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thought that their excision would afford better hope ofsound limbs ultimately resulting.CASE 2. Excision of both EGboivs.-While the foregoing

patient was under treatment a Hindoo male, aged thirty,was admitted on April 20th, 1883, with anchylosis of bothelbows. His history showed that several months ago he hadbeen maltreated by the servants of his landlord, who orderedhim to be tortured for refusal to sign an obnoxious lease.The man was beaten and his hands tied behind his back forseveral hours, but as he became insensible, he could not givean exact account of the way in which he had been tied.When released his elbows were useless, and shortly after-wards his hands became much swollen. He was treated ina village dispensary, but the elbows were not attended toapparently, and finally became anchylosed in the straightposition. On admission complicated injuries were found tohave been inflicted on each elbow. On the left side the fore-arm seemed to have undergone a semi-rotation on its longaxis; the head of the radius was lying just under the internalcondyle, which seemed to have been chipped. The olecranonprocess lay on the posterior surface of the external condyle ;the lower end of the humerus projected forwards. The fore-arm was rigidly fixed in the extended posture, and the palmof the hand directed outwards and backwards. On the rightside the head of the radius was apparently in its normalposition, but the external condyle was broken off and dis-placed upwards and backwards. The ulna accompanied thisupward and backward displacement, and thus the humeruswas displaced downwards and forwards into the upper partof the forearm. The limb was extended and the elbow firmlyfixed, permitting no movement.

Excision of the injured parts was the only procedureavailable. This was done in the ordinary way by a singlestraight incision behind the joint. Owing to the firm ad-hesions existing the ends of the bones had to be cut awaybit by bit. The left elbow was operated upon on April 26th,the right one on June 30th. In each case the limb was firstput up in the extended position. In each the wound healedby the first intention. After eight days passive motion wascommenced. The man recovered from both operationswithout a single bad symptom. He left the hospital inNovember perfectly cured. He has full power of flexionand extension, and good pronation and supination. He canlift weights, cook his food, and, in fact, has practically asuseful arms as ever.These two cases, excision of both knees and excision of

both elbows, are probably unique surgical curiosities.

Medical Societies.CLINICAL SOCIETY OF LONDON.

Epithelioma of Tongue.—Gluteal Aneurism. — VenousThrombosis after Fracture of Forearm.—Fracture ofCoronoid Process.THE ordinary meeting of this Society was held on the 25th

ult., Sir Andrew Clark, Bart., President, in the chair. Allthe papers were mainly of surgical interest.Mr. F. J. GANT related a case of Epithelioma of the

Tongue involving the Floor of the Mouth, Left Tonsil, andSoft Palate, removed by the buccal operation. In the caseto which the paper related the principal point of importancewas the unusual extent of the disease for which the opera-tion was performed. In Mr. Gant’s opinion the method bybuccal incision offers the only, or the readiest, way of remov-ing the tongue and adjoining parts involved, in order to ex-tirpate the whole of the disease under exceptional circum-stances. The question was also raised as to the desirabilityof reaching the tongue through the cheek in all cases.

Having related the history of the case, the operation, as per-formed with the chain-ecraseur, was fully described.-Mr.BOWREMAN JESSETT asked whether Mr. Gant always pre-ferred the écraseur to the scissors. With Whitehead’smethod the disease in ordinary cases could well be reachedand removed. The use of the scissors left less chance ofsloughing than after the use of the écraseur. He did notthink there was greater likelihood of haemorrhage if thescissors were employed.-Sir ANDREW CLARK inquired ofthe possible causal relationship between the epithelioma andthe irritation of the molar tooth.-Mr. GANT, in reply, said

! that the bad molar tooth was exactly opposite the commence-ment of the epithelioma, and he surmised that there was acausal connexion. There were two forms of oral operation-that of Sir J. Paget and that of Mr. Whitehead. In thesemethods in some cases the whole of the disease was not seenand not got at. When hemorrhage occurred, the oral opera-tion left but little room for dealing with it. The submentaloperation was also open to the objection that the whole ofthe disease might not be removed. A similar disadvantageattached to Regnoli’s method of this submental operation.Syme’s operation was not approved of.Mr. G. R. TURNER read notes of a case of Gluteal Aneurism.

A coachman, aged fifty-one, was admitted into the Seamen’sHospital, Greenwich, on Sept. 17th, 1883. It appeared thaton Sept. 5th the patient was thrown out of a pony carriage,and when seen by Mr. Roper was found to have a scalp,wound exposing bone on the right side of the head, and acontusion of the back, right hip, and buttock. He did welltill Sept. 14tb, when, without leave, he got up. On gettingback into bed he felt something snap in the right buttock.Immediate swelling came on, and when Mr. Roper saw himthis swelling had a most distinct pulsation. Ice was appliedlocally, and in two days the pulsation ceased and thetumour became hard and painful. On his admission into theSeamen’s Hospital the integuments over the swelling wereinflamed, and there were marks of fading bruising extendingover the buttock up to the scapula. No pulsation or thrill:could be felt in the tumour, which measured some eightinches by six. The man had been a hard drinker, probablyhad had syphilis, and both radial and temporal pulses wereatheromatous. There was some slight fever on his admission.This subsided after a few days’ rest, and the condition ofthe integuments became less inflamed. The tumour, how-ever, became larger, and fluctuation marked. At one placethe skin, on Sept. 30th, was prominent and thinned, thesuperficial inflammation returned, and the temperature roseagain. On Oct. 9th, it was evident a portion of the skin hadlost its vitality, and that the tumour was on the point ofbursting. Exploratory puncture with a fine trocar showedthat the superficial part of the swelling was solid, andgave rise to a flow of bright arterial blood from the deeperpart with no relief to the tension. On October 10ththe patient was put under ether, the sac of the aneurism laidopen from end to end, and more than forty-two ounces ofdisintegrating blood-clot turned out. An oval apertureabout the size of a split pea was found in the gluteal arteryjust as it left the pelvis. A carbolised silk ligature wasplaced on either side of this, and tied. The vessels werediseased. During the operation the rectal lever was used,,and but very little blood, except that in the sac of theaneurism, was lost. Previous examination by the rectumshowed that the swelling was extra-pelvic. The gluteusmedius, minimus, and the external rotators of the thighwere exposed at the bottom of the sac. The glutensmaximus was completely destroyed. The wound wasplugged with a carbolised sponge, and dressed with carbolicgauze. The man did well for eight days, when tetanusattacked him, and he died exhausted on the eleventh day..By that time the wound was granulating healthily; all thesloughs had separated, and all the ligatures had come away.No injury to the gluteal nerve could be detected. At theoperation the vessel was completely isolated, and seen

perfectly before ligature. No post-mortem examinationcould be obtained. The diagnosis in this case presentedno difficulty, although, but for the history, the swellingat one time might have been mistaken for an abscess.It bore no resemblance to tumour of bone. At firstit seemed possible that a natural cure would result, and itwas not until the tumour was on the point of bursting thatoperation was undertaken. As the danger of secondaryhaemorrhage is very great, laying open the sac was

delayed as long as possible. The rectal lever proved mostefficient, and should be superior to an abdominal tourniquetin such cases. Since Mr. Holmes’s lecture in 1874 two casesof gluteal aneurism have been recorded-one by Mr. Hussey,of Oxford, in the thirteenth volume of St. Bartholomew’sHospital Reports, in which death occurred from secondaryhaemorrhage on the sixteenth day after laying open the sac;and another of Dr. Sands, of New York, in the America.,Tournal of Medical Science, April, 1881. Examination bythe rectum in this case showed the sac to extend into thepelvis, and the internal iliac artery to be diseased. Pressure wasmade by the hand in the rectum on the common iliac vessels ontwo occasions for one hour and a half and three hours and a,

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quarter, and caused on each occasion some clotting of blood in more extensively on Dec. 21st, accompanied by still greaterthe sac. Eventually, however, the aneurism resumed its former pain. It again subsided, and again returned on Jan. 5th.condition, and in spite of instrumental pressure the patient This time it extended up to the shoulder. She had nowwas discharged in the same condition as on his admission.- great pain in the neck and above and below the clavicle.Mr. PlUKERiNG PICK spoke of the remarkable efficiency of By Jan. 15th the left side of the chest, neck, andthe rectal lever, which practically robbed the operation of face were much swollen and were extremely painful.its difficulties. He was certain that the gluteal nerve was There was also severe headache in the left side of thenot included in the ligature. He had proposed complete head. She was very prostrate. Dr. Carrington, who sawdivision of the vessel, and ligature of the two divided ends. the case with him at this time, also felt no doubt that theHe mentioned a case of incomplete traumatic division of the thrombosis had extended along the subclavian to the inno-temporal artery in a child ; complete division of the artery minate and internal jugular veins, and a rapidly fatal termi-was followed by immediate cessation of haemorrhage.—Mr. nation was feared. However, the swelling slowly subsidedTIMOTHY HOLMES said the case was of interest from its from the left side of the face, then from the neck, and thenrarity. Very few of the cases which he had collated were of from the side and upper arm, and by February 6th ita spontaneous nature-i.e., genuine aneurisms. In cases of was limited to the forearm and lower third of the upperwound of a vessel, without the formation of a sac, the prospect arm. On February 9th she had a recurrence of the swelling,of a spontaneous cure was very dubious. There was no which extended to the side and neck, with pain and tender-question that Mr. Turner’s operation was justifiable. The ness. This subsided, so that she was able to get about andpatient, an elderly man, with disease of superficial and deep commence to use her hand and arm, which were progressingarteries, was hardly in the same case as the child with the very favourably. The radius had not, however, united bybleeding temporal artery mentioned by Mr. Pick. Mr. bone. On April 1st, without any apparent cause, a rapidPick’s case was indeed an example of the value of immediate and complete recurrence of the swelling took place, not, how-division of a small artery, precluding the necessity of employ- ever, being accompanied by the same great pain, nor withing a ligature. This principle was very ancient, as the opera- such severe headache. The left side of the face was muchtion of arteriotomy performed on the temporal artery fully swollen, as ’Was the neck and side. This swelling of the faceproved. No surgeon would, however, think of adopting such and neck subsided, leaving by April 10th the left side anda course with the gluteal artery. An important question back of the chest about two inches larger than the right, andwas the intra- or extra-pelvic situation of the disease, the left arm a good deal swollen, so much so that shelie spoke of the value of exploring he rectum with could not use it. There was firm resistance along thethe entire hand or several fingers, by which it could be left internal jugular. She continues to improve steadily.-ascertained, as Dr. Sands had shown, whether the wound Sir ANDREW CLARK asked whether the patient was rheu-of the artery was in or outside the pelvis. Ligature of matic or gouty, and whether the kidneys were sound.-Mr.the common iliac, with all its dangers, or of the internal T. HOLMES inquired of the ultimate condition of theiliac artery, was necessitated when the wound was high up fractured radius. Mr. Callender’s paper was referred to, inand in the pelvis. The employment of Davy’s rectal lever which it was shown how wounds and other injuries of thewas at present by far the best means which surgeons had of great veins of the limb led to delay and even permanent non-restraining haemorrhage in cases of gluteal bleeding. The union of fractured bones.-Sir ANDREW CLARK remarked- case of the leech gatherer operated on by John Bell was that Mr. Lane would communicate the ultimate issue of therelated, in which an incision of great length into the tumour case to the Society after the lapse of a sufficient space ofwas made, attended with an almost fatal result. Specimens time.-Mr. LANE, in reply, doubted whether bony unionput up by John Hunter showed that the pudic artery, as would ever be effected, for six months had elapsed, andwell as the gluteal and other vessels, or their branches, had there were still displacement and looseness of the fragmentsbeen the vessel from which haemorrhage had come. Lister’s of the radius.tourniquet had its disadvantages in the danger its pressure Dr. H. A. LEDIARD’S paper on Dislocation of the Elbowmight produce, and in its liability to slip from its place. Backwards, with Fracture of the Coronoid Process, was readThe employment of an elastic band with a large pad might by Mr. R. J. GODLEE. A young fisherman, aged twenty-interfere with the action of the diaphragm, and might lead eight, fell whilst wrestling, his hands touching the groundto fatal dyspnoea. The tetanus must be regarded as acci- in the prone position with the arms extended. He heard adental, and the operation might be described as successful.- distinct snap. After undergoing a course of unsuccessfulMr. HENRY MORRIS thought it was unnecessary to speak manipulation by a bone-setter, he was admitted into thespecially of the ligature of, the superior gluteal nerve Cumberland Infirmary with displacement of both bones ofwhen we remembered the great disorganisation of the tissues the forearm backwards, causing almost complete inability toof the buttock. Why was the operation postponed till the produce either flexion, pronation, or supination. Concomi.skin became so much thinned as to be almost bursting? tant fracture of the coronoid process being diagnosed, ex-The old radical operation of Antillus of cutting down and cision of the joint was performed. The patient was well in’ligaturing both ends of the diseased vessel was often delayed a month, the movements of the new joint progressing satis-till too late to be of service.-Mr. TURNER, in reply, said factorily. The specimen, which was exhibited, showed thatthat he wished that he had divided the artery as Mr. Pick a considerable piece had been broken off the coronoid pro-had suggested after the operation was completed. The cess, the fractured surface having eroded and polished thedistinction between aneurisms proper and false aneurisms posterior surface of the trochlea. The head of the radiuswas no doubt of importance. In his case it must be remem- Jay behind the capitellum, the sigmoid cavity in its centrebered a ruptured and diseased artery had to be dealt with, being filled up with a semi-fibrous mass, which would haveand not merely a wounded vessel. There was no pulsation formed an insuperable obstacle to the reduction of the dis-or thrill to be felt, and tension when the patient was first seen, location. A small chip of bone was found adherent to thealthough present, was not great; also it must be said capitellar surface of the humerus, possibly a part of the frac-that fever and local inflammation did subside for a tured process. The opinions of most authors agree in regard-time, only to be followed by still more severe local ing this injury as extremely rare ; in two cases, however,changes. These facts explained the apparent delay in in which dislocation of the radius and ulna recurred afteroperating. He had no idea that Davy’s lever would have reduction, Dr. Lediard had been able to diagnose fractureproved so efficient. of the coronoid process, in addition to the displacement.-Mr. ARBUTHNOT LANE read an account of a case of Mr. GODLEE thought that there was some doubt as to the

Extensive Thrombosis following Fracture of both Bones of nature of the case, for the bony fragment shown was verythe Forearm. On Nov. 9th of last year the patient fell small ; he suggested that long-continued disease might haveheavily on her left side down some steps, breaking both led to absorption of bone.-Mr. T. HOLMES raised the questionbones of the forearm, the ulna at its centre, and the radius whether fracture of the coronoid process was rare or not. Aat the junction of the middle with the lower third. There specimen was in existence in St. George’s Hospital in whichwas much displacement of the radial fragments. The fracture of the coronoid process had undoubtedly occurredshoulder and arm were also much bruised. The swelling to both elbow-joints combined with dislocation, so that thesubsided within a few days, and the arm progressed very arms could be completely extended. Another case in a manfavourably till Nov. 29th, when sub-inflammatory eedema of was mentioned. He did not think the complication was offorearm set in and extended into the upper arm. It was extraordinary occurrence. In Dr. Lediard’s case the fragmentaccompanied with much pain and tenderness, especially of thecoronoid processwas probablystill attached tothetendonalong the front of the forearm and course of the brachial of the brachialis anticus. He did not concur with the remarksvessels. It almost completely subsided, only to reappear of Mr. Godlee.-Mr. GANTconsideredthattheinjurywasrare;

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he said the case afforded an admirable opportunity for per-forming excision. -Mr. HENRY MORRIS said that if the bra-chialis anticus had drawn up the fragment of the coronoid pro-cess a lump ought to have been felt corresponding to it, andthe fracture must have occurred low down for this occurrenceto take place. An interesting case was narrated in which afracture having an obliquely vertical direction had takenplace through the large sigmoid cavity of the ulna in such amanner as to break off a wedge-shaped portion of the ulna,chiefly composed of the olecranon process, leaving the shaftof the ulna with the coronoid process attached. This wasthe only instance of fracture of the coronoid he had met with,and even this case was disputed by one of his colleagues,who diagnosed dislocation.The following living specimens were shown :-Dr. Heron :

A case of recoverv from Melancholia with extreme starva-tion. Mr. R. W. Parker : Congenital Hypertrophy of LowerLimb (? nmvo-lipoma).

MEDICAL SOCIETY OF LONDON.

Infective Endocarditis.—Pyo-salpinx and Hydro-salpinx.THE ordinary meeting of this Society was held on Monday

last, Mr. Arthur E. Durham, President, in the chair. Both

papers were well received, and excited considerable dis-cussion.Dr. HENEAGE GiB]3ES exhibited under the microscope

beautiful specimens of the following conditions :-Micrococciin lymph from the inflamed endocardium; micrococci indiphtheritic membrane ; vessel in the liver blocked withmicrococci ; deposit on endocardium covered with micro-cocci ; inflammatory area in skin showing small masses ofmicrococci ; bloodvessel in spleen crowded with micrococci.

Dr. CAYLEY read notes of a case of Ulcerative Endo-carditis. The patient was a footman, aged twenty-six, whohad had an attack of rheumatic fever at the age of seventeen.He was quite well on February 24th, but on the next dayhe went out with insufficient clothing, and came homeshivering. Notwithstanding his illness, he went out againthe next day and rode home on the top of an omnibus with-out his great-coat. He slept heavily on the night of thisday, and the next morning was delirious. He remainedin bed all day and vomited twice. Later on there wasprofuse epistaxis. On admission to the Middlesex Hospitalthere were great prostration and obfuscate mental condition,perspiration, suffused eyes, dry brown lips, flushed cheek,coated tongue with red tip, diffused somewhat mottled redrash, and many purpuric spots ; also a pustule on one finger;the right great toe was swollen and livid ; there was a lividpatch over the left olecranon. There were signs of mitraldisease. The spleen was enlarged. The pulse and respira-tion rapid; temperature 104’20. The diagnosis was madeduring life. The case terminated fatally six days after itsonset. At the autopsy there were haemorrhages into themuscular and mucous coats of the intestines, splenic infarc-tions, microscopic infarctions in the kidneys, haemorrhagic fociin the liver, recent lymph on right pleura, petecbiae beneath thevisceral pericardium, pulmonary infarctions, valvular diseaseat all the cardiac orifices. Microscopical examination byDr. Gibbes revealed micrococci in all the localisations in thedifferent diseased tissues. Bacilli were also detected in thelymph spaces of the different organs.-Dr. W. H. WHITEspoke of the difficulty of diagnosis of cases of ulcerativeendocarditis. Such cases were mistaken for typhoid fever,tubercle, &c. The origin of the affection was still doubtful.He thought that the micro-organisms had not been provedto be the cause of the disease.-Dr. GREEN said that thecausal connexion between the micrococci and the diseasecould only be decided by culture and inoculation experiments.The unusually acute course of the disease in this case wasremarked upon. The irregular and intermittent type of tem.perature was said to be very characteristic of ulcerative endo-carditis. Typhoid fever in the late stages of the disease couldbe mistaken for it. With signs of the existence of valvularlesion, and of an irregular, intermittent pyrexia, the diseasemight be diagnosed. The chronicity of the affection wasillustrated by two cases. One lasted six months. Themitral valve was diseased, and there was embolic disease ofthe internal organs. Another patient had had from timeto time, and extending over a period of eighteen months,an irregular type of temperature, but it was only the lastfew days of her life that he was confined to bed. Was

there any remedy which would influence the course ofulcerative endocarditis ?-Dr. SANSOM said he would bevery sorry to lay down any rules for the diagnosis of ulcera-tive endocarditis. In a case which he had brought beforethe Society there had been no elevation of temperaturethroughout. The most marked cases which he had seenwere in puerperal conditions. He considered that therewere cases of ulcerativeendocarditiswhich wererathernecrotiethan septic. Embolic infarction in the intestines was a pos.sibility.-Dr. COUPLAND asked whether it was right touse the term ulcerative endocarditis at all. He preferredto call Dr Cayley’s case septic, or, with Virchow, malignant.Klebs had described micro-organisms in ordinary endo-carditis. A distinct septic source had been traced in manycases of " ulcerative endocarditis. Osler of Montreal hadpointed out that in many instances of this form of endo.carditis acute pneumonia was present. Micrococci hadbeen assigned as the cause of some cases of acute loba?pneumonia. In one case of septic endocarditis whichresembled ague the patient had caught cold in a graveyard.Dr. Cayley’s case ran a remarkably acute course. - Dr.HENEAGE GIBBES thought nothing definite could yet be saidof the micro-parasitic origin of the disease. Masses of micro-cocci could be found in this case which had not causedthe vessel to break down, or any inflammatory action to takeplace in the surrounding tissue. He thought that thesemasses of micrococci might have increased after death, as incases of charbon, where shortly after death the blood wasteeming with bacilli. He did not think that vessels couldbe blocked during life without setting up inflammatory actionin the tissues outside the vessels. In the skin and kidneythere were areas broken down and micrococci were found; butalso there were bacilli in the renal tubules which behavedpeculiarly. With a half per cent. solution of methyleneblue and a single crystal of a neutral salt of rosaniline thebacilli picked out the red stain. This was a curious feature.-Dr. CAYLEY thought the term ulcerative endocarditis wasinappropriate, " infective Waa, perhaps, a better term. Hehad seen cases which were indistinguishable, clinically, fromtyphoid fever.

Dr. J. KINGSTON FOWLER read a paper on the Pathology ofHydro- and Pyo-salpinx. He said that he had met with fifteenexamples of these conditions in the post-mortem room of theMiddlesex Hospital in the course of the last three years.He had in his paper intentionally omitted any reference t(}the symptoms to which the affection gave rise, or to therelief which was afforded by the operation for the removalof the tubes, as on neither point had he any experience torecord. Clinical details had also been omitted, partly becausethey were incomplete, as in none of the cases had the con-dition of the tubes been suspected to be present during life,partly al,o from the fact that nearly all the cases were com-plicated by some other general or uterine disorder, and alsobecause in most of the cases the record of the post-mortemappearances clearly indicated the course of the disease.These cases showed that the condition of pyo-salpinx was avery dangerous one, many cases of peritonitis from thatcause being ascribed to abscess of the ovary, pelvic cellulitis,or pelvic abscess. Of the fifteen cases, the condition of thetubes was the immediate cause of death in eight, all ofwhich were cases of pyo-salpinx. six being bilateraland two of the right side only. Death was due to peri-tonitis in seven cases out of eleven. These conditionsof the Fallopian tube may be set up by any inflamma-tory change in the uterine mucous membrane, howevercaused. It is probable also that in some cases theprimary change was tubercular. In many cases there wasan indurated spot close to the uterine end of the tube.Septicaemia, amyloid disease, cancer of the uterus, andscurvy were each the cause of one death. Adheions existedin nine cases of pyo- and three cases of hydro.salpinx.-Mr.DURHAM was somewhat surprised at the frequency withwhich this condition was known to exist.-Dr. ANGELMONEY had seen a specimen of pyo-salpinx in a female child,aged seven years.-Dr. PLAYFAIR was quite sure that theindependent position which Dr. Fowler had taken wouldprove most valuable. It was a revelation to him to learnthat cases of pyo-salpinx were of such frequency as thispaper showed. With regard to operation for this condition,he considered that it had perhaps been too frequently per-formed at Birmingham. On the other hand, to supposethat operation was never necessary was also a mistake. Thevia media was no doubt tbe propercourse.-Dr. C. H. ROUTII)-p’)ke of the great value of Dr. Fowler’s paper from its impar.