330

hard glands at the angle of th6 jaw. In spite of the tem- Iporary improvement under large doses of iodide of potas-sium, there could be no doubt at the present momentof the malignant nature of the disease. 2. A man agedsixty-two, with Fibro-lipomatous Tumours in the Sub-cutaneous Tissue of the Arms, marked Clubbing of theFingers, and slight Clubbing of the Toes. With the ex-ception of slight indications of emphysema and somethickening at the root of the lung (? due to fibrosis), nothingabnormal could be detected in the chest to account for theclubbing.The PRESIDENT announced that in future the chair would

be taken at 8 P.M., in order to afford an opportunity for theexhibition of living cases. Papers would be read at 9 P.M.,or as soon as these cases had been disposed of.

MEDICAL SOCIETY OF LONDON.

Excision of Bone to promote Healing of Soft Parts.-Gastric Symptoms relieved by Abdominal Section.-Ligature of Lingual Artery.AN ordinary meeting of this Societywas held on Feb. llth,

Sir William Mac Cormac, President, in the chair.Professor ANNANDALE (Edinburgh) read a paper on the

Excision of Bone in order to promote the Healing of certainWounds or Ulcers, or to relieve contraction resulting inconnexion with this process. He remarked that this pro-ceeding was not new, and that his first experience of it wasin the practice of the late Mr. Syme, more than twenty-fiveyears ago, since which time he had himself operated uponseveral cases. For conciseness he considered the subjectunder the following four heads. 1. The removal of a por-tion of bone, not including its entire thickness. 2. Theexcision of a portion of the entire thickness of a bone, or,as in the case of the forearm and leg, of two bones. 3. Thepartial or complete excision of a joint when the sore orcontraction involved the soft parts in its neighbourhood.4. The excision of a portion of the entire thickness ofone or other of the bones of the forearm or leg, in order toallow the proper approximation of the ends of its companionbone, which had suffered some loss of substance. In regardto this fourth head, it was observed that, although scarcelyincluded in the title of the paper, it was nearly allied to it.Illustrative cases occurring in the author’s practice weredescribed, and recorded cases by other surgeons referred to.One of the most interesting of these was one in which Mr.Annandale had removed two inches and a half of the shaftsof the tibia and fibula in order to promote contraction andhealing of a large sore upon the leg. The case was per-fectly successful. In conclusion, he stated that, as a primaryoperation in cases of injury, this procedure was not likely tobe useful except in rare cases, as it was impossible, in thefirst instance, to be certain of the exact amount of theloss of the soft parts, and he expressed the hope thatthe experience of the operations referred to would encouragesurgeons to make use of the principle in suitable cases.-Sir WILLIAM MACCORMAC thanked Professor Annandalefor his practical and interesting record. In the first case,he asked whether the destruction of soft parts was so greatas not to be amenable to some measure less severe thanexcision. Could not transplantation of skin from theopposite limb have been tried ? 2 The procedure of removalof bone had been devised to bring nerve ends together. Toremedy faulty union of a second bone, he thought it a goodand new idea to excise a bit of sound bone.-Mr. BRYANTremarked on the novelty of removing bone in order topermit separated soft tissues to approach each other. Hisexperience in this direction was small; he had once, in acase of injury to the heel with damage to the os calcis,removed a considerable amount of bone and brought thesoft parts together, but this was done without applyingany definite principle. He could recall two or three caseswhere this method might have been applied. - Mr. ROSEhad had two cases of fracture near the lower tibialepiphysis under his care, followed by arrest of growthand gradual malposition of foot, and he had excised twoinches of the fibula and brought the foot into position; butthis was done, not to secure union of the bone, but to rectifymalposition. In the first instance he took away three-quarters of an inch of bone, and in the second one inch.-Mr. PITTS recollected seeing two cases of disease of the oscalcis under Mr. Sydney Jones, where the soft parts weredissected off the margins of the bone and the margins

removed in order to approximate the soft parts and securemore rapid healing.-Professor ANNANDALE, in reply, saidthat he suspected the number of cases of primary operationafter injury requiring this treatment would be very lew. Hehad operated on two cases on the same principle as Mr. Rosehad done; but it was the tibia which, as the result of in-flammation, had grown more than the fibula. He cut acrossthe latter bone and put the foot straight ; this produced agap between the two cut ends of the fibula, which was after-wards filled up with new bone.

Professor ANNANDALE likewise read notes of a case inwhich long-standing Gastric Symptoms were completelyrelieved by Abdominal Section and the raising up of de-pressed ensiform and costal cartilages. A young man eightyears previously had received a severe blow upon the leftside over the lower costal cartilages and sternum ; draggingpain in the region of the stomach with vomiting had resulted,and continued, in spite of treatment, with more or lessaggravation. Being unable to work, and the diagnosisfrom external examination not being satisfactory, an

abdominal incision was made as if for gastrostomy, andthe parts explored ; no condition except a morbid de-pression of the lower costal and ensiform cartilagesbeing found, these cartilages were divided and raisedup. The result was complete relief to his old symptoms,and the patient, when seen two weeks ago (nearly sixmonths after the operation), remained quite well.-Mr.BRYANT felt it difficult to criticise such oases, whichbelonged to a class unfortunately becoming more common,where operations of exploration or discovery were under-taken with failure to find out more than was known before,though in many cases results were obtained in ways wecould not explain. Such cases were interesting, butdangerous, tempting rasher ones to explore more freely thanshould be done. One could hardly think that the depressionof the cartilages gave rise to all the symptoms described,and he thought surgeons should be grateful to ProfessorAnnandale for placing such a case on record.-Mr. TREVESreferred to the remarkable improvement which sometimesfollowed after exploratory laparotomy in apparently hope-less cases. He had seen a case of tubercular peritonitisget well after simple exploration. He had twice openedthe abdomen, discovered pyloric cancer, and closed againwithout interfering with it; one man was substantiallybetter in every way for ten days ; the second underwent soremarkable an improvement that there was a doubt asto the diagnosis; he continued better for six weeks,and then his old symptoms returned and he died, thenecropsy revealing extensive carcinoma. He askedhow far the conditions of intra-abdominal pressure wereinfluenced by laparotomy. He quoted cases such as

those of subperitoneal epigastric fatty hernise, burns, andnon-penetrating wounds, which gave rise to a train of awk-ward symptoms by exciting reflex nervous irritation.-Mr. B. JESSETT related the case of a man forty-five yearsof age, who suffered with severe and continuous vomiting,and pyloric cancer was thought to be present. He had alarge reducible hernia of twenty-five years’ standing, forwhich he had never worn a truss; after radical cure of thishe made a perfect recovery.-Professor ANNANDALE quiteadmitted his inability to explain the reason of the resultobtained, and he related a case in which distressing renalsymptoms were present, which was cured by a negativeexploratory incision. He had met with subperitoneal fattyhernia laterally as well as centrally situated, and had knownthem to cause unpleasant symptoms.Mr. F. BOWREMAN JESSETT read a paper on a Simple

Method of Securing the Lingual Artery during the Opera-tion of Excision of the Tongue with Scissors. He referredto the various means devised to control this vessel: Mr.Lockwood’s compression forceps, which had been used byhimself and others with satisfactory results; the snippingpiece by piece through the fibres of the genio-hyo-glossimuscles and securing the artery before division; and theligature of the artery in the neck, one advantage of whichwas that glandular enlargement could be removed throughthe same incision. The operation he proposed was onlyapplicable when the disease was limited to the tongueitself, the floor of the mouth being free. The tongue wasdrawn well out of the mouth, and the frsenum and mucousmembrane of the floor divided with scissors, slightly curvedupon the flat; the organ was then drawn firmly forwardsand upwards, and a few fibres of the genio-hyo-glossidivided and torn deeply through with the finger. Between

331

the two genio-hyo-glossi an ordinary armed aneurysmneedle was now thrust, and brought out through theincision in the mucous membrane and opposite to thesecond molar tooth. The ligature including the artery andsome muscle fibre was now tied firmly, and, if Chinese silkwere used, it cut easily through the soft fibres, and so heldonly the vessel. A pair of clamp forceps, curved, and some-what larger than those in ordinary use, were then applied tothe tissues, distally to the ligature in order to prevent thelatter being snipped as the organ was removed. If the wholetongue had to be ablated, the same manoeuvre- was carriedout on the opposite side.-Professor ANNANDALE agreedthat the principle was a good one to secure the arteriespreviously to removal of the tongue in order to preventhemorrhage. He himself used to tie the vessel opposite tothe second bicuspid tooth, but he now did it in the neck,as he had found that the malignant growth so frequentlyextended in the tongue along the line of the artery.-Mr.JESSETT replied that he proposed to adopt this method onlywhen the disease was entirely limited to the tongue tissueand did not involve the floor of the mouth.

WEST LONDON MEDICO-CHIRURGICALSOCIETY.

Abdominal Ancurysm-Typhlitis-Dislocation oj Hip-joint. __ Congenital Deformity. - Herniotomy. - Nephro-lithotonay.THE meeting held on Jan. 4th was a clinical evening;

Dr. Travers, President, in the chair.Dr. DONALD HOOD brought before the Society a typical

ease of Abdominal Aneurysm. The patient was a strong,well-nourished man, aged thirty-nine, who stated that whilelifting a sack two years ago he " felt something give way

"

in the stomach. Much pain followed this strain, and fortwo months lie was unable to work. For the next tenmonths he was fairly well, though he suffered at timesfrom pains in the back and over the stomach. A year agohe first noticed a lump, which throbbed.

" It appearedbelow the ribs on the left side, and was tender to the touch.He now sought advice, complaining of stomach pain onlyapparently. He was not carefully examined, and wastreated for dyspepsia until admission on Dec. 17th, 1888.On examination there was a globular swelling 3 in. by 2 in.-the long diameter being transverse-in the left epigastricregion two inches below the ribs. It pulsated strongly, andwas tender. The skin was not reddened. The pain wasmostly abdominal, though the patient stated he had sufferedmuch from backache. He had not complained of limb pain.There was no history of syphilis, and the general arterialsystem appeared healthy. Since admission the treatmenthad been complete rest in bed, thirty grains of iodide ofpotassium three times a day, and opium in varying amount,with restricted diet-30 oz. iluid and 10 oz. solid. At thepresent time (Jan. 4th) fluids have been reduced to 18 oz.,and solids in proportion. The patient has experiencedmuch relief, the tumour being smaller and much less tender.It is also harder, and the man says he is quite comfortable,being almost free from pain.

Dr. ALDERSON showed a youth aged sixteen and a halfyears, whom he attended two years and a half ago for severetyphlitis. He attended him for a gastric feverish attackfrom July 6th to 17th, 1886; there were anorexia, constipa-tion, and sickness; he returned to school rather againstDr. Alderson’s wish, but the temperature being normal, hetacitly consented. On Aug. 2nd, he was taken ill withsimilar but severer symptoms. The constipation after themildest aperient became diarrhcea. There was abdominalpain radiating to the middle line from the right iliac region.’The treatment at first controlled the symptoms. litit onDr. Alderson’s return from Brighton (the boy having beenleft in skilful hands) there was a distinct fulness in thegroin, and the general aspect and posture of peritonitis.On the night of the 16th the boy was very ill, and in theearly morning of the 17th Dr. Alderson was called hurriedly,and fluctuation was easily detected. Aspiration was per-formed, and gave great relief ; the bowels soon acted,and the temperature fell to 99° in the evening. Theabscess quickly filled, and the temperature rose. It was

again aspirated two days later, three-quarters of a pint ojsimilar pus being drawn off. Again the abscess filled, evermore quickly, and on the 21st it was laid open with a Syme’;knife, a drainage tube being inserted and antiseptic dressing,

used. A pale cicatrix of an inch and a half in lengthappeared parallel with and about an inch above the centreof Poupart’s ligament. An inguinal hernia bulged here.-Dr. DONALD HOOD drew attention to the immobility of theabdominal wall over the seat of inflammation as an im-portant symptom in distinguishing the pain of simple colicfrom that due to inflammatory action. It might be takenas granted that where the natural movement of respirationwas absent there was inflammatory mischief behind.

Typhlitis had no certain specific symptomatology withregard to initial onset.Mr. R. F. BENHAM showed four cases of old dislocation

of the hip-joint.Dr. CLII’PINGDALE showed an infant about seven months

old, with a congenital deformity of the upper limb, causedprobably by an intra-uterine disclocation, due to suddenand irregular contraction of the uterus, the result of fright.When four months’ pregnant, the mother states she made asudden movement to prevent a child getting between theplatform and a train, and felt a sudden sharp pain in theright side of the uterus. There was no history of heredity.

Dr. BONTOR, house-surgeon to the West London Hospital,read notes of three cases of Herniotomy shown by Mr.KEETLEY. Case 1: S. P., aged seventy, admitted on

Sept. 28th, with right femoral strangulated hernia (strangu-lation five days’ duration), and operated on it at once, thesac being excised. The wound healed by first intention;recovery uninterrupted. She was up, wearing a truss, onOct. 23rd. Five days later there was much pain in thecicatrix, and next day a discharge from a small opening.The patient was ordered to bed, and hot boracic fomenta-tion to be applied. The discharge continued for threeweeks; the wound then closed, and the patient was againallowed up, wearing a truss. After two days pain returned.The temperature rose, and the next day there was moredischarge; no collection of pus could be discovered. Boraeicfomentation was reapplied. This was the condition whenthe silk ligature (handed round) which had secured thestump of the sac was removed ; and now, one week after-wards, the sinus is closed, and there is but a small superficialwound. It is premature to discuss the question of radicalcure in this case. Case 2: M. F., aged fifty, suffered froma rupture. Seventeen years ago, during a confinement,hernia supervened, but until two months before admissionit was kept up by a truss, when it became much larger, andprevented the patient from getting about. On admissionthis right femoral hernia was larger than a man’s head andquite irreducible (photograph handed round). In order thatthe condition of the patient and of the hernia might beimproved, a very limited diet on the Banting systemwas ordered, all the starchy fat-forming elements beingexcluded. The foot of the bed was raised. Elasticpressure was kept on the hernia by means of knittedwoollen bags. After about a month of this treatment, thehernia was reduced, and the following day the operationperformed, the sac being stitched into the ring, which waslarge enough to admit several fingers. The outer part ofthe skin was removed, and the inner part drawn over to theouter side, in order that the wound might be removed fromthe genitalia. The wound healed by first intention. Thatthe cure of so large a hernia will be radical is almost beyondhope ; the patient will, however, be in a more comfortableposition than she has been for years. Case 3: S. M.,aged fifty-three. Had right femoral hernia. For sixmonths no truss was worn. On Sept. 28th, 1888, therupture increased in size and there were symptoms ofstrangulation, but there was still impulse on coughing,so the patient was put to bed. She had heard ofand desired the radical cure. On Oct. 2nd the opera-tion was performed, and the interest of the case was

in the fact that there was no sac, and the protrudingstructure was not bowel, but a hard white tubular process,containing a little semi-transparent gelatinous substance inits lumen. A ligature was placed round this, and the endexcised, the stump being returned into the abdomen, andthe operation completed in the ordinary way. This patientwas up, wearing a truss, in sixteen days, and has had nodiscomfort since. There is now no more impulse on oneside than the other.-Mr. KEETLEY remarked that theligature in the first case might not have been quite aseptic.It was possible to render silk ligatures aseptic by boilingthem, and in this they had an advantage over catgut. Itwas too soon to say whether a radical cure had beenestablished in these cases.