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seemed to have operated for the relief of pain and vomitingbut the-e were not the most urgent symptoms. He (llr.Kellock) thought that the vomiting was often due not so

much to the condition inside the stomach as to somethingoutside and around the ulcer. He himself had operatedon two patients with the;e symptoms. One had sufferedfor 17 years from pain and vomiting and on opening theabdomen he found a large scar in the wall of the stomach andattached to it a tough band of adhesions, which eventuallyhe excised in its entirety. The result was in every respectsatisfactory. More recently in another patient presentingmuch the same symptoms the possibility of hysteria was- entertained, but on opening the abdomen he found some-what the i-ame condition of things-namely, a depressedsoar in the wall of the stomach and adhesions to the parieteswhich he divided, simply turning in the wall of the stomachwithout opening it. This patient had been well ever since.He aked Mr. Mansell Moullin why he made another incisionin the stomach in one of his cases instead of attacking the- depressed scar from the ontside.-Mr. LEONARD A. BIDWELLasked whether adrenalin had been u-ed and mentioned the.ease of a patient who had severe haemorrhage after gastro-- enterostomy which was relieved by this drug. In the mildercases he thought that this drug should be given a trial.-Mr. MANSELL MOULLIN, in reply, recalled a case in whichgastro enterostomy had been performed and the haemorrhagehad continued ; indeed, he did not see how it could be other-wise. In the case referred to by Mr. Kellock he had closedthe anterior incision in the stomach by two rows of sutures,but the patient was so debilitated that no attempt at healinghad taken place.

DERMATOLOGICAL SOCIETY OF LONDON.

lr’xlzibition of Cases.A MEETING of this society was held on Nov. 12th, Dr.

J. J. PRINGLE being in the chair.Mr. MALCOLM A. MoRRtS showed a middle-aged man who

;had been vaccinated in April, 1902, and had been affectedwith a generalised eruption three weeks afterwards. This

- eruption was undoubtedly psoriasis and there was a doubtfulhistory of a single spot upon one arm before the vaccination.’Quite lately another eruption had made its appearance,taking the form of a long line extending from below theinternal malleolus, where it had begun, up the inner side ofthe leg to the knee, then following the line of the sartoriusmuscle to the outer side of the thigh, and finally windinground to terminate upon the buttock. The line thus formedwas made up of groups of small, flat-topped, angular papules,quite characteristic of lichen planus, though there was morescaling present than is usually seen in this disease. Thediagnosis offered was a combination of psoriasis with linearlichen planus, and with this all the members present.agreed.

Dr. JOHN LIDDELL showed an elderly man who had for iseveral months been suffering from an Eruption affecting the ’trunk, arms, and legs symmetrically and consisting of (yellowish-pink patches of extreme delicacy surrounded by afine papular margin. Infiltration was altogether absent andthere was no tendency to exudation. Dr. Liddell said thathis reasons for bringing forward the case were, first, that anexactly similar case had been seen by Dr. Unna and that hehad claimed the case as one of eczema seborrhoicum areatum,and, secondly, to show the great improvement produced insuch cases by the treatment with Harrogate waters.

Dr. H. RADCLTFFE-CROCKER showed a woman, aged 46years, who had had a Mole removed from the flank two

years ago, and who since last February had suffered fromthe appearance of multiple cutaneous and subcutaneoustumours. There were several scattered about the limbs but-the scalp was the most noticeably affected. Here could beseen numerous, irregularly shaped, bluish-red and stony-hardtumours covered with shiny skin and showing dilated vesselscoursing over them. One large one of the size of half a-walnut on the right side of the head had ulcerated and wasfungating slightly. The diagnosis was multiple secondarysarcomata of the skin.

Mr. WILLMOTT H. EvANS showed a patient who hadfor years had patches of Xanthoma Tuberosum on theelbows. Mr. Evans had treated the left elbow bv means ofthe x rays and after about 14 exposures to a moderatelyaoft tube the masses had almost entirely disappeared. A

month after the last exposure a moderate amount of reactio nhad come on, and the elbow was, at the timu ut exhibitio n,somewhat pigmented and scaling.

Dr. A. ’VHITFIELD showed a boy, aged four years andthree months, with the following history. He had been

quite healthy up to the end of September last, whenhe developed a severe cold and cough. He had be-ntreated with cod-liver oil and malt at the Children’s

Hospital, Great Ormond-street, but no local applica-tion to the skin had been used. Four days later hismother noticed some flat papules on the chest which rapidlyspread over the other parts. When shown the head and facewere covered with a diffuse silvery scale. All the other partsof the body and limbs with the exception of the palms andsoles were covered with hemispherical bright-red follicularpapules covered with a cap-like scale. The eruption wasthickest on the neck, the back, and the thighs, and had runinto sheets on the knees and elbows, so that these parts werecovered with a thick mortar-like scale. The hands, palms,and soles were also diffusely scaly but the nails were un-affected. The diagnosis offered was pityriasis rubra pilaris,but Dr. Whitfield pointed out that he had grown less certainof the nature of the disease since he had been watching it.The papules seemed to be more congestive than is usuallyfound in this disease and the scale was more like a cap andless of a central spine, thus bringing the case very near to afollicular psoriasis.

Dr. E. G. GRAHAM LITTLE shower a woman who hadbegun to develop an Eruption on the Face 18 months agoafter a bite from a mosquito. The eruption had commencedon one cheek and then started on the other, producing a sym-metrical eruption over the nose, cheeks, and ears, whichDr. Little considered to be lupus erythematosus. This was of

extremely congestive type and showed no tendency to centralatrophy, though there was considerable infiltration. The

patient had also albuminuria and he had brought her forwardas interesting from the point of view of this association, ofwhich several cases had been recently reported.

Dr. J. H. SEQUEIRA showed a man, aged 37 years, with apeculiar lungating growth beneath each eyelid. The onsethad occurred about 20 months ago, starting on the left sideas a small white raised spot of the size of a pin’s head, abouthalf an inch below the outer canthus. This increased insize and spread inwards and at the same time some of theouter portions healed up. Later haemorrhage had occurred onslight friction and the place used occasionally to swell up toabout the siz of a pigeon’s egg and then to discharge bloodand white tluid. Five months later a similar spot started onthe right cheek and other small nodules appeared about thescalp and forehead. A part of the growth removed for ex-amination had shown much epithelial overgrowth resemblingmalignant disease, and in the sections were numerous smallabscesses in the epi’ermis and in some of these were foundorganisms looking like very small yeasts. A smear preparationof these was exhibited. On exhibition, the characteristics ofthe eruption were as follows. On the cheek immediatelybelow each eye was an elliptical growth with thick, reddish,everted edges and of irregular shape. There were small,apparently ulcerative, depressions in the margin and thewhole was covered with a thick scab showing mostly driedpus with a little blood. On the forehead and the scalp thesmaller lesions, varying in size from that of a pin’s head tothat of a lentil, were of a pale pink, almost translucent,appearance somewhat resembling that of molluscum con-tagiosum but showing no distinct central depression andcore. Pressure between the finger-nails only caused hcemor--rhage but extracted no plug. The case was still underobservation, but it was thought possible that it might berelated to the disease known as "blastomycetic dermatitis.

"

The patient worked as an agricultural labourer and had agood deal to do with pigs.

WEST LONDON MEDICO-CHIRURGICALSOCIETY.

Choledoclwtomy in a case of Chronic Jaundice.-Septic Cona-plications t,f the Puerperal State.

, A MEETING of this society was held on Nov. 7th, Alr.RiCKARD W. LLOYD, the President, being in the chair.

Mr. ALBAN H. G. DORAN read a paper on Choledochotomyin a case of Chronic Jaundice with Cholangitis ; Recovery.The patient, a female, had suffered as a child from four or

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five attacks of jaundice. When 33 years of age she had aviolent attack of pain and for the first time passed gall-stones. For two years she continued to pass about onestone a month, without any jaundice but with considerablepain. On April 23rd, 1902, the patient, then aged 36 years,

’’

came under Mr. Doran’s care in the Samaritan Hospital.She was jaundiced and the gall-bladder was enlarged andhard. The motions were quite pale, with a remarkablequantity of powdery matter which proved to be of vegetablestructure. Un May lst an operation was performed. Anincision being made, the gall-bladder was aspirated and anounce of thick greenish pus came away. The common ductwas much dilated and just above the duodenal orifice a

stone was found to be impacted. A vertical incision wasmade into the dilated duct and a rough spherical calculus,three-quarters of an inch in diameter, was removed. Withthe probe no other calculi could be found. The duct wassutured, a drainage tube was placed in the gall-bladder, aplug of gauze was passed under the gall-bladder and pressedagainst the common duct, and the upper part of theabdominal wound was closed. On the third day afterthe operation two soft calculi came away. On the fifth

day there were severe vomiting, a rise of temperature,and a pulse-rate of 140. On the sixth day much

deep-yellow bile escaped from the wound and the

vomiting ceased entirely. At the end of three weeks the

patient was convalescent. Two months after the operationthere was some suppuration and a piece of ligature cameaway. During September three pieces of calculus came

away from the fistula which was now only two and a quarterinches in length. Mr. Doran said that this case showed thevalue of choledochotomy, an operation first performed byCourvoisier 13 years ago. Choledochotomy was an ideal

operation. A sandbag under the loins proved a greatassistance in pushing the duct forward. A long incisionshould always be used. The gall-stones which came awayafter the operation were probably hidden in the gall-bladderand the acute attack on the fifth day was probably a relapseof the cholangitis. The vomiting was extremely severe butwithout symptoms of septic peritonitis. A fistula connectedwith the common duct, which fortunately did not occur inthis case, was much more serious than one into the gall-bladder. There ought, however, to be no difficulty in

suturing when the patient was placed in the proper position.Mr. Doran asked for opinions on the value of calciumchloride for increasing the coagulability of the blood. He

thought the passage of quantities of sand-like powderof some interest. He called attention to the fact that

pregnancy favoured cholelithiasis.-Mr. L A. BIDWELLmentioned the value of Lane’s cleft-palate needlesin suturing deep holes in the common bile-duct. He

thought fistulas from the common bile-duct healed as

readily as those from the gall-bladder. He consideredthat the stones which came away after the operation wereprobably concealed in the hepatic duct. At any rate, itcould not be promised that there would be no recurrence ofsymptoms. He had not used calcium chloride, as a gauzedrain had always controlled the hæmorrhage.—Dr. E. PERCYPATON mentioned a specimen in the Westminster HospitalMuseum which showed dilated ducts in the liver containinga large number of stones. As to the comparatively slightimportance of a fistula after operation on the common duct,he had seen a case in which such a fistula began to dischargemilk given by the mouth and the patient died from inanition.He advocated the use of adrenalin chloride for controllingbleeding. Jaundice might not be present even when the ductwas packed with stones.-Dr. J. G. PARDOE thought that thesevere vomiting five days after operation might be due tocessation of the peristaltic action of the bowels, not un-common in septic conditions of the abdomen. He hadfound suprarenal extract very useful during operations uponthe urinary bladder.-Dr. A. H. W. CLEMOW asked for anyexperience of the internal administration of adrenalin.Five-grain doses every two hours had been followed byblanching of the nasal mucous membrane. This suggestedthe possibility of giving a few doses before such operationsas that which Mr. Doran had described.-Mr. W. McADAMECCLES had seen adrenalin of use in the vomiting of bloodafter gastro-enterostomy and also in a case of severe oozingfrom the corpus spongiosum after a plastic operation. Heused it in a solution of 1 in 1000.-Mr. DORAN, in reply, saidthat no doubt recurrence of the trouble was common.Carlsbad salts, however, seemed to help in preventing theformation of calculi. At the time of his operation he had

adrenalin ready, but it was not needed. Possibly thecalcium chloride previously given had been of some use.

Dr. FREDERICK J. MCCANN read a paper on Cases illus-trating some of the Septic Complications met with duringthe Puerperal State. In the first case the patient had had araised temperature since the second day, ranging between101° and 103° F. When she was seen six weeks later theuterus was found to be fixed in a mass of exudation withevidence of softening in Douglas’s pouch. The abscess was

opened through the posterior vaginal cul-de-sac and wasfound to be perimetric. The patient recovered. In thesecond case, which was that of a primipara, aged 24 years,the lochia ceased on the third day and on the tenth daythe temperatuie of the patient was 102° and she looked ill.The uterus was enlarged and was found to contain from twoto three ounces of pus. The cavity was swabbed with asolution of corrosive sublimate (1 in 4000). The patientrecovered. This was an example of puerperal pyometra,The patient in the third case was a primipara, aged 29 years.On the eighth day she had symptoms of septic absorptionand the uterus was swabbed as in the previous case. The

patient recovered. The value of swabbing the uterus insteadof douching was pointed out. In the fourth case a woman,aged 32 years, who had been delivered of her ixth childafterwards developed pyæmia. Three subcutaneous abscessesformed and she suffered from arthritis with effusion in theknee-joint and ankle-joint. The patient recovered after a

prolonged illness. In such cases the gravity of pulmonarycomplications was a guide in prognosis. The patient inthe fifth case was a primipara, aged 25 years, who

developed parametritis followed by an abscess. The

symptoms were delayed for ten months, when a swelling wasdetected in the right iliac fossa. The abscess was openedand the patient recovered. Such inflammatory depositsmight disappear or they might suppurate. Dr. McCannconcluded by urging that labours should be conducted ascarefully as modern surgical operations and that as fewvaginal examinations as possible should be made.-ThePRESIDENT thought that strychnia was of great service insuch septic cases ; its cumulative action, however, should beremembered. Oxygen, also, was likely to be beneficial. As

regards the causes of such septic conditions the environmentof the patient and previous pathological conditions shouldbe remembered.-Dr. J. A. MANSELL MOULLIN divided septicinfection into local and general varieties. In the local thepatient generally recovered, but the condition was a fertilesource of gynecological troubles. In general sepsis thecondition was either one of general septic peritonitis or

pyæmic in nature ; in either case the treatment was not verysatisfactory. Dr. Moullin condemned the use of the curettein septic cases. He noted the fact that auto-infection was

undoubtedly the cause of some cases of puerperal sepsis.-Mr. H. W. CHAMBERS remarked upon appendicitis as one ofthe obscure complications of the puerperium.-Dr. CLEMOWsaid that labour was a physiological process and oughtpractically to be unaccompanied by rise of temperature. If,however, the lochia became offensive careful douching wasnecessary. The douche can should not be raised more thantwo feet above the patient’s body. He advocated douches of1 in 2000 corrosive sublimate solution or, better still, ofchinosol -Mr. W. E. C. Mussow pleaded for greater powerfor the sanitary authority in regulating midwives.-Dr. G. H.DRUMMOND ROBINSON uttered a word of warning against theemployment of the curette in the removal of portions ofretained placenta ; it might fail to remove the placenta or itmight give rise to septic infection. He also called attentionto the frequency of cases of mild septic infection after labouror miscarriage, the results of which only showed themselves,perhaps, some time afterwards in pelvic pains and othercomplications.-Dr. McCANN replied.

LIVERPOOL MEDICAL INSTITUTION.

Exhibition of specimens.-The Pathology of Sleeping Sick-ness.-Post-mortem Warts.

THE first meeting of this session of the Pathologicaland Microscopical Section of this society was held on

Nov. 13th, Mr. RusHTON PARKER, the President, being inthe chair.The following specimens were shown :-Dr. E. E. GLYNN: A specimen from a case of Pulmonary

Thrombosis and sections of the clot in situ. The patient