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will be attacked so suddenly with the clinical symptoms ofabdominal pain, combined with bloody discharges from thebowels " (Rotch), there ought to be little difficulty in
arriving at a correct diagnosis. In my experience, failuresin diagnosis have been mainly due to not giving sufficientweight to the sign of blood-stained mucus, "currant jelly,"from the rectum. Bloody stools occurred in 97 per cent.,in from two to ten hours, in the 144 cases reported by Clubbe.This physical sign arises from the congestion and swellingof the entering and returning layers of the intussusceptionwhich is well demonstrated in the illustration, stronglycontrasting with the thinness of the intussuscipiens.Of course, this thickening of the two inner layers isthe cause of the difficulty of reduction. In this casecomplete reduction by means of rectal injections wouldhave been impossiule. Sir Frederick Treves states: " Ibelieve that limit (12 hours after the onset) will be
proved by experience to err on the side of liberality."Fearing the difficulty of simple end-to-end stitching of theextremely thin and fragile gut of an infant only threemonths old, and that the strain afterwards upon the stitchedpart might be too great, we judged it wiser to use a MayoRobson bobbin. Most surgeons agree with Moynihan that theperiod of artificial aids in enterectomy is past when dealingwith the gut in an adult, but I think that they would makean exception when operating upon an infant aged threemonths. The great factor in the success of this case wasthe comparatively short interval between the onset of theaffection and the operation. Holt writes 3 : "All statisticsshow that the result depends more upon the time when theoperation is done than upon any other single factor."
-Reniar7es added later.-C. H. Fagge in "Intussusceptionin Infants" described the treatment of 19 cases where to
Intussusception split open. Ileum at the lower end of
specimen and ascending colon in the upper part. Appendixto the left of the entering ileum. The thin sheath or intus-
suscipiens is well shown and the greativ thickened enteringand returning layers. The entering ileum is cut completelyacross. The ileo-csecat vah-e is about an eighth of an inchbelow the level of the number 7. The mesentery is behindthe section and not therefore shown in the illustration.
bring about reduction he used great force with very goodresults, apparently not fearing the splitting of the coats.After reading this paper the doubt occurred to me whether Ihad applied sufficient force before deciding upon enterec-
tomy. More recently another intussusception came under mycare in a boy, aged ten months, in whom it had been presentfor 13 hours. Acting upon Fagge’s advice more force wasapplied and reduction was easily produced. In this latter caseafter reduction great thickening of the ileum at its junctionwith the caecum made me suspect a polypus, but morecareful palpation revealed its true character. This operationonly occupied 15 minutes and the boy made a quickrecovery.
2 Abdominal Operations.3 Diseases of Infancy.
4 Practitioner, December, 1906.
If The interesting and highly successful series of 144 casese operated upon by Clubbe will encourage the use of rectaln injections. He found them curative in early cases and usefuls in all cases where cceliotomy is performed to reduce thet length of the intussusception before the manipulation is" applied in the abdomen. His series certainly marks an, enormous advance upon the surgery of 12 years ago when. Roughton could only find records of 16 successful laparo-
tomies for intussusception in infants, and of 18 years agoi when A. E. Barker published his first paper on the subject,r in which he urged that laparotomy could not be performed. too early in any case after irrigation had failed.! Preston.
Medical Societies.ROYAL SOCIETY OF MEDICINE.
I CLINICAL SEOTION.’ Exhibition of Cccses.-Presiderticcl Address.
THE first meeting of the Clinical Section of the RoyalSociety of Medicine was held on Oct. llth, Sir THOMASBARLOW, the President, being in the chair.Mr. T. H. OPENSHAW showed a case of a boy with Con-
genital Absence of the Fibula. The patient was sent to him fiveyears ago. Amputation had been advised. At that time thetibia was extremely curved outwards, making an angle of110°. He resected cuneiformly and straightened the leg.A year later the patient was fitted with a Hessing’s splintappliance which accurately fitted and enabled the patient towalk well. There was about four inches of shortening.Mr. OPENSHAW also showed an infant whose right tibia
was fractured in the centre ; the lower end of the upper halfprojected forwards as a conical stump under a well-markeddimple of skin. The lower half ended also in a somewhatsharp extremity. The internal malleolus was absent. Thefibula was enlarged and curved ; there was a dimple over theupper end. The external malleolus was much enlarged. Inthe left leg the upper fifth only of the tibia was present.There was a deep depression over the centre of the upperpart of the leg, corresponding with the edge of thefibula. The lower four-fifths of the tibia was absent. Thefibula was much enlarged and curved. The externalmalleolus was very prominent. There were only four toeson the foot.
Mr. DOUGLAS DREW showed a case of TuberculousSynovitis of the Knee-joint on which arthrectomy was per-formed on two occasions, a moveable joint resulting. The
patient was a girl, aged seven years. She came under obser-vation in February, 1903, with chronic synovitis ; previouslyshe had been under treatment at another hospital for somemonths. The joint was much distended by fluid but therewas no limitation of movement. The case was treatedon a splint and Scott’s dressing was applied at intervalsuntil September, 1904, but no permanent improvementresulted. On Sept. 24th, 1904, the knee-joint was openedby means of Kocher’s external incision. Owing to thelooseness of the ligaments from the distension it was
found to be possible to dislocate completely the patellainwards over the internal condyle without dividing theligamentum patellae or chiselling away the tubercle of thetibia with the ligament attached. The synovial membranewhich was studded over with miliary tubercle was dissectedaway, the inner part being rendered more accessible by dis-locating the patella. This was completely removed, except forthat part lying behind the crucial ligaments. Passive move-ments of the joint were commenced on the twelfth day afterthe operation. The case was shown before the Clinical Societyearly in 1905 and at that time appeared to te a completecure. However, a few weeks later fluid reappeared in thejoint and in spite of treatment on a splint it showed no signsof improvement. On May 16th, 1905, the joint was re-openedthrough the old incision and a small quantity of fluid escaped.The cavity was lined by a smooth, shining surface which wasstudded with minute tubercles. The synovial membrane,or what represented this structure (as the true synovialmembrane had been removed at the first operation), wascarefully dissected away. This was much more tedious to
perform than at the first operation as the structure was so
5 Diagnosis and Treatment of Intussusception, 1907.
fibrous. It was found impossible to dislocate the patella andto get at the synovial membrane of the inner part of the jointthrough the external incision. A vertical incision was madeinternal to the patella and this portion of the membrane wasremoved. The movements of the joint were demonstrated tothe meeting.
Mr. DREW also showed a case of Dislocation of thePatella (? Congenital) Cured by Operation.
Dr. A. E. GARROD showed a case of Multiple Nodules(1 rheumatic) in an adult female. These nodules were
especially marked over the knuckles. The case was not
shown as a unique specimen but as an instance of the con-dition in which the rheumatic connexion was peculiarlyclear.-Sir DYCE DUCKWORTH observed that the noduleswould disappear under treatment and considerable improve-ment might be looked for. In adults the nodules lasted for a
long time.-The PRESIDENT pointed out that in adults theassociation with organic heart disease was not so frequent asin children.Mr. F. J. STEWARD showed a case of Pyo-pericardium
successfully treated by drainage. The patient, a girl, agedfour years and four months, was admitted into the Hospitalfor Sick Children under Dr. Garrod on April 8th, 1907,with pneumonia. On April 15th an empyema was foundat the left base. After resection of the eighth rib drainagewas employed. There was a pure cultivation of pneu-mococcus grown from the pus. On May 2nd the childwas not doing well, the temperature and pulse rising(temperature 103° F. and pulse 148). On May 6th a bulg-ing mass was detected through the resection wound. Thetemperature and pulse-rate were still raised and the
patient was losing ground. A skiagram taken by Dr.I. Bruce showed the mass to be a distended pericardium.On May 9th Mr. Steward opened the pericardium fromthe back through the resection wound and about twoounces of thick pus were evacuated. A flanged rubberdrainage tube was inserted. Steady improvement tookplace and the pericardium was gently irrigated daily withnormal saline solution. By June 14th the wound wassoundly healed.-The case was discussed by Dr. S. WESTand Mr. R. J. GODLEE who recalled a similar case treated
by Sir William Savory.Mr. J. HUTCHINSON, jun., showed a case of Fusiform
Aneurysm of the Right Common Carotid Artery in a femalepatient, aged 50 years. On the right side of the neck therewas a fusiform tumour of the size of a hen’s egg extendingfrom the middle line below to the external border of thesternal fibres of the sterno-mastoid muscle, the long axis lyingobliquely from the supra-sternal notch to near the hyoidbone. Expansile pulsation, which was visible, occurred justafter ventricular systole. The second heart sound was heardover the tumour but there was no thrill or murmur. The
pulses were equal and the arteries were not thickened. The
pulse in both subclavian arteries was normal. The pupilswere equal and reacted to light and accommodation ; therewas no evidence of pressure on the sympathetic. Mr.Hutchinson explained that though the patient had had sore-throat and a rash with loss of hair there was no clearevidence as to syphilis on making a complete examination.As the condition was causing the patient pain and incon-venience Mr. Hutchinson proposed to treat the case byligaturing.
Dr. F. E. BATTEN showed a case of Cerebellar Atrophy.The patient was a male, aged 62 years. He was quite wellup to six years ago and then he had business worry. Aboutthat time he noticed unsteadiness in walking. Four and ahalf years ago he lost his balance when getting out of bedand fell down ; there was no giddiness or loss of conscious-ness and he was able to raise himself up and to get into bed.Since March, 1903, he had been unable to walk alone.He had intermittent buzzing in the left ear whichcould always be stopped by lying on the left side.He had had no headache or vomiting. The patient hadsyphilis in 1873. He was very thin and wasted buthad remarkably good muscular power and was mentallyquite clear. The gait was markedly ataxic but he couldstand well and there was no Rombergism. There was slightincoördination of the hands. The pupils were unequal,the right being smaller than the left ; they reacted well tolight and convergence. There was defective ocular move-ment both to right and left and it was attended bv finenystagmus to the right and slow nystagmus to the left. Theoptic discs were normal. The knee-jerks were active, therewas no ankle clonug, and the plantar response was flexor.
All forms of sensation were perfect. Dr. Batten, in con-cluding his demonstration of this case of atrophy of thecerebellum, pointed out that it was unusual in a man aged62 years.
Dr. H. A. LEDIARD showed a case of Multiple SarcomaCutis. The patient was a male, aged 65 years, who had onhis scalp, face, neck, shoulders, chest, and upper part of theabdomen numerous skin tumours, more or less marked, indifferent places. On the scalp the skin growths had coalescedand presented a dark-blue mass; on the temples and facethe disease showed elevated rose-red areas ; in the neck therewere also the same isolated tumours. On the shoulders andchest the growths were more easily felt but theirsituation was marked by staining of the skin a
dark-brown colour. In the neck and in the left axillathe lymphatic glands were markedly affected. At firstthere was severe pain in the head causing sleeplessness butat the present time there was none and the patient was ableto go about and to do his work of school-teaching withoutdifficulty. The disease was believed to represent thecharacters of sarcoma cutis, but no microscopic examina-tion of any growth had been undertaken as yet. The dura-tion of the disease was about three months and was
attributed by the patient to working under a hot July sunin a garden without a hat for three weeks.-Sir DYCEDUCKWORTH recommended large doses of sarsaparilla andDr. J. H. STOWERS advised in addition treatment on thelines of specific disease and the application of the lighttreatment.Mr. C. W. ROWNTREE showed a case of (?) Myxo-sarcoma.The meeting concluded with an address from the PRESI-
DENT who gave a historical survey of the services renderedto medicine by the Clinical Society of London, of which theClinical Section of the Royal Society of Medicine was thelineal representative. He detailed the work of the society,which was founded close upon 40 years since, and observedthat with respect to Gull’s paper on Anorexia Nervosa itmight be claimed that that title given by Gall was more trueand descriptive than any of those subsequently employed.The President declared that he had not the slightest wish tobelittle the value of Weir-Mitchell’s subsequent papers on itstreatment with the three formulas of over-feeding, massage,and isolation, but he considered that in this country compulsoryand specialised isolation had often been made a fetich andthat the elaborate and costly ritual of rest cure in nursinghomes had sometimes given justifiable cause for the enemyto blaspheme against British medicine. In the course of hisfurther remarks the President specially referred to the groupof cases of localised obliterative arteritis recorded by Gould,Hadden, Morgan, and Spencer. It was almost certain, heconsidered, that other types of recoverable arterial sclerosisand combined arteritis and phlebitis would be found if lookedfor, and that chronic forms of erythromelalgia yieldedevidence of localised lesions more marked on the arterialthan on the nerve side. At the conclusion of this addressthe meeting terminated with a vote of thanks to the Presi-dent; which was moved by Sir DYCE DUCKWORTH andseconded by Mr. C. A. BALLANCE.
MEDICAL SOCIETY OF LONDON.
Presidential A-ddress.-Some Unusual Cases of Diabetes.A MEETING of this society was held on Oct. 14th, Dr. J. K.
FOWLER, the President, being in the chair. The Presi-dential Address was delivered and we hope to publish it in afuture issue. ’"88
Dr. J. RosE BRADFORD read a paper on three Unusual Casesof Diabetes. He said that the term diabetes probably includeda number of conditions dependent, not only on variouscauses, but also associated in all probability with differentlesions. The view was generally held that only a proportionof cases of diabetes could be associated with lesions of thepancreas. Still, it seemed as if the number of cases of themalady that could be attributed to a pancreatic origin wasincreasing. There was still much difference of opinion asregards the nature of the pancreatic lesions associatedwith diabetes, although most observers had recordedatrophy and a peculiar variety of diffuse cirrhosis as
the most common. Diabetes had been found in associa-tion with other pancreatic lesions, as, for instance,calculi, cystic disease, and new growths ; but all these pan-creatic lesions had frequently been described as occurring