LIVERPOOL MEDICAL INSTITUTION.

931 in the bones ; the ribs, the sternum, &c., were heart, weighing 29 ounces. The necropsy revealed no cause almost of the density of ivory. There was, however, no for this increased size. The heart was exhibited and also a bone formation in the growths outside the bones. This was drawing of it made by Dr. A. Keith of London, who was also described by von Recklinghausen who saw that this of opinion that there was a stretching of the auricular canal bony change occurred not only as an irritative change and also an attenuation of the bond between the base of the produced by the growth on the old bone but was tricuspid valve and the base of the ventricle. The second case It was not a was that of a man, aged 62 years, in whom the heart block was an integral part of the carcinoma itself. of conductivity, peculiarity of any form of carcinoma but was simply a locala not complete. There was marked depression the time taken by the stimulus to pass from the auricle to attribute due to the transplantation of the growth into soil which gave rise to bone. Bone formation occurred not the ventricle being double its normal length. As a result of only with prostatic carcinoma but with other forms such as this only every other contraction of the auricles was able to mammary. The more infiltrating the growth was the more excite the ventricles to respond. The pulse-rate was 32 per likely it was to have osteoplastic changes; the more sharply minute and although the patient was apparently in good defined it was the less osteoplastic changes occurred. The health he had a very much diminished area of cardiac The note was illustrated by charts, diagrams, evidences of new bone formation were : 1. The presence response. of a small nodule of spongy bone in even the smallest extra- pulse tracings, and lantern slides.-Dr. W. B. WARRINGTON, medullary growths. 2. The great sclerosis amounting almost Dr. C. J. MACALISTER, Dr. R. J. M. BUCHANAN, and Dr. W. to eburnation of some of the bones like ithe ribs, the CARTER took part in the discussion. sternum, and the femur. 3. The formation of bone in the ’ Mr. ROBERT A. BiCKERSTETH read a note on Prostatectomy subperiosteal growths. Bone metastases occurred most fre- and after quoting histories of cases in illustration of his quently in carcinoma primary in the thyroid, the prostate, remarks he discussed the circumstances which should and the breast. The thyroid and the prostatic growths were guide the surgeon in his choice between the suprapubic said to burst directly into the veins. The order of involve- and the perineal routes. He pointed out the necessity for a ment of the bones was as follows : vertebras, femora, pelvis, very full and careful examination of each individual case ribs, sternum, humerus, flat bones of the skull, fibula, tibia, and showed how it was generally possible in this way to radius, and ulna. Bone metastases might produce erosion, distinguish in advance between those prostates which were expansion, infiltration and osteoplastic changes, and sub- easily removable and others in which removal might be a periosteal tumours and osteoplastic changes. The result matter of very considerable difficulty. For the easier cases, depended upon the infiltrating or sharply defined nature of which comprise the fibro-adenomatous enlargements and the metastases.-Dr. W. S. LAZARUS-BARLOW said that it form the bulk of the cases requiring operation, the suprawas the growths which were mainly cellular which were pubic operation, and enucleation after Mr. P. J. Freyer’s more especially associated with metastatic growth in the method, was certainly the operation of choice. There bone, whilst those growths which were mainly fibrous remained other cases, however, in which it seemed likely invaded other tissues. that enucleation with the finger would be either very difficult Dr. E. MICHELS and Dr. PARKES WEBER communicated a or altogether impossible; for these the perineal operation paper on Obliterative Arteritis leading to Gangrene of the was best, a transverse incision securing a full exposure and Extremities in otherwise healthy men in the prime of life. a good view of all the parts concerned. Lantern slides The patient, a cigarette-maker, aged 39 years, a Jew from illustrating the successive stages of such a perineal operation Roumania, had had his right leg amputated below the knee were shown and the general indications for prostatectomy in 1889 after having suffered for over a year from severe were further discussed.-Remarks were made by Mr. C. A. pain in the foot and the muscles of the calf accompanied BALLANCE (London) and Mr. D. DOUGLAS-CRAWFORD. by a kind of "intermittent claudication" of the extremity. on the Difficulties and Mr. HUGH E. JONES read a In June, 1903, he began to suffer in a similar way in the Dangers of the Radical Mastoidpaper After denning Operation. left lower extremity and in October, 1904, owing to a the and referring to the work of Schwarze, Stacke, operation certain amount of gangrene together with intolerable pain Kuster, and Ballance, he enumerated the difficulties peculiar and at the patient’s repeated request, other treatment to this operation: (1) the selection of suitable cases, having been found useless, the left leg was amputated which consisted in (a) limiting the complete operation to Since then cases which below the knee at the German Hospital. really required it; (b) deciding whether to the patient had been free from pain and the wound had or not on cases where there was grave general operate Examination of the amputated extremity healed well. disease ; (2) avoidable difficulties on the part of the operator, showed that the lumen of the popliteal artery was such as working in a poor light or without an intimate obliterated by connective tissue, apparently mainly resultof the anatomy of the part; and (3) unavoidable knowledge ing from organisation of a clot ; the arteria dorsalis pedis difficulties-e.g., variations in the position and size of the showed extreme endarteritis obliterans. No changes were, antrum, sclerosis of the bone, and a forward position of the found in the veins or the nerves. Professor J. Israel had; lateral sinus. The facial nerve was the most important recently drawn attention to an idiopathic gangrene of structure to avoid and there were several ways the lower extremities occurring in men between 30 andi in which it might be injured : (1) by the faulty intro40 years of age, especially Russian Jews. Such cases; duction or careless holding of Stacke’s protector; (2) by had, according to him, been observed at Berlin, Königs- the too free removal of the posterior wall of the meatus at berg, and Dorpat. Dr. Michels and Dr. Weber knew of. its inner end ; (3) the bone if brittle might be cracked by three cases in London in poor East-end Jews, all of theml the chisel at a point not intended ; (4) by careless curetting between 30 and 40 years of age. There was no evidence that in the of the fossa ovalis and sinus tympani; and region the affection was due to syphilis, alcoholism, renal disease,’ cells or fistulæ in the lower deep anterior curetting by (5) saturnism, ergotism, or premature senility. It was a question1 part of the petro-mastoid or posterior wall of the meatus. whether excessive cigarette smoking could play a part in thE The difficulties of skin grafting, provided the whole of the etiology-that is to say, in specially predisposed individuals, disease had been eradicated, were purely technical and could be overcome by practice and patience. Packing was advocated in cases in which it was not certain that LIVERPOOL MEDICAL INSTITUTION. the whole of the diseased tissue had been removed.

changes

’

The

Mastoid Operation. A MEETING of this society was held on March 30th, Dr. JAMES BARR, the President, being in the chair. Dr. JOHN HAY read a note on Bradycardia in which special reference was made to that form of pulsus rarus caused by " heart block." He described in detail the case of a man, aged 26 years, in whom the rhythm of the auricles was independent of, and different from, that of the ventricles. The following were the important features of the case. 1. Marked infrequency of the pulse, which varied from 17 to 30 beats per minute. 2. Transient loss of consciousness associated with disappearance of the pulse at the wrist. 3. Auricular contractions occurring much more frequently than, and independently of, ventricular contractions. 4. An enormous

Bradycardia.-Prostatectomy.-Radical

dangers peculiar

to

the

operation

were

classified.

from coincident general tuberculosis, diabetes, marasmus, disease-e.g., and congenital syphilis in infants. 2. Coincident undetected intracranial disease-e.g., serous meningitis, latent cerebral abscess, and acute cerebral abscess. 3. Pathological conditions within the temporal bone might be stirred up and cause an extension of the septic process which might result in suppurative meningitis or sinus phlebitis. 4. Leaving foci of infection by incomplete operation. This was perhaps the greatest danger of all. It was the duty of the operator, whether a general surgeon or an otologist, not only to be prepared to face and to learn to master any of the difficulties and dangers enumerated but also to see his patient safely through to a complete and final healing of the wound.as

follows:

1. Those advanced

arising

932 Mr. BALLANCE also read a paper on the same subject.Dr. W. MILLIGAN said that the fundamental principles of surgery should be adopted in the treatment of septic disease of the temporal bone-viz., free exposure of the diseased area and the establishment of free drainage. The peculiar anatomical difficulties of this region should be studied very carefully before undertaking the radical operation. He exhibited various sections of the temporal bone in order to demonstrate some of the difficulties described by Mr. Jones. The treatment of the soft parts was of the utmost importance and he was an enthusiastic advocate of the grafting operation, which not only materially diminished the length of the after-treatment but secured more certain results, especially in so far as the healing of the inner tympanic wall was concerned. Continuous and light packing was irksome to the patient and to the surgeon and he was inclined to think that it tended to promote rather than to retard the growth of exuberant granulation tissue. In the treatment of tuberculous cases he advocated in the first instance merely providing efficient retro-auricular drainage, together with the removal of sequestra and later, when the general condition of the patient had improved, the performance of the radical operation.-Mr. W. THELWALL THOMAS, Mr. E. M. STOCKDALE, Dr. EDGAR STEVENSON, Mr. J. BARK, and Dr. WARRINGTON also took part in the discussion.

Many of these cells had one or two vacuoles. The conjunctiva covering the tumour was for the most part thickened and at places cornified. Mr. GUNN showed a specimen of Gangrenous Intussusception removed from a child ; and sections, together with a model, of a Cancer of the Prostate implicating the wall of the bladder.

LEEDS AND WEST RIDING MEDICO-CHIRURICAL. SOCIETY.-A clinical meeting of this society was held on March 17th, Mr. E. Ward being in the chair.-Mr. H. Seeker Walker showed two cases of Chronic Otorrhoea, the one being complicated with cerebral and the other with cerebellar abscess. Improvement followed on drainage of the abscesses. The patients were boys aged respectively ten and 14 years.Mr. A. L. Whitehead showed a case of Retinitis Pigmentosa with Posterior Pyramidal Cataract, Degeneration of the Vitreous, and Optic Atrophy.-Mr. G. Constable Hayes showed a case of Optic Atrophy in a patient suffering from early There was a three months’ history of locomotor ataxy. gradual loss of vision but the patient otherwise felt quite There was no history of syphilis. The symptoms well. observed were optic atrophy (with some choroido-retinitis), Argyll Robertson pupil, and loss of patellar reflexes.Mr. Ward showed a man, aged 42 years, suffering from Gonorrhceal Stricture of the Urethra of 20 years’ duration. 12 months ago abscesses formed in the perineum, burst, and formed again, and urine was passed through the abscess ROYAL ACADEMY OF MEDICINE IN cavity. On Jan. llth the stricture was completely exci-ed,. the piece removed being one inch long. The whole was. IRELAND. imbedded in thick suppuratory tissue which broke down under pressure. The ends were united in the upper wall and a tube was put into the bladder. On March 7th a 9-12 inSECTION OF PATHOLOGY. strument was passed without pain and without encountering Exhibition of Specimens. any stricture.-Mr. H. Littlewood showed two cases of A MEETING of this section was held on March 17th, Dr. Colectomy for Malignant Disease of the Splenic Flexure, a H. C. EARL, the President of the section, being in the chair. case of Colotomy, a case of Splenectomy for Large MoveableSir W. THORNLEY STOKER, President of the Academy, Spleen producing several attacks of intestinal obstruction, exhibited specimens of a Columnar Cell Carcinoma of the a case of Splenectomy for Traumatic Dislocation of the Uterus in a very early stage and a Columnar Cell Carcinoma Spleen with Twisted Pedicle, and a case of Pyloroplasty.of the Rectum and Sigmoid Flexure also involving the left Mr. R. Lawford Knaggs showed a case of Appendicitis with ovary. Abscess, Fsecal Fistula, Pyopneumothorax, and Gastric The PRESIDENT of the section made a communication on Fistula. The patient, who was 13 years of age, began to cases of Human Actinomycosis and showed specimens from suffer from acute abdominal symptoms on June 5th, 1904. a case of Actinomycosis of the Right Kidney with a metaOn June 15th the contents of a pelvic abscess measuring static abscess in the cerebrum. He mentioned that many of three pints were evacuated through a median incision. the peculiar yellow grains were made up of dead organisms On July 27th a fresh abscess reaching into the pelvis was and cultivations were therefore not easy to obtain. He con- opened and the appendix with(oncretions was removed. sidered that the increase in the number of cases reported On August 8th the patient expectorated ten ounces of very was due to better observation.-Mr. K. E. L. G. GUNN foul sputum, following some lung symptoms. An empyema related particulars of cases which he had seen and also was localised at the left base. This suddenly became mentioned a case where, owing to the discovery of mycelial tympanitic and was incised on August llth. On the 18th threads in the discharge, a mistaken diagnosis of actino- food began to come through the empyema opening almost mycosis of the rectum was given. Later the disease proved directly it was taken. On Oct. lst the patient was quite to be carcinoma.-Dr. T. P. C. KIRKPATRICK mentioned a well, except for slight fascal fistula which had since closed. somewhat similar case occurring in the lip where a diagnosis Mr. Knaggs also showed a case of Punctured Fracture of the of actinomycosis was at first made but subsequently this also Orbital Plate of the Left Frontal Bone followed by Cerebral was shown to be cancer. Abscess. The patient was admitted to hospital on June llth, Mr. ARTHUR H. BENSON and Dr. H. C. MooNEY showed 1904, with a bone crochet hook transfixing the upper lip and sections of a Sarcoma of the Conjunctiva which formed a orbit for three inches. The hook was removed. The orbital black tumour, of the size of a split pea, and had been periosteum was separated and the aperture in the orbital The frontal bone removed from the conjunctiva of a married woman, aged 40 plate of the frontal bone was exposed. years. It was growing by a rather small pedicle from the was trephined, the left frontal lobe in the dura mater was conjunctiva of the globe, close to the sclero-corneal margin raised, and the aperture in the dura mater was exposed. A at the outer side of the left eye. The patient stated that she small spicule of bone was removed from inside the aperture. first noticed it 11 years ago as a very small dark reddish Satisfactory progress was made till July when double optic spot. For the past five years it had grown steadily but very neuritis, vomiting, and coma developed. On July llth a slowly and some large vessels ran to its base. It was second operation was performed. The frontal lobe bulged capable of being raised up with the ocular conjunctiva and prominently on opening the dura mater. The results of exwas excised with scissors, leaving what appeared to be a ploration were negative and the flap was replaced. On the perfectly healthy conjunctiva below it. The origin of the 15th a quantity of pus having a faint odour escaped by the growth seemed to have been one of the small collections drainage apertures. The protrusion of the brain, which of pigment sometimes seen in a perfectly healthy con- had been increasing, began to diminish. Steady improvejunctiva. Its extremely slow growth, its low degree ment followed and the patient was quite well on August 7th. of malignancy, and its limitation entirely to the con- - Mr. Walter Thompson showed a case of Rupture of the junctiva were remarkable.-Dr. MooNEY, who had made Small Intestine. The patient was a man, aged 20 years, sections of the tumour, said that it was composed who received a wound of the abdomen one and a half of two parts, the larger one consisting of small spindle- inches above the pubes, the left rectus being ruptured but celled pigmented sarcoma, the pigment being abundant. the peritoneum not opened. There was blood in the particularly near the periphery and round an excentrically cavity. Two ruptures were found in the small intestine placed non pigmented area. This non-pigmented area or about six feet apart. There was extensive laceration of the core which was placed towards the base of the tumour, mesentery. 6 feet 6 inches of the small intestine were resected and union was accomplished by end-to-end anastowas made up of large swollen-looking epithelioid cells, loosely arranged with plentiful intercellular substance. mosis. A ’small peritoneal rupture in the sigmoid region