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bone. Allusion was made to a similar case recorded by Dr.Port in the Pathological Society’s Transactions, vol. xxxi.,the only difference being in the exact seat of the growth inthe two cases. Dr. Port’s specimen was removed fromthe mucous membrane of the rectum, at about twoinches and a half from the anus; whereas in the case nowrecorded there was evidence to show that it was seated-at the juncture of the sigmoid flexure with the rectum.-Dr. FLOYER regarded the lump, which was still present in theiliac fossa, as the remains of the pedicle.-Dr. CHARLEWooDTuRNER suggested that an ovarian tumour might havepenetrated the sigmoid flexure and become inverted there.-Mr. J. B. SUTTON believed that the tumour originated aboutthe neurenteric canal, and was an example of a very raretumour. In reply to Mr. Boyd, he said the epiblast at theanus only invaginated for about half an inch to three-,quarters of an inch.-Mr. CLUTTON felt sure that the residuallump was the remains of the pedicle, and said that thecentre of the tumour contained bone.The following card specimens were exhibited :--Dr. Payne

for Dr. Jacob of Leeds: Tumour of Finger. Mr. Pollard:Dermoid Cyst of Testicle. Dr. Lediard of Carlisle: (1) SenileOvarian Blood-cyst; (2) Hernia Reduced en masse;(3) Cancer of Bectud—Excision; (4) Cancer of (Esophagus-Gastrostomy. Dr. Turner: Hepatic Cells in Blood of PortalVein. Dr. Carrington: Mitral and Tricuspid Stenosis. Mr.E. H. Fenwick : (1) Fibro-sarcomatous Polypi from Bladder;(2) Papilloma of Bladder. Mr. Makins: (1) Diastasis of’Cervical Spine; (2) Carcinoma of both Superior Maxillae.Dr. Drewitt: Heart and Pericardium from a case of Rheu-matic Nodules. Mr. Lunn and Mr. Larder: Aortic Aneurysm.

CLINICAL SOCIETY OF LONDON.

Traumatic Inguinal Aneurysm; Rupture of Scte; Ligatureof Arteries.-Aneu2ysm occurring in Stump.- Intussus-ception of Upper Part of JeJunum.-Acute IntestinalObstracction vith Acute 15ei-itonitis; Abdominal Section;Rapid Recovery.AN ordinary meeting of this Society was held on the

-26th ult., Mr. Thomas Bryant, F.R.C.S., in the chair.Mr. C. MANSELL MOULLIN read a paper on a case of

’Traumatic Inguinal Aneurysm; Rupture of Sac; Ligatureof the Common Femoral and External Iliac Arteries. The

patient, a man aged thirty-four, had received a severe blowM the groin from the edge of a flat piece of iron about fourweeks before admission. There was a good deal of swellingand discolouration about the part for some days. Threeweeks after receiving the blow the swelling reappeared, andcontinued to increase in size until the morning of admission,when, during an effort, he was seized with violent pain, and alarge pulsating tumour made its appearance in the groin,- extending into the scrotum and perineum. The foot andleg were not much swollen, but the skin in the groin wasTed and oedematous, and the scrotum much discoloured.An incision was made into the swelling over the femoralartery (after an abdominal tourniquet had been applied),and a longitudinal slit found in the wall of the vessel,immediately under Poupart’s ligament. A director waspassed down it, the artery separated and tied below theinjured part with catgut. A fresh incision was then madeabove Poupart’,s ligament, for the purpose of securing theexternal iliac above the rupture. No other vessel was tied.The blood-clot, some of which was old and very adherent,some quite recent, was turned out as far as possible, a largedrainage-tube inserted, and the limb carefully wrapped upin cotton-wool. The subsequent course was perfectlysimple, except that the wound suppurated freely, and, untila side opening was made, remained full of decomposingclots. The limb wasted exceedingly, and a small sloughformed on the side of the heel, but the gangrenous patchwas only the size of a shilling. Four months after, pulsationcould just be detected in the posterior tibial, and perhapsin the anterior.Mr. SYMONDS read a paper on a case of Aneurysm occurring

in a Stump. A man aged forty-six sustained a compoundfracture of both bones of the leg in the site of an oldsyphilitic ulcer, on the floor of which the tibia was exposed;he was admitted into Guy’s Hospital on Aug. 7th, 1883.Gritti’s amputation was performed under full antisepticprecautions. The man was cachectic, and had lost a

good deal of blood. Suppuration, with a foul discharge,occurred, and, later, two abscesses were opened on the outerside of the stump, and one on the inner. Healing tookplace very slowly, and when discharged, nine weeks afterthe operation, the stump was somewhat swollen and hard,especially on the inner side. Five days later he returnedwith blood oozing from a pin-like opening in the originalcicatrix, and two days afterwards, when admitted, the bleedingwas severe, and a large pulsating swelling was observedon the inner side. The skin over it was red and oedema-tous. There was thought to be an abscess communicatingwith the femoral artery. Before laying open the swellingthe superficial femoral was ligatured, the whole thighbeing oadematous. When cut into, blood alone escaped.The incision was enlarged, the clots turned out, whenalarming hemorrhage occurred from the femoral. Thiswas found to come from a small aneurysm which hadruptured. This was laid open and the vessel tiedabove and below. The artery was isolated by passing acatheter into it. The man ultimately recovered, thoughslowly, and had a sound and useful stump. In his remarks,Mr. Symonds said the aneurysm had formed on the vesseltwo inches above the amputation site, and existed previousto the man’s first discharge, and had ruptured soon after-wards. He referred to the rarity of the case, and to thegeneral belief that aneurysm does not follow ligature ofa healthy vessel from pressure, nor embolism of an arteryunless the embolus be in a state of active change, and setsup a similar inflammatory and softening process in the wallof the vessel itself, which then yields to the ordinary blood-pressure. Admitting these facts, Mr. Symonds thought thata condition similar to that found in embolism must be lookedfor to explain the present case. It was suggested that theexplanation of the cause of the aneurysm lay in the inflam-matory state of the stump, and Mr. Symonds thought it bestexplained by supposing the vessel to have been involved inthe acute inflammatory process which ended in other partsin the formation of pus, but in the vessel in softening only.He supposed that a peri-arteritis existed, reducing the vesselwall to an embryonic state, just as was seen to occur inthe floor of ulcers, and in inflamed connective tissue. The

localisation was explained by supposing that at the pointaffected the vessel formed part of the wall of an abscessor sinus. In support of this suggestion, the condition ofthe vessels in the walls of phthisical cavities, from whichhsemorrhage occurred, was cited. Here, either an aperturein the wall of the vessel was found or an aneurysm. Thelatter change, he believed, was not uncommon in phthisis,and Mr. Symonds suggested that aneurismal dilatation willbe found to precede secondary haemorrhage in stumps morefrequently than is now supposed. A paper which he pub-lished in the Transactions of the Pathological Society,vol. xxxv., page 146, was referred to as illustrating the case.In this paper two vessels affected with acute arteritis weredescribed and figured, on one of which several aneurysmsalso had formed, secondary haemorrhage resulting from therupture of one of these. Referring to his suggestion in theabove paper, that in secondary haemorrhage an unhealthycondition of the wound and vessel existed, and that thebleeding was determined not so much by failure of clotformation as by suppurative arteritis, Mr. Symonds said thatthe present case gave support to that view, and broughtinto harmony haemoptysis and secondary haemorrhage. Hesuggested that in both the processes, so far as regardsthe vessel, are identical, and result sometimes in theformation of an aperture, and sometimes of an aneurysm.Mr. T. BRYANT was disposed to agree with Mr. Symonds’

views, and believed that secondary haemorrhages usuallyresulted from an arteritis originating about the seat ofinjury of the vessel. Reference was made to the case of aman with compound fracture of the thigh, for which amputa-tion was performed; so rapid was the healing that only onesinus discharged purulent fluid at the end of two weeks ; butfatal haemorrhage occurred at the end of the fifth week.The femoral artery was found to be diseased by suppurationthat had destroyed the coagulum. At the time it was sug-gested that the arteritis was due to torsion of the vessel,but Mr. Bryant did not adopt that suggestion. He askedwhy Mr. Moullin laid open the traumatic aneurysm in thefirst instance, instead of ligaturing the external iliac artery.- Mr. MouLLIN said the skinwas so oedematous and red that itappeared as though suppuration had occurred.-Dr. GOOD-HART agreed with Mr. Symonds that cases of aneurysm fromembolism and haemoptysis from aneurysms in pulmonary

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cavities supported his views of surgical secondary hsemor- be associated with, and no doubt caused by the existence of,rhage. Years ago he had taught that such haemorrhages large polypoid masses of growth which sprang from thewere due to suppuration which had extended along the mucous membrane of the small intestine in several parts.tract of the artery. As the result of Listerism and con- In reply to Mr. Bryant, Dr. Goodhart stated that at no

sequent freedom of wounds from suppuration, he had not time was any blood passed per rectum, and there had beenduring the last five or six years seen cases of the kind.-Mr. no actual constipation.-Mr. R. J. GODLEE mentioned a casePEARCE GOULD asked Mr. Moullin why the upper ligature of intussusception that existed without producing consti-was placed so far above the wound of the artery, thus pation. It occurred at the North-Eastern Hospital forleaving the deep epigastric and circumflex to supply blood Children, and the child passed a large quantity of fseces.below it.-Mr. BENNETT inquired of Mr. Symonds whether Another case happened in University College Hospital manyligature-of the common femoral would not have been pre- years ago; there were symptoms of intestinal obstruction,ferable to that of the superficial femoral artery, and which led to the performance of colotomy on the right side,,then why he had ligatured above the aneurysm at all ; but without any tumour to account for the obstruction beingwould not the use of a tourniquet and local treat- found. Later on abdominal section was performed, stillwith-ment of the aneurysm have answered all purposes ?- out success. The patient recovered from both operations, andMr. MANSELL MOULLIN said the aneurysm was situate died afterwards, when a long intussusception of the largeimmediately under Poupart’s ligament, and he could bowel was discovered.-Mr. BARKER said that in this casenot have reached the artery below the ligament. No other there was a tumour of the wall of the bowel that producedartery was ligatured.-Mr. SYMONDS, in reply, said it would obstruction and led to the intussusception.no doubt have been better to have selected the common Mr. A. E. BABEBB, read notes of a case of Acute In-femoral for ligature, and admitted that it would have been testinal Obstruction, followed by Acute General Perito-better still to have controlled the vessel by a tourniquet, and nitis, for which he performed abdominal section, releasingthen to have dealt with the aneurysm; but he did not do the implicated bowel, and thoroughly sponging out thethis because he thought there was pus in the cavity, and peritoneum, with the result of rapid recovery. The patientconsidered that the haemorrhage might have proved more was a man aged twenty-three, who had enjoyed gooddifficult to control. health, with the exception of flatulent dyspepsia, up to-Mr. GooDHART read notes of a case of Intussusception of Saturday, November 14th, 1885. At 7 r.M. on that day he

the upper part of the Jejunum, of twenty-one months’ had a loose motion with a feeling of sickness, and three orstanding. Its clinical interest depended upon its long four minutes later was seized with a violent pain in theduration and upon the resemblance of the abdominal abdomen, and fell down, rolling about on the floor in the-tumours during life to a floating kidney. The case occurred most acute suffering. This pain commenced at a point mid-in the practice of Mr. Sandford Arnott of Brixton. The way between the umbilicus and the right groin. At 7.30 hepatient, a girl aged nineteen, had been first seen a year and began to vomit, and continued to do so through the night,three-quarters before her death, and was then suffering and next day, until Monday evening, when Mr. Barker wasperiodical attacks of vomiting and abdominal pain, with pro- sent for. At the onset he was seen by Mr. Knaggs ofgressive wasting. A knotty irregular tumour was felt in Camden-road, who gave large enemeta with opium internally,the lower part of the abdomen above the uterus. She then and hot fomentations over the abdomen. This treatmentattended the out-patient department at King’s College for was continued with much judgment for the next forty-eight months, and subsequently at University College, suffer- eight hours, but with no relief. On the contrary, the painidg from obstinate constipation, faecal tumours, and what was increased, and became general over the whole abdomen, thethought to be a floating kidney. She was relieved by enemata vomiting continued of a grass-green colour, but neverof sulphate of magnesia, but, notwithstanding, her attacks became stercoraceous, the abdomen grew more and more dis-recurred, and in these she was frequently seen by Mr. Arnott. tended, and the centre of acute tenderness shifted to the leftThe abdominal tumour never disappeared, but latterly it side of the umbilicus. The peritoneum also began to fillaltered its position, and came to correspond with the situa- with fluid, there was complete obstruction of the bowelstion of the left kidney. It varied in size and shape, some from the first, and no flatus was passed. No distinctdays being decidedly kidney-shaped, and generally it tumour was to be felt anywhere. When seen by Mr.had a curve in its length, the concavity being towards Barker on Monday evening the condition was verythe umbilicus. She was seen by Dr. Goodhart in her last grave, and he at once decided to perform abdominalattack, and was then pale and thin, although not appearing section, regarding the case as one probably of obstructionextremely emaciated; her mother described her as hardly from a constricting band, or from volvulus of the smallever free from sickness for more than a week, the actual intestine. With strict antiseptic precautions, the abdomenattack lasting generally twenty-four to thirty-six hours. was opened in the middle line from the umbilicus to theLately she had been sick almost daily. The abdomen being pelvis, and was found to contain much flaky serum andexposed, the existence of a dilated stomach was at once free gas ; the intestines were coated with lymph andapparent, it occupied the upper half of the abdomen, and its moderately distended. The small intestine was now passed!muscular contractions were plainly visible; but below this, through the fingers from below upwards, until the middlein the left inferior quarter of the abdomen, was a second third of the jejunum was reached. When this was drawntumour, running from the flank obliquely downwards upon, there came a sudden rush of fluid through the portiontowards the pubes. This was the mass that had been felt held in the fingers, and the next moment there came outthroughout the progress of the case. It was an elongated a loop of bowel deeply congested and ecchymosed, andtumour that underwent slow rhythmic alterations, becom- distended to about three or four times its normal girthping alternately hard and soft, and was obviously some and containing much fluid. Beyond this loop the gut waspart of the intestine "in labour." Vaginal and rectal distended and moderately congested, but was sharplyexamination gave no additional information. However, marked off against the implicated loop by the absenceit was clear that there was some intestinal obstruction, of ecchymoses. The bowel was now passed through thealthough there was no sufficient material for determin- fingers downwards, to make sure that no other obstructioning its exact nature. She had never passed any blood, existed, and then the caecum and vermiform appendix werethe evacuations being always of a light-brown colour, turned out of the wound and examined with the sameand, although she suffered from constipation, it was never object; they were quite sound, though sharing in thesuch as to resist the action of an aperient. It was arranged inflammatory distension and congestion to a slight extent.that she should be admitted to Guy’s Hospital, but before The hand was now passed into the abdomen, and every partthis was accomplished she died, apparently from the ex- of it was explored, but nothing further was found. Thehaustion of the continued vomiting. Mr. Arnott and Dr. gut having been carefully cleansed was now replaced, andGoodhart made an inspection. The dilated stomach occupied the whole abdomen was mopped out with carbolised sponges,the greater part of the abdomen; below, and to its left, in the passed into every recess on long holders. The greatestinguinal region were two or three coils of small intestine- accumulation of inflammatory products was found in thesmall, but prominent, as if something pushed them up from flanks and pelvis, and required repeated sponging. Whenbehind, and on turning them aside a large intussusception the whole cavity had been cleaned the wound was unitedwas seen ; it ran from near the spine into the pelvis, and with seven deep and two superficial carbolised silk sutureslooked more like rectum in thickness and size, but it proved in the usual way, and was dusted with iodoform andto be small intestine, the neck of the intussusception being dressed with salicylic wool, secured with a broad binder.at the commencement of the jejunum. It was about eighteen The patient bore the operation well on the whole. He had

inches in length, and when further examined was found to a good deal of pain in the night, and vomited twice before

449

morning. The vomited matter was no longer bilious, butconsisted of watery altered blood. It came up for the lasttime at 9.30, twelve hours after operation. The patientprogressed extremely well from this time, the peritonitisdisappearing rapidly. The wound was dressed for thefirst time on the fifth day, and was then found united byfirst intention. Five of the stitches were taken out, andthe wound was supported by broad strips of stickingplaster applied directly to the skin with salicylic wool anda binder over all. On the seventh day the remaining stitcheswere removed, and the wound was supported as before. Onthe eighth day a motion was passed spontaneously, andagain on the ninth. These motions were stained with oldblood. On this day, owing to an error in diet, be vomitedand burst open the upper two-thirds of the wound, in spiteof the strapping, and a knuckle of the intestine protruded.On seeing this six hours later, Mr. Barker removed the dress-ings, cleansed the protruded gut under the spray, wiped outthe abdomen and the wound, and replaced the gut. Theopening was closed as before, and similarly dressed. Thetemperature in the rectum rose on the night following to1020, but beyond this there were no disquieting symptomsthroughout convalescence, the patient being able to takelight solid food a couple of days later. The wound healed in.great part by first intention, but some of it by granula-tion. In reviewing this case, Mr. Barker dwelt upon thefollowing points:-1. The nature of the obstruction.2. The performance of abdominal section in the midstof acute general peritonitis. 3. The rapid disappearanceof the latter af’;er operation. He pointed out that from acomparison of this with recorded cases there could be nodoubt that it was a case of volvulus of the jejunum, a veryrare condition. The whole case corresponded closely withthe few others on record, only one of which had beenoperated on. The onset of general peritonitis he regardedas an extra reason for early operation in such cases, andshowed that this view was supported by pathologicalTeasoning and clinical experience. The rapid disappearanceof the peritonitis, due to the release of the intestine andcleansing of the abdominal cavity, was then commented on,and it was pointed out that the good result was, besides, ingreat part to be attributed to the judicious treatment of thecase from the first with opium and enemata, and the com-parative rest that the bowels were then placed in up to thetime of operation, which was not delayed a moment after itwas evident that other means had failed. That such anoperation could only be successful when performed early andunder the strictest antiseptic treatment was also averred.-Mn BRYANT considered that the whole case was mostsuccessful, and a brilliant piece of surgery from beginningto end. He also agreed with the diagnosis, and thoughtthat the only other condition that could account for the- case would be a band. He asked Mr. Barker to explain howthe gas developed in the peritoneal cavity. In his opinionperitonitis was not a contra-indication to abdominal section.- Dr. KINGSTON FOWLER referred to a case that occurredsome years ago at the Middlesex Hospital which was thecounterpart of Mr. Barker’s. To Mr. Hulke, who operated,Dr. Fowler suggested that the right side of the abdomenshould be searched with a view to finding the collapsedintestine ; this was actually done and the site of obstructionwas easily found. It was thought to be a volvulus thathad been untwisted suddenly by drawing on the intestine.The patient lived four days and passed several copiousmotions, but died of syncope without obvious cause. Dr.Fowler opined that it was much easier to handle collapsedbowel, and his suggestion had been followed by Mr.Pearce Gould and Mr. Clutton and others.-Dr. CARRING-iron raised the question whether Mr. Barker’s case was

not one of acute peritonitis, observing that acute peri-tonitis and effusion were not common results of acuteobstruction. The diagnosis of volvulus rested on the ecchy-mosed condition of the loop of the bowel and the passageof blood-stained matter. Both these factors might beaccounted for on the supposition that acute peritonitis hadset up an acute enteritis.-Mr. BABiCEB, in reply to Dr.Carrington, urged that the lowest four-fifths of the bowelwere certainly not inflamed, and the patient at no timepassed blood-stained fluid in the motions, or with theenemata; then, again, the work of Mr. Treves showedthat acute peritonitis was very frequent-four out of eightcases-in the recorded instances. The intestine was notcollapsed below the volvulus, but was slightly distended,which might be attributed to the peritonitis. The mode

of onset and the remarkable way in which the symptomsdisappeared after operation also favoured the diagnosis ofvolvulus.The following living specimens were exhibited :-Mr. R. J.

Godlee: A case Illustrating the Effects of Injury of theCervical Sympathetic; a large (? neuro-fibromatous) tumourwas removed from the right side of the neck of a girl agedeight, the pupil on that side was small, dilated but slightlywhen shaded, not at all with cocaine, contracted to lightand in accommodation, dilated with atropine. Mr. R. W.Parker: Congenital Tumour of the Neck in an infant twomonths old, which almost disappeared during inspiration,being most prominent during the act of crying. Mr. G. H.Makins: Congenital Syphilis in a boy aged seventeen, withthickening and elongation of radii and tibia?. Mr. C.Ballance: Compound Depressed Fracture of the Skull in theRight Temporal Region; removal of large pieces of bone,recovery.

EPIDEMIOLOGICAL SOCIETY.

Diphtheria.A MEETING of this Society was held on Wednesday, Feb. 10th,

Dr. Walter Dickson, R.N., President.In a paper read by Dr. D. ASTLEY GRESSWELL on Diphtheria

as a Chronic Malady in particular Individuals, with liability inthem to Recrudescence, he put forward the following ques-tions : " Is the chronic tonsillar inflammation which is left inparticular persons after an attack of diphtheria due to con-tinued sojourn in them of the material cause of diphtheria,and do the violent reactions of the tonsils of these personsto weather changes involve likelihood of rendering themdiphtheritically infectious?" He had of late, while prosecut-ing inquiries into diphtheria in various parts of the countryon behalf of the Local Government Board, come across aconsiderable number of persons who had been suffering fromthis condition, and he thought of them as having been thecentres for dissemination of the virus of diphtheria in asmany as six outbreaks of diphtheria. Dr. Gresswell detailedthese outbreaks. In one of the outbreaks a boy who con-tracted diphtheria by personal infection in July, 1883, andwho ever since had been subject to sore-throat, seemed tohave been such a centre. In another instance a girl had beensuch a centre. The orphan inmates of an asylum werementioned as having probably maintained diphtheria intheir own persons for several years. In a family in whichdiphtheria had been repeatedly manifesting itself for someyears past, one member seemed to have been an almostconstant source of infection. He showed from theseexamples how the prevalence of diphtheria might be supposedto be sustained in a community. Analogies were drawnbetween the manifestations of chronic and recrudescentdiphtheria and the manifestations of certain other diseases-syphilis, glanders, typhoid fever, &c. Special stresswas laid upon the analogy which diphtheria in acute andchronic phases presented to gleet and gonorrhoea. Dr.Gresswell thought of rejuvenescence, as known amongst thecryptogamia, as being a phenomenon of like nature withthat of the revival of the activity of diphtheritic and othervirus in a person once infected by the virus. Finally,he dwelt upon the unwholesomeness of the dwellings inwhich these persons have generally lived; and he con-cluded with an exhortation that our dwellings might bemade wholesome, and that the special attention of thetherapeutist might be given to those persons who suffer fromchronic tonsillar trouble sequent upon an attack of diph-theria.-In the discussion which followed, the President,Sir W. Smart, Dr. Thorne Thorne, Dr. Lawson, Dr. McKellar,Dr. Moir, and Mr. C. E. Paget took part.

SANITARY PROTECTION ASSOCIATION. -The fifthannual general meeting of the members of this Associationwas held on the 27th ult., when the council congratulatedthe Society upon the continued increase in the number ofmembers. During the past twelve months there have been424 first year’s inspections at the residences of new members,456 annual inspections, 282 inspections of works, 72 specialinspections, and 30 inspections at Eton. The latter inspec-tions were at the College and masters’ houses. The state-ment of accounts presented showed the total receipts as.E2423, and the total expenditure 1948, leaving a balancein hand of 474.