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CLINICAL SOCIETY OF LONDON.

Excision of Portion of Tarsus for Talipes Yarus.-Iodide ojPotassium Eruptaon.—Case of Discharge of WateryFluid from one Nostril.—Tapping of PulmonaryCavities.THE ordinary meeting of this Society was held on the

22nd inst. ; Dr. E. H. Greenhow, Hon. Treasurer, in thechair. After Mr. Bryant had shown a patient upon whomhe had excised a portion of the tarsus for the relief of talipesvarus, and a well-marked and severe case of eruption fromiodide of potassium had been exhibited by Dr. Duckworth,Sir James Paget read notes of a case of watery dischargefrom one nostril. The case was wholly peculiar, and SirJames could not speak positively as to the source of the fluid,which resembled cerebro-spinal fluid in its characters. Apaper, read by Dr. Theodore Williams, on a case of at-

tempted tapping of a cavity in the lung, led to an interestingdiscussion upon the feasibility of this operation.Mr. BRYANT exhibited a patient who had been the subject

of Talipes Varus, and had been treated by the removal of awedge of bone from the tarsus. The case was that of a

boy twelve years of age, who had been under surgical treat-ment for the condition from infancy. When five years of

I age tenotomy had been performed with some success, but asthe Scarpa’s shoe had caused pain, it was laid aside, andthe

, deformity returned. On admission into Guy’s Hospital themuscles of the leg were wasted, and the patient walked onthe outside of the foot, upon which had formed two largebursse. Mr. Bryant removed a wedge-shaped piece of bonefrom the tarsus, as performed by Mr. Davies-Colley inOctober, 1875. An incision was made across the dorsum ofthe foot from a point corresponding to the tubercle of thescaphoid to the outer border of the cuboid, and a secondincision along the outer border of the foot, the two incisionsforming a shape. The flaps were then turned back, andthe tendons of the extensors divided. A spatula was in-troduced around the scaphoid bone towards the sole of thefoot to protect the soft parts, and the lower section of thewedge of bone cut with a keyhole saw, one line of sectionextending across the dorsum of the foot from the scaphoidto the anterior border of the cuboid, the second bone sectionbeing made higher up; and a wedge, with its apex cor-responding to the scaphoid bone, and its base to the cuboid,one inch long, was thus cut away. After the operation theanterior half of the foot was readily brought round into posi-tion, and horsehair drainage was employed. The tempera-ture rose to 102°, but on the third day was down to 997°, witha pulse of 80. A small quantity of pus was evacuated by apuncture made into the skin, in a position corresponding tothe apex of the wedge ; in other respects the wound healedrapidly. The boy now presents a foot of good form with a flatsole, on which he walks with comfort. The foot was somewhat

. shortened after the operation. The tendo Achillis had beencut, with the object of bringing down the heel, but withlittle result. Mr. Bryant said that ablation of the cuboidhad been suggested by Dr. Little in 1854, and practised bySolly in 1857, upon which the operation now under con-sideration was a great improvement. He considered it alsomuch better than Mr. Lund’s operation for the removal ofthe astragalus, which was performed in 1872, but which hethought might be useful where the equinus was worse thanthe varus.-Mr. DAVY congratulated Mr. Bryant on theresult of his case. He believed that he himself had operatedin a similar way more frequently than any other surgeon.There was a class of confirmed and intractable cases oftalipes that resisted all methods of treatment. In 1874 herevived Mr. Solly’s operation-viz., removal of the cuboid,which had been described by that surgeon twenty years pre-viously, and had fallen into oblivion, and had even beencondemned. He did this in five cases with encouraging butnot perfect results, proceeding on strictly experimentalmethods, and not feeling justified in interfering with theastragalo-scaphoid joint, until he had proved that divisionof the calcaneo-cuboid was insufficient. In April, 1876, hepublished his experience, and in October of that year Mr.Davies-Colley anticipated him in his paper read before the

Medico-Chirurgical Society by performing the milder opera.tion, which Mr. Davy had now performed several times. Heshowed the casts of his ninth patient, taken before and afterthe operation, and the result was very satisfactory. Nodoubt, the operation was on its trial, and was opposed bymany surgeons, but he was content to abide by the results,and was glad to see Mr. Bryant commending it so strongly.Patients, after the operation, became absolutely plantigrade;the scar was small and well out of the line of pressure;there was no possibility of relapse, and a symmetrical foottook the place of an unsightly and useless member.

Dr. DYCE DUCKWORTH exhibited a patient suffering froma well-marked Eruption produced by Iodide of Potassium,the case being that of a man thirty-two years of age, whowas formerly intemperate, had suffered from rheumatic feverfour years previously, and was the subject of aortic valvulardisease and chronic tubul nephritis, with some dropsy of thelegs. On November 8th a mixture was prescribed for him,containing some ammonio-citrate of iron, and two grains perdose of iodide of potassium three times a day. On the 20thinst. an eruption appeared upon the face, and on the 22nd thepatient came under notice. He was found to be sufferingfrom coryza and general bronchial catarrh, with hoarseness.The eruption was situated almost exclusively on the faceand ears. Some portions were found on the back oi theneck, and a few scattered spots upon the backs of the hands.The bulk of it was upon the left cheek, although it wasfairly symmetrical. On the forehead were numerous hardpapules becoming vesicular, not umbilicated ; on the cheeksthe highest point of vesiculation was reached, and herenumerous coherent and confluent masses were seen, borderedby red areolae. In many the fluid was puriform. There wasno mass that could properly be called a bulla, and the erup.tion more resembled patches of herpes in some parts thanacne ; and some of the vesicles occurred on a piece of whitescar-tissue on the forehead, where probably no sebaceousstructures remained. There was no rash on the body. Someof the vesicles were found on the lips ; none manifest on thetongue. The points of particular interest were-first, itsoccurrence as the result of small doses of the drug. It

appeared that some months previously, in another hos-pital, a similar eruption had shown itself after some

medicine had been taken, and which passed away on dis-continuing it. Secondly, the case was an additionalone to certain others noticed by Mr. Baker, Dr. Barlow,&c., in which there was present chronic renal disease. Ithad been surmised that in such cases defective eliminationoccurred, and the drug was left longer in contact with thetextures of the body than in the instances where the kidneyswere healthy. Dr. Duckworth had found in some researcheson the elimination of iodide of potassium and other drugs(published in St. Bartholomew’s Hospital Reports) that insome cases the iodide does not pass out by these organs. Inthis instance, iodine was found abundantly in the urine.The contents of some of the vesicles were also examined,but the results were equivocal as to the presence of iodine.However, it was well recognised that both iodide andbromide of potassium rashes occurred in the persons ofthose whose kidneys were presumably healthy. Even insuch instances there might be defective eliminating power.Thirdly, the nature of the eruption did not warrant theterm acne being applied to it, and further observation waswanting to prove how far the sebaceous glands were thetrue seat of the inflammation. Dr. Thin’s recent examina-tion of a case (see THE LANCET, Nov. 16th, p. 696), went toprove an immunity of these structures.-Dr. GREENHOW hadunder his care a patient who, on three consecutive occasions,had suffered from an eruption induced by the iodide. Therewas no albuminuria in that case.-Dr. GLOVER said thatrenal disease was not necessary for the production of therash was shown by the fact that the most marked instancesof the eruptions, both of iodide and bromide, were met within children.-Dr. FARQUHARSON pointed out that the toniceffects of salicylic acid were most readily produced inpatients with renal disease. It was curious that, in mostcases, these eruptions were evoked by comparatively smalldoses of the drugs. It was so with bromide of potassium,and so it was with quinine (in one case on record one grainof quinine was followed by a rash). Probably the largerdoses were more liable to bring the eliminating organs intoplay than smaller ones.

Sir JAMES PAGET then read notes of a case of WateryDischarge from one Nostril. The fluid, about two ounces,shown to the Society, had dropped from the left nostril of a

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lady aged forty-nine, and Sir James stated that similar fluid made to drain the cavity by tapping. The patient, a manhas been dropping, with rare intermissions, for eighteen aged twenty-nine, had chronic pneumonia of both lungs,months. The fluid looked like pure water, or like that resulting in perfect resolution in one, and in induration andfrom the pia mater, or that from an acephalocyst. There dilation of the bronchi in the other. He subsequently hadwas no evidence of general ill-health, or any appearance of haernoptysis to the amount of three pints, and lost two stonesany kind of local disease of the nose. The history was in weight. When admitted into the Brompton Hospital innearly as insignificant. In November, 1876, the patient May, 1877, the symptoms were convulsive cough and fetidhad received a heavy blow over the left frontal sinus, but expectoration, containing large quantities of lung-tissue,it seemed to have done no harm at the time. In January, and so offensive in character as to cause frequent vomiting.1877, she had one day of intense headache, but there had There was also considerable pyrexia. The physical signsbeen no return of this. In February, 1877, she had a severe denoted consolidation of the base of the left lung, withmental shock, and in May, 1877, the dropping began. From commencing excavation. During his stay in the hospitalthat time to the present the dropping continued, except the area over which cavernous sounds were audible increasedfor a fortnight in May, 1878, when she had bronchitis considerably. Various kinds of treatment were tried to re-and took morphia, and on one occasion when it ceased lieve the cough and to facilitate and disinfect the expectora-lor a night. A small drop fell or ran down the lip tion, but all with temporary benefit ; and as the patientevery few seconds, and about four ounces had been col- appeared to be poisoned more and more by the retained ex-lected in an afternoon and evening. The quantity was pectoration, and exhausted by the cough, on October 16th,generally uniform, but was increased by much exertion 1877, a medium-sized aspirator needle was passed betweenor by straining. On long standing the fluid deposited a the eighth and ninth ribs, in the area of the cavernousminute quantity of a greyish substance, in which nothing sounds, and appeared to reach the cavity, but on exhaus-could be found but the chance materials washed off from tion only a few drops of blood followed the operation, andthe surface of the nasal mucous membrane. Dr. Russell, the puncture was consequently closed with lint. TheProfessor of Chemistry at St. Bartholomew’s Hospital, re- patient afterwards suffered pain in the infra-mammaryported the fluid to be slightly alkaline, and to contain pro- region, but as his symptoms continued to increase, a fortnightteid matter, probably albumen, chloride of sodium, phos- later a second attempt was made to reach the cavern ; this

phates, and a slight trace of iron, but no grape time the intercostal space next below the site of the firstsugar. The specific gravity was 1004. Mr. Thomas operation was selected, and a trocar and large drainage-tubeTaylor had found the specific gravity on another occa- were introduced. On reaching the pleura a pint of brownishsion to be 1009 in one specimen and 1010 in a second, fetid fluid escaped, which proved under the microscopewhen he analysed the fluid for Mr. Lawson, who had pre- to consist of broken-down pus-cells. Symptoms of collapsewiously seen the case. [Mr. Taylor’s analysis yielded followed the evacuation of the fluid, and the patient wassimilar results to that of Dr. Russell.] After suggesting with difficulty rallied with stimulants. The abscess wasseveral theories to explain the case, Sir James Paget con- washed out with disinfectants, but no improvement tookabided by expressing his opinion, though speaking with place, and the patient gradually sank three days after themuch doubt, that the fluid was derived either from a frontal operation. On post-mortem examination, it was found thator ethmoidal sinus, or from the subarachnoid space or the the lung contained a labyrinthine cavity, formed by thesac of the arachnoid membrane. He brought the case for- breaking down of the walls of several dilated bronchi, oneward in the hope of hearing that similar cases had been of which had been penetrated by the first operation. Over-observed, and that by collecting and comparing them we lying the cavity was a limited empyema, which the secondmightgainsomeknowledge oftheirnature.-Mr. BRUDENELL operation had evacuated. The right lung was affected byCARTER had met with a case of constant limpid narial dis- recent pneumonia, the result of infection through inhaled- charge in an old gentleman eighty-four years of age, who secretion from the left, this being the immediate cause ofwas the subject of gout. The discharge lasted for several death. Dr. Williams remarked that it was often difficult toyears, and was only temporarily relieved by remedies, such determine by auscultation the exact size and form of aas tannin snuff, &c. In reply to Sir James Paget, Mr. cavity; especially so when, as in the present instance, it’Carter added that the discharge came from both nostrils.- communicated with several dilated bronchi, as reverberationMr. SPENCER WATSON had met with two cases of chronic of sound in these winding and irregular passages increasednasal catarrh, in which the fluid was perfectly limpid. In the area of cavernous sound, and gave the impression of aone of these it lasted for a year or more, was mostly from larger extent of cavity than really existed. Another curiousone nostril, and was occasionally purulent. It seemed to come feature was the presence of vocal fremitus in spite of thefrom the anterior part, was of a clear limpid character, and existence of a large quantity of fluid, but this might beflowed more readily when the head was lowered. In another attributed to the very tense condition of the pleura from thecase-that of a man aged eighty-four-the discharge was amount of effusion poured out into a limited space. The-always from one nostril, and was also more abundant when failure of the first operation was due, not to any error inthe head was bent. No remedies checked the secretion, aim, for the dilated bronchus was penetrated, but to thewhich he thought to be due to chronic catarrh of the nature of the expectoration preventing its passage throughantrum.-Mr. LAWSON had had the present case under his the aspirator; and the second operation, with the trocar andcare, and was struck with the similarity of the fluid to that cannula, while it tapped the empyema, did not consequentlyflowing from the arachnoid of a boy after trephining. In reach the accumulated secretion of the bronchiectasis. -the present case it was noticeable that very little escaped Dr. SYMES THOMPSON, speaking of empyemata secondary.during sleep, which might be due either to less fluid being to ulceration of lung, approved of this treatment, and in-then secreted, or else that it dribbled down the pharynx and stanced two cases recently under his care where freewas swallowed.-Dr. HEWAN had observed a somewhat drainage of the pleura entirely relieved the purulent expec-similar discharge (but he believed of catarrhal nature) from toration. He urged specially that the openings should bethe left nostril of a phthisical young man. It was arrested dependent, and that a counter-opening should always beby hypophosphite of soda, but in six or eight months it re- made.-Mr. BRYANT also urged the great importance of a- curred, when it was again treated with good results.-Dr. really free outlet for the pus from the empyema (whetherALTHAUS inquired whether the olfactory sense was deranged. this communicated with lung or not) if any good result wereIt was possible the discharge depended on some aberration to be hoped for. He discountenanced temporising measuresof nerve-influence.-Sir JAMES PAGET, in reply, said that by aspiration.-Dr. GREEN pointed out that the questionthe sense of smell was unimpaired. The cases mentioned raised by Dr. Williams was not the treatment of localisedwere of different nature to this, which did not depend on empyemata, but the propriety of tapping pulmonarychronic coryza, or congested mucous membrane. The pecu- cavities.-Dr. DOUGLAS POWELL said that it was just thisliarity lay in the fact that the discharge had dripped during question of the feasibility of tapping pulmonary cavities onthe whole time from one nostril, in a simple continual which they wished to hear the experience of surgeons. Mr.stream, and never with any admixture of blood or pus. He Bryant’s remarks did not apply so well to cavities in themust still leave the question of its nature open, whether it lung as to empyemata, for in the former there must neces-were cerebro-spinal fluid, or secretion from the ethmoidal or sarily be large vessels met with in the walls of the vomicafrontal sinuses. Any similar cases that may be recorded which would render it less dangerous to use a blunt instru-hereafter should contain an accurate statement of the amount ment like a trocar than a knife, for it would bruise rather.and nature of the fluid. than cut the tissues. In this case, as it happened, there

Dr. THEODORE WILLIAMS read notes of a case of Bron- was an empyema complicating the pulmonary condition,chiectasis and Lung Excavation, in which an attempt was and the aspirator-needle must have traversed the empyema

774

to pierce the lung. The difficulty in the performance c

tapping pulmonary cavities lay in diagnosis from thtransmission of the signs of excavation far from theiseat of production owing to dense pleural adhesions, an<

he frequently found this true also with regard to con

solidated lung, where auscultatory signs and vocal vibration may from this cause be perceived at a lower levethan the seat of disease. Cavities at the base of the lunlwere eminently suitable for tapping, and it seemed to blwaste of time not so to deal with them. But in all theslcases, where much pus was expectorated with but little admixture of mucus, an empyema communicating with lunshould be suspected.-Dr. CAYLEY said that a few years agein Berlin several cases of tapping pulmonary cavities wererelated, and some had also been published in AmericaBut the results were not encouraging. The procedurlseemed more likely to be of benefit in basic cavitieswhich were generally the result of pneumonia, tharin apicial vomicse, which are mostly tubercular. Therthe amount of expectoration was not much guide to the siz<of the cavity, for much came from the surrounding tubes a;

well as from the cavity itself. If pure pus were expectorated, it would probably come either from a distinct abscessin the lung or from an empyema; and he mentioned a castunder his care two years ago where there were physicalsigns of a cavity and purulent expectoration, which provedto have been due to a circumscribed empyema at the backof the lung.-Mr. B. HILL had two or three years agoopened a pulmonary cavity in a case under the care of Dr.Wilson Fox at University College Hospital. The opening wasmade in the seventh right interspace, and at least ten ouncesof pus escaped, followed by free haemotrlmge, necessitatingplugging. Considerable benefit followed, but, after a while,pus was again expectorated, and fresh discharge occurredthrough the opening in the chest. The patient died frommediastinal cancer, and in the lung was found an abscess incommunication with a bronchus, and also with a fistulawhich had resulted from the abscess first opened.-Mr.MAUNDER said he had more than once suggested thatempyemata should be treated on general principles, likeabscess elsewhere. A free incision should be made in orderto favour a ready flow in accordance with gravitation, and inorder that the abscess walls may rapidly coalesce, and healby granulation. In cases of abscess in the lung, if it couldbe shown that adhesions existed between the abscess walland the parietes, there would be no hesitation about openingthe abscesses.-Dr. WILLIAMS, in reply, said that he fullyconcurred as to the advisability of free openings in empyema;but in this case he thought he was dealing only with acavity in the lung, in which case, if adhesions did not exist,a pneumothorax might be established by the operation.But as in chronic cases adhesions were pretty certain to befound, this risk was removed, and he was satisfied the pro-cedure might be safely adopted in basic cavities.

MEDICAL SOCIETY OF LONDON.

Treatment of Spinal Curvatlre by the Rigid Jacket.AT the ordinary meeting of this Society held on the 25th

inst., Mr. R. Davy in the chair, the discussion on Mr. Owen’spaper on the Use of Rigid Jackets in the Treatment ofDiseases of the Spine was resumed by Dr. FISHER, who ex-hibited Cocking’s poro-plastic felt jacket, which can bemoulded to the patient’s chest, and had the advantages ofbeing easily and rapidly applied, of durability of material,of accuracy in fitting, certainty in becoming rigid, its light-ness, and its ready removability for the sake of cleanlinessor examination. In these respects it was superior to plaster-of-Paris. Mr. Fisher suspends from the head when pos-sible, but not in the cases of heavy adults or children withcervical caries, and he advised that the suspension shouldbe done slowly and carefully.-Mr. ADAMS spoke of thegreat economy and efficiency of the poro-plastic jacket. Hedid not think Dr. Sayre intended to imply that the anglecaused by the disease could be straightened by suspension,but only that the compensatory curve could be removed.The patient should wear some support till the age of twenty.Mr. Adams had used gutta-percha supports for more thantwenty-five years ; and light steel supports had done good

f service. He believed the poro-plastic jacket would replace3 plaster-of-Paris.-Mr. GOLDING BIRD spoke from an ex-

r perience of some fifty or sixty cases, half of which were

t angular. He preferred plaster-of-Paris to felt, one reason- being that, owing to the latter splint being cut up the middle,- complete rest is not obtained by it. Mr. Bird adducedt. several objections that had been raised to suspension, such; as the effect on the child, or fainting of an adult ; that no

case of Pott’s disease with cure of the deformity could beshown when the bones had not come together was no ar-

. gument, since no museum contained specimens of a spine, which has been so treated as to prevent the surfaces comingI together. As to rudely tearing asunder the spine which is: united, Mr. Bird would say, that so long as the patient

suffers no pain, no harm can be done. That extension of a! diseased part was of some service, he instanced the effect of

extension upon a fractured femur which had becomebowed. Mr. Bird held that the boss is influenced ifthe patient be fairly suspended, and showed tracingsconfirmatory of this. - Dr. DiCK said, in some cases,suspension would be dangerous, and he urged certainobjections to all kinds of jackets, one being that theabdominal walls gave no point d’appui. - Mr. HOWAPI)MARSH had no doubt the curvature could be straight-ened out, and he could not see why anchylosis shouldnot take place if the spine were kept straight. Hewas inclined to prefer the felt jacket to plaster. Dr. Taylor,of New York, insists on the importance of early recognitionof these cases, to get the best results from treatment.&mdash;Mr.DONALD NAPIER exhibited Maw’s apparatus, and askedwhether extension might not be made from the lower ex-tremities and the shoulders, the patient lying on an inclinedplane. He asked whether the rigid jackets interfered withthe respiratory or digestive organs.-Mr. DURHAM praisedDr. Sayre’s method as being scientific in principle, basedupon the same lines as extension in fracture or in diseasedjoints, and with a view to give rest to the spine-an enddifficult to attain except on the principle of perfect in.flexibility. Numbers of children had been suspended atGuy’s Hospital, with no harm resulting, and with moderatecare and caution suspension did no injury. He pointed outthe ease with which Sayre’s system can be carried out,the impossibility of treatment by recumbency in the greaternumber of cases, and, especially in poor practice, the difficultyof getting instruments to fit on the old system. The practicewas not only scientific, easy, and economical, but eminentlysuccessful ; for in no case of genuine spinal disease so treatedhad he seen any ill-effect, but in all more or less good. Thefirst patient put up by Dr. Sayre himself at Guy’s came quitebowed, but is now quite upright, and a strong, healthychild. Each case must be treated on its own merits, forfrom time to time cases will arise where the application is.difficult.-Mr. COLES, speaking from experience with Dr.Sayre in New York, said no harm can be produced providedextension is stopped as soon as pain occurs.-Mr. DAVYremarked that Ambrose Par&eacute;, in 1545, had described a planvery similar to that of Sayre, with the exception of sus-pension, though he had mentioned the necessity of exten-sion. The recumbent position is impossible, either to richor poor. He had not found plaster-of-Paris applicable to all

cases ; it was impracticable where there was discharge.-Mr. OWEN having replied, the Society adjourned at a latehour.

PROVINCIAL MEDICAL SOCIETIES.

BRISTOL MEDICO-CHIRURGICAL SOCIETY. - At the last

meeting (October 23rd)-Dr. H. Fripp, President, beingin the chair-Dr. GREIG SMITH exhibited specimens anddrawings from two cases of Sarcomatous Tumours of theSkull. A cast of the head of one of the cases showed theenormous size to which such growths may attain, and themacerated skull of the same case exhibited in a strikingmanner the rarefaction of bone and stalactitiform growth ofosteophytes. From the other case were exhibited the cal-

varia, and a sarcomatous tumour as large as two closedfists perforating it, also secondary deposits in the sphenoidand frontal bones, several of the vertebrae causing irregularcurvature at one point and destruction of the spinal cord atanother, in one of the ribs, and in the centre of one of thelobes of the brain. Dr. Smith discussed at some length the.