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Medical Societies.ROYAL SOCIETY OF MEDICINE.

CLINICAL SECTION.

Exhibition of Clinioal Cases.-Prolapse of the Spleen.A MEETING of this section was held on Nov. 13th,

Mr. J. CHARTERS SYMONDS, the President, being in thechair.

Mr. ALAN H. ToDD showed a case of Probable Injury ofthe Crucial Ligaments. The patient, a man, aged 30 years,had injured his knee during a football match when he wasaged 15 ; he did not remember quite what happened, but hehad to be carried off the field. Nothing was very obviouslywrong with the joint at the time and the school doctor senthim into school next day. After walking on it, however, itbecame very swollen and painful and he had to remain inbed for ten days. No splint was used. The inflammationsubsided. For some years after this the joint felt weak.Sometimes it would become swollen and distended, and thenwalking would be painful. Occasionally it would go out,"

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in which case there would be severe pain. Sometimes itwould reduce with an audible click. The joint, moreover,sometimes became locked, but he had never discovered aloose body in it. He had always been able to reduce theknee by slow forced extension, but had noticed that if hewore an elastic knee-cap this prevented him from gettingthe joint back " unless he first removed the cap. At onetime, soon after he left school, he used to get attacks ofsynovicis every few weeks, but lately these had been muchless frequent. In the intervals between the attacks he hadbeen able to lead an active, athletic life, playing a goodgame of golf or tennis daily, though he had always had toavoid turning round too suddenly. Eleven years ago, whenout shooting, he jumped on some muddy ground andtwisted the knee badly. It was very painful, and a

medical man put it in plaster, fully extended, forthree weeks. After this he wore a patella-clamp fora while, but as it failed to prevent the joint "goingout" he discarded it. A slight genu varum slowlydeveloped after the original accident, but lately it had

obviously increased in amount. The patient walked with aslight limp, but there was no obvious laxity of the joint :apparently he had unconsciously acquired the habit of

keeping the thigh muscles well braced up when walking.When sitting he could make the leg slide forwards on thefemoral condyles at will. There were slight limitation ofextension and flexion and some lateral mobility of the joint.Although there was no evidence of free fluid within the

joint, or of hypertrophy of the subsynovial tissue, thecircumference of the right knee was t in. greater than thatof the left. This seemed to be mainly due to several

large osteophytes which had formed around the internaltuberosity of the tibia and the internal condyle of the femurat their margins. They were well seen in skiagrams.

Dr. W. ESSEX WYNTER and Sir JOHN BLAND-SUTTONshowed a case of Acholuric Jaundice in which splenectomyhad been performed. The patient, a young man, had sufferedfrom jaundice and anaemia all his life, with exacerbations atfrequent intervals. His mother, maternal grandfather, anaunt and an uncle on the mother’s side were similarlyaffected. The yellowness of the skin apparently increasedduring the day, being more marked in the evening than inthe morning. He had been worse during the past two years,losing strength and 2 st. in weight. Physical examinationdisclosed no abnormality of the thoracic or abdominal viscera,-except slight increase in the dulness over the spleen, whichcould just be felt on deep inspiration. The urine was clear, of adeep red-brown, and had a specific gravity of 1025. There wereno abnormal constituents, and both Gerhardt’s and the zincchloride tests for pathological urobilin were negative. Haemo-lysis occurred in 0-45 per cent. saline solution, which was aboutnormal. The white cells (5200) consisted of lymphocytes,39 4 per cent. ; polymorphonuclears, 57’5 5 per cent. ; andeosinophiles, 2 5 per cent. The temperature was 990 to100° F. before operation. The spleen was removed in July,1914, several ligatures being applied close to the hilum, butthe main artery was left unmolested. There were no com-plications, and the temperature subsequently became normal

in the course of ten days. Wassermann’s reaction was

reported positive before operation and negative after. Thereaction was considered doubtful 14 weeks later. The

patient left hospital after about a month. The red cellswere then 1,880,000 and the white cells 13,000. Theresistance of the red cells was greater than normal. Awhite cell count 11 days after the operation showedlymphocytes, 24 per cent. ; hyaline cells, 2 per cent. ;polymorphonuclears, 73 per cent. ; and eosinophiles,1 per cent. After about four months the patient had puton 1 st. and had gained strength and been free fromattacks of jaundice. Blood count: Hsemoglobin, 80 percent. ; red corpuscles, 3,700,000 per cubic millimetre ;leucocytes, 18,000 per cubic millimetre ; neutrophile poly-morphonuclears, 51 per cent. ; lymphocytes, 33 per cent. ;transitional and hyaline cells, 11 per cent. ; eosinophilepolymorphonuclears, 4 per cent. ; mast cells, 1 per cent. Afew normoblasts were present, and a considerable number ofred corpuscles showed nuclear fragments (Howell-Jollybodies). Resistance of red corpuscles to hypotonic NaClsolution: a faint trace of lysis, 0’ 45 per cent. NaCl ;marked lysis, 0 3 per cent. NaCl. Two presumably normalbloods tested at the same time showed a trace of lysis with0-45 per cent, NaCl and almost complete lysis with 0-4 percent. ; thus the patient’s red cells were of more than averageresistance. The Wassermann reaction was suspicious, butcould not be called positive.

Dr. ESSEX WYNTER and Sir JOHN BLAND-SUTTON alsoshowed a case of Splenic Anaemia after Splenectomy. The

patient, a boy aged 13 years, had been ailing for six weekssuffering from lassitude and some enlarged glands. He wassent for treatment by the school doctor, and was thought atfirst to have Hodgkin’s disease, but improved under treat-ment as an out-patient. On admission in July, 1914, theboy was seen to be anaemic and thin, but made no definitecomplaint of pain or discomfort. The thoracic and abdo-minal viscera appeared normal apart from the spleen, whichwas much enlarged and extended 4g inches below the leftcostal margin and inwards to the middle line. Small, firmglands could be detected in the neck, axillae, and groins.The thyroid was enlarged, especially the isthmus. Bloodcount : Red cells, 4,200,000; white cells, 2600; hsemoglobin,60 per cent. A differential count showed no disturbance of theordinary proportion in white cells. Temperature 99 °F. Urinenormal. Splenectomy was performed in July. There werefirm adhesions, separation of which involved considerablebleeding and some injury to the diaphragm. A gauze drainwas inserted, but the wound healed readily, and stitcheswere removed on the eleventh day. The spleen was largeand firm. For ten days after operation the temperature roseto 102° and 103°, and thereafter gradually subsided. Move-ment of the diaphragm was arrested, especially on the leftside, and there was collapse of the lower lobes of the lungswith bronchitis. This gradually cleared and the patient wasconvalescent after five weeks. Then the blood count was asfollows: Red cells, 3,650,000; white, 21,000 ; polymorpho-nuclears, 48’ 5 per cent.; lymphocytes, 21 per cent.; eosino-

philes, 5 per cent. ; and transitional, 25 5 per cent. InNovember another blood count showed: Red cells, 4,800,000;white cells, 8000 ; haemoglobin, 6G per cent.

Dr. G. HELY-HUTCHINSON ALMOND showed a case of

Myositis Ossificans (juvenile progressive type). The patient,a girl, aged 7 years, was healthy as a baby. Fifteen months

ago, when aged 5, her right hip began to get stiff, and wasfollowed by the left ; the stiffness was intermittent at first,but they had gradually become more fixed. She could onlywalk about 100 yards, and tilted her pelvis up on both sideswith each step. She was thin and her muscles were badlydeveloped. There was a slight list of the spine to the leftwith corresponding curves and raising of the right shoulder.A small patch of ossification could be felt close to the inser-tion of the biceps of the left arm. and a patch of hardnessnear the origin of the biceps of the right. The ilio-tibialband on the left side was ossified from its origin to its inser-tion. The hamstrings of the left thigh were ossified, a

skiagram giving the appearance of a calcified shell enclosingthe muscles. There was a lozenge-shaped patch of hardnessin the outer belly of the left gastrocnemius. No definite

patches of hardness or ossification could be made out in themuscles of the spine or trunk.

Mr. W. J. MIDELTON showed a case of DermatitisHerpetiformis with Tuberculous Glands in the Neck. The

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patient was a girl aged 9 years. She had been well up to ithe age of 3, but then developed scarlet fever. An eruptionoccurred after the original rash had died away and wasDiagnosed as dermatitis herpetiformis. The dermatitis con-tinued. She had been free from the dermatitis from thebeginning of August to the end of September, 1911 ; then itrecurred and persisted. Counter-irritation had been com-menced at the end of February, 1912. At that time thepustules, blebs, and scabs were well marked, chiefly on theinner aspect of the upper third of the thighs and spreading onto the abdomen. Within three weeks she became well. Occa-sional slight relapses of short duration had occurred since.About five years ago some tuberculous glands in the neckwere operated on and sinuses persisted for over two years.These eventually healed well, but one scar remained bluish-red and had whitish specks in it suggesting lupus vulgaris.In May, 1913, she had a wound on the right wrist whichbecame septic, but soon healed under treatment. In

August, 1913, one or two glands in the neck enlarged andone small abscess formed. This was incised, and completehealing took place in a few months. Other glands becameinflamed, but no definite abscess occurred. This fact was,in his opinion, significant as showing greatly increasedresistance. No sign of the dermatitis had appeared for over18 months.

Mr. MIDELTON also showed a case of Dermatitis Herpeti-formis and Chronic Bronchial Catarrh in a boy aged 9 years.He had been treated by means of continuous counter-irritation commenced in August, 1912, and carried out oncea week ever since. The treatment seemed to check theeruption and the boy’s general health had much improved.

Mr. MIDELTON also showed a case of Severe Neuritisfollowing Sepsis in a man aged 42 years. He also had beentreated by continuous counter-irritation by multiple punctureand irritants. Applications had been made once a week onvarious parts of the trunk and arms. Recovery hadfollowed.

Mr. MIDELTON also showed a case of Polyarthritis andSevere Neuritis in a man aged 48 years. One yearago pains occurred in arms and headaches returned ; pains Ialso in legs, at times severe, lately very severe indeed.Joints of fingers swelled, also knee-joints to some extent.Some slight muscular wasting, especially interossei. At "times almost helpless. No drugs were of use in relieving thepain. Knee-jerks absent. Treated with benefit by means ofblisters and savin ointment. A blister, 4 in. by 4 in., wasapplied over the upper dorsal vertebrae and left on 12 hours.This was then removed and a raw surface left. Savinointment was then applied on lint over the raw place and lefton for 12 hours. By repeating this dressing regularly every i12 hours a free, purulent discharge was maintained for i12 days. Zinc ointment was then applied and the raw 1surface healed rapidly and soundly within three days. I

Dr. H. BATTY SHAW showed a case of Hemihypertrophy 1in an otherwise healthy girl aged 11 months. :

Mr. W. G. SPENCER read a short paper on a case of I

Retroperitoneal Prolapse of the Spleen into the Left Loin. B

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MEDICAL SOCIETY OF LONDON.

Contineced Discussion on S16rgioal Experienoes of the PresentWar. 1 ’

A MEETING of this society was held on Nov. 23rd, SirJOHN BLAND-SUTTON, the President, being in the chair.

Mr. D’ARCY PowER said that the wounds which had comeunder his care were the result either of the conical bullet, ofthe round bullet, of pieces of shrapnel cases, or of theexplosion of large shells. He had seen no case of injury dueto bayonet, lance, or sword. He instanced two cases as

showing the force of impact. An officer was wounded by alarge shell which burst within ten yards. The skiagramshowed the presence of foreign bodies deep in the erectorpina3. Subsequent examination proved that two of thesesubstances were sovereigns which had been driven out ofa, money belt he was wearing straight down on to thetransverse process of the first lumbar vertebra, which wassmashed to pieces. The coins themselves were twisted andconcave ; one had upon it the impression of the milled edgeand part of the obverse of that which lay above it. In theother case part of the patient’s diary had been driveninto his thigh and for many days afterwards he

1 THE LANCET, Nov. 21st, 1914, p. 1200.

shed pieces of its leaves. The most interesting, as wellas the most difficult cases, were those in which there hadbeen injuries to the nerves and the nervous system. It wasnecessary to decide whether the subsequent disturbance wasdue to damage done by the bullet in its passage or whetherit was caused by the bullet as it lay in situ. In many casesthis could only be determined by the careful examination ofa skilled neurologist acting in association with a first-rateX-ray photographer. In such cases the surgeon’s actionmust be governed by their reports. If the damage was doneby the bullet in transit its removal would be of no benefit,whilst if the projectile itself was causing irritation it mustbe removed. He held, therefore, that each case must beconsidered on its merits, and that it was unnecessary for

surgeons to remove every bullet or piece of shell merelybecause it showed up clearly on a skiagram. The most

interesting inj uries to the nervous system and nerves werethose to which the non-committal name of "concussion" "

must be given for the present. They had to be dis-tinguished from laceration, hasmorrhage, compression, andother tangible conditions by the fact that no grosslesion was presented by examination during life. Theyoccurred in the peripheral nerves as well as in the spinalcord. Experience showed that the X-ray photographs asthey were usually presented were not infallible guides eitherto the position or to the depth of a foreign body. It mightbe necessary to undertake an extensive exploration before abullet was discovered, or it might even be missed altogether.Sloughing rather than suppuration was a feature in most ofthe wounds, and it was interesting to observe that in manyinstances where a bullet had passed completely through alimb it was only the inlet and outlet which remained aswounds, the intermediate track having healed. The causeof infection seems to have acted after the injury and not atthe time. In, consequence of the sloughing secondaryhasmorrhage needing ligature of the main artery in its con.tinuity was tolerably frequent. When wounds which hadhealed became painful it was necessary to reopen them,and in every case the pain seemed to have beendue to pieces of clothing which had been left inthe tissues, at first without causing irritation. Drydressings in most cases had had to be replaced byfomentations. Iodine had been employed extensively inthe form of 1 drachm of a 2t per cent. solution in a pint ofwarm water applied on absorbent cotton-wool. The iodinevolatilised if the water was too hot ; it was converted intoan inert iodate if a starch-containing dressing was used.Much time could be saved if the gaping edges of fleshwounds were brought together by a gridiron of strapping;union by third intention, which was healing by the union ofgranulations, then took place just as it did in a baby whosehare-lip had failed to unite at once. Mr. Power concludedhis remarks by pointing out that the surgeon needed constanthelp from the physician, the neurologist, the pathologist,and the radiographer if he was to obtain the best results forhis patient, that he must know when to stay his hand andwhen to operate, and that his attitude should be ratherfrom than towards operation. It was better to lay woundsfreely open than to plug or drain them.

Mr. J. CHARTERS SYMONDS said that before speaking onthe general question he wished to express his entire agree-ment with the broad principles laid down by Sir WatsonCheyne.2 2 He (Sir W. Cheyne) had brought them back to thetime when septic infection was the rule, and had shownthat the same conditions still prevailed when wounds wereexposed and must be met by the methods originally intro-duced by Lister. Those who worked in hospitals in the

early ’’ seventies " must recall with him many old experiencesnow recurring and agree with Sir W. Cheyne’s condemnationof the gauze drain when suppuration existed, of the imper-fection of much of the so-called sterilisation, and of thetendency of an operator to attribute failure to any causebut that due to his own lack of watchfulness. The addresshe had given was a fine confession of faith, and he (Mr.Symonds) would cordially endorse his advice to younger mento read the account of Lister’s early work, accessible in thoseadmirable volumes, in the preparation of which his two oldpupils and assistants, Cheyne and Godlee, took so large a part.It was with some hesitation that he accepted the invitationto speak on this subject because of his limited experience.Yet he supposed it to be in character not unlike that ofmost others who had been in charge of hospitals at home.

2 THE LANCET, Nov. 21st, 1914, p. 1185.