charged, apparently cured, in 1898 and 1899, thirty-one were in good health after the lapse of five years. The cured patients are living and working in all parts of Canada and the United States. In the following table is shown the mortality in Ontario from consumption since 1897, the year in which such statistics were first available. In corresponding columns the growth of the Association work is noted. There can be no doubt but that the lowered death rate is due, to a great extent, to the wide-spread influence of the sanatorium work, and the fact that these 1,500 patients have gone back to their homes full of the knowledge of the causation and prevention of the disease. ADMINISTRATION BUILDING, MUSKOKA FREE HOSPITAL FOR CONSUMPTIVES. It is to be noted that at the time the Association was beginning its work the death rate from tuberculosis was steadily increasing. 1896 None available 1897 3,154 1.4 1898 3,291 1.5 1899 3,405 1.5 1900 3,484 1.6 1901 3,243 1.4 1902 National Sanitarium Association formed. Beds increased to 50. 156 patients treated to date. 443 patients treated to date. Beds increased to 60. 723 patients treated to date. Free Hospital for Consumptives opened with 75 beds. 938 patients treated to date. M.C.S. beds increased to 70. 1,262 patients treated to date. 1,587 patients treated to date. For the care of the consumptive poor in the far advanced stages there has been recently opened the Toronto Free Hospital for Consumptive Poor, near Weston, with forty beds. This, with the work of the National Sanitarium Association at Gravenhurst, provides 185 beds for consumptives in Ontario, 115 of which are for the poor, or those able to pay only a small sum towards their maintenance. A CASE OF MULTIPLE SEBACEOUS CYSTS. BY ALEXANDER MCPHEDRAN, M.B., TORONTO. THE following case presented such a vast number of sebaceous cysts that it is an extremely rare, if not an unprecedented, one. There are a few cases on record in which the.e were from 132 to 250 tumois present,* and Chiari reports one in which several hundreds were scattered over the general surface.† The number of cysts in the following case probably far exceeds even that of Chiari's: On A. D., aged twenty-five, a healthy man without anything of moment in either his family or personal history. His skin affection was first noticed during adolescence, no attention, however, being paid to it for some years. It developed gradually and attracted attention through the occurrence of acne and the formation of large pustules, which occurred with increasing frequency. The illustrations show the wide distribution of the lesions, but convey a very inadequate idea of their number, as the great majority of them were too small to show in the photograph, or even to be noticeable to the eye. They could be felt as nodules beneath the skin, varying in size, the smallest being barely palpable, and the largest fully two centimetres in diameter. the body they were so numerous and closely set that the point of the finger could scarcely be placed on the trunk without touching one or more. Over the larger ones the skin was usually closely adherent, to some only loosely. The small nodules were, as a rule, deeply placed and only attached to the superjacent skin by an ill-defined strand of fibrous tissue, doubtless the obliterated duct. The contents of the smaller and of many of the large nodules consisted of thick, sebaceous material that exuded in a white, ribbon-like form through the linear puncture made with a bistoury. In some of the larger nodules the contents were partly sebaceous and partly a yellow oil; in a few they consisted wholly of oil. None of the cysts were pedunculated, but as they grew large, one here and there of the older ones became inflamed. The exudate into the periphery soon became purulent, and in a short time destroyed the capsule of the cyst, converting the whole into a bleb of pus in which the sebaceous contents became liquefied. The wall of the bleb usually sloughed, leaving a large, ulcerated surface, which healed with a broad, deep scar. Jamieson, Edinburgh Med. Journal, Sept., 1875, p. 223. Maclaren, Edinburgh Med.Chir. Soc'y Trans., 1888, p. 77. Politzer, Jour. Cutan, and G.-U. Diseases, 1891, p. 281. + Chiari, Zeitschrift fur Heilkunde, 1891, Vol. xii. p. 189. As the cysts were so numerous, an attempt to dissect them out seemed futile, so each day a number of the larger cysts were freely incised, the contents pressed out, and, if possible, the cavity curetted, or swabbed out with carbolic acid. This was a painful process, and, consequently, only a few cysts could be treated at one time. In not a few the treatment was unsuccessful, and required to be repeated. At the same time the acne was vigorously treated, and the general surface thoroughly cleansed daily to lessen the liability to infection of the glands and cysts, and it was rubbed to stimulate the circulation so as to improve the nutrition of the skin. After two months' stay in the hospital he left very much improved, but still with a great number of small cysts. Whether fresh cysts were forming is uncertain; many small ones grew large under observation, and some were allowed to suppurate in order to observe their natural course. The acne was greatly improved by the treatment, the comedones became much fewer and the skin much healthier in appearance. He has not been seen since. With the improvement in the general condition of the skin it is probable that the formation of new cysts would be much lessened, if not quite arrested. The number of cysts was so very great that a cure seemed almost hopeless: at least, it would require the utmost patience on the part of both physician and patient. Of course, much scarring will result. (Figs. 1, 2) The photographs, especially that of the back, show many sloughing cysts, a large one being at the upper end of the anal fissure. The axillary cysts are very large. (Fig. 3.) Medicine. ... IN CHARGE OF... J. J. CASSIDY, M.D., AND W. J. WILSON, M.D. ACUTE MENINGITIS. BY W. T. COUNCILMAN, M.D., BOSTON. By the term meningitis is understood inflammation of the pia arachnoid, the investing membrane of the brain and spinal cord Considered as a single membrane, it consists of a serous surface (arachnoid) forming one side of the subdural space and beneath this a loose connective tissue, the pia mater, which carries the blood vessels for the brain and cord. The brain, covered by this mem— brane, projects into the subdural space as the heart projects into the pericardial cavity. In addition to the vessels, there are numer— ous lymphatics, which are situated in the adventitial sheaths of the veins and arteries and which are continued with these vessels into the brain. They are true lymphatic vessels with an endothelial lining; they are thin-walled, and, when distended, communicate freely with the tissue spaces. There are no lymphatics in the tissue of the brain itself, nor have lymph spaces, similar to the spaces in other tissues, been demonstrated. The adventitial lymphatics are not continued into the capillary walls. Between the capillaries and the walls of the channels in which they run there are spaces, easily distended, which are in relation with the closely-woven web of the nervous tissue, allowing a free interchange of fluid. Such fluid easily finds its way into the adventitial lymphatics. The relation, by means of blood vessels and lymphatics, between the nervous tissue and the investing membrane is so close that infectious processes in one extend into the other. Strictly speaking, all cases of meningitis deserve the term meningo-encephalitis. The lymphatics of the membrane communicate with the general lymphatic system of the body by means of the lymphatics along the nerves and great vessels. The pia arachnoid, in the form of the choroid plexus, passes into the ventricles of the brain, and the intra-ventricular fluid finds its way into the interspaces of the membrane through the foramen of Magendie. The deep cervical lymph nodes belong to the membrane. The pia arachnoid contains the few connective tissue cells of the fibrous tissue, the cells of the blood and lymphatic vessels, and a variable number of lymphoid cells. There are various ways by which infectious agents can gain access to this tissue. They may enter it by means of the blood or by the extension of infectious processes from adjacent regions. The |