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Medical Societies.MEDICAL SOCIETY OF LONDON.

General Meeting - Operation for the Radical Cure (If./f1;moral Hernia.-dppendicitic Absoess associated nit7z

lylultiple Liver Abscesses.A GENERAL meeting of this society was held on May 14th,

Sir LAUDER BRUNTON, the President, being in the chair.The following was the result of the election of officers and

council for the ensuing year -President: Mr. C. A. Ballance.Vice-Presidents : Dr. W. Pasteur, Mr. C. W. Mansell Moullin,Mr. John Tweedy, and Sir Edgcombe Venning. Treasurer:Mr. D. H. Goodsall. Librarian: Dr. A. F. Voelcker.Honorary secretaries: Mr. C. S. Wallace and Dr. F. J.Pjynton. Honorary Secretary for Foreign Correspondence:Mr. H. J. Waring. Council: Mr. R. C. Bailev, Sir HughBeevor, Bart., Mr. C. Carter Braine, Dr. J. F. H. Broadbent,Sir Lauder Brunton, Dr. H. A. Caley, Dr. Edmund Cautley,Dr. G. H. A. Comyns Berkeley, Dr. J. H. Drysdale, Lieutenant-Colonel R W. Ford, R.A.M.C., Dr. A. E. Garrod, Mr.Francis Jaffrey, Mr. T. H. Kellock, Mr. John Langton, Dr.C A. S. Leggatt, Dr. Percy J. F. Lush, Dr. F. S. Palmer,Dr. J. S. Risien Russell, Mr. H. P. Symonds, and Mr.W. H. C. Staveley.The annual reports of the council, honorary librarian, and

c’lairman of the house and finance committee were presentedand adopted.An ordinary meeting was then held andMr. W. H. BATTLE read a paper on a Method of Operation

for the Radical Cure of Femoral Hernia. He commenced bypaying that it was more difficult to deal with large femoralherniss than with those of similar size in the inguinal region.There was also a greater tendency for the ring to enlarge.The operation he was about to advocate was first per-f Jrmed by him in 1899.1 After thoroughly cleansing thep .rts a vertical incision was made over the sac and thecontents were dealt with in the usual way. The object oft ie operation was to form two flaps, an inner and ano iter, and to slide the inner behind the outer, securingover the upper opening of the femoral canal.

T l1ese flaps were then sutured in position and thus a shuttero living tissue of great strength was placed below theigatured neck and across the upper end of the femoral canal.Usually no drainage was required. In only one case was thewearing of a truss necessary afterwards. Including thecases mentioned in his paper in THE LANCET in February,1901, Mr. Battle had operated in this way on 64 cases offemoral hernia for its radical cure. One case was under 20years of age, 14 cases were between 20 and 30, 23 cases werebetween 30 and 40, two were between 50 and 60, and two wereover 70. The duration of the hernia had varied from a fewdays to 20 or 30 years. 30 cases were reducible, 30 wereirreducible, and four were strangulated. In only four casesdid any suppuration ensue. There were no deaths. Onlyone patient had returned with a recurrence of the hernia,but it was only right to mention that some had beenonly recently operated on. A somewhat similar operationhad been described independently by Mr. R. H l’arry2 inOctober, 1901, only he advocated the suturing of the con-j )ined tendon of Poupart’s ligament to Cooper’s ligament.I conclusion, Mr. Battle claimed the following advantages fort’ie operation which he had described : (1) the suppression ofevery trace of the peritoneal infundibulum by the applicationof a ligature to the highest possible level of the hernial sac ;(2) the annihilation of the femoral ring ; and (3) the replace-ment of the septum crurale by a strong musculo-aponeuroticscreen. Cases were narrated and illustrated by lanternslides.-Mr. CUTHBERT S. WALLACE remarked on the diffi-culties of closing the internal ring in such cases and therigidity of the parts around and the proximity of the greatvessels. He thought the operation was a good one and hebelieved the main cause of its success lay in the applicationof the three sutures along the line of the inguinal canalwhich were freed from tension by the second flap. Theresults of this operation seemed to be very good.One of the Hon. Secretaries read (for Mr. H. J.

CTTRTIS of Bulawayo) a paper entitled, "A Successful Case

1 THE LANCET. Feb. 2nd, 1901, p. 302.2 Brit. Med. Jour., Oct. 19th, 1901.

of Appendicitic Abscess associated with Multiple LiverAbscesses." The patient was a man, aged 35 years, whohad suffered from malaria, dysentery, and syphilis inthe preceding years and was admitted to the BulawayoMemorial Hospital on Oct. 13th, 1904, with a history of onemonth’s abdominal pain. The temperature was 99 8° J.1’., thepulse was 128, and the respirations were 52. There wastenderness at McBurney’s point but no swelling. OnOct. 18th a tender swelling appeared in front of the rightkidney. On the 19th the abdomen was opened and aninflamed, red, and kinked appendix was removed from behindthe cæcum. While this was being done an abscess overthe kidney was opened and a large tube was inserted. Theabscess was not in contact with the appendix and reachedup to the costal margin. On the 31st a large abscess inconnexion with the liver was opened through the right tenthintercostal space. The pus was of the "anchovy paste"variety. On Dec. llth the same kind of pus was noticed inthe sputum and on the 16th there was severe hsemo-

ptysis. On the 17th the liver abscess was further exploredand a larger tube was introduced. Iodide of potassium inincreasing doses was now given and steady improvement wasmaintained until the patient was discharged on April lst,1905. - Mr. Curtis then reviewed the details of the case andpointed out as remarkable the absence of high fever whenthe patient first came under observation. It was open todoubt if the abscess was dependent on the appendix troubleor on the dysentery from which the patient had previouslysuffered. Amæbae were found in the pus and probably theappendicitis was an accidental complication of tropicalabscess of the liver. The prognosis of liver abscess com-plicating appendicitis and the frequency of this associationwere finally discussed.-The PRESIDENT, commenting on theuse of iodide of potassium, drew attention to the extremelylarge doses which could be tolerated with advantage in suchcases.-Mr. BATTLE discussed the association of the twolesions and the likelihood of their being accidentally or

causally connected. Possibly the hepatic lesion was tropicalabscess and the appendicitis simply concurrent.

CLINICAL SOCIETY OF LONDON.

Cystic Tl1mOl1r of the Spermatic Cord.— Carcinoma of the

Thyroid Glarul.-Perforated Gastric Ulcer treated byEvisceration and Irrigation.-Complete Removal of a

Multilocular Cyst of the Pancreas.A MEETING of this society was held on May llth, Mr.

H. H. CLUTTON, the President, being in the chair.Mr. CUTHBERT S. WALLACE described a case of Cystic

Tumour of the Spermatic Cord. A man, aged 41 years, wasadmitted to St. Thomas’s Hospital in 1904 with what

appeared to be an irreducible inguinal hernia and gave ahistory of abdominal pain and vomiting. However, at theoperation a tumour was revealed which consisted of twomain cysts with numerous smaller ones, the wholemass lying in the cord beneath the cremaster muscle.At the internal ring the tumour disappeared withinthe abdomen and could be felt to form a con-

siderable mass in the pelvis. The inguinal portionof the tumour was excised. The operation was followedby recovery with atrophy of the testis from damageto the spermatic artery. Mr. Wallace regarded thiscase as being of the same type as those described by theolder writers under the title " diffuse hydrocele of thecord." Percival Pott in 1773 was the first to describe thecondition and he was of the opinion that it was of the natureof an oedema and this view was the one still put forward inEnglish books which make mention of the subject. Mr.Wallace believed that this explanation could not be

accepted. The so-called cystic adenomata of the testis andkidney were supposed to arise in remains of the Wolffianbody and in their construction were very similar to thetumour under discussion. When the original relation of thetestis and kidney was borne in mind it seemed possible that thefoetal remains found in these two organs might also be foundin the spermatic cord. It appeared, therefore, not improbablethat " multilocular cystic tumour of the spermatic cord" "had a similar origin in remains of the Wolffian body.-Mr.E. PERCY PATON referred to a female patient, 30 years ofage, whom he had seen for irreducible hernia. A smallcystic tumour was found in the ingainal canal similar incharacter to that described by Mr. Wallace.-Mr. T. H.

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KELLOCK thought that such tumours resembled rather thetumours known as hydrocele in the neck, and asked if thefluid had been examined. Another possibility which had ’’

occurred to him was whether the tumour might have beenan abnormally placed and cystic kidney.—The PRESIDENTquoted a case like that narrated by Mr. Wallace and thoughtthe subject should be referred to more in current text-books. The condition was certainly not a diffuse hydroceleof the cord as at present described in text-books. ,

Mr. A. C. HUDSON read a paper, illustrated by the epidia- I,scope, on Carcinoma of the Thyroid Gland. A description ’,was given of eight cases of tumour of the thyroid exhibitingthe characters of malignant invasion and of six other casesin which, although the ordinary clinical features ofmalignant disease were absent, the tumours showed the

histological structure of carcinoma. Two tumours discoveredat necropsies were also described. Reference was then madeto the mode of origin of the capsule of a simple adeno-matous thyroid tumour and its possible significance in thestudy of the behaviour of carcinomata. The cases describedpointed to malignant disease of the thyroid being somewhatcommoner and at the same time more amenable to surgicaltreatment than was perhaps generally believed. Thesecases also emphasised the difficulty likely to be expe-rienced in correctly estimating the degree of malignancyof epithelial thyroid tumours solely from the type and

arrangement of the epithelial cells and other hi&to!ogicalfeatures. There were, moreover, cases of undoubted carcinomain which metastasis did not occur and the histological struc-ture of these tumours presented various transitional formp.-The PRESIDENT referred to several cases of carcinoma ofthe thyroid which he had operated upon. The first of thesehe met with in 1886 and the next in 1903; both of thesepatients were still living. In another case met with in 1905the diagnosis presented some difficulty ; the tumour was

partially removed and although the growth had perforatedthe trachea the patient did well. Speaking of the diagnosis,the President said that malignant growths, though they mightbe very small, were more firmly adherent to the trachea thanadenoma or any other tumour and were very often encapsu-lated. The clinical history of such cases was very differentfrom carcinoma in other places, as the tumour was so muchslower in its progress.-Dr. C. W. WIRGMAN had seen severalcases in which the bones had become secondarily involved,although some of these cases had resembled adenomata intheir clinical and microscopical characters.-Mr. W. G.SPENCER remarked that thyroid carcinoma appeared tohave such special features of its own that it would perhapsbe better to describe cases like those narrated by Mr.Hudson by a special designation, such, for instance, as

adeno-carcinoma.Mr. E. W. ROUGHTON communicated a case of Perforated

Gastric Ulcer treated by evisceration and irrigation. The

patient was a woman, aged 26 years, who had had indigestionfor three weeks followed by symptoms of perforation. Theabdomen was opened five and a half hours after the onset ofthe symptoms and the perforation was closed by sutures. Asthe stomach contents had escaped freely, soiling all partsof the peritoneum, the abdominal incision was prolonged, thesmall intestines were turned out, and the abdominal cavitywas thoroughly irrigated. The irrigation was commenced inDouglas’s pouch, so tt at the solution might flow in the

opposite direction to the extravasated stomach contents, thusminimising the risk of spreading the infection. The opera-tion caused very little shock and the patient made a goodrecovery. In Mr. Roughton’s opinion irrigation could hardlybe performed satisfactorily without turning out the smallintestines; it was important to start in Douglas’s pouch.-Mr. SPENCER remarked that difficulties existed in the

tympanites which ensued in the intestines and the strainon t2e mesentery.

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Mr. J. D. MALCOLM narrated a case of Complete Removalof a Multilocular Cyst of the Pancreas, with colo-colicanastomosis 16 days later, followed by recovery. The patientwas a woman, aged 50 years. A malignant growth of the leftkidney was diagnosed but at the operation a multilocularcyst of the tail of the pancreas was discovered andremoved. Healing caused no trouble but symptoms of apartial obstruction of the intestine developed and the abdo-men was reopened on the sixteenth day after the operation.The difficulty existed at the splenic flexure and an anasto-mosis between the transverse and descending colons waseffected, after which there were no further urgent symptoms.The tumour, which was to be preserved in the Museum of

the Royal College of Surgeons of England, was exhibited.It was a multilocular cystoma with a small amount of solidstructure between the cysts. The fluid was not examined.The solid growth, as described by Mr. S. G. Shattock, showedin parts an adenomatous and in parts a carcinomatous stiuc-ture. Another case 1 in which a similar tumour was removedby Mr. Malcolm was referred to ; also one published by Mr.Watkins Pitchford’ and one recorded by Dr. Reginald H.Fitz.3 The last named had collected eight cases, all those of"benign" " multilocular cysts of pancreatic origin which hecould find ; some of these showed no new growth of any kind.A case published by Dr. F. H. Dunning resembled the onenow recorded by Mr. Malcolm in many details. The rarity ofthese tumours was noted, the two removed by Mr. Malcolmand that from the case recorded by Mr. Watkins Pitchfordbeing the only specimens in the Museum of the Royal Collegeof Surgeons of England. The question of their origin was dis-cussed and Professor Ambrose Monprofit’s 5 case, in which itwas necessary to remove the tail of the pancreas and the spleento complete the operation, was referred to. The tumour in-this case was said to arise from the remains of the Wolffianbody because of its structure. But on some grounds manyof the foregoing cases could be attributed to the pancreas asthe seat of their development. Mr. Malcolm’s first case con-tained fluid which was strongly amylolytic and the structureof the second was very suggestive of that of the parcreas.The difficulty of diagnosis was discussed, most of the case&

having been regarded as renal or ovarian tumours beforeoperation. Complete removal was held to be the onlyrational treatment when it was possible, as drainage of amultilocular cystoma, especially if it should be malignant,was a futile procedure.-The PRESIDENT referred to a casein his experience which was mistaken for an ovarian tumour.The pancreas had to be cut through and a troublesome

pancreatic fistula ensued. Tumours which could be lifted outof the abdomen like that narrated by Mr. Malcolm must beextremely rare.-Mr. MALCOLM, in reply, expressed the beliefthat the pancreas could be cut through as fearlessly as anytissue without very serious risk of fistula.

OPHTHALMOLOGICAL SOCIETY.

Congenital Malformed Cystic -Eye.--Radium in the Treat-ment of Rodent Ulcer.—Implantation Tumour of the Iriscontaining Woud Fibres.—Exhibition of C’ases andSpecimens.A MEETIKG of this society was held on May 3rd, Mr. J.

PRIESTLEY SMITH, the President, being in the chair.Mr. S. JOHNSON TAYLOR and Mr. E. TREACHER COLLINS

contributed clinical and pathological accounts of a CysticSwelling occupying the position of the Left Eye and

apparently formed mainly by a forward bulging of theconjunctiva of the upper lid. It was present at birthand steadily increased in size. Mr. Taylor first saw thechild when three weeks old and then tapped the cyst with a,fine trocar and cannula. It refilled the following day.When next seen, about a year later, it had increased in alldimensions, standing out two and a half inches from theorbital rim and giving a most unsightly appearance. Some

discharge and blood had also been coming away fromits apex for two months. Mr. Taylor therefore operatedunder a general anæsthetic and succeeded in removingit in its entirety. Mr. Collins stated that the patho-logical examination of the specimen showed that the oyttwas really due to an enormous distension of the whole globe.The outer fibrous tissue wall appeared to be sclerotic and inplaces much attenuated. The inner coat corresponded to theretina but nowhere did that portion of it which is normallydeveloped from the innEr layer of the secondary optic vesiclelie in contact with that developed from the outer layer. Theanterior portion of the cyst was lined by the former—i.e.,tissue composed of a delicate network of fibres withbranching cells having nuclear bodies amongst them. The

posterior part of the cyst was lined by the latter-i.e., a

single row of epithelial cells deeply pigmented in places andin others unpigmented. The cavity of the cyst was composed

1 Transactions of the Medical Society of London, vol. xxi., p. 97.2 Transactions of the Pathological Society of London, vol. liv., p. 354.3 The American Journal of the Medical Sciences, New Series 120,

p. 184.4 The American Journal of Obstetrics, 1905, p. 101.

5 Gazette Médicale de Paris, March 12th, 1904.