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localised, soon becomes general throughout the abdomen ;there is, as a rule, at this stage, pain on pressure in everyregion. The abdominal distension, too, is perfectly regular,and, in the eaes I have examined, the percussion note isdear everywhere, both over the small intestines and overthe cs3cum, and along the course of the large intestines.There is one other sign upon which, I believe, great stressought to be laid. Unless the patient is stout, the- coils of the distended intestines can usually be discernedthrough the abdominal wall. Now in mechanical obstruc-tion these coils exhibit vigorous peristaltic movements untiltheir muscular walls become exhausted ; in peritonitis the,peristaltic movements are abolished as soon as the inflam-mation is established. I have not mentioned the negative i

aids to a differential diagnosis, but the importance of a rectal ’,examination, of blood or mucus in the motions, of tumoursor indurations in the region of the csecum or sigmoid flexure,and of the numerous indications afforded by the age and sexof the patients and by the previous history, are too obviousto need pointing out. The pathology of these ulcers of the’duodenum is in such a doubtful and uncertain position thatdo not propose to attempt the question. It is strange that

they should be EO much commoner in men of about thirtyyears of age than in women.Mr. Lockwood expressed his indebtedness to Dr. Cowie

lor the notes of the first case, and to Mr. Falkner for thoseof the second.

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BURTON-ON-TRENT INFIRMARY.A CASE OF LAPAROTOMY FOR INTESTINAL OBSTRUCTION.

(Under the care of Mr. PHILIP B. MASON.)THIS case is interesting from the fact that the coils

,of intestine were strangulated by the same tumour, andthat abdominal section did not lead to the discovery ofthe whole of the mischief. The negative abdominal signs,on admission led Mr. Mason to think that the cause ofthe obstruction might be impaction by the tough skins ofthe black currants, of which, according to the patient’s ownaccount, she had eaten inordinately. The pain from whichahe suffered she compared to that of her menstrual periods.’When the abdomen was first opened, the only sign of peri-tonitis was a little increase in the natural redness of the.out, 0 and the strangulated portion found, about eighteen’inches in length, did not come into view until a very largetproportion of the small intestine had been drawn out andreturned. This was carefully examined, and found to retainits polish, ending at both extremities in healthy intestine.The second strangulation found post mortem was nearlygangrenous, and it seemed that the weight of the tumourwas much more efficient as a cause of stoppage of the circu-lation when one of the coils had been drawn from beneathit. Even after death there was very little evidence ofperitonitis. Although water passed freely both into and’out of the sac, its contents were not at all faecal. Mr. Masonheard afterwards that a sister had died from intestinalobstruction, and that in her case no post-mortem examina-’tion had been made. For the notes of the case we areindebted to the house surgeon, Mr. W. Gibson.H. Fizz, a domestic servant aged nineteen, was admitted

at 7.30 P.,,4. on July 24th, 1891, complaining of pain inthe bowels and of their having been inactive for fourdays. Five days previously she had eaten very heartily of’some black currants, and on the following day had a violentaction of the bowels, since which time she has been inconstant pain and has passed nothing per rectum.

Condition on admission,-She has a flushed face anddry tongue, covered with a thin fur. Lies on her backwith the legs drawn up, and complains of pain in, theabdomen, but says that it is much better than it hasbeen during the last few days. Temperature 96’; pulse’90, fairly strong; respiration good. Abdomen slightlydistended, but quite soft on palpation, which givesvery little pain. There is a little fulness in the leftdank over the situation of the left colon. Mr. Mason sawher at nine o’clock, and considered that it was not advisableto operate until enemata had been tried. She was there-fore given a large enema of soap-and-water, with hardlyany effect. A mixture containing ten minims of tinctureof belladonna in half an ounce of water every two hourswas ordered. The enema was repeated at 12 o’clock, againwith no result. At about 1 A.M. on July 25th she vomitedabout a pint of faecal matter At 10 A. M. another enema

was given, with no effect. A consultation of the staff wasnow held, and the majority were in favour of waiting alittle longer. At 10 P.M. it was decided to perform abdo-minal section, so the patient was put under the influence ofether and the usual incision made. As soon as the smallintestines came into view they were seen to be very much dis-tended. Small pieces were drawn out of the wound, examined,and then returned. At last a piece of bowel was found,which was very congested and nearly black. As it wastwisted upon itself, it was thought to be a volvulus, and thecause of the obstruction. As the bowel was so distended,it was punctured, and a small quantity of air came away.A catgut suture was put through the small puncture. Theabdominal wound was then closed. The patient ralliedwell from the operation, but became suddenly worse on thefollowing morning and died about 10 A.M.At the examination of the body made five hours after

death, there was found, eighteen inches from the ileo-csecalvalve, a pear. shaped body about 2 in. long by loin. broadattached to the small intestine by a pedicle 11 2 in. long.This body, which was doubtles the remains of the fcetalyelk sac, contained a black, liquid, grumous material. Thispear-shaped body was wedged down in Douglas’s pouch,and was pressing a coil of small intestine against the pro-montory of the sacrum, causing without doubt the obstruc-tion.

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Medical Societies.MEDICAL SOCIETY OF LONDON.

Laparotomy for Perforating Ulcer of the Duodenum.-Amputation at the Hip-joint.

AN ordinary meeting of this Society was held on Nov. 16th,the President, Dr. Douglas Powell, in the chair.Mr. LOCKWOOD and Dr. GALLOWAY read a paper on two

cases of Perforating Ulcer of the Duodenum in whichLaparotomy was performed. The report of the cases

appears in another part of our present issue under theheading "Mirror of Hospital Practice."-The PRESIDENTasked if the temperature was depressed below the normal.It was remarkable how intense a peritonitis could existwith a subnormal temperature. He could not agree withthe authors in their disposition to operate so early beforethe diagnosis could be well established. In addition to thesigns which had been alluded to as aiding in the distinctionbetween perforative peritonitis and mechanical obstruction,it should be remembered thaD in the former the normalhepatic dulness often entirely disappeared.-Mr. JESSETTreferred to the rarity of this lesion, the diagnosis ofwhich was very difficult. The lives of many patientssuffering from tubercular and septic peritonitis had beensaved by flushing out the peritoneum. He approved inthese cases of the practice of making an incision into thesmall intestine to empty the gut before proceeding furtherwith a search for a perforation, and he deprecated the prac-tice of puncturing the intestine through the abdomen forthe relief of flatus. He was sure that an ulcer of theduodenum could be stitched up by folding in the peritonealcoat and suturing with silk.-Mr. CRIPPS, referring to thequestion of diagnosis, said that a sudden onset of painusually indicated the presence of mechanical obstruction,whereas it came on more gradually in perforation. Ibwas an important point to decide how long after a

perforation one could wash out the cavity of the abdomenwith prospect of preventing peritonitis. He alluded to acase of inguinal colotomy which had been under his care.All was going well, and on the sixth day after the operationa dose of castor oil was administered. Half an hour after afit of coughing the patient complained of pain, which in thecourse of an hour became intense in its severity. When hesaw her some time later he found that the opened intestinehad given way and had dropped back into the peritoneum,and that after this had occurred a copious motion, theresult of the action of the castor oil, had taken place intothe peritoneal cavity. He enlarged the wound andthoroughly washed out the peritoneum, re-stitched the gutto the belly-wall, and put in a drainage-tube. Almost fromthe moment of the flushing out the pain began to subside,no peritonitis developed, the patient recovered, and remainedwell a year and a half afterwards. From a study of this

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case two points were clear: that pain might be producedimmediately by extravasation, and that faecal matter

might remain in the peritoneum for three or four hours and thenbe washed out without peritonitis developing.-Mr. LocK-WOOD, in reply, said the temperature was neither depressednor elevated. He adhered to his opinion that the time tooperate was early, before distension had set in, although hewas ready to admit that there was a time which was toosoon, when diagnosis was doubtful. If there were great dis-tension of the gut with air, the liver dulness would diminishin an upward direction. The incision which he made intothe small intestine was an inch in length, and was quiteadequate to give the relief required. He felt sure that punc-turing was not a course which many surgeons would adopt,though one could not forget the brilliant results which hadbeen obtained by Dr. Oliver of Harrogate, by which he hadapparently cured some cases of chronic intestinal obstruc-tion. If he met with another such case he would probablyexplore the duodenum, and he admitted that there would beno difficulty in adequately suturing the ulcer if one shouldbe found.Mr. RICHARD DAVY then read a paper on Amputation at

the Hip joint, giving the results of ten cases. He said thatthe gravity of such a procedure ought to impel surgeons toadopt every measure to prevent its necessity. Traumatismplayed usually an important initial part; insanitation andpoverty supplemented it. He did not view excision of thehip very favourably in any but young subjects under the ageof ten; after that, the dangers were greater and the ultimateusefulness of the limb not so good. He had operated onten cases in fourteen years ; all except one were markedlyinveterate cases of morbus coxse ; four of them had sufferedexcision prior to amputation, and profuse suppuration andresulting enfeeblement had been the immediate conditionsnecessitating amputation. All those which had beendoubly operated upon bad recovered, which was one

goo argument in favour of dividing an amputa-tion at the hip-joint into two stages, as advisedby Keetley. In the series, there were six men,two boys, and two girls, and the two fatal cases were themen, aged respectively twenty-nine and forty-three Twoother of the cases had subsequently died, one eleven andthe other eight years after the operation. In one of theselardaceous disease was thought to be present at the timeof operation, though at the necropsy no trace of it couldbe found. The method of operating was described: a

circular incision was made at about the upper third of thethigh through all the soft structures down to the femur; thelower section was then drawn forcibly towards the knee togive space for the ligation or torsion of vessels. An ex-ternal incision was then made down the femur, the bonewas freed from its muscular attachments, and the limbexarticulated and removed. The acetabulum having beenscraped if necessary, the wound was irrigated and closed.Haemorrhage was controlled by the elastic ligature. Hepointed out that the assertion commonly made that inamputation at the hip-joint one-fourth of the body was re-moved was erroneous; in one of his own cases he weighed thelimb afterwards and found that it was only one-thirteenth ofthe body weight. He referred to the late Mr. Shuter’ssubperiosteal method of amputating, and alluded to thedecision of the committee of the Clinical Society on hiscase. He thought that for working people crutches wereto be preferred, as they were a great support, a warning tooutsiders, easily discarded or resumed, and were compara-tively cheap. He attributed the reduction in the mortalityto general reasons-the use of anaesthetics, the more

rigorous application of measures calculated to prevent theloss of blood, the diminished shock by cutting the soft partsthrough the upper third of the thigh, improved hygiene andnursing, and more careful selection of cases for operation.Specimens were shown to illustrate the paper.-Mr. SHEILDsaid that these desperate cases of hip-joint disease wereentirely found amongst the poor, and were usually theresult of neglect. He asked the author what he would doin a case of early and marked hip disease. Would he adviseearly excision or erasion, or would he treat it with splintsand waiting ? In the case of poor children with pus inthe joint, he felt himself that the proper treatment wasearly and complete removal of the diseased structures. Incases where necrosis of the pelvis coexisted, the diseasedbone from this region should also be removed freely at thetime of the operation. He wondered if lardaceous diseasewould disappear after cure of the lesion causing it, and

whether lardaceous disease in itself could be so severe

as to negative operation. He inquired if the author had’tried reinjecting the blood from the ablated limb, either byitself or mixed with saline fluid, or whether he had injectedsaline fluid alone.-Mr. STEPHEN PAGET asked if thefemoral were tied first before the amputation. He thoughtthat this procedure was safer and more certain than theelastic ligature or the tourniquet.—Mr. LOCKWOOD observedthat Mr. Davy had expressed no opinion with regard to the’subperiosteal method. It was so very easy to turn the femurout of its periosteum. In one case that had come under hisnotice the periosteal canal had remained as a suppuratingchannel, which led to the patient’s death from lardaceousdisease, and in another instance the badly formed new bonehad to be removed.-Mr. DAVY, in reply, said that hewould treat the early cases in the way usually at presentadopted. In all the cases in which he had operated every-thing else had been tried, such as rest, splintage, and cod-liver oil. He confessed that the only case in which he haddiagnosed lardaceous disease to be present was not foundto be so after death. He had bad no experience withintravenous injections. In a case of lardaceous disease he.would certainly perform amputation in order to save thepatient’s life. In Mr. Shuter’s case the resulb was verygood, and one advantage of the subperiosteal method wasthat it promoted free drainage.

PATHOLOGICAL SOCIETY OF LONDON.

Mandibular Tubercle and Cicatrices. -Ca?tcei, of (Esophagus.- Intestinal Co-neretion.-Lurycphadenoma oj Spine andCord. - Inoculated Tuberculosis in Snakes.-T2cbercacla°Growth in Ureter.

AN ordinary meeting of this Society was held on Nov. 17th,the President, Sir George Humphry, in the chair.Mr. BLAND SUTTON communicated a contribution on the

Mandibular Tubercle and Cicatrix, which he illustrated bypictures on the screen. The paper will be published in fullin our next issue. - Mr. STEPHEN PAGET showed Somedrawings of saccules of the lower lip which he had copiedfrom original publications. He said that in most cases inwhich these saccules had been found other deformities werepresent, especially hare-lip.-Mr. BLAND SUTTON explainedthe occurrence of these recesses on developmental grounds.The lower lip was at first widely cleft, and if perfect,coalescence did not take place, a recess or two recesses, or amedian hare-lip, remained. This condition persisted for a longtime in kangaroos, though it was rarely seen in humanbeings. It was clear that three forms of abnormality couldoccur: dermoids, recesses, or tubercles. In the lower lipthe first two had already been found, and he was convincedthat the third would be found before long if it were lookedfor. - Mr. STEPHEN PAGET could not agree entirely withMr. Sutton’s explanation; for if it were true, he thoughtthat only one median saccule ought to be found, andnot two, as had usually been the case. - Mr. SUTTON,in reply to this, pointed out that he had already shown thattwo tubercles did exist side by side in some dogs, and thesehe considered to be quite comparable to the recesses whichMr. Paget had mentioned.

Dr. W. B. HADDEN described a case of Carcinoma of the(Esophagus which extended towards the stomach, and heshowed the specimen. The patient had been treated bycontinuous catheterisation. For eight weeks he had beenfed through a catheter passed along the oesophagus into thestomach. During this time the tube was only withdrawnto substitute one of larger size. The stricture seemed tohave.dilated well, so continuous catheterisation was stopped,and he was fed by the mouth, a bougie being passed twicea week. The dysphagia soon returned, so that at the end’of eleven weeks from the commencement of treatment gas-trostomy had to be performed. At the post mortem exami-nation the walls of the oesophagus in its upper part were-infiltrated with new growth, masses of which projected intothe lumen. The main mass had a vertical extent of fourinches. In the lower half of the oesophagus the growthextended downwards from the main mass in uninterruptedlines nearly to the cardiac orifice, the lines clearly cor-

responding to the rugae. There was a small nodule ofgrowth in the mucous membrane of the stomach, just.beyond the cardiac orifice. The pathological appearances