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middle part of it, in which a strong steel ball can be fixed.The ball works in a socket attached to a plain wooden foot-piece (c). The foot-piece is screwed to the socket by threeor four ordinary screws, which can at any time be takenout and a boot attached instead when the treatment issufficiently advanced (B).The method of applying the splint is as follows :-The foot-

piece with the ball-and-socket joint is taken out of the

splint, the joint unscrewed, and the ball removed, so thatstrapping can pass under the foot-piece anywhere. Thechild’s foot is then very carefully strapped to the foot-piecein such a manner that it will not require to be renewed forsome time. The ball is then replaced and loosely screwedup, and the foot-piece with the limb fixed to the splint. Itis unnecessary as a rule to put on more than a couple ofstraps round the leg and splint, but when inversion ismarked a better fixation of the limb will be required in orderto be able to evert the foot. All that is left to be done is togently force the foot into a somewhat improved position;and screw up the ball-and-socket joint. At the next visitthis is loosened and refixed in a still better position; and asit is only the work of a minute, it can be undertaken by thesurgeon as he makes his daily rounds. Children walk abouteasily in these splints, and so far I have met with very goodsuccess in using them. If only one leg is affected, a high.sole should be made to the opposite boot to avoid obliquityoaf the pelvis.

The drawback for hospital use is the cost. There is agood deal of work in the splint, and it must be well done or thejoint will not remain fixed when in active use. Mr. Critchley’of Liverpool has taken great pains to carry out my instruc-tions in making the splint, and has succeeded very well. Heaupplies them to the hospital at a sovereign each.

Liverpool.

A RARE CASE OF SPINA BIFIDA.

BY W. T. CREW, F.R.C.S. ENG.

THE following case seems to me worthy of record in the:pages of THE LANCET.A full term, well-nourished infant, a day old, the first

.child of a mother aged twenty-one, was brought to me

.early in December of last year. Over the lumbar spine inthe middle line was a sessile tumour measuring about oneinch and a third longitudinally, and slightly less trans-versely, and raised five-eighths or three-quarters of an inch.above the integumentary surface. Its appearance exactlyresembled a blister, with two exceptions-namely, first,that a few minute bloodvessels could be detected on itssurface; and, secondly, about its centre, over a circular area,the diameter of which was about half an inch, the spinalcord, or rather the cauda equina, was bare, and presentedsomewhat the appearance of an ulcer, from which a clearfluid exuded. By transmitted light (daylight was quitesufficient), the cauda equina could be clearly seen leadingup to this spot. The tumour appeared to swell out as the- child cried. For further examination I oiled my fingers, asI feared the sac would burst by rough manipulation. On slightpressure the edges of the fissure in the spinal canal could beeasily defined, small buttresses of bone being distinctly felt allround the base of the sac, which I regarded as the edges ofthe deficient vertebral laminse. On examining the head thefontanelles were unusually large, and the sutures betweenthe various bones were excessively wide, and during violentexpiratory efforts the meninges became very prominent.At the junction of the frontal and nasal bones was a

rounded meningocele, and on the left side, through a largeWormian bone in the parietal region, was another meningo-cele the size of a large marble or small walnut. Severallarge Wormian bones were present in the frontal and parietalbones, and one in the occipital. Both thighs were tightlyflexed on the abdomen, and both legs flexed on the thighs.The right foot was in a condition of severe talipes cal-caneus, the left less so. The toes of the left foot werestrongly flexed; the arms and fingers appeared to move enaturally ; there were no convulsions, and the child, otherwisewell, took kindly to the breast. On the second day afterbirth the eerebro-spinal fluid began to escape through asmall aperture which had formed in the sac, and con-tinued to do so. On the fifth day the sac began tofeel firmer at its base; the integument appeared to be spread-

ing over the tumour. The clear fluid now became turbid,and on the ninth day the whole sac was much thickerand less translucent, partly owing to the cutaneous over-growth, and partly to the deposit of inflammatory materialsin its interior. Four weeks after birth the tumour wassmaller; its surface resembled normal skin, except forbluish, almost noevoid congestion. Pus now came awayfreely from the aperture. That portion where the spinalnerves had been bare had now become covered over withskin. The meningoceles disappeared; but the protrusionsof the cerebral membranes were more distinct between thevarious sutures, which showed no signs of contracting. Thedistortions of the lower extremities became more pronounced,and the child wasted. At the end of the fifth week slightconvulsive seizures began, and in the sixth week the patientdied. On opening the spinal canal after death, there wasexposed a fissure in the whole of the lumbar region ofthe spine an inch and a half long and three-quartersof an inch wide. The bodies of the vertebrse appearednormal. Spinal meningitis was well marked, and the sacwas filled with lymph and pus. The head was not inter-fered with.Although it was impossible to verify it post mortem, I

believe the sac was originally formed of the spinal arach-noid only, the bluish-white appearance said to result whenthe spinal dura mater is exposed being entirely absent.I may say that the mother, in describing its primaryappearance, spoke of it as "like a water-bleb," which I

thought very apt. The other point in the case which Ithought remarkable was the long period (nearly six weeks)which elapsed before the fatal termination; and it was

: interesting to note the failure of development of the cranialbones in conjunction with those of the spine.Nottingham.

_________________

A MirrorHOSPITAL PRACTICE,

BRITISH AND FOREIGN.

ST. THOMAS’S HOSPITAL.THREE CASES OF SARCOMA OF THE TESTIS ; CASTRATION ;

RECOVERY.

(Under the care of Mr. SYDNEY JONES.)

THE importance of diagnosis in cases of enlargement ofthe testis is very great, for early removal of malignant dis-ease is a large factor in the ultimate result aimed at-namely, complete cure. It is, however, difficult in the earlystage of enlargement of a testis to give a decided opinion,and in many cases even the best authorities can give nodefinite diagnosis until various remedies have been tried andthe tumour punctured; the latter with a view of examiningthe fluid withdrawn and any growth brought away in thecannula. Our readers will recollect that the chief difficultyat the commencement is to diagnose the disease from chronicinflammation of the body of the testis, and later fromchronic hydrocele and from hsematocele; and this task isrendered more difficult when the attention of the patienthas been first directed to the diseased organ by a blow orother injury, as in two of the cases recorded by Mr. SydneyJones. A progressive solid enlargement of the body of thetestis, without evidence of inflammation, the surface being ofunequal consistency, with dilatation of the scrotal veins,should always be looked upon with suspicion, more especiallyif treatment prove of no avail in arresting the increase ofthe growth.CASE l.-G. S-, aged twenty-one, a potter, was

admitted under the care of Mr. Sydney Jones, Jan. 22nd, andleft, apparently cured, March 5th, 1884. The family historywas good, and the patient had enjoyed excellent health untilfour months and a half before admission; he had neversuffered from any venereal complaint. Eight or nine monthsbefore admission he noticed a small hard lump about thesize of a pea on the outer and upper side of the right testicle,

t

Nulla autem est alia pro certo noscendi via, nisi quarnplurimas at mor-borum et dissectionum historias, tum aliorum tum proprias collectashabere, et inter se oompa.ra.re.—MOB&A&NI De Sed. et Caus. Morb.,lib. iv. Procemium. -

426

which slowly increased in size, but which was at first freelymovable. Four months and a half ago he knocked his righttestis against a table, and the injury was followed by rapidswelling; so much so that it was the size of the patient’sfist on the following morning. It was quite soft anddoughy at first, and diminished in size somewhat after theapplication of ice; but in a few days became quite hard,and had since grown slowly. The pain caused by the injurywas not severe, and there had been no pain since. After theaccident he could feel the small swelling which had existedpreviously in the middle of the soft swelling, it being thenabout the size of a walnut, but when the swelling became quitehard it could no longer be felt. When admitted he wascomplaining of the swelling of his right testicle, andappeared somewhat anaemic, pale, and was rather thin. Onexamination, there was an oblong, somewhat pyriform swell-ing occupying the right half of the scrotum and bulging intothe left half. It was hard and elastic, and no decidedfluctuation could be felt. It extended into the highestpoint of the scrotum, and could be traced as high as theexternal abdominal ring. Underneath the tumour a pro-jection from it, like an enlarged testicle, could be made out,but no pain was felt on pressure, either over this or anyother part of the tumour. There was no testicular sensa-tion. There was no impulse on coughing, and the size ofthe growth did not vary. The superficial veins of thescrotum were enlarged on the right side. The glands in thegroins were not enlarged, and no enlargement could be feltm the glands of the abdomen. The patient was otherwiseapparently healthy. There was no albuminuria.

Jan. 22nd.-The tumour, which had been punctured inthe out-patient department before admission, was againpunctured, and, as on the former occasion, only bright bloodflowed through the cannula; examined microscopically, thisshowed no evidence of new growth. From above down-wards the growth measured 11 in., and the greatest circum-ference 8! in.30th.-There had been no diminution in size under the

application of ice, ordered on the 26th, and Mr. SydneyJones decided to examine, and, if necessary, remove thetumour. The parts having been shaved and washedwith 1 in 40 carbolic solution (the patient being underthe influence of ether), a vertical incision was made,about an inch to the right of the raphe, through thescrotal tissues down to the tumour, which was found tobe of sarcomatous nature ; an elliptical incision was thencarried from the external ring to the lowermost portionof the growth and back to the starting-point; the tumourwas then rapidly dissected out, the numerous vessels beingcaught with clamp forceps; the cord was then seized witha stout pair of clamp forceps, the tumour being cut offbelow. Numerous ligatures were required to arrest thegeneral bleeding, and the cord was ligatured. The edges ofthe wound were carefully adapted by means of silk andcatgut sutures, a drainage-tube was placed from the highestpoint of the wound, and, after the parts had been thoroughlywashed with carbolic solution, the ordinary antiseptic dressingwas applied under the spray, which had been employed duringthe operation. When the growth was incised, the cut sur-faces bulged out and presented a gelatinous structure, whichappeared to have grown from the upper part of the testis;but this organ could not be distinguished. Microscopicallythe growth was sarcomatous, and consisted chiefly of smallround cells. There was some clear fluid in the tunicavaginalis, into which small bosses of new growth projected.The patient vomited after the administration of the ether.At night the temperature was 988°.31st.-At 2 A.lBL the temperature was 100’2°; at midday

101’80; at 8 P.M. 99’8°. There was no pain, and he had sleptwell.

Feb. 4th.-Wound dressed. Some purulent discharge fromthe upper part of the wound on pressure. Wound somewhatoffensive in smell. Two stitches removed. The temperaturehas varied from 99° in the morning to 100’4° in the evening.No pain whatever.6th.-Wound redressed; a good deal of pus came from the

wound, especially from the upper part; edges of wound ’,slightly red and tense. Carbolic dressings discontinued and ’,boracic acid substituted. The temperature has varied from98’4° to 100’2°. The bowels were freely open after enema ’,on the 5th. ’

After the 6th the temperature became normal or sub-normal, not reaching 100°, excepting during an attack offollicular tonsillitici which lasted from the 14th to the 17th,

when it rose to 102’60. There was discharge from the wound,chiefly from the situation of the cord, until nearly the endof the month, when the wound had perfectly healed. Therewas some slight swelling over the canal in the position ofthe stump of the cord when the patient left.

On leaving the hospital the patient went to a convales-cent home, where he remained for three weeks, resumingwork as a potter on his return to London. He was re-

admitted into St. Thomas’s on Oct. 7th, under the care ofDr. Ord, and died on Oct. 29th. It appeared that aboutthree months before he had suffered from constipation, andhad also had some vomiting; these symptoms passed off fora time, and he does not appear to have paid much atten-tion to them until he found a lump in his abdomen duringa more severe attack, three days before admission. Whenunder care the symptoms were constipation, vomiting, dis-tension of the abdomen, and the presence of a large tumourin the right side and in the iliac fossa. He died from ex-haustion. There was a small growth in the inguinal canal,measuring about three-quarters of an inch in diameter, agrowth as large as an orange over the iliac vessels on theright side, several tumours under the ascending colon onthe same side, evidently of glandular origin, and anothergrowth behind the duodenum, adherent to it about fourinches from the pyloric end of the stomach ; and on exami-nation of the mucous membrane of the duodenum it wasfound that the growth had produced an ulcer about two-inches long. The growths on section closely resembled eachother, presenting a gelatinous appearance, some being morevascular than others. These secondary growths much re-sembled the original one.CASE 2.-G. G--, aged fifty-one, a sawyer, was

admitted into the Albert ward under the care of Mr.Sydney Jones, April 7th, and left cured April 28th, 1884.There was no family history of tumours. The patient, astrong, healthy-looking man, had had no severe illnesses;he had not had syphilis. The patient stated that betweenfive and six years ago he had received a severe blow from alog of wood on his right testicle; this caused considerablepain, but he was able to return to work in about half anhour. The next morning he noticed some swelling on theright side, which became considerable in about three days,and the scrotum very red. He went to Guy’s Hospital,where they wished him to remain as an in-patient, but herefused. He was unable to work for about a fortnight,because of severe aching pain in the testicle. The painthen ceased, but the swelling did not diminish, and remainedabout the same size until a year or eighteen months ago,.when it commenced to steadily increase, and that withoutpain, excepting from its weight, which produced achingin the loins. On examination the scrotum was foundto be occupied by a large pyriform tumour, measuring fromabove downwards ten inches. It occupied the whole of theright side of the scrotum, and the testicle on that side couldnot be discovered. The left testicle was normal, and couldbe easily separated. The tumour was very heavy, elastic,.almost fluctuating in some parts, in others hard; the swell-ing was not translucent. It did not involve the cord to anyextent, as this could be traced into the upper part of thetumour and presented no evidence of enlargement. Thesuperficial veins of the scrotum were much dilated. Noenlargement of glands could be discovered. General healthgood. Sp. gr. of urine 1010; no albumen.

April 9th.-Ether having been administered, and the parts-washed with carbolic solution and shaved, two curved,incisions were made from above downwards, including anoval piece of the skin, and meeting at the bottom of thescrotum; the remainder of the scrotum was then dissectedoff the tumour and the cord freed, clamped, and the tumourremoved; the cord was ligatured. The vessels, which hadbeen secured by clamp forceps as they presented themselvesin the wound, were ligatured; a drainage-tube was intro-duced ; the edges of the wound brought together with silkand catgut, and antiseptic dressing applied; the spray wasused throughout the operation. On section of the tumourthe cut surface was undoubtedly of a sarcomatous character;there was some fluid, especially in the tunica vaginalis,.where some nodulated growths were found in its wall, pro-jecting from the principal one. Examination of the growthsome time later proved it to be sarcomatous, chiefly smallround cells. The abdomen was carefully examined whilstthe man was under ether, but no enlargement of the lumbarglands could be felt.lOth.-The patient had slept fairly during the night and

427

was without pain. Pulse 108. The temperature on the i

.evening of the 9th was 98’40. The wound was redressed t

antiseptically; there was very little discharge. On the 10th fthe temperature rose to 1006° in the morning, and to 1008° 1on the llth, but fell again next day, becoming on the 13th (

and after the 15th subnormal, continuing so for the iremainder of his residence (it had been normal before theoperation). On the 16th carbolic oil was used instead of the ]antiseptic dressing, and warm water dressing was substituted ifor this on the 18th. The wound was healed when he leftthe hospital, nineteen days after operation.CASE 3.-W. W--, aged thirty-six, a labourer, was ad-

mitted, under the care of Mr. Sydney Jones, on Sept. 22nd,and left, cured, on Oct. 8th, 1884. The family history wasgood; there was no history of any tumour. He had had noserious illness, and had never suffered from syphilis. Hefirst noticed that the left testicle was enlarged a short timebefore Christmas, 1883 ; the swelling began at the lower partof the testicle, and had gradually increased in size. The

growth had been unattended by pain, and had only causedinconvenience from its size. There was no history of injury.When admitted the patient was a strong, healthy-lookingman, complaining only of enlargement of his left testicle ;this enlargement was considerable, the swelling being veryhard and lobulated at its posterior part and irregular on thesurface. The hardness was almost cartilaginous in character,there was no testicular sensation, and the outline of thetesticle was lost. The cord on the left side appeared largerthan that on the right; the superficial veins were enlargedon the left side of the scrotum. No enlargement of theglands could be detected in the abdomen. The internalorgans appeared healthy. Urine normal; sp. gr. 1015.

Sept. 23rd.-The tumour was tapped, but nothing flowedthrough the cannula ; a little clot which remained in theend, on withdrawal, when examined microscopically, showedonly red and white blood-corpuscles.24th.-Ether having been administered, Mr. Sydney Jones

removed the testicle, antiseptic precautions being adoptedthroughout the operation, as in the other cases. Two curvedincisions were made, including an oval piece of skin, thetumour dissected out from the scrotum, the cord cleared and- clamped, and the growth removed below. After this thevessels, which had been secured by clamp forceps during theprogress of the operation, were ligatured, and then thevessels of the cord itself were separately ligatured. Theedges of the wound were brought together by alternate silkand catgut sutures after the insertion of a drainage-tube, andthe wound dressed antiseptically. Examination of thetumour showed a nodulated mass with the naked-eyecharacters of a sarcoma. On section there were severalsmall cysts; the growth appeared of more recent origin inparts, and in one part it appeared as if there was someremnant of the testicle. No record of the microscopical.examination was kept.

-

24th.-Slept after an injection of morphia, and was in nopain. Pulse 96.25th.-Wound redressed under the spray; looked healthy.27th.-Wound redressed; a few stitches removed. The

patient complained of headache, but was otherwise well.30th.-The wound was redressed, and all the remaining

stitches and the drainage-tube removed.After the operation, the temperature in the evening rose

to 100’80, to 100° on the following day, and to 100’6° on theday after. It did not again exceed 996°, becoming andcontinuing normal until his discharge, thirteen days afteroperation.

STATION HOSPITAL, HULME.ENLARGEMENT OF THE BfRSA BENEATH THE SEMI-

MEMBRANOSUS AFTER INJURY ; SUPPURATION EXTEND-ING TO THE KNEE-JOINT; ASPIRATION; AMPUTATION; ;RECOVERY; REMARKS.

(Under the care of Surgeon-Major G. C. GRIBBON, M.B.)CORPORAL C-, 3rd Dragoon Guards, aged twenty-seven

years, was admitted on Jan. 21st, 1884, with an obscurely’fluctuating swelling on the inner and upper part of the leftcalf about three inches below the joint. He was employedin the saddlery workshop. Six months prior to comingunder treatment his horse fell with him, and rolled over onhis left leg, giving rise to considerable bruising. This passedaway without any apparent ill effects, and he was able to

resume his usual occupation as a saddler. Latterly, how-ever, he had felt the left knee stiff, especially after sittingany length of time at his work, and he had got an uneasyfeeling in the calf. The patient was a delicate-looking manof very strumous appearance. The left popliteal spaceappeared somewhat full.

Five days after admission the swelling had become moreprominent and fluctuation distinct. It was rather tender,and occasional shooting pains were felt down the leg Ex-

ploration with a fine needle showed the contents to consistof oily matter, with a few opaque streaks. Under anti-septic precautions about an ounce of fluid was evacuatedthrough a small incision, and after a few days, during whichthere was a little thin oily discharge, the opening closed up.He was able to resume work on Feb. 4th. On the 17th,however, the man returned to hospital with a feeling.of tightness and stiffness at the back of the knee, andsome pain down the leg. There was no swelling in thecalf this time, but the lower part of the popliteal’spaceappeared fuller than normal. His general health was notgood.During the following two days the swelling increased

rapidly, and as it was tense, it was again emptied, and restand pressure employed, but without effect, for reaccumulationoccurred; it was therefore determined to make a free open-ing and use continued drainage. This was done on March 23rd.Antiseptic precautions were used throughout.The patient progressed satisfactorily enough for the

following four days. All his discomfort was relieved, andhe felt so well that, disregarding instructions to remain inbed and at rest, he got up and walked about in the hospitalyard. The day was cold and damp, and on returning to hisward he felt his knee very cold and numb, and soon after-wards pain set in. Acute synovitis of the knee supervened,the temperature ran up to 103°, the febrile symptoms weremarked, and the discharge from the wound became morepuriform. On the supervention of inflammatory sym-ptoms immobility was secured placing the limb in a longback splint with heel-piece. Cold, leeches, &c., were used,but to no avail. The synovitis became evidently’suppu-rative.

’

On April 18th the joint was aspirated, and 4 oz. of healthypus removed. This procedure, it was intended, should bemerely preliminary to freely opening the joint and securingfree drainage; but the relief given was so great that thelatter operation was postponed, in the hope that repeatedaspiration might prove effectual. Mr. Heath, Senior Sur-geon to the Royal Infirmary, Manchester, thought similarly.He informed Surgeon-Major G. C. Gribbon that in a caseunder his care of acute suppuration of the joint aspirationhad resulted in complete recovery (THE LANCET, Sept. 4th,

: 1880, p. 379). After each aspiration relief was experienced,,

and the febrile symptoms were temporarily allayed. Thejoint looked a little puffy, but there was no pain, and but

I little tenderness present. After ten days, however, thesymptoms, indicative of progressive inflammatory mischief,

, recurred with severity. Hectic became marked, and the

B patient was much reduced and exhausted. The jointbecame more painful, with startings on the slightest move-

r ment, and slight cedema of the thigh ’appeared. As suppu-,

ration was undoubtedly extending along it, amputation of> the thigh was decided on, and performed on May 9th. The

patient made an excellent recovery. Examination of theioint Dresented the usual features of a destructive inflam-matory process. The synovial membrane was thickenedand softened, and the articular surfaces were eroded circum-ferentially. Subchondral caries allowed of easy removal ofwhat remained, which was soft and discoloured. The peri-articular tissues were swollen and infiltrated, and col-lections of pus were found extending along the musclesof the thigh. The opening made early in the case behindthe joint could only be traced for an inch inwards. Nocommunication through it with the joint could be madeout.Remarks by Surgeon-Major GRIBBON.-Cases of enlarge-

ment of the bursa under the semi-membranosus are notuncommon, but one of so active a kind as in the presentcase is, I think, exceptional. That the swelling firstobserved on the calf and afterwards in the lower part of thepopliteal space was from inflammation of this bursa ishardly doubtful. In the place where it first showed itself-i.e., the calf-the case resembles some of those published byMr. Morrant Baker in the thirteenth volume of St. Bartholo-mew’s Hospital Reports under the title of " Synovial Cysts