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MEDICAL SOCIETY OF LONDON.
302 ———————————————————————————————————————————————
! ’
which had
Mr. T. C. ENGLISH referred to 40 consecutive cases of gastric and duodenal ulcers which had been operated’on in In 21 recovery had taken 7place. St. George’s Hospital. The latency of symptoms had been a marked feature in some cases, and he mentioned two cases in which the symptoms were very slight but a perforation had been found. He referred also to other cases in which more marked symptoms had been present and in which on opening the abdomen no ulcer had been found. Dr E. P. PATON referred to the question of drainage and asked what objection there was to local drainage. He considered that its use tended to prevent the occurrence of a subphrenic abscess. Dr. G. NEWTON PITT doubted whether anaemia was less marked in case-! of acute gastric ulcer than in cases of chronic ulcer. He asked if Mr. Moynihan had any evidence that a hard, chronic, gastric ulcer healed after a gastroenterostomy. He thought that gastric ulcers were not so rarely solitary as Mr. Moynihan seemed to suppose. Mr. MOYNIHAN, in reply, said that in any case in which there was doubt as to perforation of a gastric ulcer operation should be performed. With regard to the question of drainage he said that it was unnecessary when the peritoneum was properly cleansed. Subphrenic abscess arose from inadequate cleansing of the peritoneum. He thought that fluid should be given early and frequently after operation. The anaemia which occurred in acute ulcer was never so profound as that seen in chronic ulcer and was more transient. He said that in his experience chronic ulcers of the stomach were never solitary and he had never seen a duodenal ulcer without a gastric ulcer being present. Practically speaking, he would say that chronic ulcers were
affected. Apart from some slight throat symptoms and bronchial catarrh which were present from the beginning there were no other sequelse. CASE 3.-On Dec. 31st another sister, aged two years, presented classic symptoms of measles with Koplik and Filatow spots, slight throat affection, and bronchial catarrh. The Parotitis was child was convalescent on the sixtn day. present on the right side on Jan. 6th but it soon disappeared. CASE 4.-On Jan. 2nd another sister, aged 14 years, who had been taken ill on Dec. 25th and presented some symptoms of septic poisoning, was brought under notice for a rash which appeared on Jan. 1st. Typical measles over the face, body, &’!., with Koplik and Filatow spots, was present. There were the throat symptoms already described and a sequela of pneumonia on the 4th.
previously
been
similarly
All had the rheumatic diathesis and in no case was high fever present, but the hearts were weak in every case. The patient in Case 4 had generalised branny desquamation. It is strange that the patient in Case 3 has been running about quite well since Jan. 6th and the older members of the family-more especially the patient in Case 4 who on the llth had well-marked rheumatic symptoms-some time previously should be prostrated with various complications. Was the disease measles or was there double The absence of rash of a typical measles infection ? form from the face caused me to be specially on the alert for scarlet fever. On the 19th all were convalescent, no chorea or signs of desquamation were to be found, and the pericardial friction sound, the ulcerative stomatitis, and the chorea had left no appreciable signs. All occupied the same bedroim. Southfields, S.W. _________________
never
solitary.
Medical Societies.
MEDICAL SOCIETY OF LONDON.
ROYAL MEDICAL AND CHIRURGICAL
A MEETING of this society was held on Jan. 26th, Mr. C. A. BALLANCE, one of the Vice-Presidents, being in the chair. Mr. C R. B. KEETLEY exhibited a case of Undescended Testis after Operation. The patient was one of two who had been exhibited nine years ago as an example of what was at that date a new mode of operating for undescended testis.! At that time the testis of this patient was markedly atrophied. Some of the speakers had suggested its removal and it was further suggested that the patient should be exhibited again in order to see if the organ would grow after having been brought into il-q more normal position at the root of the scrotum. The patent was in the habit of playing football and cricket but had never incurred any injury to the testicle and both Mr. Keetley an] the patient were satisfied that it had notably enlarged. The patient, moreover, had suffered no pain or inconvenience whatever. Dr. H. CAMPBELL POPE exhibited a case of Venous and Lymphatic Nasvus of both Cheeks in a boy, aged 14 years. The appearance presented on the cheeks of this patient had come on suddenly after an attack of scarlet fever about nine years before. The cheeks were very swollen and thickened, of a bluish tint, and there was a ring of pigmentation under each eye. The swelling of the cheeks was always greater during cold weather.-Mr. J. HUTCHINSON, jun., referred 10 a case of the same kind affecting one side of the face in which the superficial lymphatics evidently possessed communications with the deeper lymphatics.-Mr. T. H. OPENSHAW referred to a case which he had treated beneficially by actual cautery.-Mr. BALLANCE regarded the case as belonging to the same category as hygroma and amenable to the same treatment. Mr. OPENSHAW exhibited three cases of Congenital Dislocation of the Hip-joint. The first case, that of a female child, aged seven years, had been treated by the manipulative method of Lorenz. The second case, that of a female child, aged eight years, had been treated by the open method of Hoffa The third case was that of a girl, aged 13 years, presenting dislocation of both hips, who had not yet been submitted to treatment ; the prospect of improvement, Mr. Openshaw remarked, was not very hopeful. He believed in general that good results could be obtained by the manipulative method of Lorenz in children up to the age of five years, but after that age he expressed a preference for the open " method of Hoffa.
Exhibition of Cases.
SOCIETY. The Operative Treatment of Gastric and Duodenal Lrlcers. A MEETING o? this society was held on Jan. 27th, Mr. ALFRED WILLETT, the President, being in the chair. Mr. B. G. A. MOYNIHAN read a paper on the Surgical Treatment of Gastric and Duodenal Ulcers, illustrated by a series of 50 cases, which will be found published at p. 294 of our present issue. Mr. D’ARCY POWER said that the treatment of perforation of gastric ulcer was passing through the same transition stage as had been seen in the treatment of hernia and Because in some cases recovery took intussusception. place without operation that was no reason for postponing operation. He thought that in all cases in which perforation had taken place operation should be performed at the earliest opportunity. He considered that drainage of the peritoneum was advisable and necessary in some cases and he mentioned a case in which some eight or ten days after operation a subphrenic abscess had formed and the patient had died. He thought that in this case the patient might have been saved had drainage been resorted to. He thought that there was rather a tendency to overfeed the patient, with the result that vomiting was induced. He quite agreed with Mr. Moynihan that pyloroplasty was an unsuitable operation and should be abandoned, as the results were unsatisfactory. He considered that the accurate adjustment of the openings in the stomach and intestine was of great importance since any tension or traction on these parts tended to
produce vomiting
The PRESIDENT said that the paper dealt essentially with important conditions : (1) perforating gastric ulcer, and he agreed with Mr. Moynihan that the sooner operation was performed the better was the patient’s chance of recovery ; and (2) chronic ulcer and cicatrisation, giving rise t) chronic dyspepsia. The success which had attended operation in these cases was very great, for not only was the immediate result of the operation good but the subsequent results were most satisfactory, for the patients were saved from the rhronic invalidism into which they often otherwise drifted. He referred to the certainty of diagnosis and pointed out that in none of the cases recorded had the abdomen been He thought that opened without finding some lesion simplicity in the operation was especially to be sought for. two
I
1
THE
LANCET, April 21st, 1894, p. 1008.
’
303 n were apparently atrophied but the other facial Mr. OPENSHAW also exhibited a child, aged six months, muscles n did not seem to be wasted. The distribution of the presenting congenital absence of the lower two-thirds of the muscles f; tibia, evidently due to an intra-uterine fracture, the mother facial atrophy corresponded roughly to the cutaneous distrib of the left fifth cranial nerve. There were three other having fallen over the back of a chair during pregnancy.- bution of atrophied skin upon the body, one upon the middle The relative advantages of the manipulative and the patches p o the back of about the size of the hand which presented a ’’open"methods of operating on cases of congenital dis- of f4 dilated venulfs characteristic of morphoea, and in this location of the hip-joint were discussed by Mr. KEETLEY few there appeared to be a slight tendency to excess and Mr. BALLANCE, both of whom expressed a general position p o of pigment. Another patch of atrophied skin might be preference for the latter.-Mr. OPENSHAW replied, s behind the right ear and a third over the outer side of ,4 Mr. JAMES SHERREN exhibited a case of Ankylosis of the seen t left knee. These, like the facial atrophy, caused the Hip following Gonorrhoeal Arthritis occurring in a man, aged the no unpleasant sensations. 20 years. 14 days before the onset of the pain in the joint he patient p Microscopic sections of t skin of the atrophied side of the face and of the had had an attack of urethritis. The right hip was fixed in the extension and there were marked wasting of the thigh and1=patch on the back were shown ; also sections from another of morphosa and of healthy skin for comparison.c case slight wasting of the muscles of the calf. f DYCE DUCKWORTH agreed with Dr. Savill in regarding Mr. SHERREN also exhibited a case of Secondary Sir c such as the one before the society as identical with Syphilitic Synovitis of the Elbows. The patient, a man, cases i and referred to a paper on the subject which he a six months had contracted venereal sore 24 morpboea years, aged previously and about a month previously he noticed that his ((Sir Dyce Duckworth) had communicated to the L1’cinburgh left elbow had become swollen and painful and a week laterMedical Journal in 1883,1 dealing with different forms of the right became similarly affected. Both elbow-joints wereaatrophy. Facial hemiatropby represented the most extreme of atrophy, not only the skin but the muscles and even J form now held in a flexed position, all movements being resisted t bones being sometimes involved. No one could doubt and painful, and there was a considerable amount of effusion the t that these lesions were of nerve origin, and in Dr. Savill’s into both joint cavities. 4 the fifth nerve and the Gasserian ganglion had probably Dr. F. J. POYNTON exhibited a case of Atavism occurring case I in a child, aged three years, who had been admitted to thebeen damaged by the accident. All of these atrophic skin Hospital for Sick Children, Great Ormond-street, under the lesions were, in his view, of neuro-trophic origin, and he care of Dr. F. G. Penrose for inability to walk properly. Whenreferred to cases in which a fall upon the head had been first set down on his feet he stood erect, but when he com-followed by rapid and total loss of hair from all parts of menced to walk he crouched and assumed a posture like the body. Dr. SEYMOUR TAYLOR exhibited a case of Ruptured Aortic that of a chimpanzee. The whole body was bent forward and the head was bent, the chin pointing to the right. The Valve. The patient, a "hammerman" by occupation, aged hands were held in front and the upper extremities were bent 50 years, was admitted to the West London Hospital on at the wrists and elbow. The hips and knees were flexed Oct. 16th, 1902, complaining of giddiness, prascordial pain, and the feet were turned in, the pressure coming upon their and dyspnoea which had come on somewhat suddenly in July, On admission he was outer borders. The crouching attitude became more marked 1902, after a long da,y’s heavy work. found to have a loud aortic obstructive murmur and a louder as the child became tired.-The case was discussed by Mr. .J
diastolic murmur. The latter was musical and was so loud that it could be distinctly heard at a distance of two inches from the chest, and with the aid of the stethoscope it could be heard all over the thorax, in the abdomen as low as the umbilicus, and down the arm. The left ventricle was hypertrophied and probably dilated. The diagnosis of ruptured valve was made on the following grounds-viz.: (1) A history of syphilis ; (2) the sudden oncoming of urgent symptoms ; (3) the patient’s occupation ; (4) the musical diastolic murmur ; (5) the presence of marked diastolic thrill ; and (6) the absence of any other definite signs of aneurysm.-Dr. A. MORISON discussed the diagnosis and regarded the case as one of aortic regurgitation in which loss of compensation had occurred rather than as a case of ruptured aortic valve. The latter was a very rare condition in which the symptoms supervened very suddenly and were continuous and cumulative. He referred to a case which he had observed in which the patient after sudden and violent exertion took to bed and died six or eight months later, ruptured aortic valve being verified at the necropsy.-Dr. H. A. CALEY agreed with the preceding speaker and thought that the symptoms in Dr. Taylor’s case might be accounted for by a sudden loss of compensation. A musical murmur and a marked diastolic thrill were not, he thought, altogether trustworthy as a means of diagnosing ruptured aortic valve.-Dr. S. VERE PEARSON referred to a case which he had observed at St. George’s CLINICAL SOCIETY OF LONDON. Hospital resembling Dr. Taylor’s case which proved at the post-mortem examination to be one of dilated aortic orifice with failure of compensation.-Dr. A. E. GARROD discussed Bx7tibitio,n øl C/fl,S88. A MEETING of this society was held on Jan. 23rd, Mr. the significance of the systolic murmur in the case.-Dr. TAYLOR, in replying, admitted that the diagnosis was open HOWARD MARSH, the President, being in the chair. the history of syphilis, the occupaDr. T. D. SAVILL exhibited a case of Facial Hemiatrophy yto doubt, but emphasised and the loudness of the musical murmur (Morphcea or Localised Scleroderma of the Face). Thetion of the ofpatient, his view. support patient was a man, aged 50 years. In 1880 he had a severe Mr. STEPHEN PAGET exhibited a case of Removal of the blow on the top of the head and thereafter suffered from Scapula of a boy, aged nine years. The patient was a thin neuralgic pains in the vertex and face, sometimes of greatt and but healthy boy. Swelling of the bone severity, until 1895, when they subsided under treatment. was delicate-looking first noticed one month before ; there was no pain or In 1885 or 1886 he first noticed that the hair of the .e left side of the scalp and left eyebrow was coming off history of injury. A hard nodular rounded mass with a broad and that the face on the left side was becoming wasted. base sprang from the rght supraspinous fossa and passed beneath the clavicle. No signs of pressure on the The wasting of the face at first gradually increased, but t forwards it had remained stationary for some years. t vessels and nerves of the arm and no enlarged glands were On the left side of the face the whole of the skin was thin, shiny, present. On April 30th, 1902, the scapula was excised and growth found to be cartilaginous. The patient made a and smooth, and the subcutaneous tissue was considerably ft good recovery and the movements of the arm were good. atrophied. The hair was almost absent from the left .anterior quarter of the scalp and was also wanting in the 1 inner half of the left eyebrow. The temporal and masseter Edinburgh Medical Journal, January, 1883, p. 616.
E. MUIRHEAD LITTLE, Dr. EDMUND CAUTLEY, and Dr. A. F. VOELCKER. Mr. HUTCHINSON, jun., exhibited a case of Macrodactylism in a man, aged 54 years. The digits involved were the right thumb and index finger, the latter being the larger. All the bones of the right index finger were the site of rounded knobs and a skiagram showed that the joints were almost completely ankylosed. The soft tissues were also hypertrophied. The hand, in spite of its ungainly digits, was useful and the patient had worked hard as a cooper. The other hand and both feet were of normal size. The condition had existed since birth. The patient had come under care for an oesophageal stricture. Dr. H. D. ROLLESTON showed a man, aged 44 years, paffering from Aortic Disease and presenting a musical diastolic aortic murmur resembling that heard in cases of ruptured valve. There was, however, no other reason to suspect rupture of a valve in this case and Dr. Rolleston did not regard it as an instance of that lesion. The patient had not had syphilis or rheumatism but had a laborious occupation. Dr. CYRIL OGLE (introduced by Dr. Rolleston) exhibited a case of Symmetrical Gangrene of the Peripheral Ends of the! Fingers of doubtful origin. ,
,
.
ein ,
the
’
! ’
which had
Mr. T. C. ENGLISH referred to 40 consecutive cases of gastric and duodenal ulcers which had been operated’on in In 21 recovery had taken 7place. St. George’s Hospital. The latency of symptoms had been a marked feature in some cases, and he mentioned two cases in which the symptoms were very slight but a perforation had been found. He referred also to other cases in which more marked symptoms had been present and in which on opening the abdomen no ulcer had been found. Dr E. P. PATON referred to the question of drainage and asked what objection there was to local drainage. He considered that its use tended to prevent the occurrence of a subphrenic abscess. Dr. G. NEWTON PITT doubted whether anaemia was less marked in case-! of acute gastric ulcer than in cases of chronic ulcer. He asked if Mr. Moynihan had any evidence that a hard, chronic, gastric ulcer healed after a gastroenterostomy. He thought that gastric ulcers were not so rarely solitary as Mr. Moynihan seemed to suppose. Mr. MOYNIHAN, in reply, said that in any case in which there was doubt as to perforation of a gastric ulcer operation should be performed. With regard to the question of drainage he said that it was unnecessary when the peritoneum was properly cleansed. Subphrenic abscess arose from inadequate cleansing of the peritoneum. He thought that fluid should be given early and frequently after operation. The anaemia which occurred in acute ulcer was never so profound as that seen in chronic ulcer and was more transient. He said that in his experience chronic ulcers of the stomach were never solitary and he had never seen a duodenal ulcer without a gastric ulcer being present. Practically speaking, he would say that chronic ulcers were
affected. Apart from some slight throat symptoms and bronchial catarrh which were present from the beginning there were no other sequelse. CASE 3.-On Dec. 31st another sister, aged two years, presented classic symptoms of measles with Koplik and Filatow spots, slight throat affection, and bronchial catarrh. The Parotitis was child was convalescent on the sixtn day. present on the right side on Jan. 6th but it soon disappeared. CASE 4.-On Jan. 2nd another sister, aged 14 years, who had been taken ill on Dec. 25th and presented some symptoms of septic poisoning, was brought under notice for a rash which appeared on Jan. 1st. Typical measles over the face, body, &’!., with Koplik and Filatow spots, was present. There were the throat symptoms already described and a sequela of pneumonia on the 4th.
previously
been
similarly
All had the rheumatic diathesis and in no case was high fever present, but the hearts were weak in every case. The patient in Case 4 had generalised branny desquamation. It is strange that the patient in Case 3 has been running about quite well since Jan. 6th and the older members of the family-more especially the patient in Case 4 who on the llth had well-marked rheumatic symptoms-some time previously should be prostrated with various complications. Was the disease measles or was there double The absence of rash of a typical measles infection ? form from the face caused me to be specially on the alert for scarlet fever. On the 19th all were convalescent, no chorea or signs of desquamation were to be found, and the pericardial friction sound, the ulcerative stomatitis, and the chorea had left no appreciable signs. All occupied the same bedroim. Southfields, S.W. _________________
never
solitary.
Medical Societies.
MEDICAL SOCIETY OF LONDON.
ROYAL MEDICAL AND CHIRURGICAL
A MEETING of this society was held on Jan. 26th, Mr. C. A. BALLANCE, one of the Vice-Presidents, being in the chair. Mr. C R. B. KEETLEY exhibited a case of Undescended Testis after Operation. The patient was one of two who had been exhibited nine years ago as an example of what was at that date a new mode of operating for undescended testis.! At that time the testis of this patient was markedly atrophied. Some of the speakers had suggested its removal and it was further suggested that the patient should be exhibited again in order to see if the organ would grow after having been brought into il-q more normal position at the root of the scrotum. The patent was in the habit of playing football and cricket but had never incurred any injury to the testicle and both Mr. Keetley an] the patient were satisfied that it had notably enlarged. The patient, moreover, had suffered no pain or inconvenience whatever. Dr. H. CAMPBELL POPE exhibited a case of Venous and Lymphatic Nasvus of both Cheeks in a boy, aged 14 years. The appearance presented on the cheeks of this patient had come on suddenly after an attack of scarlet fever about nine years before. The cheeks were very swollen and thickened, of a bluish tint, and there was a ring of pigmentation under each eye. The swelling of the cheeks was always greater during cold weather.-Mr. J. HUTCHINSON, jun., referred 10 a case of the same kind affecting one side of the face in which the superficial lymphatics evidently possessed communications with the deeper lymphatics.-Mr. T. H. OPENSHAW referred to a case which he had treated beneficially by actual cautery.-Mr. BALLANCE regarded the case as belonging to the same category as hygroma and amenable to the same treatment. Mr. OPENSHAW exhibited three cases of Congenital Dislocation of the Hip-joint. The first case, that of a female child, aged seven years, had been treated by the manipulative method of Lorenz. The second case, that of a female child, aged eight years, had been treated by the open method of Hoffa The third case was that of a girl, aged 13 years, presenting dislocation of both hips, who had not yet been submitted to treatment ; the prospect of improvement, Mr. Openshaw remarked, was not very hopeful. He believed in general that good results could be obtained by the manipulative method of Lorenz in children up to the age of five years, but after that age he expressed a preference for the open " method of Hoffa.
Exhibition of Cases.
SOCIETY. The Operative Treatment of Gastric and Duodenal Lrlcers. A MEETING o? this society was held on Jan. 27th, Mr. ALFRED WILLETT, the President, being in the chair. Mr. B. G. A. MOYNIHAN read a paper on the Surgical Treatment of Gastric and Duodenal Ulcers, illustrated by a series of 50 cases, which will be found published at p. 294 of our present issue. Mr. D’ARCY POWER said that the treatment of perforation of gastric ulcer was passing through the same transition stage as had been seen in the treatment of hernia and Because in some cases recovery took intussusception. place without operation that was no reason for postponing operation. He thought that in all cases in which perforation had taken place operation should be performed at the earliest opportunity. He considered that drainage of the peritoneum was advisable and necessary in some cases and he mentioned a case in which some eight or ten days after operation a subphrenic abscess had formed and the patient had died. He thought that in this case the patient might have been saved had drainage been resorted to. He thought that there was rather a tendency to overfeed the patient, with the result that vomiting was induced. He quite agreed with Mr. Moynihan that pyloroplasty was an unsuitable operation and should be abandoned, as the results were unsatisfactory. He considered that the accurate adjustment of the openings in the stomach and intestine was of great importance since any tension or traction on these parts tended to
produce vomiting
The PRESIDENT said that the paper dealt essentially with important conditions : (1) perforating gastric ulcer, and he agreed with Mr. Moynihan that the sooner operation was performed the better was the patient’s chance of recovery ; and (2) chronic ulcer and cicatrisation, giving rise t) chronic dyspepsia. The success which had attended operation in these cases was very great, for not only was the immediate result of the operation good but the subsequent results were most satisfactory, for the patients were saved from the rhronic invalidism into which they often otherwise drifted. He referred to the certainty of diagnosis and pointed out that in none of the cases recorded had the abdomen been He thought that opened without finding some lesion simplicity in the operation was especially to be sought for. two
I
1
THE
LANCET, April 21st, 1894, p. 1008.
’
303 n were apparently atrophied but the other facial Mr. OPENSHAW also exhibited a child, aged six months, muscles n did not seem to be wasted. The distribution of the presenting congenital absence of the lower two-thirds of the muscles f; tibia, evidently due to an intra-uterine fracture, the mother facial atrophy corresponded roughly to the cutaneous distrib of the left fifth cranial nerve. There were three other having fallen over the back of a chair during pregnancy.- bution of atrophied skin upon the body, one upon the middle The relative advantages of the manipulative and the patches p o the back of about the size of the hand which presented a ’’open"methods of operating on cases of congenital dis- of f4 dilated venulfs characteristic of morphoea, and in this location of the hip-joint were discussed by Mr. KEETLEY few there appeared to be a slight tendency to excess and Mr. BALLANCE, both of whom expressed a general position p o of pigment. Another patch of atrophied skin might be preference for the latter.-Mr. OPENSHAW replied, s behind the right ear and a third over the outer side of ,4 Mr. JAMES SHERREN exhibited a case of Ankylosis of the seen t left knee. These, like the facial atrophy, caused the Hip following Gonorrhoeal Arthritis occurring in a man, aged the no unpleasant sensations. 20 years. 14 days before the onset of the pain in the joint he patient p Microscopic sections of t skin of the atrophied side of the face and of the had had an attack of urethritis. The right hip was fixed in the extension and there were marked wasting of the thigh and1=patch on the back were shown ; also sections from another of morphosa and of healthy skin for comparison.c case slight wasting of the muscles of the calf. f DYCE DUCKWORTH agreed with Dr. Savill in regarding Mr. SHERREN also exhibited a case of Secondary Sir c such as the one before the society as identical with Syphilitic Synovitis of the Elbows. The patient, a man, cases i and referred to a paper on the subject which he a six months had contracted venereal sore 24 morpboea years, aged previously and about a month previously he noticed that his ((Sir Dyce Duckworth) had communicated to the L1’cinburgh left elbow had become swollen and painful and a week laterMedical Journal in 1883,1 dealing with different forms of the right became similarly affected. Both elbow-joints wereaatrophy. Facial hemiatropby represented the most extreme of atrophy, not only the skin but the muscles and even J form now held in a flexed position, all movements being resisted t bones being sometimes involved. No one could doubt and painful, and there was a considerable amount of effusion the t that these lesions were of nerve origin, and in Dr. Savill’s into both joint cavities. 4 the fifth nerve and the Gasserian ganglion had probably Dr. F. J. POYNTON exhibited a case of Atavism occurring case I in a child, aged three years, who had been admitted to thebeen damaged by the accident. All of these atrophic skin Hospital for Sick Children, Great Ormond-street, under the lesions were, in his view, of neuro-trophic origin, and he care of Dr. F. G. Penrose for inability to walk properly. Whenreferred to cases in which a fall upon the head had been first set down on his feet he stood erect, but when he com-followed by rapid and total loss of hair from all parts of menced to walk he crouched and assumed a posture like the body. Dr. SEYMOUR TAYLOR exhibited a case of Ruptured Aortic that of a chimpanzee. The whole body was bent forward and the head was bent, the chin pointing to the right. The Valve. The patient, a "hammerman" by occupation, aged hands were held in front and the upper extremities were bent 50 years, was admitted to the West London Hospital on at the wrists and elbow. The hips and knees were flexed Oct. 16th, 1902, complaining of giddiness, prascordial pain, and the feet were turned in, the pressure coming upon their and dyspnoea which had come on somewhat suddenly in July, On admission he was outer borders. The crouching attitude became more marked 1902, after a long da,y’s heavy work. found to have a loud aortic obstructive murmur and a louder as the child became tired.-The case was discussed by Mr. .J
diastolic murmur. The latter was musical and was so loud that it could be distinctly heard at a distance of two inches from the chest, and with the aid of the stethoscope it could be heard all over the thorax, in the abdomen as low as the umbilicus, and down the arm. The left ventricle was hypertrophied and probably dilated. The diagnosis of ruptured valve was made on the following grounds-viz.: (1) A history of syphilis ; (2) the sudden oncoming of urgent symptoms ; (3) the patient’s occupation ; (4) the musical diastolic murmur ; (5) the presence of marked diastolic thrill ; and (6) the absence of any other definite signs of aneurysm.-Dr. A. MORISON discussed the diagnosis and regarded the case as one of aortic regurgitation in which loss of compensation had occurred rather than as a case of ruptured aortic valve. The latter was a very rare condition in which the symptoms supervened very suddenly and were continuous and cumulative. He referred to a case which he had observed in which the patient after sudden and violent exertion took to bed and died six or eight months later, ruptured aortic valve being verified at the necropsy.-Dr. H. A. CALEY agreed with the preceding speaker and thought that the symptoms in Dr. Taylor’s case might be accounted for by a sudden loss of compensation. A musical murmur and a marked diastolic thrill were not, he thought, altogether trustworthy as a means of diagnosing ruptured aortic valve.-Dr. S. VERE PEARSON referred to a case which he had observed at St. George’s CLINICAL SOCIETY OF LONDON. Hospital resembling Dr. Taylor’s case which proved at the post-mortem examination to be one of dilated aortic orifice with failure of compensation.-Dr. A. E. GARROD discussed Bx7tibitio,n øl C/fl,S88. A MEETING of this society was held on Jan. 23rd, Mr. the significance of the systolic murmur in the case.-Dr. TAYLOR, in replying, admitted that the diagnosis was open HOWARD MARSH, the President, being in the chair. the history of syphilis, the occupaDr. T. D. SAVILL exhibited a case of Facial Hemiatrophy yto doubt, but emphasised and the loudness of the musical murmur (Morphcea or Localised Scleroderma of the Face). Thetion of the ofpatient, his view. support patient was a man, aged 50 years. In 1880 he had a severe Mr. STEPHEN PAGET exhibited a case of Removal of the blow on the top of the head and thereafter suffered from Scapula of a boy, aged nine years. The patient was a thin neuralgic pains in the vertex and face, sometimes of greatt and but healthy boy. Swelling of the bone severity, until 1895, when they subsided under treatment. was delicate-looking first noticed one month before ; there was no pain or In 1885 or 1886 he first noticed that the hair of the .e left side of the scalp and left eyebrow was coming off history of injury. A hard nodular rounded mass with a broad and that the face on the left side was becoming wasted. base sprang from the rght supraspinous fossa and passed beneath the clavicle. No signs of pressure on the The wasting of the face at first gradually increased, but t forwards it had remained stationary for some years. t vessels and nerves of the arm and no enlarged glands were On the left side of the face the whole of the skin was thin, shiny, present. On April 30th, 1902, the scapula was excised and growth found to be cartilaginous. The patient made a and smooth, and the subcutaneous tissue was considerably ft good recovery and the movements of the arm were good. atrophied. The hair was almost absent from the left .anterior quarter of the scalp and was also wanting in the 1 inner half of the left eyebrow. The temporal and masseter Edinburgh Medical Journal, January, 1883, p. 616.
E. MUIRHEAD LITTLE, Dr. EDMUND CAUTLEY, and Dr. A. F. VOELCKER. Mr. HUTCHINSON, jun., exhibited a case of Macrodactylism in a man, aged 54 years. The digits involved were the right thumb and index finger, the latter being the larger. All the bones of the right index finger were the site of rounded knobs and a skiagram showed that the joints were almost completely ankylosed. The soft tissues were also hypertrophied. The hand, in spite of its ungainly digits, was useful and the patient had worked hard as a cooper. The other hand and both feet were of normal size. The condition had existed since birth. The patient had come under care for an oesophageal stricture. Dr. H. D. ROLLESTON showed a man, aged 44 years, paffering from Aortic Disease and presenting a musical diastolic aortic murmur resembling that heard in cases of ruptured valve. There was, however, no other reason to suspect rupture of a valve in this case and Dr. Rolleston did not regard it as an instance of that lesion. The patient had not had syphilis or rheumatism but had a laborious occupation. Dr. CYRIL OGLE (introduced by Dr. Rolleston) exhibited a case of Symmetrical Gangrene of the Peripheral Ends of the! Fingers of doubtful origin. ,
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