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1018. The urea excretion was fairly good, and there was noevidence of organic kidney disease.The case was treated with calomel and saline aperients

and a somewhat restricted diet. X ray treatment wasapplied to the spleen. Venesection was not done. The i

subjective symptoms had now to a great extent disappeared.The liver was smaller and the spleen, though not muchchanged in size, felt less bard. The abdominal. pain wasrelieved by a belt, and the patient was now living anordinary life with little discomfort. The last blood countshowed 8,000,000 red blood cells and 13,000 white cells.

TWO CASES OF DISLOCATION OF TEETH.

BY H. MEARNS SAVERY, M.R.C.S. ENG., L.R.C.P.LOND.,LATE C.S.O., IPSWICH HOSPITAL.

THE following cases may be of general interest, as I havenot been able to find any literature on the subject, nor haveI heard of similar treatment being adopted in the samecircumstances.CASE 1.-A. lad of about 13 years received an accidental blow in the

mouth from a stick. I found that his two upper centrals had beencompletely dislocated, hanging loose in the mouth, and facing intomy hand un being touche i. Considerable laceration of the soft partsand loosening of adjacent teeth. The teeth were not broken in anywav, so having placed them in saline 1 cleansed the parts, removing allblood cl,.ts from the cavities, and using flavine (1-1C0O). I he twoteeth were then replaced, the lacerations of the gum necessitating afew points of silk suture. The patient was furnished with a lint pad tobite on and the jaw held up fairly tightly by a jaw handage. Fluiddiet only was allowed. Pad and bandago were kept on for 48 hours,ensuing treatment consisting in fluid diet and thorough cleansing ofthe tPeth and mouth twice d-tUy with swabs soakefi in flavine (1-1000).In five or six days the solid diet was gradually given.

’

Six months later I found the condition quite satisfactory. For sometime the patient had been able to bite apples and tackle hard crustswith no discomfort.CASE 2.-A. youth, 18 fears, was kicked in the mouth while playing

football. The first and second bicuspid and first molar teeth of theright upper jaw were turned almost upside down, the crowns beingforced up and separating an appreoable portion of the alveolarmargin I did not take away the teeth, there being a consider-able attichment of gum. The parts were cleansed as in Case 1.Here the restoration of the "bite" was more difficult owing tothe destruction in the continuity of the alveolar margin. After con-siderable manipulation this w.s accomplished and afrer-treatmentinstituted as in Case 1. I discharged this patient some time atterwards.The only fault in an otherwise perfect result was that two of the teethwere a fraction lower than previously, but this caused no incon-venience.

I am anxious to know if replacement of teeth is commonlycarried out. It seems a pity that permanent teeth should belost, as seems to happen so often in young people as theresult of accident, if there is any chance, and there appearsto be, that they might be saved.Budleigh Salterton, S. Devon.

INTRAVENOUS INJECTION OF POTASSIUMIODIDE IN TABES DORSALIS.

BY F. J. DEVOTA,SENIOR DRESSER, STATE HOSPITAL, KOTA BHARU, KELANTAN.

THE following case is of special interest as regards thebeneficial effects of treatment by intravenous injection ofpotassium iodide in tabes dorsalis :-An Indian, aged 41, working as a railway guard in the

F.M.S. Ry. stationed at Pasir Mas, Kelantan section, wasadmitted into the State hospital, Kota Bharu, Kelantan, fortreatment on April 27th, 1918. For the past three waeks he hadbeen troubled with occasional shooting pains in the legs. Hegave a history of gonorrhoea at the age of 27 and of havinghad a chancre when he was 57. On examination he wasfound to be suffering from many symptoms pointing totabes dorsalis--e.g., pain in the limbs, loss of knee-jerks andankle-jerks, loss of pupil light reflex, shooting pains in thelower extremities and also anaesthesia of the feet and lowerpart of the legs; the patient could hardly walk.On April 29th and May 6th and 13th the patient was given

a full dose of "914," but no improvement was noticed, andhe complained of very severe shooting pains in thelegs and feet, especially at night-time; these pains werepartially controlled by morphia. After three intravenousinjections of potassium iodide (gr. 30 dissolved in 4 oz. of normal saline solution) improvement followed and the I,patient was discharged from the hospital on May 31st. !

This patient was last seen by me on July 5th, working onthe railway line, and I was informed by the patient himselfthat the shooti’tg pains in the legs and feet had entirelydisappeared ever since he was discharged from the hospital.

Medical Societies.ROYAL SOCIETY OF MEDICINE.

SECTION OF OTOLOGY.A MEETING of this section was held on Feb. 21st, Mr.

HUGH E. JONES, the President, being in the chair.radical and Modified RadloalzVastoid Operations.

Mr. J. S. FRASER and Mr. W. T. GARRETSON (E iinburgh)contributed a paper on "Radical and Modified RaaicalMastoid Operations: their Indications, Technique, andResults." In the absence of the authors, the paper wasread by Dr. DAN McEENZtE. The contribution was basedon the analysis of 306 cases of chronic middle-ear suppura-tion, composed as follows : 238 radical mastoid operation,17 modified radical mastoid operation, 26 labyrinthitis,25 intracranial complications. The average age of the

patients was 20 years. The most common causes appearedto be scarlet fever and measles. Sometimes the aural dis-

charge had been attributed to a blow on the ear. In only66 cases did the patients or their relatives remember thecause of the ear trouble. Among the precursory illnesseswere: measles in 26, scarlet fever in 25, pneumonia 3,whooping-cough 1, mumps 1, small-pox 1, teething 2, cold 1,injury 6. Middle-ear suppuration the authors found to bemuch more common among the poor than among the better-to-do. If the cases of severe suppurative otitis media wereproperly treated when they arose there would be very littlechronic middle-ear suppuration, and consequently the radicalmastoid operation would seldom be called for. The publicauthorities had, however, turned a deaf ear so far to the remon-strances of otologists in the matter. In 1913 the InternationalMedical Congress passed a resolution in these terms :-"That it would be greatly to the advantage of the community if

experts in otology and laryngology were attached to the specialhospitals for the treatment of epidemic diseases."The duration of the condition, according to the statementsof the patients, varied from 5 months to 20 or 30 years. In

only 48 cases was cholesteatoma diagnosed before operation,though at the operation it was found in 104. There wasEustachian obstruction in 34 ; in 70 cases the membraneshowed results of chronic suppurative otitis media. In

many of the cases there were more than one indication foroperation present. In 33 cases there was chronic sup-purative otitis media and failure of the conservativetreatment ; in 93 chronic suppurative otitis mediawith polypi or granulations was present, and in 57chronic suppurative otitis media with pain, mastoidtenderness, and polypi. In 208 cases the mastoidcortex was found to be normal. Particulars of the 238cases in which the radical mastoid operation was performed(the average stay of the patients in hospital was 22 days)were briefly given as follows :-Mortality : all cases, 5’3per cent. ; of uncomplicated cases, 0’7 per cent. Findingsat operation : mastoid process sclerotic, 174 ; scleroticdiploe, 31 ; diploetic, 12 ; cellular, 8. Cholesteatoma

present in 104. Results: non-grafted (178 examined),43 per cent. cured; grafted (70 examined), 70 per cent.cured. Hearing after operation : non-grafted : improved,39 per cent. ; unchanged, 39 per cent. ; worse, 23 per cent.Grafted : improved, 29 per cent. ; unchanged, 30 per cent. ;worse, 38 per cent. Modified mastoid operation: 9 satis-factory, 3 had moist cavities. 10 had improved hearing,2 had hearing unaltered, and 1 had worse hearing.

.DMCMMMM.Mr. ARTHUR CHEATLB regarded the paper as a masterpiece

in its way. He again urged the appointment of otologists tofever hospitals. The Government were warned in 1902 ofthe loss of man-power which had resulted from- ear troubles,and the experience of the war had brought home the truthof what was then urged. Pensions would have to be paidfor many years owing to cases of ear disease which mighthave been prevented. He recommended the appointment ofa Standing Committee of six to watch the Public Health Bill.About 5 to 7 per cent. of candidates for the Royal Air Force hadto be turned down on account of chronic middle-ear suppura-tion. In 1902 he examined many school children and foundthat 88 out of 1000 had chronic middle-ear suppuration. Heconsidered that the cases in which the modified or incomplete

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mastoid operation was justifiable were very few and farbetween, and for acute and subacute inflammation of themiddle ear he regarded the incomplete operation as bad andunscientific ; in some cases the Schwartze operation had tobe performed after all.

Dr. J. KERR LOVE said there appeared to be a tendency tooperate on all cases of chronic middle-ear suppuration. Hehad always under care about 500 school children withchronic middle-ear suppuration, and he could count onrecovery without operation in more than half the cases. Hecuretted the naso-pharynx and removed enlarged tonsils,and then subjected the external auditory canal and middleear to careful treatment over a considerable period. He didthe modified operation more readily in cases in which bothears were involved, unless the evidence very stronglyfavoured the radical operation. He believed operation hadbeen unnecessarily done in many of these cases.

What Opeg-atiogi sno’U.ld be Performed?Mr. C]AARLES J. HEATH said he assumed Dr. Love did

not perform the radical operation when both ears were

involved because the modified operation was likely tosecure retention of a more reasonable amount of hearingthan was the Schwartze operation. On his, the speaker’s,recommendation the Metropolitan Asylums Board had set upa hospital in London where all the children under theircontrol who had ear discharge were sent. If, after a fewweeks’ treatment, the running did not cease they wereoperated upon by the conservative method. The ear

dressing at the hospital was not a distressing procedure.In reply to a question, he said he had not published asummary of his results.

Dr. WILLIAM HILL did not believe all the operations doneon the children under the Metropolitan Asylums Board werenecessary, nor that the best form of operation for theirtrouble was selected. The meeting should let it be clearlyunderstood that the specialty did not regard the Schwartzeoperation as obsolete, but considered it to be a good opera-tion for acute and subacute cases. By the so-called con-servative operation-that of Euster, revived by CharlesHeath-he contended that the balance of the ear as a wholewas altered, and it was exposing the ear to vicissitudes ofclimate, to draughts, and the entry of water. There was a

strong line of difference in this matter. Was Mr. Heathright, or were the majority of otologists right? The matterneeded thrashing out.

Mr. W. STUART-Low pleaded for a better education of the ’,general practitioner on the dangers of the later results of ifugitive otitis media, which would lead to cases beingsent to the otologist early. Attention to tonsils andadenoids would mostly prevent the onset of otitis. Heconsidered that the radical mastoid operation should neverbe done on children. It was very sad to contemplate deaf-ness as a sequel to the operation. He discussed the tech-nique. and uttered a warning against tight bandaging.

Dr. J. DUNDAS GRANT said that very seldom was a Schwartzeoperation done for acute suppuration of the middle ear inwhich the patient did not get perfectly well ; therefore hecontended it was unnecessary to perform an operation whichleft a chronic fistula. If a fistula were left after a Schwartze,it would be called a very bad operation. He could nothelp feeling that Mr. Heath’s teaching was responsiblefor some of the ear work which had been done on soldiers.He protested against the charge that the radical mastoid opera-tion (the Schwartze) produced deafness, as it was an unfairstatement. When the anterior part of the tympanum was shutoff from the aditus and antrum, the modified operation, heagreed, was very strongly indicated ; and he thought theresults in cases shown by Mr. Heath to-day were admirable.

Mr. SOMERVILLE HASTINGS said in many of his Schwartze

operations a sinus was left. He therefore tried the modified

operation, and in his hands the operation had givenadmirable results in acute and subacute cases, healingoccurring quicker also, and the dressing was easier and moresatisfactory. He had now largely given up the Schwartzeoperation, especially for children. For chronic cases he didthe Schwartze always.

When should a Bone Ope1’at’ton be Done ?Sir CHARLES A. BALLANCE suggested that the essential

question in the discussion was, When should an operation onthe bone be done ? There were fulminating cases of acute otitismedia in which the mastoid process was rapidly involved,

the cells becoming filled with pus after three or four days.Those required operation ; wherever pus was present it mustbe let out. He thought there was nothing better than theSchwartze for those. If adequately and thoroughly per-formed in such cases it left perfect hearing, and healingoccurred in a short time. He was interested to return, after along absence, to find attempts still being made to improve theolder methods. He was against the idea of carrying out anyrigid operation as planned in the books ; every operatorshould be prepared to vary it in such a way as to dealmost effectively with what he found present. He insistedon the importance of absolute and free drainage of thetympanum. The tympanum should be interfered with aslittle as possible.

Dr. McKENZIE briefly replied for the authors.

&pti(1 Infection of Lateral Sinus after Injury at ,

Operation.Mr. HUNTER ToD read a paper entitled "Septic Infection of

Lateral Sinus Accidentally Injured during the Operation ofMastoidotomy." The author included only those cases in whichthe mastoid operation was performed for chronic suppurativedisease of the middle-ear cleft and mastoid cells, and in which,at the time of the operation, the sinus was apparently healthy.Septic infection of the sinus after injury rarely took place.These injuries were divisible into two groups: 1. A clean cutthrough the wall of the sinus, with profuse haemorrhage,requiring obliteration of the lumen of the sinus. In thesecases he had never observed subsequent infection of thesinus. 2. Grazing of the outer layer or puncturing of thesinus wall with no bleeding or with only slight oozing ofblood for a moment or two, the injury being so slight as toescape notice unless a careful examination be made at thetime of the operation. He gave details of six cases, four inhis own practice, with one death. In the fatal case all

seemed to be going well until the eighth day, when thepatient had a rigor and the temperature rose to 103° F. Mr.Tod operated again on the ninth day, performing ligation ofthe internal jugular vein. Perforation of the sinus wall wasdiscovered and a septic clot was removed. The autopsy showedseptic thrombus and pus in the circular and both cavernoussinuses, extending into both ophthalmic veins. Mr. Tod’s con-clusions were as follows. Whenever the lateral sinus wasexposed during the mastoid operation, careful examinationshould be made to see if it had been injured, even slightly.If so, it should be exposed freely on each side and its lumenobliterated by packing with gauze well beyond the affectedarea. There might be no evidence of infection of the sinusuntil the ninth day or later ; a sudden rigor might be thefirst symptom. This, with an increased pulse-rate, should beregarded as a danger signal. If heamorrhage occurred fromthe mastoid wound a few days after operation, it was notsufficient to arrest the haemorrhage by applying pressure tothe bleeding spot; the bone should be removed from thesinus wall above and below the affected area, and a gauzeplug inserted between the bone and the outer wall of thesinus. Haemorrhage associated with pyrexia or a rigoralways meant septic infection, and in the latter case theinternal jugular should always be ligated.The paper was discussed by Dr. MoKENZtE, Mr. H. J.

BANKS DAVIS, Mr. STUART-Low, Mr. W. M. MOLLISON,Mr. HEATH, and the PRESIDENT, and Mr. TOD brieflyreplied.

LITERARY INTELLIGENCE.-A third edition ofDiseases of the Skin," byDr.J. H. Sequeira, physician to theskin department and lecturer on dermatology at the LondonHospital, is ready for publication in the hands of Messrs.J. and A. Churchill. It is illustrated by 52 plates in colourand 257 text-figures.

ABERDEEN ROYAL INFIRMARY: STAFF APPOINT-MENTS.-The vacancies on the staff of the Aberdeen RoyalInfirmary occasioned by the resignation of Dr. J. ScottRiddell and the death of Dr. A. H. Lister, the filling ofthe latter post having been postponed during the war,have been filled by the appointment of Dr. Fred. K. Smith,the senior assistant surgeon, to the office of surgeon, andDr. Thomas Fraser, the senior assistant physician, to thepost of physician. The vacancy occurring through theresignation of Dr. W. Sinclair, the late superintendent, hasbeen filled by the appointment of Miss Edmondson, thematron, who has performed the duties during the last threeyears, to the joint office of superintendent and matron.