wound, have diminishedbleeding by increasing the intrapericardial tension. The

weapon which it is alleged produced the injury was a long-bladed pocket-knife, and presumably caused the infections.It was impossible to determine definitely whether pressure,infection, or embolism caused death. The suddenness ofonset suggested the latter, but the post-mortem appearancesdid not definitely confirm this and rather suggested theformer assumption. I have to thank Lieutenant-ColonelD. Wells Patterson, R.A.M.C.(T.), for his permission topublish this case.Newcastle-on-Tyne.

A CASE OF

TERATOMA OF TESTICULAR RELIC,THROWING LIGHT ON THE ORIGIN OF PEPTIC ULCER.

BY JAMES TAYLOR, F.R.C.S. EDIN.,MAJOR, R.A.M.C.; DISTRICT CONSULTING SURGEON, ALDERSHOT

COMMAND.

THE cause of gastric ulcer has been much discussed andmany theories have been advanced. A case recently undermy care seems to throw some light on the subject.A. B. was admitted to hospital complaining of irregular

attacks of severe pain in the epigastrium of two years’ durationand recently becoming worse. This pain, which shot throughto the back, did not seem to have any definite relation to thetaking of food ; it frequently came on in the night. It wasaccompanied by nausea but no vomiting. The bowels wereconstipated; no melsena. During the previous year he hadlost 14 lb. in weight. The patient looked thin; tonguefurred. Tenderness over duodenum, but none over

McBurney’s point or end of ileum. X ray examinationshowed a stomach of normal size, contracting well. Therewas an hour-glass constriction that persisted through all theexaminations; some of the meal still in the stomach after7 hours.

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Laparotomy was performed and a large ulcer found onthe lesser curvature close to the cardiac orifice, but actualorganic constriction was not present. The duodenum wasmore dilated than in any case I have seen; it was somewhatcongested; no evidence of ulceration. Behind the peritoneumat the duodeno-jejunal junction, and partly obstructing it,was a rounded cystic swelling about the size of a duck’s egg.It was closely applied to the front of the aorta and had acommunicated pulsation from it. This obstructing tumourwas carefully separated from the aorta and removed and theulcer excised. The appendix was removed, but it was notinfiamed and was in no way obstructing the end of the ileum,nor was there any band kinking the latter.

Dr. Nathan Mutch describes the histology of the growthas follows :-

" It consists of large, pale, irregularly polyhedral epithelial cells con-taining very fine granules. Under in. objective they have an appear-ance resembling finely ground glass. Dividing these cells intoirregular masses are more darkly stained elongated epithelial cells withlong narrow nuclei. Many of these interlacing strands are made up of

cells which have coalesced to form multicellular syncytial-like masses.The whole tumour is permeated by a rich vascular network. In manyplaces blood has been extravasated, and the neighbouring tissuescontain yellow granules of altered haemoglobin. Some of the arteriesare undergoing hyaline degeneration."The case demonstrates very clearly the fact that obstruc-

tion at the duodeno-jejunal junction, which, according tothe theory advanced by Sir W. Arbuthnot Lane, is usuallyproduced by chronic intestinal stasis, and which was broughtabout here by the pressure of a tumour, may be directlyresponsible for the development of peptic ulceration.

Medical Societies.TUBERCULOSIS SOCIETY.

A MEETING of this society was held at the Royal Societyof Medicine on May 26th, Dr. HALLIDAY SUTHERLAND,the President, being in the chair, when Dr. R. C. WINGFIELDopened a discussion on

Tuberculosis in Relation to a Minist’1"!J of Health.Dr. Wingfield said that experience in the conduct of the

war had shown that only when the command was placed inthe hands of one man had progress been made. This

experience should be applied in tuberculosis. At presentadministration was divided up among so many authoritiesthat in each area facilities for treatment varied consider-ably, from the progressive authority with every facility tothe one which provided nothing. He did not think it wasright that a patient should suffer handicap by living in anon-progressive area. In order to obtain unity of control itwas not necessary that tuberculosis should be consigned to awatertight compartment, but a section in the Ministryshould be set aside for tuberculosis under the leadership ofone man. This man need not be a medical man, but heshould be aided by a financial and a medical adviser, thelatter having an advisory committee drawn from differentbranches of the work to keep him in touch withlocal conditions. Having obtained a single commandthe work in each area should be decentralised, eacharea being under the control of the tuberculosis officer,who would be responsible for the area to the Ministryof Health. He should receive all notifications and beassisted by health visitors, after-care workers, &c., respon-sible to him and have sanatorium, hospital, observation beds,and a laboratory under his control. Dr. Wingfield did notfavour after-care committees, but thought that an after-careworker with assistance was more satisfactory. Sanatoriumbeds should be provided for 14 per cent. of the casesattending the dispensary and local homes provided for2 per cent.-i.e., infectious cases which were too advancedfor hospital and where the prognosis was hopeless. Hefavoured the creation of industrial colonies in each area,not necessarily in the country, where the work should beState subsidised and controlled by trade-union rates of wages.The farm colony was not suitable for the town dweller.

The nisoussion.Dr. HALLIDAY SUTHERLAND (Marylebone) thought that

the local authority would have to be in control of the unit asthey were responsible for the taxation to provide the funds.He’considered that the colony system required further trialbefore any number were put up.

Mr. F. J. C. BLACKMORN (Woolwich) said that after-carecommittees should have funds to help the families of menundergoing sanatorium treatment. Lack of provision at

present prevented many suitable cases from going intosanatorium.

Dr. F. R. WALTERS (Surrey) said that work in manysanatoriums was very indifferently done. As such workformed the basis of treatment it should be most carefullycarried out to produce the best results.

Mr. H. DE CARLE WOODCOCK (Leeds) said that the tuber-culosis officers should not be under the medical officer ofhealth. There should be legislative power to remove

infectious cases from populous areas. The after-care com-mittee should form a vigilance society to compel the localauthority to do its duty. He thought that the PensionsMinistry had gone far to solve the problem by providing fm -the families during the patient’s absence in sanatorium

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Dr. JAMES WATT (Downs Sanatorium) thought that tomake each unit financially sound it must be under the controlof the local authority ; he did not see any reason why thetuberculosis officer and medical officer of health should notwork together under the present system, and he thought theMinistry would keep to the present relations.

Dr. A. J. SHINNIE (Westminster) considered that theafter-care committee in his area had been a failure, andadvocated the appointment of a paid adviser for this work.

Dr. H. R. WILSON (Southwark) said that the tuberculosisofficer and the medical officer of health should each be headof his own department, the tuberculosis officer beingresponsible to a subcommittee of the public healthcommittee.

Dr. WINGFIELD briefly replied.

MEDICO - PSYCHOLOGICAL ASSOCIATIONOF GREAT BRITAIN AND IRELAND.

THE ordinary quarterly meeting of this association washeld in the rooms of the Medical Society of London onMay 20th, under the presidency of Dr. JOHN KEAY.

The Maudsley Lectu’l’eship.The committee appointed to formulate conditions concern-

ing this lectureship, arising out of the bequest of the lateDr. Mandsley, reported to the society the conditions deter-mined upon. The lecturer is to receive a suitable honorariumand a gold medal and ribbon, and is to be elected by thecouncil. The lecturer, who must have made contributionsof well-recognised importance and value bearing on theknowledge of mind and its disorders, may be of any nationalityor of either sex. The lecturer is required to give two lectures,one scientific, the other popular, the popular lecture dealingwith the hygiene of mind.

Dr. C. F. F. McDoWALL (Ticehurst House, Sussex) read apaper entitled

The Genesis of Del11,sions: Clinical Notes.He said our social and political tendencies were the outcomeof an analysis, more or less critical, and believed by theindividual to be impartial. The reasoning was not alwayslogical or the argument conclusive to people of otheropinions, but the conclusion arrived at was final. Delusionsand hallucinations did not arise accidentally; they had adefinite basis, the foundation of which resided in the per-sonal experience of the sufferer. It was the duty of themedical man to analyse the processes by which the abnor-mality had arisen and to work back to what might be termedthe "taking-off point." A great step towards removing thedifficulty was to gain the complete confidence of the patient.In men the underlying cause was often very quickly reached,but women were more reticent. The mere elucidation of thecause was not enough to effect a cure ; the patient should betaught to follow, in their logical sequence, all the ideaswhich he had misinterpreted and misunderstood.

The Discussion.Sir GEORGE SAVAGE said the condition under considera-

tion he had long ago called " morbid mental growth." Somemorbid mental growths he described as ’’ innocent." A second Iform was that which modified utility, but still did not destroy;but the third, and more severe, kind invaded and destroyedfaculties, such as when a person had delusions of persecution. ’’,

Dr. R. HUNTER STEEN emphasised, by the narration of astriking case, the fact that delusions were often in the formof wish-fulfilments.

Mr. J. CARSWELL (Glasgow) expressed his gratification thatthe younger men in the specialty were devoting themselvesanew to clinical studies.

Dr. J. G. SOUTAR did not regard the method pursued bythe author as psycho-analysis, but rather a simple investiga-tion into the patient’s life-history, which showed not onlythe genesis of the delusion, but also why it took that par-ticular form. What was really needed was to know why amind, previously sound, became, either suddenly or gradually,one suitable for the growth of hallucinations and delusions.He thought many delusions were reflexes of the patient’spast failures, which only came into dominance later whenhe was in a less robust state. The re-education of thepatient he considered to be of the greatest possible value.

Dr. McDowALL briefly replied.

Reviews and Notices of Books.Clinical Mic7’oscoPy and Chemistry. By F. A. MCJUNKIN,

M.A., M D., Professor of Pathology, Marquette UniversitySchool of Medicine. With 131 illustrations. London:W. B. Saunders Company. 1919. Pp.470. 16s.

FROM the point of view of the clinical pathologist thisbook is of great value. It is thoroughly up to date, com-prehensive, and very well illustrated. There are sectionson blood work, on sputum and body fluids, urinary andgastric tests, on the stools, on media-making, on histology,and on autopsy technique. Laboratory organisation, evendown to card-index methods, finds a place. References andcounter-references are apparently faultless, which is excep-tional ; in fact, omissions of any importance are pleasinglyrare.

Amongst these, however, we note absence of the details ofDreyer’s macroscropic agglutination method, although it ismentioned ; also Fontana’s method of staining spirochsetesand the measurements of the blood cells are conspicuous bytheir absence. Bogg’s method of determining the coagula-tion-time of blood, ingenious as it may be, does not supply along-felt want-namely, an accurate method. It fails like allother coagulation-time tests in that it ignores the varyingeffects of viscosity and temperature. The technique ofagglutination tests for transfusion cases is given, and thepages devoted to the chemical analysis of the body fluids arevery full.There are a number of tests hard to come by in most

text-books of this sort, such as the cell-count for cerebro-spinal fluid and the antitrypsin content of blood test, whichare detailed. Embedding tissues with soap for section is aprocess which can be found herein. The method of countingvaccines with a hsemocytometer, which Shera suggested in1918, is also preferred to the conventional method of Wright.Howbeit, one hour does not seem to us to be long enough toallow for the bacilli to settle before counting. Tuberculinis not recommended. In Wassermann tests, Dr. McJunkinprefers a cholesterol antigen. This would seem to be thegeneral view in America. In this country we think such anantigen too prone to give false positive " reactions to besafe to use as a standard. Discriminating workers, however,find it most useful in determining the duration of treatmentin known positive cases. " Partial positive" reactions inmalaria, and so on, as detailed by the author, are more likelyto be effects due to the vagaries of the cholesterol antigenthan to bona-fide deviation.

Notwithstanding the minor defects of the book, whichinclude the abuse of the word billion (which should mean a s

million times a million), we can thoroughly recommend it asthe most concise and complete thesis of its kind extant.

.The Physiological Feeding of Ohildren. By ERIC PRITCHARD,M.A., M.D. Oxon., M.RC.P. Lond., Physician to theQueen’s Hospital for Children, &c. London: HenryKimpion. 1919. Pp. 59. 3s. 6d. net.

THIS modest volume represents a chapter on the feedingof children over one year of age, written for the new andfourth edition of the author’s Physiological Feeding ofInfants," shortly to be published. The language is simpleand can be understood by the unlearned, which, as Dr..Pritchard points out, is not the case with the majority ofstandard works on dietaries. He advocates the feedingof children according to caloric requirement, basing thecalculation upon age, weight, rate of growth, energy pro-duction, loss of heat, and certain other environmental condi-tions. The ratio or balance between the different constituentsof food is also to be decided upon a physiological basis.Foodstuffs are then to be selected with a view to taste,digestibility, absorbability, physical qualities, and variety.Tables are given showing the caloric requirements of childrenat different ages, and on these are based a series of practicaldiet-sheets containing bills-of-fare for the three or four mealsof the day, with the caloric value of each. In regard to thebalance between the different constituents of food, Dr.Pritchard considers that the ratio of 1 : 5 between the proteinand non-protein elements of the diet provided by nature for