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instance of suppuration. When this did occur the forma-tion of pus was comparatively slight and did not end inthe suture coming bodily away as with silk. Duringthe last five months he had performed 30 operationsfor the cure of hernia; 27 of these had healed by firstintention, while in three superficial suppuration occurred.The hospital records showed that operation for inguinalhernia was performed much more frequently in males thanin females. As a possible explanation he mentioned that,according to the tables of the City of London Truss Society,out of 10,770 patients applying for trusses 9900 weremales and only 870 were females. Moreover, there wereother reasons for more frequent operations in males, such asentrance into public services, their more laborious work, andthe constant risk of strangulation. The curative operationwas one adapted for girls, in whom it was more simplethan in males. Referring to the advisability of a trussafter the operation he observed that no part of thetreatment excited greater divergence of opinion thanthat. He himself always advised the use for a time of asupporting instrument, an opinion which was confirmedby experience, seeing that patients who applied for reliefat the Truss Society owing to failure of the operation werethose who had not worn any support. Of 138 cases 78 wereadvised not to wear a truss, while 60 were recommendedto wear one for a limited period. In private practicehe always recommended a truss. The operation wascontra-indicated-(l) when the age was less than six years;(2) when there was co-existent organic disease; (3) whenthe hernia was so large that the abdominal cavity was unableto receive or retain under moderate pressure the extrudedviscera (in such cases a palliative operation to retain thehernia aided by a truss might secure the patient from thechance of strangulation) ; (4) when the patients were veryold ; (5) when the tendino-muscular walls were weakand bulged for a considerable area on coughing; and (6)when septic peritonitis the result of strangulated herniawas present. Mr. Langton called attention to the almostinsurmountable difficulties in the way of obtaining anestimate of the permanent results of the operation. Twoyears was the shortest period within which an opinion couldbe expressed. Statistics gave most conflicting results. Therecords of the City of London Truss Society showed thatin the last six years 242 patients upon whom operations hadbeen performed were treated for failure of the operation,from which it might be inferred that the total number offailures must be very considerable. In private practice theresults were better known and were encouraging, 80 percent. being successful at any rate for several years.The PRESIDENT objected to the use of the term radical

cure," he himself always calling it the "operation for theradical cure." He often operated on children under six yearsof age and asked the Mr. Langton whether he would rigidlyadhere to that limit under particular circumstances, as, forinstance, in a child, aged three years with careless parentsand hernia steadily increasing in size. For suturing he pre-ferred a material which could be used for everything, such assilk, which, in his experience, did very well.Mr. STANLEY BOYD observed that it would be very useful

if surgeons could learn the ultimate results of their opera-tions. He insisted on the importance of leaving the peri-toneum smooth and tense, a point about which he was alwaysvery careful. He always applied torsion to the sac, but inone case the bladder was unfortunately included, with a fatalresult. The next important structure was the transversalisfascia which should be closed by a -continuous suture. Heurged that the muscular arch should be restored as far aspossible to the normal arrangement, thus materiallyassisting in preventing relapse. He used a fishing gutstitch to close the external oblique, removing any superfluousfat. For the last two years or more he had alwaysoperated by a flap, putting three knots on the fishgut suture,which was a continuous one, cutting off the ends close to theknot. Since he had done this he had not had an instanceof a stitch reappearing on the surface. He agreed with Mr.Langton as to removing a piece of omentum. He confessedto having had some cases of suppuration and observed thatthere was no operation in which suppuration gave so muchtrouble. He thought the best plan was to give an anaestheticand to take out some of the external stitches, passingthrough the internal oblique and transversalis and placing atube in contact with the neck of the sac. He observedthat it would be interesting to discuss the causes whichunderlay the greater frequency of femoral hernia in the

female after puberty, especially as the sexual differences inthe pelvis were as marked in a five monthsfcetus as they wereafterwards. He himself had fixed three years as the limit ofage for operation in infants, that being the age at whichchildren had acquired control over the bladder. Personally,he never recommended a patient to wear a truss unless theabdominal structures were unusually weak.

Mr. OSBORN asked Mr. Langton how long he thoughtpatient ought to wear a truss after operation, a practice ofwhich he approved, though patients were often disappointed,having looked forward to being enabled to dispense with itsuse after the operation. In young children a hernia wouldoften disappear with a truss without any operation.

Mr. LANGTON, in reply, congratulated the President onthe fact that his name did not appear on his list of Londonsurgeons responsible for the failures to which he had alluded.In praising kangaroo tendon he did not wish to decry silkand fishing gut. He did not wish to lay down any hard-and-fast age limit. In his paper he had stipulated that if thechild were well cared for he would not advise an operation.His experience at the Truss Society was that in most instanceswhen a truss was applied to a child the rupture was not heardof again. He agreed that the limit of three years was not abad one on the whole. He concurred in the importance ofleaving the peritoneum tense and smooth. The inclusionof the bladder when torsion was applied to the sac wasan accident which might happen to anyone, but he alwaysopened the sac and passed his finger into the peritonealcavity before applying torsion. (Mr. BOYD remarked thatthis was his invariable practice also.) Mr. Langton con-firmed the remarks which had fallen from Mr. Boydon the vital importance of arching over the fibres ofthe internal and oblique transversalis. In private practicehe often ordered gymnastic exercises with the object ofincreasing the musculature and tension of the abdominalwalls. He pointed out that femoral hernia occurred prin-cipally in women between puberty and the menopause, sothat the influence of parturition was probably a factor in itsproduction, though even during this period hernia in apregnant woman was inguinal in 99 per cent. of the cases.

CLINICAL SOCIETY OF LONDON.

Hydatid Cysts in the Lung and the Liver removed by Opera-tion.-Pancreatic Cyst treated by Drainage.-Removal ofMalignant Tumo2cr involving the Frontal Bone.-Brasionof the Ankle-joint.A MEETING of this society was held on March 10th, the

President, Mr. LANGTON, being in the chair.Mr. H. BETHAM ROBINSON described a case of Hydatid

Cysts in the Upper Lobe of the Right Lung and in theLiver both successfully removed. The patient was a boy,aged six years, who was admitted under his care intoSt. Thomass Hospital on June 7th, 1898. There was nothingto note in the previous history except that for some time hehad had a cough. When first noticed, three years before,the abdominal tumour was of the size of a marble and hadgradually become larger without any pain. Up to his admis-sion there had been no suspicion of the existence of a cystin the lung. On examination he was found to have a firmrounded cystic swelling in the right hypochondriac andlumbar regions, reaching almost to the middle line and tothe level of the umbilicus below. There was a roundednodular projection on its inner side just under the umbilicus.The liver dulness began at the seventh rib in the nippleline and was continued down over the tumour. The wholeswelling moved with respiration and it could be graspedbetween the hands placed in front and behind. The urinewas slightly albuminous. The chest on examination showedthat the upper part of the right side in front bulged. Thepercussion note was dull down to the third rib and dulnesswas also present high in the axilla and over the apex of thelung posteriorly. Over the dull area in front the breathingwas tubular and vocal resonance increased, but behind allsounds were diminished. No crepitations were elicited oncoughing. There was no elevation of temperature, so thephysical signs were suggestive of a hydatid in the lung. On.June 22nd the liver hydatid was operated on by an incision.n the linea semilunaris. The liver came well below thecostal margin and a cyst was seen springing from the.nferior surface having the gall-bladder on its upper surface

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and left margin. The cyst having been pushed into thewound was incised and hooked well out of the abdominalwound with the finger, preventing any contamination of theperitoneum. The hydatid membrane was removed withforceps after about a pint of clear fluid had escaped. Thefibrous wall was not interfered with, the cavity was washedout with one in 1000 perchloride of mercury solution, andthe opening was sutured with catgut except for a hole for agauze drain which was brought out of the abdominal wound.By packing, the abdominal and cyst wounds were kept asclosely apposed as possible. It will be noted that the cystwas not fixed to the abdominal wall. The subsequent pro-gress was uneventful except that the discharge becamepurulent on the tenth day with a slight rise of tempera-sure. In spite of this the wound was soundly healedat the end of a month. During this time his lung signsunderwent no change, but his liver still remained pusheddown. A skiagram made by Dr. Barry Blacker showed awell marked opacity in the upper lobe of the right lung sodense as to obliterate the rib shadows. On August 15th the.lung was operated on. The pectoralis major being splitone and a half inches of the second rib were resected andthen on careful incision it was evident that the pleural layerswere adherent. Turning the boy on his right side so asTo allow free exit for the fluid and to prevent a possibledeeding of his bronchial tubes on the collapse of the cyst ahollow needle was introduced to get a knowledge ofthe depth of the cyst from the surface. A drop offluid appeared when the needle had been introducedabout one quarter of an inch, and a free incision wasmade when several ounces of hydatid fluid gushed out.The finger was introduced and the cyst membrane wasremoved whole with the aid of forceps. The cyst was ofabout the size of an orange without any daughter cysts.There was fortunately no communication of the fibrous sacwith the larger tubes, for there was no marked coughing orbloody expectoration after the incision. A large india-rubber drain was introduced. For some few days after-wards he had a high temperature and physical signs indica-tive, of some localised pneumonia but without any signs ofpleuritic effusion. At the end of 10 days his temperature wasonly slightly raised at night and the tube was removed and.a gauze drain was substituted. At each daily dressing the boywas turned on his face so as to thoroughly drain the cavity,which was then insufflated with equal parts of aristol and9)oric acid. On Sept. 7th (the twenty-second day) the woundwas quite superficial and the lung on examination wasresonant all over, air entering well right down to thebase with expiration ; the breathing was still tubularin places but no adventitious sounds could be heard.On the 9th he got up and on the 19th, when thewound was quite healed, the lung on examination gave noevidence of any cavity. He went to a convalescent home onthe 22nd and had remained well since.-Dr. KINGSTONFOWLER asked whether the patient had continued in goodhealth, mentioning that he had recently heard of two similarcases successfully operated upon, but in both instances thepatient had subsequently developed pulmonary tuberculosis.-Mr. BETHAM ROBINSON, in reply, said that up to two months;ago at any rate the patient had remained perfectly well.

Mr. A. E. BARKER related a case of Pancreatic Cyst treatedby Incision and Drainage. The patient was a boy, aged 14years, who was admitted to hospital on July 12th,897. He had had a fall some weeks previously, strikinghis left side. He was rendered unconscious and remainedso for some hours, and for a fortnight after he was statedto have been delirious and to have suffered from haemoptysis-on several occasions. A large swelling occupied the left sideof the abdomen throughout the left hypochondriac, lumbar,and left half of the epigastric and umbilical regions.There was also slight fulness to the right of the middle line.The swelling came from beneath the left costal marginwhich was distinctly bulged. The tumour was dull on per-cussion and on the left this dulness was continuous with thatof the spleen. The tumour moved with respiration. Therewas apparently a small amount of fluid in the peritoneum.Considering it to be a pancreatic cyst Mr. Barker opened theabdomen on July 15th, 1897, by a three-inch vertical incisionthrough the left rectus muscle close below the ribs. On open-ing the peritoneum the stomach was found to be stretched overthe tumour and the transverse colon lay below it. Betweenthe two there was a small space through which the cyst wastapped, giving issue to three or four pints of fluid, at firstclear and light-coloured, but becoming slightly brown towards

the end. He sutured the lips of the cyst to the edges of thewound and left in an iodoform gauze drain. The patientdid well and left the hospital on August 15th with the woundquite healed. There had been no return of the trouble. Acareful analysis by Mr. Nabarro and Dr. Sidney Martin gavethe following result : the fluid was of a brownish-yellowcolour, of specific gravity 1010, with a sweet aromatic smell,not urinous ; the reaction was alkaline ; there was no sugaror bile, but a trace of peptone. On boiling albumin wasprecipitated ; the total solids were, 1-63 per cent. ; ash, 0 81per cent. ; and total proteids, 066 per cent. The fluid dis-played marked amylolytic action, but no fat splitting orproteolytic action.-Mr. ALBAN DORAN remarked that onecould not have a better clinical subject for surgeons todiscuss than the proper treatment of a cyst andMr. Barkers paper emphasised what the surgical treat-ment should be. In reference to the question of diagnosishe remarked that a broad-based cyst if rather large.though fixed to bone or an adjacent organ, could whengrasped be made to move laterally very freely, as had beenthe case in Mr. Barkers patient. Mr. Doran pointed outthat it was exactly the same with a pelvic cyst which couldoften be freely moved although so firmly fixed as to requireenucleation. He agreed that the best treatment for pan-creatic cysts was incision and drainage. It often happenedthat the nature of the cyst could not be diagnosed till thevery end of the operation and several operators had openlyadmitted that they would not have performed the operationof enucleating had they known beforehand what it was, therisks being too great. He recalled that Kronlein had success-fully removed a cyst, but the patient died on the tenth dayand at the necropsy the transverse colon was found to havesloughed. Poncet who had operated on several cases did avery bold operation on an almost sessile cyst in which he leftseven clamp and pressure forceps sticking out of thewound. The removal of one of them was followed byhaemorrhage and it had to be hastily reapplied though itwas impossible for the surgeon to see what he wastaking hold of. The patient recovered, but it wasobvious that in reapplying the forceps the operator mighthave grabbed anything. Eve of Nashville had removed acyst of the tail of the pancreas which was a comparativelyeasy situation, yet not only the mesocolon but also thetransverse colon were torn across. These were repaired andthe patient recovered, but that was a risk which few of themwould be prepared to face. In other cases the splenic veinand artery had been wounded. Evidently, therefore, therisks of removal were too great if one bore in mind theexcellent results of drainage, as in Mr. Barkers case, in hisown, and in the three cases under the care of Mr. BiltonPollard reported in the British Medical ,Journal. The righttreatment was not to perform an operative feat but to drain.The PRESIDENT concurred in the view that drainage was

the best treatment. He referred to the case of a manwith an enormous tumour in the situation mapped out byMr. Barker. It was not an ordinary pancreatic cyst, therebeing hmorrhage into the substance of the organ and thecase had been supposed to be one of malignant disease atthe back of the abdomen. He (Mr. Langton) thought, how-ever, that he could feel fluctuation but the exact situation ofthe tumour could not be decided. He made a median incisionand went above the stomach through the gastric hepaticomentum, giving issue to nine and a half pints of old blood.The patient, although very ill for a few days, did remarkablywell with drainage. The interest in the case lay in the factthat three years afterwards he was taken ill and ultimatelydied, and post mortem it was found that the portal vein hadbecome so constricted in the scar tissue that there waspractically no circulation through the hepatic area.-Mr.ARBUTHNOT LANE mentioned the interesting fact that inone of the cases on which he had operated the cyst, thoughdistinctly pancreatic, was made up of three separate loculi.-Mr. BARKER replied.

Mr. W. H. BATTLE brought forward the account of a caseof Successful Removal of a large Malignant Tumour withUnderlying Bone from the Frontal Region of the Scalp. Thepatient, a married woman, aged 35 years, was admitted tothe Royal Free Hospital on Jan. 21st, 1897. Eight yearsbefore a small lump had been noticed in the scalp a little tothe left of the middle line behind the hair of the frontalregion. Several operations had been performed for itsremoval and the present growth had been growing for twoyears. For some months there had been intermittent

hmorrhage from it and her general health had greatly

769

deteriorated. A large irregular nodular mass with over-hanging edges presented in the frontal region. Thismeasured about three inches by four and a half inches andprojected three and a half inches from the level ofthe scalp. Vascular and foul smelling, it presented aformidable aspect, whilst the removal of the dressings causedtroublesome bleeding, which required steady pressure to arrestit. Firmly attached to the bone it did not pulsate and was notaccompanied with glandular enlargement. On Jan. 27th,after the application of an elastic bandage circularly to thehead to control bleeding from superficial vessels, the tumourwas removed from the surface of the bone and pads wereapplied to arrest the bleeding which ensued from the skullwhere the growth had invaded it. This pressure was removednext day. On Feb. 7th the bone affected was removed ; atrephine was first applied and from the opening thus madea circular saw worked by hand motor was guided so as todivide the bone above and below, after which a few strokesof the chisel were sufficient to free the implicated portion.The growth had not invaded the dura mater but presented aseries of closely set elevations with flattened tops where ithad completely eaten away the skull. Very little haemor-rhage (comparatively) followed the removal of this piece ofbone, but one vessel in the dura mater required the pressureof a pad and a bandage to arrest the bleeding from it.She got up on Feb. 25tb. Granulations soon sprang upand on March 2nd skin grafts after Thierschs methodwere taken from the thigh and placed on the duramater with full success. She left hospital on March 22ndgreatly improved by her stay. There was then anirregular circle of dead bone around the area of opera-tion which gradually separated during the next fewmonths and cicatrisation took place around. The reliefto the patient and the improvement in her general con-dition and appearance were very great. Wearing a hand-kerchief across the forehead and round the head shewas comfortable, and there was no suspicion aroused of theunderlying deformity. No attempt had been made tocover over the area left after removal of the bone bymeans of a plate. Mr. Battle drew attention to thevarious methods of removing portions of the skull nowavailable and Messrs. Down showed instruments adaptedto this object during the course of the evening. The rarityof such cases was mentioned and the unusual character ofthis fungating growth, the microscopical examination ofwhich showed it to be a spheroidal-celled carcinoma. Thecase was also interesting from the fact that it was necessaryto apply grafts to the dura mater in order to provide for itsbetter protection from the air.-Mr. BARKER agreed withMr. Battle that the motor had very considerable drawbacks,being difficult to direct and apt to jam. Possibly with alarge fly-wheel it might be more practical. He recommendedthe use of Giglis wire saw which he himself had recentlyused with very satisfactory results. He suggested, however,that instead of the loops, if the ends were shaped like asound it would be more easy of introduction.-Mr. BATTLE,in reply, said that at the time he did this operation he wasnot acquainted with Giglis wire saw.Mr. ARBUTHNOT LANE read notes of a case illustrating an

operative procedure for Erasion of the Ankle-joint whichgave a clear field for the complete removal of tuberculousmaterial from this joint without offering some of the objec-tions he had found to arise occasionally in the method whichhe had described. In that operation he divided by means ofa transverse incision all the structures around the jointexcept the internal lateral ligament, the tibialis posticus,and the flexor tendons of the toes. The divided tendonswere carefully sutured, but in spite of this, oftenowing to infection of the joint previously to operation,they occasionally united imperfectly and deformity andimperfect control of the foot resulted. Besides thetransverse incision through the skin he now madevertical incisions of sufficient length to enable him toexpose the several tendons for a considerable length. Inthe young infant he found he could expose the interior ofthe joint by dividing the peroneus tertius alone as well asthe external, anterior, and posterior ligaments, the othertendons being turned out of their sheaths and hooked aside.In other children he also divided the peroneus longus andhigh up, cutting through muscular and tendinous fibres,securing larger and more vascular areas in accurateapposition, and keeping the sutured portion at a distance

1 Transactions of the Clinical Society of London, vol. xxv.

from the joint and so minimising infection of it. He tookthe same precaution with the peroneus tertius. By thismeans the objections to the other operation were practicallycompletely avoided without diminishing its thoroughness.

OPHTHALMOLOGICAL SOCIETY.

Implantation Cysts of the Iris.- Green Vision in a Case ofTabes Dorsalis.-Albuminuric Betinitis in a Cltild.-Strabismus Fixus.

AN ordinary meeting followed by the annual genera)meeting of this society was held on March 9th, the President,Mr. H. R. SWANZY, being in the chair.Mr. DEVEREUX MARSHALL recorded three cases of

Epithelial Implantation Cysts of the Iris which he hadrecently examined and showed photographs by the lanternof the points of interest which each exhibited. The firstcase was that of a boy, aged 12 years, whose eye waswounded eight years before. It remained quiet until threemonths before removal, since which time it had been painfuland irritable. There was found to be a crescent-shaped scarof the cornea, to which the iris was adherent. At thebottom of the anterior chamber there was found a large cyst.On further examination the walls were found to be formed

by the iris, which was split into two unequal parts ; theiris itself was so atrophied that at one place the wall wascomposed solely of epithelium. The second case was that;of a youth, aged 17 years, whcse eye was wounded sevenyears ago with a piece of wood. It remained quiet untilit received a severe blow two weeks before removal. Asmall cyst was then found at the upper and inner part ofthe anterior chamber. The anterior wall of this was com

posed of an extremely thin piece of atrophied iris lined withepithelium and adherent to Descemets membrane. Itsposterior wall was composed of the greater part of thethickness of the iris ; the epithelium was laminated andsimilar to that of the cornea. The third case was thatof a man, aged 29 years, whose eye was wounded someyears before and had recently become painful and quiteblind. The eye was enucleated and in the anteriorchamber was found a small mass near the inner corneo-scleral junction. It had developed in the muscular part ofthe iris. The cyst was found to be lined with epitheliumwhich had undergone great proliferation, so much so that its.cavity was filled with degenerated epithelial cells which hadbecome shed and having no place of escape had becomecollected together in the interior of the cyst, thus givingrise to the dense white appearance noted during life. Theepithelium in this case apparently arose from a portionof cutis which had become driven in at the time ofthe original accident, whereas in the other cases thoepithelium of the cornea was almost certainly thecause of the cystic development. The question ofcysts in general was shortly discussed and somemuseum preparations of eyes illustrating the subjectwere shown.-Mr. TREACHER COLLINS said that these cystsvaried greatly in situation ; they were sometimes found inthe substance of the cornea, sometimes in the anteriorchamber after cataract extraction, and sometimes in the iri&itself, being occasionally caused by development of the root-sheath of an eyelash carried into the eye. They were also.found in the vitreous, beneath the conjunctiva, and in the-orbit. They might be classified as deeply pigmented and,unpigmented, the former ones being due to a separation ofthe two uveal layers of the iris, the latter or unpigmentedones being either mesoblastic, due to dilated crypts of theiris, or due to epithelial inclusion after injury, in whichcases their contents might be either clear or sebaceous,according to the source of the included epithelium.

Mr. WORK DODD related the case of a patient, aged 32years, the subject of Green Vision in a case of TabeaDorsalis. In 1886 his sight was quite good ; in 1891 hehad diplopia, from which he recovered. His colour visionremained good till 1897 and he complained of defective sighsshortly before being seen in July, 1898. When first eenthe vision of the right eye was -62. and that of the left eyewas 1/60 He had Argyll-Robertson pupils, optic atrophy,. and contraction of his visual fields ; his gait was ataxic andhe had occasional trouble in passing urine. In September,1898, the vision of the right eye was reduced to 1/60 while withthe left eye he could only perceive movements of the hands.