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one case where the peritoneum has been injured, althoughfluid distension had been practised, and students not

infrequently puncture the peritoneum on the dead bodyin performing supra-pubic cystotomy, unless the teacher pointsout this danger and its remedy with emphasis. Mr. GeorgePollock, who was present at the operation, has introduced avery pronounced curve at the end of the sound, which allowsthe tip to hook round the symphysis and elevate the bladderwall at the same time. I can testify to the facility given byhis instrument in the performance of the operation, and itseems to be preferable to the sonde à dard advocated byFrère Jacques of Orleans. It is satisfactory to note that theurethral obstruction has benefited by the removal of spasmcaused by the stone in the bladder. The patient passes hisurine now in a normal stream.

SOUTH DEVON AND EAST CORNWALLHOSPITAL, PLYMOUTH.

COCCYDYNIA ; EXCISION OF COCCYX.

(Under the care of Mr. LUCY.)THERE are many conditions for which it may be necessary

to excise the coccyx, but we rarely meet with any of them in l

practice. The patients usually give a history of injury to thepart, which on examination is found to have sustained

fracture or displacement, or the injury may have led to achronic inflammation of the bone or joint or to necrosis ofthe bone. The formation of a tumour or a congenital elongationof the bone may necessitate excision. There is also a group-of which the following is an example-in which after removalno abnormal change in the bone is found. It is difficult todiagnose these cases of coccydynia from hysterical or reflexcases. The condition is somewhat rare in men. Descrip-tions of the operation have been published in THE LANCETfrom time to time. We may instance cases under the careof Mr. Whitehead1 and Mr. Odell, and an interesting letterby Dr. Nott.3J. M-, aged sixty-three, single, cook, was admitted onFeb. 4th, 1892, complaining of great pain in the lower partof the back when sitting down, which had been present forover a year. A few years ago she slid off a table and hurt"the bottom of her spine " on a tiled floor. She had no

pain on walking or on defecation. There was a small swellingthe size of a marble to the right of the tip of the coccyxand presenting a small dimple on the surface. The coccyxwas freely movable forwards at the sacro-coccygeal joint,the movement causing the patient intense pain. She alsohad a slight anal fissure and an intero-external hæmor-rhoid. So, thinking that the neuralgic symptoms mightbe due to the latter, she was given chloroform on

Feb. 12th, and the sphincter was stretched and thehæmorrhoid removed by crushing. She quickly got wellfrom this operation, but the severe pain on sitting per-sisted ; therefore, on Feb. 26th she was again anaesthetised.A longitudinal incision was made over the coccyx down tothe bone, the periosteum was divided and separated by araspatory and the coccyx removed. At its tip there was asmall dermoid cyst containing sebaceous material, which wasdissected out. Haemorrhage was pretty brisk from severalsmall arteries in front of the coccyx. The wound healed bygranulation. She got up on March 30th, the wound beingquite sound, walked on April 9th, and left the hospital [onApril 26th, being able to sit comfortably without any pain atall. She was last seen on May 26th, three months after theoperation, the wound was soundly healed, and she was backat her work, was quite free from pain on sitting down, andwas putting on flesh.

1 THE LANCET, vol. ii. 1886. p. 112 2 THE LANCET, vol. i. 1887, p. 1088.3 THE LANCET, Nov. 5th, 1870, p. 654.

MEDICO-PSYCHOLOGICAL ASSOCIATION OF GREATBRITAIN AND IRELAND.-The next quarterly meeting will beheld at the Royal College of Physicians, Edinburgh, on

Thursday, the 10th inst., when a paper will be read by Dr.G. M. Robertson on the " Treatment of Acute Mania," andDr. Turnbull will open a discussion on "Asylum Dietaries."The next examination for the Certificate in PsychologicalMedicine will be held in December and for the NursingExamination in May.

Medical Societies.CLINICAL SOCIETY OF LONDON.

: Macrocheilia treated by Electrolysis.—Subcutaneous Suture ofPatella.—Transverse Fracture of Patella.—Raynaud’sDisease.—Amputation of Arm for Lymphatic Œdema incases of Breast Cqneer. - Cowqenital Deficiency of a portionof Chest-wall.—Sinus in Loin connected with PosteriorMediastinal Abscess.-Sarcoma of Skin.—Complete Erasioiaof Ankle-joint.

- - -

A "CLINICAL" meeting of this Society took place onOct. 28th : the President, Sir Dyce Duckworth, in the chair.

Mr. ARBUTHNOT LANE showed a man, aged twenty-eight,who was employed at the General Post Office and who three’years and a half ago struck his upper lip ; this was followedby very great swelling, and two months later the lower lipalso became swollen. The swelling was hard and brawny,and after a short time the cheeks became hypertrophied inthe same way. Having refused to yield to other treatment,electrolysis was employed on several occasions, and the lips.had returned to their normal state, except that the lower lip,

was still a little larger than it should be.Mr. BARKER showed a man, aged twenty-five, a porter, onwhom he had performed subcutaneous suture of the patella., The wire still remained round the bone, which was united bya strong fibrous band. He was on a splint for three weeks-

after the operation and left the hospital at the end of a,

month. It was done in March, 1891, the fracture being:)

transverse and the wire for the suture being one-sixteenth of an. inch thick. The patient had been doing very hard work since,and the movements were very free. Since then he had. operated on a second case, and he had allowed him up without: a splint at the end of a week, and he was able to walk freely

in six weeks.Mr. PAGE also showed a case of transverse fracture of the

patella in a patient aged thirty-three, in which subcutaneous. suture, according to Mr. Barker’s method, was done on: May 18th, 1892. The man was a coalheaver by trade, and the, result was good, as he thought that the union was bony. He

; had since treated in a similar manner a case of compoundfracture of the patella, which had also done well ; but in both

: cases he had used silk and not wire.Dr. F. LITTLE showed a girl employed at a florist’s, who was

.

the subject of Raynaud’s disease. When aged nineteen both.

the hands and feet began to feel cold, but this was unaccom-panied by pain. Ulceration then commenced around the

. nails of all the fingers except the little fingers, and sincethen shortening and clubbing of the terminal phalanges had. occurred. The nails of the toes had not been affected.

There was nothing in the family history to throw light on the,

case. The body temperature was normal but the surfacetemperature of the hands was 65° F. There had been nc’

hæmaturia or hsemoglobinuria. The treatment consisted in

the exhibition of nux vomica and steel, together with thelocal employment of galvanism.

, Mr. BLAND SUTTON showed two cases of amputation ofthe arm for lymphatic cedema in cases of cancer of the breast.

The first was a woman aged forty-three, who, two years anda half ago, had the right breast removed for cancer. Sir

months later some knots began to form in the skin of thet scar, and later the whole of the neighbouring parts were’

, invaded en cuirasse. The arm then became much swollen

c and oedematous, being three times its normal size, extremelyheavy, and it had already induced a moderate degree of

lateral curvature. The limb was removed at the shoulder-joint and the patient made a good recovery, being ableto get about without pain. The second case was that of apatient aged sixty-four, who, four years ago, underwent the’

. operation of removal of the right breast for scirrhus. Eighteen’

months ago recurrence occurred, and a large mass formed inthe axilla. The arm presented a more marked degree oflymphatic oedema than did that of the last patient; she was

obliged to carry the limb in a sling, and it was exceedingly. painful. In this case he followed Mr. Treves’splan, dividing the1 clavicle and amputating the humerus and scapula. The limb,’ after removal and after much of the fluid had drained away,1 still weighed fourteen pounds. The wound healed in threeweeks and the patient left the hospital much relieved.

Dr. ABERCROMBIE showed a child with a congenital defi-

1047

I ciency of a part of the anterior chest-wall. The infant was jtwo months old ; there was absence of the third and fourthcostal cartillages on the left side and defect of the left 1

second rib. The gap left was protected by nothing but skin;there was also some deformity of the fingers of the left hand.He likewise showed the chest-wall of a child who had beenuder his care ten years ago with a similar deformity. I

Dr. SIDNEY PHILLIPS showed a museum preparation of asomewhat similar case, which, when alive, he had shown atthe Society. There was a deficiency of the xiphoid cartilage,and the diaphragm failed to gain an attachment anteriorly,so that the heart’s apex lay in the abdomen.

Mr. SPENCER showed a girl who had a sinus in the leftloin connected with an abscess in the posterior mediastinum.’The collection of pus in the loin formed painlessly, and he

I opened it and slit up the sinus, finding a narrow channelI xunning in front of the twelfth rib. He cut through the neck’

of this rib and found that the sinus ran up beside the spine.The examination of it involved great care on account of theproximity of the pleura. The discharge was very profuseand there was a fear of amyloid disease. He contemplatedthe desirability of extending the search further up by cuttingthrough the necks of the ribs.

Dr. BRISTOWE made a communication on a case of sarcomaof the skin which resembled granuloma fungoides. He had

unfortunately mislaid his notes, and therefore gave a ’l’éS1(’1néof the case from memory. The patient was aged abouttwenty-two and had been ill for several months before hisadmission into St. Thomas’s Hospital. He was then emaciatedand hectic, and half a square foot of his right axilla, chest-wall and neck were involved in the disease, which progressed

, aeapidly. The skin was covered with projecting noduleswhich were raised from a quarter to half an inch above thecutaneous surface. They had an appearance very much likeerythema nodosum and there were depressions from ulcera-tion. A few of the nodules seemed to die away. On

inspecting the ulcers a certain amount of new growthwas seen upon their floors. It struck him as beingmore rapid and more ulcerative than granuloma fungoides.Some of those who saw it considered it to be a case of tuber-culosis of the skin, though it was not like lupus. The patient<lied, and Mr. Shattock pronounced the growths to be sarco-mata. But it was a curious point that the lungs were studdedwith minute tubercles and that the patient had haemoptysisbefore his death.-Dr. HADDEN inquired if the lung-growthsmight not be miliary sarcomata.-Dr. RADCLIFFE CROCKER- said that there were two varieties of granuloma fungoides ;one in which chronic dermatitis was the first thing, and thiswas followed by the development of growths, the duration ofthe case being slow. In the second variety the tumours wereformed first, and the case was more rapidly fatal. The Frenchclassified these cases under the head of lympho-sarcomata.A case such as those of the second class had been brought byMr. Swinford Edwards before the Pathological Society.-Dr.PRINGLE inquired as to the method of the spread of the growthat its margin. Sarcoma, in contradistinction to granuloma,,usually spread by nodules at the margin ; these were at firstsubcutaneous and only to be discovered by palpation.-Dr.BRISTOWE in reply said that the growths did spread by nodulesat the margin: these were at first discrete and subcutaneous ;- some of them disappeared, while others enlarged and joinedthe main growth.

Mr. ARBUTHNOT LANE related two cases illustrating anoperation of complete erasion of the ankle-joint, by whichthe articulation could be exposed most fully and everyiparticle of its synovial membrane could be seen and removedif necessary. The operation was performed in this manner :A more or less horizontal incision was made from the anteriormargin of the internal malleolus, outwards, across the frontof the ankle-joint, backwards immediately below the externalmalleolus, and inwards above the heel to a point over thetendon of the flexor longus hallucis, everything being divideddown to the bone. The only structures about the ankle-jointwhich were not cut through were the internal lateral liga-ment, the tendons of the tibialis posticus, flexor longus digi-torum, and the flexor longus hallucis, the posterior tibialvessels, nerve and the superjacent connective tissue and skin.On adducting the foot any portion of the interior of the ankle-joint was fully exposed, and the narrow prolongation ofsynovial membrane which ran up between the tibia andfibrlla could be examined and dissected out by cuttingthrough the inferior interosseous and the anterior inferiortibio-fibular ligaments. It was therefore apparent that theinterior of no other joint in the body could be more fully

exposed and cleared of its synovial membrane than could thisone by means of the operative procedure suggested. Shouldthe disease have extended to the subastragaloid articulationit was necessary to divide all the structures covering in thisjoint superiorily and externally together, with the interros-seus ligament connecting these bones, and in extensivedisease of the astragalus this bone might be excised withadvantage. Whether the cut surfaces of the several tendonswere sutured together or not seemed to affect the subsequentutility of the foot little if at all. Some care was, however,required in putting the foot up in plaster bandages after theoperation that the fibula did not drop back a little off its faceton the astragalus.-Mr. CLUTTON had performed this operationby another method. Seven years ago he did the first case witha good result, and since then he had done six others, onlyone of which had afterwards to be submitted to amputation.He made an incision on each side from below each malleolusanteriorly; through these cuts he introduced a sharp spoonand his finger and scraped out the joint; cartilage and bonewere removed as well if necessary. He subsequently put thelimb on a knee-rest and kept it up for one or two years.Mr. Lane’s method was evidently good if there was asequestrum to be removed from the astragalus. In his owncases there had been no trouble as regarded movement of thetoes, nor had the bones become displaced.-Mr. GODLEEsaid that he made lateral incisions and chipped off themalleoli, and thus got a good view of the joint.-Mr. PAGEsaid that in order to do a thorough erasion it was necessaryto get such a view that every part of the joint could beseen; yet he could not help thinking that the cut neednot be so free as Mr. Lane had made it, the anteriorincision alone from malleolus to malleolus being in his

opinion sufficient.-Mr. SILCOCK said that two yearsago a case was shown at that Society of erasion ofthe ankle-joint by an anterior incision, which relieved thepatient of the disease and ended in perfect mobility of thejoint. After anterior erasion he had seen sensation restoredover the dorsum of the foot in a few days, even although thenerve had not been sutured.-Mr. GOULD thought that if thejoint could have been satisfactorily dealt with without soextensive a division of tendons it would be better for the

patient. He questioned Mr. Lane as to the precise resultshe had obtained in the cases he had related, more especiallyas to the mobility of the joint.-Mr. LANE, in reply, said thathe had unfortunately lost all trace of the first case. Whenhe last saw him the foot was a good one for walking on,though it was flat and he could not turn the toes up well ;there was some mobility in the ankle-joint. The second casehad a very good foot. As the child could not move the toes, hehad since shortened the tendons. It should be rememberedthat the cases were so bad that a Syme’s amputation wasthe only alternative, and as opposed to that the results werevery good indeed.

____

MEDICAL SOCIETY OF LONDON.

- Z<?’-0?’<*K? A1lSCu.ltation.-Sz(’’l’gicaZ Treatment of Cysts ofthe Vulvo-vaginal or Cowper’s Glands.

AN ordinary meeting of this Society was held on Oct. 31st,the President, Mr. Hutchinson, in the chair.

Dr. B. W. RICHARDSON read a paper on Intra-thoracicAuscultation: a New Departure in Physical Diagnosis,which we publish in another column.-The PRESIDENT,after congratulating the author on the excellence of hiscommunication, referred to the possibilities of diagnosisopened up by this new method.-Dr. ROUTH recalled a paperhe had read some years ago before the British MedicalAssociation on vaginal auscultation as an aid to the diagnosisof pregnancy &c.-Dr. RICHARDSON, in the course of someremarks in reply, demonstrated the effects of tubes constructedof rubber, metal and cane, his preference being at present forthe former.

Mr. ALBAN DORAN read some notes on the Surgical Treat-ment of Cysts of the Vulvo-vaginal or Cowper’s Glands. He

began by reading notes of a case in his own practice. The

patient was forty-eight years of age, and came to him forrelief on account of an unusually large swelling of the leftlabium, which had existed for several months and caused greattrouble whenever she walked or sat down. It fluctuatedfreely and could be felt extending far into the ischio-rectalfossa. He thought it advisable to remove the entire cyst,the portion in the ischio-rectal fossa being carefully dissectedaway. Four arteries were divided and required ligature.