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as one or two smaller vessel, and it was hoped they wouldprove to be all, as the axillary vessels and nerves appearedto be uninj ared; but on moving the arm blood rushed from theaxillary artery/and it was found that there was a slit on itsupper aspect in the third part of its course. It was tiedand the wound then closed, drainage-tubes being inserted,and, as the man’s home was two miles from the colliery, hewas then sent in an ambulance to the hospital, a distanceof about ten miles. Next day there was lack of sensationin the fingers, and on the following day, as gangreneappeared to be commencing, a consultation was held todecide whether to amputate at once at the shoulder or towait for demarcation. It was decided to wait, in the hope ofbeing able to amputate at the elbow later on, sensation stillbeing good to some inches below that joint. In the courseof a week the gangrene had greatly advanced to just belowthe elbow, and now a gangrenous patch showed itself on theinner aspect of the upper arm. The patient became deliriousAnd the semi-purulent discharge from the wound was fetid.He took nourishment pretty well, but the pulse and tempera-ture ranged high, and he looked very pale, thin, and ill.On the evening of Jan. 12 h (twelve days after the accident)secondary haemorrhage occurred, and he lost several ounces.of blood. It was evident that amputation must be at onceperformed and the bleeding vessel secured. Ether wasaccordingly administered, and it was found that thegangrene now extended to the middle of the arm. Ampu-ration at the shoulder was effected by outer and inner flaps.No large vessels bled, the axillary artery being plugged withclot and the slit in it being clearly visible. On clearing outthe suppurating cavity in the axilla, it was seen that thesecondary haemorrhage was from a hole deep down on thevertebral border of the scapula, so deep that the only wayto secure the vessel was by leaving a pair of long pressureforceps on it. Is was apparently the posterior scapularartery, which had ulcerated on the separation of an escharcaused by the burn. Whilst this vessel was being securedthe parent’s pulse entirely failed, and two pints ofsaline fluid were at once injected into his right basilicvein, with marked improvement in his aspect, anda return of the radial pulse, which became full andbounding. In a fev minutes, however, the pulse againbegan to disappear, and was soon imperceptible at thewrisb. Ether was injected under the skin and a brandyenema given, and then the saline injection was resumed.When half a pint had been used the pulse again returned,and continued to improve whilst the remainder of thesecond quantity of two pints was being injected; but itnever became as strong as it did during the previousinjection. When the injecting was finished the respira-tion was very feeble and shallow, and the pulse soonbecame imperceptible even at the groin, and breathing.ceased. Artificial respiration was now resorted to, combinedwith inversion of the body, and faradaism was applied tothe neck and prsecordium, but none of these means availedto restore either circulation or respiration, though persistedin for half an hour.

Medical Societies.ROYAL MEDICAL & CHIRURGICAL SOCIETY.

Ligature of the Second Part of the Left Subclavian Arteryfor the Cure of Axillary Aneurysm.-Symptoms andPathology of Psilosis.AN ordinarvmeeting of this Society was held on Aprlll2bh, .

Sir Andrew Clark, Bart., President, in the chair.Mr. GODLEE, read a paper on a case of Ligature of the

Left Stibelavian Artery for the cure of an Axillary Aneurysm.The subjecb of this paper was a man aged sixty-six, whowas suffering from a large axillary aneurysm on the leftside, with dilatation of the left subclavian artery and signsof pressure on the brachial plexus. There was also somesuspicion of atheromatous disease of the aorta. Tuffnell’streatment was employed for three weeks without effect, andthe aneurysm appeared to be increasing in size. The sub-clavian artery was accordingly tied in its second part withcatgut. The wound healed by firsb intention and theaneurysm was gradually contracting. The patient com-plained of gain in the upper arm. Appended were notes by

Dr. J. Mihcbell Bruce, describing the condition of thethorax both before and after the operation. The justifi-ability of the operation, the best method of performingit, and the best form «f ligature, were finally discussed.-Mr. BARWELL agreed that the old statistics on thissubject were valueless, as, owing to the advance of surgery,those complications formerly so common were now no

longer to be feared. In 1879 he had operated byasome-what similar method, and in his writings he had more thanonce recommended it. He referred to a tabulated list ofnine operations of this kind, and mentioned the causes ofdeath in the five which succumbed. The artery being wellsupported by muscle fibres between the scaleni was lesslikely to be diseased there, and hence would better bear aligature. This aneurysm was much rarer on the left side,and it appeared from Dr. Bruce’s description of the presentcondition of the chest that other large arteries wereinvolved, probably by a prolongation of the aneurysmalcondition downwards. This complication was always to befeared in these cases.-Dr. TAYLOR said that the patient,who had resumed his occupation, stated that he was weakerthan he originally was, though he now only complainedof a slight pain over the heart. After the operationthere was considerable pain of a neuralgic nature inthe hft arm.-Mr. MAUNSELL said that suppuration inthe sac and secondary hæmorrhage were causes of deathin these cases. The former had been practically aboli hedbv antiseptic surgery, and, with regard to the latter, timealone could show whether it would be possible to ligaturesuccessfully the second part of the subclavian on the lightside; that vessel being almost in a straight line with 1h3ascending aortic arch, and therefore exposed to the full forceof cardiac contraction ; it also had branches springing fromit, which was not the case on the left side.-Mr. HOLMEScongratulated the author on the success of the operation,and remarked on the necessity of keeping an accurate recordof all the cases He himself had never resorted to this pro-cedure nor bad he seen it done, but he remembered aninstance in his own experience in which he would have beenbetter advised had he endeavoured to tie the second partinstead of the third ; the aneurysmal sac was so much inhis way that in endeavouring to apply the ligature he per-forated it and the man bled to death. There were of coursedangers in the operation, bat personally he did not regardthe possibility of injuring the thoracic duct as a very seriousone, for it was alax structure and not liable to be wounded ;on the other side ligature of the superior intercostal nervehad to be guarded against. The use of ligatures whichno longer cut through the coats of the vessels hadgreatly diminished the risk of secondary haemorrhage.Statistics drawn from the past were valueless, for thepractice of Liston and Astley Cooper was something quitedifferent to that of the present day, and their experiencewas practically useless. As to the material used for liga-ture, he himself had used ox aorta with much success,though he admitted that the catgut ligature was, if notsuperior, at any rate equal to any other. For general use,however, he preferred kangaroo tendon ; it was less bulky,more easily tied, and more trustworthy than catgut. Asthe latter was prepared by a process of putrefaction, itcould not so easily be rendered perfectly aseptic, and thiswas a point of great importance in relation to the so-calledsecondary, but in realitv primary, haemorrhage, whichhad proved so fatal. He preferred so to ligature thevessel as to divide the internal coats. These cases

were exceedingly dangerous, and their fatality was

due to the fact of the proximity of the vessel to the aorta.-The PRESIDENT agreed with Mr. Holmes when speaking ofthe uses of past statistics ; they were not only unreliable,but misleading.—Mr. GODLEE, in reply, said that in thepaper to which he had referred there was an account ofeight cases, and in five of them the ligature had been appliedbetween the scaleni. The phrenic nerve was usually quiteout of the way of injary, but the duct stood in greaterdanger of being divided. It was situated in a region inwhich surgeons had carried out extensive operations for theremoval of glands, and he had seen the duct or a largetributary thereof divided in a woman, who subsequentlybecame very much emaciated. He felt sure that silk wouldanswer perfectly well to ligature the artery in its con-

tinuity ; still a ligature made of several strands ofcatgut could be easily placed and tied into a very smallknot.Dr. GEORGE THIN gave a communication on the Sym-

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ptoms and Pathology of Psilosis Linguse et Intestini. Theauthor referred to his previous publications on the sym-ptoms and pathology ot this climatic affection, and illus-trated the characteristic changes in the mucous membraneof the mouth and throat by relating in detail the historiesbf two typical cases, the appearances being illustrated bywater-colour drawings. In order to emphasise the points ofdistinction between psilosis and other forms of tropicaldiarrhoea, he related the histories of two cases of the latteraffection; and showed on what symptoms the differentialdiagnosis depended. In the two cases of psilosis whichwere now specially described, microscopic examination byDr. Wethered of large, creamy, soft masses, which werepassed with the stools after the motions had become solid,showed that they consisted of almost pure cultivations ofbacteria, a rod shaped bacterium, of moderate and definitesize, largely predominating over the other organisms present.With convalescence, this mass gradually diminished in

quantity, and, when recovery had taken place, was nolonger observed. The mass was much larger in one of thecases than in the other, but the characteristics were thesame in both. In the liquid diarrhoea motions of the acutecondition the colour of the stools was a pale yellow; butwhen the diarrhoea had ceased, and the motions becamesolid, the patient passed, usually once daily, a large,formed, white, colourless stool; the colourless condition ofthe motion coinciding-over weeks and months-with adiet containing milk, farinaceous foods, fish, eggs, andchicken, with a moderate amount of vegetables and fruit.Six cases were referred to in illustration of this fact.Clinical evidence, and the evidence of a previously pub-lished case-in which there was a post-mortem examina-tion-was adduced to show that these white stools werecoincident with a normally healthy condition of theliver and pancreas. In one of the ca>es the faeces, on apure milk diet, were analysed by Dr. Wynter Blyth, whoassociated himself with the investigation of this part of thecase ; and it was shown that the general percentage com-position was : water, 82.73; organic solids, 14 -00 ; chemicalmatters, 3’27. More than half of the organic solids con-sisted of neutral fats, apparently milk fat, which hadpassed without being digested or saponified. Nearly 6 percent. of bile acids were present as a soap. A smallquantity of organic sulphur was present as taurin, but thecolouring usually found in fseees was entirely absent. Asthe fat in the stool was only a fraction of the quantitytaken in the milk, it followed that a considerable pro-portion of the milk fat was digested. In both cases theexhibition of iron was not followed by the ordinary blackiron stool, minute grains of metal being interspersedwith the motion. Reference was made to a paper

by Allan Macfadyan, Nencki, and Nieber, in which,in a case of fistula near the ileo-cæcal valve, it wasshown that the food mass which passed into the colonwas acid, whilst the reaction of the mucosa of the ileumwas alkaline; and both the mucosa and the contentsof the large bowel were alkaline. Reasons were given toshow that in psilosis the alkaline secretion of the mucosa ofthe ileum was wanting; that the food mass that passedinto the large bowel was more than usually acid ; and thatthe fæces were acid. It was argued that the abnormalreactions of the intestine must produce abnormalities in thedevelopment of the bacteria normally present in the bowel;and it was suggested that the normal colouring matter ofthe stools, under the influence of abnormal bacterialproducts, either was not formed or was destroyed. Thesame condition, but to a less marked extent, obtained insome cases of ordinary tropical diarrhcea. Clinically, thefact was established that persistent white stools mightexist, whilst both the liver and the pancreas were healthy.-Dr. ECCLES said that he was in a position to confirm whathad been said by the author as to the condition of theintestinal contents in this very rare disease, and he referredto a paper read by him at the International Congress atBerlin in which he demonstrated that the action of salolwas greatly prolonged in certain forms. He had found thatwhen the motions were frothy and white, salol did not appearIt tbf urine for three or even four hours after ingestion.That was a very marked prolongation, for in the healthyman it could be detected at the expiration of forty. fiveminutes. The explanation of this was presumably thatsalol was insoluble in acids, but easily so in alkalies, andit followed from this that if the salol were a long timebefore being split up, it must be in the presence of an acid

medium. In certain cases of sprue under his notice it wasfound that when the motion was yellow or white and frothy,and for some time after the motions had become cylindricalybut still white, the delay in the appearance of salol was stillprolonged, but when the motions became coloured as wellas cylindrical, the reaction of salol appeared much morepromptly, taking place in as short a time as fifty minutes.Persons might have a slight attack of sprue in a countrywhere the disease was met with, and then the disease wouldseem to cease and the patient return to this country. Butas long as ten years afterwards a period of cold, dampweather would determine a fresh outbreak. He had hadan opportunity of applying Gunnsberg’s test as to thecondition of the digestive juices in sprue, and had foundthat there was but little gastric activity ; there seemed tobe an over-secretion of hydrochloric acid, from which itfollowed that gastric digestion might be prolonged after thefood reached the small intestine, and so setup the conditionof irritable ileum referred to by the author.-Dr. SCRIVENsaid that sprue was quite a different disease from ordinarytropical diarrhoea; it was common in the Himalayan highlands,and had been attributed to the water. It was very chronic,extending over several years, the patient getting graduallythinner, with enfeebled digestion, associated with vomitingand sore mouth. The abdominal organs were usuallyfound wasted, but apparently healthy; he had occasionallyseen ulceration of the large intestines, but in that case heconsidered that the disease had been superadded to dysen-tery. He had also met with a kind of roughness of theileum which seemed to form part of the disease, though asa rule the mucous membrane was smooth and thin. The;most important observation of recent years with regard tothe disease was that it could be cured by the aid of milk,.and without medicine. He was in the habit of orderingthree ounces an hour for sixteen hours daily, graduallyincreasing the quantity to six pints per diem. Where therewas much trouble in inducing the patients to keep to themilk diet he allowed a small quantity of bread to becrumbled with the milk, and he referred to an instance inwhich wonderful improvement took place after seven

weeks, even although a small quantity of bread had beenallowed. In another case, where the patient had sufferedfrom diarrhoea for three years, when on a milk diet thetrouble ceased, and the motions became solid and white; whenthat occurred, the patient at once, against advice, took togeneral diet, with the result that a relapse took place; herepeated this five times in one year, and eventually died of thedisease.-Dr. MANSON referred to the work of Bertrand andFontan on the " Enterocolite chronique des Pays Chauds," ill’which they gave an account of the pathology of the disease.He himself did not regard the disease as an endocolitis,.but thought that it was a condition generally superaddedto some previously existing affection. such as dysentery,operations upon the lower part of the. bowel, such as piles,fistula, &c., and in debilitating conditions, such as preg-nancy, haemorrhage, fatigue, mental worry, and depression.There occurred in the tropics forms of the disease in whichthe lower bowel was not involved, the typical tongue beingpresent, together with dyspepsia and white stools; this.condition might remain without advance for months if thepatient were careful as to diet, but any error in this direction might initiate a well-marked attack, extending downthe alimentary canal. It was of the utmost importance intreatment to procure physiological rest to the digestiveapparatus, the patient being sent to bed so that thenourishment of the body might be carried on with thelowest possible diet capable of sustaining life. He beganby ordering sixty ounces of milk, with directions that unlessthe diarrhoea ceased it was to be reduced ten ounces dailyto a minimum of ten ounces. Patients who were refractoryto milk diet could be given koumiss, which was just asefficacious. In one analysis the stools were describedas containing a trace of bile acids, while in othersthese were altogether wanting. In several necropsiesthey found that the pancreas contained centres of degenera-tion and even suppuration; it was the most fatal of the-chronic morbid conditions to which the Anglo-Indian wasliable. French authors stated that in Cochin China thedisease was just as common on the coast as in the interiorand in low-lying districts as on the highlande. The mor-tality among the army of occupation had been enormousfrom this cause, and 10 per cent. of their deaths were’

ascribed to it.-Dr. JOHNSON said that the disease was atany rate indirectly caused by residence in malarial districts>

917

Though it had been met with as an idiopathic condition,yet a great many cases were consecutive to dysentery andmalarial fever. Immediate change of climate gave theonly chance of recovery, and it usually answered admirablyif adopted in an early stage of the disease. From the factthat in was so very common in such places as the valley ofthe Yang-tse, Batavia, and other well-known hotbeds ofmalaria, it was impossible to avoid the conclusion that itwas not merely a disease which might occur in any tropicalclimate, but that there must be some preceding malarialpoisoning.-Dr. THIN, in reply, said that he had purposelyavoided all allusion to treatment, with which he had fullydealt elsewhere. His particular object was to demonstratethe condition of tongue and throat peculiar to the affection.With relation to the existence of white stools, they hadbeen taught by tradition that a temporary condition of thiskind indicated inaction of the liver amenable to appropriatemedication ; but this was an affection not associated withthe liver, and yet accompanied by colourless motions. Hedid not admit that it was a malarial affection, for though itoccurred in countries where malaria was common, yet plentyof people suffered from malaria without having this disease,and it also existed in countries where malaria was unknown.He had been struck by the number of French troops whichhad been affected, but they probably included all casesof tropical diarrhoea, under this head. Though it was aptto attack people weakened by age or pre-existing maladies,it also attacked the young and the strong. He quoted acase in which the malady could not have been superaddedto any pre-existing disease, and he maintained that if thedisease attacked weak people, the weakness had nothing todo with it. He quoted several opinions to show that thedisease was not the same as the "hill diarrhoea" of India,and referred to the difficulty of distinguishing between itand the "sore mouth " of Ceylon. With regard to the con-dition of the pancreas, he observed that that organ wasfound to be healthy in the majority of cases examined.-The PRESIDENT desired to call attention to the similaritybetween this affection and certain varieties of disease knownin the provinces as "mucous disease."

MIDLAND MEDICAL SOCIETY.WEDNESDAY, MARCH 9TH.

Mr. BENNETT MAY, F.R.C.S., President, in the chair.

Piece of Brass in Lens.-Mr. ANTROBUS showed for Mr.Eales a lad aged fourteen, brassworker, with a piece of brasssituated in the lower and outer part of the crystalline lens,which had been there fourteen aays, the lens retaining itstransparency.Perforated Appendicitis.-Mr. RATCLIFFE showed a case

of perforative appendicitis. H. W-, aged fifteen, glass-worker. Five years ago the patient was in hospital sufferingfrom typhoid fever. On Jan. 22nd he returned from work

seeming well. He lay down on the sofa, and soon after-wards complained that he had the "bellyache," the painbeing in the upper part of the abdomen, above and in theregion of the umbilicus. He came to the hospital and wastreated as an out-patient. On the following day (23rd)he was admitted as an in-patient, under the care ofDr. Wilson. There was no constipation before the com-mencement of the illness, but it was marked after. Onadmis-sion, the abdomen was distended all over. No tumour couldbe felt anywhere, and the pain was almost entirely confinedto the left iliac region, there being little or none on theright. The patient continued in this condition till the30th, when he suddenly became collapsed, with profuseperspiration and feeble pulse, and the abdomen becameextremely distended and tender. He was taken to thetheatre for operation, but died before it could be done.Necropsy : The small intestine was somewhat distendedthroughout. There was marked general purulent peritonitis.Over the anterior surface of the vermiform appendix a pieceof small intestine was matted by peritonitis so as to forman abscess cavity the size of a walnut, the upper boundarybeing the last two inches of the ileum, the outer wall formedby the caecum. This cavity had burst into the generalperitoneal cavity. The appendix was hidden in this cavity.There was a stump a quarter of an inch long attachedto the csecum. This stump had its lumen occluded. Thezest of the appendix was adherent to the wall of the

abdomen outside the cavity. No calculus could be found.There was no pus behind the cæcum. In the left iliac fossathere was a coil of small intestine more markedly inflamedthan the rest, but nothing else.-Remarks: Ib is interestingto note that this boy had had typhoid fever previously, thisprobably causing narrowing of the opening of the appendix,which, becoming blocked, had formed a cyst, not givingrise to any symptoms. The first symptoms would beprobably due to rupture of this cyst. Adhesions formingthe second and final symptom were due to the bursting ofthis into the general peritoneal cavity. Perhaps the mosbinteresting feature of the case is that at no time could anyparticular tenderness or any signs of tumour be discoveredin the right iliac fossa. In the first instance the pain wasabove the umbilicus, and after admission entirely confinedto the left iliac fossa, render ing the diagnosis of appendicitiswellnish impossible.

I Cysticercus G’eGduGosce.-lVlr. RATCLIFFE also showed aCystJicercus Celluloaae in the Arm. J. L——, a middle-agedman, who lived largely on pork and bacon, came up com-plaining of a small swelling, about the size of a large hazelnub, on the inner side of the biceps muscle of the right arm.It had been growing for a year, and had given rise to painfor the last two months. On removal, it was found to be asmall cysticercus about half an inch in diameter.Imperforate Anus with a Penile F4tula -Mr. Heaton

showed an infant on whom he had operated for the reliefof imperforate anus with a penile fistula. The child, anotherwise healthy male infant, had on the under surfaceof its penis, about three-quarters of an inch from the endof the glans, a small fistula, from which for the first fewdays of its life a constant discharge of meconium took place.The anus appeared natural, but on examination was foundto lead into a blind cul-de-sac. The rectum was foundabout three quarters of an inch from the end of the analcul-de-sac. It was opened and its mucous membranestitched to the edges of the skin incision. The opening ofthe fistula into the rectum was on its anterior surface abouthalf an inch from the blind end. The fistula had no con-nexion with the urinary passages. Since operation thechild had gained in weight, and at present there was notendency to contraction of the newly made anus.Mr. HEATON read a paper on Anaesthetics.

BRADFORD MEDICO-CHIRURGICAL SOCIETY.TUESDAY, FEB. 6TH.

ROBT. MERCER, M.R.C.S., President, in the chair.

MR. ALTHORP showed a patient recovering from CompoundComminuted Fracture of the Patellao

Auto-i,n.fection in Scarlatina.-Dr. BATES read notes of acase of apparently typical Scarlatina in a girl of nineteen,who, having complained of slight joint pains at the end ofthe first week, was apparently in the course of convalescencewhen the temperature ran up and the typical rash againappeared. On the fourteenth day the urine was albuminous.,with blood and casts present ; on the seventeenth some ery-thema nodosum appeared; on the twenty-first day the rashcame out again, and after this the fever abated. On thethirty-fifth day the urine became scanty, and cedema of theface appeared. Hot-air baths re-established diuresis; de-squamation continued until about the eightieth day. Hewas at a loss to account for the symptoms except on the hypo-thesis of auto-infection.-Drs. Carter, Burnie, Rabagliati,and Jobnstone criticised the case.Antipyrin in Asthma.-Dr. BATES read notes of two cases.

in females. In one abortion had occurred from the severityof the attacks. Local measures and arsenic, pushed to theextent of a drachm of the liquor in the day, had been use-less. A large dose (twenty. five grains) of antipyrin gavethe first relief for months. Both cases had relief now under

continued treatment with antipyrin.Hœmatocele.—Dr. GOYDER read a paper dealing with the

Pathology and Treatment of Pelvic Hæmatocele, especiallythe later stages. He dwelt on the obscurity of the diagnosisoccasionally, and advised medical rather than surgicaltreatment for the majority of cases.—Mr. HORROCKSstrongly advocated surgical treatment ; the medical trean-ment he regarded as trifling.—Dr. JOHNSTONE mentionedthree cases treated expectantly, in each of which an ovum