1282 BT Barr= I PATHOLOGICAL SOCIETY OF LONDON. [MAY 22, 1897.

REPORTSON

MEDICAL & SURGICAL PRACTICE IN THE HOSPITALSAND ASYLUMS OF GREAT BRITAIN, IRELAND,

AND THE COLONIES.

NORTHAMPTON GENERAL INFIRMARY.CASE OF RUPTURE OF THE BLADDER: OPERATION: DEATH.

(Under the care of Mr. PERCIVAL.)T. F., a stout muscular man, aged about 35, was admitted onFebruary 21st, I897, at 10.30 A.m. He stated that he had beenkicked in the lower part of the abdomen on the previousnight at about ii P.M., when in a public-house yard. He wasdrunk, and believed that his bladder was full at the time ofthe injury. During the night he had passed only a smallquantity of blood. He complained of great pain in theabdomen, and of inability but strong desire to micturate. Hisabdomen was tender, the thighs were flexed, and there wasno bladder dulness above the pubes. A soft red-rubbercatheter was passed, and 9 ounces of very blood-stained fluiddrawn off. Rupture of the bladder was diagnosed, but, tomake certain, 6 ounces of warm boric acid lotion were injectedinto the bladder after it had been again,emptied, and 7 ouncesof blood-stained fluid returned. As this made the diagnosisuncertain operation was postponed for a time, but at 6 P.M., asthe symptoms continued, 25 ounces of warm borie acid lotionwere injeicted, with the same precautions; and, after twentyminutes, only 12 ounees of it had returned, and that was veryblood-stalned.

It was now determined to operate, and at 7 P.M. theabdomen was opened, and a rent about 4 inches in length wasdiscovered in the middle line on the posterior surface of thebladder, a large amount of blood clot and urinous fluidescaping through the abdominal incision. The mucous mem-brane of the bladder prolapsed a good deal through the rent,and a row of about ten Lembert silk stitches was first insertedclose to the rent. Another row of thirty or more silk sutureswas next inserted external to the others, and this seemed tothoroughly close the wound. It was now tested by injectingwarm boric lotion into the bladder, and as there was a slightleak in two places four more sutures were inserted, when itwas found to be quite water tight. The abdominal cavity wasthoroughly washed out with warm boric lotion, a large numberof clots and much urinous fluid being removed. The abdominalwound was closed completely, no drainage tube was used, anda soft catheter was tied in the bladder, and connected byindiarubber tubing with a vessel containing carbolic acidlotion. The operation lasted about two hours, and the manbore it remarkably well.On February 22nd, the patient had had little pain and was

fairly comfortable. The abdomen was less tense; I6 ouncesof urine had drained away. The temperature was 99.40. Hewas allowed only ice to suck.On February 23rd, a pint and a half of urine had drained

away during the night, and urine was constantly passing bythe side of the catheter. As the bowels were relaxed, a simpleenema was given, when a large .amount of freces were evacu-ated. He took ice, milk, and soda water, and a little tea.The temperature was 990.On February 24th, urine was passing freely, chiefly by the

side of the catheter, which was removed, and as it was foundquite clear it was left out, and during the rest of the day hepassed his water naturally and without any difficulty. Thetemperature was 97.60, and the pulse improving.On February 25th, at about 3 A.M., he became very cold and

sick, his face anxious and pinched. his pulse much weaker.Nutrient enemata with brandy were given; he rallied a littleat first, then gradually sank, and died at 8.30 A.M.Post-mortem E.xamination.-The external wound was quite

healthy; internally were evidences of peritonitis, with aboutT ounce of opaque bloodstained fluid in Douglas's pouch.The rent in the bladder was quite healed and completelyclosed. On injecting water, the bladder was found quitewatertight.REMARKS.-The quantity of lotion (6 ounces) first injected

was too small, and led to slight error, but this was perceived,

and the mistake rectified by injecting more on the secondcoccasion. It is difficult, however, to understand how abladder with such a large rent could have held any lotion.It would have been better perhaps to have injected air. Iattribute the fatal result to the omission of using a drainagetube in Douglas's pouch. It was felt at the time it would bersafer, as a large amount of clot and urinary fluid had collectedamongst the coils of intestine; and though much time wasemployed in trying to completely remove it, such could nothave been done. My objection to using a drainage tube wasthat the bladder wound was so exactly in the middle linethat any tube must necessarily press on it and retard itsunion.

REPORTS OF SOCIETIES,PATHOLOGICAL SOCIETY OF LONDON.

HENRY TRENTHAM BUTLIN, D.C.L., President, in the Chair.Tuesday, May 18th, 1897.

INTESTINAL OBSTRUCTION DUE TO GALL STONE.DR. NORMAN MOORE recounted the case of a man in whom,complete intestinal obstruction resulted from the impactionrof a biliary calculus in the lower part of the jejunum. Thepatient was seized with sudden pain and vomiting, at firstbilious afterwards faecRl. Death took place during lapar-otomy. After death the bile duct was found dilated andulcerated. Two cases had been recorded in the ClinicalSociety's Transactions, both being accompanied with similarsymptoms to those above detailed; in one of these suddenrelief followed the passage of a large gall stone by therectum.

TERATOMA OF THE SCALP.Mr. DOUGLAS DREW exhibited this specimen, which

was removed from the right side at the posterior and upperpart of the parietal region. The growth was an inch and aquarter in diameter, and had been noticed seven years; itlay close beneath the skin, and was readily enucleated. It,comprised histologically the structures of hyaline cartilagein process of ossification, fibrous tissue, fat, glandular tissue,and spaces lined, some with horny epithelium, others withcolumnar.Mr. J. H. TARGETT had seen one similar tumour from the

ovary of a girl; this contained in addition unstriped musclefibre and what appeared to be cerebral grey matter. Similargrowths, as was known, were met with in the testicle.Dr. NORMAN DALTON remarked upon the similarity of the

growth and that known as coccygeal or sacral tumour.

CHARCOT'S DISEASE.Mr. J. H. TARGETT illustrated, by means of lantern slides

and specimens, certain points in connection with the abovesubject. In some cases there was no production of new bone(atrophic form), in others there was, and this might be ex-tensive (hypertrophic). Exactly similar lesions of the joints.were to be observed in syringomyelia. At times intra-articularfractures of the bone in process of destruction took place, thefracture being, perhaps, repaired. In illustration, such afracture of the inner condyle of the humerus was exhibited.There might be extensive bone formation in the tendons,etc., about such joints. In the foot a remarkableshortening of the toes now and then took place fromextreme atrophy of the metatarsal bones, whichwere converted, it might be, into cords of fibrous tissue.Moreover, at times dorsal dislocation occurred of the meta-tarsus on to the tarsus in consequence of destruction of thearticulating parts of the bones. The great cedema (whichwas of the solid kind) that sometimes accompanied such dis-ease of the foot was probably associated in all cases with.septic conditions of the soft tissues consequent upon per-forating ulcers. Ankylosis might ensue, and this when therehad been no suppuration.

A CASE OF ACROMEGALY.Dr. NORMAN DALTON briefly recorded a recent case of the

above. The patient was an adult, who died with diabeticcoma. He had had typhoid in 1893,and the acromegaly datedfromthattime. Besides the usualenlargementofthehands, feet,

MAY 22, 189.] CLINICAL SOCIETY OF LONDON. [M Twu BalOru 1283KUDI!ALLJOV3LWAT,

and face there was a general enlargement of almost all theviscera. The skin was pigmented in the axilla, and inpatches on the abdomen, but no disease of the adrenals was

seen. There was tonsillitis, and the whole of the alimentarytract was congested, and showed enlargement of the solitaryglands. The organs obviously enlarged were the liver,spleen, pancreas, thyroid, thymus, and pituitary body. The,enlargement of the last named was not sufficient to causeatrophy of the optic commissure, as sometimes happened. Aeimilar instance of visceral enlargement in acromegaly,essociated also with diabetes, had been described in Belgiumby Dr. Dallemagne.

Dr. H. D. ROLLESTON suggested that the pigmentationnoticed in the case might have been due to the condition ofithe thyroid, the association of acromegaly with exophthalmicgottre being a recognised one; the disease had obscure rela-tions with myxcedema, and had been successfully treated bymeans of thyroid extract, although the work of Schafer andOliver had shown that extracts of thyroid and of pituitarybody were antagonistic in action.

CARD SPECIMENS.Mr. CECIL F. BEADLES: (I) Intussusception at Ileo-caecal

Valve; (2) CEsophagus with two distinct Growths.-Dr. H. D.-ROLLESTON: Aneurysms of the Lunulae of the Aortic ValveSegments.-Mr. A. H. TUBBY: Fracture Dislocation of Spine.-Lr.ALLCHIN: Two cases of Ulcerative Colitis.-Dr. R.HEBB: (i) Hydronephrosis; (2) Tuberculosis of Tongue; (3)Two specimens of Monocellular Cirrhosis; (4) Microscopicsections of three cases of Rodent Ulcer indicating the con-tinuity of the columnar layer of the rete with the new

growth.Th'is being the annual meeting of the Society, the election

of officers for the ensuing year followed the ordinary business-of the meeting.

CLINICAL SOCIETY OF LONDON.THOMAS BUZZARD, M.D., F.R.C.Pq, President, in the

Chair.Friday, May 14th, 1897.

CHRONIC HYDROCEPHALUS, FATAL AT THE AGE OF i6.DR. FREDERICK TAYLOR described the case of a boy, agedi63years, who was admitted into Guy's Hospital, under Dr.Taylor's care, with cerebral symptoms. He had had a largeiead from early infancy, and at 8 months of age he hadbronchitis and fits. But he subsequently grew up strong andwell, went to school, learned at 12 years of age to play theviolin, became a compositor whenI31 years of age, and con-tinued in that employment until the time of hislast illness.

On September 2nd,I895, he complained of headache, andvomited. On the 6th, returning from work, he felt giddy, andvomited. He stayed at home, had constant severe headache,and vomited four or five times daily. On September i ith hecame to the hospital with constant headache, chiefly frontal,but also occipital, vomiting and unsteady gait. The headmeasured 23 inches in circumference. A few days later hishead was retracted, and vomiting and headache continued.On Septemberigth there was loss of power in the legs, andpain was felt in the back of theneck. On September20th thearms were weak, paralysis extended to the diaphragm, andslightly involved the face. With increasing embarrassment.of respiration he died the same day, but was conscious withinthree hours of his death. The necropsy showed much thin-ning of the bones of the skull. The cerebral ventricles con-

tained3o ounces of liquid. The pia arachnoid was thickenedat the base of the cerebellium, especially near the foramen of-Majendie. The spinal cord and nerves were not examined.Dr. Taylor called attention to the unusual occurrence of-chronic hydrocephalus practically without symptoms up to'the age ofi66, and leaving, so far as could be ascertained, theintellectual faculties unimpaired, but terminating in a short4llness of three weeks' duration, which could only be-explained by a spontaneous increase in the quantity of

Jiquid.The PRESIDENT asked if the atrophy of the thenar muscles

was part of a general wasting, or if it was referred to the spinal.cord

Dr. TAYLoR, in reply, said there was nothing like general

wasting. But it appeared to him that no disease of the cordwould have explained the clinical symptoms.

WOUND OF THE MESENTERY WITH SUBSEQUENT GANGRENE OFTHE INTESTINE.

Mr. C. B. LoCKOOOD read notes of the case of a man, aged64, who had endeavoured to commit suicide by stabbing him-self in the left side of the abdomen with a carving knife. Hewas found unconscious, lying in a pool of blood, with intes-tines protruding from the wound. When he had partiallyrecovered from the shock the abdomen was opened to stophaemorrhage. Bleeding was found to come from several rentsin the mesentery. Several large vessels were secured, and therents were closed. One rent, three-quarters of an inch long,was half an inch from the bowel. This was also sewn likethe others. It was hoped that there was room for anastomosisin the mesentery betwixtthe wound and the bowel. When theman died two days afterwards the bowel opposite the woundwaseither dead or on the point ofgangrene. The vascular supply ofthe mesentery and bowel had been examined in the dissectingroom, and no anastomotic loops were found less than an inchfrom bowel. Therefore it was erroneous to suppose ana-stomosis could occur, and without doubt the intestine ought tohave been resected.Mr. W. G. SPENCER would have laid greater stress on the

wound and ligature of an artery, described as large as theulnar artery, as the cause of the gangrene.Mr. HOWARD MARSH described the case of a gentleman

who fell, was at first collapsed, but, feeling well went to thecity and lunched. He then suddenly became alarmingly ill,and died in thirty hours from the time of the accident. Theabdomen was opened, and a large portion of the small in-testine found gangrenous, and the wound was closed. Helived only an hour or two. At the necropsy a rent of themesentery was found, which had severed a branch of thesuperior mesenteric artery.Mr. MACADAM ECCLES inquired what was the direction of

the other rents in the mesentery. Further, was it theportion of bowel which was protruding when the man wasfirst seen which afterwards became gangrenous?

Dr. F. TAYLOR described the case of a child who becamevery ill with abdominal symptoms. At the post-mortemexamination blood was found in the peritoneum. One of thebranches of the mesenteric artery was narrowed by a depositof calcareous matter in its wall. There was thrombosis atthe same point, and the bowel fed by the diseased artery wasgangrenous. The free anastomosis of the vessels had notprevented the gangrene from occurring.Mr. LoCKWOOD, in reply, said that the portion of gangrenous

intestine was exactly opposite the rent he had described, andwas not opposite the large branch of artery which he hadtied. Hesaid there were many other rents in the mesentery,but many of them were at right angles to the bowel, and theyhad not all divided vessels.

STRANGULATED INGUINAL HERNIA: OPERATION: FREE INCISIONAND EVACUATION OF INTESTINE: RECOVERY.

Mr. HOWARD MARSH described a case of inguinalhernia,in which the coils of small intestine were so tensely dis-

tended with fluid that it was necessary, before theycouldbe returned to incise them freely. The incisions made wereclosed by Lembert's suture, and the man recovered. Thepatient, a man, aged 38, who had had a reducible inguinalhernia for some years, found, on getting up without puttingon his truss, that the hernia had come down. He couldnot return it, and twelve hours later was admitted intoSt. Bartholomew's Hospital. The symptoms were severeand he was becoming collapsed. On opening the sac itwas found that there was no fluid in its cavity, but thatthe contained coils of small intestine were so distendedwith fluid that there seemed danger that they would burst.They were at once freely incised in three places. Thefluid consisted of blood-stained serum, such as is oftenfound in the sac itself. The incisions were closed by Lem-bert's sutures and the coils were returned; the patientrecovered without drawback. The author of the paperthought that the practical explanation was that theperi -

toneal coat of the gut had, by paralytic distension of thecoils, been so firmly pressed against the interior of the sac

TI8 B1LTrr1284 MUDICAL JOUUNLL EDINBURGH OBSTETRICAL SOCIETY. [MAY 22, 1897.

that the exudation produced by obstructed venous returnhad been prevented, and that exudation had thus occurredfrom the mucous membrane, so as to collect in the canalof the intestine.Mr. LANGTON did not consider effusion so uncommon as

usually described. He said that strangulation might beginfrom without inwards, inflammation following the samecourse in the knuckle ofintestine, and the mucous membranebeing the last to be affected; in which case the effusionwould take place into the sac of the hernia. Or the inflam-mation might begin at the mucous membrane first, andproceed outwards, in which case the effusion would first takeplace into the cavity of the bowel. Many of these casesbegan with enteritis, He would in such cases as Mr. Marsh'salways puncture the intestine and let out the fluid. In twocases he did so, and both recovered.Mr. LocKwoOD had come across a largely distended jejunum

in a case of acute strangulation. He dropped it back throughthe large opening into the peritoneal cavity without openingthe bowel; in a few hours afterwards a large quantity ofblood was passed per rectum. Puncture and wounds of intes-tine made when it was in sight, if carefully sutured, alwaysdid well; but punctures out of sight, as those done for dis-tension with the trocar, were very dangerous. The trocarwhen introduced might be aseptic, but when withdrawn itwas septic. In a recent case he had seen septic peritonitisthus produced.Mr. W. G. SPENCER said that, as a result of experiment. if

a ligatured portion of intestine had its nervous supply cut,fluid collected in it, in consequence of the paralysis of itsnervous supply; probably in Mr. Marsh's case the nervoussupply of the bowel was interfered with.Mr. MARSH, in reply, adopted this explanation.

IRREDUCIBLE FEmORAL HERNIA IN WHICH THE VERMIFORMAPPENDIX ALONE OCCUPIED THE SAC.

Mr. BIDWELL read a paper on two cases. Both were females,and the hernia, though irreducible, had given rise to nosymptoms of strangulation. In both his cases he had re-duced the vermiform after notching Gimbernat's ligament,and he recommended this treatment instead of excision inall cases where the appendix was not diseased. In most ofthe other recorded cases of this condition the appendix hadbeen removed.Mr. LANGTON said that in these cases the symptoms of

strangulation were not so acute as in those cases in whichthe sac contained bowel. The cases were usually in women;they were inguinal and on the right side. When healthy theappendix might be returned to the abdomen without risk ofother trouble; when there were adhesions or ulceration headvised its removal. He was opposed to incision of Gimber-nat's ligament; if incision were necessary, it should be madeupwards and inwards through Hey's ligament.Mr. MACADAM ECCLES had come across one case of femoral

hernia in a man which contained appendix alone. Thepatient died from another cause, and the hernia was onlyfound post mortem. There had during life been no symptomsreferable to that lesion. The appendix in that case was 7inches long; possibly this extra length was due to stretching.If the appendix were adherent it should be removed, and thestump left in situ. Cases of appendix in a hernia occasionallygave rise to hydrocele of the sac.Mr. BIDWELL, in reply, said the appendix was not adherent

in either case; both were of short duration when first seen,and were attended by a large collection of fluid in the sac.

EDINBURGH OBSTETRICAL SOCIETY.Wednesday, May 12th, 1897.

JAMES RITCHIE, M.D., Vice-President, in the Chair.SPECIMENS.

DR. J. C. KYNOCH (Dundee) showed what appeared to be aspecimen of interstitial pregnancy. On the suggestion ofDr. HAIG FERGUSON, the specimen was referred to a smallcommittee for examination and report.-Dr. BREWIS showeda small Tumour which he had that day removed, and whichwas supposed to be ovarian, but might be parovarian.

INTERSTITIAL PREGNANCY.Dr. J. C. KYNoCH,(Dundee) read a paper on this subject,

with notes of a supposed case. The subject of eetopicgestation was one which had received considerable attentionfrom several of the Fellows of the Society during the past fewyears. Those contributions had for the most part referred tothe tubal form, but a case of interstitial or tubo-uterinepregnancy had not been reported. By interstitial pregnancywas generally understood that form where the fertilised ovumlodged in that part of the Fallopian tube which traversed theuterine wall, and there underwent further development.Dezeimeris described four varieties of gestation in the uterineend of the tube: (i) Tubo-uterine interstitial pregnancywhere the ovum developed in the uterine end of the tubeand, by its further growth, pushed through the muscular waliof the uterus from below upwards, but always remained coveredby the thinned-out wall of the tube. (2) TUtero-interstitialpregnancy where the ovum by its increased growth pushed it-self through the wall of the tube into the muscular substanceof the uterus, and finally became covered by the expandeduterine fibres only. (3) Tubo-uterine pregnancy where theovum developed in the Fallopian tube, and by its furthergrowth pushed itself into the cavity of the uterus. Such aform would be considered as an unusual form of uterinepregnancy. (4) Utero-tubal abdominal pregnancy where theplacenta was situated in the uterus, the umbilical cord in thetube, and the foetus free in the abdominal cavity. The casenow reported would probably come under that variety wherethe fertilised ovum had become attached to the innermost.part of the left Fallopian tube, and by its subsequent growthad pushed itself into the muscular substance of the uterus,

and finally become covered by the distended muscular fibresof the uterine wall. Mrs. D., 25, was admitted into the DundeeRoyal Infirmary on January 27th, 1897, complaining of pain inthe back, persistent vomiting, and frequent micturition,of three months' duration. She had been under treatmentin the infirmary two years ago, when she complained of painin the right iliac region, especially during menstruation,and which she dated from the birth of a child threemonths previously. At that time the uterus was foundretroflexed and movable; there was some tenderness inthe right fornix, with enlargement of the correspondingovary. She was treated with douches and ichthyol plugs.and later the uterus was replaced, and a pessary introduced.The present was her fourth pregnancy. Her last menstrua-tion ceased on October m7th, I896. She was anaemic, and!poorly nourished. Breasts fairly developed, contained milk,and there was well-marked areolar pigmentation. Palpationof abdomen caused pain in the epigastric and right iliac-regions, and a swelling was felt slightly to the right of themiddle line, reaching to a point midway between umbilicusand symphysis. Per vaginam: Cervix soft, os patulous, ad-mitting the point of the finger; slight leucorrhceal discharge,no swelling in either fornix. Bimanually there was found aswelling, apparently continuous, and moving with the uterus,reaching upwards to a point 3 inches below the umbilicus.On passing a speculum there was noted a well-marked purplediscoloration of the vaginal mucous membrane. The sicknessand abdominal pain complained of on admission continuedduring her stay in the hospital. The case being regarded asprobably one of extrauterine pregnancy, operation was pro-poEsed; but this the patient declined, and by herown desire left the infirmary ten days after admis-sion. A week later she again presented herself, stillcomplaining of sickness, frequent micturition, and constant.pain across the lower abdomen. She persisted in remainingat home. Examination under chloroform at her own home, a.miserable one-roomed house, showed that the swelling pre-viously noticed reached upwards to a point 24 inches below-the umbilicus continuous with the uterus, and resembled at.its upper part a tense ovarian cyst, the lower part, from itsconsistence, being obviously the body of the uterus. Bothfornices were free. There could be no doubt that the patientwas pregnant. The uterus measured a little over 3 inches.Tubal pregnancy was excluded first, on account of the absenceof any symptom pointing to rupture of the sac at the periodwhen this accident usually happens in such cases, namely,the twelfth to the fourteenth week; secondly, the com-plete absence of any swelling in either fornix, andthe central position of the abdominal swelling. Thepatient refused to return to the hospital for operation.

MAY' 22, 1897.1 ROYAL ACADEMY OF MEDICINE. [TRN Barn=x 2a85MEDICAL JOURNAL

She became worn out from want of sleep, and on account ofthe persistent abdominal pain and sickness. The consent ofthe friends having been obtained, an operation was per-formed. On opening the abdomen there presented in themiddle line a tense thin-walled cyst about the size of amelon, continuous with the uterus below. Both ovaries andtube appeared normal. The cyst was punctured, and liquoramnii escaping, the opening was enlarged and a living fcetusextracted. On dividing the wcord some traction on the pla-cental attachment was exerted, as this was immediatelyfollowed by a gush of blood. The placenta was pulled off,and what represented the sac came away with it. There wasan opening on the fundus of the uterus, admitting the pointof two fingers. From this opening the hremorrhage con-tinued very profuse. The broad ligament on either side wasligatured close to the uterus, a strong temporary ligatureput round it, it was amputated above this point, and themucous and peritoneal layers of the stump brought togetherwith continuous catgut suture. The patient stood the opera-tion well, and her condition continued satisfactory until earlyof the morning of the third day, when symptoms pointing tohEemorrhage came on. The abdomen was reopened, and aconsiderable quantity of blood was found in the pelvis withoozing from the stump. The abdomen was sponged out, andas the uterus had not been amputated close to the vagina, thestump drawn up, and fixed to the lower part of the abdominalwound as in the ordinary extraperitoneal treatment of thestump. Attempts to inject saline infusion into the rectumwere useless as the fluid was not retained for any time, Shedied from exhaustion twenty-four hours later. The partsremoved consisted of the upper parts of the uterus, dividedinto two compartments, the lower one the cavity of the uterusproper, the walls of which were enormously thickened andlined with a well-marked decidua, and above this, andseparated from it by a thin septum, the sac where the ovumhad developed, and out of which it had pushed itself throughthe muscular substance of the uterus. A probe passedthrough the left Fallopian tube appeared to communicatewith this cavity the right did not. The foetus correspondedto about the fourth month; the placenta had battledore inser-tion of the cord; the wall of the sac evidently consisted ofamnion and peritoneum only. The termination of cases ofinterstitial pregnancy as compared with the tubal form wasinvariably fatal on account of the date of rupture of the sacbeing later, and, as a consequence, more copious free haemor-rhage into the abdominal cavity. The only favourable casesfor operation were those that came under observation pre-vious to rupture of the sac, a very rare occurrence, and ex-emplified by the present case. With reference to the treat-ment adopted, Dr. Kynoch regretted attempting to treat thepedicle intraperitoneally in 'place of the ordinary extraperi-toneal method. Whatever might be the drawbacks of thelatter, it had certainly the outstanding advantage of givingcomplete control over the occurrence of secondary hsemor-rhage, an event which was the cause of the unfortunate termi-nation of this case.The paper was discussed by Drs. FREELAND BARBOUR,

HAULTAIN, and HAIG FERGUSON; and Dr. KYNOCH replied.

VAGIINAL HYSTERECTOMY.Dr. FREELAND BARBOUR read a paper on vaginal hysterec-

tomy by Doyen's method, with six illustrative cases. Thefirst extirpation of the prolapsed uterus for cancer was doneby Andreas a Cruce in 1560. The non-prolapsed uterus wasremoved per vaginam for the first time in 1822 by Sauter, ofConstance. In 1829 Blundell also extirpated the cancerousuterus successfully per vaginam. A year later, R6camierplaced the operation on a scientific basis by ligaturing thebase of the broad ligament. For the next fifty years, atten-tion was chiefly directed to hysterectomy for fibroide, but inthe large majority of cases a portion of the uterus was leftas a pedicle. The modern history of extirpation of the uterusfor malignant disease date from 1878, when Freund de-scribed his operation for removal by the combined method.The mortality of this operation was shown two years later byAhlfeld to be 71 per cent. for the 93 cases collected, a mor-tality which condemned the operation. About the sametime extirpation began to be carried out from the vaginaalone by an operation elaborated by Czerny, Schroeder, and

Martin. The mortality was only 25 per cent. in 32 cases col-lected by Hegar and lKaltenbach. By this method the partslooked no worse than in a patient who had undergone repair ofthe perineum. The difficultywas to get at the broad ligamentsso as to efficiently control the blood supply. To do this byligature implied a more or less tedious operation, and it wasthe use of the clamp instead of the ligature, with the advan-tages of this method, which formed Dr. Barbour's reason forbringing his communication before the Society. At firstsight it might seem that the credit of this operation wasdue to M. B. Freund. It would seem, however, that thereal credit was due to Spencer Wells as Pozzi said. In I882this was suggested, and Jennings put it into practice in 1883.Pdan and Richelot made the method a practical success.Doyen of Rheims also used the clamp method with great suc-cess, and introduced new methods, if not also new principles.Pdan used the clamp as a preventive measure; Doyen usedit in a definite and final way, and checked any bleedingduring his operation by traction on the uterus. Pean andRichelot applied the clamp from above and below up-wards, Doyen where possible from above downwards. Doyenalso emphasised the advantage of splitting the uterusanteriorly, which allowed it .to collapse, and allowed theoperator to take a fresh hold along the free margin of the in-cision. Dr. Barbour then described the technique of theoperation, and in reviewing the procedure as a whole, saidthe following were the advantages of the method: (i) It al-lowed of more rapid operation. (2) The vigorous tractioncontrolled all bleeding, and no haemorrhage had to be at-tended to until the final stage, when the clamp was applied.(3) The splitting of the uterus allowed it to collapse, andgave a fresh hold for the forceps. (4) The rotation of theuterus and the application of the clamp over the uppermargin of the ligature first enabled one more easily and morecertainly to get the whole ligament within the bite. (5) Theweight of the clamp kept the broad ligament pediclesdown in the vagina. (6) The layers of the perito-neum thus became apposed, and were adherent abovethe clamps, which further favoured drainage per vaginam.The disadvantage was a longer convalescence. But theshorter operation had to be set against that. Dr. Barbournext gave notes of six successful cases. The first was begin-ning carcinoma of the cervix, the second was malignantinfiltration above the os externum, the third sarcoma uteri,the fourth had a suspicious nodule in the cervix, which brokedown, leaving an irregular cavity with friable margins, thefifth had prolapsus uteri, and the sixth had glandular cancer.All the patients recovered without any bad symptoms. Thestatistics of various operators, English and German, werenext quoted, the frequency of cases where operation waspossible referred to, and the result as to non-recurrence.The mode of dissemination of cancer by the lymphatics wasdescribed, and the researches of Poirier, Seelig, Winter,Russell, Stiles, and others. Local recurrence might be due tothree causes: (i) Incomplete removal of affected lymphatics;(2) nuclear operation, cancer cells inoculated on raw surfaces;(3) reappearance of the disease from the same cause whichoriginally produced it.The paper was discussed by Drs. JAMES RITCHIE, N. T.

BREWIS, KEPPIE PATERSON, and FORDYCE; and Dr. BARBOUIRreplied.

ROYAL ACADEMY OF MEDICINE IN IRELAND.SECTION OF STATE MEDICINB.

J. M. REDMOND, M.D., President, in the Chair.Friday, April 30th, 1897.

THE DISSEMINATION OF MICRO-ORGANISMS.PROFESSOR CHARLES TICHBORNE read a paper on the dissemi-nation of micro-organisms and on the best method of de-stroying germ emanations from sewer gas. He pointed outthat the solid germs were in most. cases carried about, asProfessor Tyndall had pointed out, in a manner which heentitled the "raft" theory-the dry atmospheric dust actingas rafts disseminating the dry atmospheric microbes. Inenteric fever and allied diseases the sewer gas was stated,with considerable force of evidence, to be a fertile source ofspreading the disease, and, in spite of some recent re-

I

ErnTiaxm II286 CAL 70URNALJ LEEDS MEDICO-CHIRURGlCAL SOCIETY. [MAY 22, 1897.

searches, the author was still of opinion that the weight ofevidence almost proved this to be the fact. But there wassomething wanted to explain the theory. Even the smallestgerms that microscopes had yet revealed had a certainweight. This fact was shown by the absence of germs at highaltitudes or in the very still atmospheres. The authorhad demonstrated this as far back as 1870 in anafternoon lecture delivered at the Royal Dublin Society.In the microbes of enteric fever we had an organismwhich, when carried in water or brought mechanicallyto a receptive surface, was capable of producing disease,and yet it was also found that it was capable of risingin such a vapour as sewer gas. The author used the term"vapour" not in the vulgar sense of a non-permanent gas,capable of condensation, but in the sense that meant any-thing flying or escaping off. In this sense atmospheric dustwas a vapour. Although a germ was so small that the finestbalance would not weigh it, and though it might be onlyTuTth of a millimetre in length, it might as reasonably beconceived that the coarser microscopic life, such as rotatoria,entomastraca, etc., which could almost be seen with the eye,would be volatilised as a vapour as to conceive that patho-genic microbes would be so transmitted. Professor Frank-land had shown that liquid sewage matter was not likely tobe scattered into the air except by gas generated in it. Theauthor was of opinion that here lay the clue to the dissemina-tion of microbes, but not exactly in the direction whichFrankland indicated. We must suppose, in a system of townsewage, certain spots in the mains where microbes werescattered into the air during fermentation, or by violentconcussions breaking the sewage into the spray. Then camethe question, How are they disseminated through the wholearea of the air space of the whole system of drains? Theauthor conceived that they could be carried by a condensedvapour exactly represented by ordinary dew. At certainhours of the night, just as the rising vapour was seen settlingas dew in a valley, the temperature of the water-laden vapourof the sewer was lowered by being met with the layer of coldnight air through the open traps, which determined a dewpoint in the sewers themselves. He had found from actualexperiment that the temperature of the sewer water as itflowed from the large sewers was generally 2 or 3 degreesabove the temperature of the night air. Each particle of dewbecame a raft which would carry microbes upon its surface,perhaps for miles, as long as the condition lasted, and as thesun's warmth dissipated the morning dew, the water raftdisappeared, leaving the microbe suspended in mid air. Orcould it not be supposed that if the sewer dew were carried in-to a warm shaft connected with a dwelling house, it was againapparent that we had the water rafts converted into perma-nent gas, whilst the now dry germs floated about seekingwhom they might devour? The author proposed to disinfectsewers with insoluble disinfectants, which would have agravity of 850 to 950, so that they would float on the sur-frce of the sewer water. Carbolic acid and disinfectantswhich were heavier than water were perfectly useless, becausethe unaffected stream of sewage passed over their surface.In reply to Sir C. CAMERON, Dr. DOYLE, and Dr. S. M.

THOMPSON, Professor TICHBORNE said, with regard to thequestion of the transmission of the typhoid germ by sewergas, or, in other wordh, the capability of the organisms torise from water and become permanent contaminations ofthe atmosphere, that he did not presume to state that suchwas the fact, but nevertheless he believed that such a thingreally did occur.

REPORT OF VACCINATION COMMISSION, I896.The SECRETARY read Dr. ALFRED E. BOYD'S paper on the

report of the Vaccination Commission for 1896. The paperdealt with the history of small-pox and the history of inocu-lation and vaccination; then with the Commission, its scopeand its recommendations. With regard to revaccination, hesays, in these days of compulsory education, means couldsurely be found for revaccinating children at the time whenthey enter school, although there would still be a numberunaccounted for; on the whole, the number of revaccinationswould be larger than at present. With regard to the honestobjector. could an objection founded on ignorance properlybe called honest? Was the honest objector to be freed from

his obligations in the case of laws dealing with matters otherthan vaccination ?Dr. A. N. MONTGOMERY, Dr. NINIAN FALKINER, Sir C.

CAMERON, and Dr. MARTLEY spoke.On the motion of Sir CHARLES CAMERON, seconded by Dr.

MARTLEY, it was resolved:That the Council of the Academy be asked to give their opinion as to

whether there should be a special meeting of the Academy to discuss theimportant points raised by Dr. Alfred E. Boyd's paper.

PATHOLOGICAL SOCIETY OF MANCHESTER.T. HARRIS, M.D., F.R.C.P., President, in the Chair.

Wednesday, May 1lthk 1897.SOLID TUMOURS OF OVARY.

DR. DONALD showed some solid tumours of the ovaryremovedby abdominal section. The specimens included: (i) a solidtumour, about the size of a foetal head, removed in I893 froma child aged 6 years and i month. On microscopical evidencethe growth was pronounced to be a spindle-celled sarcoma,but there had been no recurrence after operation. (2) Threecases of Fibiomata of the Ovary removed from patients aged26, 39, and 52 respectively. In the third case the tumourweighed i9 lbs. (3) A Fibromyxoma of the Ovary. (4) AFibroadenoma of the Ovary. Microscopic sections of thevarious tumours were also exhibited.

CYSTIC SARCOMA OF MUSCLE.Mr. E. STANMORE BISHOP showed a cystic sarcoma of the

semitendinosus muscle. The whole muscle was convertedinto a fluid sac, and was removed entirely. The patientrecovered and could walk well. Sections of the wall of thegrowth (for which he was indebted to Dr. Kelynack) wereshown. They exhibited a small spindle-celled structurewith some myeloid cells.

LEUKMEMIA.Dr. Fox EDWARDS showed specimens of blood from cases of

leukiemia, which illustrated the marked differences betweenthe myelo-splenic and lymphatic forms. Dr. Edwards showedthat between the ordinary finely granular oxyphile cell and themyelocyte with oxyphile granulation there were many cellsintermediate in character, which fact made it possible thatcertain of the myelocytes might be abnormally developedfinely granular oxyphile cells, the change occurring in theblood and not in the bone marrow. He also pointed out thatwhile minute basophile granules occurred quite frequently inthe lymphocytes, oxyphile granules also occurred, but onlyvery occasionally.

INTRAHEPATIC THROMBOSIS.Dr. KELYNACK showed specimens from a case of stenosis of

the hepatic vein, with extensive thrombosis of its branches inthe liver. The patient was a woman, aged 32. The chiefsymptoms were enlargement of the liver, ascites, and jaundice.The illness lasted six weeks, death resulting apparently fromchol9emia.

INTRAOCULAR HYDATID CYST.Dr. HILL GRIFFITH mentioned this case, and remarked on

its extreme rarity.CARD SPECIMENS.

The following were shown:-Dr. BRINDLEY: Biliary Cir-rhosis.-Dr. MOORE: Microscopic Preparations from "Alco-holic Heart."-Dr. WOODCOCK: Foreign Body from Pharynx.-Dr. WOLSTENHOLME: (i) Lung from case of Glanders in aHorse; (2) Cultures of Bacillus Mallei.-Dr. YONGE: Singer's"Node" of the Vocal Chord.-Dr. KELYNACK: MalignantGrowth of Heart.-Dr. MCNEILAGE: Anencephalic Fcetus.

LEEDS AND WEST-RIDING MEDICO-CHEIRURGICAL SOCIETY.

JAMES BRAITHWAITE, M.D., President, in the Chair.Friday, April 30th, 1897.TRIPLETS PLACBNTlE.

MR. C. J. WRIGHT showed the placentze from a case of trip-lets attended by Mr. J. V. Hartley in the maternity of theinfirmary-one large placenta with two cords, and a secondsmaller one with one cedematous funis; the amniotic bagswere Eeparate. The patient, aged 25, -a 2-para, was one of a

a

MAY 2, 1897.] ULSTER MEDICAL SOCIETY. rETu BouTAL Jon= 1287

family of thirteen, amongst whom were twins on three occa-sions; her mother was a twin, as also her grandmother; thusthere were multiple births through four generations. Thepresentations in the above case were (i) vertex, (2) trans-verse delivered by podalic version, (3) face; number one wasliving on the the fifteenth day; the others died on eleventhand twelfth days respectively.

TRANSPOSITION OF HEART.Dr. WARDROP GRIFFITH showed a girl, aged 7, with trans-

position of the heart; there was no transposition of the liver.Cyanosis and dyspncea had been present from the age of 3.There was cardiac hypertrophy with a loud bruit, with itsmaximum intensity in the pulmonary area-in this case thethird right cartilage. Pulmonary stenosis was diagnosed,with possibly a deficiency of the cardiac septum.

THE BACTERIOLOGICAL DIAGNOSIS OT ENTERIC FEVER.Dr. TREVELYAN read a paper on this subject, including the

examination of (z) the excreta (feces and urine), and (2) theblood. The technical difficulties, and especially the timerequired, were serious disadvantages in the examination ofthe stools. The presence of the typhoid bacillus in the urinefrom 2 cases of typhoid fever was demonstrated, and the testsdistinguishing this micro-organism from the colon bacillusshown. The importance of dealing efficiently with the urinefrom the point of view of preventing the spread of the dis-ease was emphasised. Under the examination of the bloodDr. Trevelyan described Widal's serum test, and showedspecimens illustrating it. As regards technique, themethods recommended by Del6pine and by A. Fraenkel wereboth easy to carry out.

MESENTERIC CYSTS.Mr. MOYNIHAN read a paper on mesenteric cysts, detailing

the history of the following two cases upon which he hadoperated, and quoted cases observed by Mr. Jessop, Mr. MayoRobson, and Mr. Edwin Lee of Dewsbury. (i) Chylous Cyst.-M. R., aged i8, female. When first seen was suffering fromacute intestinal obstruction. There was an ill-defined swell-ing to the right of the linea alba. On opening the abdomena mesenteric cyst was exposed, causing kinking of the gut.The cyst was opened, stitched to the parietal peritoneum,and drained. Recovery was uneventful. (2) E. W., male,aged 7. Seen with Dr. Churton, with symptoms of acuteintestinal obstruction. On opening the abdomen a very largemesenteric cyst, containing 42 ounces of pure chyle was ex-posed. The pedicle of the cyst was cut through, the peri-toneal edges inverted and stitched, the cyst being removed.The boy died about two hours after the operation. Onepoint worth noticing in this case was the excessive amount-of indican present in the urine. The following classi-fication of mesenteric cysts was proposed: (I) Serouscysts, (2) chyle cysts, (3) hydatid cysts, (4) bloodcysts, (5) dermoid cysts, (6) cystic malignant disease.This classification excluded all cases where the cyst, arisingelsewhere, became mesenteric only by a later extension.Cases of all the varieties of cyst were alluded to. Thedliagnostic signs were pointed out to be: The presence of acyst in the abdomen, at first laterally placed, but becomingwith increasing size more and more central; resonanceabove, below, and across the tumour-the three " diagnostic#igns " of Tillaux-the latter being due to the portion of gutattached to the mesentery involved; extreme mobility in alldirections and the freedom with which the tumour could berevolved round its central point. A tumour presenting allthose signs could not but be a mesenteric cyst. Clinicallymesenteric cysts might be classed under three headings:(i) Those in which no symptoms are present, the cyst beingdiscovered either during3the performance of abdominal sectionfor some other disease or during a post-mortem examination;(2) those in which the symptoms are chronic and are chieflyreferable to the presence of an abdominal tumour; and (3)those in which acute intestinal obstruction is the first andonly clinical indication. The following methods of treat-ment are mentioned: (i) Opening and drainage of the cyst;(2) removal of the cyst by cutting through the layers ofperitoneum in the pediele; (3) enucleation.

9

- -~~~~~~~~~~~~~~~~~~~SEIES

SPECIMIENS.The following were shown:-Mr. LITTLEWOOD: (i) Case of

Elephantiasis of Legs; (2) (with Dr. CHADWICK) Gangreneof Forearm in a Diabetic: Amputation (patient and speci-men). Mr. JESSOP: Deposit of Bilirubin found in a HydatidCyst of the Liver.

ULSTER MEDICAL SOCIETY.Professor SINCLAIR, M.D., Ex-President, in the chair.

Thursday, May 6th, 1897.OXYGEN TENSION OF ARTERIAL BLOOD.

DR. LORRAIN SMITH explained shortly the method which Dr.Haldane and he had employed in the research which theyhad now for two years been carrying out in regard to this sub-ject. The conclusion to which the research led them inregard to man was that the oxygen tension of the blood as itleft the lungs was on an average 26.2 per cent of an atmo-sphere. During the past winter further experiments hadbeen carried out on animals, resulting in a general conclusionthat, during the normal respiration of all the animals ex-amined, the oxygen tension of the arterial blood as it leftthe lungs was higher than could be explained by the principleof the diffusion of this gas from the alveolar air into theplasma. Inquiry was also made into the effects of some ofthe more obvious conditions known to modify respiration, andas to the nature of death from lack of air. In regard to thefirst of these questions, tables of results were given showingthe effect of diminution and increase in the oxygen of theair breathed, the effects due to the presence of carbonic acidgas, the effects of cold sufficient to lower the body tempera-ture, and the effects of the lack of oxygen which arises incases where the hiemoglobin of the blood was 6o per cent.saturated with carbonic oxide. The results of these experi-ments went to support the conclusion already arrived at, andto prove the physiological importance of variation in oxygentension. In conclusion two series of experiments were re-counted, which tended to show that death from lack of oxygenin the air breathed was due essentially to a fall in oxygentension of arterial blood in the lungs.Dr. CECIL SHAW had charge of the lantern.Professor THOMPSON and Professor REDFERN made remarks.

VESICAL CALCULI.Surgeon-Major CUNNINGHAM, I.M.S., exhibited a large col-

lection of vesical calculi (92) and a still larger collection ofcrushed fragments in bottles (258), which were removed fromthe bladder by him in India. Some of the calculi removedby lithotomy were rare and interesting specimens, and manywere of large size. The crushed specimens comprised all thevarious kinds of stone met with in the human bladder per-haps, and ranged from 6 grains to over 8 ounces in weight;a large proportion of them were of considerable size, andmuch larger than calculi generally met with in this country.These specimens were presented to the Surgical Museum ofQueen's College, Belfast.

STONE IN THE BLADDER AND THE OPERATIONS FOR ITSREMOVAL.

Surgeon-Major CUNNINGHAM read a paper on the subject ofstone in the bladder and the operations for its removal,which will be published.In reply to Dr. J. W. BROWNE, Professors REDFERN and SIN-

CLAiR, and Drs. DARLING and MITCHELLSurgeon-Major CUNNINGHAM said that as far as his own ex-

perience went food did not appear to exercise any great in-fluence on the causation of stone in India. He believed theparamount cause of stone in India to be either or both of theinfluences mentioned in his paper-namely excessive limesalts in the drinking water, and hyperconcentration of theurinary secretion accompanied by derangement or disease ofthe urinary tract. The consumption of oatmeal might beeliminated as a cause, as this was never used as food by tl enatives of India. With regard to sounding, elaborate methodswere never found necessary. By means of a Thompson'shollow sound a stone of 6 or 8 grains could generally be de-tected without difficulty. The smaller the stone, if too largeto pass into the urethra, the more likely was it during urina-tion to block the passage of water, and this when it occurred

128 TlxTBIUI. 1128 KMZDICL JOUXEELJ SOCIETIES.

was an infallible sign of stone. On one occasior, in which re-currence took place in a patient who had already had a stonecrushed in his bladder, and who presented himself early aftersymptoms set in, sounding by an assistant and himselfutterly failed to detect the concretion; but the patient in-sisting that a stone undoubtedly existed in his bladder, hewas aneesthetised and a lithotrite introduced, when at once asmall stone was caught and crushed. This patient had alarge prostate. He would not advocate as a general practicethe crushing of calculi by means of cocaine anmesthesia, but ifgeneral anausthesia was considered unsafe, a#mall stonemight safely and easily be thus crushed and removed. In hisexperience recurrence was as frequent after the cutting asafter the crushing operation. In experienced hands frag-ments were very seldom left behind in the bladder, and if anywere left they would be so small as to pass subsequently withthe urine. Any person in whom the diathesis existed, andwho remains exposed to the influences which caused a stonein the first instance was very liable to recurrence, andwhen this occurred it was not necessary to attribute it to afaulty operation. The operation which removed the stoneleft the diathesis unaffected. In the class of patientsfrom which his cases were drawn it would be impossible toexercise supervision in diet, etc., with the object of prevent-ing recurrence. One year and a-half was the youngest patienton whom he performed litholapaxy. No limit of age existedfor this operation. The only cause which would prevent theoperation would be so small a urethra that the necessaryinstruments could not be passed. The urethra of the youngestchild would generally admit a No. 5 lithotrite, but occasion-ally cases were met with where childrenof 4 or 5 years wouldnot admit the smallest lithotrite. His reasons for condemn-ing the suprapubic operation were the high mortality thatfollowed it; 42 per cent. of deaths in 147 cases during fiveyears in India was an enormous mortality. In a fat subjectit was a difficult operation. During after-treatment the urinetrickling over the abdomen, saturating the dressings and thebed and irritating the skin, was a painful nuisance, andfinally cutting into the fundus of the bladder would be fol-lowed by a subsequent rigid cicatrix, which must interferemore or less with the efficient working of this contractileorgan, and if, as he suspected frequently occurred, a fixedpoint was produced by the union of the bladder and abdo-minal parietes in one common cicatrix a very inefficientorgan remained to the patient, which was likely to be asource of trouble for the remainder of his life.

SPECIMENS.Dr. McKiSACK showed some microscopic specimens on

behalf of Dr. DARLING.

HARVEIAN SOCIETY.-At a meeting on May 13th, Dr.Dr. R. H. MILSON, President, in the chair, Dr.CAaNEY read a paper on Some Resources in the Diagnosis ofNervous Diseases, and exhibited a series of illustrative cases,the symptoms of which he investigated before the Society,demonstrating the use of electric cuirents to determine thecondition of the peripheral nervous system. He pointed outhow indispensable was this method in a large number ofinstances, and how often for the want of knowledge on thissubject a diagnosis which should be a matter of certainty wasallowed to remain little better than a guess. He citedinstan( es to show that, especially in hysterical subjects, anorganic and curable malady-as, for instance, an alcoholicneuritis-might easily be overlooked unless established bythe tests in question, and he exhibited as a case in point amiddle-aged woman. the subject of hysteria, with, amongstother things, complete and universal analgesia, the sense oftouch being perfect, together with a typical neuritis affectingtheanteriortibial group. With regard to these cases hepointedout that the assumption commonly made that a diagnosisshould rest between hysteria and organic disease, that if apatient had functional therefore he had not organic disorder,wan unwarranted, and more often wrong than right. Thisassumption, made in the face of all probability, was every daythe cause of regrettable errors, and in many instancesthe errors would be entirely avoided by an intelligent in-vestigationwith the galvanic current. The knowledgerequisitefor this investigation was, he feared, rare, yet it was easy of

[MAY 22, 1897.

attainment, and he contended that every physician should beprepared to avail himself of it on occasion.-Mr. GRIFFITHdesired to know if electricity could be utilised in the diagnosisof ocular paralysis, and so assist the prognosis of such cases.He had met with a number of cases in which the cause hadbeen obscure, and though many had yielded to iodideof potassium others had behaved most obstinate to treatment.-Dr. CAGNEY, in reply, said that the ocular muscles were not.within reach of the ordinary method of examination.

BRITIsH LARYNGOLOGICAL, RHINOLOGICAL, AND OTOLOGICALAssocIATION.-At a meeting on April 30th, Dr. MILLIGAN,President, in the chair, Dr. F. TRESILIANshowed: (i) A caseof Stenosis of the External Auditory Meatus, where there wasno history of discharge or acute aural trouble, the meatusbeing narrowed by a diffuse bony growth. (2) Web Formationin the External Auditory Meatus situated between the orificeand the membrana tympani. (3) Hereditary Syphilis of the-Nose, with extensive destruction of the bony tissue. (4) Lupusof the Vestibule and Inferior Turbinate Bone. The cases werediscussed by Dr. MILLIGAN, Dr. DUNDAS GRANT, and Dr.MACNAUWHTON JoNES.-Mr. G-. C. WILKIN showed a case ofSyphilitic Laryngitis, the left cord being fixed in abduction,the patient breathing comfortablyand speaking well.-Dr.MILLIGAN showed a case of Empyema of the Frontal Sinus,cured by operation. Dr. BARCLAY BARON believed that thesuccess of these operations depended on proper drainagebeing secured through the infundibular tract into the nose.-Dr. DUNDAS GRANT showed: (i) Two cases where projectionforward of the cervical vertebre caused Nasal Obstruction.(2) Extrusion of an Attic Cholesteatoma through the externalauditory meatus. (3) Audible Metallic Clicking on swallow-ing, probably due to the sticking together of the sides of theEustachian tube.-Dr. MACNAUGTON JONES read notes of a caseof Esthiomenic Menstrual Ulcer of Nose. On various occasionsthe sloughs were removed and the surfaces painted withfuming nitric acid or solid nitrate of mercury, for which zincpaste was afterwards substituted, light applications of salacto)being used to soften any crusts, and a wash and cotton plugsaturated with a solution of chinosol I in 6oo. The case ulti-mately recovered with very slight contraction; two photo-graphs were exhibited, showing little signs of scarring.Microscopical and bacteriological examination of portions ofthe tissue failed to elucidate the nature of the disease. Dr.MILLIGAN asked if Dr. Macnaughton Jones had tried any in-oculation experiments in his investigation. Mr. LAKIE wasdisposed to consider the ulceration due to conscious orunconscious irritation by the patient.-Dr. WHISTLER showeda case of Supraglottic Growth in a young man, attached to theright side of the base of the epiglottis.-Mr. LAKE showed acase of Lupus of Larynx and Left Septum and InferiorTurbinate, with active mischief in the lung.-Dr. MILLIGANexhibited the following microscopical specimens: (i) Sarcomaof Nasal Septum. (2) Tuberculous Growth (septum nasi).(3) Rodent Ulcer (external ear).-Dr. GREVILLE MACDONALDopened a discussion on the indications for, and the methodsof removal of, Nasopharyngeal Adenoid Vegetations., Heformulated the rule that the necessity for operation dependednot on the extent of the growths but on the mischief theywere causing. Dr. DtJNDAS GRANT referred to the variousways of performing the operation and the instruments used,preferring the upright position himself, and the administra-tion of nitrous oxide. The discussion was continued by Mr.LENNOx BROWNE, Mr. ST. GEORGE REID, Mr. WYATTWINGRAVE, Dr. BARCLAY BARON, Dr. MILLIGAN, Mr. BARK,and Dr. NOURSE.GLASGOW OBSTETRICAL AND GYNAECOLOGICAL SOCIETY.-At

a meeting on April 28th, Dr. MALCOLm BLACK (President) inthe chair. Dr. E. ARTHUR GIBSON and J. MUNRO CAMPBELLread notes of cases treated by the antistreptococcic serum.In Drs. Gibson's case-a primipara, aged 25-the presentationwas occipito-posterior, and the labour tedious and necessitat-ing the forceps. The perineum was torn and sutured, and thepuerperium was apyretic and apparently normal till thefifteenth day, when there was a slight rigor, and the tempera-ture rose to 1020. The vagina was afterwards douched withCondy's solution, and quinine was given. Rigor, however,occurred on each of the following days. On the nineteenth

MAY 22, 1897.] SOCIETIES. TEI BRT= I2189IC JO NA

day Dr. Gibson saw her, and recommended the injection ofantistreptococcic serum. The temperature was 1040 at thetime, abdomen soft and not tender, lochia almhost driedup and not at all fcetid, small granulating wound atedge of the perineum apparently healthy, cervixsplit on both sides, nothing on the chestj andthe urine free from albumen. Marmorek's serum wasused, Io c.cm. being given at each injection. Two injectionswere given on the nineteenth day, and marked improvementin aspect and symptoms was soon observed. On the twentiethday one injection was given, and on the twenty-first dayanother, and on the twenty-second day the fifith and lastinjection, as the temperature never afterwards rose to ioo0,

and the patient gradually recovered. Dr. Campbell's casewas also a primipara. The labour was tedious but natural.The perineum was lacerated, but not stitched. The patientwas exhausted, and there was considerable nervous excite-ment in the last stage. Dr. Campbell saw her for the firsttime several days later, when she was still nervous but other-wise well. On the twelfth day she suddenly became worse,and on the thirteenth day the temperature was 1030 and pulse145 ; the lochia were scanty and offensive, and the milk secre-tion was suppressed. She rapidly became delirious, and re-fused nourishment. Antistreptococcic serum (IO c.cm.) wasinjected. On the fourteenth day the temperature was 1020

and pulse 130, but there was still delirium and profuse per-spiration. Twenty c.cm. were now injected, and later thetemperature fell to I0OI and the pulse was 130, the patientbeing noticeably more rational. On the fifteenth day, themorning temperature being IOI.40 and pulse 130, and theevening temperature being 102.60 and pulse 140, 10 c.cm.were given, and the same quantity was injected on the six-teenth and seventeenth days. On these latter days therewas severe diarrhoea, with very offensive stools passed un-consciously. On the eighteenth day the pulse fell to I 12 andthe temperature to 990, and the patient now took nourish-ment freely and was more rational. The recovery was after-wards progressive and uninterrupted. Dr. Campbell directedattention to several points: (i) The serum was given early andfreely, 6o c.cm. in five days, and there was no local irritation.(2) Immediate improvement resulted, the patient neverrelapsing into the desperate condition existing prior to thistreatment. Doses in the evening were followed by greaterimprovement than those given in the morning. (3) Othermeanswereemployed,thatis,uterine douchingwith perchlorideof mercury (I in 4,000) twice daily, and vaginal douching withcarbolic solution (i in 8o) every four hours; iron and quinineinternally. (4) The perineal laceration was foul, and coveredwith pus on the twelfth day, and there was some tendernessover the uterus, but there was otherwise nothing to accountfor the high temperature and great constitutional disturbancethat took place.-Dr. EDGAR read a paper on a series of casesof Extrauterine Pregnancy, with remarks on Diagnosis andTreatment. The following were the cases: i. Haemorrhageinto right Fallopian tube, without escape into peritonealcavity; heematoma of right ovary; salpingo-oophorectomy;recovery. ii. Incomplete tubal abortion, with expulsion ofuterinedecidua; appendicitis; salpingo-oophorectomy, andemoval of vermiform appendix; recovery. iII. Incompleteubal abortion; salpingo-odphorectomy ; recovery. iv. Doubletubal pregnancy, each ending in rupture of tube; doublesalpingo-o6phorectomy; recovery. v. Tubal abortion; subse-quent abortion or rupture ending in formation of retrouterineheematocele; medical treatment; improvement. vi. Retro-uterine haematocele; vaginal incision, followed by emptyingof sac and drainage: recovery. vii. Abdominal pregnancy,septic symptoms; vaginal incision, followed by removal ofplacenta, and four anda-half months' foetus; drainage; re-covery. Dr. Edgar remarked with regard to diagnosis: (I)That preceding sterilitywas not to be relied on. All hispatients had had children. In one the ectopic pregnancy hadoccurred only fourteen months in two only seven and a-halfmonths after delivery of a full-term child. (2) That earlysigns and symptoms of pregnancy, though of immense impor-tance when present, might be absent, for example, in Case ii.

(3) That it was difficult to differentiate between tubalrupture, tubal abortion, and hiemorrhage into tube with-out escape into the perineum. The question was usuallysettled by the degree of severity of the symptoms, the first

being the most, the last least severe. (4) The value ofcuretting in diagnosis. This was done in Cases I, iv, andand vii with positive and in vi with negative result. Doubt-less the decidua in vi had been completely expelled. (5)Differential diagnosis between tubal abortion or rupture anduterine abortion. The points on which he laid stress indifferentiating were: (a) The condition of the patient wasmore serious; (b) the uterus was not of the same size, shape,or consistence; (c) there were no chorionic villi nor pla-cental tissue; (d) if the swelling was made out at the sideit waq tubal, as evidenced by feeling the isthmic portion o#the tube, it was boggy; pulsation was often more marked inthe corresponding fornix. With regard to treatment,it was advisable always to operate. The usualcourse was to perform abdominal cr vaginal salpingo-oophorectomy. He referred to cases of Prochownick andMartin, in which the contents of the tube were removed andthe tube afterwards sutured, and said that this treatmentought to be adopted in suitable cases. As to hiematocele,vaginal incision, and drainage after emptying the sac wasbetter than expectant treatment, and preferable to abdominalsection. In advanced cases also the vaginal was preferable tothe abdominal operation, for drainage was thus secured at thelowest point, there was no risk of ventral hernia, less shock,and quicker recovery, and the peritoneal cavity was notopened. The objections to the vaginal operation were thatextraction might be difficult if the child were far advanced,and there might be dangerous hiemorrhage. In hWematocele,too, the gravid tube was left. Search should be made for thetube in emptying the sac. The danger of cutting into pla-centa is the same in both methods, and the placenta if notfound at or near the site of incision is left alone as in theabdominal operation.

BRISTOL MEDICO-CHIRURGICAL SOCIETY.-The eighth meet-ing of the session was held on May 12th in the MedicalLibrary of University College, Dr. HARRISON in the chair.Mr. EWENS showed a case of Congenital Deficiency of bothFibuke, with extreme Calcaneo-Valgus, remedied by tenotomyand instrumental appliances. Professor FAWCETT and Dr.RIGG made remarks.-Mr. MORTON showed a patient fromwhom the Head of the Tibia had been excised for myeloidsarcoma, and the shaft screwed to the lower end of the femur.Mr. EWENS and Dr. SWAiN remarked on the patient.-Dr.FYFFE read notes on some of the Infectious Diseases of PublicSchools. Dr. HARRISON, Dr. SHINGLETON SMITH, Dr. SYMESMr. TAYLOR, Dr. SKERRITT, Dr. PARKER, Dr. EDGEWORTH, andMr. MORTON made remarks on the paper.-Dr. SHAW madesome remarks on a case of Haemophilia with Joint Lesions.-Dr. SWAIN, Mr. EWENS, Mr. FENDICK, and Dr. PARKER maderemarks on the case.-Dr. PARKER spoke on a case of LeadPoisoning presenting Hiematoporphyrin.

BRADFORD MEDICO-CHIRURGICAL SOCIETY.-At a meetigon May 4th, Dr. GODFREY CARTER, President, in the chairDr. JOHNSTONE CAMPBELL showed (i) a case of MediastinalTumour; (2) a case of Peripheral Neuritis exhibiting ex-treme wasting of the muscles of arm and shoulder.-Dr.JASON WOOD showed a patient with Transposition of Viscera.-Dr. CARTER gave a demonstration of Microscopical Objects.-Dr. WEBB related a case of Acute Nephritis comlicatingPregnancy. The patient was a single woman, aged i8, fivemonths pregnant. Venesection was performed, 12 ounces ofblood being withdrawn, and i1 pint normal saline solutionwas then transfused; after this the patient seemed muchbetter. Artificial labour was induced, and the patient wasdelivered of a living child, which survived twenty-four hours.After more than one relapse, she finally made a good re-covery.-Dr. BELL related a group of cases of invaccinatederyFsipelas. He pointed out that if the disease is inoculatedat the time of vaccination, the erysipelas would show itselfabout the fourth day. Nine children were vaccinated froman apparently healthy child. Cases I, 2, and 3 ran anormal course. Cases 4, 5, and 7 developed erysipelas of thearm in the first week, but the vaccination pocks ran a normalcourse. Case 6 had an axillary abscess, and the development of the pocks was more rapid than natural. In Cases 8and 9 the pocks developed more rapidly than natural, but

I290 MDICALL JOU.i]J REVIEWS. LMAY 22, 1897.there was no other inflammation. The vaccinifer in thesecases was apparently normal at the end of the second week,at the end of the third week there was enlargement of theaxillary glands, which subsided without suppuration.-Mr.MIALL related a case of Myxcedema in which treatment bythyroid gland and extract was followed by a complete cure ofall the symptoms.-Mr. HORROCKS related a case of RecurrentAppendicitis successfully treated by abdominal section andremoval of the vermiform appendix, the peritoneum beingstitched over the end of the stump. Mr. Horrocks regardedas indications for operation in these cases, (i) increasingseverity of attacks, (2) shortened interval between attacks,(3) a feeling of discomfort during the intervals of attack, pro-viding the patient is otherwise sound.

REVIEWS,AN AMERICAN TEXTBOOK OF PHYSIOLOGY. By HENRY P.BOWDITCH, M.D.; JOHN G. CURTIS, M.D.; HENRY H.DONALDSON, Ph.D.; W. H. HOWELL, M.D.; FREDERICK S.LEE, Ph.D.; WARREN P. LOMBARD, M.D.; GRAHAM LUSK,Ph.D.; W. T. PORTER, M.D.; EDWARD T. REICHERT, M.D.;-and HENRY SEWALL, M.D. Edited by WILLIAM H. HOWELL,Ph.D., :M.D. Philadelphia: W. B. Saunders. London:The Rebman Publishing Company. I896. (Roy. 8vo, pp.1052. 258. 6d.)

'THIS is a very complete and comprehensive textbook; it in-eludes the whole range of physiology as usually taught, but-does not embrace anatomy or histology, except in certain-cases where reference to or fuller description of such facts isnecessary to develop the matter under discussion.

It is the work of several authors, a plan of bookmakingwhich has of late come much into favour, but one which wedo not remember to have seen employed in a student's text-book. The preface contains a very interesting discussion ofthe value of such a method in preparing books for the use ofstudents. It is pointed out that on this method each authoris enabled to base his elementary account upon a more com-prehensive knowledge than the individual author who at-tempts to deal with the whole bulk of one science. Thispoint will be accepted by all those who are acquainted withthe difficulty of making a satisfactory homogeneous elemen-tary presentation of the complex and unsettled questions of,which the modern science of physiology is composed. Dog-matic statements and generalisations, such as are frequentlynecessary in textbooks, if they are to leave any impression atall upon the student, are usually trustworthy in proportion-o the fulness of information possessed by the writer.

Again, by the use of the method of collaboration the readergains the advantage of each subject being treated from the,point of view of a specialist; more especially will this be%it in those portions of the subject which overlap and aretreated of by several writers. Each writer will give inaddition his own methods of investigation, and thus theadvantage is gained to the reader of seeing the same problemattacked by several experimental methods-physical,chemical, microscopical, etc.The general plan of the work is to take the several physio-

logical (rather than anatomical) entities of which the scienceconsists and to entrust each to an individual author.

Professor HOWELL, in addition to his editorial work, con-tributes an able introduction in which the scope and aims ofthe science are set forth and the various methods of attack-ing the subject experimentally briefly indicated. The sectionson secretion, chemistry of nutrition, the blood, and move.ments of the alimentary canal are also from his pen. Thesesubjects are all treated in a very clear and lucid style.Thoroughly up to date and accurate as the whole volume is,we find here not only an account of the subjects written froma recent standpoint, but in addition the expression of opinionand estimation of varying importance of the different subjectstreated of by one of the first American physiologists.The rest of the volume is written in a manner equally

authoritative and clear, and from the list of authors givenabove it may be gathered that we have in this textbook anaddition to pbysiological literature of great importance. We

congratulate the editor and his collaborators on the con-spicuous success which has attended their efforts.

0

LIFE IN WEST LONDON: A STUDY AND A CONTRAST. ByARTHUR SHERWELL. Second edition. London: Methuenand Co. 1897. (Cr. 8vo, pp. 214. 28. 6d.)

ANY treatise on social disease is likely to give an exaggeratedidea of the evil, and to lead readers into the belief chat theunsound parts exceed the sound parts. Many treatises seemdeliberately to aim at such a result, and by fostering a morbidappetite for what is abnormal have done injury to the reform-ing spirit. Mr. SHERWELL has not done so. It may be thathis book will leave an impression not altogether justified byfacts, but the fault is with those whose minds too easily takesuch an impression, and not with the author. He, as a pupilof Mr. Charles Booth, has gone to work in a scientific way.He has observed, inquired, compared, and gathered statistics,and in the end he presents a picture of a district in a centreof London which demands attention. First of all he showshow abrupt is the division between Soho and the adjoiningMayfair. In Soho the percentage of poverty is 42.4, in May-fair it is 2.7. In Soho there are 13 persons to a house, againstan average all over London of 7 persons, with 232.21 personsto an acre, against 41.1i58 in Mayfair, and, of these persons,IO per cent. share one room with 3 others. The result of suchovercrowding is easily to be imagined. In Soho the deathsfrom phthisis per I,ooo is 3.2, against 1.7 for all London,while the rate of infant mortality is 36 per I,ooo higher thanthe average of all London, and 64 per I,ooo higher than thatof the neighbouring district of St. George. Mr. Sherwellhaving given, as it were, an outline by such figures, pro-ceeds to fill it in byan account of the trades, the social habits,and the recreations of the people. He is particularly struckby the invertebrate character of the district, and by the de-moralisation caused by the neighbourhood of a pleasure-seeking class. "In the East and South the colour of life,if deadly dull, is more even, but in Soho the poor are madeto feel they are aliens for life on the very borders of their ownhomesteads."When Mr. Sherwell proceeds to consider remedies, he does

so in the same level-headed way. He does not ask for morephilanthropic agencies. He finds, in fact, that so far as"ordinary Christian and other philanthropic agencies areconcerned the West End is probably at least as effectivelyserved as any other district in the metropolis," and he showsthat there is one official Christian worker to every 462 per-sons in North London, against I to every 878 persons in EastLondon. Mr. Sherwell sees hope (i) in the more efficientworking of existing legislation, and (2) in a further develop-ment of healthy public opinion. He shows, for instance,what might be done under the Labouring Classes LodgingHouses Act, or under the Public Health Act of 189I, and howlittle has been done. It is curious how social enthusiasmturns aside from the plodding work which uses the law to im-prove dwelling and cleanse dirt. People who are roused toindignation at the disease and wretchedness are impatient ofthe only road to reform. They want a new law or a newgospel. Mr. Sherwell shows what might be done if inspectorsprevented overcrownding and collection of dirt, and how thiswill only be done when enthusiasm is put in the shafts oflocal government.The promotion of a more healthy public opinion which

will counteract the effect of the example of luxury and ofseasonal trade is a matter of greater difficulty. All that canbe said is that the altruistic sense is growing, and that thereis a measureless power in the undeveloped capacities ofhuman nature.

SOME ASPECTS OF INFANTILE SYPHILIS. By J. A. COUTTS,M.B.Cantab., F.R.C.P. London: Rivington, Percival, andCO. 1897. (Cr. 8vo, pp. 136. 38. 6d.)

THE subject treated in this small work is one of great, per-haps growing, importance. Dr. COUTTS has therefore donewell to reprint his course of Hunterian lectures deliveredbefore the Royal College of Surgeons last year. The authormodestly says that he has dealt with only a limited portionof the subject, 1 ut at the same time the topics which he