1067ROYAL SOCIETY OF MEDICINE : ORTHOPEDICS.

hearing involvement. On opening the orbits from above theorbital tissues were found to be very cedematous, but withthe exception of an increase in the orbital fat otherwisenormal. The lateral ventricles and choroid plexuses werenormal. There were nowhere signs of meningeal tubercle.The conclusion arrived at as a result of the operation

and autopsy was, that this condition originated pro- bably in an attack of cerebro-spinal fever some years previously which had cleared up and left a thickened

pia-arachnoid which interfered with the return flowof lymph from the orbit. The condition, in fact,seemed to be one of lymphatic oedema of the orbitaltissues with most pronounced bilateral exophthalmos.

A CASE OF

SARCOMA OF THE KIDNEY IN AYOUNG BOY.

BY FRANK M. HUGHES, M.D. BRUX., M.R.C.S. ENG.

SARCOMA of the kidney being unusual at an earlyage makes the following case worth recording.A boy, aged 4 years, was brought to see me recently, with

the following history : Six weeks previously he had fallenover a brick on to his abdomen. He was carried home andwas unable to sit up for a week. There were no signs orsymptoms of injury and no vomiting. A week after theinjury he was able to walk, and shortly afterwards appearedquite to have recovered. The child was brought to see mebecause his mother had noticed a large swelling on the leftside of his abdomen displacing the lower ribs and extendingdownwards on the left side. She had observed this whenbathing him a week before.On examination I found a large hard swelling extending

from the left loin down to the anterior superior spine. Itwas quite painless on palpation and dull on percussion. Thechild had obviously recently lost much weight. X rayexamination showed a mass extending from the left loindown to the anterior superior spine and across the abdomenand up towards the right renal region. The diagnosis ofsarcoma of the kidney was confirmed by Sir Hugh Rigby andDr. Cecil Wall. Laparotomy was considered inadvisable.Autopsy was refused.The case is of interest in comparing the diagnosis

with that of a diagnosis of congenital cystic kidney.

A CASE OF

STRANGULATED INGUINAL HERNIA

COMPLICATED WITH TORSION OF AN UNDESCENDED

TESTICLE.

BY C. P. G. WAKELEY, F.R.C.S. ENG.,ASSISTANT SURGEON, KING’S COLLEGE HOSPITAL, LONDON.

THE following case is sufficiently rare to meritrecord :-A youth, aged 19, was admitted to King’s College Hospital

in April, 1922, complaining of a swelling and pain in theright groin. On the day previous to admission, while thepatient was lifting some heavy boxes, he experienced anacute pain in the right inguinal region and fainted. He wastaken home to bed ; he vomited most of the night and wassent up to hospital next day. On admission there was aswelling the size of a hen’s egg in the right inguinal canal ;it was very tender and the skin over it was oedematous. Itwas seen that there was only one testicle in the scrotum andthe patient stated that he had never noticed more than onetesticle. There was a purulent urethral discharge. At firstit appeared that the case might be due to a gonococcalepididymitis in an undescended testicle ; but the vomitingand fainting attack on the previous day suggested a bowelcondition. An incision was made over the swelling in thedirection of the inguinal canal, the right testicle was exposed,and behind it was a knuckle of acutely inflamed small intes-tine. The right testicle was of an almost black colour andwas twisted on its cord. It was not thought justifiable to tryand perform an orchidopexy, owing to the very inflamedcondition of the testicle ; also the vessels in the cord appearedto be thrombosed. Consequently, an orchidectomy wasperformed, and the loop of gut, after enlargement of theopening into the abdomen, was found to assume a morenormal colour, so it was returned to the abdomen. Theinguinal canal was completely repaired. :

Recovery was uneventful. A microscopic sectionof the testicle showed haemorrhages throughout theorgan.

Medical Societies.

ROYAL SOCIETY OF MEDICINE.

SECTION OF ORTHOPÆDICS.

EXHIBITION OF CASES.

A MEETING of this section of the Royal Society ofMedicine was held on Nov. 7th. In the absence of thePresident (Mr. T. H. OPENSHAW), Mr. E. LAMINGEvANS was in the chair.

Mr. H. A. T. FAIRBANK showed two cases of

Ischcrmic Paralysis.The first was a boy, aged 11, who had sustained asupracondylar fracture of the right humerus in May,1918, which was treated " for a few weeks " by splints ;on the removal of the splints contraction of the fingersand thumb was noticed. Massage was given withoutbenefit. In August, 1918, operation was performed ata provincial hospital and some bone removed, andthis was followed by prolonged massage and electricaltreatment. On admission to the Hospital for SickChildren in April, 1922, there was marked flexion ofthe fingers and thumb ; extension could not be per-formed voluntarily and passive extension was onlypossible when the wrist was flexed. There were nosensory changes and no wasting of the intrinsic musclesof the hand, but there was general wasting andweakness of the forearm muscles. The contractureof the flexors was so marked that a diagnosis ofischaemic contracture was made, although no definitehardness of those muscles was detected. Very greatimprovement resulted from treatment by gradualstretching on plaster slab and metal splint, coupledwith treatment in the physio-therapeutic department,and complete cure was anticipated.The second case was that of a boy, aged 9, who

sustained a fracture of the lower end of the righthumerus in December, 1921. No history of the treat-ment then received was available. He was admittedto the Hospital for Sick Children in January, 1922,with typical ischæmic contracture of the right fore-arm. There was flexion of the wrist and inter-phalangeal joints with some hyper-extension of themetacarpo-phalangeal joints, all of which were stiffwith only a small range of painful movement. Thelong flexors of the hand were just acting but there wasno power in the interossei. The general nutrition ofthe hand was very defective and the skin purple.Sensation to cotton-wool was lost over the wholehand on both aspects and to pin prick over the samearea except over the hypothenar eminence and theulnar side of the dorsum. Radiograms showed an oldsupracondylar fracture in very bad position. Only10 of movement from 90° to 100° were possible at theelbow-joint ; there was a scar apparently from a deeppressure sore on the anterior aspect of the forearm.Treatment on the same lines as that adopted for theother case had produced considerable improvement ;but there was still anaesthesia in part of the mediannerve distribution, and the median intrinsics remainedalmost completely paralysed ; while movements atall the joints were defective, and there was only slightpower in the long flexors. Mr. Fairbank invitedopinions as to whether or not the median nerve shouldbe explored.

Mr. W. R. BRISTOW thought exploration of themedian nerve should certainly be carried out with theobject of obtaining a return of the valuable mediansensation in the hand. The physiological division ofthe nerve was probably in the region of its muscularbranches to the pronator radii teres and long flexors,so that little could be done to secure a return ofmuscular power. Mr. Bristow also showed sectionsillustrating the differences in the changes which tookplace in muscle : (a) in a peripheral nerve lesion, and(b) in ischæmic contracture.

1068 ROYAL SOCIETY OF MEDICINE: ORTHOPEDICS.

Mr. P. B. Ro’rn suggested operating on the bonydeformity first, since in his experience of these casesthe deformity was often responsible for the paralysis-the brachial artery and median nerve being stretchedover the bony projection. If this were done the nervemight recover.

tn reply Mr. FAIRBANK said he preferred explorationof the nerve. For the bony deformity at this late stagehe was content to perform t simple osteotomy.

Mr. P. MAYNARD HEATH showed a case of

7’rvcctiora Fracture of the S’mall Trochanter of the Femur.A boy, aged 15, was sitting on the end of his bed and

slipped off, landing on the floor on his buttocks. Heimmediately experienced great pain on the front andinner side of his right thigh and found lie could notraise his right leg. He crawled into bed and wastreated by rubbing and fomentations. He was seenby Mr. Heath eight days after the accident, when therewas no deformity, but active flexion of the hip-jointwas impossible either when lying or standing. Inwalking the leg was swung forwards. Attempts to flexthe hip caused pain shooting down the inner side ofthe thigh. There was tenderness behind the greattrochanter and also in Scarpa’s triangle on deeppalpation. X rays revealed a fracture of the smalltrochanter with very little separation. No retentiveapparatus was employed, and the boy returned toschool, where lie took things easily. He was now(five months after the accident) playing Associationfootball, but there was still some wasting of the thighand buttock. Ludloff’s sign (inability to flex the thighwhen sitting, with deficient, flexion, only about 30°,when lying down) was still present. Mr. Heath saidthat this was a rare condition, this being the twenty-eighth recorded case. Ruhl, who had made a studyof these cases, had come to the following conclusions:(1) This fracture occurs chiefly during the seconddecade, but cases occur in old age. (2) It is anarrestation fracture due to muscular effort to avoidfalling. (3) Ludloff’s sign is the chief symptom.(4) Pain is felt on pressure in the direction of the smalltrochanter either from the ilio-pectineal fossa in frontor from the gluteal fold. (5) The separation is incom-plete, since the thigh can be maintained in a positionof slight flexion, adduction, and rotation outwards.(6) Treatment : rest in bed for two or three weeks withthe thigh flexed, abducted, and rotated outwards,combined with hot-air baths, massage, and activeexercises to induce movement. (7) Should death notoccur from intercurrent disease (a grave risk in oldpatients), prognosis as regards the restoration ofcomplete function is good.

Mr. W. T. GORDON PUGH had had a case of the samenature. This was a boy aged 14, who had previouslybeen under the speaker’s care for acute osteomyelitisof the lower ends of both femora and of the right tibiafrom which he had made a good recovery. He wasdischarged with good movement. Three months laterhe was readmitted to Queen Mary’s Hospital with ahistory that while running and in the act of lifting theleft thigh he heard a crack and felt a severe pain inthe inner part of the left groin. He did not put theleft foot to the ground but fell over to the right.There was no deformity or shortening, but all thighmovements were slightly limited and painful. X raysrevealed a fracture of the lesser trochanter, whichunited in the displaced position after treatment by Iflexing the knees over pillows. On his discharge five months later there was full movement and notenderness.

Mr. ROTH had had a private patient in whomhe had diagnosed this fracture, but he had been unableto confirm the diagnosis by X rays.

Mr. D. MCCRAE AITKEN had seen a case in a managed 60 who complained of pain and limitation ofmovement. Movements were improved by massagebut the pain continued.

Mr. FAIRBANK had inflicted this injury on a boyaged about 10 or 11 during manipulation of thehip, fortunately without serious inconvenience to thepatient. ’

Mr. AITKEN showed radiograms of three differentstages of

Osteo-Choidritis of the Hipin three members of the same family-T. M., aged 7(male) ; and A. M., aged 13, and R. M., aged 20(females), In addition to the hip condition A.M.had a, slight luxation forwards of the upper ends ofboth radii, and R. M. had developed considerablelimitation of movement of both radii associated withhtxation of the heads of the radii and scoliosis.X ray plates of the last case showed arthritic changesof the head of the femur in addition to some mush-rooming.

Mr. ll. C. ELMSLIE recalled a paper by Calot onsubluxation of the head of the femur associated withcoxa pla,na.

Mr. A. H. TUBBY regretted that he had not obtainedlate radiograms of three cases of congenital disloca-tion of the hip in members of the same family, all ofwhich he had treated.

Mr. FAIRBANK suggested that the cases were ofarthritis rather than of true pseudo-coxalgia. Theappearances in the X rays suggested to him anulcerative or absorptive arthritis.

1fr. LAMING EvANS inquired whether there wereany signs of rickets in the three cases.

Mr. AITKEN, in reply, said that there was noevidence of rickets in any of the cases, and that hehad not seen Calot’s paper. While he agreed that inthe eldest case there were definite arthritic changessuperimposed on the original osteo-chondritis. headhered to his original diagnosis.

Mr. HEATH also showed a case of

Subluxation of the harzer End of the Right Claviclein a man aged 30. There was no history of directinjury, but the condition was thought to have occurredduring the unaccustomed exercise of bowling. At thesame time there was severe pain behind the right ear.The swelling had not altered since first observed lastJune, but there was still severe pain in the back ofthe head during certain movements of the right armand pain in the right shoulder when lying down.Examination shQwed a prominence of the inner endof the right clavicle, and X rays revealed no enlarge-ment of the bone. He asked for suggestions as totreatment.

Mr. TuBBY had had a similar case in a man aged 55,and he agreed that treatment presented a difficultproblem. In his case he had eventually operated andscraped out a quantity of gelatinous material whichproved on microscopic examination to be thyroidtissue. There was no evidence of a growth else-where. For Mr. Heath’s case he suggested explora-tion if ordinary treatment by counter-irritation failed.

Mr. BRISTOW showed a case of

Tendon Transplantation.The patient suffered from a gunshot wound of thethigh in 1918. He had a large scar on the front ofthe thigh ; the quadriceps extensor femoris was notfunctioning, and he was unable to extend the knee.The biceps and some of the inner hamstrings weretransplanted to the front, and attached to the patellaat a hospital in the country. The patient stated thathe was worse as a result of this operation, for althoughhe could strongly extend the knee-joint he could nolonger flex it more than a few degrees on walking.He was unable to flex the knee against gravityexcept when lying on his face, when 15° to 20° offlexion were possible-the transplanted muscles andthe remaining hamstrings both acting strongly. Thevastus internus, which had recovered, remainedflaccid. It therefore appeared that the transplantedhamstrings still acted with the flexors. Dr. J. Sains-bury (in charge of the Physical Training Departmentat Shepherd’s Bush) thought further treatmentby physical means, by which the patient had alreadybeen treated for nine months at another hospital.unlikely to be successful. While there was un-

doubtedly a mental factor in the case, Mr. Bristowwas inclined to think the only available treatmentwas to undo the transplant.

1069MEDICAL SOCIETY OF LONDON.

llr. FAIRBANK, Mr. ELMSLIE. Mr. PUGH, and othersagreed that the transplant should be undone.Mr. ELMSLIE showed two cases of

Congenital Deformity of the Upper Limbs.The first case was that of a boy, aged 15, who had

formerly been under the care of Mr. Openshaw forcongenital deformities of the arms and bilateral

congenital talipes equino-varus. He had been treated

by manipulation of the feet and division of the

plantar fascia at the age of 3 years, and four yearslater the wrists were manipulated and plaster applied.In 1916 the right elbow was fixed in plaster at a rightangle. In 1922 the patient came under the care ofMr. Elmslie. He then had bilateral talipes equinuswith much wasting of the legs. The hands were heldfully pronated, with the elbows extended and wristsflexed. There was marked wasting of the shoulders,arms, and forearms, but there was some power in theflexor and extensor muscles of the forearm and hands.)Ir. Elmslie had treated the left foot (which was moreseverely affected) by osteotomy of the fibula and ofthe neck of the astragalus, followed by wrenchingand plaster. The hands were manipulated andextended by splinting. An arthroplasty was per-formed on the right elbow. The second case was oneof congenital deformity of the upper limbs in a littlegirl, The deformity strongly resembled that seen inErb’s paralysis, but was symmetrically bilateral, sothat he regarded it rather as a congenital deformitythan a birth palsy.

lfr. BRISTOW congratulated Mr. Elmslie on theimprovement already obtained in the first case. Hehad a similar case now under his care which hadpreviously been treated by unnecessarily severe andprolonged splintage, and had developed a certaindegree of ischaemia in consequence. He thereforethought that in such cases periods of splintage shouldalternate with periods of physical treatment.Mr. BujNDELL BLANKART remarked that the first

case had good scapular movement which might bemade use of by arthrodising the shoulder. The littlegirl, he thought, would benefit by a similar operationto that performed for Erb’s paralysis.In reply Mr. ELMSLIE said he still had the question

of performing an arthrodesis of the shoulder underconsideration, but up to the present was concentratinghis efforts upon attempting to get the patient’s handsinto such a position that lie would be able to feedhimself.Mr. ROTH showed a case of

? Injury to Epiphysis of Left Acromion Process.The patient, a girl aged 16, complained of pain in

the left shoulder which had lasted intermittently forfour months and was relieved by resting the arm. Onexamination at hospital the tip of the acromion was acutely tender, there was marked limitation ofabduction, and all movements of the shoulder pro- duced pain. X ray examination showed partial (fusion of the left acromial epiphysis with displace- ]ment upwards, whereas on the right side the epiphysis remained distinct. The patient improved with restto the arm in a sling, but pain recurred on using the arm contrary to advice. tMr. BLANKART suggested a diagnosis of neuritis s

since there was no history of injury, and he thought che could feel a tender nerve running down over the c

spine of the scapula.Tendon Transplantation for Talipes.

llr. LAMING EvANS showed a girl, aged 9, in whom c

he had performed a tendon transplantation for para- v

lytic talipes equino-varus. Treatment by rnanipula- J.tions and instruments having failed, he had trans- e

planted the tibialis anticus tendon to the base of the nJifth metatarsal, thus converting it into a pronator, awith a satisfactory functional result. pMr. BRISTOW, while complimenting Mr. Evans upon b

the excellent result obtained, could not agree that the btibialis anticus had now been converted into a pronator. He would rather say that by putting the atibialis anticus into its new insertion the muscular nbalance of the foot was restored. b

MEDICAL SOCIETY OF LONDON.

PERNICIOUS ANEMIA.

A MEETING of this Society was held on Nov. 13th,with Lord DAWSON OF PENN, the President, in thechair.

Dr. P. N. PANTON introduced the discussion onPernicious Anaemia. He said that this condition wasuncommon, and was almost invariably fatal. Duringa period of 11 years 117 cases had been collected atthe London Hospital. In this disorder we did notknow whether we were dealing with a single clinicalentity derived from a single underlying factor, or agroup of associated conditions with differing factors.Pernicious anaemia was a condition of very severeanaemia which could not be accounted for by thepatient’s history nor by cl inical examination. It wasevidently the result of a slow and continuous internalhaemolysis, not of a sudden one as in paroxysmal haemo-globinuria or in poisoning by arsenuretted hydrogen(AsH3) gas. This clinical picture was associated witha constant and well-defined blood picture-a low redcell count, with a high colour-index, and the presenceof abnormal red cells (more particularly megaloblasts)in the peripheral circulation. This association ofclinical state and blood picture defined the disorderand made diagnosis comparatively simple. Theclinical state alone might occur in a very differentpathological process, as aplastic anaemia, or the bloodstate alone might occur in poisoning from AsH3 gas.Achylia, glossitis, fever, and intestinal disturbanceswere features . fairly constantly associated withpernicious anaemia, but associated conditions were rare,with the exception of subacute combined degenera-tion of the cord. Fatty degeneration of the heart,free iron pigment in the internal viscera, and hyper-plasia of the red marrow were found post mortem-Dr. Panton proposed dealing with the following facts.emerging from study of the 117 cases admitted to theLondon Hospital between 1909-1920 inclusive : oral;sepsis, achylia, pyrexia, treatment.

Oral Sepsis.In 13 of the cases studied there was no record of

the state of the mouth, and among the other 104patients in only 21, or in about 20 per cent., was thereno past or present dental sepsis. Taking into accountthe average age (46 years) and the class of patient.the speaker did not consider that the evidence thatoral sepsis had any bearing on the aetiology of per-nicious anaemia was very striking. It could not bedenied that secondary anaemia might result fromseptic absorption in the mouth, and in this case dentaltreatment was indicated. If cases with oral sepsisand secondary anaemia with perhaps some poikilo-cytosis of the red cells were diagnosed as perniciousanaemia, and their oral sepsis were cured, they wouldrecover. In this connexion it should be emphasisedthat the haematological diagnosis ot perniciousanaemia from a blood film alone was unjustifiable.Many of the patients in the series considered receivedthe most thorough dental treatment, but Dr. Pantonsaid he had never been convinced that a single caseof true pernicious anaemia had been cured as a resultof this treatment.

Achylia.This condition was almost invariably present in

cases of pernicious anaemia, and associated with itwas an atrophy of the gastric mucous membrane.. ..Achylia was present in 33 of the 35 cases of the seriesexamined for this condition. The achylia of carcinomanight rarely produce a blood picture similar to,alhough never absolutely identical with, that ofpernicious anaemia. The artificial achylia produced)y gastrectomy had been stated to have been followed)y pernicious anaemia. The speaker had never seenuch a case. Pernicious anaemia might occur withoutachylia; achylia frequently occurred without per-Licious anæmia; secondary anaemia might be followed’y achylia, and this when once set up, might persist