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Medical Societies.BRISTOL MEDICO-CHIRURGICAL SOCIETY.

AT a meeting held on April 13th, with Dr. L. E. V.EVERY-CLAYTON, the President, in the chair, Mr. C. A.JOLL (London) gave an address on the

Surgery of the Thyroid Gland,based on 432 cases operated on by himself and illus-trated by a number of epidiascope pictures.Discussing the aetiology of various forms of thyroiddisease, he objected to the septic theory of the origin ofexophthalmic goitre on the ground that there was noevidence to support it. lie spoke of various forms of

thyroiditis, alluding to the chronic " ligneous " thyroiditis ofRiedel, and the possibility of mistaking it for malignantdisease. The occasional association of adenomata withthyrotoxic symptoms, and the formation of adenomatawithin simple parenchymatous goitres, as well as the i

possibility of malignant changes within the latter, were Itouched upon. Turning to Graves’s disease, Mr. Joll gave itas his opinion that it was to be distinguished from "non-hyperplastic toxic goitre," a distinction of importance in viewof the smaller surgical risk of cases in the latter group.He laid stress on the relation between Graves’s diseaseand progressive myocardial degeneration, speaking of thevalue of electrocardiography in tracing the course of thelatter. Operation is, he said, indicated for any simple goitrecausing pressure symptoms unless it respond quickly toother forms of treatment ; also for simple goitre causingtoxic symptoms and other forms of chronic ill-health. Heclaimed, further, that Graves’s disease was curable only byearly operation: saying, however, that patients with thisdisease, who didnot wish to undergo operation, should not bepressed to do so, as such patients did not do well. Thetechnique of operation was demonstrated by an admirableseries of line drawings, and something was said as to thevalue of ligation of the superior thyroid artery as analternative to thyroidectomy in certain cases. Localanaesthesia, Mr. Joll thought, was indicated only in thepresence of much stridor or cardiac disease, or where thepatient feared a general anaesthetic. On the other hand,general anaesthesia should never be deep, not more thanenough to stop involuntary movement. Some of thedifficulties and dangers of operation were discussed. Acutepost-operative hyperthyroidism was, in the speaker’s experi-ence, a rare complication. He claimed that surgical treat-ment resulted in a cure of Graves’s disease in 75 per cent. ofthe cases operated on. Recurrence of symptoms afteroperation was due to failure to remove enough of the gland.The paper was followed by a discussion, in which the

PRESIDENT, Mr. E. W. HEY GROVES, Professor F. H.EDGEWORTH, Dr. C. F. COOMBS, Mr. STUART V. STOCK,and Mr. J. LACY FIRTH joined.-In his reply Mr. JOLLsaid that he had never seen myxoedema follow

thyroidectomy for Graves’s disease.

NORWICH MEDICO-CHIRURGICAL SOCIETY.

Exhibition of Cases and Specimens.A CLINICAL meeting of this Society was held at the

Norfolk and Norwich Hospital on April 5th, SirHAMILTON BALLANCE, the President, in the chair.Dr. S. H. LONG showed a child who had had splenectomy

performed for splenic ansamia, with excellent results. Healso exhibited the spleen removed.Dr. F. W. BURTON-FANNING read notes of a case of

Rat-bite Fever,and demonstrated the points of interest on the patient. Heremarked on the rarity of the disease, only 15 cases havingbeen recorded in the British Isles, two of which had beenunder his care. The fever always followed on the bite of arat or of an animal, such as a ferret or cat, which had beenbitten by a rat. There was an incubation period after thebite, when the wound became re-inflamed and sloughy, butthere was no formation of pus. The patient shown wasbitten on the thumb, and an unhealthy sloughing woundwas seen. Lymphangitis was a conspicuous feature andwas followed by a rash which very much resembled a

papular secondary syphilitic rash. The disease was causedby a spirochsete, which, however, had not been found ondirect examination of the patient’s blood, but was dis-covered when some of his blood had been injected into awhite mouse. The fever was of intermittent type. As

to treatment, quinine was found to be quite useless, and the.only treatment of any value was the intravenous injectionof novarsenobillon.Mr. A. J. BLAXLAND showed the Pedunculated Intra-vesical

Middle Lobe of a Prostate causing urinary obstruction,without hypertrophy of the lateral lobes, which he hadremoved from a man of 56 with complete relief to thesymptoms. He also exhibited three specimens of thePyloric Half of the Stomach, which he had excised forchronic ulceration. In his opinion this operation was moresatisfactory than the usual one of excision of the ulcerby itself. It was easier to perform, there was practicallyno shock at the end of the operation, and the immediateafter-results in his cases had been excellent.-The PRESIDENTsaid that Mr. Blaxland had raised a very important surgicalquestion. He agreed as to the comparative simplicity of thisoperation, but he considered that for most small ulcers in anaccessible position local excision did all that was required.The PRESIDENT exhibited an Ovarian Tumour, weighing

10 lb., with a twisted pedicle, which he had removed from awoman of 51. A peculiar feature of the case was that hefound an extensive thrombosis of the veins in the omentum.In order to deal adequately with this thrombosis it wouldhave been necessary to remove several feet of the smallintestine and its mesentery, and he decided not to interfere.No bad symptoms had occurred, and he therefore concludedthat after the removal of the large twisted tumour thethrombosed condition of the veins subsided.Dr. A. BURTON showed a specimen of Tubal Mole from

a case of Ectopic Gestation of less than two months’duration.Dr. A. J. CLEVELAND brought forward a case of Occupation

Neurosis in a man, aged 28, who had worked in a boot factory;and developed a condition of pseudo-chorea. The right armwas chiefly affected. When the patient extended the armto do anything it developed ÍIwöordinated movements,and the condition was so severe that the man was quiteunable to work. Treatment seemed to have no effect, andin Dr. Cleveland’s opinion the prognosis was very bad.

DEVON AND EXETER MEDICO-CHIRURGICALSOCIETY.

A MEETING of this Society was held at the RoyalDevon and Exeter Hospital on April 2lst, Dr. W. GORDONin the chair.

Dr. F. A. ROPER read a paper on the .

-N7cit,it)-e and Ty°ectt7raent of Surgical Shock.He first acknowledged the great help given to all who hadspecially to deal with this condition during the war by thereports of the Medical Research Committee and ThirdArmyShock Committee. After differentiating between primaryand secondary shock, he went on to describe the bloodchanges in the latter condition found experimentally inanimals by Dale, Laidlaw, Trevan, and Bainbridge, and alsofound in man. These were due to leakage in the capillaryarea, and accompanied by fall of blood pressure, cold beinga further important factor in producing stagnation. Aninvariable result of this stagnation, leading to deficient intra-cellular oxidation, is acidosis. The defect of the adrenalintheory of shock is that shock is often fully developed longbefore sympathetic adrenalin exhaustion can have occurred.This leads to the consideration of other possible factors, firstand foremost the respiratory exchange. The automatic com-pensating acidosis postulated by the acapnia theory mightwell be at least a considerable additional factor, in view ofthe well-known observation that acids dilate peripheralvessels. Cannon’s experiment of clamping the aorta andobserving the resulting acidosis and shock on removal of theclamp was corroborative and should be remembered in usingthe tourniquet. There was, lastly, considerable similaritybetween the reaction of the body towards infection andtowards injury by violence. Dr. Roper showed that, asregards treatment, it was important to draw a sharp dis-tinction between haemorrhage and shock, best distinguishedin doubtful cases by the use of the hsemoglobinometer.Dr. Roper advocated the method of "forced fluids"in the treatment of shock, and spoke of the advan-tages of Bayliss’s 6 per cent. gum acacia solutionin normal saline in largely obviating leakage from thecirculation. No striking results seemed to be obtainedby use of alkaline solutions, but the consensus was thatthese were of benefit in acid-forming toxasmias resemblmgshock. Blood transfusion was of great value in shock,.but results were not so striking as in hemorrhage. In Dr.Roper’s opinion the citrate method was to be preferred. Heurged the advantages of nitrdus oxide and oxygen anass-thesia in obviating further shock due to fall of blood pressureduring or after operation, and envisaged the possibilities offuture progress in successful treatment on the lines of keeping.