813

The discharge from the mouth drained through the loweropening, and was only slightly offensive.From this time the patient made a rapid and steady re-

covery, and was discharged on February 21st to go toEastbourne. He returned in March with the mouth quitehealed. In November, 1880, the patient visited the hospitalin perfect health, having grown stout and strong for his age.The mouth was perfectly sound, the gap in the jaw beingfilled by firm, dense cicatrix, covered with healthy mucousmembrane, and the right side of the jaw being drawn in-wards by the action of the muscles, as is usual in cases ofdivision of the mandibles.

GLASGOW ROYAL INFIRMARY.INTRODUCTION OF A TRACHEAL TUBE THOUGH THE MOUTI

FOR THE ADMINISTRATION’ OF CHLOROFORM DURING

AN OPERATION FOR THE REMOVAL OF EPITHELIOMA

FROM THE MOUTH AND FAUCES.

(Under the care of Dr. MACEWEN.)

FOR the following notes we are indebted to Mr. McCall,house-surgeon.

J. B-, aged forty-five, was admitted on July 31st, 1880,suffering from epithelioma of the posterior portion of thetongue on the right side, and also of the right pillar of thefauces, extending to the epiglottis. Eleven weeks previousto admission the patient’s attention was drawn to thetumour. For several years he had been in the habit of in-dulging excessively in alcohol. His heart was enlargedand was slow and feeble in action. He had slight chronicbronchitis. His mind was somewhat obtuse.On August 3rd a tube was inserted through the mouth into

the trachea, through which chloroform was administered.The upper portion of the epiglottis was occluded round thetube to prevent the entrance of blood. An incision wasmade through the right cheek from the angle of the mouthto that of the lower jaw, the latter being sawn through andheld aside. The right half of the tongue, with the exceptionof a quarter of an inch from the tip, was removed, as wellas the implicated portion of the fauces. The bleeding wasarrested, the angle of the jaw drilled and secured by a coupleof wire sutures, the soft parts being brought together, thepatient was loused from the chloroform, and the tube waswithdrawn from the trachea.On August 10th the wound was looked at for the first

time, and found healed, with the exception of the aperturesthrough which the wires from the jaw protruded. Thewires were removed, the one on August 31st, the other onSept. 5th. A slight swelling remained on the right side ofthe face.Ren,bar7,s.-The insertion of the tube into the trachea -,va,3

easily effected ; it was followed by little spasmodic cough ;the inspirations were perfectly carried on through it. Theadministration of the chloroform through the tube, the ex-tremity of which projected several inches beyond the mouth,was continuous during the whole operation, without in anyway interfering with the operator. This is the fourthpatient on whom these tubes have been passed through themouth into the trachea.

ASHBURTON AND BACKFASTLEIGHCOTTAGE HOSPITAL.

CHRONIC EFFUSION INTO BURSA PATELLÆ AND BURSA

LIGAMENTÆ PATELLÆ; COMMUNICATION

BETWEEN THE TWO BURSÆ.

(Under the care of Dr. JAMES ADAMS.)D. T-, aged sixty-nine, a shoemaker, with marked con-

genital talipes varus in each foot, was admitted on July17th, 1880, with an unhealthy ulcer, a3 large as half-a-crown, over light patella, and with the bursa patellæ andbursa ligamentæ patellæ much distended with fluid. Thetwo bursæ communicated, for the fluid cuuld be distinctlvpressed from one to the other. The patella could be obscurelyfelt through the bag of fluid over it. For two years he hadhad considerable enlargement of the knee, unattended withpain and not interfering with his work. About two monthsbefore aelmiaiun the skin over the patella broke down, anda fortnight before admission there was, he said, a copiousdischarge of fluid from this spot. Twice during the last twomonths he had the bursæ tapped and emptied, but the fluidsoon returned.

On July 19th a grooved needle was passed into the bursapatella; through the ulcerated surface, and five or six ouncesof straw-coloured fluid pressed out. There was no pus. Hewas kept in bed, and a bandage applied as tightly as possibleover both bursae. A poultice of linseed-meal and charcoalwas applied to the ulcer.On the 26th the ulcer was healthy, and healing. Lead-

lotion was ordered instead of the poultice. There had beena small amount of fluid discharge from the bursæ, sufficientto stain the bandages.On August 3rd the bandages were taken off. The bursa

patellae was normal, but the bursa ligamentæ patellae wasrefilling. Tincture of iodine was applied twice a day to it.Five grains of iodide of potassium and one-sixteenth of agrain of perchloride of mercury were taken thrice daily.On the 10th the bursa ligamentse patellse was getting

larger. Cantharides plaster was applied over it instead oftincture of iodine. To continue the medicine.On the 19th the patellar ulcer was filling up. The inter-

nal and local medication had no effect on the refilling bursa.It was therefore punctured with a small lancet, at the lowerpart, under carbolic spray. Two ounces of dark-coloured fluidwere evacuated, and the wound was then strapped firmlywith diachylon plaster, and a common splint put on underthe knee, with a pad tightly bandaged over the bursa. Hewas kept in bed a week with splint and pad on, and everyother day a probe was passed as far as possible through thelancet puncture into the bursa. He was discharged Aug. 28thwith both bursæ empty.When seen afterwards there had been no return of fluid in

either bursa.

Medical Societies.PATHOLOGICAL SOCIETY OF LONDON.

Congenital Deformity of Leg and Foot.-Congenital Mal-formation of Heart.—Rickets.—Cranio-tabes.

THE ordinary meeting of this Society was held on Tuesdaylast, Mr. T. W. Nunn in the chair. There was a very largeattendance of members, attracted by the discussion on

rickets. In accordance with the desire of the council ashort portion of the time was devoted to the consideration ofa living specimen and a card specimen. The debate onrickets was opened by Dr. Hilton Fagge, who was followedby Drs. Barlow and Lees. Dr. Ctisp spoke to the occurrenceof rickets in the lower animals, and then, on the motion ofDr. D. Powell, the discussion was adjourned.Mr. PEARCE GOULD showed a child three years old, the

youngest of a family of seven children, all the others ofwhom were well formed. The mother of the child, whenbetween two and three months advanced in piegnancy, fell

heavily on her face and belly, and received a severe shake.The pregnancy advanced normally, but the child at birthwas found to have a deformity of the left leg and foot. The

thigh and knee-joint were normal, but the leg was shorterthan its fellow ; the tibia was sharply curved forwards below,and over the prominence of the crest the skin was grooved.There was nothing to be felt of any part of the fibula. Thefoot was small and shot, and had only the three inner toes,the two outer of which were webbed. The child walked onthe inner malleolus of the tibia, and inner side of the foot.The muscles of the leg were all present, and Mr. Gouldthought he could feel a thick interosseous membrane runningdown the outer side of the leg. There was no evidence ofthe existence of the cuboid and fourth and fifth metatarsalbones. The biceps cruris muscle was small, and could betraced to its attachment to the outer condyle of the tibia.Dr. Meyersohn had collected eleven cases of completeabsence of the fibula. In Dr. Forster’s work on malforma-tions another case is figured, and Dr. Humphry has statedthat he found a specimen of absence of the fibula and cuboidon both sides in the Musee Dupuytren, and the case shownwould make a fourteenth case. Instances of absence of apart of the fibula are more frequent.-Mr. ADAMS thoughtcases of partial absence of fibula were not unfrequent; hehad seen several such, in all there was a dimple in the skin,which had been taken as evidence of intra-uterine fracture,

814

but this was incorrect. He thought in such cases there wasreally fusion of the two bones ; it was well to rememberthat in the adult there was always three to five inches ofshortening.Dr. PEACOCK showed as a card specimen a Heart removed

from a child six years old, in which there was markedstenosis of the pulmonary artery, a large aperture in theventricular septum, the aorta arising from both ventricles.The foramen ovale was closed. This was the commonest ofall the congenital deformities of the heart.

THE DISCUSSION ON RICKETS

was then opened by Dr. HILTON FAGGE, whose address wepublish in full in another page.Dr. LEES communicated the results of an investigation

which had been carried on by Dr. Barlow and himself, witha view to determine the true nature and causation of thecondition called cranio-tabes, which has since the time ofElsasser, its discoverer, been generally accepted as the firstsign of rickets. Cranio-tabes consists in an abnormal

softening of portions of the parietal and occipital bones,causing them to yield to moderate pressure, and impart to afinger pressed upon them a sensation like that derived fromstiff parchment or from the surface of a bladder. There isnow no doubt that some symptoms occurring in the firstyear of life, which have been ascribed to rickets, are reallydue to congenital syphilis, and it seemed a questionworthy of examination whether cranio-tabes is not reallya result of syphilis, and how far it seems to be con-

nected with rickets. It was soon found that the conditionwas one quite common amongst the children of the poor ofless than one year of age. The authors collected 100 cases,and investigated them as carefully as they were able. Forthe second 50 cases printed forms were used which directedattention-(1) to the maternal history, especially as to pre-vious miscarriages, or stillborn or premature children; (2) tohistory of syphilitic symptoms in older children; (3) to thehistory of the child suffering from cranio-tabes, includingsyphilitic symptoms and those usually deemed rickety;4) to its weight and age, with an account of the way it hadbeen fed; (5) to its present symptoms in detail, especiallythe state of the skin, mouth, nose, voice, skull, thorax, longbones, and viscera, particularly the liver and spleen. Theresults of these investigations were submitted to the Societyin a tabular form, from which it appeared that in 70 out ofthe 100 cases the condition of cranio-tabes was marked, in30 it was slight. After weighing the evidence as to syphilisin each case, the authors felt satisfied as to the existence ofthe taint in 47 cases, and thought that this conclusion couldnot fairly be challenged in more than six or seven instances.In about 40 more of the cases there were some indications ofsyphilis, of greater or less value. In 12 cases no evidenceof syphilis could he found. It was pointed out that even inthese latter syphilis might possibly be the cause at woik, forthe children of undoubtedly syphilitic parents at times shownothing beyond cranio-tabes and marasmus. Cases werenarrated which seemed to show that sometimes cranio-tabesis the only sign of a gradually diminishing syphilitic taint.It was pointed out that marked cranio-tabes not unfrequentlyoccurs in well-nourished infants, who have never had a day’sillness, and have been brought up exclusively at the breast.A list was given of seven such children, with their age andweight. A list of the weight and age of nine marasmic children,who were extremely wasted, and yet had no cranio-tabes,was also given. The inference was that crauio ta,bes isnot simply a part of a general marasmns. Some commentswere made on the cases narrated by Elsiisser and on thedifference in symptoms accompanying the cranio-tabesaccording to Elsässer, and in the experience of the authors.The conclusion at which they arrived was that syphilis is byfar the largest factor in the causation of cranio-tabes. Todetermine whether it is the sole cause it would be necessaryto examine a large number of infants in reference to whomthe question of syphilis could be absolutely excluded.The authors strongly suspect that when this has been doneit will be found that cranio-tabes is always a result of

syphilis. To determine whether it has any connexion withrickets they tabulated the rickety symptoms (if any) observedin 53 cases of crauio-tahes, arranged according to age, fromtwo to nineteen months old. It was found that all the latercases in this ta.>le showed some, though at times very slight,evidence of rickets. It would not, however, be safe to infer atonce from this fcr,;t that cranio-tabes is the first sign of ricketswithout an inquiry into the manner in which the children

had been fed. Of the thirty-five infants in this table of notmore than six months old twelve had been brought up exclu-sively at the breast. Not one of these showed any evidenceof rickets whatever. Fourteen had been partly suckled andpartly fed by hand ; 9 suckled for less than one month ornot at all. Nine of the former 14, 6 of the latter 9, showeddistinct signs of commencing rickets. Of the 15 children inthis table of more than six months of age, 5 were stillpartly suckled at the time that their cranio-tabes was noted.Of these 1 showed very slight signs of rickets, 1 slight signs,and 3 a moderate amount. But of 9 who had been suckledfor less than six weeks, 2 showed slight signs, 3 a moderateamount, and 4 a marked degree of rickets. These factstend, so far as they go, to show that the rickety manifesta-tions bear some definite relation to the diet. The fact,therefore, that all the older cases of cranio-tabes showedsome signs of rickets does not itself prove the truth ofElsässer’s idea, for they were all more or less improperlyfed. And a syphilitic child may be expected to be at leastas liable to injury from a faulty diet as a child free fromthis taint. Even if it could be proved that crauio-tabes isthe first sign of rickets, that would, of course, in no wayinvalidate the proof that cranio-tabes is itself the result ofsyphilis. The only conclusion would be that syphiliticchildren are specially apt to become rickety. Whether it isso or not is uncertain ; for themselves the authors confessedthat if cranio-tabes and enlargement of spleen be transferredfrom the category of tickety symptoms to that of thesymptoms of inherited syphilis, they have as yet no proofthat syphilislrocr se is a cause of rickets.

Dr. CRISP had found rickets most common in childrenreared in poor, overcrowded neighbourhoods, but had seenmany cases among the well-to-do classes. He thought thecause lay rather in the quality than the quantity of the food.He thought the cause of rickets was better known than thatof any other disease, but it was a cause that might produceother diseases, and, in illustration of this, cited the case of afamily in which one child died of tubercular meningitis, andanother of chronic hydrocephalus, and a third suflered fromsevere rickets, which caused permanent deformity. Amonganimals the disease was so widespread that thera were novertebrata in which it might not occur when they wereplaced under special favouring conditions, but it was not soprevalent as in man. Dr. Harley had shown at the Patho-logical Society the bones of a rickety horse, Dr. Dick thebones of two Italian greyhounds, also rickety, and he him-self had more recently exhibited the rickety bones of severalyoung pheasants which had been kept in a confined spaceand fed on improper food. London-bred poultry, which areoften not well fed and kept in bad air, have a markeddeficiency of phosphate of lime in the sternum,which is soft and bent. A young ostrich hatched atthe Zoological Society’s Garden died at once from thefalling in of its soft ribs ; and all the lions born in the Gar-dens had soft bones, and nearly all of them had died beforereaching maturity, while lions born in travelling menageriesoften live. Large dogs are often thus diseased, as are alsolambs in cold, bleak places. Rickets had also been seen infoals not getting enough milk, or where the mother wasbeing worked. It had also been seen in the hog. Thesefacts were sufficient to show that the same changes follow inanimals and children when placed under similar conditionsas to air and food. Another conclusion he drew was, thatas syphilis was not known in animals, it had no connexionwith the production of rickets. In reference to the resultsobtained by giving lactic acid to young animals, he thoughtthat too much stress should not be laid upon them, for pro-bably similar effects would follow the administration ofmany other extraneous matters ; thus Guérin fed youngdogs on nesb exclusively, and produced rickets.The meeting then adjourned.

CLINICAL SOCIETY OF LONDON.

Stretching of Facial Nerve for the relief of Spasm of FacialMuscles.—Myxœdema.—Persistent Gyrate Erytherna.THE ordinary meeting of this Society was held on the

12th inst., Dr. E. H. Grecnhow, F.R.S., President, in thechair. The subject of nerve-stretching for the relief offf c:a1 spasm was raised in a paper by Dr. Sturge and Mr.Godlee ; and Mr. Croft related a case of division of the in-, fra-orbital nerve for neuralgia. A paper on- myxœdema