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represented in the nose, and in the submucous tisslHof the upper lip, whilst the hard nodule in the upperlip to which the cell-infection could be directly traced fronthe submucous alveolar masses was composed of the tubula]variety. Both in the narrow tubular masses and in the larg(alveolar masses Dr. Thin had recognised and been able t(isolate a membrana propria. (Thiersch had found no membrana propria). With regard to the source of the new epithelial growth, he had been unable to find in any of thefour cases that it communicated directly -with the retE

mucosum, sebaceous glands, or hair-follicles. Where iicame in contact with those structures it could still be dis.tinguished from them, eosin being here specially useful. InSir James Paget’s case and in Mr. Morrant Baker’s secondcase he had, however, found some sweat-glands the seat ofnew growth; and, although he had not traced this newgrowth into unbroken continuity with the cell-masses, hebelieved it pointed to the disease being an adenoma of thesweat-glands. He quoted cases from Verneuil and Thiersch,in which he believed the drawings bore out this view. Hewas unable to satisfy himself that the drawings in Thiersch’s"Atlas" bore out the interpretation put upon them bythat author, that the cell-growth began in the sebaceousglands. Mr. Hulke had not found any new growthfrom the rete mucosum or sebaceous glands. Dr. CollinsWarren had described cell-nests and large epidermiccells in rodent ulcer. Dr. Thin had not found similarappearances, and was forced to believe that Dr. Warrenhad confounded with them remnants of hair-folliclesor other epidermic elements which had not been completelydestroyed.-Mr. BuTLlrr, who had seen three of the casesreferred to by Dr. Thin, was not prepared to admit that thethird was an instance of rodent ulcer rather than epi-thelioma. It had more the aspect of the latter during life,and his own specimens of it showed thickening and down-growth of the rete mucosum, and the formation of cell-nests.- Dr. SANGSTER, in examining a nodule from the neigh-bourhood of the rodent ulcer, found its characters to bequite like those described by Dr. Thin in the early stage ofrodent ulcer. The rete Malpighii, instead of .being over-grown, was atrophied by the pressure of the new growthbelow it, this growth appearing to arise in the sweat-

glands, the lamina and margin of which were obscured byproliferating cells.-Mr. M. BAKER said that Dr. Thin hadestablished microscopically the distinctions which surgeonshad long made clinically between rodent ulcer and epi-thelioma. If he was not mistaken, Dr. Thin at first thoughtall rodent ulcers were epithelial cancers, but his investiga-tions had led him to the opposite view.The meeting then adjourned.

CLINICAL SOCIETY OF LONDON.

Injury to Arm, with Loss of Conductivity in Radial andMedian Nerves. — Suprapubic Lithotomy. - Pistol-shotWound of S’kull.THE first meeting of this Society after the recess was held

on the llthinstant, the President, Mr. G. Callender, F.R.S.,in the chair. Three papers of considerable surgical interestwere read: one by Mr. Hulke, of complete recovery from asevere injury to the arm, with restoration of nerve-power,temporarily suspended, by the stretching of the median andradial nerves; one by Mr. Hutchinson, on a case of supra-pubic lithotomy for the extraction of a calculus of unusualsize ; and, lastly, one by Mr. Clement Lucas, of a pistol-shot wound of the forehead, followed by death from menin-gitis. The discussion on this paper led to several cases beingcited of recovery after severe gunshot injuries of the head,or after considerable destruction of brain-substance.The eleventh volume of the Transactions was laid on the

table by the President, who took the opportunity of thank-ing the secretaries for their labour in its preparation.Mr. HULKE read notes of a Case of Fracture of both

Humeri; Rupture of the Left Brachial Artery; Loss of

Conductivity of Median and Radial Nerves of the Left Arm,and other injuries ; Recovery, with complete Restoration ofNerve-function. The patient, a silver-polisher, was broughtto the Middlesex Hospital for severe injuries inflicted bymachinery. There was a comminuted fracture of the left

humerus at its lower third, considerable swelling of thlower half of arm and upper half of forearm, and purplis]discoloration of the lower half of forearm. No pulse coul4be felt at the wrist ; but the brachial artery pulsated amiddle of arm. On inner side of arm was a small woundfrom which venous blood was oozing. The area of distribution of the median and radial nerves was found to be whollanaesthetic. There was also fracture of the right humerusand of one or more of the middle ribs near their angles ; alsofracture of both ilia, wounds in the left thigh, with laceration of the tendon of the quadriceps extensor muscleOn the third day after the receipt of the injury, the pulsecould be felt at the left wrist. The patient kept Mbed for six weeks, and at the end of another fortnighleft the hospital. The anaesthesia of the hand and finger;continued for some time, but sensation has graduallyreturned, and is now perfect. Flexion of the left elbow i:checked at an angle of 90 degrees. (The patient was showito the Society.) Mr. Hulke remarked that the suspensiolof conductivity in the median and radial nerves was dueprobably to those nerves being over-stretched but not com.pletely torn through. The case also showed the facilitywith which collateral circulation was re-established in theupper limb, and the small risk there was of further hæmor.rhage when the vessel was completely torn through-a factwhich led him not to amputate the arm. The man’s abste-miousness and good general health no doubt favoured hisrecovery.-The PRESIDENT said, with reference to the effectproduced by the stretching of the nerves, that in a somewhatsimilar case under the care of the late Mr. Holmes Coote, inwhich a child had sustained fracture of the humerus 01

compound dislocation of the elbow, it was evident that themedian nerve was stretched over the broken bones. Theresult was not so satisfactory as in Mr. Hulke’s case, for theparts supplied by the nerve never recovered sensibility, andconsiderable sloughing took place from the loss of nerve-supply. It was very difficult to measure the precise amountof stretching a nerve could sustain without impairment of itsconductivity.—Mr. HEATH thought the return of collateralcirculation after injury to the artery to be rapid, although ina case of gunshot wound of the arm which he had reported(Clinical Society’s Transactions, vol. ix.), where the evidenceof division of the brachial artery was even clearer thanin Mr. Hulke’s case, pulsation could be felt in theulnar and radial arteries three days after the injury. Inthat case Dr. Poore reported upon the electrical conditionof the limb, and found that, although the ulnar nerve re-covered, the median remained permanently damaged. Hehad lost sight of the man, and could not say what his presentcondition was. He inquired if the wound was treated onantiseptic principles.-Mr. MARSH pointed out that age wasan element in the rapid establishment of collateral circulation.He had known it effected within twenty-four hours in youngchildren.-The PRESIDENT said, although in the presentcase there could be no doubt that the recurrence of sensi-bility was due to recovery of the nerve-trunks, yet in somecases, as Weir Mitchell had shown, it would appear thateven after permanent injury to a nerve-trunk, sensibilitywas often restored through other nerve-channels in communi-cation with the branches of the injured nerve.-Mr. HULKEhad no doubt that the conductivity of the damaged nerve wasrestored, and that the return of sensation in this case wasnot due to any compensatory ingrowth of the nerve-supply.A more striking case, exemplifying the rapidity with whichcollateral circulation was established in the upper extremity,came under his notice some five or six years ago. Thepatient, an epileptic youth, nineteen years of age, fellthrough a window in a fit, cutting across the arm down tothe elbow. A compress was applied, the limb bandaged,and the youth taken home. Next day he was brought tothe Middlesex Hospital, and the forearm and hand werefound to be almost black and cold. There was a gapingwound at the bend of the elbow, laying bare the brachialartery, which was completely severed. On removing a padwhich had been wedged tightly into the wound, evidentpulsation was seen in the distal end of the divided vessel.Thus, within twenty-four hours, and under most adversecircumstances, collateral circulation had been set up. Thetreatment of the injury in the case he had related was basedon scrupulous cleanliness, but the circumstances of hisclinique did not enable him to carry out the antisepticsystem in all its details.Mr. HUTCHINSON related particulars of a case of Supra-

pubic Lithotomy for a large stone-the only case that had

550

come under his personal notice. The patient was a man purpose were shown. One was particularly ingenious. Ittwenty-six years of age, who had suffered no inconvenience was the invention of an Italian, and consisted in a cup-until six months before admission, when he began to have shaped blade or scoop, something like the female blade offrequent and painful micturition and haematuria. On sound- the lithotrite, which received the stone, whilst a long drilling, a stone of large size was detected, and it could also be was passed up the tube, and as soon as a hole of smallfelt by the rectum. The bladder was very irritable, and depth had been drilled, the stone could be broken up by athe urine contained pus and blood. The man was also slight tap against a steel rod which was passed down intomuch emaciated. It was evident that it could not be re- the drill-hole. It was remarkable how little force wasmoved by the ordinary operation, and on consultation with thus necessary to break up hard stones.-Mr. BARKER hadMessrs. Curling and Luke the question as to its removal recently seen Sir H. Thompson perform the high operation,through the rectum or by the high operation was raised, and when the greatest difficulty was experienced in reaching theit was eventually decided to perform the latter. No special stone, and was only finally effected by Sir Henry grasping thedifficulty arose in the operation except in the extraction of stone with a lithotrite and directing it towards the wound.-the calculus, and the bladder was drained by means of The PRESIDENT intended to bring some cases before thean india-rubber tube passed through a catheter into the Society, in which he had performed suprapubic puncture ofbladder. This was not very effectual, and, in spite of the bladder, and in one of these cases there was certainlymany other devices, the urine could not be prevented from some difficulty in reaching the bladder, nor was anythingwelling over the edge of the wound. The case did gained by pressure on the bladder through the rectum. Towell for the first week, when pyaemic symptoms set in obviate the trouble of urine welling up through the woundand the patient sank. At the post-mortem examination (which might be avoided by placing the patient in the pronethe bladder was found contracted and rigid from a thick position) lie had used a catheter as a syphon. At first hephosphatic deposit lining its interior. The ureters were had found this to fail, owing to the blocking of the catheter,dilated, and there was suppurative nephritis and pysemic but when, instead of one perforation, several holes weredeposits in the liver and lungs. The case showed the facility made in the sides of the instrument, no further difficultywith which the high operation could be performed, but also arose, as all the apertures did not get blocked. In his ownthe difficulty of keeping the bladder empty after the opera- case of suprapubic lithotomy the urine was drawn off by thetion. This would not have happened if the rectal operation urethra.-Mr. HUTCHINSON, in reply, said that every formhad been performed, but the occurrence of fistula was a of syphon action was tried and failed, and if holes were madedrawback to that procedure. The stone, composed of lithic in the tube above the extremity surely air would be admitted,acid, weighed six ounces and a quarter, and its circumference and the syphon fail.-Mr. CALLENDER said that the bladdermeasured nine inches in one direction and seven in another. contracted round the instrument. - Mr. HUTCHINSON re-Mr. Hutchinson exhibited the stone, and also the cast of marked that the bladder in his case was rigid from phosphaticanother, about a quarter of an ounce heavier, which had been deposit. No difficulty was experienced in any step of theextracted by the late Mr. J. Adams by the lateral operation, operation, except perhaps in the extraction, which wasand after severe traction. That case did well. For stones effected by means of lithotomy forceps. The ill result wasof usual size the lateral operation was no doubt preferable.- to be attributed to the patient’s low state of health at theMr. NORTON suggested that, in cases of the high opera- time. Other operations were discussed at the time, and hetion, the bladder might be drained by an incision into doubted whether the bilateral operation could have been donethe urethra and through the prostate in the perineum.- without an undue amount of laceration, and, although theMr. GANT thought the bilateral operation of Dupuytren stone might have been extracted through the rectum, therepreferable to the high operation, and sufficient for the was the drawback of a fistula resulting from that operation.extraction even of large stones.-Mr. HEATH remembered Mr. R. CLEMENT LUCAS read notes of a case of Pistol-shotsseing Sir H. Thompson perform the suprapubic opera- Wound of the Skull. A young man, twenty-one years oftion some years ago in the case of a boy with deformed age, shot himself with a revolver in a police-cell on Feb. 2nd,pelvis and a calculus too large for extraction by the 1878. Five of the chambers of the revolver had been dis-perineum. Mr. Erichsen had previously tried extrac- charged, but two only of the charges had been directedtion, but failed. Mr. Heath had also, of late years, seen against his head. He was brought to Guy’s Hospital in aSir Henry perform suprapubic puncture of the bladder in semi-conscious state, when about the centre of the foreheadcases of prostatic disease. It was not always easy, and were seen two small holes close together, with slightly in-he would like to know if Mr. Hutchinson experienced any verted edges, and but little blackening of surrounding skin.difficulty from the bladder being contracted. He had re- When Mr. Lucas saw him he had recovered consciousness,cently read how, by distending the rectum, the bladder but had some bleeding from the nose. Chloroform wascould be pushed upwards and forwards so as to appear above administered, and a crucial incision made over the wounds,the pubes; but he had not personally confirmed that state- displaying a blackened cavity beneath the skin, and atment, which was based on experiments on the dead subject. the bottom of this cavity was a reniform aperture in theFor drainage of the bladder he was in the habit of per- frontal bone, and lying far back, on what proved to beforming recto-veaical puncture in cases of hopeless injury to the indriven inner table, were the two flattened bullets.the spine, thereby saving all the trouble of passing a catheter These were extracted, as well as fragments of the diploein a paraplegic subject. As to the extraction of large calculi, and outer table, and then, on raising the fragments ofit was well known that quite lately a successful case of ex- the inner table, the dura mater was exposed on eithertraction, per perineum, of a stone weighing six ounces side of the longitudinal sinus ; it was pulsating, and athad occurred. He agreed with Mr. Teevan in urging one part a small puncture was seen in the membrane.that free division of tissues by the knife was preferable The upper part of the wound was brought together withto their laceration in a forcible extraction. Such cases sutures. The patient complained of great pain at the backwere suitable for the method carried out by Mr. Mac- of the neck, and in the evening the temperature rose tonamara in India-viz., of first performing lithotrity, and 99’8°. Next day the pain in neck persisted ; temperature-then extracting the fragments by lithotomy. "Perineal 100’2° to 102.1°. On Feb. 5th there was great swelling oflithotrity" has been advocated by a French surgeon.- eyelids ; towards evening he became drowsy and semi-con-Mr. HULKE did not think it necessary that the bladder scious; the temperature was 1024°; pulse 100; and re-

should be punctured through the perineum or rectum in spiration 25. On Feb. 6th he was unconscious and restless;cases of suprapubic lithotomy, for it would appear that the had an attack of general convulsions in the night, afteronly object in keeping the bladder dry was to obviate the which rigidity of the left leg was noticed. Later this gaveannoyance to the patient of the dribbling of urine, and not way to naccidity of the left limbs and rigidity of right arm.because there was much risk of extravasation or cellulitis. The temperature continued to rise till, on the evening of theThe writer of the article on the subject of lithotomy in 7th, it reached 1086° (rectum). Temporary reduction in thePitha and Billroth’s Surgery says that in his earlier supra- temperature was effected by a bath cooled from 90° to i3°,pubic operations he was apprehensive of ill results from this but the temperature again rose, and he died early in thesource, and devised methods to obviate it, but finding that, morning of Feb. 8th. At the necropsy, an aperture measur-as a matter of fact, the only inconvenience suffered from the ing one inch by half an inch was found in the frontal boneoverflow of urine through the incision was slight sloughing just above the sinuses ; the inner table was seen to be frac-of the margins of the wound, he ceased seeking to prevent tured and depressed, and a small rent had been made in theit. With reference to the procedure of breaking up a stone dura mater. There was suppurative meningitis on thethrough the perineal wound, Mr. Hulke said that at the surface of the right hemisphere and the anteriorExhibition of 1862 several instruments intended for this part of the left, and slight bruising of the cortical

551

substance of the anterior part of each frontal lobe.Mr. Lucas remarked that had the bullet been directeda little more to the middle line the dura mater mighthave been spared, and the man might have recovered,for the small wound in the membrane was, no doubt,the cause of the fatal meningitis.-Mr. HUTCHINSONsaid that he had observed hemiplegia to occur in meningitisof the convexity of the opposite side now sufficiently oftento believe the paralysis to be an important diagnostic sign.Dr. Sutton had suggested to him that in all such cases theremust be an encephalitis in addition to the meningitis, and inone case, examined microscopically, this was found to be so.Was the cerebral substance examined microscopically inMr. Lucas’s case ?-Mr. HULKE, many years ago, had seena large number of gunshot wounds of the skull, but did notrecollect any instance of survival when the bullet hadactually lodged in the skull. One of the most remarkableinstances of recovery he saw a few years ago at the Middle-sex Hospital in a young man, who was under the care ofMr. G. Lawson. This patient had extemporised a pistolout of an iron gaspipe, filled it with powder and a plug oflead, and discharged it at his forehead. Certainly no onethought he would survive. There was a large ragged woundin the forehead, at the bottom of which blood-clot mingledwith brain-matter was seen. A great plug of lead was ex-tracted by Mr. Lawson, as well as a considerable portionof the frontal sinus and fragments of the ethmoid bone.In spite of such desperate injuries, the man recovered.He could confirm Mr. Hutchinson’s statement as tothe occurrence of hemiplegia in one-sided meningitis. -Mr. HEATH, six months ago, saw a gentleman who wastotally blind, and who was said to have become so afterhaving fired a pistol at one side of his head. There was noevidence of a bullet at the spot where the mark was, buton the opposite side, under the temporal muscle, was a

prominence which felt like a foreign body. This might havebeen the bullet or a piece of displaced bone, but certainlythe ophthalmic surgeon (whom he had first consulted)thought the blindness due to division of both optic nerves,the third nerve on one side and the sixth on the other beingalso apparently severed. Mr. Heath concurred in this view,although it was remarkable that the carotid artery shouldhave escaped. In another case, in which a man shot him-self in the temple, the bullet rebounded into the brain fromthe inner table of the opposite side of the skull.-Mr.BARKER related two cases of bullet-wound in the frontalregion. In one a Chassepot ball penetrated three-quarters ofan inch; death took place some months after from convul-sions. In another the ball traversed the orbit, fracturing themalar bone, and was cut out above the molar tooth on theopposite side.-Mr. HULKE said that in Larrey’s Memoirs isthe record of a man who was shot through one temporalregion. Larrey passed a catheter through the wound andthrough the track of the bullet in the brain, and discoveredthe bullet on the opposite side ; he trephined over the spot,extracted the ball, and the man recovered.-Mr. HowsE hadrecently trephined over the skull to cut out a bullet. A childwas shot by a revolver presented at one side of, but not closeto, the forehead. There was a ragged wound of entrance onone side, but no aperture of exit. However, he thought hedetected some irregularity of bone in the skull exactlyopposite to the wound, and, on cutting down over this spot,found the bone fractured, and, trephining, extracted thebullet, which was lodged between the dura mater and thebone. The child survived thirty-six hours.-Mr. HUTCHIN-SON said that in the Leeds Museum there was preserved theskull of a young woman with a bullet resting against theinner angle of the sphenoidal fissure. This was quite a post-mortem discoverv. She was not known to have ever beenshot, and her death was from fever.-The PRESIDENT re-marked upon the very great injury which the brain mightsustain without ill results, and he was fast coming to theopinion that the grey matter could be dealt with sur-

gically, like any other tissue, and, if care be taken toremove all débrls, wounds of brain-substance wouldreadily heal up. He had lately under his care a ladwho had sustained compound fracture of the parietalbone in a machinery accident. Much brain-substanceprotruded from the wound. He (Mr. Callender) scooped outwith his finger as much of the damaged nerve-substance hecould, and washed out the remainder with solution of car-

bolic acid (1 in 20). In that way a very considerableamount of brain-tissue was washed away. The youth re-covered completely. Another case, still under treatment,

was that of a man who sustained a severe scalp wound anddepressed fracture of the occipital bone from a plank fallingon the back of his head. Trephining was practised, and alarge piece of bone removed, when an extensive rent wasfound in the dura mater, through which the finger could bepassed for the depth of nearly two inches. Mr. Callenderwashed out the brain very freely with carbolic solution, andinserted a drainage-tube. The patient passed through aperiod of over-action after this, marked by restlessness andby convulsions. Then he lost the power of co-ordinating hismuscular movements, but eventually he got quite well. Infine, Mr. Callender was coming to the opinion that largeamounts of cerebral surface-structure may be got rid of with-out fear, provided the injuries were treated on the sameprinciples as open wounds of other parts.-Mr. NORTON hadlately seen a farm labourer, twenty-four years of age, whowas delivered at his birth by means of craniotomy. Theoperation could not have been very successful, for the child,put aside for dead, began to show evidence of vitality, andhad now grown to manhood, with a misshapen skull, buthaving " as much intelligence as most farm labourerspossess."-Mr. LUCAS, in reply, said that the paralysis on.the side opposite to the meningitis was not complete, and inthis case there was also paralysis of the opposite arm. Hethought injuries to the anterior lobes of the brain were morereadily recovered from than those of other parts, but that thetendency to recovery was in great measure proportionate tothe small amount of education.-Mr. CALLENDER promisedto bring his second patient before the next meeting of theSociety.The Society then adjourned.

OBSTETRICAL SOCIETY OF LONDON.i

AT the meeting of this Society held on the 2nd inst.(Charles West, M.D., President, in the chair), WilliamBurton, L.R.C.P.Edin., and H. Macnaughton Jones, M.D.,were elected Fellows.

Dr. HERMAN exhibited a child showing one of the pos-sible results of the use of the Forceps. A little behind theright frontal eminence was what felt like an irregular gap inthe bone, a.bout two inches long by about half an inch wide.This was occupied by a pulsating swelling. The superficialveins in the neighbourhood were larger than on the oppositeside. Running obliquely across the skin over its lower partwas the scar of a laceration, which, according to the medicalman in attendance, had been undoubtedly caused by theforceps. The child’s mother said that a piece of bone hadsubsequently come away from the wound. - The President,Dr. Edis, Dr. Playfair, Dr. Hayes, and Dr. John Williamsoffered some remarks.A paper by Dr. HERMAN was read, on the Treatment of

Pregnancy complicated with Cancerous Disease of theGenital Canal. The author first narrated two cases whichhad come under his own care. In one, labour was obstructed

by a cancerous tumour of the rectum. The patient wasdelivered by cephalotripsy, and died from peritonitis. In

the other, the cervix uteri was fixed by cancerous disease;abortion was induced at the end of the fifth month. The-

patient lived seven months afterwards, marked relief to thesymptoms having followed the abortion. An analysis of180 recorded cases, collected from different sources, and

classified, was then given. From them he drew the follow.

ing conclusions :—1. That whatever influence cancer of theuterus may have upon conception is adverse to its occurrence.This was inferred from the small number of cases in whichthe patient was suffering from cancer at the time conceptiontook place, as compared with the frequency of the disease.2. That cancer of the uterus tends to produce the intra-uterine death and premature expulsion of the fcetus. Thisconclusion followed from the large proportion of prematurebirths, and of not only still-born, but decomposing children.3. That the growth of cancer of the uterus is, as a rule,accelerated during pregnancy. This was supported by à

priori arguments from general pathology, by the analogy ofthe breast, and by the improvement which often followedthe termination of the pregnancy. 4. That with cancerous