1841CLINICAL NOTES.-ROYAL SOCIETY OF MEDICINE : SURGICAL SECTION.

Clinical Notes:MEDICAL, SURGICAL, OBSTETRICAL, AND

THERAPEUTICAL.

NOTE ON A CASE OF STRANGULATED MECKEL’SDIVERTICULUM IN A RIGHT INGUINAL

HERNIA.

BY A. F. STOKES, M.B., CH.B.,HOUSE SURGEON, HOSPITAL FOR SICK CHILDREN, GREAT ORMOND-

STREET.

THE patient, aged three months, was admitted to the

Hospital for Sick Children, Great Ormond-street, on

May 16th, 1908. He had been breast-fed and was always ahealthy baby except for occasional attacks of abdominalpain, during which the legs were drawn up and the stomachseemed full of "wind." There had been no attacks ofvomiting, no diarrhoea, and no passage of blood or mucus bythe bowel. A rupture had been first noticed two days beforeadmission to hospital which could not be reduced by thepractitioner who had attended the child. The lump hadgradually got larger and the skin over it had become red.The baby had vomited once two days previously. He hadalways been constipated but the bowels opened naturally onthe day of admission. Micturition was normal. The patientwas a pale, feeble-looking child, with drawn face and sunkeneyes. The heart and lungs were normal, the pulse was about100, and the temperature was subnormal. There was a tense

swelling in the right inguinal region, tightly gripped by theexternal ring and extending into the scrotum, where thetestis was felt to be enlarged and hard below the tumour.Squeezing the testis caused no pain ; the left testis was fullydescended.At the operation the right inguinal canal was cut down

upon, the external oblique split up, and the sac, which wasvery oedematous, was exposed. On being opened it wasfound to contain a loop of small intestine adherent by filmyadhesions to the sac wall ; there was very little fluid in thesac. At the upper part of the neck there was a strangulatedclub-shaped Meckel’s diverticulum originating from a sepa-rate loop of gut and nipped at its base. The internal obliquewas nicked so that the diverticulum and loop of gut mightbe delivered-there was a small perforation at the spot whereit had been constricted. The base was clamped, tied off withsilk, the diverticulum was removed, and the peritoneum wasbrought over the stump by purse-string suture. The testis,which was gangrenous, was removed. Radical cure wasperformed after Bassini’s method.With regard to the after-history of the case the child at

first was rather collapsed, but on the next day he was doingwell. Unfortunately, vomiting and diarrhoea began on

May 18th, but this was checked by usual remedies. On the20th vomiting began again and the child died in a few hoursfrom exhaustion. No post-mortem examination was

obtained.I am indebted to Mr. H. Stansfield Collier, in whose ward

the patient was, for permission to publish this case.

NOTE ON A CASE OF SUICIDAL CUT-THROAT.

BY A. BANKS RAFFLE, M.D. DURH.

THE following case is of interest as presenting manyfeatures that we usually look for in homicidal cases.The patient, a miner, aged 54 years, after inflicting serious

injuries on his wife and child, cut his own throat with arazor and died in eight minutes (roughly) from the time ofcommitting the act. He was a man of violent temper whoindulged intemperately in alcohol, but apparently he wassane. The wound was very severe, extending in a perfectlytransverse direction across the neck to the border of thesterno-mastoid muscle which was slightly divided on eitherside, and it divided the thyro-hyoid membrane and severedboth external carotid arteries just above their origin fromthe common carotid. The wound on section was bow-shaped,being deepest in the middle part and tapering at each end,extending down to the body of the vertebra at its deepestpart. There were no wounds except the one mentioned.

The case is of interest, since the wound presented more ofthe features of a wound that was inflicted by another than aself.inflicted wound. The man’s determination was remark-able ; on being caught he levered the edge of the razor bothupwards and downwards, attempting also to injure one of hiscaptors.Westoe, South Shields.

DERMOID CYST OVER THE MASTOID PROCESS.

BY P. MAYNARD HEATH, M.S. LOND., F.R.C.S. ENG.,ASSISTANT SURGEON TO THE EVELINA HOSPITAL FOR SICK CHILDREN,

SOUTHWARK BRIDGE-ROAD, S.E.

THE patient, a boy. aged four years, had suffered from aswelling behind the left ear since birth. It bad graduallyincreased in size and at the time of examination was half aninch in diameter. The swelling was cystic and freely move-able under the skin and over the deeper structures. Thecyst was removed and was found to be lined by a simplestratified epithelium and to be filled with cheesy material.There was no deficiency in the underlying bone or periosteum.The case is recorded as dermoid cysts in this situation seemto be somewhat uncommon.

Devonshire-street, W.

Medical Societies.ROYAL SOCIETY OF MEDICINE.

SURGICAL SECTION.

Reduction of an Old Subcoracoid Dislocatian of the ffunierqis-by Excavating the Glenoid Cavity through a PosteriorIntermuscular Incision,.-Cystic Tumour of the SuprarenalBody successfully Removed by Operation.-Compound,Fracture of the Arm.-Ununited Fracture treated byPlanting Small Fragments of Bone between the Ends.A MEETING of this section was held on June 16th, Mr.

J. WARRINGTON HAWARD, the President, being in the chair.Mr. W. G. SPENCER read a paper on the Reduction of an

Old Subcoracoid Dislocation of the Humeius by Excavatingthe Glenoid Cavity through a Posterior IntermuscularIncision. He said that the forcible reduction of old disloca-tions at the shoulder had been often described as a successfulmeasure, but the use to which the patient could afterwardsput the limb or whether he had thereby been predisposed toa recurring dislocation had generally been passed overwithout mention. The employment of forcible measures hadfrequently caused additional injury, many dying fromrupture of the axillary artery. That method would only nowbe practised in a limited fashion. Some cases, for onereason and another, remained unreduced, the patientsmaking what use they could of the mobility of the scapula.Kocher’s method of reduction had been recently reviewedand defended by Bach.l Excision of the head of thehumerus in order to regain mobility formed the subject of apaper by Sheild.2 In the paper, and in the discussion whichfollowed, a number of cases were mentioned and since thenthat operation had often been practised. Some form ofanterior incision had been adopted. The operation wasdifficult because the operator had to cut freely through dis-placed and altered structures which could not be wellidentified; the circumflex nerve was always in danger ofbeing injured, as were also the ! other axillary structures.There was left a wound cavity in which blood tended tocollect and to break down. Although the result obtainedmight be good as regarded mobility there might belittle strength in the arm. Lord Lister in his presi-dential address to the Hunterian Society in 1890 de-scribed two cases of bilateral dislocation for which hehad performed arthrotomy. After freeing the head fromits muscular attachments he reduced the dislocation bythe aid of pulleys. Keetley3 advocated arthrotomy andincluded a full history of the subject. Lister’s methodof arthrotomy, aided by extension by pulleys, left the

1 Deutsche Zeitschrift für Chirurgie, 1906, vol. lxxxiii., p. 27.2 Transactions of the Royal Medical and Chirurgical Society, 1888,

vol. lxxi., p. 173.3 THE LANCET, Jan. 23rd, 1904, p. 207.

1842 ROYAL SOCIETY OF MEDICINE: SURGICAL SECTION.

shbulder with very limited mobility. After prolonged d

passive movement and massage the patient would gene- tlrally not be able to raise his arm above the level f(of the’ shoulder. Subcutaneous division of bands and tldsteotomy of the neck of the humerus had not obtained any gvogue. The method of obtaining reduction through a tc

posterior intermuscular incision by excavating the glenoid t]cavity suggested itself to Mr. Spencer because it seemed an t]

adaptation to the shoulder of the procedure previously u

employed at the hip. For a traumatic dorsal dislocation of v

the hip of five months’ standing in a boy aged seven years he had made an anterior incision between t]muscles, and without injuring any important structure dexcised the obstructing capsule and the dense fibrous tissue filling the acetabulum. After making a well-marked o

cup the unaltered head of the bone was returned into place t

by manipulation without using any force. He afterwards a

showed the boy at a meeting of the Clinical Society of dLondon with a good return of movement. 4 He could not find gthat he had been anticipated in the description of the opera- ttion which he had adopted on the shoulder, nor in putting tforward the considerations which seemed to him to support c

the method. As to a posterior incision to expose the Ishoulder-joint Kocher in his "Operative Surgery" described r

cutting through the acromion and infraspinatus. He had tfollowed the recommendation in the case of tuberculous tdisease in a child in which the glenoid cavity was the chief t

part affected and a caseous abscess was pointing behind. But j that was a quite different operation. Indeed, all writers con- a

templated old dislocations of the shoulder from the front. s

The only illustration of a dissection from behind which the had met with was contained in a tract by Bonn in a

the library of the society. It was a drawing from a a

dissected post-mortem specimen and it showed in particular s

the mass of thickened capsule with calcareous plates e

resulting from the injury. Moreover, in old shoulder c

dislocations placed in museums they had usually been r

dissected from the front. He showed an exception to that ffrom the Royal College of Surgeons Museum. It was a po3t-mortem specimen dissected by Flower and it exhibited the relations of the muscles, but much of the thickened (

capsule had been cut away as well as part of the deltoid, the infraspinatus, and the teres minor. The relation of 1the long head of the biceps and that of the triceps zto the dislocation was the chief point to which he t

would draw attention in the specimen. The occasion for the employment of the operation was as follows. A iweakly man, aged 53 years, had had ten years before a cerebral vascular lesion causing right hemiplegia and japhasia, From that he had so far recovered but his ]

right side remained weak, and his speech was difficult to 1understand, though that was partly due to his being 1edentulous. In August, 1907, he was walking on the pave- ment when he slipped off the curb and fell into the gutter, Ihurting his left shoulder. He went at once to a medical man who, so he said, told him that there was nothing wrong withthe shoulder. Three weeks later, on the advice of a friend,he attended the out-patient department of a general hospital ;then he was anaesthetised and an attempt at reduction wasmade. He was then admitted to the hospital ward and twofurther attempts at reduction were tried, both underan anaesthetic. He was afterwards given to under-stand that nothing more could be done for him and heleft the hospital. Two months later he went to Dr.S. G. Tippett of Staines who at once sent him intothe Westminster Hospital under him (Mr. Spencer).His left arm could hardly be moved at all from the side onaccount of a subcoracoid dislocation by which the head ofthe humerus was firmly fixed to the scapula. There wasextensive eczema in the axilla and around owing to the armbeing kept to the side. The dislocation on the left side,along with the hemiparesis on the right, rendered him quitehelpless. Thus an operation to free the left shoulder wasparticularly indicated, whatever objection might be made toit on account of the weakness of the patient and the probablestate of his cerebral vessels. He operated on Nov. 13th,1907, three and a half months from the time of the accident,after especial care had been devoted to preparing the arm-pit, owing to the eczema which had followed the adductionof the arm. The patient was laid on his right side andhe (Mr. Spencer) stood behind him on the left; the

4 Transactions of the Clinical Society of London, 1895, vol. xxviii.,p. 293.

dresser held the left arm as much raised as he could sothat the posterior surface of the arm looked upwards andforwards and at the same time pushed the humerus towardsthe operator. This was a primary feature of the method ; theglenoid cavity and neck of the scapula could be thus pushedtowards the incision and held there fixed by making use ofthe head of the humerus in its displaced position underneaththe coracoid process. A semilunar skin flap was turnedupwards over the acromion by making a curved incisionwhich commenced over the middle of the spine of thescapula and ended over the posterior fold of the axilla. Thenthe upper border of the latissimus dorsi was freed, retracteddownwards, and the posterior border of the deltoid wasretracted upwards. The next step was to raise by meansof a raspatory the teres minor and infraspinatus fromtheir origin near their tendons so as to explore the

axillary border and a small triangular area of thedorsum and neck of the scapula. That led to a

good view of the origin of the long head of the

triceps from the lower edge of the glenoid cavity andthe axillary border of the scapula. He then began tocut away piecemeal a tough mass of tissue representing theposterior part of the capsule and to chip away the posteriorrim of the glenoid cavity until he had reached the origin ofthe long head of the biceps from the upper margin. He hadthen the long head of the triceps below and the long head ofthe biceps above, both well defined at their origin but unin-jured. Between these two tendons was a mass of fibrous tissueand fat representing the capsule, and remains of blood clot,some of which had become altered into melon-seed bodies, inthe former joint cavity. No actual joint cavity remained, buta section under the microscope of a piece which had been cutaway showed synovial membrane and greatly thickened sub-synovial tissue. The rest of the thickened capsule was laterexcised in small bits, progressively with the removal of bonechips from the middle of the glenoid cavity, until the anteriorrim which had come to form the posterior margin of thefalse joint below the coracoid process had been removed.When that was done the head of the humerus was exposed.Thus a cup-shaped cavity had been excavated between theorigin of the biceps above and the triceps below and all thealtered capsule had been cut away. A manipulation of thehumerus by Kocher’s method then caused the head to bereduced into the excavation. This manipulation withoutusing force had been tried before but it was only after the

.

complete removal of the anterior rim of the glenoid cavity,. including the posterior border of the false joint, that reduc-

tion readily occurred. That a false joint had formed was. further shown by the escape from it of synovial fluid whilst; none was found at the site of the true joint. After reduction

the head of the bone could be well inspected: its cartila-. ginous surface was unaltered, its muscular attachments were. uninjured. When extension was made on the arm the head of, the bone was only pulled downwards just enough to allow

of the fingers being inserted between the head of theacromion. When extension was relaxed the head came into

, contact with the acromion. That was due to muscles and; ligaments having shortened. The head could not be pusheds further back than the excavated glenoid cavity on account ofthe tenseness of the subscapularis. In the excavated cavityr the head rotated easily and the arm could readily be carried- into the vertical position. On removing the retractors the

muscles returned into place and as the head of the bone now. filled the deepest part no wound cavity remained, so the

skin was sutured without a drain. He had expected to. meet with the dorsalis scapular artery, but he did not cut far1 enough down the axillary border to wound it. The wholef plan of the operation had kept him far away from thes circumflex nerve and of course from the large axillary1 vessels and nerves. The wound healed well ; before the, sutures were removed the arm could be readily rotated. As soon as there was firm union massage, passive movement,s and electrical excitation were adopted. The arm could beoraised easily to the vertical and the patient slowly regainede the use of the limb in a way which was quite satisfactory

considering his general debility. That method of treatingold shoulder dislocations appeared to have the following

L- advantages :-1. The joint was exposed without dividing anyn important structure and the muscles which had been drawnd aside fell back into place, so that no wound cavity wase left in which blood clot could collect nor was drain-- age required. 2. Through the incision could be removed

the impediments to reducticn, viz., the altered joint’’

capsule, and the bone forming the posterior rim of the

1843OPHTHALMOLOCAL SOCIETY. -

ialse joint and the middle portion of the glenoid cavity,without disturbing the important origins of the biceps andtriceps from the upper and lower borders of the rim.3. At the operation an assistant could cause the deformityresulting from the dislocation to aid the surgeon ; by meansof the arm he could push the neck of the scapula towards thesurgeon and hold it fixed whilst the glenoid cavity was beingexcavated. 4. The head of the humerus was replaced withits muscular insertions and its articular surface intact. It- could then move freely in the excavated glenoid cavity. Butit was not liable to become displaced again, for all themuscles were still attached yet had become somewhatshortened in the time which had elapsed after the accident.Hence passive and active movements could be begunearly. If indeed the operation were to be adoptedfor a quite recent dislocation, whilst the rotators ofthe head were still stretched or perhaps partly torn,then it might be necessary to limit the movements ofthe shoulder until the muscles shculd have contracted up.-The PRESIDENT said that the value of the operation was inobviating the division of the important muscles round theshoulder-joint.-Mr. RUSHTON PARKER said that enough wasnot done in these cases to make surgeons acquainted withthe amount of defect that might be tolerated without impair-ing the power of a working man to earn his living. He

thought that the operation described by Mr. Spencer was,deservirg of recommendation.-Mr. T. H. KELLOCK gavethe details of a similar case in which he had performed anoperation like that described by Mr. Spencer, but he (Mr.Kellock) had used an anterior incision. He suggested that aposterior and an anterior incision would be the most satis-factory way of approaching the joint in these cases.-Mr.SPENCER replied.

Mr. ALBAN H. G. DORAN read a paper on a CysticTumour of the Suprarenal Body successfully removed by- operation. He reviewed the records of 13 cases of cystictumour of the suprarenal body, large enough to be of clinical,and surgical interest, including one in his own practice of awoman aged 62 years who had been subject for ten years to.attacks of pain after food, and recently to sharp painsreferred to a firm oval tumour in the left hypochondrium. Itwas half hidden under the ribs but could be pushed down.wards below them. There was resonance on percussion overpart of its anterior surface. Diagnosis was uncertain. He

operated, making the abdominal wound along the outerborder of the left rectus. The peritoneum was incisedexternally to the descending colon and the tumour wasenucleated with ease. Some large vessels running into itsupper and inner part required ligature. The left kidney wasseen lying internally to the tumour and mainly below it. No

drainage was employed. The tumour was a thick-walled uni-locular cyst, containing half a pint of bloody fluid. Muchadrenal tissue was detected in its walls. It was an instance ofthe struma suprarenalis cystica hæmorrhagica of Henschen.:Several other cysts of this class were included in the series,to which was added a doubtful case recorded by Lockwood.The minority were adenomatous or lymphomatous cysts. A

history of injury existed in two out of the 13 cases ; attacksof local pain were the rule ; bronzing of the skin was notedin one case only (McCosh) and it disappeared after removalof the tumour. Incision and drainage had proved most un-satisfactory ; the wall of a blood cyst was soft and in oneinstance tore itself away when sutured to the abdominalwound, with a fatal result. In another case the patient died,and it was afterwards found that the cyst could easily havebeen enucleated. This incomplete operation was adopted in athird case because the cyst was believed to be pancreatic scits base was not removed. The patient recovered. Com.

plete removal of the cyst was the proper surgical treatment’Recovery followed respectively in Pawlik’s, McCosh’s, anchis own (Mr. Doran’s) cases, as well as in Lockwood’s casewhere the nature of the cyst was doubtful. The proximity o:the aorta or vena cava should always be borne in mind. Sixof the cases were mainly of clinical interest, not having bee!subjected to operation.-Mr. C. B. LOCKWOOD said that hihad in 1898 exhibited a retroperitoneal cyst supposed to hav4.originated in remains of the Wolffman body and he ha<operated in two additional cases in which both the patientwere young women, recovery following the operation in eacl-case. Both the cysts were in the left side. One was th<usual type of cyst, full of clear fluid and freely moveable"The other cyst was attached to the lower end of the lef

5 See THE LANCET March 5th, 1898, p. 615.

kidney and at its attachment some solid growth was foundwhich proved to be adrenal tissue. Mr. Lockwood consideredthis case to supply a very important link in the chain of evi-dence which had led him to attribute the ongin of theseretroperitoneal cysts to remains of the Wolffian body which,as was well known, gave origin to the adrenal body and

. adrenal remains. These retroperitoneal cysts had fairly con-. stant clinical characters. The patients were nearly always

females. The tumour was on the left side, it was freelymoveable, and was usually thought to be a moveable kidney.It caused continual pain and discomfort. In the four casesof which Mr. Lockwood had had experience the cysts were

, safely removed by incision into the abdomen through thei outer edge of the left rectus abdominis, the cysts beingl exposed by dividing the descending meso-colon. In the caseE of the cyst attached to the kidney the kidney substance was, incised and brought together with catgut.-Mr. DORANE replied.- Mr. RUSHTON PARKER read a paper on a case of veryi severe Compound Fracture of the Arm which he illustrated

by photographs and lantern slides. The points to which hedesired to draw attention were the slinging of the arm to

1 the neck and the flexion of the elbow to a more or less- acute angle. In a fracture of the lower fourth of the3 humerus on account of the invariable tendency to adductions of the condyles under the weight of the elbow a twist

imparted to a metal splint hollowed to fit the limb effectually1 maintained the lower smaller fragment in line with the. upper while controlling both.a Mr. PARKER also read a paper on Two Cases of Ununited. Fracture treated by Planting Small Fragments of Bone. between the Ends.

OPHTHALMOLOGICAL SOCIETY.

An Epidemic of Contagious Conjunctivitis Due to the Pneumo-coccus.-Hereditary Eye Disease.-Secondary Xerosis.-Lower Corneal Plaques.-Exhibition of Cases and Card

Specimens.A MEETING of this society was held on June llth, Mr. R.

MARCUS Gmm, the President, being in the chair.Mr. P. E. H. ADAMS read a paper on an Epidemic of Con-

tagious Conjunctivitis due to the Pneumococcus. He saidthat the epidemic occurred in the spring in a small school of37 boys, 21 of whom were attacked. The eldest boy affectedwas 14 years of age, the youngest beirg nearly ten years old.All the smears taken except one showed numerous Gram-positive diplococci. Most of them were typically flame-

shaped pneumococci with capsules, though a few of themwere rounder in shape and in some the capsules were notevident. This agreed with the description given by Schmidt 1of smears taken from cases of pneumococcal conjunctivitis.On blood agar the colonies were typical slow-growingpneumococci and there was no growth on agar. Only threeof the cases were at all acute, most of them being subacuteor quite mild. Four cases of relapse were reported. Thecondition found on examination was fairly constant-generalcongestion of the lower palpebral conjunctiva, with slightinjection of the ocular conjunctiva, and in the acute caes athin line of muco-pus in the folds of the conjunctiva of thelower lid. The upper lid showed slight enlargement offollicles at the angles, and a row of minute follicles alongthe everted edge. The whole epidemic lasted about fiveweeks and spread in spite of isolation. It agreEd in almostevery respect with previously reported outbreaks, the chiefdifference being the generally mild nature of the cases.

Mr. E. NET’rLESHIP read notes of three cases of HereditaryEye Diseases. Case 1 was that of a husband and wife whohad senile cataract at an advanced age, and both were

operated on with success. They had ten children, seven ofwhom had cataract in various degrees, two of these havinghad them "matured and operated upon at a much earlierage than in their parents. There were also slight lenticularchanges in the grandchildren of the original couple. Thesecond family showed the occurrence of I I Cioppock " ordiscoid cataract, and lamellar cataracts of various sizes, andlikewise of retinitis pigmentosa. Among about 250 personsMr. Nettleship had been able to trace, belonging to the

family, 32 with family cataract and 15 with retinitis

pigmentosa. The sex incidence and mode of descent were

shown to be different for the cataract and retinal disease1 Archives of Ophthalmology, vol. xxxvii., No. 2.