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tthe tendon, as is generally supposed; but to regulate thelength of new material, or, as it may be called, the newtendon, whilst we have the opportunity of so doing, andthe rate at which this is to be accomplished must havereference to the activity of the reparative process, and to<the length of new tendon required. In the Achilles tendonthis can be easily observed, and I always examine it care-fully twice a week. In well-nourished infants the full lengthrequired in the divided Achilles tendon should, accordingto my observation, be obtained in a fortnight, if prac.ticable; in a well-nourished leg in an adult it should beobtained in from three to four weeks; but in atrophiedparalytic limbs it should not be obtained in less than fromwur to six weeks. The extension described as rapid-i.e.,gaining the length required at intervals of a week-is morerational, the foot being put up either in a plaster-of-Parisbandage or any immovable splint, but I prefer the gradual.extension by means of a Scarpa’s shoe with rack-and-pinion,movements, which can be regulated as required.

In contractions of the knee- and hip-joints the extension.can often be made satisfactorily by means of the ordinaryweight extension apparatus. With regard to the thirdprinciple of treatment - ie., by physiological means topromote the restoration of muscular power,-there can beno doubt that the improved system of massage, now soably taught in some schools of instruction, and by professorswho have established this system upon a scientific basis, is’ef the utmost value; and in many cases this may be stillfurther assisted by a well-regulated course of galvanictreatment. In reference to the fourth principle of treat-ment&mdash;viz., the employment of mechanical supports, so

constructed as to compensate for the more or less com-plete paralysis of certain muscles, which in severe cases

eften remain as a permanent defect, there can be no doubt.as to the necessity of employing such mechanical assist-ance, and the instruments now in use are constructed- spon the most scientific principles, with various ingenious- contrivances adapted to the special requirements of each<ease, and a variety of these appliances I now exhibit toyou. There can be no doubt that by a combination ofthese different principles of treatment the results are nowobtained in the class of paralytic deformities which weretotally unknown to and not within the reach of our pre-decessors. Before leaving the subject of tenotomy and itsresults I would refer to one point which has long attractedmy attention-viz, the fact that after tenotomy in casesof paralysis in which the feet are always cold and cannotbe warmed by artificial means, a very marked increase oftemperature rapidly follows the operation of tenotomy,and the feet remain warm.The mother of a boy, aged twelve, upon whom I operated

<six weeks ago at 9 A.M.-dividing the Achilles tendonfor paralytic contraction of the foot,-told me that sheobserved an increase of temperature the same evening;and this has been maintained. Only yesterday I operatedupon the other foot, which was also paralysed and con-tracted, and a very marked difference in the temperature ofthe two feet was observable, the one about to be operated<apon having remained cold. It is of common occurrence atthe Orthopaedic Hospital for the mother of a child whichtad been recently operated upon for paralytic contractionto draw attention to the fact that the child’s foot becameand has remained warm since the operation, whilst she hadbeen unable to keep the foot warm by any extra clothingr other means before the operation. As to the explana-tion of this increase of temperature after tenotomy, itceemed to me that it might be due to a certain amount ofmuscular action taking place after the tendons of the con-tracted muscles had been divided. But Dr. Brown-Sequard,to whom I mentioned the occurrence of this event at thetime he was connected with this hospital as one of thephysicians, said that he believed it to be due to a directreflex action of the spinal cord, and that a local increase oftemperature probably followed all surgical operations, butit would be most observable in cases of paralysis.

In the surgical treatment of contractions occurring ic.eases of paralysis it is necessary to bear in mind that thesEare essentially of muscular origin, and are due either tcactive muscular contraction, or adapted shortening of aratrophic and passive character. There are no adhesions,’either intra-capsular or extra-capsular, in paralytic contractions, although the deep ligaments and bands of fascia ar(subject to adapted structural shortening. If there is an3law firmly established by long experience in the surgica

treatment of contracted joints in deformities due to

paralysis it is, never attempt to overcome muscular contra,c-tion by forcible extension. By gabcutaneous tenotomy wecan at once remove all, or nearly all, the muscular contrac-tion without the least possible risk, and gradual mechanicalextension will overcome the other obstacles. I wish moreespecially to draw your attention to this law, as I havefrequently seen cases in which serious injury has resultedfrom some failure to rocognise the importance of it,such as fracture of the femur, or separation of the lowerepiphysis in a case of knee-joint contraction ; laceration ofthe skin when this is in an atrophic condition, as in theso-called glossy skin occasionally met with in cases ofparalysis ; a liability to dislocation of the hip &c.

In addition to the contractions and deformities chieflyaffecting the lower extremities in paralytic cases which wehave been considering, there are other deformities affectingthe spine and the pelvis, as well as also the occasional dis-placement from ligamentous relaxation, and in some casesthe complete dislocation of the head of the femur on thedorsum ilii. These results occur only in one class of cases-viz., the most severe form of infantile paralysis, in whichboth legs, both arms, and the muscles of the trunk areaffected. The natural recovery in these cases is very slow,partial, and incomplete, the permanent defect remainingthrough life being considerable, and the complications ofsevere spinal curvature, pelvic tilting, and partial or com-plete luxation of the hip-joint seriously interfere with anyadvantage gained by surgical or mechanical treatment.

Clinical LectureON A

CASE OF CYST OF THE PANCREAS.Delivered at the London Hospital,

BY FREDERICK TREVES, F.R.C.S.,SURGEON TO AND LECTURER ON ANATOMY AT THE HOSPITAL.

GENTLEMEN,-I wish to draw your attention to the caseof a man now lying in No. 3 operation ward, who is aboutto leave the hospital convalescent. The case is of interestboth in so far as it illustrates the clinical features of a rareand remarkable disease and in so far as it emphasises thevalue of an exploratory incision in a certain form ofabdominal affection. Briefly, it may be said that the manwas the subject of an enormous pancreatic cyst, that thedisease was not only not diagnosed, but was not even sus-pected before the operation, and that the patient has madea good recovery. The rarity of the affection may be illus-trated by the fact that, so far as I can discover, a record ofno similar case is to be found in the surgical registers of thehospital, and, so far as I know, no other operation upon acyst of the pancreas has been performed in this country.l

, The patient, a railway foreman, aged forty, was admittedinto the hospital on July llth, 1888.2 He had beenpreviously under the care of Dr. John Cotman. and hadbeen seen also bv my colleague, Dr. Stephen Mackenzie.He was a well developed, vigorouq, and muscular man,leading a healthy and very active lite. He was stout, butnot coarse, and had always had exceptionally good health.There was nothing worthy of note in either his family orhis personal history. Seven or eight months ago lie noticeda throbbing sensation in the region of the umbilicus, whichwas perceptible only when he lay upon the abdomen, whichceased when he altered his position, and which gave himneither trouble nor anxiety. A little later than this henoticed that he became tired sooner than usual, and hadnow and then a dragging pain which started from the righttesticle and spread into the abdomen. He continued withhis work until within five weeks of his admission. He thensought Dr. Cotman’s advice on account of vague painsabout the abdomen. These pains were never severe, were

1 This statement is modified in the concluding paragraphs of thislecture.2 The publication of this lecture has been deferred until the final

state of the patient could be reported on.

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more or less constant, were located in the region of theumbilicus, and were always worse when he was in theupright position. lIe had noticed nothing else the matterwith his abdomen. Dr. Cotman at once discovered a medianswelling in the vicinity of the umbilicus. It appeared to hesmall, about the size of two large fists, was rounded, andfree from pulsation. Its characters could, however, be butin) perfectly made out owing to the thickness of the abdo-minal wall. The patient weighed 15 &t., and the measure-ment of the abdomen at the umbilicus was 42 in. The onlysymptoms complained of at this time were the feeble painsalready alluded to, a sense of fulness after every meal, sothat he had to loosen his clothes, a slight feeling of nauseanow and then, some lassitude, and considerable depressionof spirits. His appetite was good, his bowels regular, therewas neither ascites nor jaundice, the urine was normal, and,indeed, the patient exhibited no other morbid signs thanthose named. He had up to this time not lost weight.When I saw the patient shortly before his admission the

abdomen was of great size. No further symptoms of a pro-nounced character had, however, developed. The maincomplaint was of lassitude and debility, of great mental de-pression, of some abdominal pain about the umbilicus, and,above all, of a great sense of fulness after food. He had lostbut little in weight. He had some nausea, but had nevervomited. The bowels were regular, and the stools passedwere of perfectly normal appearance. There was no

jaundice. The urine was acid and clear, and now containedone-twelfth of albumen. Its specific gravity was 1015.Some undue frequencv of micturition had been noted duringthe last few days. There had been neither hiccough nordisturbance of respiration. The tongue was clean. Muchflatus was said to have been "passed upwards." The manappeared very weak, was the subject of much depressionand varied forebodings, and his movements exhibited theutmost lassitude. The aspect of his face was quite note-worthy. The eyes were a little sunken, and the expressionwas that of utter and hopeless melancholy. The complexionwas of a dirty-brown colour, not unlike fading sunburn.The tint, which was limited to the face and was uniformthere, attracted immediate attention. The pupils wereequal, were contracted almost to pinholes, but still actedto light. He spoke as a man would speak who is intenselydrowsy. As the patient was an active foreman in somelarge railway works, this mental change was striking. Hehad taken no narcotic of any kind. His pulse was 78 andof good volume. I ascribed the pigmentation of the face, andpossibly the contraction of the pupils, to pressure exercisedupon the region of the solar plexus. In the abdomen was atumour which, although quite median, was a little moreprominent on the left than on the right side. Its upper limitwas some three inches above the umbilicus, and below itreached to the pubes. It extended so far laterally as tooccupy nearly the whole of the front of the abdomen. Thearea indicated was quite dull on percussion. Both flankswere resonant, as were also both iliac fossce. There was noevidence of ascites. There was a resonant area between thetumour and the liver. Nothing abnormal could be felt perrectum, nor could the tumour be reached in that direction.To the hand the mass felt perfectly smooth and wellrounded ; it was firm and elastic, and exhibited no sense offluctuation; it was quite fixed. Respiratory movementshad no efl’ect upon it, and, while it could apparently bemoved a very little from side to side, it was quite immovablein the vertical direction. The whole abdominal wall wasvery tense; the skin was smooth and glistening, and markedby many wide linear albicantes. Below the umbilicus werea few distended veins visible beneath the integument. Thetumour was the seat of no pain, and rough manipulationelicited no tenderness. The patient was seen by Dr. StephenMackenzie. He did not consider the symptoms such aswould form the basis for a definite diagnosis. I inclined tothe belief that the tumour might be sarcomatous. Itsgrowth had been very rapid. It felt elastic; it did notfluctuate. Although the patient had wasted but little, thealteration in his appearance hardly suggested an innocentgrowth. The idea of a cyst was never entertained; themass appeared to be solid and heavy. I pointed out thedifficulties of the position to the man, and suggested anexploratory incision. I was so influenced by the Impressionthat the tumour was malignant that I could in no way urgethis step. It was rather the outcome of the patient’s in-tense anxiety that "something should be done."

"

Thisinstinct probably saved the man’s life.

The operation was performed on July 13th. Many of yomI will remember the circumstances of it. The abdomen was,, opened in the median line below the umbilicus. The tumour

was- at once exposed, and the fact that it was a very greatlydistended cyst became directly evident. Its outer surfacewas perfectly smooth and of a reddish-brown colour. There:were no adhesions of any kind. The cyst was quite median,in position, and nearly touched the symphysis pubis. Itevidently was placed beh&Iacute;1ul the peritoneum of the posteriorparietes. It was quite fixed. The reflections of the peri-toneum from the sides of the tumour on to the kidney andthe meso-colon were noted. The growth was in close con-tact with the spine, and this intimate association wasretained as low down as the fourth lumbar vertebra. The-small intestines were for the most part below the tumour,.and to the left. The omentum and transverse colon wereabove it. The stomach was also above it, and to the left.The cyst was punctured in the middle line, and a jet of fluid;was projected with great violence across the theatre. Thetenseness of the cyst was remarkable. The cavity was>

freely opened, and the margins of the cyst wall were attachedby fourteen sutures to the parietal wound. Two sutureswere introduced into the latter wound. A piece of drainage-tube one foot in length and with a diameter of one inch was.inserted. The interior of the cyst was perfectly smooth.Its wall was about 1,1.1 to 2 lines in thickness. On introduc,ing the hand the cyst was traced up to the region of thepancreas. Its upper boundary was transverse, and it was.closely attached to the spine and the aorta. ]Eighty-fiveounces of fluid were collected. Probably about a hundredounces escape<1 in all. The fluid was thick, opaque, and of &pound;a brownish-red colour. It was alkaline, and was shown tc.contain many b)ood-corpuscles, some albumen, but no bile-and no urea. Al;out a teacupful of brownish blood-clot wasremoved from the cyst after the fluid had escaped.The after.history of the patient calls for little comment.

The bowels were opened on the sixth day; the stitches.were removed in part on the seventh day and in part on the,tenth. A little morphia was given during the first forty-eight hours. No trace of albumen was discovered in theurme after the third day. The discharge was at first very- ’

copious, but soon became thin and pale, like mutton broth.It did not "digeat" the skin, nor did it, indeed, cause’

undue irritation of the integument. The most remarkable’feature during the period of convalescence was the state ofdrowsiness into which the patient passed. For nearly four-teen days he ronfuned strangely apathetic, and appeared tobe nearly always asleep. His condition resembled that of a"man who was under the influence of morphia-a Tesemblancesupported by the abiding contraction of the pupils. Thecyst cavity contracted rapidly. It suppurated, ami for some-weeks the temperature was high. The patient did notleave bis bed until nearly six weeks had elapsed, and he&deg;is now about to be discharged from the hospital, just twomonths after the operation. There is merely a sinus, intowhich a medium-sized drainage-tube is introduced to a:

depth of four inches. The man may now be said to be well. ’

Lrzter repoi,t.-Iii another month the sinus had entirelyclosed, so that three months were occupied in the obliterationof this great cyst. Twelve months after the operation thepatient callie to the hospital to show Iiimse]L He stated thathe was now as well as ever, and as well able to do his work.The face was no longer pigmented, and the pupils, although’still small, were no longer contracted. The abdominalwall bad yielded a little at the site of the wound, and tosupport it the patient wore an elastic belt. His digestioowas perfect and his bowels acted regularly. He had,indeed, no symptoms. No trace of the cyst could be felt-At the present date nearly two years have elapsed since’the operation was performed, and as the patient still remainsquite well, he may be considered as cured.With regard to the general features of cysts of the

pancreas, the most substantial contribution to our knov;’ledge of the subject has been provided by Dr. Senn inhis monograph in the American Journal of the MedicalSciences, July, 1885, and Jan., 1887. In this very ad -mirable paper examples of eleven cases treated by opera-tion are collected. Since 1887 a large number of cases

have been placed on record, and upon a study of these’the following general account of the features of the-disease may be based.The trouble would appear to be more frequently met with

in men than in women, and to be distinctly an affectionof middle life. The average age is about thirty-six. The-

657

youngest patient, so far as the recorded cases at presentstand, was sixteen, the oldest seventy-two. In the matterof etiology there is little to be said. In the majority ofcases the trouble, as in the present instance, appearedwithout apparent cause. In a few examples the cyst madeits appearance within a comparatively short time of thenreceipt of an injury. In one case at least the troubleseems to have followed an attack of " acute gastro-enteritis." In the majority of cases the symptoms, apart from the,appearance of the growth, have been almost negative. Thetumour has usually increased rapidly, and the chief com-

plaints have been of a painful sense of fulness after food, of.distension, of digestive disturbances, and possibly of nausea.Eructations are common, and the patients are usually- described as languid, feeble, or depressed. Emaciation to.any extent is seldom present ; vomiting is comparativelyyare. In Dr. Bull’s case there was h&aelig;morrhage from thestomach and bowel. The pain complained of has usually’been slight and of a vague neuralgic character. The appear-ance of the cyst has been preceded by periodic attacks ofpain or by a long-standing sense of discomfort in the- epigastrium. The bowels have in most of the examplesacted regularly. Diarrhoea is mentioned in many instances,but in no case do fatty stools appear to have been passed.Albumen or sugar in the urine is noted in not a fewexamples. There is no ascites, and, as a rule, no jaundice.’The skin is usually described as dusky, dirty, earthy, un-healthy looking, or yellowish. The tumour is round andtense. It is elastic and may not give a sense of fluctuation.It is of clear outline, often presents aortic impulse, but isusually not movable. Adhesions are quite uncommon. Itris situated above the umbilicus in the epigastric region. Itmaybe in close contact with the liver ; it may be largeenough to fill the whole abdomen. The fluid is usuallyturbid, brownish, odourless, and of fairly high specific- gravity. It is alkaline or neutral in reaction, containsalbumen, but neither bile nor urea. It has the power ofemulsifying fat and of converting starch into sugar. Inmany cases it has caused the skin about the wound to be’very sore and raw, and it has been described as

" digestingthe skin." The brownish colour of the fluid is due to anadmixture of blood, and in the rarer cases the fluid hasexhibited lighter tints, and has been described as yellow,- and even as white. It appears to be always turbid. It maypossess no digestive properties, just as the fluid in hydro-mephrosis may possess few, if any, of the specific features of’mine.When Senn’s paper was written, in no instance had a

correct diagnosis been made before operation. Since thattime, however, the nature of the affection has been reco-gnised by many, by Lardy, Subotic, W&ouml;ltler, Bull, and’others. In not a few cases an exploratory tapping has notenabled the surgeon to make a sure diagnosis. Pancreaticcysts have been mistaken for ovarian tumour, hydatid cyst,.malignant growths, lipoma, circumscribed peritonitis, and’even aneurysm. Senn’s statement, that "a positive dia-gnosis of a cyst of the pancreas is impossible," must now be,modified, &nd with the knowledge we now possess there ismo reason why the condition should not, in all uncompli--cated cases, be recognised. The disease, if left to itself,appears to be always fatal, and I believe nothing is knownof any mode of spontaneous cure.In the matter of treatment, I have collected twenty-four

examples of cyst of the pancreas treated by operation.They may be thus arranged :-

No. of cases. Recoveries. Deaths.

incision and drainage...... 16 ......... 15 ......... 1Removal or attempted re-moval ........................ 6 ......... 1 ......... 5

.Simple tapping ............... 2 ......... - ......... 2

24 16 8

It must be understood that in those who recovered afistula was left which was in some cases many months inclosing. The possibility of a permanent fistula may be dis-regarded. Among the cases of recovery i-t Dr. Bull’s case.’The patient survived the operation, and may be said tohave entirely recovered from it when he died of diabetes.The figures given above show very conclusively that theline of treatment should be by incision and drainage, andrthat no attempt should be made to remove the cyst. Thetreatment by repeated tapping has nothing to recommenddt, and an exploratory tapping is also to be condemned.

Literature.-The following are the papers upon which theabove observations are founded:&mdash;Salzer: Zeitschrift fiirHeilkunde, Bd. vii. Kootz:" Inaug. Diss.," Marburg,1886. Kuster: Berliner Klin. Wochens., 1887, No. 9.Subotic: Wiener Alett. Zeitung, 1887, No. 23. Bull: NewYor7c Ned. Jour., vol. xlvi., 1), 376. Nieholls: New YorkMed. Jour., vol. xlvii., p. 575. K&uuml;hnast : "Dissert.,"Breslau, 1887 (forty-five examples). Lardy : Korrespon-denzblatt fur Schweizer Aerzte, 1888. W&ouml;lfler : Zcitschriftfiir Heilkunde, Bd. ix., p. 119 (diagnosis made beforeoperation in the case of a female aged twenty-one).Tremaine: 1’raTis. Amer. Surg. Assoc , 1888, p. 557. Fengerand Steele: Chicccyo Med. Jour., April and May, 1888.Annandale: Brit. Med. Jozcr., June 8th, 1889. The follow-ing monographs which bear indirectly on the subject mayalso be mentioned :&mdash;Hagenbach: Deutsche Zeitschrift f&uuml;rClcircergie, Bd. xxvii., p. 110. Martinotti : Centralblatt f&uuml;r C7nrM?y/ts (abstract), 1889, p. 141. At the time that thislecture was given I was not aware that a case of pancreaticcyst had been operated upon in this country. ProfessorAnnandale’s case was not published until 1889, althoughoperated upon early in 1885. The operation was perfectlysuccessful. Mr. G. Smith, in his work on "AbdominalSurgery, alludes to an unpublished case operated uponby Professor Ogston. Other cases have no doubt beenmet with and operated upon, although the details have notbeen placed on record. The literature of the last few yearswould appear to show that cyst of the pancreas is a lessrare affection than was at one time supposed.

ON GASTRIC ULCER AND ITS TREATMENTBY ENEMATA.

BY H. B. DONKIN, M B. OXON., F.R.C.P.,PHYSICIAN TO WESTMINSTER HOSPITAL.

A CAREFUL study of the clinical symptoms and post-mortem facts of round ulcer of the stomach forces one to

acknowledge that oftentimes the diagnosis is a matter ofdoubt. The first symptom of such a gastric ulcer is some-times that of perforation, unheralded by any complaintwhich points to stomach disorder. Two instances of this Ihave seen and examined post mortem where death followed inthe one case in ten hours, and in the other in two days, on thefirst sign of any illness. And on the other hand, it is wellknown that healed gastric ulcers are seen at necropsies incases where there is no history of any marked attack of theusual symptoms of the disease. Diagnosis is thereforeliable to error both on the side of excess and of defect: thelatter may lead us into serious mistakes, while the former isas harmless as it is of ben unavoidable. From a considerableexperience and thought over such cases I feel sure that it isalways wise to recognise in every protracted case of localisedand unerrant pain after food continuing for any length oftime, and especially when followed and relieved by vomiting,a possible gastric ulcer. Haematemesis clinches the diagnosisas a rule, after the exclusion, of course, as far as possible,of other primary and secondary morbid conditions of thestomach; but as a matter of safe practice it must not be lookedupon as necessary for the diagnosis of the disease. We err onthe safe side, if we err at all, in thus construing as liberallyas possible the symptomatology of gastric ulcer. Doubtlessthere will be many cases in the remembrance of allexperienced clinicians where much difficulty has been foundin making the diagnosis between gastric ulcer and markedan&aelig;mia with abdominal neurosis, especially epigastrictenderness. But when such doubt exists, it is well, atleast for a time, to treat the case as one of ulcer, in spiteof such treatment being most inappropriate to the alternativecondition. At the worst, but a, little time is lost, whichcan soon be made up for when the diagnosis becomes clearerby instituting a vigorous course of tonic and nutritive treat-ment and abandoning local measures. I am well assuredthat by avoidance of all food given by the mouth, thuskeeping the stomach empty and restful, is much theshortest way of relieving, and, in some cases, curinggastric ulcer. In instances where the diagnosis is certainand the symptom of h&aelig;matemesis recent, I now begin atonce with this line of treatment, and give the patient smallenemata of milk and beef-tca, at short intervals; and in