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Medical Societies.ROYAL MEDICAL AND CHIRURGICAL

SOCIETY.

Ligature of the Subclavian Artery for Aneurysm.—Ligatureof the Carotid Arteries for Tonsillar Hœmorrhage.—Irreducible Hernia.

A MEETING of this society was held on May 26th, thePresident, Dr. HowsHr DiCKINSON, being in the chair.At the commencement of the meeting the President pro-

posed that a loyal address should be drawn up and forwardedto Her Majesty conveying the congratulations of the RoyalMedical and Chirurgical Society on the celebration of herDiamond Jubilee. He remarked that in 1840 the Queen aspatron signed the book of the society, following the precedentset by her predecessor, William IV. The motion wascarried by acclamation, and the book containing the Royalsignature was handed round for the inspection of theFellows. ,

Mr. H. H. CLUTTON read a paper on a case of SubclavianAneurysm successfully treated by Ligature. The case wasone of an aneurysm of the third part of the right subclavianartery, for which the first part of the artery was ligaturedtwice, and a few days after the second occasion a distalligature was also applied to the first part cf the axillaryartery. The patient, a spare, healthy man, fifty-fouryears of age, was seen by Dr. Sharkey in February,1896, and fent to him (Mr. Clutton) with the statementthat the heart and aorta were free from any obvious

signs of disease. There was a small sacculated aneurysmin the third part of the right subclavian artery reachingfrom the outer border of the scalenus anticus to theclavicle. On March 18th, 1896, a ligature prepared fromgoldbeaters’ skin was applied on the proximal side at thejunction of the first and second part of the subclavian artery.The ligature was tied by means of the "stay-knot recom-mended by Ballance and Edmunds with sufficient tightnessto arrest the circulation, but without rupturing the coats.The superior intercostal artery was also tied at thesame time and in the same manner. At the end offive or six weeks the aneurysm and the radial arterywere pulsating as they did before the operation. Thiswas probably due to the ligature becoming absorbed. OnJune 10th the first part of the subclavian artery was

exposed and tied with floss 5ilk on the proximal side ofthe first ligature. The internal mammary and thyroidaxis were also tied at the same time. The stay-knot wasemployed for each ligature, and the walls of the vessels wereapproximated without sufficient tightness to rupture thecoats. Pulsation in the aneurysm and in the radial arteryceased as the ligature on the main vessel was beingtightened. On June 17th the aneurysm was again pulsating.The first part of the axillary artery was therefore immediatelytied in the same manner with floss silk, so as to cut offall the collateral vessels from the intercostals in the axilla.After this operation the aneurysm ceased to pulsate andgradually disappeared, so that the patient left the hospitalon Aug. 8th without any swelling above the clavicle. Mr.Clutton considered it probable that if the first ligature hadbeen of silk instead of an animal material the subsequentoperations would have been unnecessary.-Mr. BARWELLremarked that until the last few years ligature ofthe subclavian artery had only rarely been undertaken.He was glad to see that Mr. Clutton supported theview which he (Mr. Barwell) had advanced fifteen yearsago, that it was dangerous to rupture the coats of a vesselso near the heart as the subclavian artery, as it wasnot safe to trust the vessel with only part of its coats

exposed to the strong pulsation unavoidable in that position.For even if the ligature held there was great risk that, ifthe middle coat was torn and retracted, an aneurysmmight form at the seat of the ligature. He had seenthe ligatures of goldbeaters’ skin, but had no personalexperience of their use and would not expect that they wouldbe sufficiently firm to ensure occlusion of the artery. It wasa difficult matter, requiring experience and delicacy of touchto judge the exact amount of force necessary to completelyarrest the pulsation without rupturing the coats. He agreedwith Mr. Clutton that, owing to the short length of artery

available and the high arterial pressure, it was not safeto ligature the artery in two places and divide it.-Mr.BERNARD PITTS said that he had met with a similarcase, and had operated on it at St. Thomas’s Hos-

pital a short time ago. The man had an aneurysminvolving the second and third part of the right sub-clavian artery and also a cardiac lesion. He cut downon the first part of the subclavian artery and had no diffi-

culty in exposing and ligaturing it with a floss silk ligature.He endeavoured, unsuccessfully as it proved, to avoid

rupturing the coats. Owing to the encroachment of thetumour it was not possible to find and ligature the branchesof the vessel. The pulsation and pain returned after a shorttime, and Mr. Ballance, in his absence, explored the site ofthe ligature and found a swelling, which afterwards provedto be an aneurysm, at the proximal side of the seat of theligature. Mr. Ballance ligatured the first part of the axillaryartery, but haemorrhage occurred a few weeks later from thesite of the exploration, and it was found that at the firstoperation the coats of the artery had been ruptured owing totheir being unusually soft, and that an aneurysm had formedon the proximal side of the ligature. There was no suppura-tion after the operation in this case.

Mr. CLUTTON also read a paper on a case of PharyngealAbscess followed by Haemorrhage, and treated by Ligature ofthe Carotid Arteries. The case was one of very severe hmmor-rhage from an abscess in the roof of the pharynx above theright tonsil, which was eventually successfully arrested by theligature of the common external and internal carotid arteries.A man, aged twenty-eight years, a victualler by trade, wasadmitted into St. Thomas’s Hospital, under Dr. Sharkey, onJune 20th, 1896, for a " sore-throat " and general pains. Theday after admission he bled rather profusely from an

abscess in the pharynx above the right tonsil. Onthe 24th the soft palate was divided for the purpose of acomplete examination of the abscess. A hole was thenfound passing through the wall of the pharynx into the

tissues of the neck, from which rapid oozing took place.This opening was enlarged and the cavity plugged withcyanide gauze, as it was thought from the character of thehemorrhage that the bleeding might be from the internaljugular vein. During the night following this operation hebled so profusely that no doubt could be entertained as tothe haemorrhage being from a large artery, probably theinternal carotid. The next day, the 25th, the bifurcationof the common carotid on the right side was exposed, and agoldbeaters’ skin ligature applied by means of a " stay-

L knot" to the common carotid and its two branches. Ai saline infusion of two pints was given whilst the wound

, was being closed with sutures. The wound in theneck healed by first intention, and the abscess cavity

; in the pharynx was found by digital examinationi to have closed on July 16th. He had no furtheri haemorrhage after the ligature of the carotid arteries, and, left the hospital for a convalescent home on July 25th. Con-, sidering the difficulties in determining the exact source of

hemorrhage when it occurred from a pharyngeal abscess, Mr., Clutton considered it to be the safest practice to tie both, the external and internal carotid arteries, as well as the. common carotid, for all three arteries were reachedl through the same incision at the bifurcation. The necessityl for tying two of them had been well shown by Mr. Pitts’, paper in the "St. Thomas’s Hospital Reports," vol. xii.,I and the addition of the third scarcely increased the lengthi of the operation -Mr. PITTS said that fifteen years ago aJ patient was admitted into St. Thomas’s Hospital, in whom! a discharge of pus suddenly occurred from the right

, tonsil. A few days afterwards there was considerable: haemorrhage, which soon stopped, but a few nights laterI the patient brought up about a pint of blood, andl ligature of the common carotid artery was hastily per-I formed. Twenty - four hours later profuse haemorrhageI recurred and proved rapidly fatal This showed that ligature. of the common carotid alone could not be relied on. He: made experiments on the cadaver, and found that if glassi tubes were put in the internal and external carotid arteries oflone side and coloured fluid were injected from the oppositeL common carotid artery the fluid appeared almost im-l mediately in the external artery, and also, though muchs later, in the internal artery. In his case the source ofi haemorrhage had proved to be the internal carotid, and her had been led from his experience in this case to insist1 on the ligature of at least the common and externalr carotid arteries in such a case.-Mr. HARRISON CRIPPS

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said that some years ago, being dissatisfied with the planof ligaturing the common carotid, he also had been led toexperiment by injections on the cadaver. He found, however,that if he divided a branch of the facial branch of theexternal carotid and injected from the opposite commoncarotid that the fluid escaped from the proximal end of thecut artery, and he attributed this to regurgitation along theinternal carotid by way of the circle of Willis. He hadcollected sixty-eight cases of ligature of the common carotidand had been struck with the high mortality, largely frombrain symptoms, occurring immediately or a few days afterligature, or from secondary haemorrhage, in most cases due toregurgitation down the internal carotid, so that ligature ofthe common carotid was a very formidable operation. Outof all the cases that he had collected there was clear evidence

only in one that the internal carotid was the source of thehsemorrhage, and when that occurred death would probablytake place at once, so that the question of operation didnot arise. He thought that in most cases ligature of theexternal carotid would suffice and was much less dangerousthan ligature of the common trunk.Mr. WARRINGTON HAWARD read a paper on Irreducible

Hernia. The paper was based upon an analysis of eighty-five cases in which an operation was performed for irreduciblehernia. The cases were tabulated so as to show the sex andage of the patients, the situation of the hernia, the durationof the hernia and of its irreducibility, the occurrence ofstrangulation, the contents of the sac, the cause ofirreducibility, the treatment adopted, and the result. Thedangers of irreducible hernise were described and illustrativecases quoted. The conditions on which irreducibilitydepended were then considered and arranged as follows :thickened and adherent omentum, 31 cases ; adhesion ofomentum to sac, 34 cases ; twisting of omentum, 1 case ;cysts in omentum, 1 case ; adhesion of intestine to sac,12 cases; adhesion of coils of intestine, 4 cases ; largeamount of intestine, 3 cases ; and other causes, 5 cases.

In a few cases more than one of the above causes of irre-ducibility were present. It was shown that in nearly everycase these conditions are such as are remediable only byoperation. From the facts and arguments adduced thefollowing conclusions were drawn :-1. That irreduciblehernia is a condition of serious danger, the gravity of whichincreases with its duration or neglect. 2. That the applica-tion of a truss upon an irreducible hernia is not only useless,but harmful. 3. That irreducible hernias which consist

wholly or in part of bowel are very apt to become

strangulated. 4. That bernise consisting wholly of bowel,upon which no truss has been worn, may (even whenof large size and of considerable duration) generallybe returned by appropriate treatment. 5. That of thecases of hernia in which proper treatment fails toobtain reduction the great majority are irreduciblebecause of adhesions of, or changes in, the protrudedviscera-conditions which are remediable only by operation.6. That the most common cause of irreducibility is the

presence in the sac of adherent omentum. 7. That thepresence of irreducible omentum in the sac of a hernia is asource of constant danger, which can, nevertheless, beremedied by an operation of extremely small risk. 8. Thathernias containing irreducible bowel are more dangerousthan those containing only omentum, and that as the

danger of operation increases with the magnitude of thehernia and with the occurrence of adhesions these hernia3should be operated upon as soon as they are provedby the failure of proper treatment to be irreducible-Mr. A. E. BARKER endorsed all the conclusions at whichMr. Haward had arrived. There was one form of irreduciblehernia with which he had met three times in about 200operations for the radical cure of hernia-viz., a hernia ofthe sigmoid flexure. The bowel in these cases had beenextremely difficult to reduce, and he found that the bestprocedure was to strip the sac bodily off with the intestineand return it.-Mr. MACREADY was hardly able to assent tothe conclusion that operation was always indicated in thesecases. He thought that properly applied pressure by meansof a truss would succeed in many instances in reducing thehernia. Two-thirds of the inguinal and half of the femoralhernise that he had treated in this way had been reduced.He thought that there was unnecessary fear lest the pressureof a truss should cause adhesions, and held, on the contrary,that it favoured the absorption of adhesions.-Mr. HAWARD,in reply, said that he had not met with the cases of hernia ofthe sigmoid flexure described by Mr. Barker. He thought

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that the pressure of a truss had often done harm in thesecases, and that had induced him to bring forward this paper.He had used elastic pressure, combined with purgation, lowdiet, and elevation of the end of the bed, and had found itsuccessful chiefly in patients who had not previously worn atruss, which he believed to be responsible in many casesfor the formation of adhesions.

BRITISH GYNÆCOLOGICAL SOCIETY.

Exhibition of Specimens.—The Valve of ExploratoryLaparotomy.

A MEETING of this society was held on May 13th,Mr. MAYO ROBSON, President, being in the chair.Mr. F. &bgr;OWREMAN JESSETT showed :-(1) Flbro-myoma of

the Uterus-sub-peritoneal hysterectomy; (2) Fibro-myomaof the Uterus-oophorectomy ; (3) Myoma of the Uterus-double pyosalpinx, sub-peritoneal hysterectomy; and (4)Large Fibro-myoma of the Uterus, complicated with

pregnancy. - The PRESmvT, Dr. PURCELL, Dr. C. H. F.ROUTS, Dr. GODSON, and Dr. HEYwOOD SMITH made someobservations, and Mr. JESSETT replied.

Dr. HERBERT SNOW read a paper on the Value of Ex-

ploratory Laparotomy per se in (a) Real and (b) SupposedMalignant Disease of the Abdominal Organs. Dr. Snow hadbeen struck by the remarkable improvement in certain casesof indubitable malignant disease which followed a simpleincision without any further operative procedures, and

thought if future explorations were scanned in the light ofexpected amelioration it would be found that the peritoneumthus stimulated behaves to a certain extent as in tuber-culosis. A small part of the tuberculous deposit only isremoved, yet the remainder somehow disappears, and thepatient becomes and continues well. In malignancy theresulting benefit has hitherto been oVErlooked through thecommon practice of sending patients home as incurabledirectly the wound has healed. In Case 1 a woman, agedforty-nine years, with advanced carcinoma of the sigmoidflexure, gained flesh and lost all bad symptomf, though thefavourable change lasted only six weeks. Case 2 was thatof a woman, aged fifty-three years, with a rapidly advancing,very vascular deposit in the omentum, secondary to scirrbusof the breast. After incision the acva,nce was matErialychecked, the mass diminished in size, there was no ascitictrouble, and the woman lived eighteen months. Czse 3 wasthat of a man, aged fifty-eight years, with extensive depositof carcinoma along the whole posterior surface and most ofthe greater curvature of the stomach; great improvement tookplace after incision, but the patient was soon lost sight of.Case 4 was that of a man, aged sixty-four years, with a largesarcomatous mass infiltrating both recti ; exploration wasmade in June, 1896. The growth had diminished in size, theman had no bad symptom, and was now able to workregularly as a sawyer. Case 5 was that of renal explorationfor a growth thought to be cancerous and infiltrating thelumbar muscles. All bad symptoms had subsequentlyvanished. Case 6 was that of a woman, aged forty-eightyears, with cancer of the gall-bladder. After explora-tion she stated that she ’’ felt better and more freefrom pain than she had done for months." She wenthome and has since succumbed. From a recent paperby Mr. Leonard Bidwell two cases of diffused peritonealcancer were quoted in which very pronounced benefitsimilarly followed laparotomy. Others were cited inwhich the diagnosis of abdominal "lumps" " was shown tocontain, in even the ablest hands, a strong element ofuncertainty. Dr. Snow concluded that routine explorationshould be resorted to in every case of supposed abdominalcancer for two reasons: (a) the possibility of error ; and(b) the fact that as a mere matter of treatment this stepalways improves, and often materially checks, the advance ofthe disease, permitting scope for the administration, on whichhe placed the greatest reliance, of opium with cocaine.-The PRESIDENT said that he had himself operated on caseswhere, on opening the abdomen, he believed that he bad todo with ineradicable malignant disease and had closed theabdomen without proceeding further, yet the patients had gotquite well. In one case the operation was in the reg:oJ. of thegall-bladder ; before she left hospital the patient was alreadymuch better ; and now, several years after the operation, sheremained quite well. Last week he had a somewhat similar