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CLINICAL SOCIETY OF LONDON.-

Symptoms resembling Myxædema.—Enlargement of theLower Lip.—Transpatellar Excision of the Knee.

THE annual meeting of this Society was held on Friday,the 12th inst., Mr. J. Lister, F.R.S., in the chair. The lasthalf hour of the time was devoted to the special business ofthe annual meeting. The cases described were : one of a childpresenting many of the appearances of myxoedema, one ofremarkable hypertrophy of the lower lip cured by operation,and one of excision of the knee-joint by an incision carriedthrough the patella.Dr. COXWELL related the case of a child, aged thirteen,

with symptoms resembling those of Myxoedema. Untileight years of age she differed in no way from other children,and could read, write, and learnt arithmetic. A greatchange then came over her; she would often fall asleep evenwhen eating her meals ; her memory became defective, andif sent to do anything she would wander about in an aimlessfashion. Later her speech became thick and indistinct, shesuffered from headache, her head drooped forward on to herchest, her hands and feet became very cold, her legs becameweak and her gait unsteady. She was lately a patient inthe National Hospital for the Paralysed and Epileptic,under the care of Dr. Hughlings Jackson. The appearanceof her face is very suggestive of myxcedema, her skin beingtranslucent, with a circumscribed patch of redness in thecentre of the cheeks, the lower eyelids swollen, the nosebroad, the eyes prominent and heavy looking. Her limbsare slender and well formed. The thyroid gland seemsdiminished, and there are no abnormal fatty tumours in theregion of the neck or elsewhere. While under operationher temperature was frequently as low as 956°. She wasoften extremely restless at night, and had frequent attacksof screaming. Her power of speech became worse, till atlast she could hardly utter a single sound, the lips being seento move ineffzetually while she attempted to do so. Shecould not kiss her mother or puff out her cheeks, and herfood would often remain seven or eight minutes between herteeth and lios. There was a general over-clouding of theintellect. Dr. Coxwell drew attention to the fact that verypronounced mental disease has been reported in myxcedema,and that Dr. Ord has had a patient suffering from thatdisease with marked affection of the bulb, a point ofsimilarity with the present case of some importance. If thecase was one of myxcedema, it was of interest as beingthe first recorded in a child. If it was one of simpleimbecility, it was remarkable on account of the bulboussymptoms and the likeness it bore to myxoedema. The argu.ments in favour of sporadic cretinism were few, and werEout-balanced by the absence of most of the characteristics 01that disease.

Mr. J. N. C. DAVIES-COLLEY read notes ot a case ot

enormous Enlargement of tke Lower Lip, cured by operation.Richard B. D-, a clerk, aged thirty-six, was admittedinto Guy’s Hospital in August, 1881, with a remarkableswelling of the lower lip. Fourteen years before he had achancre (?) on the penis, followed by soreness of the tongueand swelling of both lips, especially the lower. There wasnever any rash on the skin. He was a very great drinker.The lower lip was of enormous size, everted and pendent, sothat its border was on a level with the tip of the chin, whilethe lower teeth were in front completely exposed to view.The mucous membrane was fissured in parts, but otherwisenatural. The tissues were a little firmer than usual, butnot at all indurated. There was a little tenderness on pres-sure. From side to side it measured three inches, fromabove downwards an inch and a quarter, and in thicknessseven-eighths of an inch. The upper lip and tongue showedsigns of chronic inflammation. There was no enlargementof the adjacent glands. He left off smoking, and was atfirst treated with anti-syphilitic remedies. The mucous mem-brane became more healthy, but the lip remained of the samesize. Some reduction was then effected bv pressure betweenthin slips of wood. The lip became smaller and flaccid, bu1was still everted and’pendent. On November 8th a V-shapecpiece was removed from the centre of the swollen lip, and arapid recovery ensued. When last seen he had no longe-any eversion of the lip, which had assumed a perfectlyhealthy and normal aspect. Mr. Davies-Colley brought thecase forwaid as a striking example of the enlargement o

the lip which occasionally results from chronic inflammation.There was nothing in the patient’s family history to indicatea scrofulous tendency. The evidence of secondary syphiliswas doubtful, and there was no record of mercurial salivation.On the whole, Mr. Davies.Colley was disposed to attributethe ’disease primarily to syphilis and secondarily to theirritation of the inflamed surface by excessive smoking. Mr.CLEMENT LUCAS had seen this case, the interest of which,he thought, lay rather in its cause than in its cure. Hebelieved that any chronic ulceration of the lip might producesuch hypertrophy. He thought that the so-called strumouslip was far oftener due to congenital syphilis than tostruma. He suggested that the internal use of mercurymight have had some effect upon producing this hypertrophy.He remarked, too, that smoking was very injurious inthose suffering pain from secondary svphilis. as it keptup the ulceration of the lips and tongue. He referredto a young lady who suffered from chronic thickeningof the upper lip in which there were two lateral incisorswhich were carious and stopped, and at the bottom of oneof them was a sinus. On extracting these two teeth theoedema quickly subsided. He asked whether the teeth inMr. Colley’s case wereall sound.-Dr. HADDEN thought thatthis hypertrophy corresponded to a form of lymphatic ob.struction which had been described by certain Germanauthors as occurring in the tongue : the microscopic appear-ances bore out this view. He did not think the evidencepointed to the syphilitic nature of the affection.-ProfessorLISTER thought the case very interesting from its rarity,and also from the success of the treatment, for the partof the lip left behind returned to its normal size, and inthis respect it resembled the contraction of an hypertrophiedtonsil after excision of its more prominent portion, with atthe same time lessening of the thickening of the Eustachiantube and the neighbouring parts, and thus improvementof hearing, so often observed after this simple operation.The same thing happened in lipoma of the nose. In acase where he had removed the greater part of a largeunsightly mass of chronic inflammatory thickening, theneighbouring diseased part of the skin improved and thenose was now almost normal.-Dr. MEADOWS mentioned

, the case of a lady with enlarged mons veneris and labium,: which he removed with an ecraseur. Although only thirty-, three years of age, menstruation entirely ceased in two or. three months, probably from sympathetic atrophy of the

ovaries.—Mr. DAVIES-COLLEY remarked that the tension ofthe parts of the lip left and the correction of the pendulousposition of the lip were important in leading to the recoveryof the parts not excised. He did not see any evidenceof lymphatic obstruction; there were no enlarged glands.He had no note on the condition of the teeth exceptthat the necks of the exposed teeth were denuded byretraction of the gums, and were thickly covered with tartar.He thought the hypertrophy was due to secondary syphilisand to the continuous irritation of tobacco smoke.Mr. GOLDING-BIRD read a paper on a case of Transpatellar

Excision of the Knee, which he had previously exhibited tothe Society. The operation was in the person of a lad, agedthirteen; fairly healthy himself, but with a family historyof phthisis. There was a year’s history of articular ostitisof the right knee with pulpy disease. Excision was even-tually performed on May 9th, 1882. It differed from an

ordinary excision in that the transverse incision was madeacross the middle of the patella, which was then sawn intwo, the two fragments, with the soft parts, being turnedup and down. The excision was then completed as usual,the articular surfaces of the tibia and femur being

removed. Some pulpy thickening was removed fromthe underside of the patella, and when the limb hadbeen straightened two carbolised silk sutures were passedthrough its substance, and its two fragments thus united.Primary union was obtained, and nothing more was seen ofthe patella sutures. Until September 12 di he walked aboutwith a stiff bandage at the knee and with crutches ; afterthat date he was ordered to discard all support. He nowhas a movable patella and half an inch shortening He hasall the advantages of retaining the patella; but besides that,there is a gain by this method of operating, since the surgeoncan freely examine and manipulate the joint, more freely,indeed, than where, with the idea of retaining the knee-cap,the lateral incisions are employed. Two great advantagesremain to the patient by keeping the normal attachmentsof the patella: The quadriceps opposes the ham-strings, sothat the necessity is obviated of employing a stilff bandage

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for years to prevent posterior displacement of the leg;the rectus femoris, considered as arising below, has itsfull play upon the trunk in preserving equilibrium, whilstit also allows of the perfectly natural forward motion of thelimbs in walking; this last is not the case where the liga-mentum patellæ has been sacrificed.-Mr. HOWARD MARSHthought all surgeons must be disatisfied wi’h mauy of theresults of excision of the knee, znd he was very glad of thissuggestion of Mr. Golding-Bird’s, which seemed to be anobvious improvement.-Mr. GANT thought that it was rareto find the patella not involved in the disease when excisionof the knee was necessary. When not diseased he had leftthe patella, and he had not seen any advantage from sodomg. His results after removal of the patella had beenvery good. In the average of his cases of excision the uniontook place in three months, and he then put on a

movable back splint for a fuither three months or le"s.In one case, a woman aged fifty three, the patient was upwithin two montha and a half.-Mr. C. HEATH said Mr.Golding-Bird’s case was a very successful one; but heagreed with Mr. Gant that in most of the cases usually sub-mitted to excision the patella was diseased ; in fact, whenthe patella was free an argument against excision wasfound. He thought that Mr. Golding-Bird’s case was in anearly stage of disease, and might possibly have been treatedby other means. He thought, too, that even where theepiphysial cartilage was not, to all appearance, interferedwith, the operation was attended with impaired growth ofthe limb.-Mr. LISTER said that many years ago Volkmannadvocated the transpatellar excision of the knee. If bethought only of the old-fashioned excision of the knee incases with open sinuses, and without strict asepsis, he should

quite agree with Mr. Gant. But if the skin were un-broken, he would proceed on totally different principles;he would remove a much smaller part of the femur, havea broader surface for union with the tibia, and cause

less shortening. In such a case none of the patellaneed be taken off, and possibly the lagging behindof the growth of the limb might be prevented by leaving theaction of the quadriceps unaffected. He was, however,doubtful whether excision of the knee was really needed inMr. Golding-Bird’s case. In many similar cases in his prac-tice free antiseptic incision, with scraping away of the diseasedsynovial membrane and gouging out of diseased bone, had pre.served limbs of normal length, and even movable at the knee-joint.-Mr. GOLDlNG-BiRD, in replv, said that the case wasone which might have succeeded under such treatment as Mr.Lister had described. At the time of the operation therewas some lateral movement with grating in the joint, andthe ligaments and fibro-cartilages were replaced by pulpytissue. If the case had been in private he should not haveoperated, but his experience with hospital out-patients wasthat if left alone they ended unfavourably. He thoughtthat, in young people especially, when the patella wasremoved there was a tendency to posterior displacement ofthe tibia, to guard against which it was necessary to wearsome form of apparatus for months or even years.The business of the general meeting was at this period

proceeded with, and subsequently the meeting adjourned.

MEDICAL SOCIETY OF LONDON.

A Case of Anæsthesia and Analgesia.—Tension of theAbdomen and its Variation.

A MEETING of this Society was held on Dec. 15th, 1882,Mr. F. Mason, Present, in the chair.

Dr. DE HAVILLAND HALL read notes of a case of Anæs-thesia and Analgesia. The patient, a boy twelve and a halfyears of age, had suffered

" on and off with headache since

a fall upon the chin three years before; and two weeksbefore admission he is said to have tempora,ily lost powerin the right band and arm. He occasionally fell down, andfive days before admission had a fit in the night. He,however, appeared quite well when seen, and complainedonly of some pain and tenderness in the right thigh and lossof feeling in the thumb. At times he saw everything "red."Examination proved the thumb to be perfectly anmstheticand analgesic—a condition which obtained to a certain degreeover the whole body. On Dee. 5th he complained of head-ache ; on the 6th, of pain in the lower part of the legs ; andon the 7th there was found perfect anaesthesia and analgesiain both legs, from the soles of the feet to an inch and a halfabove the patella. He could walk well, but said he

could not feel the ground under him. The special tenses arenormal beyond slight deafness in right ear, attributable toa chronic otorrhoea, and impairment of the smell in rightnostril and of taste in the right half of the tongue. Therewas no history of diphtheria. His father had epilepsy. Thecase was brought forward on account of the sudden appearanceof anaesthesia in the legs, which may disappear as suddenly.The boy suffered much from worms.—Dr. OWEN suggestedthat the cause of the complaint might be in the digestivetract.-Dr. WILTSHIRE alluded to a case in which pain inone arm, with hyperaesthesia, followed by ascending paralysisof the limb, followed a blow on the thumb. The patient, ayoung lady, rapidly recovered under mercurial friction. Healso mentioned a similar case produced by a fall on thehand ; and a case of sciatica relieved by like treatment aftermorphia had failed. The morbid condition ascended inthese C9ses from the injured extremity towards the cord.-Dr. HERON thought the exaggerated tendon reflex pointedto some cerebral lesion, and suggested that the case was oneof contrecoup.

Dr. BRAXTON HICKS read a paper on the Tension of theAbdomen and its Variations. First of all alluding to theform of the abdominal cavity, and its natural tendency toassume the spheroidal shape, unless interfered with by itsbony wall, the author discussed the physical conditions ofthe viscera within, or implanted, or attached to its walls,He then described the tension normally existing both be.tween and during respiration, pointing out work he hadalready done and published in the Royal Society’s Pro.ceedings, and that the respiratory movement of the abdo-men could be registered as a wavy line on the drum of aniustrument, like the cardiograph. He then demonstratedthat the effects of body and jimb movements were verypowerful on this wavy Ime, and that tension was not onlyincreased thereby, but also lessened to a similar degree, andthat thus the belief of many obstetricians that at timesthere was an insuck into the cavity, received confirmation.This being accepted, the author then pointed out the con-clusions which followed, of much importance practically-namely, that any opening existing, it was possible by anysudden movement for any irritating orseptic matter to be drawninto that opening, whether it ends in a lymph space, veins, orperitoneum, and as pressure was momentarily taken off fromthe vena cava and iliac veins, a rush from the veins belowwould occur, which might detachand move heartward any clotin the ftmoral vein. Dr. Hicks then showed the effects ofincreased tension on the organs and on the muscular system,both of the abdomen and general body, and the effects ofthe opposite state, showing that without external supportthe abdominal vessels unduly filled, robbing the generalsystem of so much of its blood, causing the shrivelled,flabby, and worn-out appearance of those who had lost alongwith the flaccidity of their abdominal walls the tone of thevascular system, and that the abdominal vessels being fullof blood, a facility for hæmorrhage from uterus or bowel, &c.,is given. The effect of relaxed peritoneum, as bearing onthe positions of liver, uterus, &c., was then noticed, as alsothe effects of the pressure from within on the pregnantuterus. The paper ended with allusions to many otherpoints flowing from the consideration of the subject..

OPHTHALMOLOGICAL SOCIETY OF THEUNITED KINGDOM.

Growth of the Crystalline Lens.-Paralysis of the T7tlrdNerve, with Cerebral Symptoms.—Paralysis of the SixthNerve, with Choreiform Alovements of the Face.—Move-ments of the Eyes in Ear Disease.-Peeuliur Growthdeveloping from a Cidiuna to the Anterior Chamber.THE ordinary meeting of this Society was held on the

llth inst., Mr. W. Bowman, F.R.S., President, in the chair., Mr. PRIESTLEY SMITH read a paper upon the Growth ofthe Crystalline Lens, commencing by a quotation from thechapter by Otto Becker, in the Handbook of Graefe andSanniscb, to indicate the present position of knowledge onthis subject. He then proceeded to describe an originalresearch carried out during the last two years. He hadexamined 142 lenses, removed in their capsules shortlyafter death, from the eyes of eighty-three adult subjects.Special precautions were taken to avoid changes from ab-sorption or evaporation of moisture. Each lens was accuratelyweighed, its volume was then measured by means of a

specially-devised instrument, acting by displacement of fluid