964

as follows. He was apparently a fairly well-nourished man ;superficial examination showed that above the claviclesand on both upper arms there was a diffuse and profusegrowth of what felt like subcutaneous fat ; on both fore-arms there were lumps varying in size from that of a walnutto that of a golf ball, with an elastic semi-fluctuatingfeel, freely moveable on the muscles but incorporatedwith the corium ; in fact, with all the physical signs usuallyassociated with multiple and diffuse lipomata. The thighspresented a similar but much less marked condition thanthe upper arms. On the tendons of the wrist and onthe tendon of the rectus femoris on each side theie wereone or two small lumps more firmly adherent to the tendonsheaths. On the left first rib at its junction with the

, sternum and over the right pectoralis major were one or

two lumps of a much firmer consistency, feeling verysuspiciously like glands infiltrated with some form of

growth. The veins on the left side of the chest in frontwere rather more prominent than was usually the case

though not sufficiently so to suggest serious blockage of largedeep veins. Examination of organs gave no indications ofdisease, the air entered both lungs freely to the base withoutadventitious sounds or alteration of the natural ones ; theheart beat was regular in rhythm and the sounds were satis-factory ; and in the abdomen there was nothing to be feltthat could be called abnormal unless it was a little tender-ness to palpation in the upper abdomen generally. Dr.Smith gave the above details, or rather called the attentionof the Fellows to the above points, and then consideredthe diagnosis. He stated that in his opinion therecould be no doubt that the majority of the lumps werelipomata, but he was in doubt whether there were

not also some glandular involvements; he hoped to be ableto persuade the patient to allow one of the quasi-glandularlump to be removed for microscopic examination. His

suspicions were especially aroused by the history ofgastric trouble, though he thought this might perhapsdepend upon a chronic ulcer. He drew attention tothe absence of any history of previous stoutness of the

patient, a history which was commonly present in cases ofmultiple lipomata. He promised a further communicationon any new facts in the case.

Dr. SMITH also showed a case of Leucocythoemia. The

patient was a man, aged 32 years. His illness began in 1901with a continued drowsy and sleepy feeling ; he then noticedthat his abdomen was swelling and that he got short ofbreath. He was then told that his spleen was enlarged. Hewas admitted to hospital under the care of Dr. Smith in

July, 1902, was treated with arsenic, and was dischargedimproved in September with a blood count showing--whitecorpuscles 171,600, red corpuscles 2,000,000, and haemo-

globin 45 per cent. He was readmitted to hospital onFeb. 21st, 1903, with loss of energy, shortness of breath,and swelling of the eyelids and ankles. He gave a historyof haemorrhage from the gums with attacks of faintnessand giddiness ; he had also cramps in the muscles. Ablood count showed-white corpuscles 320,000 and haemo-globin 50 per cent.; a stained film showed some poikilocy-tosis of the red cells and a few nucleated ones with everydescribed variety of white cell with a preponderance oftransitional forms ; many blood platelets, in clumps andsingly, were also present. The fundi oculorum showed no

pathological changes of any kind. The spleen reachedfrom the diapliiagm to the pelvis. Dr. Smith remarked thatthe case showed no especial features of its own, but he had

brought it as an example of a somewhat uncommon disease.He was having a research carried out upon the uric acid inthe mine by Dr. MacLeod in the Pathological Institute ofthe London Hospital.

Dr. W. H. KELSON showed a man sufferirg from Ulcerationof the Epiglottis, Intcr-arytsenoia Fold, and both Vocal Cords.Tubercle bacilli were present in the sputa. There wereevidences of slight changes in the lungs. The patientcomplained chiefly of pain on swallowing, which had beenmarkedly relieved bJ orthoform insufflations. He had alsobeen getting hoarse for about a month. Dr. Kelson, in

rel:,lying to questions, said that orthoform powder had provedof great value in the relief of pain attending tuberculousulceration.

Dr. T. GLOVER LYON showed a case of Cured Phthisis."The patient was a girl, aged 11 years. She was saidto have had a cough with slight expectoration for two

months, occasional slight spitting of blood, and had wastedshocking." On admission to Victoria Park Hospital she

was very thin, with shiny skin and pasty complexion,looking very ill. The physical signs were much the sameas described later except that the heart’s apex beat wasnormal in position. The patient rapidly improved in

general condition and in eight weeks her weight increasedfrom 4 stones 4 pounds to 5 stones 1 pound, an increaseof 16 per cent. After two months in hospital the physicalsig[1s were as follows : the chest was well formed, movingslightly less on the left than on the right side ; in frontthere was dulness and much increased resistance over thelung area above the heart, the apex beat of which was inthe fourth interspace. There was tubular breathing withmetallic (dry) crepitations. There were increased vocalresonance and decreased vocal fremitus. Behind there wereslight dulness, metallic crepitations, and increased vocalresonance and vocal fremitus over the upper half. Coughand expectoration had entirely ceased and the child lookedhappy and well. The expectoration had ceased soon afteradmission and no examination of it had been made, but therewas no doubt about the tuberculous nature of the diseaseThe temperature had shown a tendency to rise from time totime up to 101° F., but the child had been allowed to

get up without apparently any effect upon these rises of

temperature.-Dr. SMITH, Mr. W. HARRIS BEST, Dr. W. H.KELSON, Mr. A. W. GALLOWAY, Dr. W. RAWES, and Mr.JOHN ADAMS discussed the cases.

LEEDS AND WEST RIDING MEDICO-CHIRURGICAL SOCIETY.

Exhibition of Cases and Specimens.A CLINICAL meeting of this society was held on

March 20th, Mr. JOHN IRYING, the President, being in thechair.

Mr. J. G. E. COLBY showed a lad with TransposedViscera.

Dr. E. WARD exhibited two cases of (?) MolluscumFibrosum-

Dr. T. CHURTON showed : 1. A woman, aged 39 years, whohad been under Anti-syphilitic treatment since December,1901. At first the subclavian arteries, especially the left,were thickened and greatly dilated, the pulsation beingvisible above the inner aid below the oui,er part of theclavicle. The carotids were similarly but less affected andpulsation was felt behind the manubrium. All these arteriesnow appeared to be perfectly normal. The other signs of

syphilis had disappeared. Diffuse arteritis in an early stagewas apparently as curable as diffuse syphilitic hepatitis in anearly stage. 2. A woman, aged 49 years, with AorticAneurysm pulsating in the second left intercostal space. A

systolic bruit was audible at the margin of the sternum, in ’

the second interspace, and also over the trachea. 3: A caseof Glycosuria of uncertain origin in a man, aged 56 years, inwhich "renal diabetes" had been excluded by finding anexcess of sugar in the blood by Williamson’s test.

Mr. W. H. BROWN showed some Results of Plastic

Surgery.Dr. J GORDON SHARP showed : 1. A man, aged 40 years,-

exhibiting Infiltration of the Soft and Hard Palate, Epiglottis,Inter-arytenoid Region, and Ventricular Bands, probablytuberculous in nature, although no bacilli were found in thesputum. The condition had greatly improved under the localapplication of 75 per cent. lactic acid. The same patientalso showed great hypertrophy of the lingual tonsil causingno inconvenience and untreated. Six months pieviouslyhehad pleurisy. 2. Three caes of Vaso-motor and TrophicDisease treated for ;-ome weeks with dried adrenal gland andcod-liver oil. During the past month five grains had beengiven twice a day. Case 1 (that of a girl, aged 13 years)was one of true Raynaud’s disease, showing remnants ofnecrosis of the soft parts of the fingers and toes. Lastwinter the girl had to be confined to bed on account of thesores. Under the present treatment she had this winterbeen able to move about and to do household work ; allsaving one sore on the toe had healed. Case 2 (thatof a girl, aged 11 years) was considered to be one ofsevere "broken" chilblain with large areas showing localasphyxia. The sores had nearly all healed and the nutritionof the skin and parts in general had improved. Case 3 (thatof a girl, aged nine years) was one of doubtful Raynaud’sdisease showing the results of malnutrition of the nails of the

965

fingers and toes, sores ot the sott parts, areas ot asphyxia, and glossy skin. Although on first consideration a sub- on

stance like adrenal gland which contracted vessels would no

appear to be contra-indicated in local syncope, yet, as sug- ar

gested by Dr. A. Mantle, the agent might act beneficially by on

raising the blood pressure. vo

Mr. H. LITTLEWOOD showed ten cases of Acute PerforatedGastric Ulcer which he had successfully operated on during the last seven years. In all the cases the perforation was in 01the anterior wall of the stomach and nearer the lesser than su

the greater curvature. The quantity of extravasated material wivaried from a general flooding of the peritoneal cavity to a ofsmall amount in the region of the ulcer and hypochondriac in

regions. Case 1.-The patient was a young woman, aged w:

18 years. Operation was performed on May 2nd, 1896, sevenhours after perforation. Much extravasation was present. L:The ulcer was excised and the stomach opening was closed w:with interrupted silk sutures. The abdomen was drained. bsCase 2.-The patient was a young woman, aged 18 years. clOperation was performed on July 21st, 1896 six hours after clperforation. The ulcer was excised and the opening in the olstomach was closed with interrupted silk sutures. Much 2.extravasation was present. The abdomen was drained. h;Case 3.-The patient was a single woman, aged 28 years. R

Operation was performed on April llth, 1899, five hours after al

perforation. The ulcer was excised and the stomach was Mclosed with interrupted silk sutures. There was not much ta

extravasation. The abdomen was closed without drainage. b:Case 4.-The patient was a single woman, aged 28 years.Operation was performed on Dec. llth, 1900, five hours after Ct

perforation. The ulcer was excised and the stomach wasclosed with interrupted catgut sutures. The abdomen wasclosed without drainage. Case 5.-The patient was a singlewoman, aged 24 years. Operation was performed on

Sept. llth, 1902, about 24 hours after perforation. The ulcer Iwas excised and the stomach was closed with a continuous

catgut suture. Extravasation was limited to the upper partof the abdomen. The abdomen was closed without drainage.Case 6.-The patient was a single woman, aged 24 years. t

Operation was performed on Oct. 25th, 1902, about 18 hours 1:

after perforation. The ulcer was excised and the stomachwas closed with a continuous catgut suture. A good deal t

of extravasation was present. The abdomen was drained. r

Case 7.-The patient was a single woman, aged 20 years, t

Operation was performed on May 15th, 1902, about 14 hours ):after perforation. The ulcer was excised and the stomach i

was closed with a continuous catgut suture. There was 1

much extravasation. The abdomen was drained. Case 8.- iThe patient was a single woman, aged 23 years. Operation <

was performed on Feb. 26th, 1903, about ten hours after &sect;perforation. The ulcer was excised and the stomach was Iclosed with a continuous catgut suture. There was notmuch extravasation. The abdomen was closed without

drainage. Case 9.-The patient was a young woman, aged19 years. Operation was performed on March 1st, 1903.eight hours after perforation. The ulcer was excised andthe stomach was closed with a continuous catgut suture.Not much extravasation was present. The abdomen wasclosed with ut drainage. Case 10.-The patient was ayoung woman, aged 18 years. Operation was performed onMarch 16t,h, 1903 The ulcer had perforated on March 12th.There was very little extravasation, as the stomach aroundthe perforation was adherent to the under surface of theliver. The ulcer was excised and the stomach was closedwith a continuous catgut suture. The abdomen was closedwithout drainage.

Dr. T. WARDROP GRIFFITH showed : (1) Cases ofRaynaud’s Disease ; (2) a case of Cerebral Diplegia ; and(3) an extensive Rodent Ulcer which had undergone com-plete cicatrisation under the use of the x rays during fivemonths.

Mr. A. L. WHITEHEAD showed: (1) A case of TraumaticOcular Paralysis ; (2) a case of partial Embolism of theCentral Artery of the Retina ; and (3) a case of Detachmentof the Retina.

Dr. DOUGLAS SEATON showed : (1) Two cases of CongenitalSyphilis ; and (2) a case of Malignant Disease of the Floorof the Mouth.

Mr. H. R. BEALE showed a case of Lesion in the Middleof the Pons. There was palsy of the left internal rectus forconjugate deviation to the right, but not for convergence ;the pupils were normal. The superior obliques were normal.Sensation in the face wa normal. Paralysis of the musclesof mastication, palsy of both external recti (greater on the

ht), ancl racial palsy were present, and deatness existedi the right side. The remaining cranial nerves were

)rmal. Palsy, incoordination, and numbness of the rightm and hand were present. There was increase of reflexesi the right side. The patient suffered from headaches andImiting.Mr. R. LAWFORD KNAGGS showed a patient in whom thereat Sciatic Nerve had been Severed six years ago by arowbar that had tr}JDsfixed the thigh. The nerve had beenitured on the following day. The patient could walkithout a noticeable limp but sensation over the lower part’ the leg and foot was still very imperfect. Considerable

iprovement had taken place during the last two years andas continuing.Dr. E. F. TREVELYAN showed : 1. A series of cases of

aryngeal Affections in Phthisis among which were (a) a ladith a fixed left cord, enlarged glands in the neck, tubercleicilli in the sputum, and no definite abnormal signs in theiest ; (b) a man with persistent hoarseress and no obviouslange in the larynx ; and (c) a man with laryngealostruction due to infiltration of the ventricular bands.I A case of Tabes Dorsalis of long standing in a man whoad worn a shade for many years on account of diplopia.,emoval of the shade caused a great increase in the ataxia[though the diplopia had quite disappeared. 3. A case offarked Silver-Nitrate Pigmentation. This patient hadtaken for 11 months a solution of nitrate of silver prescribedy a herbalist as a remedy for venereal disease.Dr. S. M. HEBBLETHWAITE showed a case of Tricho-

ephaliasis.

LIVERPOOL MEDICAL INSTITUTION.

Pathology of Progressive Muscular Atrophy.-Acute Intus-susecption 7vith Ulceration of the Jntestine.-Exhibitionof Specimens.A MEETING of the Pathological and Microscopical Section of

this society was held on March 26th, Dr. R. J. M. BUCHANANbeing in the chair.

Dr. A. W. CAMPBELL gave an account of the histology oftwo cases of Progressive Muscular Atrophy and made specialreference to changes in the Cortex Cerebri. In both instancesthe muscles, the peripheral nerves, the spinal cord, and thebulb showed typical alterations ; in both also a serial exa-mination of the Rolandic area in the whole of its extentrevealed the remarkable fact that in the part of the ascend-ingfrontal gyrus and paracentral lobule which an examinationof healthy brains proved to be the normal residence of thegiant cells of Betz scarcely any of these elements wereto be discovered, and their disappearance was associatedwith a general distortion of the cells which remained,atrophy of efferent fibres, and distension of corticalblood-vessels. The ascending parietal and other neigh-bouring convolutions were relatively healthy. The viewthat the spinal changes in progressive muscular atrophywere primary was rendered unstable by the findings inthese two ca-es, because from an experience of the corticalalterations in instances of interference with the system ofmotor neurons at a lower level (cases of myelitis and ampu-tation) it was idle to suppose that a complete retrogradedestruction of the cells of Betz could occur during theprogress of a disease which usually did not last more thanthree years. The alternative views mentioned were thateither the cortical changes were primary or else in progressivemuscular atrophy an expression could be seen or a generaland more or less simultaneous affection of the whole systemof motor neurons. The fact that the alterations were

entirely confined to the area of distribution of the cells ofBetz ave support to the view previously expressed by Dr.Campbell on histological grounds that in man the topo-graphy of the motor area was analugous to that whichProfessor C. S. Sherrington and De. A. S. F. Griinbaum haddefined in the anthropoid ape ; further, since sensation wasunimpaired in cases uf progressive muscular atrophy, thechanges noted could be used as an argument against thetheory of the mixed sensori-motor function of the centralconvolutions. The paper was illustrated by drawings andmicroscopic sections and in one of the latter an abundanceof muscle spindles was seen remaining in an extremelyatrophied muscle, an appearance which strengthened theview that these bodies were concerned with muscle sense.-Dr. W. B. WARRIGTON considered that Dr. Campbell hadmade an important addition to the pathology of this disease