THE BRITISH MEDICAL ASSOCIATION. MEETING AT CARLISLE.

502 last is the most extensive. A sub-peritoneal abscess may arise in the tissue itself or in structures around it or even in structures outside the abdomen, as after varicocele. Chopart gives a case where a sub-peritoneal abscess arose after castration. Whatever the origin of a sub-peritoneal abscess it may involve any portion of the sub-peritoneal space. The tissue may be implicated directly or indirectly from a’viscns, either by direct contact or by perforation after peritoneal adhesions or by a localised peritonitis. Sub-peritoneal abscesses always tend to reach the surface. An intraperitoneal abscess generally opens into a viscus ; this is The new rare in the case of a sub-peritoneal abscess. growths of the tissue are but little known. The lipoma may grow very rapidly and to an enormous size and surround the abdominal vessels. As a rule, most patients have died from shock. There is a hernial variety of the lipoma, which may simulate a hernia and may reach the weight of 14 Ib. ; it is most commonly met with in the inguinal canal; it prepares the way for a true hernia by drawing down a pouch of peritoneum. The fibromata may reach a large size, and it is generally very dangerous to interfere with them. The myomata contain involuntary muscular fibres. Sarcomata are not rare ; they are utterly beyond treatment. Hæmorrhages may occur into the tissue, as by the rupture of an aneurysm. Lymph exudations may also occur; and other matters, such as bile or fasces, may be extravasated into the tissue. Gaseous infiltrations may occur and be derived either from the lungs or from the bowel. There is an atrophic form, which may give rise to movable kidney, especially in

THE

BRITISH MEDICAL ASSOCIATION. MEETING AT CARLISLE. THE annual dinner of the Association was held in the New Dr. Public Market on the evening of Friday, July 31st. Henry Barnes presided and some 200 guests were present. The Bishop of Carlisle, the Mayor of Carlisle, Dr. Saundby, Surgeon-Captain Whitchurch, V.C., Dr. Maclaren, Dr. Unna, and Sir Thomas Grainger Stewart were among the speakers, and their words were very hearty and enthusiastic. On the same evening a dance was given in the large ballThis room of the County Hotel by the Mayor of Carlisle. was largely attended by the members of the Association and by the officers of the regiment quartered in the city. The music and the floor being both good a pleasant evening was

spent.

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there were excursions to Derwentwater, Moffat and St. Mary’s Loch, Naworth and Lanercost among other place,. On

Saturday

Abbotsford,

women.

The general impression that all the visitors carried away from Carlisle was that they had had a very pleasant meeting. The Sections were fairly well attended, some of the debates were very interesting, the pathological museum was a well-arranged and excellent collection, the social functions were enjoyable, and, lastly, the organisation was For this the visitors had in the first place, very good. in so many previous years, to thank Mr. Fowke, as the general secretary of the Association ; but the success of llr. Fowke’s efforts was much enhanced by the admirable way in which the local arrangements were carried out by Dr. Henry Barnes, the President of the Association, Dr. Helm, and Dr. Roderick Maclaren, each and all of whom spared no trouble to make the meeting at Carlisle a memorable

Dr. MACDoUGALL said that in cases of appendicitis the were very grave when the sub-peritoneal tissue became involved. He had seen a case of ovariotomy where the patient became exceedingly pale and looked as if there were internal hæmorrhage, but she rapidly recovered after an abscess had been opened in the sub-peritoneal tissue of the anterior abdominal wall. He remembered, also, a case of sarcoma of this tissue which had been mistaken for a sarcoma of the kidney. Mr. C. A. MORTON (Bristol) had recently seen a case where a sarcoma growing from the sub-peritoneal tissue of the pelvis had caused complete retention of urine in a child. He had seen also a case of a large abscess developing behind the mesentery caused by a fish-bone perforating the bowel wall. Professor OGSTON (Aberdeen) considered Mr. Anderson’s paper an epoch-making one. He mentioned a case he had seen of a young woman under twenty years of age with an enormous abdomen due to a lipoma of the sub-peritoneal tissue ; the intestine was in the substance of the tumour; there was no general wasting. He had also seen a case where general hypertrophy of the sub-peritoneal and omental fat had simulated a tumour. He mentioned also a case of a myoma involving the left ureter in which it was necessary to excise the portion of ureter in connexion with the tumour. He inserted the proximal portion of the ureter in the distal and stitched it round, with a perfect result. Dr. LAUENSTEIN (Hamburg) mentioned a case where a large abscess had developed in the sub-peritoneal tissue of the right side of the pelvis, though it was necessary ultimately to open it in the left ischio-rectal fossa. Mr. W. ANDERSON, in reply, thanked those who had spoken, and remarked that there was an immense amount of information on the subject scattered about, but it had never been collected. resuits

one. ___

SURGERY. FRIDAY, JULY 31ST. The Surgery of the Sub-peritoneal Tissue. Mr. WILLIAM ANDERSON (London) read a paper on He remarked the Surgery of the Sub-peritoneal Tissue. that neither Quain’s nor Gray’s Anatomy mentioned the subperitoneal tissue. At an early stage of development it could be recognised as a mesoblastic mass surrounding the great vessels of the abdomen ; it was carried with the vessels into all the abdominal viscera; one process of it surrounded the kidney and another entered the mesentery; it surrounded the liver, fixing it to the diaphragm, and also penetrated its substance in the form of Glisson’s capsule. The amount varied greatly in different parts. It consists of highly elastic connective tissue, with a variable amount of fat and some involuntary muscular fibres. There is a portion of the circumference of the small intestine which is uncovered by peritoneum ; this portion is in close contact with the sub-peritoneal tissue. In the broad ligament the sub-peritoneal tissue is in intimate relation with the ovary and Fallopian tubes. It is loosely attached to the parietal peritoneum and the fasciæ’ lining the abdomen, but it cannot be demonstrated in places where it is firmly attached to the viscera. From its structure it is liable to certain new growlhs ; it lies in close contact with the pelvic wall and ibe vertebras, and so all diseases of these structures will affect it. It is also necessarily implicated by everything which affects the peritoneum. The varieties of inflammation of the sub-peritoneal tissue may be grouped regionally or e’iologically ; the latter is the more! modern. The regional groups include (1) the retro-peritoneal, (2) the sub-phrenic, (3) the perinephric, (4) the iliac, (5) the pelvic, and (6) the prevesical. The etiological classification is of more value. It includes the idiopathic, tuberculous, syphilitic, metastatic, traumatic, and consecutive forms ; thisv , .

,

The Use of Tuberculin in Surgical Diagnosis. Dr. SANDBERG (Bergen) read a paper on the Use of Tuberculin in Surgical Diagnosis. He remarked that the reaction against tuberculin had probably gone too far. The surgical treatment of tuberculous joints is not satisfactory;Y arthrectomy has displaced excision in the hope of obtaining better movement, but not very successfully, and injections have attempted to replace arthrectomy. He had tried the effect of tuberculin in thirty cases, and though he did nol think that any harm had resulted yet he was not sure that any marked improvement had been due to the tuberculin, But in pome cases it could be used to determine if all the tuberculous disease had been removed, and to this limited extent it might be useful. Disinfection oj the Hands. Dr. LEEDIIAM GREEN read a paper on the Disinfection of the Hands. The method employed to test the condition of the hands was to scrape the skin with small ivory slips and

503 also to scrape under the nails. The slips were then dropped described his methods of obtaining sharp definitions and into tubes of agar-agar. Simple washing, washing with sand how they might photograph and see organs in different and with turpentine all gave results indicating a septic con- planes of the body. By this means they could photograph dition of the hands. Alcohol gave better results, but these the spine and omit the heart and sternum, and, on the A further series of experiments other hand, the latter could be got and the spine omitted. In were by no means perfect. was made with hands which had been purposely rendered the same way any part of the cranium could be selected for septic before the cleaning process was commenced, with a photography. He used heavy currents, as high as 30 amperes, similar result. Antiseptics (chiefly perchloride of mercury, carefully measuring them on Lord Kelvin’s ampere gauge and 1 in 1000) were also used with results but little more cell tester. His coil took heavy currents through the primary wires, and great attention was paid to the interrupter, which encouraging. for rapid exposure was of the mercury form. He described his Intussusception. Dr. J. C. RENTON (Glasgow) read a paper on Three methods of obtaining instantaneous photography, but pointed Cases of Intussusception in which operation was successful. out that this could not yet apply to the trunk and denser parts The children were of the ages of ten months, eleven months, of the body. For screen purposes he used the barium salt often, and three months, and they all recovered rapidly and com- and in some instances thought it better than the potassium Whether this might be true or not he now pletely after laparotomy. There can be no use in waiting ; platino-cyanide. the operation should be performed early. Rapidity in limited himself to these two salts after trying many different of fluorescent screens. Dr. Macintyre operating was also of great importance. He showed a bowel kinds in the preparation to then which he had found of use in If much proceeded compare the use of fluorescent screens and clamp operating. the patient is very weak a local anaesthetic only should be photography, and said he had been able to see shot in the - used. scalp in one case, and that some foreign bodies were easily seen in the tissue of the neck. He had seen most parts of 80rne Recent Modifications in the Operative Treatment of the face and some of the tissues of the neck. Passing to the Diseases of the Attic and Mastoid Process. chest he saw deposits in the apex in one case thrown as Dr. ADOLPH BRONNER (Bradford) read a paper on Some a shadow on the fluorescent screen. The limits of the pleural Recent Modifications in the Operative Treatment of Diseases cavities, the heart in movement, the diaphragm in action, of the Attic and Mastoid Process. He said that many enlargement of the heart, liver, &c., had all been seen. surge:ms were in favour of making a permanent opening Passing further to the question of photography he demonbehind the ear, but this required frequent dressing for a long strated, by means of the magic-lantern slide, specimens of time, and a preferable method was to make an opening from fracture of the skull in which the differential diagnosis the external auditory meatus into the mastoid, making at between pressure from effusion and the presence of a bullet the same time two flaps of skin, which were stitched back- had been made in a case of paralysis of the extremities. wards into the sides of the wound so as to form a permanent The tissues of the larynx, the whole thorax in one plate, opening. The danger of the operation was slight if the with both shoulders and both elbows, were also thrown surgeon possessed a good knowledge of anatomy. The upon the screen. Photographs of the heart, diaphragm, liver, results were good. and these in health as well as hypertrophied, were exhibited. A case of renal calculus photographed and since successTwo Cases of Jacksonian Epilepsy treated by Operation. Mr. ALBERT MORISON (Hartlepool) contributed a paper fully operated upon was described. A large number of other examples of normal and diseased structures in the on Two Cases of Jacksonian Epilepsy treated by Operation with a New Method for defining the Fissure of Rolando. The lower animal kingdom and in man were also shown, as first case was that of a young man who had fits of increasing well as specimens of instantaneous photography. Nearly hundred "x" photographs were also exhibited as prints severity on the right side ; they commenced in the right toe. aand hung round the walls. The skull was opened and a collection of two ounces of straw-coloured fluid was found in the sub-arachnoid space. The recovery was rapid and perfect. In the second case the OBSTETRICS. fits commenced two days after a severe blow on the head. FRIDAY, JULY 31st. On raising the scalp flap a fissured fracture was seen. The bone was trephined and some clot removed. Except for The Relative Advantages of Forceps and Version in Cases of some slight twitchings in the arm the recovery was unModerate Pelvic C’ontraction. eventful. The method Mr. Morison suggests for finding the MILNE MURRAY (Edinburgh) opened the discussion on Dr. fissure of Rolando is to take a point half way between the this subject. He said that by the use of forceps intra-uterine glabella and the external occipital protuberance, and then to is avoided and also the dangers of compression take a point the breadth of the little finger behind it. An manipulation of the cord and traction on the neck to which the child isosceles triangle is then mapped out on the scalp ; its sides is exposed after the performance of podalic version. In cases are 3 3/4 in. long, and one lies in the middle line with the apex of flat pelvis the ordinary long forceps are not very satisThe base is anterior and at the point mentioned above. and it was thought that this was due to the comThe posterior side of the triangle is over the factory measures 4 1/8in. of the child’s head by the blades, in the transverse pression fissure of Rolando. diameter of the pelvis and the consequent bulging of the " Z" nay Demonstration with Special Reference to the Soft head in the conjugate diameter. This, however, is not the Tissues. true explanation, as with the head lying transversely at the Dr. J. MACINTYRE gave a demonstration to the Section. brim he has found it possible to compress it with the forceps He first described the apparatus by means of which he had to the extent of one and a half inches without giving rise to first obtained results in his attempts to photograph and see any bulging in the opposite diameter. Under such circum,on screens the deeper-seated structures of the body. He stances the head swells vertically by a kind of telescopic first pointed out that in photographing the lower animals he action. The real difficulty of delivering the head through a had got fairly satisfactory shadows of certain organs within flattened brim by means of long forceps was that they did the cavities. Proceeding to make a series of experiments he I not enable traction to be made in the axis of the inlet, and had found, contrary to expectation, that greater currents the amount of force wanted is greater when the pelvis is flat were required. One might have thought that if photographs than when it is normal. By the axis traction principle this of the bones were to be got with certain apparatus in a difficulty is entirely overcome, as by means of axis-traction given time then by diminishing the exposures it might rods the line of traction can be made to coincide with the be possible to catch the soft tissues before they disappeared. axis of the inlet and the angle of error is thus abolished; even This was not altogether true, although in certain experiments in cases where the head has not yet entered the brim and no by this method he had been able to photograph the bones lateral tilting has occurred it is possible to deliver with axisand flesh in such a way as to show hip-joint disease with the traction forceps, and with such an instrument he has delivered internal pathological changes and external deformities seen on several occasions living children through a conjugate of on the same plate. They had to remember, however, that to three and a quarter inches. A pair of forceps made to obtain good results it was necessary to place the focus-tube coincide with the curve of the normal pelvis is not quite a long way from the body, the distance increasing as the suited for cases where the pelvis is flat. To overcome this object to be photographed was situated far from the difficulty Dr. Murray has invented an instrument called the plate. Further, in the centres, particularly the heart, adjustable axis-traction forceps. The traction rods are the tissues were dense, and for these and other carried down for some distance, and then pass backwards at reasons it was necessary to use large currents. He right angles, giving a horizontal limb. The handle is slipped