I have frequently observed in operations for radical cure in adults that the conjoined tendon is unduly narrowed, very thin, or the muscles attached to it ill-developed. Félizet has CASE 4.-An infant, aged nine weeks, was admitted with described in infants imperfect development of one or both of a very large scrotal hernia which had been strangulated the pillars of the external ring. The fact should not be lost twenty-four hours. The rupture existed at birth. On sight of that the immediate cause of hernia is in a large exposing the sac it was found to be occupied by the cæcum. proportion of cases an increase of the intra-abdominal Attached to the bottom of this was a gangrenous tag, tension, either persistent or intermittent. This is especially evidently the vermiform appendix. A ligature was applied obvious in the hernia of infants. Defective closure of the to its base and pure carbolic acid was painted on the vaginal process may be present at birth, but a hernia often gangrenous stump. The bowel was then returned and the does not develop because the determining factor is absent. peritoneal cavity closed by ligaturing the neck of the sac. This is supplied in a large proportion of cases by distension The condition of the child would not permit of any further of the abdomen with tympanitis due to chronic gastromanipulation in the way of a radical cure. The patient made intestinal catarrh, often associated with rickets; or there a good recovery. may be phimosis with adherent prepuce, vesical calculus, ascarides, prolapsus ani, causing straining during micturition or defecation. It is often noted that the hernia was first observed during an attack of whooping-cough. Ascites is also an important determining cause.

condition of the testicle reminded one of a grape hanging by its stalk.

[JAN. 21, 1899. 141 cord b, and below this was another constriction separating it from a hydrocele of the tunica vaginalis o. In this case the constriction of the vaginal process d normally occurring at the internal ring appears to have been pressed down the canal by a hernial protrusion. The orifice d was too narrow to allow of the fluid being returned by pressure into the sac. CASE 12.-In another boy, aged seven years, I also found a small, incomplete funicular hernia above a closed hydrocele of the cord. The swelling was of course irreducible, but there was an impulse on coughing. Fig. 4 shows a condition somewhat similar, met with in FIG. 4.

CASE 9.-A boy, aged eight months, was admitted to the Evelina Hospital with a tender swelling projecting just beyond the external abdominal ring. This was at first thought to be a strangulated hernia. As the symptoms were not acute I was not sent for at once. No further symptoms developed and the swelling subsided gradually. When I saw the child a week after admission it was evident that the tumour was an undescended testicle and torsion was diagosed. In the operation the same condition was found as in the previous case. The organ was dark in colour. On cutting into it no blood escaped and its substance was marked by dark striæ of effused blood. Evidently the circulation had not at once been cut off.

In a third case which I saw in the out-patient room of the London Hospital the progress of this accident was watched, the parents refusing to allow the child to come into the hospital.

CASE 10.-On Nov. 19th I saw a boy, aged seven years, with a softish, very tender swelling, apparently of the size of a walnut, in the left inguinal canal. There was no impulse and no vomiting or constipation. Torsion of the testicle was diagnosed. When I saw him again on Dec. 10th the swelling had subsided and nothing remained but the wasted body of the testicle.

In cases of retained testicle I have noted that the band containing the cord and attaching the organ to the wall of the sac is often narrow and the sac itself within the inguinal canal is not infrequently bulging and voluminous. The conditions are therefore very favourable to the occurrence of

torsion.

DIAGNOSIS FROM HYDROCELE OF THE Cord.

One of the chief difficulties of diagnosis in infants and young children consists in the differentiation between hernia, irreducible or otherwise, and hydrocele of the cord when the latter extends up to the internal ring. If the hydrocele of the cord be congenital (i.e., communicates with the peritoneal cavity) the manner in which the fluid slowly flows back under pressure as distinguished from the slipping back of a hernia serves to settle the diagnosis. But the congenital variety of hydrocele of the cord is rare. Usually the fingers can be inserted above a hydrocele, the upper part of the cord being felt free; and where this sign is wanting it will be found that the hydrocele is pulled down by traction upon the testicle, whereas a hernia is uninfluenced. It may be remembered that an enterocele in the young is nearly as translucent as a hydrocele. Again, in cases of strangulated enterocele resonance is sometimes absent owing to filling of the lumen of the bowel with sanious serum the result of exudation and migration of red corpuscles. This is due to pressure on the veins of the mesentery at the neck of the sac.

In reference to the diagnosis of hydrocele from hernia I will illustrate by means of diagrams some curious and unusual conditions met with in the course of herniotomy or in exploratory operations. Some of them may be considered unrecognisable before dissection.

CASE 11.---A boy, aged five months, was admitted to the
FIG. 3.

Hernia and hydrocele of cord, a, Sac of hernia, b, Hydrocelo of cord. c, Hydrocele of tunica vaginalis. p, Peritoneum. T, Testicle. d, Constriction normally occurring at internal ring.

Evelina Hospital with a large fluctuating translucent swelling extending along the inguinal canal to the bottom of the scrotum. The testicle could be felt at its lowest part. There was distinct impulse on coughing, but the swelling was irreducible. The condition found is illustrated in Fig. 3. At a is a small hernia sac which occupied the inguinal canal. It communicated by a very narrow orifice with a hydrocele of the

a

b...

T-

Hernia and hydrocele of cord. a, Sac of hernia. b, Hydrocele.
T, Testicle.

the course of an operation for radical cure in an adult. At
is a hernia sac which occupied the inguinal canal and slightly
protruded through the external ring. Below it a narrow
prolongation of the vaginal process extends to the testicle.
The result of this
This process contained only fluid.
condition was that the fluid could be expressed from the
swelling in the cord in a manner characteristic of congenital
hydrocele, although there were in addition the ordinary
signs of hernia.

CASE 13.-Another child, a boy, was admitted to the Evelina Hospital with an elongated swelling in the right inguinal canal and upper part of the scrotum. It was irreducible, but there was an impulse on coughing and the testicle appeared to occupy the upper part of the swelling viz., within the canal. The diagram (Fig. 5) shows the

condition found on dissection. At the lower part of the
a closed cyst a and above it was the
swelling was
testicle T, its tunica vaginalis distended with fluid.
I also removed a precisely similar cyst which was attached
to the lower part of the tunica vaginalis of a completely
descended testicle in a lad. These cysts appear to have
originated in the following manner. It is well known that
a diverticulum of the peritoneum precedes the descent of the
testicle. Supposing that the testis did not descend to the
bottom of this diverticulum, then the constriction cutting off
the lower part of the vaginal process (i.e., that which
normally forms the tunica vaginalis) from the upper or funi-
cular part might form below the testicle a cyst such as was-
met with in these two cases.

IPSWICH CLINICAL SOCIETY.-At a meeting held on Jan. 12th Mr. S. O. Eades was elected President for the year and Dr. W. W. Sinclair was re-elected honorary secre tary. Mr. Hossack showed a case in which he had successfully removed the Right Half of the Tongue together with the Sub-maxillary Gland for Epithelioma by a Modified Whitehead Operation. Mr. Branford Edwards showed a case of Tuberculous Disease of the Kidney. Dr. Brown and Dr. Vincent made remarks. Dr. Vincent and Mr. J. R. Staddón showed some Old Curious Surgical Instruments. Mr. C. K. Moseley brought up the question of the want of provision made in the town for the reception and treatment of cases of diphtheria requiring tracheotomy and it was decided to discuss the subject at the February meeting.

Further examination showed that the external iliac artery

TRANSPERITONEAL LIGATURE OF THE was lying just outside the vessel ligatured. The common iliac was very short and the internal was correspondingly long and lying in almost the whole whole of of its

ILIAC ARTERIES.1

course

BY BERNARD PITTS, M.A., M.C. CANTAB., F.R.C.S. ENG., above the brim of the pelvis, parallel with the external

SURGEON TO, AND LECTURER ON SURGERY AT, ST. THOMAS'S
HOSPITAL; SURGEON TO THE HOSPITAL FOR SICK
CHILDREN, great ormoND-STREET.

THIS paper is really an account of two cases of ligature of the iliac vessels-(1) of the internal iliac for pulsating tumour of the buttock; and (2) ligature of the common iliac for hæmorrhage from a pelvic abscess. In both these cases any method of securing the vessels without opening the abdominal cavity would hardly have been adopted by any surgeon of the present time. The advantages of the direct method of ligature seem to me to be so obvious that it is not necessary to discuss them. Connected with these cases are many points of obscurity in diagnosis and of general interest which seem far more worthy of discussion than the particular method of reaching the vessels. I may say in brief that for ligature of the common iliac, internal iliac, and perhaps with rare exceptions of the external iliac, the transperitoneal operation is the one I would choose.

CASE 1.—A man, aged forty-one years, was sent to me in January, 1894, by Mr. Mennell of Shepherd's Bush with a pulsating swelling of the right buttock which had been first noticed in October, 1893. Five years Five years before the patient had a fall on to his sacrum and six months later he had sciatica in his right leg which lasted some weeks. After this he remained well until December, 1892, when he began to have pain in the right leg, and in July, 1893, he complained of numbness as well as pain and consulted a medical man who treated him with iodide of potassium, There was a doubtful history of syphilis. On examination, he was found to be an anxious-looking man complaining of swelling in the right buttock with pain down the leg and a feeling of numbness. During the last month he had been troubled with irritability of the bladder and pain extending from the anus to the penis. A marked swelling was seen in the right gluteal region which pulsated visibly. The most prominent portion of the swelling and the greatest pulsation was at a point just external to the right sacro-iliac synchondrosis. The swelling extended from the middle of the sacrum to a point 5 in. external to this and from the crest of the ileum to a point 5 in. down; it was firmly fixed to the deep structures. The skin was freely moveable over it and showed no discolouration or glazing. There was no apparent glandular enlargement. Pulsation could be greatly diminished by pressure along the line of the iliac crest. The pulsation was somewhat expansile in character and a loud bruit was present. Nothing abnormal was detected in the vascular system beyond a slight aortic systolic murmur. Examination of the chest showed signs of old bronchitis and emphysema of the lungs. My first impression was that the case was one of pulsating sarcoma of the pelvis, and I sent the patient into hospital for observation. During the next fortnight he complained of great pain and the incontinence of urine and fæces became very marked. There was considerable difference of opinion amongst my colleagues as to the nature of the swelling and by several it was thought to be aneurysmal in character. Even supposing my view that it was a sarcoma was correct, treatment by ligature of the internal iliac might do good and relieve some of the pain.

On Feb. 3rd an incision was made in the middle line of the

abdomen, the intestines were held aside with flat sponges and broad retractors and the posterior peritoneum was divided also in the middle line and reflected to the right, oarrying the ureter with it. Search was then made for the internal iliac artery-but without success. To gain more room a transverse incision was made through the greater part of the right rectus muscle. A vessel was exposed below the pelvic brim, which was clearly not the internal iliac but probably the gluteal. Having failed, as I thought, to find the internal iliac I exposed and ligatured what I believed to be the common iliac-two goldbeater-skin ligatures were employed-but after drawing these ligatures tight it was found that pulsation still continued in the femoral vessel.

1 1 A paper read before the Medical Society of London on Dec. 12th, 1898.

vessel. By ligature of the internal vessel all pulsation in the
tumour was arrested. The peritoneum was replaced and
secured in the middle line by a few fine silk sutures. The
relief afforded by the operation was at first very marked; the
pain diminished and the swelling besides losing its pulsation
seemed to get a little smaller. I was fully convinced that
In about a week
the aneurysmal view was the correct one.
some pulsation was again observed but it never returned to
the same degree as before operation. On the sixtieth day
whilst the patient was turning himself in bed spontaneous
fracture of the right femur occurred just below the great
trochanter and it became obvious that the primary tumour of
the buttock must be a sarcoma. The fracture was treated
by a long outside splint and extension. He remained in a
bed-ridden and distressing condition but without any
evidence of tumour at the seat of fracture and no
increase in the gluteal swelling. The liver showed
the gall-bladder a hard nodule could be felt.
some increase in size and just outside the position of
On the
158th day after ligature the limb was removed to give
the man a better chance of leaving his bed. The amputation
was just outside the capsule of the joint. No evidence of
growth was discovered at the seat of the ununited fracture
at the time of amputation. Microscopical examination by
Mr. Shattock showed a round-celled sarcoma in the medullary
canal. Great improvement in the patient's general condition
followed and he was soon able to get about on crutches
and he left for his home in the country 232 days after
admission. He came up to see me some six months later in
greatly improved condition. The gluteal swelling was larger
and still pulsated slightly; he had still loss of control over
somewhat tender on pressure. He was, however, able to get
the sphincters. The nodule in the liver was larger and
about and to attend a little to his business and was much less
troubled with neuralgic pains. He had an attack of con-
gestion of the lungs a year later, from which he died.
Unfortunately a post-mortem examination could not be

obtained.

In

When the patient was first under observation the main points in favour of the tumour being a sarcoma were that the pulsation was much more intense in one particular area and that comparatively superficial pressure along the crest of the ileum considerably diminished the pulsation. The with an aneurysm of a vessel like the gluteal at its origin. swelling was more widely diffused than one would expect On the other hand, there was no evidence of bone expansion, point of greatest intensity of pulsation corresponded fairly as so often occurs in pulsating tumours of bone, and the well with the main trunk of the gluteal. The treatment by ligature was followed by decided improvement and I believe delayed the growth considerably in its developin cases of tumour unsuitable for radical removal. ment and certainly encourages one to adopt this course out clearly the common iliac and its bifurcation before huntligature of the internal iliac artery it is desirable to make ing for the internal iliac in the pelvis. The abnormality met with in this case is, I believe, not very uncommon, and much time would have been saved if it had been recognised at the first stage of the operation. Certainly the transverse section The of the rectus muscle might have been avoided. behaviour of the spontaneous fracture was remarkable. I ture from carcinoma, but never when it is the result of have several times seen union occur in spontaneous fracsarcomatous invasion of the bone. I did not therefore expect to get union when I treated the fracture by splints, but I expected to find evidence of growth around the broken ends and was much surprised when at the amputation no such appearance presented itself. Mr. of the medullary tissue at the seat of fracture reported that it Shattock, however, on making a microscopical examination showed a round- or polyhedral-celled sarcoma with a large number of blood-vessels, the latter giving a nævoid condition to the growth. to the growth. The tumour might therefore be termed a cavernous or nævoid sarcoma. It is interesting to note that although the patient lived for nearly eighteen months after the amputation and that this was done so close to the growth yet no return took place in the stump.

CASE 2. Hæmorrhage from pelvic abscess treated success➡ fully by ligature of the common iliac artery. A man,

with Mr. Kitching as he had had a temperature for several days ranging from 101° to 103° and again a good deal of tenderness about the sinus and in the right iliac region. I dilated the sinus and introduced a larger tube; the discharge was of a thin unhealthy character. Warm boric fomentations were ordered. The teraperature fell to normal, but on Oct. 27th-i.e., two months after the operation-he suddenly had severe hæmorrhage from the sinus which was stopped by pressure and a tight compress. On arrival I found him blanched and with a rapid pulse and constitutional signs of loss of blood. The mattress was soaked with blood. The compress was removed and blood began to come freely from the sinus, and it evidently came from the deeper parts of the abscess cavity; compression of the common femoral or the epigastric or circumflex iliac with the finger in the wound did not arrest it. A careful plugging of the cavity with iodoform gauze was done under chloroform. The following day the patient's temperature was 104 4°, but it gradually came down and all went well for a week, the gauze plug being changed on the fourth day. On Nov. 5th I was again sent for as the hæmorrhage had recurred and the patient was in a very exhausted and critical condition. Mr. Stabb saw the patient with me and I was prepared to ligature the internal iliac artery. The position of affairs was difficult for the patient's father who was just returning from America was expected in a few days' time. The wound was carefully replugged and it was decided to remove him in an ambulance by road (a distance of twenty miles) to thè St. Thomas's Home for Paying Patients. Mr. Stabb and Mr. Kitching kindly travelled with him. During the next few days he improved in condition. On the morning of Nov. 15th severe hemorrhage again took place which was stopped by the resident medical officer of the home with firm pressure over the gauze plug. On arriving I repacked rapidly and determined to operate without further delay. The father had in the meantime returned from America and both he and the patient were wishful for radical measures to be adopted.

aged twenty-four years, was brought to see me in October, 1894, by Mr. Kitching of Cobham with the following complicated history. He was perfectly well till the age of fourteen years; he had then whilst at school in Scotland in February, 1886, a boil on his neck attended with fever and some pleurisy of the right side. He was two months in bed and towards the end of this time he had an abscess in the right lumbar region which was incised and which discharged for a few days. Some contraction of the left leg was then found and extension was ordered. He returned home to Liverpool and was seen by Mr. Mitchell Banks who treated him with continued rest for an inflamed psoas. Mr. Banks informs me that he could find no evidence at that time of any mischief in the vertebræ or pelvis. After some months' continued rest in a leather splint he was taken for a sea trip and he got apparently quite well. He returned to school after an absence of eight months and in ten days the leg was again giving trouble-viz., soreness and pain and he had to return home and remained away from October, 1886, to May, 1887. In August, 1887, his right shoulder became painful and an abscess discharged spontaneously in October at a point corresponding to the insertion of the deltoid. The arm was kept to the side for six weeks and the sinus healed and he remained perfectly well till October, 1888, when pain and swelling recurred in the shoulder and an incision had to be made, and the arm had to be kept quiet for eight weeks. In the following June an incision was again necessary. He left school in July, 1889, and, except for most obstinate constipation, he remained well till October, 1893. He was at Oxford from 1890 to 1893. In 1893 he went to America and on the voyage he had sciatica of the right leg, and during his stay of two months the condition of constipation greatly increased. In June, 1894, he was again troubled with pain down the right leg and in the loin and along the iliac crest, with increasing difficulty with the bowels and occasional feverish attacks with a rise of temperature. He was an only son; his parents were alive and very healthy. The patient was a very tall, strong-looking man and beyond a scar in the right loin and one in the right shoulder nothing surgical could be detected. The operation took place on Nov. 15th at 2 P.M. The anæsI referred him to my colleague, Dr. H. P. Hawkins, and thetic was given by Mr. Tyrrell and I had the advantage of under treatment he made some improvement and was able to the able assistance of Mr. Stabb, Mr. Abbott, Mr. Edmunds, return to business in May, 1895. ^ In July he suddenly de- and Mr. Kitching. The condition of collapse was such that veloped another attack of pain in the legs and tenderness in we expected to have to infuse during the operation. A free the groin and a little thickening and resistance were to be felt central incision was made from just below the umbilicus to the at the outer part of the iliac crest. He afterwards went to pubes. The colon was examined and it was found that the Ireland and was very well for a month there. In October he appendix was normal, but that the large bowel was very again had pain down the leg with fever. In January, 1896, elongated and the sigmoid flexure had a very large omegahe went to India, returning home in April. He was in shaped curve, thus accounting for the great trouble for considerable discomfort during the whole trip, with great so long a time with the evacuation of the bowels. irregularity of the bowels and feverish attacks accompanied incision was made in the peritoneum over the medial by pain about the right hip. At times he noticed some blood line of the sacrum, and the internal iliac artery was and mucus with the motions and thought that an abscess exposed without difficulty. The gauze plug could be was discharging per rectum. He had much pain when felt extending behind the peritoneum to within an inch straining at stool and was unable to walk straight on account of the main trunk. The vessel was found to be very of discomfort about the groin. In July, 1896, he went into fixed by chronic inflammatory products and all attempts a nursing home in London and the symptoms seemed to to pass an aneurysm needle failed. I was particularly: point to the appendix as the seat of trouble. He had a anxious to ligature the internal vessel, since owing to tender, deep swelling which felt very hard in the iliac region, his anæmic condition I was fearful of the circulation in below and outside the usual portion of the cæcum, with a the limb if the common iliac were ligatured. An attempt temperature varying between 99° and 101°F. The evacuations was therefore made to pass the aneurysm-needle behindwere carefully watched and with the decline of the tempera- the artery and vein and so to ligature on masse. ture, the relief of the symptoms and the diminution of the siderable gush of blood took place from a wound of the vein swelling there was a definite discharge of pus in the stools. which was arrested by pressure on the common iliac. The It was now clear that he had a deep-seated abscess which attempt was therefore abandoned and the common iliac was periodically discharged into the bowel and both Dr. Hawkins exposed and a stout floss silk ligature passed and the vessel and I were convinced that the appendix was the cause of the tied by a surgeon's knot. We found that the circulation trouble. So definite a discharge of pus had taken was not controlled, the ligature being too thick for the place and with such a marked improvement that opera-hitches to be efficiently tightened. The vessel was then tion was decided against. He returned home and was tied in two places with a thinner floss silk ligature carefully watched by Mr. Kitching who sent him again to with an interval of in. between them. The original the home in London on August 24th as he then had some thick ligature was then removed. The circulation was hardness and redness of the skin over Poupart's ligament. now effectively controlled. The peritoneum was adjusted An incision was made and a small quantity of thick pus was but not sutured and the operation was finished as quickly evacuated (about 2 or 3 drachms). A long sinus was traced as possible. The patient took the anaesthetic remarkfrom the incision just outside the femoral vessels under ably well and it was not found necessary to infuse. Poupart's ligament into the pelvis, but no bone could be felt abdominal wound healed without trouble and the warmth by a bullet probe. It was now clear that the abscess was of the limb was well maintained, though pulsation in the independent of the appendix and most probably was due to tibials was not re-established for some weeks. A remarksome obscure bone trouble in the lumbo-sacral region. A able change took place in the chronic abscess lining-it drainage-tube was inserted. The after-progress was satis- necrosed and a very offensive discharge of a free character factory; there was very little discharge in the dressings and continued for several weeks. Rapid repair then set in and in the temperature became normal. He left for his home six weeks the sinus was soundly healed and has never given in three weeks' time. On Oct. 23rd I saw him again any trouble since. During many of the short febrile attacks

An

•

A con

The

BY J. BEARD, D.Sc. VICT.,

UNIVERSITY LECTURER IN COMPARATIVE EMBRYOLOGY, EDINBURGH.

which the patient had had between 1894 and 1896 he often had pain and considerable tenderness in the right shoulder THE TRUE FUNCTION OF THE THYMUS. and several times I expected suppuration to occur there, but these symptoms always passed off with the improvement in other conditions. He remained in St. Thomas's Home for seven or eight weeks and left for his own home greatly improved in condition. The right leg was diminished in size, but the collateral circulation was well established. He shortly afterwards changed his residence for a more bracing atmosphere and has since been under the care of Dr. A. Lyndon. The patient wrote to me on Nov. 15th, 1897, being the anniversary of the last operation, and expressed himself as feeling extremely well and putting on flesh at such a rate that all his old clothes had to be let out; he was moving about in the house freely without orutches, but using them as advised when out of doors. The bowels were still a difficulty and the use of enemas was frequently necessary. Occasionally he had spells of soreness above the hip, but much fewer and milder than formerly. His general health was perfect. In December, 1897, I was asked by Dr. Lyndon to see him for a swelling at the lowest part of the abdominal cicatrix. The swelling was ducible and had some impulse and it was difficult to say whether it was a hernia or an abscess presenting through the cicatrix. The swelling was a little tender and there was a sense of fluctuation. It was covered with gauze and wool and a few days later burst and a large quantity of laudable pus escaped into the dressings. Careful examination of the sinus showed that it led deeply into the pelvis but without apparent connexion with the former abscess cavity, the cicatrix of the old sinus remaining perfectly sound and free from tenderness. He was kept at absolute rest by Dr. Lyndon and in March, 1898, the floss silk ligature presented itself in the discharges. After this the sinus slowly closed and has been for some months soundly healed. I last saw the patient in London and ordered him to wear a truss for a weakness of the lower part of the cicatrix. He was in very good health; he weighed 14 st. and was apparently at last free from any inflammatory condition.

re

The points for consideration in this case seem to be as follows. 1. The original infection. I believe it to have been tuberculous. We have pleurisy as an early symptom, and this was followed by several suppurative troubles, most probably connected with superficial caries of the humerus just outside the joint. The affection of the left psoas which was so obstinate can be best explained by similar bone trouble low down in the vertebra. We have then a long period of intermission and again chronic inflammatory trouble in the pelvis affecting the right side. It is not likely that any inflammatory affection other other than a tuberculous one would have remained latent so long. 2. The diagnosis between inflammatory trouble due to chronic appendicitis and that due to bone disease is sometimes very difficult. Looking back on the case I think that more attention ought to have been paid to the pains down the leg which appear so often in the history but were never at all prominent whilst the patient was under observation. One prominent feature in the case case was the constant association of discomfort and slight rise of temperature with constipation and the relief afforded by laxatives and enemas. 3. Hæmorrhage from chronic abscess ulcerating into vessels is usually significant of bone trouble and occurs perhaps most frequently in popliteal abscess due to caries of the back portion of the femur. The recurrent and sudden outbursts of bleeding in this case pointed to a communication with a large vessel and was of quite a different character from the bleeding sometimes met with from unusual vascularity of the granulations. I do not know of any case where ligature of the internal iliac or the common iliac has been necessary, but am confident that this patient's life could have been saved in no other way. 4. The behaviour of the ligature in this case was unusual. After lying apparently quiescent for a year it set up suppuration and was eliminated. For a large artery I believe the stay knot suggested by Mr. Ballance and Mr. Edmunds in their work on the Ligature of Arteries is the best I have used it several times and cannot now explain why I did not employ it in this instance. My attention was so occupied with the other circumstances of the case that I probably did not give this point full consideration at the time. In tying the artery, however, I endeavoured to stop the circulation with the least amount of constriction and I believe that I did not rupture the coats.

Harley-street, W.

THERE is hardly an organ in the body about whose functions in the embryo and at later periods so little is really established as the thymus. Since Kölliker1 discovered its mode of origin in mammals from the epithelium of a gillpouch and since he stated that the original epithelial cells gave rise to lymph-cells or leucocytes two views have been held concerning it. On the one hand, Stieda 2 and His have maintained that the leucocytes which always form. integral parts of the thymus soon after its first origin have migrated thither from the exterior, possibly from the mesoblast. In this conclusion they have been supported by the researches of Dohrn, Gulland," and Maurer," and by almost every text-book of embryology and comparative anatomy published since 1879. On the other hand, Kölliker has stoutly maintained his original position and the results of his investigations have in recent years been emphatically confirmed by Prenant, Oscar Schultze, and myself." According to the views of Stieda and His, Hassall's concentric corpuscles are supposed to arise from the original epithelial cells and the function of the thymus is still absolutely unknown. serious attempt has ever been made to convert this hypothetical origin of the concentric corpuscles into fact by systematic investigation. On this view, then, nothing of the least practical use and value is at present known regarding the nature of the thymus. According to Kölliker the original epithelial cells of the thymus give rise to lymph cells or leucocytes. And although he made no attempt to explain Hassall's corpuscles it must be evident that, if his established. conclusion be correct, something of positive value is thereby As already stated, the three most recent students of the thymus have entirely accepted Kölliker's results. None the less in the latest English edition (1897) of Wiedersheim's " himself obliged to say: Comparative Anatomy the author felt himself obliged to say: "The function of this organ, though doubtless a very important one, is not understood."

No

I have long suspected the function of the thymus to be a very important one but, in spite of repeated attacks on the problem, my researches had until last summer yielded little or nothing beyond a confirmation of Kölliker's brilliant discovery. Even now, when success has completely crowned the failures of past years, at a time when the developmental history and function of the thymus in one vertebrate animal (Raia batis, the smooth skate) can be demonstrated on numerous preparations with the utmost certainty and ease, the problem owes its solution in the first instance not to direct attack on the organ itself, but to the unravelling of another puzzle. While engaged on general developmental researches a little, but significant, fact forced itself into notice. This was that for a relatively long period of the development the blood contained only nucleated coloured that this had originally been noted by Kölliker some years corpuscles and no leucocytes whatsoever. It was recalled who had ventured the conjecture-a very safe one-that the ago and that it had been commented upon by H. E. Ziegler condition persisted until some lymphoid organ or other arose. The question was asked, "At what period of the development and from what source or sources do the white corpuscles of the blood or leucocytes arise?" It had previously been recognised that there was a particular epoch of the developfoundation of every organ of the body was present as such. ment, termed by me 10 the "critical period," at which the It was obvious that, if the existence of a critical period had ing integral parts of a vertebrate animal, ought to be present a groundwork of fact, the leucocytes of the blood, as form

1 Entwicklungs-geschichte des Menschen und der höheren Thiere, 1879, pp. 875 to 880. 2 Untersuchungen über die Entwickelung der Glandula, Thymus, &c., Leipsic, 1881. 3 Anatomie Menschlicher Embryonen, 1880, p. 56.

4 Mittheilungen aus der Zoologischen Station zu Neapel, 1884.

5 Reports of the Royal College of Physicians of Edinburgh, 1891. 6 Morphologisches Jahrbuch, Band xi., 1885.

7 Développement du Thymus-La Cellule, Tome x., 1894.

8 Grundriss der Entwicklungs-geschichte des Menschen, &c., 1897. The Development and Probable Function of the Thymus, Anato mischer Anzeiger, Band ix., 1894.

10 Vide Certain Problems of Vertebrato Embryology, Jena, 1896, and The Span of Gestation and the Cause of Birtli, Jena, 1897, both published by Gustav Fischer,