in opening the bladder by the suprapubic method because of its contraction and retraction.

Dr. A. M. Vance: In connection with the cases narrated by Dr. McMurtry I would like to relate the following: The patient is a young lady who has been suffering with frequent micturition for ten years. She has been treated all along the lines. There has never been any sign or evidence in the urine of inflammatory trouble, as I understand it. She is about twenty-eight years of age, and the history is that she has been compelled to empty her bladder every hour or less for ten years. She went to St. Louis, Missouri, some time ago and placed her self under the care of a distinguished specialist in genito-urinary surgery and gynecology. After a thorough examination of the bladder he found nothing indicating inflammatory trouble or indeed any cause for the bladder symptoms with which she suffered, and thought he found the cause in a displaced left ovary, which he removed, without any benefit whatsoever. She went back to her home in the interior of this State, and as she did not improve she returned to the St. Louis surgeon, and after making another examination he found that the cause of her trouble was in a movable kidney on the left side which he had overlooked at his former examination; this was fixed to the muscles without any benefit whatever. benefit whatever. He then told her that the right kidney was also movable and he would subsequently fix that, but she did not go back. The patient next came to Louisville and had her sphincter ani muscle dilated, as was also the urethral sphincter. I saw her three days after this operation in consultation, and I then obtained the history which has been given you. I asked the patient how the difficulty with the bladder commenced, whether she had ever sustained an injury which could possibly have any connection with the present trouble, whether the bladder symptoms were primary or whether they followed some other condition. She said she remembered, about ten years ago, while on roller skates she sat down very hard upon the floor in a fall, which was followed by considerable pain, and it was from this time that the bladder trouble began. I asked to be allowed to make a thorough examination. The dilatation of the sphincter ani muscle had been done so recently that I could not determine whether the tenderness about the region of the coccyx was due to that cause, or due to the fall ten years before.

The patient went home, and as she was no better at the end of three weeks she came back. Exquisite tenderness was still present about

the coccyx, and I believed her whole trouble came from this. The parts were so tender that a complete examination could not be made without a general anesthetic, but I thought in addition to the tenderness that the coccyx was extremely movable. I proposed that the coccyx be removed, which was done two weeks ago.

This girl is not hysterical, and I believe her bladder symptoms were of a reflex character, and that the original trouble was the result of the severe fall she sustained, as the coccyx since that time has always been movable to a greater degree than natural and has always been exquisitely tender. She now goes much longer without having to void her urine, and it has only been two weeks since the operation. She rests better at night. I believe she is going to get well.

She had general systemic treatment, tonics, etc., after fixation of the left kidney, and gained considerably in flesh. I could not find any mobility of the right kidney, and advised against its being interfered with. The only thing I could find in a careful investigation of the case was the tenderness about the coccyx, it was bent forward into the bowel, and was so tender that she could not bear the pressure incident to defecation. I removed the coccyx through a very small opening. I was taught that it required a very bloody operation to remove the coccyx, that you had to make a large wound, cutting many blood-vessels, and that the dissection was a difficult matter. It has been my practice to take out the coccyx through a very small opening-about half an inch. In this case, however, I made about an inch incision. I first cut down and divided the base, then lifted out the base of the coccyx with a strong volsellum forceps, dissecting from the base to the tip without enlarging the incision. There is only one difficulty about this small incision, and that is to close up the dead space through such a small wound, but I believe if we have a little seepage of bloody serum it is better than making a large wound. With the incision I have mentioned it only requires one suture; you raise the rectum up and in this way destroy the dead space to a large extent.

I believe this is a very common trouble in young women. I recog: nize that frequent micturition in women is usually hysterical, but this woman does not appear to be an hysterical subject.

Discussion. Dr. L. S. McMurtry: The subject presented by Dr. Vance is an extremely interesting one. The case he has narrated is especially interesting, because it seems that he has made a solution of

I have

the problem, and that he is going to cure this young woman. seen a large number of cases of nervous bladder; they are most intractable cases to treat; they usually have been the rounds, and extensive treatment of the bladder has been practiced. The majority of cases like he has described belong to the neuroses; but the history of the case as he gives it is not a typical one of neurosis, because they nearly all improve for a time after any operation. The history in his case is that after none of the previous operations was there any improvement whatsoever in the symptoms, but since the operation he performed there has been marked improvement. These cases of irritable bladder in neurotic women are exceedingly troublesome.

I would like to ask Dr. Vance, as I know he has had considerable experience with these cases, and has kept up with the literature of the subject in a general way, whether the operation for removal of the coccyx has not very much diminished in surgical favor. It used to be a very common operation.

Dr. A. M. Vance: I have had possibly ten cases of the coccyx operation in my whole surgical experience. In all the cases there was a history of injury, usually with active pain upon sitting down, especially on an irregular surface. In all the cases in which I have performed the operation there was complete relief from all the symptoms. I have never seen a case where there seemed to be any disease of the coccyx proper; there is nearly always increased mobility of the coccyx, great tenderness and pain, always preceded by an injury. I have operated perhaps ten times under such circumstances, and only once have I operated upon a man. JOHN MASON WILLIAMS, M. D., Secretary.

Foreign Correspondence.

LONDON LETTER.

[FROM OUR SPECIAL CORRESPONDENT.]

Meat and Milk and Tuberculosis; Payment of Coroners' Juries; The New Medical Register; Epileptic Colonies; Oysters and Typhoid; Ambulance Work on Railways; Critical Position of the London Hospital.

The long-expected report of the Royal Commission appointed to inquire into the administrative procedures for controlling dangers to man through the use as food of the meat and milk of tuberculous animals has been

laid on the table of the House of Commons. The Commissioners conclude their report with a series of important practical recommendations. They suggest that machinery should be provided by the Local Government Board for the examination of milk imported from abroad at the port of landing, that the sale should be prohibited of meat that has not been killed in a duly licensed slaughter-house; that the Local Government Board should require local authorities to enforce regulations as to dairies and cowsheds where they are not enforced already, and that meat inspectors should be subjected to an examination prescribed by the Local Government Board.

The whole of the London coroners, with the exception of the city of London's, have commenced a system of payment to jurymen. The county council have fixed the amount at two shillings per head for fifteen jurymen, but, as it is usual to summon more than that number, in certain instances some difficulty may be experienced. The fee is not to be paid to those attending as substitutes, or those summoned from the street in cases of emergency. The amount of recompense to jurors in the city coroner's court is fourpence a head for seventeen "good men and true.”

The medical profession in Britain is not, it appears, increasing at the rate it was thought to be. The total number of names on the just-issued Medical Register is 34,642, an increase of only 164 on the year. The Dental Register shows the fact that the number of qualified dentists is augmenting and the number of unqualified men decreasing. There are 4,937 dentists registered for the present year, and of these 1,614 are licentiates in dental surgery, an increase of ninety-five on the year.

At the recent meeting of the Harveian Society of London Dr. Aldren Turner read an interesting paper upon the treatment of epilepsy in epileptic colonies, more particularly mentioning the arrangements at the epileptic colony at Chalfont St. Peters, Bucks. This institution was inaugurated for the purpose of giving employment to those epileptics, of both sexes, who, on account of their disease, were unable to obtain work, or who had lost good employment on account of epilepsy. The farm colony has been working for about four years, and it has been conclusively shown that the younger the epileptic and the sooner the treatment is initated after the commencement of the seizures, the more chance there is of improvement as the result of the general management and regime under which each inmate is placed. At Chalfont St. Peters the following simple principles are enforced: (a) Removal of the sufferer from town to country; (b) regular directed employment; (c) the maintenance of a well-ordered and regular mode of life, particularly the avoidance of all excitement and alcoholic liquors; (d) abundance of good but simple nourishment. Under treatment in many cases most gratifying results were obtained, the fits diminishing to an extraordinary extent both in number and severity. Dr. Turner considered it most important that all epileptics should be deprived of alcoholic drinks. A deputation concerning the dangers from eating contaminated oysters and other shell fish has attended the Local Government Board.

A

memorial on the subject was signed on behalf of many corporations, including those of Brighton, Liverpool, Cardiff, Bradford, Nottingham, and Newcastle on Tyne. It was pointed out that a large proportion of cases of typhoid fever resulted from consuming sewage contaminated oysters, or other shell fish in an unwholesome condition, the oyster beds being too often situated close to sewage outfalls, and the contaminated oysters being sold without restriction to the prejudice of the trade and the injury of the public health. The chairman of the Board said he thought the time had arrived when legislative action ought to be taken, so far at least as concerned oysters, and he hoped soon to introduce a bill into Parliament on the subject.

Dr. Manson, lecturer on Tropical Medicine in the Medical School of St. George's Hospital, will next month commence a course of lectures on Diseases of Tropical Climates. The lectures are especially intended for medical men about to practice in the tropics or in Eastern Asia.

The Great Northern Railway Company's chief officers have recently presented a challenge cup to be competed for annually by the ambulance men in the employ of the company. A series of competitions having taken place on various parts of the system, the King's Cross London team was adjudged the winner, three other teams were also awarded prizes.

The largest hospital in London is reported to be in a serious financial condition. The London Hospital last year treated over 11,000 patients. It is the only general hospital for the whole of East London, which means for a million and a half of people. Legacies have fallen off, and in order to pay their way the authorities have had to sell no less than £30,000 of their investments within the last two years. The necessary alterations imposed as a condition of the grant from the Prince of Wales' Fund will necessitate the sale of further investments to the value of £80,000 to £100,000. Every year it appears the sum of £70,000 is required in order to carry on the institution, which means that £10,000 a year should be received in addition to its present income.

Sir Dyce Duckworth, M. D., in addressing the members of the Chemists' Assistants Association, said that year by year the relations of doctor and chemist were growing closer and closer, and this was to be attributed, he alleged, to the advance in pharmaceutical education. He mentioned as a regrettable incident the marked tendency to adopt the tabloid form of prescription to the detriment of ordinary drugs and more general prescribing, a defect due, he supposed to deficient training in pharmacy.

A religious journal has the following advertisement, which is probably a new departure, "Lady leaving England permanently, must sell family grave, hold five."

LONDON, April, 1898.