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Massage was kept up for a fortnight; the treatmentincreased in strength while passive movements at the ankle-joint were added. No ecchymosis appeared for three days ;the first signs were at the junction of the muscle and tendonof the gastrocnemius ; later there was an intense livid dis-colouration on the inner side from the back of the knee to thesole of the foot, and in patches on the outer side ; thesepractically disappeared in 14 days. The leg has been, andis still, kept supported by a bandage.

For the first ten days walking was painful and it was

impossible to advance the left leg, and any thrust or extraweight was extremely uncomfortable. The injury appearsto have been to the muscle on the inner side, for the internalsaphenous nerve down to the ankle became acutely tender topressure; this has now disappeared. I have not been

absolutely laid up the whole time, though it has beennecessary to curtail outside work as much as possible.My professional friends considered that I was-well, very

unwise, not to lie up, with a back splint or a plaster-of-Pariscase on my leg, but with the amount of effusion that therewas rest; would have resulted in organisation of lymph andformation of adhesions which would have taken weeks tobreak down.

Antiphlogistine properly applied in reducing the inflamma-tion of traumatic effusions is of great value and not suffi-cientlv appreciated by many practitioners. I am quite surethat the period of absorption was greatly reduced by its use.The massage must also be given by one who has the requisiteskill; practically every evening small adhesions were foundin the subcutaneous and intercellular tissue, and theserequired care and patience for their removal.Amwell-street, E.C.

A CASE OF ACUTE POISONING BY ANTIPYRIN.

BY G. D. H. WALLACE, M.R.C.S. ENG., L.R.C.P. LOND.,D.P.H. CAMB.,

RESIDENT SURGEON, BIRMINGHAM GENERAL DISPENSARY.

A HEALTHY looking girl, aged 20 years, was brought tosee me on April 2nd. She had been suffering from toothacheand on the advice of a friend had sent to a druggist for tengrains of antipyrin. Within 15 minutes of taking it she

complained of a feeling of faintnes3 and suffocation, andher face became "blotchy " and swollen. When I saw hershe was perspiring freely, the skin of the face and neck wascedematous, and there was a profuse urticarial eruption onthe face, neck, and upper part of the chest. The pulse was120, very soft, feeble, and irregular. The temperaturewas 95-50F. Whilst being examined she suddenlycollapsed, her face became very cyanosed, and shelost consciousness. Brandy by the mouth and strychninehypodermically were administered and in the course ofa few minutes she regained consciousness. She was put tobed, hot water bottles applied, and a calomel powder given.Three hours later the temperature had risen to 970, thepulse-rate was 90, and the oedema of the face and neck hadmarkedly diminished. She was kept on a milk diet for twodays, by which time the temperature had risen to normaland the swelling and urticaria had completely disappeared.There was no diarrhoea or vomiting throughout, and the casediffered materially from cases of ptomaine poisoning. Itsmost marked features were the rapid onset and recovery, thelow temperature, and the great prostration. The patient hadnever had a previous attack (she had never taken antipyrinbefore), and a careful inquiry failed to elicit a history ofanything eaten which might have caused the symptoms.Birmingham.

A CASE OF EXTRA-UTERINE PREGNANCY OCCURRING TWICE IN THE SAME PERSON.

BY GEORGE A. GORDON, M D. EDIN.

IT must be an exceedingly uncommon thing for a woman tobe the victim of an extra-uterine gestation on two distinctoccasions, and it is this fact which makes me put on recordthe following case which came recently under my rare.

Beyond its rarity the case presents no points of exceptionalinterest.The patient was married in August, 1904, and continued to

menstruate more or less regularly until July, 1906 She thenmissed one period and shortly afterwards began to suffer some

abdominal pain, which she imagined was a bilious attack."She consulted Mr. T. W. Goldney of Richmond, who foundconsiderable tenderness in the hypogastrium with distensionof the abdomen; also the presence of a bloody dischargefrom the vagina. On vaginal examination he diagnosed thecase as one of ruptured tubal gestation. The patient wasremoved to the Royal Hospital, Richmond, where Mr. H. R.Wadd, who operated, found the left tube ruptured and thepelvis full of blood. The tube was afterwards found tocontain a fcetus of about seven weeks. The patient after asomewhat critical convalescence made a good recovery. ,

In June, 1909, almost three years after the operation, thesame woman came under my care complaining of pain inthe lower part of the abdomen and some blood-stained dis-charge from the vagina. She stated that since the operationshe had menstruated regularly but had just missed one

period. On examination I found great tenderness in theregion of the right tube and some abdominal distension.Per vaginam, the uterus was found to be enlarged, and in theregion of the right tube a swelling of about the size of apigeon’s egg was distinctly palpable. Suspecting the case tobe one of extra-uterine pregnancy, I had the patient removedat once to the hospital. Dr. S. S. Burn, who operated,found that there had been some oozing of blood from theright tube, but that this had not ruptured. On its removalit was found to contain a foetus of about six weeks. Thepatient made an uninterrupted recovery and is now in goodhealth, her one fear being that she should become pregnant athird time.Richmond, S.W.

Medical Societies.ROYAL SOCIETY OF MEDICINE.

MEDICAL SECTION.

.An W csezltator,y ,’phygnometer.-Dorsa Pereiission of theThorax and Stotiiaelt.

A MEETING of this section was held on June 28th, Dr. J.HITCHELL BRUCE being in the chair.

Dr. GEORGE OLIVER read a paper on a Combination ofractile and Auscultatory Methods of Reading the Systolicind Diastolic Blood Pressure. This procedure is accurateIn determining the exact point of maximum systolic pressureand diastolic pressure in an artery. The method employedis to apply an ordinary Riva Rocci band to the arm andas the pressure is increased the observer listens to the

artery below the band. At a certain pressure a I I thud" "

becomes audible and persists till it disappears, when themaximum systolic pressure is reached. The middle of theperiod during which the "thud" " is audible represents thediastolic pressure. A specially arranged phonendoscope isattached by a bracelet to the front of the elbow below theband, which enables one examiner to make a completeobservation.

Dr. WILLIAM EWART read a paper on Dorsal Percussionof the Thorax and of the Stomach, in which he reviewed thepresent knowledge of the systematic dorsal percussion andplexigraphy of the viscera. This had hitherto remained in-

complete owing to the omission of the stomach. He filledthat gap by introducing a method of "post-gastric per-cussion." and described a clinical sign in the back, hithertounpublished, called "the dorsal gastric nucleus of reson-ance " The dorsal gastric nucleus of resonance was normallycircular, under three inches in diameter, hyper-resonant, andsituated below the inferior scapular angle, and thereforeabove the diaphragm. With Piorry’s nucleus of dulness itsapparent analogy is much less than its contrasts. But in thefield of diagnosis its behaviour resembled that of the latter.Its lateral enlargements corresponded with those of the

underlving organ it<e]f There was, therefore, the same

tendency to an ultimate bclt-like fusion at the axillary baseof the dorsal percussion ontline with the anterior. As regardsthe wider su’f*rt of the dorsal percussion of the stomach, anearly stndv f’f which was contained in a paper by Dr. Ewarton the rlihbtiofts nf the stomach upwards and backwards,

1 Transacti ons of the Clinical Society of London, vol. xxxiii , 1896.

102

he again laid stress upon the neglected value of a dorsal

percussion and upon the major importance of the dorsal

variety of upward dilatation, which commonly remainedunsuspected in spite of the gravity of its symptoms. Dr.Ewart, in concluding, said that visceral plexigraphy, as

hitherto restricted to the prascordium and epigastrium, wasstill in need of greater accuracy and completeness. It shouldbe extended to the back and utilised in any situation, andwhenever it might serve a useful purpose. The range of"dorsal" plexigraphy was in reality the larger range fornormal organography, particularly in connexion with theabdominal organs. Its list of normal findings included theheart and its left auricle, the liver, the spleen, an indi-cation of the mediastinal structures, the kidneys, and anindication of the mesenteric structures, not to mentionthe pelvic district. For clinical purposes, too, consider-

ably more pathology was revealed by percussion in theback than in front. ’’ Vertebral" percussion possessed afield and a method exclusively its own. Besides its medical

aspects, "vertebral" " percussion was specially availablefor the early surgical diagnosis of spinal affections. Newfields for diagnosis by the surgeon and by the physicianalike were opened up by " dorsal" percussion in three mostimportant regions inaccessible from the front-namely, theposterior mediastinum with its glandular, inflammatory,aneurysmal, tracheal, cesophageal, and other affections ; theno less vital and no less remote " mesenteric " region inconnexion with the varied affections of the central abdo-minal organs ; and the iliac " region, which was of specialimportance in these days of epidemic appendicitis. Anaccurate knowledge of the normal percussion value ofindividual vertebras, on the skeletal pleximetric principle,might often afford the means of detecting at an earlierdate some of these centrally situated abnormalities-

e.g., vertebral or glandular disease before the forma-tion of paravertebral abscess, cesophageal or trachealdisease before the advent of perforation and of pulmonarygangrene, &c. The value of Grocco’s triangular dulness forthe diagnosis of empyema versus serous effusion, of supra-diaphragmatic verS1M infra-diaphragmatic fluid collections,&c., was still imperfectly understood, but was of growingpractical importance. For stomach diagnosis a fresh depar-ture was contained in the demonstration that normally thestomach was distantly accessible to our examination in theback. The percussion of the gastric nucleus would prob-ably be regarded in the future as part of the routine ofclinical examination. The existence, still practically un-recognised, of mainly dorsal varieties of gastric distensionshould render the dorsal examination indispensable inall "gastric" " cases. Dr. Ewart urged that the evi-dence adduced (which also included a series of originaltracings taken from the chest on transparent paper,showing the normal nucleus and its enlargements and de-formities, and also its belt-like fusion with an enlargedTraube’s semicircular resonance) might justify the plea fora systematic teaching of "dorsal" percussion and of" vertebral" percussion, and also the opinion that thiswould not be successfully accomplished until the prevailingprejudice against their only instrument of precision in

percussion, a suitable pleximeter, was laid aside.--AfterDr. A. M. GossAGE and Dr. BRUCE had spoken Dr. EwARTreplied.

NOTTINGHAM MEDICO-CHIRURGICAL SOCIETY.-The new premises of this society were formally opened byProfessor W. Osler on June 28th, in the presence of theprincipal physicians and surgeons in the city and thedistrict around. There has been in the last year an in-crease of 60 in the membership, which now totals 180,justifying the acquisition of the new quarters, which areadmirably adapted to the needs of the society. They in-clude a large lecture-room, an excellent library, a capitalbilliard-room, and a card-room, and the premises will,therefore, serve the triple purpose of a library, a placeof mutual instruction, and a club.-The President of the

society (Dr. A. Fulton), who was supported by Dr. F. H.Jacob and Dr. H. Bell Tawse (honorary secretaries), re-

called that the earliest record of the society was in1828, when the Nottingham Book Club was founded. Themeetings were at first held in the members’ houses, and thefirst president was Dr. Howitt, whose family was still well

represented in the membership. Later the books were

removed to the office of the Nottingham Journal, and in 1835the society moved to the Dispensary. In 1843 its title waschanged to the present name, but the membership was not large.For a few years the society was in a state of suspended ,

animation, until, in 1883, the present society was recon-structed, and many of the present members were at itsbirth. Again the meetings were at first held in themembers’ houses, and afterwards, till this year, at the Dis-pensary.-Professor Osler gave an address on the advantagesto the profession and the public of unity and fellowshipamong medical men and the right method of keepingthe general practitioner abreast of the modern de-

velopments. No men needed more acutely the benefitof cooperation, and yet they were notoriously difficultunits to combine. They lived of necessity, after leavingthe university, lives of isolation, of great loneliness,even in the cities, where a busy man might see verylittle of his colleagues. It was in the nature of the work,of course, that the physician must think of himself last, andthe profession could never be organised on a commercialbasis. It was difficult to combine the altruistic and thebusiness sides of the work. The labourer was worthy of hishire, and in many callings obtained the cash equivalent, butthat could never be so in the medical profession. Discordand jealousy often existed, largely owing to the attitude ofthe seniors towards the juniors, and Professor Osler laiddown three rules for all : < " Listen to no tales told by apatient of a doctor; believe no tale told of a doctoreven if you know it to be true; tell no tale your-self, even if you are itching to do so." The medical

society, he continued, should be a post-graduate schoolon a small or large scale, a sort of clearing-house of

experience of the profession in any district. Good patho-logical specimens should be exhibited at each fortnightlymeeting, and debates, among the younger men particularly,should be encouraged. The library was one of the mostimportant things in connexion with the society, and hepointed out how it could be made to include all the new goodmedical literature. Secondly, the general hospital couldbe made a great factor in the organisation of the

profession. They all needed advice and counsel, andthe public needed first-class consulting physicians and

surgeons. Such men could not be grown in a communitywithout a first-class hospital, and it was for the profession toencourage the type of men who would do them best servicein connexion with the general hospital. He should like tosee the general hospital a consulting centre for the wholedistrict, and the physician should take, not send, a difficultcase there. The general hospital should be a genuine post-graduate school for the city and district in all departments,for a doctor without a post-graduate course was stale in fiveyears, in a rut in ten years, out of which only a prolongedcourse would remove him, and in 20 years in a well, out ofwhich nothing would bring him. There was no countryin the world, said Professor Osler, in which there wassuch a high average of general excellence in the care

of the patients in the hospitals as in England. Pro-fessor Osler, however, could not find words sufficient tocondemn the general attitude in English hospital manage-ment towards the scientific side of medicine. In the publicinterest, to grow one’s own consultants, and to enable thepatients to receive the best out of the profession, thereshould be good pathological, clinical, and chemicallaboratories, well equipped, each under paid officials ofthe hospitals.-A hearty vote of thanks was accorded Pro-fessor Osler, on the motion of Alderman Dr. F. R. Mutch,the oldest member of the society, seconded by Dr. C. H.Cattle.

LONDON COUNTY COUNCIL : MEDICAL APPOINT-MENTS.&mdash;The Asylums Committee of the London CountyCouncil has appointed Dr. Percy Charles Spark, the medicalsuperintendent of the Epileptic Colony at Epsom, to bemedical superintendent of Banstead Asylum in successionto Dr. D. Johnston Jones. Miss Mary Amelia Pilliet, M.B.,Ch.B., until recently assistant house surgeon at the GlasgowRoyal Infirmary, has been appointed a woman inspector inthe public health department of the London County Councilunder the Midwives Act, 1902. The salary is .cZ50, rising to.6350 a year.