885

Side of the Pharynx and Larynx, occurring in a male Ipatient, aged 54 years. He had been under treatmentfor interstitial nephritis and had a blood pressure of230 millimetres. On the afternoon of March 4th,his neck had suddenly begun to swell. On admissionto the German Hospital at 7 P.M. the whole thyroidgland, especially the right lobe, was much enlarged,tense, and tender. There was likewise considerable generalswelling of the neck and over the upper part of the sternumand there was great cedema of the right side of the pharynxand larynx. The pharynx was scarified and the patient wasmuch relieved by a morphine injection, rest in bed, and theexternal application of ice to the neck. The swellinggradually subsided. At present (March 17th) the man feltalmost in his usual condition but the thyroid gland wasenlarged and the skin of the neck and the upper front partof the chest was discoloured, as from extensive bruising, andthere was still much ecchymosis of the mucous membrane ofthe pharynx and larynx.-Dr. DAVID FORSYTH said that theanatomical structure of the thyroid gland made it improbablethat a haemorrhage occurring therein would produce sym-ptoms such as those described, but Dr. WEBER replied thatthe effusion must have taken place into the thyroid.Mr. H. BETHAM ROBINSON showed a case of Enlargement

of the Clavicle and Lower Jaw. The patient was a boy,aged 13 years, with chronic inflammatory swelling of theright clavicle and the left side of the lower jaw dating froma fall six months before. There was some nodular enlarge-ment of the right half of the thyroid gland. There had’been some reduction in size under iodide of potassium

Dr. HARRY CAMPBELL showed a case of Disappearance ofthe Subcutaneous Fat above the Region of the LowerExtremities occurring in a woman, aged 21 years. The dis-

appearance was especially marked in the face, chest, andabdomen, including the region of the mons Veneris. Therewas no disappearance of fat from the mammary glands orthe orbits. There was an abundant deposit of subcutaneousfat in the buttocks and lower extremities generally. Thepatient was said to have been perfectly normal up to theage of seven years. From this time until the age of 14

I

years there occurred a gradual disappearance of fat fromthe affected regions.-The PRESIDENT compared the con-

dition to morphoea.Mr. DONALD J. ARMOUR showed a woman, aged 29 years,

from whom a large Polycystic Kidney had been removed twoand a half years previously. She had been quite unaware ofthe tumour and there had been no urinary symptoms.-Dr.PARKES WEBER referred to a recent case in which a Frenchsurgeon had removed what he took to be a cystic kidneybut which proved at the necropsy to be a polycystic pararenalgrowth of Wolffian origin.

Mr. SPENCER showed a case of Obliteration of BilateralPsoas Abscess. The patient, a woman, aged 25 years,had recovered, apparently completely, after several opera-tions.-Mr. WARREN Low referred to the advantages of

closing the wound after operation in such cases.-Mr.SPENCER, in reply, said that it was at first impossible todo so in this case, as the sac was already septic when he-first saw the patient.

Mr. A. E. J. BARKER showed a case, in a woman, aged 24years, of Fixation of the Jaw. The left masseter was fitrous.-The PRESIDENT noted the elongation of the lower jaw andsuggested alveolar trouble as the cause of the condition.

OPHTHALMOLOGICAL SOCIETY.

Thrombosis of the Cavernous Sinus.-z5’ympathetic Irritation.-Cysts of the Pars Ciliaris Retinae.-Kmkibition of Casesand S’p60MK)MM.A MEETING of this society was held on March 14th, Mr.

PRIESTLEY SMITH, the President, being in the chair.Dr. W. C. ROCKLIFFE (Hull) read notes of a case of

Thrombosis of the Cavernous Sinus associated with Menin-gitis, originating in a septic sore on the upper lip. Thepatient was a fish-dock labourer whose general health but foroccasional bronchitic attacks had been satisfactory. When ’,first seen on Nov. 18th there was proptosis on the right side,with fixation of the globe, swelling of the lids, and chemosis.Five days previously a small pimple had appeared on the rightside of the upper lip, which had been picked and eventuallypricked with a pin. The lip and face became greatly swollenand were subsequently treated with a linseed-meal poultice."During the two days the patient was in the infirmary there

was delirium and the temperature ranged from 102° to 105° F.A lumbar puncture was made and cocci were identified inthe leucocytes. Cultures proved the infection to be staphy-lococcus pyogenes aureus both in the spinal fluid and lip.Death occurred on Nov. 20th, two days after admission andseven days after the spot appeared on the lip. At the

necropsy the meninges at out the cavernous sinuses werecovered with lymph. The right and part of the left cavern-ous sinus and the transverse sinus were thrombosed. Theorbital tissues on the right side were inflamed and swollen,but there was no pus. The case differed from one ofcellulitis of the orbit, which did not tend to affect the

opposite side.-Mr. J. B. LAWFORD cited a somewhat Eimilarcase of cavernous thrombosis in a man, aged 36 years,which resulted from a pustule in the nostril. There wascellulitis of the nose, face, and orbit. Death occurred infour days, though antistaphylococcic serum was given.

Dr. RocKLIFFE also recorded four cases of Sympa-thetic Irritation occurring 18, 22, 28, and 50 years afterinjury to the other eye. In two of these cases a foreignbody was found and a fragment of stone was probablypresent in the eye in the third case, the fourth being apunctured wound. Considerable ossification of the choroidwas present in three.-Mr. E. TREACHER COLLINS com-mented on the wide field of discussion opened up by Dr.Rockliffe’s communication. He thought that three of thecases were rather of the nature of sympathetic inflam-mation than irritation on account of the presence ofkeratitis punctata. In the other, glaucoma occurring inthe second eye might be attributed to the shock of excision,as it not infrequently followed this. In reference to thespecimens shown he said that ossification of the iris wasunknown, though such change might occur in the adjacentchoroidal processes or the capsule of the lens.Mr. A. R. BRAILEY read a paper on Cysts of the Pars Ciliaris

Retinae and stated that clinically these structures had fre-quently been mistaken for sarcomata of the ciliary body, butlittle was known of their pathology, though their study mightthrow some light on the secretion of the aqueous fluid. Theywere found in such a variety of conditions that he was onlyable to classify them according to their apparent mode oforigin. Two changes which played an important part in theorigin of some varieties limited to the cells of the un-

pigmented epithelium were multiplication of the cells andvacuolation of the cell bodies. This proliferation was mostfrequently found in senile eyes and was commonly associatedwith hypertrophy of the ciliary processes. The cells of thepigmented layer appeared to play a mere passive rôle, andeven in cysts arising by simple detachment of the epitheliumit was the unpigmented layer alone which was affected, theadhesion between the pigmented epithelium and the under-lying ciliary body being a peculiarly intimate one. Thedifferent modes of origin appeared to be: (1) detachmentof the non-pigmented epithelium ; (2) proliferation of thenon-pigmented epithelium cells, with the formation of a

cavity arising either by a simple separation of the cells or bytheir vacuolation and destruction ; and (3) proliferation andunion of the cells of adjacent processes, leading to a portionof the posterior chamber being shut off from the remainder.The number of the specimens was too small for him to cometo any conclusion as to the relative frequency of thesevarieties. The contents of the cysts were usually lost duringthe preparation of the specimen, but when present theyconsisted of a deeply staining, homogeneous, coagulablefluid.The following cases and card specimens were shown :—

Mr. F. F. BURGHARD and Dr. E. L. PRITCHARD: CavernousSinus Aneurysm cured by a new method after failure of theusual operation.

Mr. G. COATS : A case of Oxycephaly.Mr. L. J. PATON : Oxycephaly.Mr. W. I. HANCOCK: Peripapillary Atrophy.Mr. CoLLINS : A Corneal Affection in Myxoedema.Mr. H. B. GRIMSDALE : Unusual Opacity in the Lens.Dr. RocKLiFFE: A Completely Calcareous Lens ; Totally

Ossified Iris (?). _________

LIVERPOOL MEDICAL INSTITUTION.

Exhibition of Cases.-TAe Treatment of the Almte PatlwgenioInfections with Vaccines and Sera.

A MEETING of this society was held on March 21st, Mr.FRANK T. PAUL, the President, being in the chair.Many cares of interest were shown, among them being:

886

Medical cases by Dr. A. G. GULLAN, Mr. F. A. POND, Dr. 1;NATHAN RAW, and Dr. R. G. WILLIS ; Surgical cases by the (

PRESIDENT, Dr. DAVID MORGAN, and Mr. K. W. MONSARRAT ; r

Skin cases by Dr. H. LESLIE ROBERTS, Dr. F. H. BARENDT, IDr. G. G. S. TAYLOR, Dr. R. W. MACKENNA, Dr. W. C. 1

ORAM, and Dr. E. L. ANDERSON; Eye cases by Dr. K. A. IGROSSMANN, Mr. R. J. HAMILTON, Dr. W. E. LIVSEY, and s

Dr. A. N. WALKER ; and Ear cases by Mr. E. M. STOCKDALE. B

The PRESIDENT showed the following cases: 1. A boy, 1;

aged 11 years, who had been Scalded when two years old onthe Side of the Chest. Subsequently the mother noticed a c

swelling in the region of the left pectoral muscle. This had 1;

gradually grown until it was now of the size of a hen’s egg.It had been examined and found to consist entirely of muscle. I2. A case of Immense Hypertrophy of the Gums of Both Jaws, Ishown previously before the society and now cured. The i

gums were removed by four operations two years ago without f

extracting the teeth, and recurrence had taken place. A 1;second series of four operations was undertaken with removal c

of the entire alveolar processes resulting in complete cure. c

(Models of the original condition were shown by Mr. E. J. M. t

PHILLIPS, dental surgeon to the Royal Infirmary). 3. A 1

woman, aged 53 years, who had received an Injury to the c

Fifth and Sixth Cervical Nerves from a fall on the shoulder 1;causing paralysis of the muscles supplied by those nerves, t

Dr. RAW read a paper on the Treatment of theAcute Pathogenic Infections with Vaccines and Sera. He c

particularly mentioned the great value of antidiphtheritic Iserum if given early in pure cases of diphtheria but said that Iin mixed infections it did not seem to exert the same ibeneficial influence. He had treated 212 cases of erysipelas, c

puerperal fever, and other septic infections with anti- c

streptococcic serum and was convinced that in streptococcal 1infections the serum if given early had a marked curative 3effect. The use of a polyvalent serum had immensely c

improved the results of treatment. In the treatment of a 1large number of cases of tuberculosis he had come to the 1conclusion that tuberculin R. had not much curative value E

in phthisis pulmonalis, even in the early stages of the disease, sbut in the so-called surgical forms of tuberculosis, such s

as lupus, tuberculous glands, joints, and peritonitis, 1tuberculin R. had a most marked curative effect and hisresults of treatment of numerous such cases were astonish- (

ingly good. He was not favourably impressed with the r

value of antitetanic serum.-Dr. W. B. WARRINGTON con- tsidered antistreptococcic serum to be of little utility in (

medicine and pointed out that it was the recognition of this Jthat led Sir A. E. Wright to introduce the method Eof vaccines. He alluded to the value of endoneural sinjection of the antitoxin in tetanus.-Dr. ERNEST E. GLYNN, I

commenting upon the very favourable results obtained 1

by Dr. Raw with anti streptococcic serum in puerperal 2septicaemia, asked what evidence there was that the cases s

were true septicasmia and also due to streptococci, as cultures I

were not made in the majority of instances. Might not 1

many have been cases of intoxication and recovery been the s

result of local treatment of the uterus ? 7 Dr. Raw’s success s

in treating lupus with tuberculin uncontrolled by the opsonic E

index and unassisted by light treatment was not in accord 1with the experience of many, for lupus was very refractory. 1He was also surprised that Dr. Raw had cured three cases (

of tuberculous meningitis with tuberculin, especially as the (

opsonic index had not been taken.-Dr. A. S. PARKINSON tsaid that the earlier tuberculin was given in pulmonary s

tuberculosis the greater the probability there was of a good 1;

result. He thought that the failure in advanced cases was (

sometimes due to secondary infection of the lungs by pyo- 1

genic organisms, and that the immunity of such patients 1against secondary infections should be raised as well as the ttreatment by tuberculin injections carried out.-The follow- 1ing gentlemen also took part in the discussion : Dr. TAYLOR, ‘Dr. J. HILL ABRAM, Dr. B. SUMNER, Dr. N. E. ROBERTS, iDr. R. J. M. BUCHANAN, and Dr. ORAM.

I

ROYAL ACADEMY OF MEDICINE INIRELAND.

SECTION OF OBSTETRICS.Exhibition of Speaimcns.-Pubiotomy (Hebotomy).

A MEETING of this section was held on March 8th, Dr.R. D. PUREFOY, the President, being in the chair.

Dr. ALFRED J. SMITH exhibited a Uterus showing a Fibro-myoma in the Fundus and Cancer in the Cervix. The patient

was 40 years of age. Dr. Smith had diagnosed and dis-covered polypus of the uterus and had made up his mind toremove it as the cause of the haemorrhage from which thepatient suffered. During the removal of it he found anulcerated spot in the cervix which under the microscopeproved to be an adeno-carcinoma.-Sir ARTHUR V. MACANsaid that the specim 3n was interesting as showing two thingswhich were extremely rare in combination, though neitherwas rare by itself.

Sir ARTHUR MACAN exhibited specimens of Carcinoma andof Sarcoma of the Body of the Uterus. One of the patientswas 50 and the other was 60 years of age.

Mr. E. HASTINGS TWEEDY, Master of the Rotunda Hos-pital, Dublin, described a case in which he had delivered aprimiparous woman of a living child at full term through aninternal conjugate measuring 6’5 centimetres by the per-formance of a left-sided hebotomy. Hemorrhage had beenvery severe and had resulted in a considerable degree ofcollapse. Delivery had to be hastened because of prolapseof the cord, which took place before the operation was under-taken. Deep lacerations of the cervix, of the soft partslying between the severed bone, and of the perineumoccurred, requiring catgut sutures. The patient’s recoverywas uneventful and she left the hospital in perfect health inthe ninth week with a living child.

Dr. M. J. GIBSON read a paper on Pubiotomy, with Noteson Three Cases. He said that the idea of improving theprognosis for the mother and child in cases of contractedpelvis, and of lessening the number of Csesarean sections,inductions of premature labour, and perforations of the livingchild, by an artificial enlargement of the pelvis was a very oldone. Symphysiotomy, first demonstrated by Courvee in1655, was first performed on the living subject by Sigault 100years later. Symphysiotomy was not a very satisfactoryoperation. To Gigli belongs the honour of being the first topropose as a substitute for it an incision through the os

pubis. The great danger in Gigli’s operation lay in the largeeasily infected incision which he employed. Doderlein’ssubcutaneous pubiotomy was really a new operation, at oncesimple and effective. It was indicated in cases of narrowpelvis when the cervix was fully dilated and when, in spite ofgood contractions, the head moved freely about the brim.Good uterine contractions might by preparation of thematernal soft parts and by moulding of the foetal head drivethe latter through a pelvis so narrow that natural deliverycould hardly have been expected. The operation might beperformed in cases of flat pelvis with a conjugata vera up to6’ 75 centimetres, and in generally contracted pelvis up toseven centimetres, but for these very low conjugates the headmust not be larger or harder than normal. He adoptedDoderlein’s method in his cases. A small incision, sufficient toadmit a finger, was made over the bone, usually at the leftside between the symphysis and the tubercle. Doderlein’sneedle was passed down behind the bone and its pointbrought out in the greater labium. Gigli’s saw was attachedand the bone divided. The haemorrhage was as a rule easilystopped by compression. The patient should not be deliveredexcept it was absolutely indicated. After labour was com-pleted a few strips of adhesive plaster were put around thepelvis, a binder was applied, and the patient was kept lyingon her back for 12 days. She might get up on the fourteenthor sixteenth day. The advantages over symphysiotomy werethat the undivided soft parts prevented the pelvis from

springing suddenly apart, while the bladder and urethrawere not so liable to injury during the operation. The

operation was also more easily and more rapidly performed.He performed his first operation on August 16th, 1906 ; thepatient was 34 years of age and had been pregnant ninetimes but had no living child. Premature labour hadbeen induced twice. The pelvis was generally contractedwith a true conjugate of eight centimetres. A child weigh-ing 12 pounds was delivered without difficulty. The patientwas walking about on the twenty-first day, and left thehospital with her child two days afterwards in perfecthealth. The second patient was 32 years of age and hadalso been pregnant nine times. Her second child wasdelivered with forceps and was still alive. She had prematurelabour induced three times. In her last pregnancy she wentinto hospital after being in labour for 14 hours. Thecervix was fully dilated, the membranes were ruptured, andthe fcetal head was small and was free above the brim. The

pelvis was generally contracted and flat with a true

conjugate of 7’ 5 centimetres. The fcetal pulse-rate reckonedfrom the heart sounds was about 160, but was very irregular.Meconium came away in large quantities. The mother had