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THE SECTIONS. MEDICINE.
544
permanent and the THE
BRITISH MEDICAL ASSOCIATION. MEETING AT CHELTENHAM.
THE SECTIONS. MEDICINE.
FRIDAY, AUGUST 2ND. THE
closing meeting of
the section commenced with the
by Dr. EDOUARD Ris2 (Paris) on reading Tlae Bteteriology of Fœtid and Ganyrenous Suppuration. of
a
paper
He said that in diseases where foetorwas present, such as appendicitis, mastoiditis accompanied by crackling cedema, and in
of empyema, if the pus
treatment harmless.
In addition to its
cholagogue and intestinal antiseptic calomel was the most powerful and harmless of diuretics. As adjuvants to the calomel treatment he employed hot water and quinine when use as a
place.
After describing his treatdefervescence had taken ment of cholera infantum and post-partum inflammation by the same means Dr. Riviere concluded : "All diseases can be referred to one cause-intoxication, and, above all, autointoxication, which in my opinion depends directly on the disturbance and deficiency of the hepatic function. The microbe only enters the lists when the machine is foul and choked because it has not been washed out in time." The PRESIDENT (Dr. E. T. WILSON, Cheltenham) and others discussed the paper. Mr. CHISHOLM WILLIAMS (London) read a paper on
The Treatment of P7tt7tisis
by Means of Electrical Currents of
High Frequency and Potential.
examined under the be made Treatment by these means had given such striking results in out. The polymorphism of this assemblage of micro- his hands that lie wished to summarise his results in 43 cases. These were all of over a year’s duration. The organisms was very marked, yet after preparing culture- difference between the currents obtained by an ordinarv tubes from the same pus, though a luxuriant growth would of Ruhmkorff and that Tesla was that in the latter the coil occur, yet on microscopical examination only a few common forms of bacteria would generally be found. It was not alternations were infinite and the electro-motor force was high. Thus in the former they might have likely that these common forms were the active agents proportionally in producing foetid inflammation, gaseous phlegmon, or dis- alternations of 200 per second and electro-motor forces from crete gangrene in the lungs. It had occurred to Dr. Rist that 10,000 to 20,000 volts, while in the latter alternations of the reason why the rarer forms of bacillus would not grow 1,000,000 per second and the electro-motor force from 100,000 was that the conditions of culture did not suit them. Dr. to 1,000,000 volts. In using these he found general electrifiVeillon of Paris had devised a simple method of anaerobic cation better than local and a combination better still. Under culture free from the difliculties of the hydrogen and this treatment the temperature first rose and then fell and other methods. Diluted pus was mixed with liquid progress could be gauged by noting if the reactionary rise could longer be induced. If it could not be sugared agar and with this tubes were filled to a induced any even prolonged exposure to the currents the by The of about four and a inches. was half height agar then solidified by placing the tubes in cold water. Under patient might be considered well. Cough was relieved, these circumstances all the microbes except those occupying sputum was lessened., and bacilli were reduced in numbers the upper superficial layer of the culture medium were grow- and dwarfed in shape. He did not think they were killed by the current. subsided and the ing under anaerobic conditions. A profuse growth generally increased. Mr. Sweating Osler as saying that 95 per Williams quoted occurred and on examining specimens taken from the lower cent. of patients were unable to afford any treatment away of the tube were found to be layers very many organisms from their own homes. By this method they could all be growing, and Dr. Rist gave a long list of names of the bacilli treated by their own medical man. Of his 43 cases 42 which had been isolated and described by himself and his on weight and lost all symptoms except in a few put colleagues, some being new t science. He hoped that in other hands the method might lead to the further elucidation where a slight cough remained, and a few bacilli might be found occasionally. of the nature of the so-called anaerobic bacilli. Dr. J. RIVIERE said that he had been using high frequency Dr. H. J. CAMPBELL (Bradford) asked if the pneumocurrents for more than five years and had had good results coccus of Fraenkel could cause suppuration, as he thought with them. He used even more powerful ones than did Mr. it had done so in one of his own cases. Dr. RIST, in reply, said that it could do so, but that in his Williams. Dr. D. J. A. CHOWRY-MUTHU (Isle of Wight) read a opinion, if foetor were well marked, they ought to be able to find the anaerobic organisms he had been describing, which paper on The Diagnostic Value of Bacilli in Relation to Phthisis. he considered were the true cause of such conditions and not the bacillus coli communis. He related six cases as illustrating this subject. They all Dr. McPHEDRAN (Toronto) and Dr. WILLIAM GOLDER presented the clinical appearance of phthisis, but in none of communicated a paper on them could the bacillus tuberculosis be demonstrated in the A Case of lndigouria. sputum. They all recovered and were found out to be really The condition was merely a clinical curiosity. A male cases of chronic pneumonia, syphilitic disease of the lung, chronic bronchitis, &c., and one case appeared to be mycotic patient, aged 24 years, consulted him for general malaise and tired feelings. No objective signs were discovered, but he bronchitis, a large quantity of muco-purulent matter being He rementioned that his urine was of a blue colour. On a speci- expectorated which contained mycelial threads. cognised the difficulty of demonstrating the bacilli in some men being passed it had the characteristic bluish-green colour of indigo. Its specific gravity was 1029. It con- cases, but thought that if after thorough search they were tained no albumin or sugar. On microscopical examination found to be absent they might provisionally pronounce the the pigment could be seen in small blue granules. Dr. case to be non-tuberculous. Dr. F. W. FoRBES Ross (London) thought.that the severity McPhedran made some remarks on previously published of cases of phthisis could not be determined by the number of ,cases and said that the cause of the condition was quite bacilli present in the sputum. In some cases which, from unknown. the point of view of symptoms, had been stationary for years Dr. J. RIVIÈRE (Paris) read a paper on bacilli were very abundant. The Abortive and Curative Treatment of Acute Alimentary Mr. GRIFFITH C. WILKIN (Yeovil) read a paper on Diseases, and particularly Ente?’ic Fever and AppendiRheumatic Endocarditis. citis, by a Judicious Use of Calomel, Water, He related a case of this affection in which the patient was Ifeat, and Quinine. The motto of the paper was, "As the microbe so is man extraordinarily susceptible to the influence of three drugskilled by his own toxins and refuse." Starting from this morphia, quinine, and nux vomica-given at separate times. thesis Dr. Riviere contended that the best way to treat One and a half minims of injectio morphinag hypodermica, diseases such as those mentioned, which interfered with the B.P., were given for joint pain in the early stages of the proper excretion of refuse matters, was to administer such a disease. The patient became comatose and was only saved drug as calomel. His practice was to give five grains each from death by large doses of atropine and electricity energetiof calomel and sodium bicarbonate placed directly on cally administered. She shortly afterwards had pneumonia the tongue at midnight, followed next morning by and then left hemiplegia from embolism. Quinine was given castor oil beaten up with hot water or eight grammes of but caused intense headache. When she began to recover magnesia. Such treatment seldom failed to reduce fever small doses of tinctura nucis vomicse, B. P. (five minims), were and he thought that in many cases the reduction was given three times a day. These caused after a week rigidity some cases
was
microscope very many bacillary forms could easily
body-weight
’
545 which only stopped when the nux vomica was discontinued. Dr. H. J. CAMPBELL (Bradford) read a paper on The Treatment of Cardio-arterial Disease. arterio-sclerosis caused a disturbance of circulation Diffuse and nutrition which was temporarily compensated for by cardiac hypertrophy. After a time, however, when this had reached its maximum, continued high arterial tension was likely to lead to post-hypertrophic degeneration of the cardiac muscle. A correct appreciation of the degree of this tension was desirable, and Dr. Campbell was accustomed to use Hill and Barnard’s sphygmometer for that purpose and considered that it answeredvery well. It did not indeed record very well the extreme degrees of high pressure, but that was of little moment so long as they recognised that the high routine treatment in these pressure existed. He cases, but thought that each should be considered on its own merits. Harm might be done in one by treatment which would be quite appropriate in others. If kidney sclerosis In were also present it additionally complicated matters. this case he was accustomed to rely on an exclusive diet of milk and large doses of sodium iodide. and
opisthotonos,
deprecated
Dr. FORBES Ross read a paper on the Treatment of Tuberculosis by Meat Albumin, which will be found at
p. 523. Mr. STUART-Low (London) read an unannounced paper the Use of Mucin in Diseases of the Alimentary Tract, and Dr. J. HADDON (Hawick) one on a Change of Life in Men as well as in Women. Owing to the room allotted to this section having been changed on each day it was very poorly attended on the last day, members not being able to find it. ,on
SURGERY. Mr.
FRIDAY, AUGUST 2ND. HOWARD MARSH (surgeon to St. Bartholomew’s
Hospital, London) opened a discussion on Injuries of Joints, with Special Reference to their Inamediccte and Remote Treatment by Massage and Movement. This subject, he said, was very suitable for discussion at such a meeting as the present. Both massage and movements have long been employed in English surgery, but lately they ’have come into much more general use. Both are valuable "remedies, but if used as a matter of routine both may do great harm. As methods of surgical treatment they must be closely supervised, care being taken to watch their effect, and especially to be sure that no element is present in the case which renders their employment undesirable. It is necessary to have a clear idea as to what has ’been termed the -physiology of massage "-as to the different ways, i.e., in which it acts. 1. It enlarges the amount of blood circulating through the part concerned. This is obviously apparent in the skin, which instead of remaining cold and pale becomes warm, and ’more or less red. The same result was experimentally demonstrated in regard to the muscles by Brunton and Tunnicliffe who showed that the amount of blood passing through them both during massage and after its cessation was increased. This increase of blood is in It maintains or improves the - every way advantageous. nutrition of all the various tissues ; it promotes the restoration of the functional activity of injured muscles, and it plays an important part in the absorption of lymph and ’extravasated blood. 2. Its action is mechanical. By kneading and percussion extravasated blood and lymph which have coagulated in the tissues and led to brawny oedema are broken up ,and dislodged, while by stroking from below upwards they are swept onwards and brought within the reach of healthy lymphatics and a normal venous circulation, so that they can more readily be absorbed. 3. It - is an efficient stimulant to damaged muscles through its influence on the nervous system. In such minor injuries as sprains and contusions probably the small nerves ramifying in the injured part are seldom torn across, for they are tough -rather than brittle, they are well protected in the subcutaneous tissue and the deeper structures, and their course is often tortuous so that they are not easily put on the stretch. Nevertheless, they are not infrequently so far injured that their functions, for the time being, are more or less suspended, and massage is then a very useful agent in stimulating them to a resumption of activity. It probably acts
always
similar manner on the vaso-motor nerves which preside 4. No one who has the arterial system of the part. watched its sedative effect when applied in cases of recent injury can doubt the influence of massage in reducing muscular spasm and relieving pain. Here it must be used very gently and be limited to stroking and light friction for short periods three or four times a dav. 5. Probably massage promotes the absorption of recently formed adhesions provided they are not too extensive and firm. This is a matter of considerable interest. Just as provisional callus, formed in the repair of fractures, is absorbed, so is the new connective tissue which is developed after injury of the soft parts. Perhaps the most obvious instance of this is met with in the case of adhesions following peritonitis Often even extensive adhesions gradually yet completely disappear, probably as the result of constant disturbance and traction during peristalsis. Much the same result is produced by what may be termed the interstitial disturbance and traction which take place during the different movements employed in massage. As to movements these are of three kinds : those performed under an in
a
over
anaesthetic, passive movements, and voluntary movements on the part of the patient often carried out against resistance. As to movements under an anaesthetic they can be safely applied only when a careful diagnosis has been made. In the first place it must be ascertained that the joint itself is not, nor has been, actively diseased, so that it has undergone no considerable structural changes such as follow tubercle, or locomotor ataxia. The or osteo-arthritis, septicaemia, cases in which this form of movement is most successful are those in which the joint itself is practically healthy while it is hampered by changes in the parts around. Passive movements are chiefly useful in restoring movements that have been lost, or in preventing stiffness in joints which a healthy ankleare to be long disused-for instance, the patient having disease of the hip or the knee. Voluntary movements on the part of the patient, especially when performed against resistance, are in many instances more valuable than massage. Several forms of apparatus have been introduced for use in these movements and many of them are very satisfactory. In all cases, however, efficient supervision must be maintained. Diagnosis is, of course, of essential importance. It cannot always be exact, but it must be carried far enough to indicate that the case belongs to the general class in which these agents are useful and that no element is present which renders them unsuitable. The conditions for which massage and movements are most useful are sprains and contusions of previously healthy joints unattended with any serious complication, such as dislocation or fracture, any wide laceration of muscle, rupture or displacement of tendons, or such pre-existent conditions as tubercle, gout, or hfemophilia. The treatment of recent fractures by massage was so fully discussed at the meeting last year at Ipswich that it is needless to consider it now. The after-treatment of dislocations has of late years undergone a great and very advantageous change. In the case, e.g., of the shoulder the arm is no longer bandaged to the side for a fortnight or three weeks, but passive movements and massage are regularly used after the second or third day. He had seen a patient thus treated able to move his arm freely in every direction in the course of three weeks. He had also seen a patient walk freely and without lameness three weeks after The chief the reduction of a dislocation of the hip. symptoms which indicate the use of massage and movements are stiffness and pain ; but before they are employed the cause of the symptoms must be ascertained as to whether the mischief is inside or around the joints. Take the shoulder. The arm may be stiff and there may be severe pain and marked muscular wasting. Is this a case of disease of the joint itself or of adhesions outside ? There is, he believed, only one test to be relied on to determine this question. This is to ascertain whether the joint is as stiff as it at first sight appears to be, or whether, within certain limits, movements are free and smooth. If these free and smooth movements-limited though they be-are present the fact is a strong indication that the joint is sound and that the symptoms depend on adhesions. (Cases in illustration were related.) As to pain, it is very important to remember that it cannot be used to differentiate between real joint disease and surrounding adhesions. Indeed, in many cases pain due to adhesions is more severe than that produced by joint disease. Muscular wasting-a principal symptom in disease of a joint-may be present
surrounding
permanent and the THE
BRITISH MEDICAL ASSOCIATION. MEETING AT CHELTENHAM.
THE SECTIONS. MEDICINE.
FRIDAY, AUGUST 2ND. THE
closing meeting of
the section commenced with the
by Dr. EDOUARD Ris2 (Paris) on reading Tlae Bteteriology of Fœtid and Ganyrenous Suppuration. of
a
paper
He said that in diseases where foetorwas present, such as appendicitis, mastoiditis accompanied by crackling cedema, and in
of empyema, if the pus
treatment harmless.
In addition to its
cholagogue and intestinal antiseptic calomel was the most powerful and harmless of diuretics. As adjuvants to the calomel treatment he employed hot water and quinine when use as a
place.
After describing his treatdefervescence had taken ment of cholera infantum and post-partum inflammation by the same means Dr. Riviere concluded : "All diseases can be referred to one cause-intoxication, and, above all, autointoxication, which in my opinion depends directly on the disturbance and deficiency of the hepatic function. The microbe only enters the lists when the machine is foul and choked because it has not been washed out in time." The PRESIDENT (Dr. E. T. WILSON, Cheltenham) and others discussed the paper. Mr. CHISHOLM WILLIAMS (London) read a paper on
The Treatment of P7tt7tisis
by Means of Electrical Currents of
High Frequency and Potential.
examined under the be made Treatment by these means had given such striking results in out. The polymorphism of this assemblage of micro- his hands that lie wished to summarise his results in 43 cases. These were all of over a year’s duration. The organisms was very marked, yet after preparing culture- difference between the currents obtained by an ordinarv tubes from the same pus, though a luxuriant growth would of Ruhmkorff and that Tesla was that in the latter the coil occur, yet on microscopical examination only a few common forms of bacteria would generally be found. It was not alternations were infinite and the electro-motor force was high. Thus in the former they might have likely that these common forms were the active agents proportionally in producing foetid inflammation, gaseous phlegmon, or dis- alternations of 200 per second and electro-motor forces from crete gangrene in the lungs. It had occurred to Dr. Rist that 10,000 to 20,000 volts, while in the latter alternations of the reason why the rarer forms of bacillus would not grow 1,000,000 per second and the electro-motor force from 100,000 was that the conditions of culture did not suit them. Dr. to 1,000,000 volts. In using these he found general electrifiVeillon of Paris had devised a simple method of anaerobic cation better than local and a combination better still. Under culture free from the difliculties of the hydrogen and this treatment the temperature first rose and then fell and other methods. Diluted pus was mixed with liquid progress could be gauged by noting if the reactionary rise could longer be induced. If it could not be sugared agar and with this tubes were filled to a induced any even prolonged exposure to the currents the by The of about four and a inches. was half height agar then solidified by placing the tubes in cold water. Under patient might be considered well. Cough was relieved, these circumstances all the microbes except those occupying sputum was lessened., and bacilli were reduced in numbers the upper superficial layer of the culture medium were grow- and dwarfed in shape. He did not think they were killed by the current. subsided and the ing under anaerobic conditions. A profuse growth generally increased. Mr. Sweating Osler as saying that 95 per Williams quoted occurred and on examining specimens taken from the lower cent. of patients were unable to afford any treatment away of the tube were found to be layers very many organisms from their own homes. By this method they could all be growing, and Dr. Rist gave a long list of names of the bacilli treated by their own medical man. Of his 43 cases 42 which had been isolated and described by himself and his on weight and lost all symptoms except in a few put colleagues, some being new t science. He hoped that in other hands the method might lead to the further elucidation where a slight cough remained, and a few bacilli might be found occasionally. of the nature of the so-called anaerobic bacilli. Dr. J. RIVIERE said that he had been using high frequency Dr. H. J. CAMPBELL (Bradford) asked if the pneumocurrents for more than five years and had had good results coccus of Fraenkel could cause suppuration, as he thought with them. He used even more powerful ones than did Mr. it had done so in one of his own cases. Dr. RIST, in reply, said that it could do so, but that in his Williams. Dr. D. J. A. CHOWRY-MUTHU (Isle of Wight) read a opinion, if foetor were well marked, they ought to be able to find the anaerobic organisms he had been describing, which paper on The Diagnostic Value of Bacilli in Relation to Phthisis. he considered were the true cause of such conditions and not the bacillus coli communis. He related six cases as illustrating this subject. They all Dr. McPHEDRAN (Toronto) and Dr. WILLIAM GOLDER presented the clinical appearance of phthisis, but in none of communicated a paper on them could the bacillus tuberculosis be demonstrated in the A Case of lndigouria. sputum. They all recovered and were found out to be really The condition was merely a clinical curiosity. A male cases of chronic pneumonia, syphilitic disease of the lung, chronic bronchitis, &c., and one case appeared to be mycotic patient, aged 24 years, consulted him for general malaise and tired feelings. No objective signs were discovered, but he bronchitis, a large quantity of muco-purulent matter being He rementioned that his urine was of a blue colour. On a speci- expectorated which contained mycelial threads. cognised the difficulty of demonstrating the bacilli in some men being passed it had the characteristic bluish-green colour of indigo. Its specific gravity was 1029. It con- cases, but thought that if after thorough search they were tained no albumin or sugar. On microscopical examination found to be absent they might provisionally pronounce the the pigment could be seen in small blue granules. Dr. case to be non-tuberculous. Dr. F. W. FoRBES Ross (London) thought.that the severity McPhedran made some remarks on previously published of cases of phthisis could not be determined by the number of ,cases and said that the cause of the condition was quite bacilli present in the sputum. In some cases which, from unknown. the point of view of symptoms, had been stationary for years Dr. J. RIVIÈRE (Paris) read a paper on bacilli were very abundant. The Abortive and Curative Treatment of Acute Alimentary Mr. GRIFFITH C. WILKIN (Yeovil) read a paper on Diseases, and particularly Ente?’ic Fever and AppendiRheumatic Endocarditis. citis, by a Judicious Use of Calomel, Water, He related a case of this affection in which the patient was Ifeat, and Quinine. The motto of the paper was, "As the microbe so is man extraordinarily susceptible to the influence of three drugskilled by his own toxins and refuse." Starting from this morphia, quinine, and nux vomica-given at separate times. thesis Dr. Riviere contended that the best way to treat One and a half minims of injectio morphinag hypodermica, diseases such as those mentioned, which interfered with the B.P., were given for joint pain in the early stages of the proper excretion of refuse matters, was to administer such a disease. The patient became comatose and was only saved drug as calomel. His practice was to give five grains each from death by large doses of atropine and electricity energetiof calomel and sodium bicarbonate placed directly on cally administered. She shortly afterwards had pneumonia the tongue at midnight, followed next morning by and then left hemiplegia from embolism. Quinine was given castor oil beaten up with hot water or eight grammes of but caused intense headache. When she began to recover magnesia. Such treatment seldom failed to reduce fever small doses of tinctura nucis vomicse, B. P. (five minims), were and he thought that in many cases the reduction was given three times a day. These caused after a week rigidity some cases
was
microscope very many bacillary forms could easily
body-weight
’
545 which only stopped when the nux vomica was discontinued. Dr. H. J. CAMPBELL (Bradford) read a paper on The Treatment of Cardio-arterial Disease. arterio-sclerosis caused a disturbance of circulation Diffuse and nutrition which was temporarily compensated for by cardiac hypertrophy. After a time, however, when this had reached its maximum, continued high arterial tension was likely to lead to post-hypertrophic degeneration of the cardiac muscle. A correct appreciation of the degree of this tension was desirable, and Dr. Campbell was accustomed to use Hill and Barnard’s sphygmometer for that purpose and considered that it answeredvery well. It did not indeed record very well the extreme degrees of high pressure, but that was of little moment so long as they recognised that the high routine treatment in these pressure existed. He cases, but thought that each should be considered on its own merits. Harm might be done in one by treatment which would be quite appropriate in others. If kidney sclerosis In were also present it additionally complicated matters. this case he was accustomed to rely on an exclusive diet of milk and large doses of sodium iodide. and
opisthotonos,
deprecated
Dr. FORBES Ross read a paper on the Treatment of Tuberculosis by Meat Albumin, which will be found at
p. 523. Mr. STUART-Low (London) read an unannounced paper the Use of Mucin in Diseases of the Alimentary Tract, and Dr. J. HADDON (Hawick) one on a Change of Life in Men as well as in Women. Owing to the room allotted to this section having been changed on each day it was very poorly attended on the last day, members not being able to find it. ,on
SURGERY. Mr.
FRIDAY, AUGUST 2ND. HOWARD MARSH (surgeon to St. Bartholomew’s
Hospital, London) opened a discussion on Injuries of Joints, with Special Reference to their Inamediccte and Remote Treatment by Massage and Movement. This subject, he said, was very suitable for discussion at such a meeting as the present. Both massage and movements have long been employed in English surgery, but lately they ’have come into much more general use. Both are valuable "remedies, but if used as a matter of routine both may do great harm. As methods of surgical treatment they must be closely supervised, care being taken to watch their effect, and especially to be sure that no element is present in the case which renders their employment undesirable. It is necessary to have a clear idea as to what has ’been termed the -physiology of massage "-as to the different ways, i.e., in which it acts. 1. It enlarges the amount of blood circulating through the part concerned. This is obviously apparent in the skin, which instead of remaining cold and pale becomes warm, and ’more or less red. The same result was experimentally demonstrated in regard to the muscles by Brunton and Tunnicliffe who showed that the amount of blood passing through them both during massage and after its cessation was increased. This increase of blood is in It maintains or improves the - every way advantageous. nutrition of all the various tissues ; it promotes the restoration of the functional activity of injured muscles, and it plays an important part in the absorption of lymph and ’extravasated blood. 2. Its action is mechanical. By kneading and percussion extravasated blood and lymph which have coagulated in the tissues and led to brawny oedema are broken up ,and dislodged, while by stroking from below upwards they are swept onwards and brought within the reach of healthy lymphatics and a normal venous circulation, so that they can more readily be absorbed. 3. It - is an efficient stimulant to damaged muscles through its influence on the nervous system. In such minor injuries as sprains and contusions probably the small nerves ramifying in the injured part are seldom torn across, for they are tough -rather than brittle, they are well protected in the subcutaneous tissue and the deeper structures, and their course is often tortuous so that they are not easily put on the stretch. Nevertheless, they are not infrequently so far injured that their functions, for the time being, are more or less suspended, and massage is then a very useful agent in stimulating them to a resumption of activity. It probably acts
always
similar manner on the vaso-motor nerves which preside 4. No one who has the arterial system of the part. watched its sedative effect when applied in cases of recent injury can doubt the influence of massage in reducing muscular spasm and relieving pain. Here it must be used very gently and be limited to stroking and light friction for short periods three or four times a dav. 5. Probably massage promotes the absorption of recently formed adhesions provided they are not too extensive and firm. This is a matter of considerable interest. Just as provisional callus, formed in the repair of fractures, is absorbed, so is the new connective tissue which is developed after injury of the soft parts. Perhaps the most obvious instance of this is met with in the case of adhesions following peritonitis Often even extensive adhesions gradually yet completely disappear, probably as the result of constant disturbance and traction during peristalsis. Much the same result is produced by what may be termed the interstitial disturbance and traction which take place during the different movements employed in massage. As to movements these are of three kinds : those performed under an in
a
over
anaesthetic, passive movements, and voluntary movements on the part of the patient often carried out against resistance. As to movements under an anaesthetic they can be safely applied only when a careful diagnosis has been made. In the first place it must be ascertained that the joint itself is not, nor has been, actively diseased, so that it has undergone no considerable structural changes such as follow tubercle, or locomotor ataxia. The or osteo-arthritis, septicaemia, cases in which this form of movement is most successful are those in which the joint itself is practically healthy while it is hampered by changes in the parts around. Passive movements are chiefly useful in restoring movements that have been lost, or in preventing stiffness in joints which a healthy ankleare to be long disused-for instance, the patient having disease of the hip or the knee. Voluntary movements on the part of the patient, especially when performed against resistance, are in many instances more valuable than massage. Several forms of apparatus have been introduced for use in these movements and many of them are very satisfactory. In all cases, however, efficient supervision must be maintained. Diagnosis is, of course, of essential importance. It cannot always be exact, but it must be carried far enough to indicate that the case belongs to the general class in which these agents are useful and that no element is present which renders them unsuitable. The conditions for which massage and movements are most useful are sprains and contusions of previously healthy joints unattended with any serious complication, such as dislocation or fracture, any wide laceration of muscle, rupture or displacement of tendons, or such pre-existent conditions as tubercle, gout, or hfemophilia. The treatment of recent fractures by massage was so fully discussed at the meeting last year at Ipswich that it is needless to consider it now. The after-treatment of dislocations has of late years undergone a great and very advantageous change. In the case, e.g., of the shoulder the arm is no longer bandaged to the side for a fortnight or three weeks, but passive movements and massage are regularly used after the second or third day. He had seen a patient thus treated able to move his arm freely in every direction in the course of three weeks. He had also seen a patient walk freely and without lameness three weeks after The chief the reduction of a dislocation of the hip. symptoms which indicate the use of massage and movements are stiffness and pain ; but before they are employed the cause of the symptoms must be ascertained as to whether the mischief is inside or around the joints. Take the shoulder. The arm may be stiff and there may be severe pain and marked muscular wasting. Is this a case of disease of the joint itself or of adhesions outside ? There is, he believed, only one test to be relied on to determine this question. This is to ascertain whether the joint is as stiff as it at first sight appears to be, or whether, within certain limits, movements are free and smooth. If these free and smooth movements-limited though they be-are present the fact is a strong indication that the joint is sound and that the symptoms depend on adhesions. (Cases in illustration were related.) As to pain, it is very important to remember that it cannot be used to differentiate between real joint disease and surrounding adhesions. Indeed, in many cases pain due to adhesions is more severe than that produced by joint disease. Muscular wasting-a principal symptom in disease of a joint-may be present
surrounding