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Treasurer: William Cayley, M.D. Honorary Secretaries:Samuel West, M.D.; Rickman J. Godlee, M.S. Council:C. E. Beevor, M.B.; Sidney Coupland, M.D.; H. ItadcliffeCrocker, M.D.; William Ewart, M.B.; Percy Kidd, M.D.;E. Emanuel Klein, M.D., F.It.S.; Stephen Mackenzie,M.D.; J. Arderne Ormerod, M.D.; George Thin, M.D.;W. Hale White, M.D.; William Anderson; H. TrenthamButlin; Victor Horsley, B.S., F.R.S.; Jonathan Hutchinson,jun.; G. H. Makins ; Herbert W. Page, M.C.; Bernard PittsA. Quarry Silcock, M.D.; J. Bland Sutton ; FrederickTreves.The usual votes of thanks to retiring officers closed the

proceedings.Sir JAMES PAGET, in reply to a hearty vote thanking him

for the able and efficient manner in which he had preaidedover the Society’s meetings during his term of office, said,in a few well chosen words, that any work lie had done forthe Society had been well rewarded by their election of himas President late in life. He was glad to embrace thatopportunity of explaining why for some time he had delayedjoining the Society. He, with others, had made the pro-found mistake of imagining that the effect of establishing anew society would be to detract from the value of the olderEoya.1 Medical and Chirurgical Society, but the excellentwork that had been done by both since proved this appre-hension to be ill-founded.

CLINICAL SOCIETY OF LONDON.

Laryngeal Cancer.THE annual general meeting of this Society was held on

;he llth inst., Dr. W. H. Broadbent, F.R.C.P., President,.n the chair. The following papers were read on laryngealcancer.

Dr. NEWMAN read a case of Auto-inoculation in LaryngealCarcinoma, and two cases illustrating the danger of Intra-laryngeal Interference in Cancer of the Larynx. In thefirst case, the patient, J. K-, aged forty-nine, applied onaccount of hoarseness and dysphagia, apparently due toacute laryngitis. This subsided under treatment, afterwhich an elevated ulcer was detected on the left false cord,midway between its anterior and posterior attachments.This presented the characteristic appearances of an ulcerat-ing carcinoma, and covered about a quarter of an inchsquare. At this time (April, 1887) the mucous membraneof the interior of the larynx was practically normal, buttowards the last week of June a localised hyperaemia of themucous membrane, covering the right false cord, wasnoticed. This change was limited to a point on which thefree surface of the tumour impinged upon the right side ufthe larynx. An ulcer then developed on the right side, andby December the second ulcer was the larger in size. Boththe anterior and posterior portions of the larynx were freefrom disease. The patient had a severe cardiac affection,with a ventricular systolic murmur, and chronic bronchitismd emphysema. In February, 1888, the patient was re-admitted to the Glasgow Royal Infirmary. The laryngeallisease was practically the same as in December, with theexception that the inflammation was more intense, andseveral small erosions were observed at the base of theepiglottis. The patient, who had been rapidly ema-

,iatin,y, died at the end of April from pulmonary diseaseconsequent upon fatty metamorphosis of the heart andnitral regurgitation. On removal of the larynx afterleath, two ulcerating tumours were found to occupy theposition of the false cords, and extended forwards towards,lie commissure, so as almost to meet in the middle line.n front. The growths were soft, with deeply-injectedloors and thickened edges. The ulcer on the rightside was larger and more irregular than that on the left.rhe mucous membrane was thickened, cedematous, andtypersemic, and extending up from the base of the epiglottis.here was a very irregular but superficial erosion, and;everal small round erosions on the trachea. These eroded)arts presented a striking difference from the ulceratingleoplasm ; their edges were sharp and marked by a thin)right red line, while their floors were pale and com para-;ively smooth. External to the larynx there was no can-cerous disease. After a careful search several lymphatic;lands were found in the neighbourhood of the larynx,iome of which were slightly enlarged, but none were found,o be cancerous. Microscopic examination showed the

growths to be distinctly carcinomatous. Dr. Newman re-marked that this case was of interest in several respects, asan example of auto-inoculation, and in its being a casewhere death had occurred previous to the disease becomingextra-laryngeal. Here the disease clearly spread from theprimary growth to the opposite side of the larynx, by directcontagion rather than, as was usually the case, by continuityof tissue. In the second case the malignant growth wasstrictly limited to the cavity of the larynx. The patient,who was sixty years of age, came under care three yearsago, to have the tumour removed by partial laryngec-tomy. The growth, which was situated on the left falsecord, and about the size of a horse-bean, proved to be anepithelioma. The patient was duly informed of this fact,and urged to have the operation of partial laryngectomyperformed at once. But he insisted on waiting for atleast a month. Ten days after the intra-larygngeal opera-tion a swelling about the size and form of half a horse-bean was discovered over the left superior cornu of the thy-roid cartilage. This ultimately proved to be a carcinoma-tous lymphatic gland. The third case was that of a femaleaged fifty, suffering from a tumour on the posterior third ofthe right vocal cord, about the size of an orange seed. Thetumour presented the appearance of an inflamed papilloma;the mucous membrane was deeply injected, and the historyof the case favoured the diagnosis of papilloma. Thepatient had little or no discomfort or pain. There was no

lymphatic involvement. Dr. Newman was then led toremove a small fragment of the growth, which presentedthe microscopic appearances of a papillomatous adenomawithout the least suspicion of the structure of an epithelioma.Shortly after this a larger portion was removed. Followingthe second operation a diffuse swelling appeared in theneck, but in seventeen days this swelling subsided, andrevealed two enlarged lymphatic glands, one on either sideof the thyroid cartilage. The subsequent course of the caseproved them to be carcinomatous in their nature, and thegrowth within the larynx, which, on examination of thefirst specimen, was believed to be a papilloma, ultimately,on examination of subsequent specimens, proved to be anepithelioma, and the patient died from the disease.

Dr. FELIX SEMON read a case of Laryngeal Cancer, inwhich haemorrhages, perichondritis, and exfoliation of thegreater part of the laryngeal cartilages occurred, with sub-sequent pleuritis and gangrenous pneumonia, resulting indeath. The notes of this case were illustrated by macro-scopic and microscopic specimens. The patient was anofficial of the Cape Government, aged fifty-two, whoseillness began in April, 1886. The first symptom was hoarse-ness ; later on dyspnoea supervened, and in September, 1887,tracheotomy had to be performed. He came under Dr.Semon’s observation in January, 1888. At that time thelaryngeal appearances were entirely those of perichondritis.But externally, below the tracheotomy tube, there was asoft reddish ulcerating tumour, through which a probepenetrated to the laryngeal cartilages, and which, on micro-scopic examination of a fragment, was found by Mr.Shattock to be of typical carcinomatous nature. Thepatient passed the last six months of his life in St. Thomas’sHospital, under the joint care of Sir William Mac Cormacand Dr. Felix Semon. During this time he gradually gotworse; haemorrhages from the tube, which had alreadypreviously occurred, became more frequent, and sometimesserious; fragments of gangrenous muscles, later on ofcartilages, were expectorated ; cancerous granulationswhich had formed round the tracheotomy wound brokedown, formed again, broke down again, &c., leaving theaperture larger and larger each time. The expectorationof cartilaginous fragments continued; on one occasion alarge part of the cricoid plate, on another almost one-halfof the thyroid cartilage, were expelled; the expectora-tion became purulent, very profuse, and fetid; pleurisyand pneumonia on the right side set in, and on July 27th,1888, the patient died exhausted. At the post-mortemexamination, it was found that the larynx was changedinto an enormous cavity, 6 ’5 centimetres in length, the wallsof which were ulcerated throughout. Of the laryngealcartilages, only the greater part of the epiglottis, a part ofthe left half of the cricoid, and the left arytenoid cartilagewere found, the rest having been destroyed or’eliminated.The trachea was healthy, and ii’lere was no perforation ofthe oesophagus. One gland on the right carotid showedevidence of carcinomatous infection. There was purulentpleurisy on the right side, and the right lung was coh-

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solidated, and contained numerous gangrenous cavities.Microscopic examination of the an’ected parts showed thecancerous nature of the laryngeal ulceration. In his re-

marks on the case, Dr. Semon considered especially: 1. Theoccurrence of haemorrhages in laryngeal cancer. 2. Thecomplication of cancer with perichondritis and the elimina-tion of fragments of cartilage. 3. The frequent absence ofglandular swellings in these cases. 4. The clinical historyof the cancerous vegetations round the tracheotomy wound.5. The mode of death in laryngeal cancer.Mr. BUTLIN read the sequel of a case of Epithelioma of

the Vocal Cords for which partial excision of the larynx wasperformed. Recurrence of the growth took place aboutnine or ten months after the operation of partial excision.Tracheotomy was performed exactly one year after the firstoperation. The patient survived the operation of tracheotomyone year and two months, when he died slowly of exhaustion.Mr. BUTLIN also read a paper on two cases of Thyrotomy

for the removal of Malignant Disease of the Larynx. Inpursuance of an opinion expressed by the author in a previouspaper that it was not necessary to remove the cartilaginousor bony framework of the larynx in certain cases of intrinsiccarcinoma of the larynx which are suitable for operation,two cases were reported. The first was a case of squamous-celled carcinoma (epithelioma) of the larynx in a womantwenty-seven years of age. The thvroid cartilage wasdivided in November, 1887, and the disease was cut andscraped out. She made a good recovery, and was well ayear later and free from every sign of cancer. The secondwas a case of the same disease in a man fifty-one years old.A similar operation was performed in 1888. The manrecovered without hindrance, and was well in September.The author pointedly drew attention to the comparativelytrivial nature of the operation in cases of malignant diseaseof the larynx of limited extent. In another instance inwhich he performed an exploratory thyrotomy in a manadvanced in years, and found the disease too extensive forremoval, he closed the wound, and the man recovered andleft the hospital, wearing a tracheotomy tube.

Dr. DE HAVILLAND HALL related the history of some casesto prove the difficulty of diagnosis of the nature of laryngealcancer. In one case of hoarseness in a gentleman examinedfor life insurance the signs were simply those of chroniccatarrh. Later on abscesses developed in the right aryepi-glottic fold. Tracheotomy was advised but objected to, andthe patient died suddenly two years after his life had beenaccepted by the insurance office. Microscopic examinationswere made, and the disease found to be malignant, thoughthe death certificate gave chronic laryngitis as the cause ofdeath. In a second case the diagnosis was malignantdisease, because of the existence of a fungating mass in theinterior of the larynx. Tracheotomy was performed, butexhaustion led to death in two months. The researches ofDr. Hebbproved that the disease did nobcontaincarcinomatouselements. Perichondritis was in practice either of syphilitic,malignant, or phthisical origin, but the fact of improvementby the use of iodides did not prove the syphilitic nature ofit. He considered that the cases reported by Mr. Butlinwere arguments in favour of resorting to early opening ofthe thyroid.

Dr. SEMON reported a case of a well-known Germandeputy, who at seventy years of age was found to have apapilloma of the anterior commissure of the vocal cords.Removal and recurrence took place on more than one occa-sion. It seemed to be nothing more than a wart, but themicroscope proved it to be carcinomatous. It was removedagain, and an enlarged gland appeared ; this was extirpatedand found to be carcinomatous. Yet the patient remainedalive and well. In the British 3medical Journal of Junelast he published another interesting case of a clergyman,who remained well and did his work. The case of a well-known magistrate on whom Hahn had operated, on Dr.Semon’s advice, was also referred to as an instance of suc-cessful removal of new growth by external operation.Mr. KEETLEY mentioned a case of chronic laryngeal dis-

ease in a man aged sixty. Perichondritis and necrosis ofcartilages occurred. Thyrotomy was performed, and mostbut not all of the disease was scraped away, but thedisease rapidly recurred, and death took place some monthslater. At the time of operating there were no signs ofenlargement of the glands. :

Mr. BUTLIN remarked that some curious impressions Ihad been made upon the public and upon the profession iwith respect to the relative value of the operations for the

removal of cancer, and it was desirable that they, as.

surgeons, should define as clearly as possible their positionin regard to questions of diagnosis and treatment.The following are the officers appointed :-President: Mr>

Christopher Heath. Vice-Presidents: Drs. W. HowshipDickinson, R. Douglas Powell, and C. Theodore Williams;Mr. J. Warrington Haward, Sir William MacCormac, andMr. Alfred Willett. Treasurer: Dr. William Miller Ord.Council: Drs. Thomas Churton, J. Kingston Fowler, A. E.Temple Longhurst, Stephen Mackenzie, T. J. Maclagan,Angel Money, Isambard Owen, F. Charlewood Turner,Samuel West, and W. Hale White; Messrs. T. Colcott Fox,W. H. Bennett, Henry Trentham Butlin, Rickman JohnGodlee, Cuthbert Hilton Golding-Bird, H. Ambrose Lediard,W. Appleton Meredith, C. W. Mansell Moullin, F. ShirleyMurphy, and Charters J. Symonds. Honorary Secretaries:Dr. Thomas Barlow and Mr. R. W. Parker.

MEDICAL SOCIETY’OF LONDON.

InguinczZ Colotomy.-Distribution of Rickets, Acute andSubacute Rheun.atis9t, Chorea, Cancer, and Urinal’)!Calculus in the British Islands.

AN ordinary meeting of this Society was held on the14th inst., Mr. Edmund Owen, Vice-Presidert, in the chair.Mr. HERBERT ALUNGHAM read a paper entitled "An Im-

portant Supplement to the Operation of Inguinal Colotomy."He had observed that after several of his cases of inguinalcolotomy the patients had suffered from a distressing pro-cidentia of the intestine through the inguinal opening. Hehad at first imagined that this had arisen from too large anincision in the groin; acting on this, he diminished thelength of the wound, but the results failed to verify thishypothesis. At length lie came to the conclusion that!procidentia occurred only when the sigmoid mesentery wasof considerable length. By the aid of diagrams he showedhow a lengthy mesentery would allow of procidentia occur-ring at each action of the bowels. To prevent this hedevised the following method of operating in cases wherethe condition of the mesentery was as above described.He pulled out through the wound all of the intestine thatwould possibly come forth. These portions he allowed torest upon the abdomen, and then sutured. From twelvehours to three days afterwards he entirely removed all thesepieces or bunches of intestine, first of all applying a clampabout an inch from the wound to prevent the intestineslipping. Experience taught him that the clamp must bespiked, and must possess a firm and tenacious grip, other-wise severe haemorrhage might ensue. The clamp shouldbe allowed to remain on for twelve hours ; indeed, so longas any slackening of it produced bleeding. A necropsyat St. George’s Hospital on a patient who died some monthsafter undergoing inguinal colotomy had furnished the re-quisite confirmation of his theory, there being no mesenteryand no procidentia. He admitted that this further pro-cedure, by increased danger of haemorrhage, aggravated theseriousness of the operation, but to his mind to allow proci-dentia to occur or to continue, practically nullified the goodeffects of inguinal colotomy. In all cases, therefore, of inno-cent strictureor growth, where the patients were likely to livefor some time, he would draw out, make tense, clamp, andremove the intestine. In bad cases of malignant diseaselie would not carry out this operation. He had treated fivecases by the method above described, and he related thesein detail to the Society. The chief points in the operationwere-1. The fact that pain occurred when cutting throughthe mesentery, but not when dealing with the intestineproper. In the former case the use of ether was necessary.2. The supreme importance of using a spiked clamp thatwould under no circumstances slip or relax its hold; itscorrect use would prevent serious haemorrhage, the onlything really to be feared. 3. The great length and weightof the portions of intestine removed. Specimens were shownvarying in length from four to twelve inches, and in weightfrom three ounces and a half to six ounces. He advocatedthe adoption of his method in lumbar colotomy where pro-cidentia also occurred.-Mr. EDMUND OwEN failed to seehow the slack mesentery could be brought into the woundin lumbar colotomy when the peritoneum was not usually ’i,opened.-Mr. G. R. TURNER had operated by the inguina!method three times, two being cases of malignant diseaseand one a child with imperforate anus. None of these bad has3