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quantity of dark-green fluid. He was treated by a medical man for indigestion and there had been no vomiting since.

were the flexor carpi radialis, palmaris longus, and part of the flexor sublimis digitorum, all torn away about two inches He came under Dr. Bruce’s care on Oct. 12th, 1897, and from their origin at the internal condyle of the humerus, but there was found a swelling about two and a half inches preserving their distal attachments. The median nerve was in diameter situate above and to the left of the umbilicus. torn across above and was coiled up near the wound of the The skin over it was slightly reddened and it derived skin. Both the radial and ulnar arteries were intact. Mr. This pulsation disappeared Ray decided to attempt to save the limb and made an a pulsation from the aorta. when the patient was placed on his hands and kneea. incision on the front of the forearm from a point about two The heart and urine were normal. On the 20th he inches below the elbow to the lacerated wound mentioned the Roentgen rays, but above, and also for a short distance towards the wrist. was examined by means of nothing could be made out. On the 22nd the swelling He found that the pronator radii teres was partially was very tender, the skin over it was slightly cedematous, and divided, as well as the deep flexor muscles of the fluctuation was detected. The following day after consulta- forearm, whilst the median nerve was divided about tion the patient was ansesthetised and Mr. Morgan made an an inch after passing between the heads of the pronator incision in a vertical line directly over the swelling. On radii teres. About three-quarters of an inch of the radius cutting through the skin some few ounces of foetid pus having been removed on the proximal side, Mr. Ray sutured escaped. The abscess cavity was scraped and scrubbed with the median nerve, pronator radii teres, and the deep flexors, antiseptic swabs. A finger was then introduced and passed and he replaced the muscles that had been torn from the region through a circular aperture with thickened edges into the of the elbow-viz., part of the flexor sublimis digitorum, the cavity of the peritoneum. The small intestines were felt palmaris longus, and the flexor carpi radialis. The nerve below, the stomach and edge of the liver above, and the was sutured with fine silk and the muscles with mediumpulsating aorta. At the bottom of this cavity was felt the sized catgut. The aponeurotic investment of the front tip of a sharp, hard foreign body, lying loose and freely move- of the forearm was next brought together with a conable ; the axis of the body appeared to pass upwards tinuous catgut suture and silkworm-gut was used for the and to the right. It was carefully seized with a skin. Dry dressings were applied and the limb (the long pair of cesophageal forceps and extracted. It elbow flexed and the forearm semi-pronated) was placed proved to be a piece of steel stay-busk rather over four on an internal angular splint, and was not looked inches long, perfectly clean and untarnished. When found at for ten days, when everything had healed with the it lay at some depth from the surface, but its end exception of the meeting of the skin incisions with the must have pressed against the abdominal wall and thus have lacerated wound. The patient remained in hospital for caused the irritation which resulted in a superficial abscess. nearly four weeks and was an out-patient for some time As to the nature of the cavity in which it lay it is difficult to longer. Firm union has taken place in both the radius and speculate. It contained no fluid, but was probably shut off ulna and he can flex and extend the limb through fully 90° by adhesions from the general peritoneal cavity. The area at the elbow, and has some power of pronation and supination. The replaced muscles are again active and flexion of the was washed out with warm boracic lotion and the wound was sewn up, a drainage tube being inserted and the digits is easily performed, whilst sensation over the median usual antiseptic dressings applied. The temperature rose to nerve area is normal. Remarks by Mr. RAY.-The above case is a good example 1010 F. the same evening, but fell to normal next day. The patient was fed by nutrient enemata for five days, but on the of the application of conservative surgery in the treatment sixth day he was given milk and eggs. Nothing interfered of a severely injured limb. I am indebted to Mr. Hardie with his subsequent progress and in less than a month he for kind permission to publish the case. left the hospital in perfect health. Remarks by Mr. MORGAN.-This adds another to the long list of articles swallowed by would-be suicides and its subsequent history is as fortunate as it is remarkable. That so large a substance should penetrate the stomach and remain in the abdomen without causing disturbance and then set up a superficial abscess in the abdominal wall is a sequel that PATHOLOGICAL SOCIETY OF LONDON. could hardly be anticipated by the most hopeful surgeon. That such an abscess could be opened and the foreign body Umbilical Hernia. -Immunisation against Streptococei.extracted without the slightest sign of inflammation or of Aortic Incovametence.-Exhibition of Specimens. disturbance of the peritoneum is a tribute to modern antiA MEETING of this society was held on Feb. 1st, the septic surgery. President, Dr. J. F. PAYNE, being in the chair. Mr. W. G. SPENCER showed a specimen of Strangulated MANCHESTER ROYAL INFIRMARY. The infant passed Umbilical Hernia from an infant. A CASE OF SEVER COMPOUND FRACTURE OF THE RADIUS meconium in the usual way after birth, but afterwards there AND ULNA WITH AVULSION OF THE FLEXOR MUSCLES was no action of the bowels and symptoms of obstruction IN THE FOREARM; REPLACEMENT OF THE developed and on the fourth day a swelling was noticed at the umbilicus. The child was admitted to the MUSCLES; RECOVERY. when five days old. There was general dishospital of J. H. late Mr. resident RAY, (Under the care surgical of the tension and a tumour the size of a abdomen officer to the infirmary.) hen’s egg presented at the umbilicus. At the apex of the THE following case is well worth recording as an tumour was the dried stump of the umbilical cord and the excellent example of what can be done by conservative skin in the neighbourhood was inflamed and sloughing. An incision was made at the site of the cord and a large amount surgery at the present time. Both bones were broken and of fæcal material and flatus relieving the child for nerve were and an muscles torn, yet by the time. Fæces continued toescaped, from important many the artificial anus escape energetic treatment an almost perfect functional result was thus formed, but the child died from exhaustion ten days obtained. It is not long ago that a limb injured to this later. Post mortem the hernia was found to contain a loop extent would have been amputated without any serious idea of ileum with the cascum and it was the wall of the ileum presenting itself that it might be possible to retain it. It which had sloughed. Thespur"on the opposite side is probable that one of the most important points which formed a considerable projection.-Mr. TARGETT thought contributed to the recovery was the fact that the ulnar and that the hernia could not have been due to developmental radial arteries were uninjured. malformation, but must be looked on as acquired A man, twenty-one and a half years old, was admitted into through some cause during intra-uterine life. Mr. the Manchester Royal Infirmary on Sept. 13th, 1897, with D’ARCY POWER thought that a distinction should be a compound fracture of both bones of the right forearm, and drawn between umbilical hernia proper, or exomphalos, and ventral hernia occurring at the umbilicus. Mr. .a mass of muscles and tendons hanging out of a transverse wound of the flexor surface of the limb, due to the pulley and Spencer’s specimen belonged to the latter class. He strap of a driving shaft, round which his forearm was carried. referred to specimens of each class which he had brought The bones were broken rather below the middle of the fore- before the society on a previous occasion. He thought that in this case the gangrene had begun from within as the arm and the proximal part of the radius projected about half The skin below the stump was comparatively healthy,-Dr. an inch from a lacerated transverse wound of the limb. wound was four and a half inches long and hanging from it CHARLEWOOD TURNER thought that the specimen was one

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367 of prolapse of the csecnm everted through a Meckel’s diverticulum. He did not see how a true hernia should show everted mucous membrane. There was a specimen of the condition he suggested in the Museum of the London Hospital.-Mr. SPENCER, in reply, said that he thought from the appearance of the skin during life that the sloughing was due to an extension of septic processes from the stump of the cord. Mr. BOKENHAM read a paper, illustrated with charts and lantern slides, on the Immunisation of Animals against Streptococcal Infection. In his investigation he employed streptococci derived from various sources. The culture medium was one he had devised of a mixture of fresh veal broth with peptone and salt solution and boiled under pressure for several hours. He also sometimes used an alkali albumin made by acting on blood serum with an alkali. The age of the culture at the time he made the; inoculations was never less than three weeks as the resultsI were more constant when the streptococci had ceased to grow. The virulence of the organisms was often increased by passing them through several rabbits. The filtrate from the cultures was highly toxic to rabbits, producing glomerulonephritis and haemorrhages into the mucous membrane of the alimentary canal. Injection of the filtrate into horses or asses caused reaction and rise of temperature with tolerance to subsequent doses of the same. Repeated inoculations were necessary before the serum was found to have much immunising effect. If the serum were taken from an animal too soon after inoculation before the inflammatory reaction had completely subsided there was often local reaction when it was injected into another animal, the inflammation occurripg some time after the injection. If, however, it were taken from the animal later it could be injected without any local disturbance. It was doubtful whether there was a true antitoxic action, but a marked increase in phagocytosis could be demonstrated in the peritoneal fluid after its use. He had had many opportunities of observing its use in cases of streptococcus infection in man. There was almost always speedy loss of headache and restlessness, the patient becoming drowsy; the skin became moist instead of harsh and dry. The temperature sometimes rose at first, but then came down and might be kept down by repeated injections. In erysipelas the erythema might actually disappear in twenty-four hours. He began with a dose of 10 c.c. and this often required to be repeated several times.-The PRESIDENT said that the specimens of nephritis shown were remarkably like those seen in scarlatinal cases. He asked whether the serum had been tried in cases of ulcerative endocarditis. He had recently had three cases of this condition under his care in which Dr. Louis Jenner found organisms in the blood, staphylococcus aureus in one, a diplococcus in another, and streptococcus only in a third.-Dr. LAZARUS-BARLOW said that Mr. Bokenham’s observation that the blood must not be taken too I soon after inoculation agreed with the observations of Charrin and Gley, who found in their researches on the bacillus pyocyaneus that it was necessary to wait seventeen days after inoculation before the toxin had left the animal. There was a delay befoxe these local signs showed themselves and the observations had an important bearing on the question of the incubative period after the inoculation of chemical products, a field almost unexplored. Such an incubation period had been noticed after the ingestion of poisonous articles of food.-Mr. BOKENHAM, in reply, said that the striking resemblance to scarlatinal nephritis had struck him also. He had seen an exactly similar condition in rabbits after the injection of a substance obtained from the spleen of scarlatinal patients. He had tried the serum in two cases of ulcerative endocarditis, in one with only temporary relief, while in the other recovery took place after 150 c.c. had been injected altogether. In animals immunity appeared to be conferred for six weeks or longer. Dr. NEWTON PiTT showed four specimens of Aortic Incompetence without Disease of the Aortic Cusps. All the specimens showed atheroma and dilatation of the aorta, chiefly of the first part, and dilatation and hypertrophy of the left ventricle. This had led to a stretching of the ring supporting the valve and incompetence although the cusps of the valve were perfectly healthy. Dr. Pitt mentioned that the condition had been recognised by the late Dr. Moxon and four other cases were found in the records of Guy’s Hospital occurring in four years. The following card specimens were exhibited Dr. NEWTON PITT : Sarcoma of the Suprarenal Body. Dr. W. HUNTER; (1) Typhoid Lesion of the Vermiform ,

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Appendix; (2) Suprarenal Body from a case of Addison’s ’ Disease; (3) Acute Tuberculosis of the Spleen; (4) Diphand (5) Gouty Deposit in a Joint. theria of the Larynx, &c. ; Dr. HBBB: (1) Adipose Infiltration of the Heart from a case of Ether Poisoning; and (2) Sections of the Spinal Cord from a case of Tumour compressing the Cervical Cord. Dr. Eden’s demonstration of the Age Changes in the Placenta and Fcetal Membranes was postponed till Feb. 15th. CLINICAL SOCIETY

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Sudden Death in Acute Rheumatism.-Internal Hernia.Obliterative Arteritis. A MEETING of this society was held on Jan. 28th, the President, Mr. LANGTON, being in the chair. Dr. W. P. HERRINGHAM read a paper on a case of Sudden Death in Acute Rheumatism. A girl, aged sixteen years, was. admitted to St. Bartholomew’s Hospital on Feb. 27th, 1897, on the second day of a first attack of rheumatic fever, with a temperature of 103° F., a pulse of 128, and a respirationrate of 32. Many joints were inflamed. The heart was not. enlarged at the time of admission, the apex beat being within the nipple line, but there was a double apical murmur. She complained much of pain in the umbilical region, for which no cause could there be found. The joints pains quickly ceased under salicylate of soda, but she continued to feel much pain in the epigastric and prascordial regions and became pale and cyanotic. The hearts enlarged, the apex beat passing beyond the left nipple, and small rales became audible over the lungs and the fever persisted. Impairment of resonance was found over the left lung and the respiration rose to 64. This state continued until March llth. During the previous night she had slight haemoptysis and at 10.30 AM. a sudden change for the worse occurred and she died in a few minutes. A post-mortem examination showed oedema of both lungs and fatty degeneration of the walls of the left ventricle with much increase of cells in the interstitial connective tissue-acute myocarditis. This acute change in the heart was probably the usual cause of the few cases of sudden death in rheumatic fever. A certain diagnosis appeared impossible ; but suspicion should be atoused if along with cyanosis for which there appears no sufficient cause in the lungs there exists considerable pain in the epigastric or prascordial regions.-Dr. MACLAGAN remarked that the best account which they had of the subject dated from as far back as the time of Corvisart, who scheduled these cases " The distinct"cases were as "distinct" and as "latent." those in which there was evidence of direct changes in ’ the heart and the "latent " those in which no such evidence was obtainable. In the latter class of cases almost invariably the symptoms were referable to the nervous system. He referred to a case recorded in one of the earlier volumes of the Transactions of the Royal Medical and Chirurgical Society (1816) by Mr. Stanley of a boy who died with symptoms thought to be due to inflammation within the head. Post mortem nothing was found there, but there was inflammation of the muscular substance of the heart. It was important to recognise the fact that it did occur as a serious complication in rheumatism. The subject had been brought before the society some years ago by Dr. Ord in connexion with pericarditis with and without head symptoms. He believed that the cases in which head symptoms occurred were those in which the pericarditis was complicated by myocarditis. He believed that the inflammation spread from the pericardium to the myocardium but never from the endocardium to the myocardium and he pointed out that endocarditis never spread all over the heart but was limited to certain spots. The changes in the myocardium might, however, occur independently of either one or the other. The treatment followed in this case was ten grains of salicylate every four hours, but he was of opinion that there was no possibility of doing any good with such a dose. He bimself never gave salicylate of soda in cases where he suspected the heart, preferring salicine. He recalled the fact that Charteris had stated that the deleterious effects sometimes observed after salicylate of soda were due to its containing an impurity in the shape of creosotic acid. Alluding to Dr. Herringham’s remark that death was due to hyperpyrexia, probably the result of the action of the rheumatic poison on the nervous system, he said he failed to see what authority there was for such a view, this complication not being limited to acute rheumatism.-Dr. LEES