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has of late years been so reduced that it adds little or

nothing to the mortality of an operation, and again, in allthe methods of radical cure now practised the sac, havingbeen isolated, is opened to insure its being empty ; conse-quently the abdominal cavity is opened in one case as muchas in the other.

Description of operation.-The patient having been pre-pared and anaesthetised in the usual manner, an incision ismade two and a half inches long commencing in the semi-lunar line and ending over the external abdominal ring. Thisincision extends in its whole length through skin, super-ficial fat, fascia, &c., and exposes the external abdominal

ring in its lower part. The upper one and a half inches ofthis incision are now prolonged down through the abdominalmuscles, &c., the peritoneum is exposed, and all haemorrhagehaving been stopped the peritoneum is opened. A finger isnext introduced through the opening into the peritonealcavity and passed downwards through the internal ring intothe hernial sac, which is then thoroughly and carefullyexplored. There being no adhesions between the sac and theabdominal contents these are steadily and carefully reducedby means of the hand outside and finger inside. Havingemptied the sac, the first finger being still insideand used as a director, a pair of volsellum forceps arepassed along its palmar surface and the apex of the sac isseized and brought up inverted into the upper part of thewound. Having thus got the inverted sac into the upperwound it is twisted once or twice on itself to obliterate itscavity and stitched carefully to the cut surface of the peri-toneum with fine silk or stout catgut and the abdominalcavity thus closed. The pillars of the ring are then broughttogether with fine silk sutures, taking care not to inj are thestructures of the cord. The abdominal muscles are next

brought together in layers over the upper part of the incisionand the edges of the skin are brought together with con-tinuous or interrupted sutures of silkworm gut.To recapitulate, the operation may be divided into seven

stages: (1) an incision two and a half inches long in the lineasemilunaris, ending over the external abdominal ring andpassing through skin, fat, and superficial and deep fascia;(2) deepen the upper one and a half inches through theabdominal muscles, transversalis fascia, and subperitonealfat, and having arrested all hemorrhage open the peri-toneal cavity; (3) explore the sac with the finger andremove any gut ; (4) insert forceps along the palmar surfaceof the finger, seize the apex of the sac and invert it, bringingit out into the upper wound ; (5) stitch the sac, after givingit a couple of twists on itself to obliterate its cavity, to theperitoneum; (6) stitch up the external abdominal ring ; and(7) close the wound by bringing the structures layer by layerinto accurate apposition.The advantages claimed for this operation by Mr. Symonds

are as follows. Firstly, it is expeditious. The most tedious. part of a radical cure is often tha finding of the sac, itssubsequent separation from the structure of the cord, result-ing in many cases in considerable manipulation andfrequently laceration of the walls and contents of theinguinal canal and scrotum-by this method the sac is ’,found immediately. It might be argued that there would beconsiderable difficulty in seizing and inverting the sac, butsuch is found not to be the case, and if it should occur onestill has the advantage of immediately defining and exploringthe sac before proceeding further. The following case is anillustration of this point. A well-built labourer, aged 36years, was admitted to the Radcliffe Infirmary for rightinguinal hernia. 12 months previously he had been operatedupon for the same thing, but three days after the operation hedeveloped pneumonia and was very ill for three weeks withcontinuous cough. Owing to cough and straining the woundhad given way and he had since been obliged to wear a truss.In this case Mr. Symonds decided to operate by the intra-peritoneal method, though owing to previous operation andhaving worn a truss he anticipated some difficulty in in-verting the sac. On exploration omentum was adherent tothe sac, but it inverted readily and the omentum was strippedo:ff in the upper wound where any bleeding could be easilyseen and arrested. Secondly, the neck of the sac isobliterated high up. Thirdly, the inverted sac aids in

forming a firm scar. Fourthly, the sac and contents canbe explored and if necessary the sac opened below quicklyand safely. Fifthly, the incision allows any methods ofclosing the inguinal canal and external ring to be carried outwhich the operator may desire.Banbury, Oxon.

A CASE OF PRIMARY CARCINOMA OFTHE VERMIFORM APPENDIX.

WITH REMARKS.

BY T. R. C. WHIPHAM,, M.B. OXON.,, M.R.C.P.LOND.,MEDICAL REGISTRAR TO ST. GEORGE’S HOSPITAL.

THE patient, a female, aged 45 years, was admitted intoSt. George’s Hospital on Sept. llth, 1900, under the care ofMr. G. R. Turner, with great swelling of the abdomen anda tumour in the left iliac region which was diagnosed ascarcinoma. Surgical interference being deemed impracticableshe was transferred to the care of Dr. F. G. Penrose, towhom I am much indebted for permission to publish thecase. There was nothing noteworthy in the patient’s historyand she had always enjoyed good health until five or sixweeks previously to her admission. From that time, how-ever, she had been rapidly losing flesh and strength, and forthe last fortnight had noticed that "the stomach was

swelling " and that she had passed very small quantities ofurine. Defecation was normal and regular. Her conditionon admission to the hospital was one of marked emaciationand her complexion had a malignant sallow tinge. Theabdomen was much distended and tender, the skin beingwhite and shiny, with cedema present over the lower part.The superficial veins on the abdomen and lateral aspects ofthe chest were enlarged. In the left iliac fossa and theadjoining part of the hypogastrium was a large, bard,irregular mass of about the size of two fists and arisingapparently in the pelvis. There were dulness in the flanks,though unaltered by position, and a marked thrill as of freefluid in the peritoneal cavity. The liver was not apparentlyenlarged. The legs were. slightly oedematous. Per rectuma large mass was felt in Douglas’s pouch, but a vaginalexamination by Dr. A. F. Stabb failed to throw any furtherlight on the case. No enlarged glands were felt. The urinewas normal and the temperature was not raised. The courseof the case was one of steady decline accompanied byoccasional attacks of vomiting. The patient was keptunder morphia for the relief of the pain and she died onOct. 3rd.At the necropsy the abdomen was found to be greatly dis-

tended by a large quantity of serous effusion. The peritoneum over both the parietes and viscera was denselystudded with innumerable nodules of growth, a large numberbeing on the abdominal surface of the diaphragm. Theintestines were matted together, the omentum was thickenedand infiltrated, and the mesenteric glands were enlarged.

Vermiform appendix in transverse section, actual size, showinggreat thickening of the intima. M, Mesentery.

Throughout its entire length the mucous membrane of thealimentary canal was intact, with the exception of a smallportion at the origin of the vermiform appendix which wasoccupied by new growth. One or two secondary deposits ofthe size of peas were found in the liver, and the left ovarywas transformed into a mass of growth measuring aboutsix by four inches, the surface of which was irregularand presented some minute cysts. In the right ovary wasa unilocular cyst of the size of a cricket-ball. The otherviscera showed no signs of new growth. The lymphaticglands in the neck, in the anterior mediastinum, and in thegroins were hard and enlarged.

The above case, in which I performed the necropsy, is

320 ’

interesting on account of the rarity of cases recorded inwhich the appendix has been the seat of a primary carcino-matous invasion. That this was the case in the presentinstance there is apparently but little doubt. To the naked

eye cross section of the appendix showed a notable increasein the thickness of the inner coats with but comparativelyslight involvement of the muscular layers, and none of theperitoneal, points which are well brought out in the accom-panying drawings of a transverse section (Fig. 1 and Fig. 2.).The mucous membrane is seen to be extensively involved byspheroidal-celled carcinoma, some of the gland tubes show-ing early proliferation of their cells, while the muscularcoats are invaded to a much less degree. That thiswas the only part of the intestinal tract involved

points strongly to its being the original focus of thedisease, and the cancerous condition of the left ovary maybe considered as due to dissemination, that organ beingliable to infection in cases of abdominal carcinoma. To Dr.H. D. Rolleston my thanks are due for the expression of his

of the appendix is overlooked are: (1) that appendicesafter removal are not submitted to microscopical examinationas a routine practice ; and (2) that in dissemination of thedisease the appendix may be involved in a large mass ofgrowth implicating the csecum or other parts which may bethought to have been the origin of the affection. In Dr.Rolleston’s case it may be noted that the appendix wasexamined more or less by chance, and in the present case itwas fortunately lying comparatively free.The literature of the subject up to the date of his case is

fully set forth by Dr. Rolleston in the article above referredto, but he has kindly drawn my attention to the fact thatsince then Elizabeth Hurdon has recorded a case of primaryspheroidal-celled carcinoma of the appendix in a woman,aged 24 years, who was thought to have a floating kidney.The appendix after removal was found to have a small ovalswelling projecting into its lumen so as practically toobliterate it. On further examination it proved to be carci-noma. Kelly 3 has collected from literature 18 cases of

opinion on the microscopical evidence which is in accordwith this view. It is further remarkable that Dr. Rollestonhimself recorded a case of primary carcinoma of the

appendix 1 which occurred at St. George’s Hospital as

recently as in March last, though from a clinical point ofview these two cases afford a marked contrast. In neither,it is true, was cancer of the appendix suspected. Dr.Rolleston’s case was apparently one of ordinary relapsingappendicitis, whereas the present case ran a course which isusually associated with malignant disease and presented nosymptoms of the appendix being involved.

It has been stated that primary carcinoma of the vermi-form appendix is perhaps not quite so rare an affection ashas been commonly supposed, and certainly the occurrence ofthese two cases at St. George’s Hospital within a period ofseven months would favour that view. The reasons why cancer

1 THE LANCET, July 7th, 1900, p. 11.

primary cancer of the appendix, and to this number he addstwo of his own which were both of the spheroidal-celledvariety. He also describes an endothelioma and refers tothe previously published cases of an endothelial sarcoma byGlazebrook and of a psammoma by Kanthack and Lockwood.Innocent tumours of the vermiform appendix, according tothe same observer, appear to be even rarer than are those ofprimary malignant disease, and he has only met with twocases of fibro-myoma of the appendix, both of which wereassociated with similar growths in the uterus. As evidenceof the large amount of work that has been done in thisdirection it may be noted that during the years 1897-1899Kelly examined 706 appendices removed by Deaver at theGerman Hospital, Philadelphia, while Maydl and Nothnagelhave analysed altogether 41,838 necropsies performed in

2 Johns Hopkins Hospital Bulletin, July-August, 1900, p. 175.3 Proceedings of the Pathological Society of Philadelphia, 1900, p. 109.

Transverse section of the vermiform appendix under a low power.

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ienna, including 3585 cases of carcinoma, and found that in two only was the vermiform appendix primarily affected.

Grosvenor-street, W.

Clinical Notes :MEDICAL, SURGICAL, OBSTETRICAL, AND

THERAPEUTICAL.

A CASE OF DIPHTHERITIC PARALYSIS.

BY A. J. RICE OXLEY,, M.B. DUB.

THE following notes of a case of diphtheritic paralysisafter very slight sore-throat are so interesting and emphasiseso clearly some of the points referred to by Dr. E. F.Trevelyan in his able paper that I venture to think theymay be worth recording.A boy, aged 10 years, was brought to me some little time

ago by his father who stated that the boy could not swallowproperly, fluids returning through his nose, and that therewas something in the throat or nose causing this state ofthings. He wished to know if an operation was necessaryfor the removal of the obstruction. Two medical menhad seen the boy and one of these said he hadfound the growth and was very anxious to have the

boy anaesthetised and operated on without delay. I- elicited the fact that the boy’s sight was also so muchinterfered with that he was frequently reprimanded at schoolfor inattention when in reality he was unable properly todistinguish Sgures and writing on the blackboard. Thecharacter of his voice and the history that he had been athome for two days with slight sore-throat made me sus-

picious and on examination the palate was found to bepractically motionless. Except for this and the affectionof vision there were no other very marked symptoms of anykind. The boy, as I have stated, had returned to schooland but for the regurgitation of fluids through his nosewould probably have continued at school. Some of thehome circle were inclined to look upon the nasal regurgita-tion as a bad habit or trick, the boy’s general condition wasso good and the sore-throat had attracted so little attention.Removal from school and a course of the usual tonics curedthe paralysis and the impaired vision.Streatham.

A FOREIGN BODY IN THE ARM FOR 10 1/2 YEARS.

BY A. R. HENCHLEY, L.R.O.P.,, L.R.C.S. EDIN.,L.F.P.S. GLASG.

ACCOUNTS are so often given in the columns of themedical press of cases where foreign bodies have migratedfrom the position of entrance to some more or less remote

part of the body that the present case seems worth mention-ing. In this case the foreign body remained practically in,the same position as it entered notwithstanding the greatlapse of time and its being situated in the arm.On Dec. 26th last a young man, working as a labourer,

came to me saying that he thought he had a piece of glassin his arm that he wished removed. He said that 10½ years.ago while "playing at horses" with some boys he stumbledand fell on some broken glass. His left arm bledfreely, but healed up all right in due time and gave nofurther trouble till a few days before, when a friendhappened to pinch him just over the place and he felt asharp pricking pain. On examination of the arm I found a

stellate-shaped scar about three inches above, and slightlyexternal to, the internal condyle of the humerus, and one anda half inches internal to and on the same level as the scarwas to be felt a fairly moveable oblong body about twoinches in length. After having made the skin aseptic Isprayed it with ether and made a vertical incision three-- quarters of an inch long, and eventually got out a piece of.glass a quarter of an inch thick and about one and a

1 THE LANCET, Nov. 24th, 1900, p. 1482.

half inches long and the shape of an old-fashioned f. It wasimbedded in a considerable amount of tissue.Blagdon, Bristol.

__ ___

A PECULIAR COMPLICATION IN MIDWIFERY.

BY JAMES MORE, M.D. EDIN.

SOME little time since I was called in by a midwife to seea patient of hers who had been in strong labour all daywithout any appearance of its coming to a satisfactorytermination. The midwife informed me that there was

something unusual in the case as she could not make outthe presentation. On examination I was myself quite at aloss as to its nature. I found the lower outlet of thepassages completely blocked up by some part of the childbut what that part was I could not make out. It seemed likea spongy mass with one opening in the centre, into whichthe finger could be easily introduced. It was not themouth as the jaw was absent, nor the anus as the pelvicbones were not within reach. I determined to introduce myhand and explore, and on doing so I was surprised to find thatthe mass was indeed the breech with the foetal vagina muchswollen and congested. On delivering I found this part ofthe child very much swollen and almost black, evidentlycaused by the nurse poking her finger into the opening underthe idea that it was the os uteri-a mistake I could quiteunderstand under the circumstances and which I was on theverge of committing myself.Rothwell.

_______________

A MirrorOF

HOSPITAL PRACTICE,BRITISH AND FOREIGN.

Nulla autem est alia pro certo noscendi via, nisi quamplurimas etmorborum et dissectionum historias, tum aliorum tum propriascollectas habere, et inter se comparare.—MORGAGNI De Sed. et Caus.Morb., lib. iv., Proœmium.

ST. MARY’S HOSPITAL.TIGHT BANDAGING ; ISCHÆMIC PARALYSIS IN

AN ADULT.1

(Under the care of Mr. EDMUND OWEN.)THE paralysis following the application of a splint has

been termed "ischæmic paralysis," on the supposition thatthe pressure on the vessels of the limb has impaired theblood-supply of the part so that the muscles have sufferedand perhaps a chronic inflammation with sclerosis of themuscles has followed. Mr. H. Littlewood attributes its merelyto contraction of the muscle in healing after being torn. Itis, however, not improbable that another factor is concernedin the production of this variety of paralysis, and this otherfactor is a neuritis of the motor nerves of the part resultingfrom the excessive pressure of the splint. In some casesone of these factors, in other cases the other, may be thechief or only cause of the palsy, but it is not improbable thatin most instances both causes act.A man, 30 years of age, a carpenter, was admitted into

St. Mary’s Hospital on March 31st, 1900. 17 months pre-viously, when working on a wall at Krugersdorp, in theTransvaal, he fell about 15 feet, and stretching out his lefthand to save himself, he " broke the outer bone" of hisforearm a few inches from the wrist. (The fracture dulyconsolidated.) He was treated by a Scotch practitionerand a Boer practitioner in consultation, who fixed the armbetween an anterior and a posterior splint which reachedfrom the bend of the elbow to the wrist. The patient saidthat the splints were bound on very tightly by three piecesof bandage which were put on through looped ends-" bowlines"—and hauled taut. He said that he com-

plained at the time that the splints were too firmlybound on, but that no notice was taken of his com-

plaint ; so he thought that such harsh treatment

1 Reported at a meeting of the Medical Society of London on Jan.28th, 1901, and the case exhibited.

2 THE LANCET, Feb. 3rd, 1900.