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CLINICAL SOCIETY OF LONDON.
932
might be relegated to a secondary position of gout. It was to be regretted that this
legs. By the end of March there complete paraplegia without muscular wasting. The pure breathing was almost entirely diaphragmatic, the right
in the causation line of research
had not been extended and it was unfortunate that adenin was almost impossible to obtain. Apart from xanthin the amount of alloxur bases appearing in the urine was so exceedingly small that their separate estimation was a matter of great difficulty. Dr. Bain suggested the possibility that the retention of adenin within the system might determine the deposition of biurate in the tissues. Dr. A. E. SANSOM confessed that he was still in a maze of doubt as to the pathology of gout, though experiments seemed to be elucidating some of the problems. There was no doubt that the deposit of urates was the cause of a gouty attack ; but why should it, he asked, be afterwards got rid of in some cases but not in others ?7 The absence of pain, It seemed to him too, in some cases was inexplicable. doubtful whether those violent and destructive paroxysms of acute gout sometimes observed could be explained wholly and solely by sodium biurate. Surely there must be something that was associated with it which prevented metabolism. The subject of treatment also was beset with difficulty. If sodium salts promoted and potash salts delayed deposition why was it that they got such good results from the two together ? Piperazin in his experience did seem to do good in some cases. Laboratory experiments were very useful, but they were still a long way off the truth. The PRESIDENT congratulated Dr. Luff on his welcome and interesting researuhes. He had never thought very much of piperazin or lysidin in the treatment of gom and he had mostly come back to the potash salts or a combination of potash and soda. Dr. Bain’s case was an interesting one and he remembered to have met with a case resembling this in the extreme gouty development without anything to account for it, for the patient was both a teetotaler and a vegetarian. Dr. A. P. LUFF, in reply, thought that the disappearance of the deposit in some cases and not in others depended upon the alkalinity of the blood. If this was high then the blood could not remove the deposits. The presence or absence of pain in different cases depended, he believed, upon the rapidity of deposition. It was the suddenness of the deposition which caused the pain. Referring to the necrosis of certain tissues he doubted whether such a process occurred in cases of true gout. He had never seen necrosis of cartilages in true gout, and he thought it possible that the alleged cases were rheumatoid arthritis on which acute goat had supervened. Dr. Bain’s case bad been very carefully investigated. He would like to know what were the relative lengths of time for the administration of the different substances. He thought that in so many experiments in one patient the gouty state must have been in different phases at different times. The fact that gua1acllm eliminated uric acid was quite, in keeping with his experience and that of Sir Alfred Garrod.’ Given in the form of resin it was certainly a prophylactic. Dr. BAIN, in reply, mentioned the doses and duration of the administration of the different drugs. There was an interval of three days between each, but the patient began by being put on a fixed diet for nine days. He thought the question of pain would depend upon the structures that were involved. As to the necrotic changes he quite agreed with Dr. Luff. Dr. Chalmers Watson had found in chronic gout a myelocyte which was not to be found in normal blood, but Dr. Bain had not found tbis in one case which he had examined. He quite agreed with Dr. Sansom that there must be something besides the biurate to produce gout and he had suggested that it might be adenin. The marked effect which this had had upon the blood-pressure and the occurrence of uric acid in the kidneys of Minkowski’s dogs were arguments in favour of this view.
of loss of power in the was
hand was much stronger than the left, and all forms of sensation were lost up to the level of the nipples ; there was no hypera39thetic zone ; there was severe pain shooting down both intercosto-humeral nerves and round the chest along the second intercostal nerves, the lower limbs were rigid, the knee-jerks and plantar reflexes were exaggerated, and there was great superficial tenderness over the second, third, and fourth dorsal spine. There was incontinence of urine with cystitis and obstinate constipation and great distension of the abdomen. The pulse was 120 and the temperature generally was about 101° F. There were no signs pointing to caries and aneurysm. The diagnosis was that there was some collection of fluid or a new growth within the spinal canal irritating the second dorsal nerve and compressing the cord below it. There was no evidence that this was syphilitic or that it was malignant. An exploratory laminectomy was performed, the second, third, and fourth dorsal arches being removed. A grey tumour situated upon the outer surface of the dura mater was exposed, which reached out of sight both above and below. Pieces of the growth were snipped away. The patient quickly rallied from the operation and the wound healed by first intention. The tumour proved on microscopical The patient was examination to be a dermoid cyst. seen again by Dr. Hale White and Mr. Fripp eight weeks later. The pulse and the temperature were normal. There was slight and occasional voluntary movement in the legs. The exaggeration of the knee-jerks was less and the rigidity had disappeared. There was almost complete return of all forms of sensation down to the groins, but no improvement in the lower extremities. The chest moved The radiating pains had disappeared. better. The cystitis and incontinence had disappeared and the constipation and abdominal distension were less. There was a large bedsore on the sacrum and another on the buttock. Considerable as had been the improvement it appeared to Dr. Hale White and Mr. Fripp that as much of the tumour had been leftbehind, and as the pressure symptoms were far from completely relieved, the only chance of benefiting the patient lay in a further attempt at complete removal. A second operation was performed. A large mass of the tumour was found to have grown backwards through the gap in the spinal canal made at the first operation. The first, fifth, and sixth dorsal laminae were removed, but still no limit could be seen to the growth. The patient rallied well but sank again eight hours after the operation.-The PRESIDENT remarked that the case was of interest as bearing on the question how far interference was justifiable in cases of this kind.-In reply to the President, Dr. HALE WHITE said that the case was unique as regarded the nature, though not as regarded the position, of the tumour. Cases of dermoid cysts had been recorded in the middle line between the skin and the spines, but not within the spinal canal. Mr. ROBERT JONES (Liverpool) and Mr. A. H. TUBBY communicated a paper on the Reduction of the Deformity of Spinal Caries, based on 99 cases of angular deformity from Pott’s disease treated by Manual Rectification, including the results of the 25 cases which had been brought before the Clinical Society of London in November, 1897. In this first series of 25 cases the following results had been obtained: five patients had died, four had discontinued treatment, 15 were alive, well, and able to walk, and one was still recumbent and sickly. As to the causes of death, one died four days after the operation, but post mortem no abnormality was found beyond some enlarged mesenteric glands; one died from tabes mesenterica 15 months after the operation ; one died from pulmonary tuberculosis 16 months CLINICAL SOCIETY OF LONDON. afrer the last stretching, one from intestinal obstruction twelve months after, and one from diphtheria. Billroth, A Case of Dermoid Cyst within the Spinal Canal.-Reduction Menzel, Ja,S6, and Mohr estimated the death-rate from Pott’s of the Deformity of Spinal Caries by -Jfan?tal ect4 fication. disease to be 25 per cent., the death-rate of the series A MEETING of this society was held on March 23rd, Sir observed by Mr. Jones and Mr. Tubby being only 12 per cent. Four of the cases developed abscesses, of which R. DOUGLAS PowELL, Bart., President, being in the chair. Dr. W. HALE WHITE and Mr. A. D. FRIPP communicated two healed and one patient became paraplegic eight months after the operation, but had since recovered. Five of a paper on a case of Dermoid Tamoar growing within the Spinal Canal in which an attempt was made to remove the the 25 patients recovered from paraplegia as the immediate growth. The patient was a man, aged 26 years, who had been result of the operation, recurrence taking place in one case. suffering from a very chronic form of Hodgkin’s disease. In five cases the curvature was practically obliterated and He was first seen by Dr. Hale White and Mr. Fripp with remained so with a spinal support, and the curve was much Mr. A. F. Wilson at the end of March, 1899. In the improved in ten of the cases. In a parallel series of nonmiddle of January, 1899, the patient began to comp’ain recdaed cases three patients had died from tubercle, four
933 had developed abscesses (twa of them healing), four had extension was far too high. Even that of 12 per cent. become paraplegic with two recoveries, and in seven the observed by Mr. Jones and Mr. Tubby in the cases which deformity was very marked. Mr. Jones and Mr. Tubby then they had operated on was distinctly high, being above that brought forward a series of 74 cases subsequently operated observed by Mr. Clarke in cases treated in London. It was to Of these seven patients had died, 29 were walking, be noted that in more than one of the cases in the paper no on. 28 were recumbent, and 10 had discontinued treatment. real diminution of deformity had been obtained, and as As to the causes of death, one patient died from empyema regarded the future of the patients there was no proof that four weeks after operation ; one died from general tuber- as soon as the apparatus was left off deformity would not culosis thirteen days after operation, and another two years return as the patient grew up owing to damage to the epiafter ; one died from pulmonary phthisis eighteen months physeal discs. The many contra-indications pointed out later and one from pneumonia two years after; one died which would have to be observed in deciding to perform from exhaustion ; and one died six months after reduction forcible rectification approximated closely to Mr. Clarke’s own for paraplegia, without relief, from diarrhoea. Three views, which were to the effect that this operation was only patients were operated upon while abscess was present and called for in exceptional cases. The chief indication was a 13 developed abscesses subsequently, of which nine had paraplegia that had resisted a patient trial of gentler means.healed. Seven patients had recovered from paraplegia, Mr. RICHARD BARWELL questioned whether the good done or the condition had been relieved and had remained was as great as they were asked to believe, and he doubted In 16 the curvature had either not improved or had whether there had been actual straightening in many of the so. become worse, but not necessarily as the result of the opera- cases of the angular curve. On the whole he did not think tion. Mr. Jones and Mr. Tubby deprecated the employ- that the results were better than would be obtained in three ment of much force, their plan having been to proceed by years by other methods of treatment. He observed that in stages with an interval of a month between each attempt. the case of a child, who was said to have had paraplegia, the They laid it down that the after-treatment should not be less child was under two years of age at the time and possibly than three years. Their conclusions were as follows : (1) was unable to walk; moreover the mother said that the child that danger to life was inot great; (2) that-far from in- had been able to move his legs. He pointed out that by ducing paraplegia the operation was actually a curative lifting the patient by the arms and watching the angle it was measure; (3) that abscess formation was, if anything, less easy to see whether the ulcer of the bones had healed. On frequent ; (4) that the risk of disseminating tubercle was a the whole he thought the results were somewhat disappointnegligible quantity ; and (5) that there was no risk ing.-Mr. BERNARD ROTH said that since seeing these cases of a flail-like spine. The contra-indications were: (1) he thought there was more in the treatment than he had cervical and high dorsal curves, unless associated with imagined, but he would like to see the cases a year after all paralysis; (2) ankylosed spines; (3) large and angular instruments had been left off.-Dr. E. PERCY PATON asked deformities; (4) evidences of tubercle elsewhere ; (5) in how long the patients had remained in hospital under treatchildren under two years of age and in adults over 22 years; ment and he pointed out that prolonged recumbency in the and (6) the presence of abscess unless there were paraplegia. homes of the poor could not be desirable.-Mr. HOWARD They advised the operation only when the spine was yielding MARSH commended the authors of the paper for the vast and in comparatively strong children free from abscess and amount of patience and labour which they had devoted to the tubercle. They pointed out that the operation was not to subject. They must, however, all feel that the subject had obliterate all the prominence, but to give as erect a position not been thoroughly threshed out though many interesting as possible. Lastly, they urged that cases for operation points had been raised, and he thought the question was one must be selected with great care, that personal attention to that might advantageously be referred to a committee for the patients must be unremitting, and that fresh air investigation and report. He was tempted to raise the was an all-important factor in the after-treatment. They questioii whether the conclusions arrived at by Mr. exhibited a selection of the first series of 25 cases Jones and Mr. Tubby were justified by the facts which showing the actual results.-The PRESIDENT observed they had brought forward. He challenged the estimate that whatever they might think of the ultimate results of 25 per cent. as the probable death-rate from Pott’s of the treatment the facts brought before them disease. He himself would put it at 5 or 6 per cent. He must materially alter many of their present views. H pointed out that paraplegia was equally recovered from asked whether albuminuria due to myeloid disease had dis. under other methods of treatment, and he concurred in the appeared when the surgical deformity was remedied.-Mr. J view that the correction of the deformity was often more JACKSON CLARKE said that.be had followed the revival oj apparent than real.-Mr. BERNARD ROTH seconded the forcible correction of deformity in spinal disease with greal reference to a committee, and some discussion ensued interest. He believed that he was the first surgeon t< I as to the scope of the reference and the way in perform the operation in London. In order to understand which the inquiry could be carried out. Ultimately the results obtained in the cases before the society i j the proposal to nominate a committee was agreed was necessary to consider the methods previously employed to, the precise terms of the reference to be submitted Mr. Tubby had put it on record that up to 1896 he ha< l to the council.-Mr. TUBBY, in reply, said that he thought it chiefly used corsets of plaster or of felt. Mr. Clarke ha( l would be conceded that they had done their best to fulfil found the results of such appliances to be very disappointing their pledge of two years ago to follow up those cases. He Mr. Jones had chiefly employed Thomas’s cuirass which wa ; pointed out that they did not insist so much upon the value also used in the after-treatment of many of the cases befor s of the operation in remedying the curve. With reference to the meeting. This cuirass, which exerted a leverage actioi i albuminuria he said that it disappeared when the abscess on the spine, had certain defects, though it was, in Mi ceased discbarging and no patient had died from lardaceous Clarke’s opinion, better than any other corset. It did no t disease. He did not believe that equally good results could be lend itself to periodical re-adjustment and thus was n ) obtained with instruments. In reply to Mr. BARWELL he said help to gradual correction of deformity ; it did nc t that the child stated to have had paraplegia had the lower provide for alterations required by the growth of th e limbs rigid with exaggerated reflexes and could not walk. He patient, and again it did not readily lend itself to th e added that the labour, difficulty, and anxiety entailed by the addition of a head-piece needed in high dorsal an 1 endeavour to afford the society such a demonstration of cervical cases. By the use of an antero-superior suppoi t results as that before them were very great, and he did not which did not possess these disadvantages Mr. Clarke ha 1 think that they could in any way manage to approve of a obtained results which he believed compared very favourabl 9 committee being sent about the country to inspect their with those seen in the cases now shown by the authors c cases, but the committee would, of course, be welcome to the paper. Thus in some cases of lumbar disease to e egamine the records. deformity had been obliterated ; in other cases it had bee n considerably diminished. These results had been obtaine CHELSEA CLINICAL SOCIETY. sometimes after a period of rest in bed or on the couch, bi more often with ambulance treatment throughout. TtI educational aspects of spinal cases had to be considered an The Treatment of Rheumatism. a method of treatment that allowed a patient to be taught! THE adjourned meeting of this society from March 13 h home or to go to school was, other things being equa was held in the Parish Hall, Pavilion-road, Chelsea, on to be preferred to one that demanded two or three yea March 20th, Mr. FOSTER PALMER being in the chair. of fixation upon an apparatus in the dorsal recumbe: The CHAIRMAN said that at the last meeting the Treatposition. The death-rate of 25 per cent. quoted fro ment of Rheumatism which they principally heard about, and Billroth as being observed in cases tiered without forcib .
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might be relegated to a secondary position of gout. It was to be regretted that this
legs. By the end of March there complete paraplegia without muscular wasting. The pure breathing was almost entirely diaphragmatic, the right
in the causation line of research
had not been extended and it was unfortunate that adenin was almost impossible to obtain. Apart from xanthin the amount of alloxur bases appearing in the urine was so exceedingly small that their separate estimation was a matter of great difficulty. Dr. Bain suggested the possibility that the retention of adenin within the system might determine the deposition of biurate in the tissues. Dr. A. E. SANSOM confessed that he was still in a maze of doubt as to the pathology of gout, though experiments seemed to be elucidating some of the problems. There was no doubt that the deposit of urates was the cause of a gouty attack ; but why should it, he asked, be afterwards got rid of in some cases but not in others ?7 The absence of pain, It seemed to him too, in some cases was inexplicable. doubtful whether those violent and destructive paroxysms of acute gout sometimes observed could be explained wholly and solely by sodium biurate. Surely there must be something that was associated with it which prevented metabolism. The subject of treatment also was beset with difficulty. If sodium salts promoted and potash salts delayed deposition why was it that they got such good results from the two together ? Piperazin in his experience did seem to do good in some cases. Laboratory experiments were very useful, but they were still a long way off the truth. The PRESIDENT congratulated Dr. Luff on his welcome and interesting researuhes. He had never thought very much of piperazin or lysidin in the treatment of gom and he had mostly come back to the potash salts or a combination of potash and soda. Dr. Bain’s case was an interesting one and he remembered to have met with a case resembling this in the extreme gouty development without anything to account for it, for the patient was both a teetotaler and a vegetarian. Dr. A. P. LUFF, in reply, thought that the disappearance of the deposit in some cases and not in others depended upon the alkalinity of the blood. If this was high then the blood could not remove the deposits. The presence or absence of pain in different cases depended, he believed, upon the rapidity of deposition. It was the suddenness of the deposition which caused the pain. Referring to the necrosis of certain tissues he doubted whether such a process occurred in cases of true gout. He had never seen necrosis of cartilages in true gout, and he thought it possible that the alleged cases were rheumatoid arthritis on which acute goat had supervened. Dr. Bain’s case bad been very carefully investigated. He would like to know what were the relative lengths of time for the administration of the different substances. He thought that in so many experiments in one patient the gouty state must have been in different phases at different times. The fact that gua1acllm eliminated uric acid was quite, in keeping with his experience and that of Sir Alfred Garrod.’ Given in the form of resin it was certainly a prophylactic. Dr. BAIN, in reply, mentioned the doses and duration of the administration of the different drugs. There was an interval of three days between each, but the patient began by being put on a fixed diet for nine days. He thought the question of pain would depend upon the structures that were involved. As to the necrotic changes he quite agreed with Dr. Luff. Dr. Chalmers Watson had found in chronic gout a myelocyte which was not to be found in normal blood, but Dr. Bain had not found tbis in one case which he had examined. He quite agreed with Dr. Sansom that there must be something besides the biurate to produce gout and he had suggested that it might be adenin. The marked effect which this had had upon the blood-pressure and the occurrence of uric acid in the kidneys of Minkowski’s dogs were arguments in favour of this view.
of loss of power in the was
hand was much stronger than the left, and all forms of sensation were lost up to the level of the nipples ; there was no hypera39thetic zone ; there was severe pain shooting down both intercosto-humeral nerves and round the chest along the second intercostal nerves, the lower limbs were rigid, the knee-jerks and plantar reflexes were exaggerated, and there was great superficial tenderness over the second, third, and fourth dorsal spine. There was incontinence of urine with cystitis and obstinate constipation and great distension of the abdomen. The pulse was 120 and the temperature generally was about 101° F. There were no signs pointing to caries and aneurysm. The diagnosis was that there was some collection of fluid or a new growth within the spinal canal irritating the second dorsal nerve and compressing the cord below it. There was no evidence that this was syphilitic or that it was malignant. An exploratory laminectomy was performed, the second, third, and fourth dorsal arches being removed. A grey tumour situated upon the outer surface of the dura mater was exposed, which reached out of sight both above and below. Pieces of the growth were snipped away. The patient quickly rallied from the operation and the wound healed by first intention. The tumour proved on microscopical The patient was examination to be a dermoid cyst. seen again by Dr. Hale White and Mr. Fripp eight weeks later. The pulse and the temperature were normal. There was slight and occasional voluntary movement in the legs. The exaggeration of the knee-jerks was less and the rigidity had disappeared. There was almost complete return of all forms of sensation down to the groins, but no improvement in the lower extremities. The chest moved The radiating pains had disappeared. better. The cystitis and incontinence had disappeared and the constipation and abdominal distension were less. There was a large bedsore on the sacrum and another on the buttock. Considerable as had been the improvement it appeared to Dr. Hale White and Mr. Fripp that as much of the tumour had been leftbehind, and as the pressure symptoms were far from completely relieved, the only chance of benefiting the patient lay in a further attempt at complete removal. A second operation was performed. A large mass of the tumour was found to have grown backwards through the gap in the spinal canal made at the first operation. The first, fifth, and sixth dorsal laminae were removed, but still no limit could be seen to the growth. The patient rallied well but sank again eight hours after the operation.-The PRESIDENT remarked that the case was of interest as bearing on the question how far interference was justifiable in cases of this kind.-In reply to the President, Dr. HALE WHITE said that the case was unique as regarded the nature, though not as regarded the position, of the tumour. Cases of dermoid cysts had been recorded in the middle line between the skin and the spines, but not within the spinal canal. Mr. ROBERT JONES (Liverpool) and Mr. A. H. TUBBY communicated a paper on the Reduction of the Deformity of Spinal Caries, based on 99 cases of angular deformity from Pott’s disease treated by Manual Rectification, including the results of the 25 cases which had been brought before the Clinical Society of London in November, 1897. In this first series of 25 cases the following results had been obtained: five patients had died, four had discontinued treatment, 15 were alive, well, and able to walk, and one was still recumbent and sickly. As to the causes of death, one died four days after the operation, but post mortem no abnormality was found beyond some enlarged mesenteric glands; one died from tabes mesenterica 15 months after the operation ; one died from pulmonary tuberculosis 16 months CLINICAL SOCIETY OF LONDON. afrer the last stretching, one from intestinal obstruction twelve months after, and one from diphtheria. Billroth, A Case of Dermoid Cyst within the Spinal Canal.-Reduction Menzel, Ja,S6, and Mohr estimated the death-rate from Pott’s of the Deformity of Spinal Caries by -Jfan?tal ect4 fication. disease to be 25 per cent., the death-rate of the series A MEETING of this society was held on March 23rd, Sir observed by Mr. Jones and Mr. Tubby being only 12 per cent. Four of the cases developed abscesses, of which R. DOUGLAS PowELL, Bart., President, being in the chair. Dr. W. HALE WHITE and Mr. A. D. FRIPP communicated two healed and one patient became paraplegic eight months after the operation, but had since recovered. Five of a paper on a case of Dermoid Tamoar growing within the Spinal Canal in which an attempt was made to remove the the 25 patients recovered from paraplegia as the immediate growth. The patient was a man, aged 26 years, who had been result of the operation, recurrence taking place in one case. suffering from a very chronic form of Hodgkin’s disease. In five cases the curvature was practically obliterated and He was first seen by Dr. Hale White and Mr. Fripp with remained so with a spinal support, and the curve was much Mr. A. F. Wilson at the end of March, 1899. In the improved in ten of the cases. In a parallel series of nonmiddle of January, 1899, the patient began to comp’ain recdaed cases three patients had died from tubercle, four
933 had developed abscesses (twa of them healing), four had extension was far too high. Even that of 12 per cent. become paraplegic with two recoveries, and in seven the observed by Mr. Jones and Mr. Tubby in the cases which deformity was very marked. Mr. Jones and Mr. Tubby then they had operated on was distinctly high, being above that brought forward a series of 74 cases subsequently operated observed by Mr. Clarke in cases treated in London. It was to Of these seven patients had died, 29 were walking, be noted that in more than one of the cases in the paper no on. 28 were recumbent, and 10 had discontinued treatment. real diminution of deformity had been obtained, and as As to the causes of death, one patient died from empyema regarded the future of the patients there was no proof that four weeks after operation ; one died from general tuber- as soon as the apparatus was left off deformity would not culosis thirteen days after operation, and another two years return as the patient grew up owing to damage to the epiafter ; one died from pulmonary phthisis eighteen months physeal discs. The many contra-indications pointed out later and one from pneumonia two years after; one died which would have to be observed in deciding to perform from exhaustion ; and one died six months after reduction forcible rectification approximated closely to Mr. Clarke’s own for paraplegia, without relief, from diarrhoea. Three views, which were to the effect that this operation was only patients were operated upon while abscess was present and called for in exceptional cases. The chief indication was a 13 developed abscesses subsequently, of which nine had paraplegia that had resisted a patient trial of gentler means.healed. Seven patients had recovered from paraplegia, Mr. RICHARD BARWELL questioned whether the good done or the condition had been relieved and had remained was as great as they were asked to believe, and he doubted In 16 the curvature had either not improved or had whether there had been actual straightening in many of the so. become worse, but not necessarily as the result of the opera- cases of the angular curve. On the whole he did not think tion. Mr. Jones and Mr. Tubby deprecated the employ- that the results were better than would be obtained in three ment of much force, their plan having been to proceed by years by other methods of treatment. He observed that in stages with an interval of a month between each attempt. the case of a child, who was said to have had paraplegia, the They laid it down that the after-treatment should not be less child was under two years of age at the time and possibly than three years. Their conclusions were as follows : (1) was unable to walk; moreover the mother said that the child that danger to life was inot great; (2) that-far from in- had been able to move his legs. He pointed out that by ducing paraplegia the operation was actually a curative lifting the patient by the arms and watching the angle it was measure; (3) that abscess formation was, if anything, less easy to see whether the ulcer of the bones had healed. On frequent ; (4) that the risk of disseminating tubercle was a the whole he thought the results were somewhat disappointnegligible quantity ; and (5) that there was no risk ing.-Mr. BERNARD ROTH said that since seeing these cases of a flail-like spine. The contra-indications were: (1) he thought there was more in the treatment than he had cervical and high dorsal curves, unless associated with imagined, but he would like to see the cases a year after all paralysis; (2) ankylosed spines; (3) large and angular instruments had been left off.-Dr. E. PERCY PATON asked deformities; (4) evidences of tubercle elsewhere ; (5) in how long the patients had remained in hospital under treatchildren under two years of age and in adults over 22 years; ment and he pointed out that prolonged recumbency in the and (6) the presence of abscess unless there were paraplegia. homes of the poor could not be desirable.-Mr. HOWARD They advised the operation only when the spine was yielding MARSH commended the authors of the paper for the vast and in comparatively strong children free from abscess and amount of patience and labour which they had devoted to the tubercle. They pointed out that the operation was not to subject. They must, however, all feel that the subject had obliterate all the prominence, but to give as erect a position not been thoroughly threshed out though many interesting as possible. Lastly, they urged that cases for operation points had been raised, and he thought the question was one must be selected with great care, that personal attention to that might advantageously be referred to a committee for the patients must be unremitting, and that fresh air investigation and report. He was tempted to raise the was an all-important factor in the after-treatment. They questioii whether the conclusions arrived at by Mr. exhibited a selection of the first series of 25 cases Jones and Mr. Tubby were justified by the facts which showing the actual results.-The PRESIDENT observed they had brought forward. He challenged the estimate that whatever they might think of the ultimate results of 25 per cent. as the probable death-rate from Pott’s of the treatment the facts brought before them disease. He himself would put it at 5 or 6 per cent. He must materially alter many of their present views. H pointed out that paraplegia was equally recovered from asked whether albuminuria due to myeloid disease had dis. under other methods of treatment, and he concurred in the appeared when the surgical deformity was remedied.-Mr. J view that the correction of the deformity was often more JACKSON CLARKE said that.be had followed the revival oj apparent than real.-Mr. BERNARD ROTH seconded the forcible correction of deformity in spinal disease with greal reference to a committee, and some discussion ensued interest. He believed that he was the first surgeon t< I as to the scope of the reference and the way in perform the operation in London. In order to understand which the inquiry could be carried out. Ultimately the results obtained in the cases before the society i j the proposal to nominate a committee was agreed was necessary to consider the methods previously employed to, the precise terms of the reference to be submitted Mr. Tubby had put it on record that up to 1896 he ha< l to the council.-Mr. TUBBY, in reply, said that he thought it chiefly used corsets of plaster or of felt. Mr. Clarke ha( l would be conceded that they had done their best to fulfil found the results of such appliances to be very disappointing their pledge of two years ago to follow up those cases. He Mr. Jones had chiefly employed Thomas’s cuirass which wa ; pointed out that they did not insist so much upon the value also used in the after-treatment of many of the cases befor s of the operation in remedying the curve. With reference to the meeting. This cuirass, which exerted a leverage actioi i albuminuria he said that it disappeared when the abscess on the spine, had certain defects, though it was, in Mi ceased discbarging and no patient had died from lardaceous Clarke’s opinion, better than any other corset. It did no t disease. He did not believe that equally good results could be lend itself to periodical re-adjustment and thus was n ) obtained with instruments. In reply to Mr. BARWELL he said help to gradual correction of deformity ; it did nc t that the child stated to have had paraplegia had the lower provide for alterations required by the growth of th e limbs rigid with exaggerated reflexes and could not walk. He patient, and again it did not readily lend itself to th e added that the labour, difficulty, and anxiety entailed by the addition of a head-piece needed in high dorsal an 1 endeavour to afford the society such a demonstration of cervical cases. By the use of an antero-superior suppoi t results as that before them were very great, and he did not which did not possess these disadvantages Mr. Clarke ha 1 think that they could in any way manage to approve of a obtained results which he believed compared very favourabl 9 committee being sent about the country to inspect their with those seen in the cases now shown by the authors c cases, but the committee would, of course, be welcome to the paper. Thus in some cases of lumbar disease to e egamine the records. deformity had been obliterated ; in other cases it had bee n considerably diminished. These results had been obtaine CHELSEA CLINICAL SOCIETY. sometimes after a period of rest in bed or on the couch, bi more often with ambulance treatment throughout. TtI educational aspects of spinal cases had to be considered an The Treatment of Rheumatism. a method of treatment that allowed a patient to be taught! THE adjourned meeting of this society from March 13 h home or to go to school was, other things being equa was held in the Parish Hall, Pavilion-road, Chelsea, on to be preferred to one that demanded two or three yea March 20th, Mr. FOSTER PALMER being in the chair. of fixation upon an apparatus in the dorsal recumbe: The CHAIRMAN said that at the last meeting the Treatposition. The death-rate of 25 per cent. quoted fro ment of Rheumatism which they principally heard about, and Billroth as being observed in cases tiered without forcib .
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