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almost the entire scalp ; besides these severe injuries he hadreceived many abrasions and contusions in different parts ofthe body. The symptoms of shock were severe; he waspale, cold, and pulseless, but not unconscious. The humeruswas first put up in a moulded gutta-percha, splint overcotton-wool ; the wound in the fractured forearm was wellsyringed out with a 1 in 20 carbolic lotion, the bones gotinto position, a full dressing applied, and wooden splintsput on the back and front of the limb. The wound in con-nexion with the fractured femur was on the outer and back

part of the middle of the thigh; it was well washed outwith the 1 in 20 lotion, and a full dressing applied; nodrainage-tube was used. Both fractured femora were put upwith short splints around the thighs and long Liston’s splintson the outer side from the axilla to below the foot, andfastened by means of a towel pinned to the pad of the splintand folded round it, and the limb from the ankle to thegroin; extension was made by means of weights attached tothe leg by a cord passing over pulleys at the foot of the bed,counter-extension being kept up by raising the foot of thebed about nine inches from the floor. The abrasion andtumour of the scalp were dressed with protective and cotton-wool and bandage. Temperature 100° on evening of firstday.-Second day: Temperature 996°. Both compoundfractures taken down in consequence of blood-stained serumhaving come through the dressings, but the "deep dressing

"

was not disturbed in either case. Spray used; bowelsopen; feels comfortable.-Third day: Temperature 100° lastevening and 99’4° this morning. No discharge throughdressings; slept well; had two grains of opium.-Ninth day:No pain or uneasiness, but the temperature, which had beenabout normal for two or three days, is rising. Last eveningthe temperature was 1006°, and this morning 99’2°. Bothcompound fractures taken down; in the case of the forearmthere was no discharge whatever, and the " deep dressing "was not removed, but a full dressing was applied. From thewound in the thigh a good deal of blood-stained serous dis-charge had come through the dressings, and the wound wasaccordingly uncovered. No pus was to be seen, but a gooddeal of dark blood and serum could be squeezed out; therewas no pain, redness, or swelling. Bowels not open; to havesaline laxative. - Eleventh day: Discharge again throughdressings of the thigh. Temperature 100.6° last evening and99° this morning. Discharge lighter in colour, and of badodour. The wound was well syringed out with the perchlo-ride of mercury (l-16th to 8 oz.) lotion, a large drain put in,and full dressings applied.—Thirteenth day : Wound in thethigh suppurating; spray and gauze dressings omitted; agutta-percha splint moulded from the buttock to the knee,a window being left opposite the wound. The woundwas well syringed out with a chlorinated soda lotion(3 dr. to 8 oz.), a tube put in, and dry salicylic woolplaced over it. Very little discharge. Temperature 100’6°last evening, and 99° this morning. Wound of forearmquite dry and aseptic.-Eighteenth day: Feels quite com-fortable ; the discharge from the thigh wound more healthyin smell and colour, and not great in quantity; a tube leftin, and dry salicylic wool applied outside. The tempera-ture ranged from 100° to 99 ’4°. —Thirtieth day: Deep dressingremoved from the compound fracture of the forearm for thefirst time since admission, and the wound found quite healed,and the bones firm ; the humerus and right femur quitefirm; good union has also taken place in the left femur, buta sinus leads down to a piece of necrosed bone.-Forty-second day: All splints removed; the dead bone at thebottom of the sinus is not loose; very little discharge; thelegs are the same length.-Sixty-second day : Some piecesof dead bone have come away since the last report, but alittle more still remains; can walk well with crutches; asmall tube put in the sinus, and covered with a pad of salicylicwool.The boy discharged, and to attend the hospital.

FRACTURE OF BOTH OSSA CALCANEA.

C. R-, aged fifty-three, was admitted on Feb. 19th,1884, having fallen twelve feet from a ladder on to an ironflooring. He alighted on his heels, and the os calcis of eachfoot was found to be fractured. He was carried to thehospital immediately after the receipt of the injury. Therewas no displacement, but great pain, and some concussionof the brain and spine; the hip-joints were also painful. Aplaster apparatus was applied to each foot and leg, afterwhich the man suffered but little pain or inconvenienoe, andhe was sent to his own home at the end of a week.

GENERAL INFIRMARY, LEEDS.CASE OF OSTEOTOMY FOR GENU VALGUM (MACEWEN’S) ;

WOUND OF THE POPLITEAL ARTERY; LIGATURE;RECOVERY.

(Under the care of Mr. MCGILL.)FOR the notes of the following case we are indebted to

Mr. J. Hick.W. E. S-, aged seven, was admitted on Sept. 3rd,

1883, for operation for genu valgum. When standing withthe internal condyles of the femur in apposition, the internalmalleoli were eight inches apart.On Sept. 6th Mr. McGill operated on the left leg, dividing

the femur transversely above the condyles, according to thedirections given by Dr. Macewen. When the chisel wasfirst withdrawn, it was found that the bone was not com-pletely divided, and that it would not break with ease. Thechisel was consequently introduced a second time, so as todivide the posterior part of the bone more completely;this was done by a few gentle strokes. As the chisel waswithdrawn it was followed by a gush of blood; a woundof the popliteal artery was suspected, but as it seemedpossible that the haemorrhage was due to injury of thesaphenous vein or a large articular branch, a pad of silkwas placed over the wound, an outside splint was applied,and the bleeding arrested by firm pressure with a bandage.The child did not rally from the operation in the usualmanner, and in three hours blood began to ooze through thetightly applied pads. The foot was cold and blue, no pulsecould be felt in the posterior or anterior tibial arteries, andthe general condition of the patient was extremely bad. Onremoving the splint and bandages free haemorrhage re-

commenced ; the popliteal space and neighbourhood of theknee-joint were seen to be much distended, apparentlywith blood. After consultation it was determined toexpose the popliteal artery and secure it. The patient beinglaid on his face, Mr. McGill made an incision about fiveinches long over the outer border of the semi-membranousmuscle, and exposed the artery. This proceeding was ren-dered difficult by the presence of clots of blood, which werefound filling the popliteal space and separating, displacing,and discolouring the various structures in its neighbourhood.It was found that the artery was completely and transverselydivided. The two ends were secured with catgut and thebleeding satisfactorily arrested. The edges of the woundwere approximated by a few points of suture, and the opera-tion, which was done with antiseptic precautions, was com-pleted by the application of a salicylic silk dressing. Theafter-progress of the case was satisfactory; no hæmorrhagerecurred, and the wound healed by granulation. It was notdeemed expedient to apply much pressure, so as to make theleg perfectly straight; but after a fortnight a splint wasapplied to the outer aspect of the limb, and the result, thoughnot perfect as regards position, was tolerably good.Nov. 8th : The wound on the left limb being now healed,

Mr. McGill performed Macewen’s operation on the rightside; no difficulty was experienced in the operation; thedressing was changed for the first time on Nov. 15th, whenthe leg was placed in a plaster-of-Paris splint, and the patientwas discharged from the hospital two days afterwards. Thechild has been seen lately (March 30th, 1884) running aboutwith the left leg nearly straight and the right leg perfectly so.

Medical Societies.ROYAL MEDICAL & CHIRURGICAL SOCIETY.

Pelvic and Parietal Tumour of the Abdomen.—Method ofSounding for Impacted Gall-stones.

AN ordinary meeting of this Society was held on Tuesday,Dr. George Johnson, F.R.S., President, in the chair. Dr.

Harley’s paper was freely discussed by well-known Fellowsof the Society, though the meeting was in point of numbersthinly attended.

Mr. F. J. GANT read a paper on a Pelvic and ParietalTumour of the Abdomen removed by operation, withrecovery. The author related the particulars of a case inwhich a tumour grew from the ileum, and lay between themuscles of the abdominal wall. The question of diagnosis

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had reference principally to the distinctive characters of a undertake earlier than heretofore the artificial removal oftumour thus located and an ovarian or a uterine tumour ; dangerously impacted gall-stones-an operation which thebut the differentiation between a pelvic fibroma, as in this author of the paper thinks ought to be, under ordinary cir-case, and other forms of pelvic tumour was also noticed, and cumstances, no more hazardous to the life of the patientthe circumstances which indicated its parietal relations than the operation of lithotomy, believing as he does thatwere considered. The operation was then described, includ- the fatality that has hitherto attended the operation hasing the precise relations of the tumour and the antiseptic been almost entirely due to the fact of it having been delayeddressing employed. The descriptive and histological cha- until the exhaustion of thepatient precluded the possibility ofracters of the morbid growth were specified. Some references recovery.-Dr. GEORGE JOHNSON said the paper hadopenedup(e.g., T. Holmes in the Pathological Transactions, 1864, and a very interesting question in the diagnosis of cases of chronicNelaton, in the Gazette des Hpitaux, 1862) to similar cases jaundice, which were not always due to a calculus. A casewere appended, but they were rare in the records of surgery. was mentioned in which a stricture was found, though aAll such cases agree in two particulars : they have occurred calculus had been diagnosed. He would like to be sure thatonly in women who have borne children ; and, whether bile was innocuous in the peritoneal cavity, but the evidencefibrous or apparently recurrent fibroid, the growth has not adduced on this point was up to the present insufficient.-returned after removal by operation. The increasing and Mr. F. B. JESSETT said that Mr. Lawson Tait had reportedsometimes rapid growth of these pelvic and parietal tumours four cases of successful removal of gall stones from the gall.demands surgical interference; but the liability of opening bladder by operation. He questioned whether it would notthe peritoneum, accidentally or unavoidably, and the almost be better to make an exploratory abdominal incision, whichcertain result of a ventral hernia through the weakened need not be large, and might be made parallel to and a littleabdominal wall, might so far deter the surgeon from having below the margin of the ribs. The stitching of the dividedrecourse to operation were it not for the assurance that he walls of the gall-bladder to the edges of the abdominalhas to deal with a tumour which has hitherto proved to be incision had been advocated by Mr. Lawson Tait. Thisnon-recurrent.-Mr. BARWELL congratulated Mr. Gant on would prevent bile gravitatiog into the peritoneum. It wasthe success of the operation. In tumours which arose from not necessary to leave a fistulous opening -Mr. GANTthe inner parts of the pelvis, it was difficult to say whether paralleled the operation with that of nephro-lithotomy, thethey were malignant or innocent. Hence the reluctance main difference being that urine could not escape into thewith which surgeons interfered with tumours of this region. peritoneum. He was acquainted with the fact of peritonitisThe non-appearance of a ventral hernia was probably partly being the result of the extravasation of bile. Would it notexplained by the fact that the tumour developed outside the be safe first to empty the gall-bladder by means of au-

transversalis fascia, which covers the peritoneum in this aspirating syringe ? In some cases was it not possible forsituation.-Mr. GANT, in reply, thought that surgical inter- jaundice to appear suddenly ?-Sir WM. MAC CORMAC askedference with cases of malignant disease of this site should be how Dr. Harley could consistently speak of the operationundertaken with great precautioo. The hard and painless as a safe one, seeing that peritonitis followed the pro-character, with slowness of growth, of the tumour removed cedure in his case. He could not help thinking that theby him led him to think that the new growth was innocent. employment of an instrument with one end blindlyIn the operation it was important not to " button-hole the moving in the abdomen was dangerous. He preferred toperitoneum. The patient was shown in the ante-room, speak of an exploratory incision such as was now performed

Dr. GEORGE HARLEY read an account of an Easy and Safe for so many morbid conditions within the abdomen.-Method of Sounding for Impacted Gall-stones. The method Dr. DYCE DUCKWORTH thought the discussion had somewhatrecommended in this paper for indubitably ascertaining the wandered from the subject of the paper. However, theexistence of impacted biliary calculi was illustrated by the method of sounding was not in his opinion an easy and safenarration of a case in which it was successfully performed in one. The operation was, he considered, one of extremethe following manner :-The patient, a lady aged thirty-six, difficulty. He wished to know what further procedure waswho bad been under the care of Dr. Diver for many weeks necessary after the operator had supposed that he had strucksuffering from the signs and symptoms of obstructed bile and ascertained the presence of a biliary calculus. Gall-duct, was placed under an anaesthetic. Dr. George Harley stones were sometimes impacted very tightly in the gall-inserted a six-inch long French exploring trocar midway duct. A clumsy hand working in the dark in such an im-between the umbilicus and margin of the liver an inch and portant region was very likely to do great mischief.-Dr.a half to the right of the median line. Its point being BERNARD O’CONNOR related the case of a lady aged fortypushed upwards and backwards in the direction of the with a tumour below the liver, without jaundice or h-paticcommon bile-duct, no hard substance was met with; on the enlargement. He diagnosed impacted gall-stones in the gall-stilette being withdrawn, ascitic fluid came away, and the bladder. He asked Dr. Harley whether in the case narratedcannula could be moved freely in all directions. The the liver was enlarged, how large the gall-bladder was,.instrument was withdrawn and reinserted an inch higher and whether there had been any severe paroxysmal pain.up, and about two inches to the right of the umbilicus. He did not think the method was a safe or an easy one.-On pushing it in the same direction as before to the depth Mr. BARWELL said there was much dislike on the part ofof six inches, its point struck against a hard substance, patients to be subjected to an incision unless they could bepresumably a biliary calculus. It was endeavoured to promised beforehand that something would be found. In thisestimate the size of the stone by pressing the end of the regard Dr. Harley’s method might be looked upon as a valuablecannula without the stilette firmly against the hard sub- preliminary. He thought the author was unfortunate in the-stance, and moving the point of the instrument all round point he had aimed at. He said it would be dangerous toit. The inference was that the stone was of the size of a search for a biliary calculus elsewhere from the outside whenhazel-nut. The punctures were closed by means of sticking- there was none in the gall-bladder. He suggested that theplaster and the abdomen bandaged. The signs of obstruction fundus of the gall-bladder should first of all be explored. Itnow began rapidly to disappear, and it was supposed that the calculi be detected there, Dr. Harley’s instrument might beoperation had caused the stone to change its position in the used as a guide in the performance of cholecystotomy.duct, and had thus enabled it to pass along into the duo- The mode of exploration was, however, regarded as ofdenum. Convalescence at once set in, but was of short possible future value. The assumption that bile was

duration, for an attack of enteritis supervened, followed by innocuous in the peritoneal cavity was very hazardous.peritonitis, and the patient succumbed twenty-seven days Needles might penetrate the human heart without end-after the sounding, and twenty-four after the stone had ing fatally, as Mr. George Callender had shown.-Dr. C.evidently left the duct. At the autopsy the thirteen calculi J. HARE referred to the site of impaction of the gall-shown to the Society were found still in the gall-bladder, the stones. Was it in the gall-bladder itself or in a biliarylongest being an inch in length, the next of the size of a hazel- passage ? Sometimes the former was distended with fluid;nut, the remainder all much smaller. The facets on the at others it was empty. The gall-bladder was not alwaysoppositeendsof the large calculus showed that anotherstone, of at an equal depth from the abdominal surface. Thethe size of a hazel nut, must have existed, but had come away. instrument had only given information of the existence ofThe paper ended with the following conclusions :-(a) That one gall-stone, when there were so many others. How wasthe presence of an impacted gall-stone may be readily as this ? He looked with fear and trembling on the method.-well as safely ascertained in the way described ; (b) that not Dr. GEORGE HARLEY, in reply, began by saying that veryonly the position, but even the size and shape, of an impacted few medical men knew much of gall-stones either in Eng-biliary calculus may be instrnmentally ascertained ; (c) that land or elsewhere. Erroneous notions concerning gall-stonesa knowledge of these facts may possibly induce surgeons to were alarmingly prevalent. He recommended the perusal

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of M. Cyr’s recent work. The difficulties of diagnosis werespoken of : cancer, stricture, ulceration of the duodenum,and other conditions sometimes exactly simulated the impac-tion of gall-stones. Most of the organs of the body, includ-ing the intestines and urinary bladder, had been puncturedwith a fine instrument without evil result. He emphasisedthe fact that his patient greatly improved after the surgicaltreatment. Sickness and vomiting were the invariable signsof impaction of a gall-stone in the gall-diiet. Undoubtedlythere was risk in exploring by the method advocated, butthen it must be remembered that danger existed everywhereand in every surgical procedure.

CLINICAL SOCIETY OF LONDON.

Successful Operation for Intestinal Obstruction clue to aDiverticulum &mdash; Treatment of Fracture of Patella.&mdash;Hydrocephalus followed by Insanity and Death.SiR ANDREW CLARK, President, was in the chair at th<

ordinary meeting of this Society, held on May 9th. Th(

meeting was of a decidedly successful turn. The Presidentbroached the question of an additional meeting to be heldthis session.Mr. CLUTTON related a case of Intestinal Obstruction by

a Diverticulum successfully treated by operation. A boyaged ten was brought to Mr. Clutton’s notice by Dr. Powis,of Greenwich, for an attack of which he had several othersof a similar kind, but lasting only two or three days, andalways terminating with a copious evacuation from thebowels after enemata. On this occasion he was taken illsuddenly at the seaside with vomiting and great pain in theabdomen. He was brought home to Greenwich on the thirdday, and, as treatment by enemata and opium proved of noavail, Mr. Clutton was asked by Dr. Powis on the fourthday of the illness if operation would be likely to affordthe patient relief. He was at once transferred to St. Thomas’sHome, where, after the administration of an ansesthetic,the abdomen was opened. A collapsed portion of bowelwas soon found, and, on bringing it to the surface,a tight ring-like cord could be felt and seen to be thecause of strangulation. This band was clamped by twopairs of forceps and divided; each end was then ligaturedwith catgut and the forceps removed. The bowel was foundafter the division of the constricting band to have been setfree from strangulation. It was not thought desirable tomake more than a cursory examination for the origin of theband causing the obstruction, as the boy was much collapsedbefore the operation was commenced. Thetwocatgutligaturesformed the means of recognising the original position of thenow divided band. One of these ligatures was situated atthe extreme point of a diverticulum two inches in length,and the other was placed upon the wall of the same loop ofintestine at a distance of about six inches. A portion ofbowel of about three inches in length between these twopoints of attachment was the part strangulated, and was ofan extremely dark colour with a deep sulcus at each side.The boy made an uninterrupted recovery, and left thehospital on September 12th. The explanation of the con-dition found in the abdomen seemed to Mr. Clutton to beas follows :-The vitelline duct had been obliterated atthe umbilicus, and set free from the abdominal wall, butremaining patent towards the ileum the lower end hadbecome a pouch-like diverticulum from the intestine. Thisdiverticulum terminating in a pointed extremity or cord-part also of the vitelline duct which had been obliterated-had remained floating about among the intestines till itbecame attached to the bowel in contact with it. Thegut between the two points of attachment had slippedbeneath the cord which united them, and being unableto extricate itself had become strangulated.-Dr. COUP-LAND said that Mr. Clutton was to be congratulated on

the successful result, which was perhaps greatly due toprompt interference. The mortality of cases of obstruc-tion from Meckel’s diverticulum was very great. Mentionwas made of an instance in which the umbilicus was muchdepressed, probably owing to the traction of a persistentvitelline duct adherent at that spot. Another case ofextreme rarity was under the care of Dr. Greenhow, but diedwithout being operated on, and here there was a coil ofileum which had passed through the mesentery of the diver-ticulum, which in this case contained the obliterated omphalo-mesenteric vessels enclosed in the free fold of the mesentery of

e the diverticulum.-Mr. TREVES said that Peyrot had col-" lected twenty-nine cases of intestinal obstruction treated by. operation, of which only four were strangulations by Meckel’s.- diverticulum. He had collected altogether fifty cases, but thed mortality remained the same-i.e., about eight in thirtyd recovered. There was, however, only one recovery in four,,1 perhaps less, when strangulation resulted from diverticula.s This kind was considered to be the most acute form ofVstradgulation known. Mr. Clutton’s case was of rather sub-t acute course. It was important to remember that the strangu-e lating agent was also a piece of gut, and this would entail

increased nerve excitement and distress. Generally thesediverticula were attached to the mesentery; in some cases to thegut at the site most remote from the meeenteric attachment.He asked for further particulars of the minute clinical

aspects of this case. He did not think that a history of pre-tvious attacks was of much importance. Such cases did not- amount to 12 per cent. He also inquired as to the

nature and seat of the pain in Mr. Clutton’s case. When, the obstruction was complete the pain was continuous ; theJ seat of pain was probably no guide to the seat of obstruction.What relation did the attacks of vomiting bear to the pain?G This was the first case in which the tubular diverticulum

l had been divided to relieve strangulation.-Dr. MAHOMEDcould not agree with Mr. Treves in believing that the pain

r of complete obstruction was continuous. He was sure that. paroxysmal pain might go with complete obstruction. He. believed that extreme distension meant obstruction of the largeI bowel. The incision for operation ought preferably to be made

to the right of the right rectus. -Mr. TREVES explained that: out of fifty fully recorded cases of complete obstruction, only

five were described as having purely intermittent pain.-, Mr. SYMONDS spoke of the selection of the site of incision.Sometimes he had chosen the seat of greatest distension.The seat of obstruction had been twice hit upon by takingthis indication as the guide. He should prefer the mid-linefor the incision as a general rule. The mortality of suchcases was undoubtedly great. Earlier operation was stronglyadvocated.-Mr. HENRY MORRIS narrated a case of intes-tinal obstruction, in which operation was early performedand the incision was made in the median line. A leftinguinal hernia was found to have been reduced en masse,the constricting band was divided, but diarrhoea followed,and death of the patient ensued in thirty-six hours. Whenthe obstruction was in the large intestine, the seat of greatestdistension was in the cseeum, and here the overstrain led tothinning and perforation. The preliminary performance ofright colotomy might be carried out without preventing thefinal use of incision in the median line should the ascendingcolon be found to be empty. If the colon be distended, thenby opening it the patient’s sufferings might be relieved, eventhough the obstruction be high up and in the small intestines,as in a case of Dr. Douglas Powell’s, to which reference wasmade.&mdash;Mr. CLUTTON, in reply, pointed out that he saw thepatient on the third day of obstruction ; that the boy was onlyten years old, and that at the time of his first visit therewere no symptoms except feebleness ; the patient did notmoan or cry, and the vomiting had ceased for twelvehours. In a case of obstruction by the vitelline duct, in ayoung man aged nineteen, death did not follow for ninedays; so that all cases were not fatal in four days. Hereminded Mr. Treves that the fibrous cord at the top of thediverticulum was the constricting band. He opposed themethod of employment of an incision to the right of therectus abdominis in cases of intestinal obstruction.Mr. CHRISTOPHER HEATH read a brief paper on the

Treatment of recent Fracture of the Patella in fulfilment ofhis promise at an earlier meeting of the Society to producepatients treated immediately after the accident by plaster-of-Paris. He gave Mr. Hutchinson the credit of first com-bating the old teaching that separation of the fragmentsdepended on muscular action, and agreed with him in

believing that it was the fluid in the joint which was thedifficulty. Mr. Heath, if necessary, draws off the fluid by

aspiration, and has never seen any bad result from the prac-tice, but prefers, when possible, to prevent effusion by atonce enclosing the joint in plaster-of-Paris. This requiresrenewal in about six weeks, and at the end of three monthsa leathern splint is applied to the knee and thigh so asto control the action of the extensor when the patient iswalking. Two women and a man were shown, in all ofwhom the plaster was applied within an hour of theaccident with very good results as to short fibrous union.-Mr. HENRY MORRIS spoke of the cases which he exhibited