1673LIVERPOOL MEDICAL INSTITUTION.

Cervix Uteri in which he had performed vagino-abdominalhysterectomy. Finding that the epithelioma was operablellie removed the uterus and the growth by a combined vaginaland abdominal operation without previous induction oflabour. The specimen and micro’scopic section of the growthwere described and shown. He discussed the ethics and’the treatment adopted under the following heads-(1) thatwhere pregnancy and operable cancer of the cervix co-existthe life of the mother is alone to be considered ; (2) thatanterior to the fourth month of pregnancy vaginal hyster-ectomy is the orthodox treatment ; (3) that after this periodthe alternative methods are (a) induction of labour followedby vaginal hysterectomy, and (b) hysterectomy, with-out induction of labour, by a combined vaginal andabdominal operation; and (4) that the latter of thesealternatives, having regard to the improved statistics ofabdominal hysterectomy, was in this case to be preferred.-Dr. W. W. H. TATE congratulated Dr. Sanderson on thesuccessful result of his operation. He thought, however,that it was not necessary to have subjected the patient to the;risk of a vagino-abdominal hysterectomy, and that the opera-tion might have been more safely performed by the vaginalroute alone. By making a longitudinal incision through the.cervix and emptying the uterus of its contents it was

possible to remove a uterus in which the pregnancy hadadvanced to the sixth month, if not later. Six years agohe (Dr. Tate) had treated a case of carcinoma of the cervix.complicating a five months’ pregnancy by the older method-of inducing abortion and removing the uterus per vaginam10 days later. Although the case was a favourable one foroperation, the disease rapidly recurred.-Dr. J. H. DAUBER

thought that time alone would decide whether the operationthat had just been described afforded the patient a longer.period of immunity from recurrence than the more usual,method of procedure in these cases. That operation wasthe best which came nearest to effecting a real and

permanent cure. He would like to know in threeor five years’ time if Dr. Sanderson’s patient were

alive and well. and he hoped that the society mightbe informed on that point. He hims-elf had had asimilar case under his care in 1898. He emptied the uterusand then waited for its involution, when he performedvaginal hysterectomy. Recurrenoe occurred within 18months. This he considered unsatisfactory. The foatuswas destroyed and the mother did not long survive.-Dr.W. S. A. GRIFFITH agreed that vaginal hysterectomy after- emptying the uterus was at present the best operation,the mortality being very low and the prolongation of life in

many cases being considerable.-Dr. AMAND J. M. ROUTHsaid that vaginal hysterectomy could be performed at a muchlater date than that of a four months’ gestation. By incisingthe anterior uterine wall along its centre as it was pulled- down into the vagina the contents could be readilyevacuated. The uterus promptly retracted and its sizebecame so materially diminished that its removal became

’easy by the vaginal route. The alternative procedureto this operation in such a case would be some-

what as follows : firstly, a temporary removal of the- cervical growth by scissors, gouge, or cautery, treatingthe stump with pepsin dressings to digest any sloughs ;secondly, induction of abortion ; and thirdly, in a week’stime, to allow some involution to take place, vaginal- hysterectomy. In early pregnancies he much preferred theformer plan. In every case the uterus should be emptiedbefore removal per vaginam.-Dr. HERBERT R. SPENCER

agreed that it was not necessary to resort to abdominalsection in this case. In a recent paper by E. Altherthum,who had himself performed vaginal hysterectomy for cancerat the sixth month, a list of 18 cases was given in which theuterus was thus removed, all the patients recovering.Nevertheless there was a tendency at the present time to

operate by the abdomen in these cases, not for the simpleremoval of the uterus as in Dr. Sanderson’s case, but inorder to remove the broad ligament and glands as widely aspossible. This operation received support from the researchesmade in Professor Rosthorn’s clinic which showed that57’5 per cent. of cases of cancer of the cervix in the operablestage already had the glands infected, and therefore avaginal operation would be useless from the point of viewof cure. If these researches were confirmed they wouldconsiderably alter their views upon the treatment of cancerof the uterus. As far as he knew the results had notbeen good, but a sufficient time had not elapsed to allowthem to judge of the chances of ’’ cure." At the present

time he (Dr. Spencer) believed that in the case under dis-cussion a better operation would have been high amputationwith the cautery followed by removal of the ovum. He

thought also that high amputation after induction ofabortion was a good operation, if the growth was not in aseptic condition. He had not had a case of early pregnancycomplicated by cancer in an operable stage ; but in threecases of cancer complicating labour he had amputatedthe cervix and part of the lower segment after deliveryand the patients were now well after eight and a

half, six, and five years. He did not know of suchgood results after any kind of hysterectomy for cancer

complicating pregnancy.-The PRESIDENT agreed that itwas nearly always justifiable to consider the mother alonewhen both she and the child could not be saved, though hethought that it might so happen that it would be justifiableto save the child. He could not help agreeing with those whoadvocated the vaginal route, and even where the uterus wastoo large, as when the child was viable, he advocated theinduction of labour and then waiting until involution had

proceeded far enough to allow of vaginal extirpation. More-

over, in the earlier states of pregnancy he considered it bad

practice to try to drag an unemptied pregnant uterus

through the opening made in the vaginal roof ; it was farbetter to remove the contents, thereby reducing the bulk ofthe uterus to a minimum before extracting it. The removalof the cancerous mass first, leaving the uterus to be dealtwith afterwards, had not been considered by Dr. Sanderson,but he agreed with Dr. Routh that it might in some casesbe practised with advantage. In operating he used numerousshort forceps, grasping very little tissue and removing themin 30 hours. In this way by the help of formalin douchesoffensive discharges following upon the operation were re-duced to a minimum.-Dr. SANDERSON, in reply, recognisedthe justice of the criticisms in the debate on this case.

He, however, found it difficult to understand why a com-bined hysterectomy should be a more severe operation thana vaginal or an abdominal one. Whether the cervix wascircumcised from below or from above, as in Doyen’soperation of abdominal hysterectomy could make littleor no difference in the severity of the operation ; and hebelieved that in the future, as abdominal methods improved,the abdominal or combined route would be preferred to thevaginal.A short paper by Dr. J. P. MAXWELL of Changpoo, China,

was then read, on two fatal cases of Pernicious Vomiting inPregnancy.-This was discussed by the PRESIDENT.A report of the sub-committee upon the President’s

specimen of Deciduoma Malignum was then received.The following cases and specimens were shown :-Dr. CUTHBERT H. J. LocKYER: Two Septicæmic Uteri,

with bacteriological investigations.Dr. GRIFFITH : A Person of Uncertain Sex.Dr. C. HUBERT ROBERTS: A case of Male Pseudo-Herm-

aphroditism.Dr. AMAND ROUTH : Tubal Gestation where Rupture

occurred during the Process of Tubal Abortion ; OperationRecovery.

Mr. H. S. STANNUS (introduced by Dr. TATE) : A case ofOrbital Tumour in a Hydrocephalic Foetus with Hydramnios.The specimens were discussed by the PRESIDENT, Dr. G. F.

BLACKER, Mr. A. C. BUTLER-SMYTHE, Dr. C. J. CULLING-WORTH, Dr. F. J. McCANN, Dr. G. H. DRUMMOND ROBINSON,and Mr. J. H. TARGETT.

LIVERPOOL MEDICAL INSTITUTION.

Exhibition of Cases. -A Series of Various Foreiqn Bodies.THE fourth meeting of the session of this society was

held on Dec. 5th, Mr. EDGAR A. BROWNE, the President,being in the chair.

Mr. ROBERT JONES showed two cases of Congenital Eleva-tion of the Scapula and stated that the condition was firstdescribed by Sprengel in 1890 and was known as ’’ Sprengel’sdeformitv." It consisted of an elevation of the scapulaabove the level of its fellow, accompanied by rotation,approximating the lower angle to the middle line, withlimitation of scapular and humeral motion and sometimeswith a slight curvature of the spine. The etiology of theaffection was doubtful, but the probability was in favour ofconstrained foetal position. The first case was that of a boy,aged five years. The deformity was noticed when he was

1674 LIVERPOOL MEDICAL INSTITUTION.

vaccinated at the age of three months. The child was weird-looking, and he walked with a stoop and carried his headslightly bent to the left side. The left shoulder was raisedtwo inches above the right. The distance from the inferiorangle of the scapula to the spinous process of the vertebrawas one and a half inches, on the right side it was two and ahalf inches. The left superior angle was three-quarters ofan inch from the spine, the right being two inches. The

scapula was therefore rotated. The length of the posterioroorder of the left scapula was four inches and that of theright five inches. From the left acromion to the episternalnotch measured three and three-quarter inches ; from theright four inches. The arms were of equal length.The dorsal spine was slightly curved, the convexity pointingbackwards. There was a marked limitation in the movementof the scapula. Rotation of the arm was normal and abduc-tion and adduction were limited. The trapezius muscle wascontracted and tight. No exostosis could be felt and therewas no articulation with rib or spinous process. The secondcase was that of a girl, aged seven years. The left scapulawas displaced upwards, its lower angle touching the fifthrib, whereas the right touched the seventh rib. The move-ments of the shoulder were limited, so that the arm onlycame up to a right angle without movement of the scapula ;she could not place the hand on the back of the neck. Theright scapula, as shown by the radiogram, was normal insite and structure. The left or displaced bone had theaxillary border shorter and more curved than that on theopposite side. The posterior border consisted of an upperportion, with which the extraneous portion of bone arti-

culated, and a lower portion which was nearly straight. Atthe junction of these two portions there was a distinct pro-jecting angle. The abnormal portion of bone was triangular,its outer border articulating with the upper portion of theposterior border of the scapula and its inner angle with aspinous process of the cervical vertebra. The extraneous

portion of bone was removed in order to increase the range ofscapular movement and the operation pioved successful.Examined three years later the patient had improved muchand she stood with shoulders square. There was a projec-tion of the upper and inner angle of the scapula and thisstill interfered with the movement of placing the handbehind the back of the neck. The deformity was noticed amonth after birth.

Mr. JONES also showed a case of Congenital Dislocation ofthe Shoulder and remarked on the literature, stating thatcases described might be grouped into’ those due to faultydevelopment and those due to injury during birth. Thepatient, aged nine years, showed the head of the humerus dis-placed backwards under the acromion and rotated inwards,so that the rounded portion was felt posteriorly. On pressingin front the inner margin of the glenoid cavity was felt.The condyles of the humerus pointed antero-posteriorly asthe arm fell by the side. Measurements : the length of theposterior border of the left scapula, five inches ; of the

right, four and a half inches ; from the angle of the scapulato the left acromion, six inches ; to the right, five and a halfinches ; the posterior border of the left scapula, five and aquarter inches ; of the right, four and a half inches ; the armfrom the apex of the right acromion to the external condyle,seven and three-quarter inches ; and from the left acromion,nine inches. There was an elevation of the scapula and onfixing it the humerus could be slightly abducted, but notadducted. The range of scapular movement was increased,so that in spite of humeral fixation the bov could place hishand both behind his head and behind his back. A radiogramshowed the glenoid to be thickened, not due to exostosis,but to the new socket formed on its posterior aspect. Thehead of the humerus was smaller than its fellow and theshaft was attenuated. Mr. Jones classed the case amongstthe co-natal traumatic displacements, and as to treatment hetrusted to stretching exercises.

Dr. W. B. WARRINGTON brought forward two cases. Thefirst was a case of Acute Pneumonia characterised by longduration and an intermittent type of pyrexia, the crisis notoccurring until the nineteenth day. This condition suggestedthat the case might be acute phthisis beginning with acute pneumonia. The symptoms were profuse sweating, l

progressive emaciation, and haemorrhage. The subsequent course of the disease showed that a migrating pneumonia, (possibly due to influenza, had to be dealt with. The isecond case was one of Acquired Hydrocephalus in a man, (

aged 35 years. The patient for eight months showed signs of cerebral tumour-viz., marked optic neuritis with head-ache and some vomiting, tremors in the tongue, slight

exophthalmos of one eye, and weakness in the legs. Hismental faculties became markedly impaired and he

gradually passed into a comatose condition. At the

necropsy dilatation of the lateral ventricles was the onlygross lesion found ; the microscope showed inflammatorythickening of the ependyma of the fourth ventricle. Thenature and diagnosis of such cases were briefly discussed.-Dr. T. R. GLYNN briefly remarked upon the second caseand related a case similar to it in which there were marked

optic neuritis, headache, reeling gait, staggers, &c., a

diagnosis of cerebellar tumour being made. The patientwas trephined over the cerebellum. No tumour was

found, but some cerebro-spinal fluid escaped after open-ing the ventricle and the patient recovered. Such cases

explained those instances of recoveiy from apparentcerebral tumour.-Mr. DAMER HARRISSON related a similarcase of relief of symptoms after opening the lateralventricle.

Mr. RUSHTON PARKER read a note on a Series of FourteenForeign Bodies, various in nature and locality, and re-

marked that some foreign bodies were mere curiosities moreor less amusing ; others, while extraordinary, were curiousfrom the little harm they did ; while others, commonplacein themselves, might be the cause of danger and even oftragedy. The cases were with one exception from hisown practice. 1. A wooden splinter over two and ahalf inches long and from a quarter to half an inch inwidth and thickness, embedded in the pterygo-maxillaryregion of a man, where it was broken off a bundle of

swinging boards that struck him in the right lowereyelid. The object was thought to be loose bone and waswithdrawn after a few weeks, early in 1878. 2. A piece ofsailor’s knife blade, two and a quarter inches long and three-quarters of an inch wide, broken off in the left pterygo-maxillary region of a man who was stabbed in New York. The

object was removed 14 days later at the Liverpool NorthernHospital by Mr. Chauncey Puzey in 1879. 3. A gun-breechand a screw-bolt, forced by the bursting of a fowling-pieceinto the middle of the owner’s face and lodging five years inthe nose, which were removed through an incision under theupper lip on Dec. 20th, 1883. The objects weighed threeand a half ounces and measured three inches by oneand a half inches by one inch. 4. A piece of parasolrib, three inches long, broken off in a woman’s fore-arm and removed after 12 days. 5 and 6. These werecases in which a bullet was displayed by radiographyand removed from subcutaneous regions of the leg andhand respectively in boys. 7. Radiograms of a smallbullet which was flattened against the lower end of theradius in a young man. When seen two days after theaccident the wound was healed and the bullet was left alone.Five years later no inconvenience had been caused and thebullet was radiographed again. 8. Radiogram of a leadenpellet from an air-gun between the metacarpal bones. Thesubstance was removed a fortnight later as it caused annoy--ance and apparently pressed on a nerve. 9. A photographof a piece of red-rubber catheter over three inches longencrusted with phosphatic calculus which had been takenfrom the bladder of a man, aged 71 years. The calculus wascrushed and evacuated and the cathether was removed byLithotrite. 10. A photograph of a silver tooth-plate measur-ing two inches by one and a quarter inches extracted fromthe pharynx of a man, aged 36 years. after nine hours.11. A photograph of a tooth-plate, vulcanite and metal, withattachment hooks, measuring two inches by one inch by oneinch, which had been swallowed and which was removedeight days later by oesopbagotomy with success. 12. An ironstaple one inch long and one inch wide which had beenswallowed by a boy. A radiogram showed it to be lying inthe pelvis three days later and it was passed per anum onhe next day. 13. A piece of turned oak, seven inches byhalf an inch by three-quarters of an inch, known as a" knitting-sheath," which was removed from the rectum ofa man, aged 70 years, after a fortnight. No harm resulted.L4. Radiograms of the ankle of a girl, aged 15 years, show-ng a piece of glass broken off a strip of window-glass)ne inch long, more than one-eighth of an inch wide, andess than one-eighth of an inch thick. The object had been,here five years, causing slight but very persistent disability)f the ankle-joint ; it was removed with an end to all.rouble. A radiogram was shown of the parts after removal .)f the glass.-Mr. DAMER HARRISSON. Dr. W. ALEXANDER,.Dr. C. A. HILL, and Professor H. BRIGGS related instances)f other foreign bodies and commented upon some of Mr.. 3 a rker’s series.

1675LEEDS AND WEST RIDING MEDICO-CHIRURGICAL SOCIETY.

LEEDS AND WEST RIDING MEDICO-CHIRURGICAL SOCIETY.

Axis-traction Forceps i-n Midwifery.-Resonance to Por-czcssion over Ovarian Tumours.-Exhibition of Cases,Pathological Specimens, 4-c.A MEETING of this society was held on Dec. 6th, Dr. A. G.

BARRS, the President, being in the chair.Dr. J. B. HELLIER read a paper on the Use of Axis-

traction Forceps in Midwifery- He briefly sketched the

development of the midwifery forceps, demonstrating theneed of the third or perineal curve. He described the

points requisite for the construction of an efficient tractioninstrument and showed and criticised various patterns nowon the market. He examined the objections urged againstsuch instruments in several modern works on midwiferyand alleged that the difliculty of application could be veryeasily overcome. It was quite a mistake to assert that inany way the prognosis to the child was less favourable thanwhen ordinary forceps were employed. Axis-traction forcepswere suitable for low cases as well as high. He believedthat if anyone who had had experience of old patternswould use the axis-traction forceps sufficiently to becomefamiliar with their application and would apply them in afew really difficult cases they would not again abandon theiruse.—Mr. C. J. WRIGHT, Dr. J. BRAITHWAITE, Dr. E. 0.CROFT, and Mr. J. W. DRAPER took part in the discussion,and Dr. HELLIER replied.

Dr. E. 0. CROFT read notes of cases illustrating Resonanceto Percussion over Ovarian Tumours. He said that the chiefconditions which might give rise to a resonant note over thesituation of an ovarian tumour had been described thus : (1)by intracystic changes producing gas, such as decompositionof contents after tapping or suppuration associated with

gas-forming bacilli ; (2) by the entry of air into a cyst froma communication with the bowel produced by the breakingthrough of an adherent portion ; and (3) by the displacementforwards of coils of intestine and their adhesion to the frontof the tumour. The following illustrative cases were

. described. In the first case, that of a married woman, aged27 years, the mother of one child who was born seven yearspreviously, abdominal enlargement was noticed about 18months before. She had " caught cold " during menstruationwhich was arrested. Three months afterwards a severe attackof peritonitis occurred. The tumour was then discovered andthere were normal physical signs of an ovarian cyst of aboutthe size of a child’s head. The symptoms were subsiding andoperation was therefore postponed. A few weeks later theoutline of the cyst could be felt as before, but over its wholearea the percussion note had altered to one of tympaniticcharacter. Ovariotomy was performed. The tumour, withtwisted pedicle and many adhesions, was found to be full offcetid gas. Only a very small amount of foul pus existed inits lowest pocket. There was no opening of communicationwith any portion of bowel. The gas was evidently producedby gas-forming bacilli associated with suppuration, theinfection probably having gained access by means of the

damaged vitality of the adherent portion of bowel wall. The

patient made a good recovery. Unfortunately a bacteriologicalexamination was not made. The second case was that of amarried woman, aged 38 years, who had undergone two preg-nancies, the last one 10 years ago. For four or five years she hadsuffered from severe attacks of abdominal pain at intervals.About 12 months ago she had had an attack of peritonitisand about one month before operation a more severe attack.Menstruation was regular throughout. On examination theabdomen was seen to be enlarged by an obvious cystictumour. On percussion a central area of dulness existedwith the umbilicus at its centre. The area of dulness wasdistinctly surrounded by tympanitic areas in the epigastric,in both the hypochondriac, and in the lumbar regions, but inaddition a broad tract of tympanitic resonance existed acrossthe iliac and hypogastric regions. The physical signs werethus suggestive of a pancreatic or mesenteric cyst. A pelvicexamination revealed, however, the fact that when the uteruswas pulled on by vulsellum forceps it dragged on the tumour.A probable diagnosis of ovarian tumour with long pedicle andabnormal relations of bowel was made. The abdomen wasopened. The tumour proved to be a large dermoid of theleft ovary embedded in adhesions. The pedicle was twistedso that the original left surface of the tumour had passed

across anteriorly to the right and in doing so had drawnwith it a mass of adherent bowel which was found lyingacross the lower half of the front of the tumour. The tumourwas removed and the patient recovered.-The PRESIDENT,Mr. H. LITTLEWOOD, and Dr. HELHER discussed the paperand Dr. CROFT replied.The following cases, pathological specimens, &c., were

exhibited :—

Dr. HELLIER : (1) Various Patterns of Axis-tractionForceps ; (2) Vesicular Mole which caused HyperemesisGravidas; (3) two specimens of Early Adeno-carcinomaof the Fundus Uteri removed by vaginal hysterectomy ; and(4) Schultz’s Obstetric Phantom with an appliance for con-tracting the pelvis.

Mr. LITTLEWOOD : (1) Erasion of the Knee-joint for Tuber-culous Disease (a man, aged 40 years) ; (2) three sets ofUterine Appendages removed for salpingitis associated withovarian cysts ; (3) photograph of an enormous InguinatHernia; and (4) (with Mr. T. CARTER) a case of Ex-cision of the Upper Jaw (the patient was fitted with anobturator).

Dr. C. M. CHADWICK and Mr. EDMUND ROBINSON: Pur-puric Eruption of 30 years’ Duration.

Dr. CHADWICK : (1) Unusual Skin Condition ; (2) En-

larged Spleen with Hemiplegia in a patient who had sufferedfrom Malta fever ; and (3) Chorea in a Child, aged threeyears, following on Acute Rheumatism with Involvement ofthe Mitral Valve.

Dr. T. WARDROP GRIFFITH : (1) A case of AcquiredSyphilis in a Child; and (2) a specimen of ExtensiveRheumatoid Arthritis.

Mr. G. CONSTABLE HAYES: (1) Two cases showingRemains of Pupillary Membrane ; and (2) a case of DetachedRetina with Haemorrhages in a Boy, aged eight years.

Mr. B. G. A. MOYNIHAN : (1) Several specimens of RenalCalculi ; (2) specimens from three cases of Partial Nephrec-tomy-two solitary cysts and one tumour of doubtful nature ;and (3) specimens from cases of Complete Nephrectomy-(a) papillomata of the pelvis of the kidney, (b) growth ofsuprarenal capsule involving the kidney, and (e) cystickidney.

Mr. MAYO ROBSON : Uterus with a Fibro-myoma expandingthe Layers of the Broad Ligament.

Dr. H. J. CLARKE (Doncaster) : An Abnormal PrematureFoetus.

Dr. E. F. TREYELYAN : (1) A case of Profuse Hsematemesisin a man (treated with gelatin) ; (2) an unusual case ofWasting of the Muscles of the Forearm ; (3) a case ofFunctional Intentional Tremor of the Arm ; (4) a case ofGraves’s Disease with a previous history of acute insanity; t(5) a case showing Retrogression of Marked Cerebral Sym-ptoms with the exception of the papillitis which had passedinto atrophy (? quiescent tuberculous tumour) ; and (6) a caseof Laryngeal Paralysis.

EDINBURGH MEDICO-CHIRURGICALSOCIETY.

Exhibition of Cases.-Tenaperatecre oj Phthisis.-SuprapubieProstatectomy.

A MEETING of this society was held on Dec. 4th, ProfessorT. R. FRASER, the President, being in the chair.

Dr. W. ELDER and Dr. A. MILES showed a patient afterthe removal of a Tumour from the Left Prefrontal Lobe of theBrain. The case was that of a man, aged 47 years, whobecame more and more apathetic, dull, and emotional untilhe became comatose. There was an indefinite history ofsyphilis. As he appeared to be dying the skull was

trephined and an apparently organised gumma was shelled.out from the left prefrontal lobe. He made an excellentrecovery.

Dr. G. LOVELL GULLAND and Dr. A. LOGAN TURNERshowed a patient after operation for Laryngeal Tuberculosis.

Mr. JOHN SHAW M’LAREN exhibited a patient afterrecovery from a Compound Depressed Fracture of the Skulland Lepto-meningitis.

Mr. DAVID WALLACE, C. M. G., showed Beckmann’s Appa-ratus for ascertaining the Freezing-point of Blood.