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Marion Sims’s operation of the removal of a conical portionof the cervix with much benefit. He did not believe that

potassa fusa could exercise any curative influence on malig-nant disease of the cervix.-Dr. C. H. Rourn was struckwith the circumstance that in the cases narrated the patientsdied in from four to nine months. He believed that cancer,if left alone, would last longer than if operated on. Potassafusa in his hands had proved harmful; bromine was themost effectual. External vegetations were best healed bytincture of gall-nuts or hazeline.-Dr. ROGERS said thatpotassa fusa had been used for all sorts of uterine ulcera-tion ; in his hands it had set up so much irritation of thebladder that he was compelled to give up the use of it.--Dr. HEYwOOD SMITH said that potassa fusa was of value inareolar hyperplasia of the cervix uteri. He had observedthat Chian turpentine changed the character of the secre-tions, and.in other ways proved beneficial.-Dr. H. SNOWbriefly replied.Mr. SPENCER WATSON showed a case of Exophthalmic

Goitre in a female, with slowness of speech and dulnessof intellect, in which tonic treatment had been beneficial.-Dr. ORD said that in some of the cases of myxoedema whichhe had seen he had observed in the early stage symptomswhich usually accompanied exophthalmic goitre.

ISOCIETY OF MEDICAL OFFICERS OF HEALTH.

AT the meeting on April 17th, Dr. J. ORME DUDFIELD,President, in the chair,

Dr. THOMAS STEVENSON read a paper on Sewage Disposal.The author commenced his paper by expressing regret thatthe possibility of dealing with excreta directly on the soilwith Arcadian-like simplicity was confined to the very few.He said that the processes, inorganic and organic, by whicheffete matters are got rid of by the soil can be but feeblyimitated by man; yet it is by the study of these processesand their more exact imitation that we must look for amore satisfactory disposal of sewage in the future. Theauthor traced the different methods of excrement-disposal,from the primitive privy to the introduction of the waterclosetin 1810, since which time the latter has become the common,although by no means universal, method of removal, notableexceptions being found even in large towns such as Leeds,Bradford, and Birmingham, in which there were manyhouses without waterclosets, while in Stafford a water-closet was phenomenal. At the beginning of the presentcentury, and for long afterwards, cesspools were universalin London, and although sewers existed it was penal to usethem for sewage. At this time the river water at London- Ibridge was drinkable, and many persons still livingremember the waterworks opposite Fishmongers’ Hall,which were used for the supply of the city. The use ofwaterclosets increased the volume of water in the cesspoolsand necessitated an overflow to the sewers, so that in a fewyears the state of the law underwent a complete reversal; andnow, instead of the discharge of sewage into sewers

being a punishable offence, it is penal not to drain into asewer if one be accessible. The author said that the com-position of sewage varied much less than might be expected,and that the difference was one of degree rather than ofkind; that there was little difference between the sewageof a watercloseted town and a non-closeted town. Takingthe average of the community, the dry solid excrement is1 oz. per head per day, which is distributed through 300 lb.of water-say, 15 grs. per gallon; and as for the urine,whilst the major portion, of that of adult males, never findsits way direct into the sewers, of the 2t oz. solids dis-tributed through 300 lb. of water, 14 oz. only is organic,one-half of which, urea, is speedily converted into innocentcarbonate of ammonia. Although the solid excrement formsthe most important polluting agent of sewage, it is by nomeans the greatest in aggregate amount, and, indeed, formsonly a small fraction of the total polluting material, whichcomes from the innumerable articles of domestic economy.He thought that in no British town could the difficultiesattending sewage disposal be greater than those which pre-sented themselves in London-a site much of which is belowriver level, an immense area, a city remote from the sea, withno available area close to its boundaries, and a situation nearthe upper end of the tidal reaches. He considered that muchcredit was due to those who had hitherto dealt with the dis-posal of the sewage of London, and great blame would rest

on the responsible authorities if they did not at once man-fully set themselves to do all that can be done to mitigateand abate the nuisance of the filthy condition of the Thames.When fresh and freely exposed to air, as in sewers onlypartially filled, sewage has little odour, and can scarcely beconsidered as offensive; but once let it accumulate in largequantities and come to comparative rest, putrefaction setsin, and it becomes vilely odorous-a seething mass full ofthose minute organisms which live, and grow, and multiplyin an airless, deoxygenated medium. To prevent this,sewage must be dealt with in one of three ways: (1) Thesewage may be at once thrown into a large volume ofwater, a river, or the sea, where it can be carried away bycurrents, diluted by diffusion, and oxygenated by thedissolved oxygen, without appreciable nuisance. (2) Itmay be applied directly to land, if sufficient area beobtained to dispose of the sewage without offence. (3) Itmay be treated with chemical agents, such as either destroythe organic matter, or those that destroy the agents ofputrefaction, the lower organisms. The author briefly dis-cussed the first method, but only to condemn it, as causingnuisance and danger to health. In speaking of the secondmethod, utilisation on land, he said that while in principlethis was no doubt the right one, the fertility of the land beingdependent on the restoration to it of the mineral constituentsof the food grown upon it, the method from a pecuniarypoint of view could rarely be profitable, and commonlyentailed loss. He estimated the value of a ton of Londonsewage (the quantity yielded per head of the population perweek) if its manurial constituents were in a solid andportable form, at twopence; but when sewage had to beutilised on land in a highly diluted form, and in all weathers,the actual value was found to be only a halfpenny, and thisleaves no margin for cost of transport, so that when thesewage had to be pumped the cost of pumping exceeded thevalue of the article pumped. There is, however, no agentwhich so efficiently deodorises sewage as the soil, which actsnot only as a checker of putrefaction but also absorbs thegases of sewage, and, further, is the nidus of the wellnighdemonstrated nitrifying agent-i.e., the bacterial organism-by which ammonia and nitrogenous organic matter, imme-diately or through the intermediate stage of ammonia,are converted into nitrates. The author referred to theresearches of Sclaesing and Miintz and of Warington to showthat it is probable that such a bacterium does exist, and playssome such part in nitrification, as yeast in a saccharine in-fusion does in setting up alcoholic fermentation. A pointof great practical importance referred to in this connexionwas that the nitrifying action is limited to the superficiallayers of the soil, decreasing as we descend, until, at 18 in.below the surface, the action entirely ceases. This pointsto the possibility of economy in the cost of carrying out the

, process of intermittent downward filtration, as, by keeping, the superficial layers of the soil in good condition for nitri-I fication, the great expense of deep excavation and prepara-. tion of the soil may be saved ; while broad irrigation,. where a sufficiency of land is available, offers a satis-I factory mode of sewage disposal, and is one which, holds out more likelihood of realising some portion of. the value of sewage than any other. It is seldom,, however, for obvious reasons, applicable to the sewage: of large towns. There is an erroneous notion prevalent that

sewage can be effectually treated by means of chemical sub-; stances alone. Any chemical which will effectually destroy; the spores of bacteria, or deprive them of potential life, will. certainly render the sewage unfit to be disposed of any-, where, for by such addition it becomes a poisonous fluid.; Chemical treatment directed to the end of clarifying sewage,. but not of rendering it non-putrescent, is a great advantage,, for the suspended solids of sewage are the chief source of; difficulty in treating sewage. As to the agents to be used; for clarification, the author said if the sewage is to be usedI for broad irrigation, simple straining will suffice; when land

filtration is the plan to be adopted, something more isl advisable; and when the effluent is to be turned into a, stream without any other treatment than a chemical; one, efficient clarification is indispensable-such a clari-- fication as leaves less than a grain of suspended solids. in each gallon of effluent, and even with this degreel of efficiency no effluent ought to be turned into a stream. unless the volume of running water is enormous in propor-l tion to the sewage it is to receive. The chemicals to be used. for precipitating sewage may be varied. Of these lime has; been largely used both on account of its being reasonably

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efficient and because of its cheapness; it should be dissolvedprevious to its use. Fifteen grains of lime to each gallon ofsewage is an ordinary proper proportion, but it is better toaccurately adjust the quantity to the degree of hardness ofthe water of the district-i.e., one grain of lime per gallonof sewage for each degree of hardness of the water-supply.An excess of lime is hurtful, for subsequent putrefaction isapt to occur; it may kill fish, and according to Waringtonmay entirely prevent nitrification. The addition of a littlesulphate of aluminia is beneficial, as it carries down aflocculent precipitate, entangling the lower organisms andtheir spores, difficult to remove by lime alone. Moreoverthe use of alum neutralises any excess of lime which mightoccur in the effluent. Sulphate of iron is another salt whichmay be usefully employed, but it is questionable whetherthis is a useful addition when the sewage is subsequentlyapplied to the land. The author concluded his paper withthe following remarks: " So far as I can foresee, the sewagedisposal of the future for our large towns will be onewhere application to land supplements a preliminaryprecipitation process ; and the land treatment will be a filtra-tion process by which the area of land requisite will be limited.Such a combined process fulfils all the requisites of goodpurification, and is based upon these fundamental data. Thesewage must be dealt with speedily before putrefaction hasbegun; and the agents of putrefaction, the bacteria, mustbe removed by clarification, which secures the removal ofmost of the bacterial organisms. The precipitated andclarified sewage is then to be brought as speedily as possibleunder oxidising influence, and nothing more effectively doesthis than the nitrifying organism. Putrefaction andnitrifi-cation are antagonistic processes; and so long as nitrificationis going on, putrefaction is, I believe, impossible. Sewage,when clarified by any simple process-and the simplerthe better-and then passed through land is odourless, andthis cannot, strictly speaking, be said of sewage simply pre-cipitated ; and is also insusceptible of putrefaction. Any-thing that falls short of the result obtained by the combinedprocess I have referred to cannot be considered a verydesirable mode of sewage disposal, albeit a less efficientprocess may under certain circumstances be permissible.-In the discussion which followed Drs. Drysdale, Edmunds,Bernays, C. E. Saunders, and Messrs. Rogers, Field, Corner,Edmunds, Jacob, and Winter Blyth took part.

ACADEMY OF MEDICINE IN IRELAND.

A MEETING of the Surgical Section was held on January23rd, the President, Dr. E. H. Bennett, in the chair.

Professor STOKES, in a paper on Astragaloid Osteotomy inthe Treatment of Flat-foot, commenced by drawing attentionto the usually accepted theories as regards the etiology offlat-foot-viz., ligamentous relaxation and a paralyticcondition of certain muscles connected with the ankle andfoot. He adduced various arguments to disprove theseviews. Attention was drawn to Professor Ogston’sresearches in this direction, and an account given of theoperation he has devised for the cure of the deformity inquestion; and objections to it were taken, based on theoperation being complicated and difficult, and followednecessarily by an obliteration of the medio-tarsal joint.illr. Stokes believed that the defect causing flat-foot is due,primarily, to alteration in the tarsal bones, notably theastragalus, which change in it may be either congenital orthe result of disease-probably rickets,-and that thisstretched rather than relaxed condition of the ligaments isa secondary rather than a primary change. In illustrationof this view, he exhibited a specimen of the deformitytaken from the museum of Trinity College, and for whichhe was indebted to Professor Bennett. Having regard tothe fact that in the irreducible cases of flat-foot osseousdeformation is the chief factor, Professor Stokes believedthat the rational treatment for such cases should be to dealexclusively with the deformed astragalus, and to do so

without necessarily obliterating Chopart’s joint. This hedid in the case of a youth aged fourteen, and with completesuccess. The parts to be operated on were renderedperfectly aseptic, and an incision an inch and a half inlength along the inner edge of the foot made, the centre ofwhich incision was the prominence caused by the head ofthe astragalus. At the centre of the incision another was

made at right angles to it, a little behind the situationof Chopart’s joint, and the two triangular flaps of skindissected back for about half an inch. A wedge-shapedpiece of bone from the enlarged head and neck of theastragalus was then removed with an osteotome, and it wasthen found that by adducting and supinating the foot thearch was perfectly restored. The wound during its unionwas aseptic throughout, and the patient afebrile. Themethod Professor Stokes adopted for keeping the foot in aposition of adduction was by the application of a Dupuytren’ssplint applied as in a case of Pott’s fracture of the fibula.The result of the operation was most satisfactory, and castsof the foot, taken before and after the operation, wereexhibited.Mr. KENDAL FRANKS gave the details of a case in which

he had performed Ogston’s operation for Flat-foot on

Oct. 16th last. The paper was illustrated by two impressions,taken in charcoal, of the foot, before and after operation.The first impression showed the foot resting on the lengthand breadth of the sole; a remarkable prominence on theinside, corresponding to the astragalo-scaphoid articulation,showed where this joint rested on the ground. The secondimpression showed that the arch of the foot had beenrestored, so that when the sole of the patient’s foot wasblackened with charcoal, and she was placed standing on amoistened sheet of paper, the paper received an impressiononly of the heel, the outer side, and the anterior portion ofthe foot. The operation wound was perfectly healed on thesixth day, and the highest temperature recorded was 99’2°.The adjourned discussion on the Operation for Flat-foot

took place on February 20th, when Mr. CORLEY said he wassatisfied that the disease commences in the ligamentous andtendinous structures; that if the bones eventually exhibitdeformity, it is from growth in some direction from whichnatural pressure has been removed.-Dr. SWAN said that heconsidered most of Mr. Stokes’s statements were misleading,and some of them appeared to him to be erroneous. Mr.Stokes had stated that the deformity of flat-foot wasdue to a mal-development of the bony structures of thetarsus, and, without considering the degree or state of theaffection, he condemned all methods of treatment as use-less except the operations, in which doubtless he includedOgston’s as well as his own. He had himself seen

thirty-four cases in minor or greater degree, and hadobserved it under three distinct phases. It commencedwith the sliding of the astragalus inward and the uppersurface of the os calcis relaxing, the ligament connectingthe outside of the astragalus with the calcis. This pro-duced, as Mr. Corley observed, an obliquity at the ankle-joint. The axis of the weight was thrown on its side.Next, there was a relaxation of the plantar ligament.Looking at the anatomy of the parts, the outer division ofthe plantar ligament fills up the sinus pedis, which pre-vents displacement of the head of the astragalus, butthe interval between the os calcis and the scaphoid is

lengthened. Mr. Stokes stated he had observed this in personsof robust health; that was not, however, his experience.In the second stage it was accompanied by a fusion of themuscular structures, which were chiefly of the anteriorportion of the foot. The adductor pollicis and the muscleson the inner portion of the foot were atrophied, and thebones could be distinctly felt through those muscles. Thetibialis posticus was involved. The third and last stage wasone for which no doubt an operation of some kind would bedesirable--namely, when the sole of the foot was altogetherflattened and the head of the astragalus came upon theground, and he believed also occasionally the projectingpoint of the scaphoid. With regard to treatment, it wouldbe too much to admit that all those cases which in the firstand second stages did not present serious inconveniencewere suitable for operation. The true clue to the treatmentof the affection in the earlier stages was to approximate theextremities of the tendinous structures binding the bonestogether. If bony enlargement or mal-development causedthe affection, how was it that in all those cases the foot couldbe reduced to its pristine symmetry by manipulation ? Thatcould not be done in the case of bony deformity. Therewas a distortion and rotation inwards of the astralagus, asMr. Corley observed, but there was no enlargement until thelast stage, when osteitis was the cause of the enlargementof the bone. He had seen spontaneous cures of the affec-tion. in the case of a patient condemned to long-continuedrest the foot regained its natural shape. Ogston’s seemedto be the natural method to restore the arch of the foot,