ROYAL MEDICAL AND CHIRURGICAL SOCIETY.

1100 X.,Bain=] ROYAL MEDICAL AND CHIRURGICAL SOCIETY. [Nov. 18, 1893.
easily be put on one side, on the grounds that the injury
might have been due to an epileptic seizure, although, of
course, the suggestion that the injury was not the cause of
the disease may be correct. Anyhow, it was impossible to
localise the seat of injury or any special centre of disease,
which might have made an operation advisable. In fact the
whole history of the case suggests a widespread lesion.
Hi8tor.-B. L. P., male, aged 13, was admitted on October
3rd, 1892. Two or three years previous to admission he was
knocked down by a horse and trap, which went over him,
the shaft striking him on the back of the head. He was
stunned and remained unconscious for about three hours.
Before the accident he was a bright intelligent lad, but was
never the same again. At first his home lessons caused him
difficulty; these were diminished, but in time he became
quite unable to learn anything. Fourteen months before
admission he had a kind of seizure in which he lost power on
the left side. The weakness remained, and from that time
he gradually got worse, and finally became unmanageable.
He shouted and screamed without cause, tried to run away,
and became dirty in habits and violent in conduct.
On Admiwsion.-He was a thin, fair-haired boy. Eyes grey;
pupils equal and sluggish. Power of left leg diminished.
No disease discovered in abdominal or thoracic viscera.
Mentally was quite unable to appreciate his surroundings or
to understand what was said to him.
After-HYistory.-After admission, he was noted to be very
weak on his legs, and fell about the ward. He was noisy and
troublesome, and dirty in habits. On November 18th, the
following note was made: Left pupil larger than right: knee
jerks intensely exaggerated; ankle clonus not obtained; gait
spastic; would open his mouth, and bite at any object held
in front of him; tongue tremulous, protruded straight;
speech hesitating; holds his hands in front of him all day,
and rubs them together, at the same time talking unintelligibly
if spoken to, he echoes the last part of the sentence.
On November 26th, he had a seizure, in which he did not
appear to lose consciousness. Twitching of the right eye
and hand were first noticed, and later the muscles of the
right side of the face were involved. After the attack, the
right leg was found to be weak, so that he fell over on trying
to walk. After the seizure, he fell asleep, as after an ordinary
epileptic fit. He then gradually became thinner and
weaker, so that in February it was found necessary to keep
him in bed. Since then he has had two other seizures, one
involving the left side and the other the right. No marked
alteration has taken place.
At the present time he lies in bed all day, with his knees
drawn up touching his chin, takes no notice of his surroundings,
and passes a purely vegetative existence; takes food
when it is offered him, but also opens his mouth to bite at
anything else that is placed in front of it. Exercises no control
over his emunctories. Muscles atrophied, but irritable.
Knee jerks cannot be obtained. Tdche c6r6brale well
marked. Mumbles incoherently, and is often noisy at night.
Is much emaciated, in spite of a voracious appetite well
satisfied. Has never suffered from vomiting, or had optic
neuritis.
REPORTS OF SOCIETIES,
ROYAL MEDICAL AND CHIRURGICAL SOCIETY.
WILLIAM CHURCH, M.D., F.R.C.P., Vice-President, in the
Chair.
Tuesday, November 14th, 1893.
DEATH OF SiR ANDREW CLARK.
DR. CHURCH, at the opening of the proceedings, refelred in
a brief but most admirable speech to the great loss which the
Society had suffered by the loss of its President, Sir Andrew
Clark. Subsequently a resolution of condolence was adopted.
[A full report of Dr. Church's speech and of the text of the
resolution will be found at page 1111.]
OPERATIONS WITHOUT ANAESTHESIA.
Mr. C. B. KEETLEY, who read this paper, said that after the
discovery of surgical anaesthesia certain causes led to its
abuse: (1) its dangers were not at first realised; (2) surgeons
and the public forgot what could be done without it. Nevertheless,
local ancesthesia received a hearty welcome; but its
applicability was, of course, strictly limited, especially since
it had been known that cocaine had its dangers. An alarming
case in the author's own practice led him to perform
various operations under a nominal cocaine aneesthesia, and
experience then acquired gave him an insight into what could
be done in operative surgery without, anaesthesia. But he
first learned the full possibilities in this direction by the
necessity of operating on certain thyroid tumours without
anaesthesia. A case was shown in which the operation lasted
over three hours. The sensitiveness of different structures
was then compared. Although a tissue might be itself insensitive,
its connections might make it practically very
sensitive. If the question of the sensitiveness of the peritoneum
was treated from a practical point of view, that of the
parts immediately beneath it must be considered at the same
time. The amount of pain evoked depended greatly on the
instrument used. Could any rules useful in practical
surgery be deduced from the facts passed in review?
General anaesthesia should, as a rule, be avoided in cases of-
(1) Strangulated hernia in old and exhausted subjects; (2)
colotomy and colectomy in similar subjects, when the course
of operation could be foreseen and planned beforehand; (3)
mere tapping, aspirating, sounding, or even laparotomy by
small incision for exploring, combined perhaps with evacuation
of fluid (or even of simple non-adherent cysts ?). On the
other hand, general anaesthesia was decidedly indicated in
operations on the trunk and head, the full extent of which
could not be foreseen, and for such extensive operations as
major amputations, excisions, osteotomies, and trephinings.
Nitrous oxide was available for many cas&s in which it was
now usual to employ ether or chloroform, especially for
special operations which the surgeon concerned was much
practised in; for simple incisions, however long; for encapsuled
tumours, however large, if superficial; and for refracturing
mal-united bones. It was exceedingly economical
of time, a most important consideration in these days.
The use of cocaine was. limited by the dangerous susceptibility
of some individuals to any but very small doses.
Nevertheless, it was available for many thousands of minor
operations for which patients were every year exposed to the
risks, discomforts, and expense of chloroform. Many cases in
which cocaine was supposed to have acted well were really instances
of nominal or imaginary anaesthesia, and especially
when the part operated on was the abdomen. Such, also,
probably were many cases of hypnotic ansesthesia. The paper
concluded with critical remarks on certain questions relating
to the subject.
Mr. POWER noticed that the author had not touched upon
the use of anaesthetics with reference to affections of the eyes.
Before the advent of chloroform, such an operation as enucleation
of the globe was occasionally a very serious business.
Now, except for the more serious operations, as enucleation
or abscission, chloroform wvas not even necessary, a 5 per cent.
or 10 per cent. solution of cocaine being quite sufficient to
render such operations as iridectomy perfectly painless.
Dentists were the people who came most directly in contact
with acute pain, and Mr. Power mentioned the exhaustion
and depression which followed the abstraction of a large
molar. Guthrie, in his commentaries on the war, alluded to
a wounded soldier who ran with his intestines in his hands
to a farmhouse, where a milkmaid had washed them in warm
milk, and replaced them in the abdomen, and the man finally
recovered. Mr. Power had been surprised that once, when
suffering from pleurisy, the passage of a trocar through his
chest wall had been quite painless.
Dr. KENNETH MCLEOD thought that the option of the
patient should always be considered. He mentioned that
alcoholic intoxication produced complete aniesthesia. It was
as important to relieve the anticipation of pain as the actual
pain djring the operation.
Mr. GEORGE EASTEs referred to the enormous variation in
relation to pain of different individuals, and quoted a case
in his father's practice in which a labourer had had a toe
amputated without making a face, and he had himself that
morning given an aneesthetic to a lady for the removal
of piles, and, although the conjunctivse were quite insensitive,
she yet had evinced signs of pain at the commence-

Nov. 18, 1893.] CLINICAL SOCIETY OF LONDON. ITnuBVLn 1 101
ment of the operation. In reference to puncture of the chest,
a lump of ice previously applied for two or three minutes
deadened sensation sufficiently. It was always necessary to
determine the depth of aneesthesia suitable to any given
patient, and one great value of aneesthesia was to deaden the
menital impression so that the surgeon could go quietly to
work.
Dr. HEWITT considered that Mr. Keetley had done good
service in bringing forward this question. There was no
doubt that general anaesthesia was not so successful in some
classes of cases as in others. He quite agreed that one
should not use a general anaesthetic if local aneesthesia was
sufficient. He himself thought that in some cases of strangulated
hernia in which the patient was very bad, local ansesthesia
was preferable to general. He also thought that in
some cases of tracheotomy for diphtheria, in cases of innominate
aneurysmi with urgent dyspncea, in large goitres
pressing on the trachea in which the patients were suffering
from bronchitis or advanced phthisis, local anmesthetics were
again preferable to general. One must always remember,
however, that this kind of cases constituted but a very small
minority of operations. In all cases where the mental element
came into consideration a general anaesthetic was necessary.
Again, in some pulmonary and pleural conditions,
there was a certain degree of risk in the use of a general
anaTsthetic. He congratulated Mr. Keetley on having been
able to operate for three hours in removal of a thyroid without
any anaesthetic.
Mr. WALTER SPENCER thought that the danger of general
anmesthetics must be chiefly laid to the door of those who
administered chloroform without having had sufficient experience.
He considered that operations about the rectum
could only be undertaken when the patient was under a
general anmesthetic. Although not much used now, one of
the quickest and most satisfactory ways of incising the skin
was by transfixion.
Mr. BALLANCE quite agreed with Mr. Keetley in operating
on the thyroid without a general anaesthetic. In many
cases he felt sure that it was of great advantage to intermit
the administration of a general aneesthetic during operations.
He always felt that a patient was never so near death as when
under profound anesthesia. Still, for all serious operations
lhe was sure that general aneesthesia was of advantage to
both patient and surgeon. In abdominal cases prolonged
anaesthesia was by no means always necessary, and if the
surgeon would get his sutures into place whilst the patient
was unconscious a large part of the operation could be done
without continuing the anaesthetic. He considered that
general anesthetics were absolutely necessary in operations
upon children.
Mr. KEETLEY, in reply, quite agreed that anesthetics
should always be used for children, except for such an
operation as that for imperforate anus in early infancy. He
agreed with Mr. Spencer that transfixion was the best way of
removing non-malignant tumours. He defended the removal
of the goitre without an aneesthetic on the ground that in a
previous case the an.esthetic had been almost impossible to
administer, owing to impending death more than once during
the operation, and it was well known that surgeons who
operated largely on bronchoceles, such as some of the Swiss
surgeons, had discarded the use of anmesthetics. He thanked
Mr. Power for his most interesting remarks on his personal
experience of the times before the introduction of anoesthetics.
THE Russian Government is understood to have expressed
a wish that the Twelfth International Medical Congress, to
be held in 1896, should meet at Moscow. It has promised the
sum of 50,000 roubles towards the expenses of the Congress.
THE NOTIFICATION OF PHTHISIS.-At meetings of the Oldlham
Medical Society on October 24th and November 7th, the
notification of phthisis formed the subject of a prolonged discussion.
The following resolution was carried unanimously:
"That the Society, having had its attention drawn to the infection
of tuberculous diseases and to the great mortality and
injurT to the population arising therefrom, is of opinion that
these diseases should be the subject of voluntary notification
to the sanitairy authority."
7
CLINICAL SOCIETY OF LONDON.
JOHN WHITAKER. HULKE, F.R.C.S., F.R.S., President, in the
Chair.
Friday, Noveinber 10th, 1893.
TRAUMATIC ARACHNOID H +EMORRHAGE, WITH SYMPTOMS ON
THE SAME SIDE AS THE LESION.
MR. C. MANSELL MOULLIN read notes of tllis case. T. C., a
stevedore, aged 43, was admitted into the London Hospital
on May 30th in a state of almost complete coma, having been
struck a violent blow on the right side of the head three
hours before by the hook of a swinging crane. He was not
stunned, and continued to work until shortly before admission,
when he suddenly became faint. The muscles of the
right side of the face were paralysed; the right arm and leg
were very rigid, and he could not be made to move them.
The seat of injury was explored, but there was no fracture.
The next day the coma was less, but the paralysis of the faceand
limbs more marked. This continued until the eighth
day, when the coma became much deeper, with intervals of
delirium. The right-sided paralysis remained the same, the
tongue in addition being a0ected. As the patient was sinking
the left side of the brain was explored over the motor
area and found to be uninjured. The day following the
patient died, the temperature rising to 1060 F. At the
necropsy there was no fracture, nor was there anly lhemnorrhage
between the dura and the bone. The arachlnoid space
on the injured side was filled with a coagulum which covered
the surface of the hemisphere, but which could be washed off
with a gentle streani of water, leaving the surface of the
arachnoid uninjured. The source of the hmmorrhage appeared
to be one of the branches of the posterior division of
the middle meningeal. The brain was carefully examined on
both sides, but no sign of contusion or laceration could be
detected. Attention was drawn to the peculiar occurrence
of the haemorrhage, without fracture or aneurysm, and without
any distinct evidence of atheroma, and to the fact that
the symptoms throughout were on the same side as the
injury, neither the face nor the body on the opposite side
having shown the least sign of motor paralysis.
The PRESIDENT, referring to the question of the site of the
lesion, described a similar case. A man stooping down was,
struck on the right temple by a falling ladder. Ile rose
dazed. A bruise formed which disappeared after three or
four days. He had headache and difficulty of walking, and,
ten days afterwards, was brought to the hospital suffering
from right hemiplegia. A medical colleague advised that
he should, on physiological grounds, be trephined on the
side opposite to the injury, but Mr. Hlulke cut down at the
seat of injury and trephined. Here the bone was quite right,
and the dura mater had nothing abnormal external to it.
Upon its being incised some bloody serum escapedl from beneathi
it. He recovered consciousness, and was finally restored
to health. If the operation had been done oIn the
opposite side on physiological grounds the collection of
serum would have been missed and the patient in all probability
have died.
Mr. J. H. DAUBER mentioned a case of right hieiniplegia,
following injury of the right parietal bone. The man was in
a well when a pulley fell on him. For a month after the
accident, however, he kept at work. lie had by that time
an abscess at the site of injury; pus was running from the
wound. Pieces of bone were removed from the wound, but
the patient succumbed. At the post-mortem examination.
meningitis and cerebritis were found, and one piece of bone
was found still embedded in the brain.
Dr. BEEVOR said that most cases of hemiplegia on the sameside
as the lesion were traumatic, and it was difficult in such
cases to localise the lesion exactly. All the weight of physiological
evidence was against the supposition that the right.
half of the brain could regulate the right half of the body.
Dr. HALE WHITE remarked that he knew of one case in
which a surgeon had trephined on the same side as the paralysis,
but had found nothing, and after death the lesion was.
found to be on the other side of the brain. The cortex on.
the other side in Mr. Moullin's case should have been examined
microscopically, to prove that it was uninjured, before
one could, on such evidence, overthrow the teachings of
physiology.

1102 MEDICAL JOURNAtl MEDICAL SOCIETY OF LONDON. [Nov. 18, 1893.
Mr. MANSELL MiOULLIN regretted lie had not made such a
microscopical examination of the other half of the cortex; it
had seemed to him that a large blood clot was sufficient evidence
of the site of the lesion.
DISEASE OF THE CORPORA QUADRIGEMINA.
Dr. FREDERICK TAYLiOR read a report of this case. The
subject was a boy, aged 4, who, four months before admission
into the Evelina Hospital, became ill, would not eat, and had
drooping of the eyelids. Gradually after this lie lost strength.
Fourteen days before admission he began to stagger. On admission
lie was somewhat drowsy, and spoke slowly; there
was ataxy of both upper and lower limbs, and the head and
neck oscillated in an antero-posterior direction. There was
nearly comnplete double external ophthalmoplegia, including
double ptosis, more marked on the right side. There was
some lateral nystagmus. The pupils were slightly and uneqtially
dilated, and reacted to light. There was no optic
neuritis nor choroiditis. The child could not see. A month
later lie was semiconscious, swallowing with difficulty, and
ithe arms and legs fell flaccid when lifted from the bed. He
,becaine more unconscious, the breathing became of the
4Clieyne-Stokes character, swallowing became difficult and
finally impossible, and he died two months after admission,
-or six months after the first symptoms. The necropsy showed
that the cerebellum was perfectly healthy, but the corpora
.quadrigemina were flattened, broader, and more extensive
than normal, and grey and gelatinous in appearance. There
wias a similar grey substance showing at the base of the
Ibrain between the crura cerebri, and invading them in their
inner halves; the third nerves were lost or torn away from
their attachments. In the right orbit all the muscles supplied
by the third nerve were atrophied, and the nerve and
its branches could not be found; in the left orbit the nerves
-ud their branclhes were present, and the muscles were fairly
'healthy. The minute investigation of the parts was unsatisiaotory
from failure in the preserving methods; but there
-w.s n1o doubt that the corpora qiuadrigemina and adjacent
jptrts were changed by new growth, probably of glio-sarcomatous
niature. The case illustrated, more or less completely,
the formula laid down by Nothinagel for the diagnosis of diseise^
of, or in the neiglhbourhood of, the corpora quadrigemina.
According to him, the diagnostic signs were "i an unsteady reel-
inga gait, especially if this appeared as the first symptom," and
" oplithalmoplegia existing in both eyes, but not quite sym-
,metrically, nor implicating all the muscles in equal degree."
)r. MOTT, speaking as a physiologist, said that the early
'and persistent ataxic symptoms which seemed, as Nothnagel
poinited out, when combined with oculo-m-iotor paralysis to
be diagnostic, mih-lt be explained in one of three ways.
k(l) The fillet might easily be involved, and physiologists con-
*sidered that the fillet conveyed inpulses from the nuclei of
'tle posterior columns of the spinal cord. According to
Fleclisig alnd Hlisel, the fillet passed to the sensori-motor
area of the central convolutions. The fillet was, therefore, in
all probability a path for muscular sense impressions, and
inasmuchl as it lay between the crusta of the crus cerebri
and the corpora quadrigemina, a portion of it very close to
tIme latter, it was difficult to understand how the fillet could
escape if a tumour grew in these bodies. (2) Were the
superior cerebellar peduncles involved ? They lay very close
to the posterior corpora quadrigemina, and on the surface of
tlhe Auperior peduncle turning round to reach the vermis.
Just behlinid the posterior corpora lay the ventral portion of
the direct cerebellar tract of the spinal cord. (3) A number
of fibres could be traced up the antero-lateral columns of the
spinal cord after their section, these fibres terminating in the
corporla quadrigemina, and Dr. Mott suggested that possibly
tlhey served to co-ordinate the spinal actions of the limbs and
eyes.
Dr. BrEEvOR had about ten years ago publislhed a case of a
tumour that grew from the upper surface of the cerebellum.
a-lnd comiipressed the corpora quadrigemina. There was ataxy
combined witlh paralysis of ocular muscles, double optic
neuritis, anid volniiting. The tumour pressed forwards on the
corpora quadrigemina, as proved at the necropsy.
Dir. TAYLOR, in reply, said hiis case sliowed that there might
be ataxy in a clhild due to disease that was not in the cerebellum.
lHe was confident thlre wwas no extensive lesion in
the superior peduncle in his case, as the disease was almost
entirely confined to the corpora quadrigemina.
SYPHILITIc TuMOURS OF SPINAL CORD, WITH SYMPTOMS
SIMULATING SYRINGOMYELIA.
Dr. BEEV'OR detailed this case. P. S., aged 50, married,
gardener, about two days after exposure to wet, on July 1st,
1892, dragged the left leg and grew weaker in a few hours;
he also had numbness in the right knee. In a few hours he
had weakness of the left arm. On admission into the National
Hospital for the Paralysed and Epileptic in September, 1892,
he presented wasting of both the upper limbs, especially the
left, anld weakness of the left lower limb so that he could only
just raise the leg off the bed. Sensation was lost to pain,
lheat, and cold in the right leg and the right half of the trunk
up to the fourth rib, while tactile perception was normal.
The knee-jerk was excessive on the left, and left ankle clonus
was present. Later on the loss of painful sensation spread
up to the right arm ulnar border, and involved the radial
border of the left forearm. There was loss of electrical reactions
in the interior muscles of the hand. Later he had
paralysis of the sixth nerve of the right side, and he gradually
became worse and died on November 14th. On examination
post mortem two syphilitic tumours were found on either side
of the brachial enlargement of the cord, the left one passing
nearer the cord than the right, but the cord was too soft for
accurate examination. Attention was drawn to the fact that
loss of heat, cold, and painful sensations had lately been
associated with syringomyelia when unattended by tactile
anwesthesia, but in this case seemed to have been caused by
pressure of a growth from without.
Mr. EASTES asked for further information as to the treatment
adopted in the case.
Dr. MoTT asked if there was a tumour on the right, as well
as one on the left, side of the cord; and whether microscopical
examination had been made to show what tracts
were degenerated. In two cases of unilateral syringomyelia
it lhad been reported that the analgesia was on the same side
as the cavity in the cord.
Dr. BEEvOR, in reply, said that the question of treatment
had naturally turned on the diagnosis. The case had been
regarded as one of tumour of the cord, and it was a question
as to whether it was one to be explored by operation. The
loss of heat and cold sensation pointed to syringomyelia,
which was the diagnosis adopted. Small quantities of iodide
of potassium were given, but the drug was not pushed. The
patient's statement that lie had not had syphilis was believed.
It was impossible to trace accurately the degeneration in the
various tracts of the cord, as it was so very diffluent.
MEDICAL SOCIETY OF LONDON
J. SYER BRISTOWE, M.D., F.R.S., Presidenit, in the Chlair.
MlVonday, November 13th, 1893.
STRANGULATION OF THE TESTICLE DUE TO AXIAL ROTATION
OF THE SPERMATIC CORD.
AIR. EDMUIND OWEN reported a case of this nature. The
patient was a schoolboy, aged 13, who had an undescended
testicle on the left side. After bowling at cricket lie was
seized with pain and tenderness in the left inguinal region,
and began to vomit. He was soon afterwards sent into hospital
as a case of strangulated hernia. Between the external
abdominal ring and the scrotum was a painful swelling the
size of a small lien's egg. There was no impulse in it, and
the skin was not discoloured. On gently dragging the
tumour downwards the spermatic cord was foiind to be free,
and the external abdominal ring clear. Mr. Owen gave
it as his opinion that the swelling was due to engorgement of
the epididymis and testis, the result of rotation of the cord.
On exposing the parts the cord seemed to be normal. Wlhein
the capacious tunica vaginalis was opened much blood-stained
serum escaped, the testis and epididymis being found
blackish, and in a conditioni of potenitial gangrene.
He, therefore, removed them after tying the cord.
Subsequently, on carefully examining the parts, he
discovered that the cord was twisted so close to the epididymis
that the twist was hidden beneath the upper part of
the tunica vaginalis, which itself was implicated in the

-Nov. 18, 1893.1 _ OBSTETRICAL SOCIETY OF LONDON. rM;ALJOURN 1103
twist. The boy went home cured in less than a fortniglht.
Mr. Owen briefly detailed eleven other cases of a like nature
which had been recently reported--most of them in England.
He thought that not a few cases of sloughing testieles
and of testicles wasting after acute inflammation were
of this nature. The condition was almost as likely to occur
upon the right side as the left, but was specially likely to be
found in boys and young adults who were the subjects of undescended
testis. It was impossible to differentiate certain
of these cases from strangulated hernia, but, as operation
would probably be needed in each condition, the want of
precision in diagnosis would lead to no harm. lie was of
opinion that when the engorged mass was exposed the operation
should be completed by its removal.
Mr. T. BRYANT said he was the first to call attention to this
particular condition, but he admitted his inability to aflord
any satisfactory explanation of the twisting of the cord in
such cases, though the association with undescended testicle
or other developmental deformity was interesting. He
failed to see the close resemblance to strangulated hernia
that had been claimed. If the tumour could be separated
from, or was outside, the ring the diagnosis was easy, but,
under any circumstances, he pointed out that the local symptoms
were much more intense in these cases than in hernia,
and, in addition, the constitutional disturbance was absent.
There was no abdominal pain, no abdominal distension, and
the sickness was not persistent as was the case in hernlia.
He agreed that early intervention was desirable, but he
deprecated any rule for general application involving the
routine removal of the testicle.
After some remarks from Mr. NASH, Dr. RICHARDS suggested
that there might be a congenital twist of small extent
which became complete subsequently.
Mr. OWEN, in reply, admitted the possibility of a congenital
twist.
NEPHRECTOIMy FOR HYDRONEPHROSIS.
Mr. BLAND SUTTON read a paper on this subject. He wished
to call attention to the comparative safety of nephirectomy
when carried out on certain definite lines. The greater part
of the cases of hydronephroses were due to obvious obstruction
in some part of the genito-urinary tract, hence they were
termed retention cysts. Such hindrance to the flow of urine
to produce hydronephrosis must be incomplete, or if complete,
only temporary, for when the ureter was completely
and permanently blocked the kidney rapidly atrophie(l. Ihe
most startling fact was tlhat in many of the largest hydroniephroses
no obstruction could be demonstrated, and this
could not in most cases be explained on the hypothesis of
ablnormal movements of the kidneys. Thle largest lhydro-
niephroses were those subject to intermissions, tlley underwent
great dimilnution a-nd even temporary disappearance.
He related a case in whiclh such an intermission took
place during the operation for its relief. In this
case there was no evidence of obstruction, nor, owing
to the connections of the cyst, could abnormal movements
have been possible. He showed an unusual specimen of
unilateral hydronephrosis removed, post mortemn, from an old
iiman in whom no trace of obstruction could be found.
Although the course of a hiydronephrosis was silent, it
promptly revealed its presence if it suppurated. This was
one of the greatest dangers to which such patients were
liable. They must distinguish between a pyonephrosis and a
suppurating hydronephirosis. The latter was comparable to
a suppurating ovarian cyst, and required the same principles
of treatment. A primary pyonephrosis was inflammatory
from the onset; it rarely attained a large size, and, as it wvas
usually associated with calculus, it demanded nephrolithotomy
or nephrotomy rather than neplhrectomy. A hydronephrosis
miglht become septic through the colon, for in
some cases the wall separating the cyst from the colon miglht
bec-ome so thin as to permit of osmosis of fluid, and so establisli
suppuration. In such cases the synmptoms might simulate
those of typhoid fever, of which he meiitioned an example.
The recognition of a suppurating hydronephrosis
was comparatively easy, but it was extremely important to
distinguish between renal tuberculosis, pyonephrosis due to
calculus, and a suppurating hydronephrosis. The practice of
resorting to aspiration for diagnostic purposes could not be
too strongly condemned, for it often misled, and was, more-
over, the source of much danger. As to treatment, the
disorganised organ slhould be removed if the other was in good
working order. The removal of one'lydronephrotic kidney,
if both were similarly,affected, might lead to disaster. In such
cases nephrotomy was safest. The principal points in the
operative procedure were-having opened the peritoneal
cavity in front in the middle line to establish the diagnosis,
the wound was closed, and the cyst was exposed through an
incision in the ileo-costal space. No attempt should be
made to enucleate,the tumour until the finaer was well within
the capsule-a point to which he attached considerable importance.
After emptying and ligaturing any large dilated
ureter, the pedicle should be transfixed as close to the cyst as
possible. The pedicle should never be clamped with large
forceps before securing the ligature. Success in nephrectomy
demanded decision, celerity, and gentleness-qualities which
could only be acquired by constant familiarity with renal
operations. The fate of a patient who had undergone
nephrectomy, judging from the facts at his disposal, was, on
the whole, very reassuring.
Mr. ALBAN DORAN deprecated operating with too mucl
haste in hydronephrosis associated with floating kidney,
because this might ultimately subside of itself. He related
a very striking instance in which the tumour disappeared
only a few hours before the nephrectomy was to be done. In
that case a floating kidney remained, which had since been
kept in position by means of a belt, and no recurrence
had taken place. In another case the ureter, though not
altogether impervious, would not empty the cyst unless the
kidney was turned upside down, so that no natural relief
could be anticipated. He objected to nephrotomy because a
second operation so often became necessary. Even hydronephrosis
of long standing did not appear necessarily to involve
atrophy of the kidney substance, in which case restoration
of function was more likely to take place if nephrotomy
with drainage was resorted to, provided the ureter could be
made patent.
Mr. HENRY MoRRis admitted that no cause of obstruction
could sometimes be discovered, but he pointed out that the
original cause of obstruction might have become obliterated
in the changes associated with the formation of a hydronephrosis.
Obstruction low down in the ureter did not of
necessity involve dilatation extending up the ureter and into
the pelvis of the kidney, for the ureter might yield in one
spot, and the bulge thus formed might press upon and
obliterate the tube higher up, just as was the case in some
aneurysms which obliterated the artery above or below. It
did not follow, therefore, that the obstruction was in the
pelvis of the kidney because no dilatation of the ureter could
be found lower down. He suggested that various conditions
might determine the formation of small cysts in the kidney
substance, which by coalescing might go on to form a hydronephrosis.
He alluded more particularly to two forms of
liydronephrosis between which a distinction ought to be
made-first, the thiin-walled hydronephrosis which collapsed
if tapped during the operation, and the other variety in
which hypertrophy of the cortex took place pari passu witl
dilatation, so that on opening the kidney one saw the calices
separated from one another by tllick fibrous septa. This
variety might result from the wasting or removal of one diseased
kidney, while the other underwent hypertrophy
previous to dilatation in its turn. Such kidneys, he
admitted, might require to be dealt with as solid tumours.
In removing these tumours lie agreed that it was desirable to
get well within the capsule before attempting enucleation,
but he doubted whether this could be done in the case of
thin-walled cysts, because in tryincg to get inside the cpsule
one was likely to get inside the cyst cavity.
Mr. SUTTON replied.
OBSTETRICAL SOCIETY OF LONDON.
G. E. HERMAN, M.B.Lond., F.R.C.P., President, in the
Chair.
Wednesda.y, Novemzber 1st, 1893.
SPECIMENS.
THE following specimens were shown:-Dr. LENVERS: Patient
on wlhom he had performed Symplhysiotomy.--Dr. EDEN:
Ovarian Cyst, with Sarcomatous Growth.-Dr. A. ROUTH:

1104 TMDICALBOUAL1 OBSTETRICAL SOCIETY OF LONDON. [Nov. 18, 1893.
Fibroid of Broad Ligament.-- Dr. HAYES: Hydrosalpinx.-Dr.
BoxALL: Uterine Myoma.
A FOXTEER CONTRIBUTION TO THE CLINICAL KNOWLEDGE OF
PUERPERAL DISEASES.
Dr. J. BRAXTON HICKS read this paper. He said it had yet
to be ascertained whether the variations in intensity might
not be due to a greater or less quantity of the poison taken
into the system, 6r to the greater susceptibility of the patient,
or whether the specific poison was accompanied to a varying
extent by other poisons generated from the same source; or,
indeed, whether a modification or, in regard to bacteria,
whether a new phase of growth (common to these organisms)
might not determine a modification of kind as well as of
intensity of the symptoms arising therefrom. He insisted on
the fact that the rapidity of action of the poison, whatever it
might be, was much greater than that seen in surgical cases
generally; that gave rise to the question whether the entrance
of the poison by the genitals and the special circumstances of
the situation would suffice to explain the difference in this
respect. Further, the special influence of the gonorrhceal poison
contracted before delivery, and yet to be determined. Finally,
in estimating the influence of infectious diseases, especially
those which conferred some sort of immunity, it must be
inquired how far patients had been rendered immune by a
previous attack-a condition which must obviously be of
frequent occurrence. His first group of three cases was
derived from the practice of a medical man in a village where
a young woman died after a day's illness of some obscure abdominal
trouble, ascertainedpost mortem to be purulent peritonitis,
the source of which could not be determined. The
medical man attended a labour case the same evening, and
another on the following day, followed by a third on the
fourth. In less than a week all three were dead with similar
symptoms. His next series started with a case of old-standing
disease of the femur, in which a surgical examination was
followed by an outbreak of phlegmonous erysipelas. Thereupon
the practitioner ceased to attend midwifery, but after
three weeks had elapsed, though still dressing the ulcers, he
resumed his attendance on obstetric cases. The first died
within thirty-six hours with symptoms of intense intoxication.
A second died within two days of labour, and a third
narrowly escaped. The medical man gave up attending cases
for three or four weeks, but his first case after that interval
died with pyrexia, headache, and a scarlatinal rash, and a
woman whom he attended in an abortion shortly after had a
similar fate. It transpired later that in the room in which the
first fatal case occurred the previous tenant had died in
the same bed of some offensive disease the nature of
which could not be ascertained. Case VII was that of a
young married lady in her first confinement. She had a
fairly good labour, but the forceps was used, and within
twelve hours she fell ill with the usual symptoms, and
died three days later, a bright scarlet rash making
its appearance pretty well all over the body. Eight
days later the baby was attacked by erysipelas and died.
No sanitary defect was found in that house, though diphtheria,
attributed to a defective sewer, had occurred in the
house of which the garden abutted on the garden of the
house in question. Case VIII. A woman in the eighth month
of pregnancy developed symptoms of influenza. Three days
later premature labour set in, in the absence of the medical
man, who only arrived half an hour later. She was then
greatly exhausted with vomiting, had a high temperature,
and complained of a pain in her " stomach.' Next day the
temperature rose to 106.60, and the right elbow-joint was
inflamed, distended, and painful. Diarrhoea supervened,
and four days later the left elbow followed suit, and diphtheritic
vulvitis made its appearance, the same condition
then appearing on the throat. She died on the ninth day
after delivery. The sanitary arrangements of the house
appeared to be perfect, but there had been erysipelas and
diphtheria in the neighbourhood. Case ix. A woman whom
he saw in consultation four weeks after her confinement was
thought to be suffering from influenza, several cases of which
had occurred in the house. After a few days of feverishness
the perineal rent, which had been stitched up, became -inflamed
and became the seat of erysipelas. This condition
lasted three weeks, but when Dr. Braxton Hicks saw her the
erythema had subsided. This patient recovered. The child!
was not affected. It afterwards came to his knowledge that.
the nurse had been nursing her mother with erysipelas just
before. They could not fail to be struck by the extreme
virulence of the virus, only a small quantity of which could
have been introduced. It seemed to him, moreover, that
the amount of poison received by the patient diminished as
time lengthened between the original infection of the hand
and the infection of the patient, which probably amounted
to saying that the rapidity and severity of the symptoms
depended on the quantity of the poison received. He was
unfortunately unable to give any information as to the kind
of purification of the hands (if any) employed in these two,
groups.
Dr. ROUTH asked whether any special atmospheric influences
were noted, as a low barometric pressure led to'
emanation of gases from the earth. It was well known that
before rain common sewers and drains were especially offensive
and sources of infection.
Dr. BOXALL thought that time might serve to dilute, but
not destroy, septic material. He thought it ought to be
generally known that by the adoption of efficient antiseptic
precautions, rather than by abstaining from practice, must
safety after exposure to infection be secured.
Dr. HANDFIELD JoNEs had notes of three cases in which
foul sewer emanations seemed to have played an important
part in the production of puerperal poisoning, and he considered
that a woman who for days or weeks before delivery
lived in a tainted atmosphere mi ht be so impregnated with
poisonous particles that after delfivery her tissues would become
a favourable breeding ground for septic germs. Where
such a condition occurred removal to a purer atmosphere
hastened recovery.
The PRMESIDENT wished to express in the strongest way his
opinion as to the futility in preventing the transference of
infection by mere temporaly abstention from practice. He
did not believe that any mere lapse of time would ever disinfect
infected hands and clothes. On the other hand, if the
person, instruments, and clothes were properly disinfected
(which could be done in a few hours), there was no necessity
for further abstention from practice. Many cases were published
in which patients who were delivered in houses with
defective drainage had been attacked with puerperal illness,
and had begun to improve on removal to a purer atmosphere,
but he knevr of no evidence that the relation between the
drainage and the illness was anything more than coincidence.
A paper was recently read before the Epidemiological Society
by Dr. Sweeting, in which he endeavoured to prove the connection
between outbreaks of diphtheria and bad drains, but he
entirely failed to do so. He (the President) believed that.
Duerperal septiciemia was produced by infection by contact.
It did not necessarily follow that the medical man or the
nurse was always the vehicle of contagion, although in the
great majority of cases it was one of the two.
Dr. HoRRocoe said that so long as a medical man was in
attendance upon a puerperal fever case of the grave type he
was unfitted for attending midwifery cases. So he should
obtain the help of another practitioner either to attend the
puerperal fever case or his other cases of midwifery. Whilst
admitting the possibility of time not destroying germs, yet
he thought it would have the same effect practically by
ultimately getting rid of the poison. He considered absolute
disinfection coull be secured in forty-eight hours (or even
less) by a change of all garments, a bath, repeated washing of
the hands, and placing them in an antiseptic solution.
Dr. HAYES said what was wanted was a thorough cleansing
of the hands, not mere washing in soap and water, but that
conjoined with a 1 in 20 solution of absolute phenol. He
thought the influence of drain poison or miasma, although a
cause of puerperal septiciemia, had been greatly exaggerated.
Dr. DUNCAN could not agree with the last speaker that it
was superfluous to change the clothing before attending a midwifery
case after having been in attendance on a case of puerperal
septieaemia. He thought, however, that if the clothing
was hung up in a small room and some iodine burnt over a
spirit lamp, disinfection was secured. With this precaution,
in addition to taking a bath and thoroughly washing the
hands in soap and water, and afterwards dipping them in a 1 in
1.000 mercuric chloride solution, lie considered he might

Nov. 18, 1893.] ROYAL ACADEMY OF MEDICINE IN IRELAND. [TM_BRIT 1105
with perfect safety attend a midwifery ease in twenty-four
hours.
Dr. LEWEIRS believed that complete personal disinfection
was quite possible, and that it was not at all essential for a
man to abstain from midwifery practice because he had
examined a case of puerperal fever. TIe was very sceptical
as to bad drains having much to do with puerperal
septieaemia.
r. A. RouTH expressed his belief in the importance of
sewer' gas in producing puerperal septiceemia, and mentioned
some cases which he considered supported the view.
Dr. CULLINGWORTH considered it a very dangerous doctrine
to send forth that puerperal septicaemia could be caused by
defective drains and sewer emanations. He agreed with the
President as to the unimportance of the time element in ridding
a man of infection. If thorouglh personal disinfection
were carried out he did not think abstention from practice at
all necpssary.
Dr. FRANcIs TAYLOR asked whethler it was to go fortlh as the
dictum of that Society that the presence or absence of sewer
gas in the bedrooms of parturient women was a matter of
little or no consequence? He quoted cases which pointed
the other way.
Dr. WALLACE pointed out that some of the cases mentioned
supported the thesis indicated by the President, that
there was no positive proof of the existence of a causal relation
between sewer gas poison anld puerperal septiciemia. It
was clear that where the pyrexia and other symptoms imme-
'diately disappeared after the patients were removed from
their insanitary surroundings, the cases were suffering from
sewer gas poisoning and not from puerperal septicsemia.
Dr. HICKS, in reply, said he had mentioned the atmospheric
surroundings because in looking at the causes of puerperal
-diseases it was proper to include all things that might act
detrimentally to the pregnant and lying-in woman. At
present we were ignorant on many of these points, and many
of the speakers spoke with more positiveness than our knowledge
justified. We used the term sepsis-septicamia, but as
a matter of fact we did not know their nature, neither did we
know what sewer gas was, nor how many poisons it might
contain. What we did know was that it produced detrimental
effects on the system, and in a lying-in woman ill.
health interfered with the reparation necessary of those
parts bruised, ecehymosed, and lacerated by labour; and so
we may have absorption of unhealthy matter, and that
whether any specific agent had been introduced or not.
OPHTHALMOLOGICAL SOCIETY OF THE UNITED
KINGDOM.
-HENRY POWER, M.B., F.R.C.S., Vice-President, in the
Chair.
Thursday, November 9th, 1893.
NEOPLASM OF THE IRIS.
Mn. LAWFORD read the report of the Committee on Mr.
Beaumont's case of Neoplasm of the Iris.
BENZOYL-PSEUDO-TROPEINE AS A LOCAL AN.ESTHETIC IN
OPHTHALMIC SURGERY.
This paper was read by Mr. T. J. BOKENHAM. He said
benzoyl-pseudo-tropeine, or tropa-cocaine, was a new cocabase
extracted from the small-leaved coca plant of Java, and
-was identical with the pseudo-tropeine obtained from
hyoscyamus. The alkaloid as obtained from the plant had
-considerable irritating properties when introduced into the
eye, but this was not the case when it was obtained by
synthesis. The specimen of the synthetically prepared alkadoid,
in the form of hydroeblorate, was made into a 3 per
-eent. solution, and tested by the author. It was found most
-efficient for inducing aniesthesia of the cornea, and had the
-advantage of causing no dilatation of the pupil, and none of
the ischaemia characteristic of the action of cocaine. There
was no disturbance of accommodation following its use. As
an anaesthetic to the lid before applying mitigated stick or
lapis divinus, a 10 per cent. solution had been found as
,successful as a corresponding strengtll of cocaine. This had
been found sufficient in such operations as strabismus,
edivision of stricture of lachrymal duct, and opening of
Meibomian cysts. Tropa-cocaine had the following advantages
as compared with cocaine: It caused no dilatation of the
pupil, and no disturbance of accommodation; it was much less
poisonous than cocaine, and it did not, if swallowed, produce
delirium. The vascular condition of the eye was not affected
by it, and in the form of a solution it kept better than
cocaine.
SPONTANEOUS RUPTURE OF CAPSULE AFTER IRIDECTOMY
PRELIMINARY TO CATARACT EXTRACTION.
This paper was read by the SECRETARY for Mr. J. T. RUDALL
(Melbourne). Five months after an uncomplicated preliminary
iridectomy it was found that the cortex of the lens had
undergone partial absorption, allowing a clear space between
the nucleus, which appeared to be somewhat tilted backwards,
and the upper edge of the cornea. It was probable
that a limited spontaneous rupture of the capsule had taken
place. Fearing that the nucleus of the lens might fall back
into the vitreous, the author removed it with a vectis. No
vitreous was lost, and the recovery was uncomplicated.
EXTREME HYPHAEMIA OF BOTH EYES WITH CORNEAL ABSCESS
OF RIGHT EYE OCCURRING AS A SEQUELA OF SMALL-POX.
This paper was read by the SECRETARY for Mr. KENNETH
SCOTT (Cairo). Ten months before admission into the Kasrel-Aini
Hospital the patient, a boy aged 9, had been attacked
by small-pox, which was immediately followed by loss of
vision in both eyes. At the time of admission there was a
circumscribed abscess of the centre of the right corn,a, the
anterior epithelium being intact. There was no pain nor
lacrymation, and only moderate injection. The anterior
chambers of both eyes were filled with a dark red brown
mass, completely concealing the iris. There was no trace of
irritation of the left eye. The tension of both eyes was normal.
Vision equalled perception of light. After seven weeks'
treatment the corneal abscess disappeared, and the upper
third of the red brown mass in both anterior chambers had
become of a light buff colour, and quite transparent. The
patient was kept under observation three months longer, but
the eyes remained in exactly the same condition.
CARD SPECIMENS.
The following were the card specimens: Messrs. CBITCHETT
and JULER: A Case of Pemphigus of the Conjunctiva.-Mr.
G. ANDERSON CRITCHETT: A Case of Conical Cornea treated by
the Galvano-Cautery without Perforation.-Mr. JULER: A
Case of Central Colloid Changes in the Retina. - Mr.
FREDERICK BASS: A Pocket Refraction Case.-Dr. RAYNER
BATTEN: Persistent Hyaloid Artery branching in Vitreous.
Mr. DONALD GUNN: A case of Sypllilitic Conjunctivitis.
ROYAL ACADEMY OF MEDICINE IN IRELAND.
SECTION OF PATHOLOGY.
Professor-J. ALFRED SCOTT, President, in the Chair.
Friday, November 3rd, 1893.
PRESIDENT'S ADDRESS.
THE PRESIDENT delivered his opening address on the Microchemistry
of Cells in Relation to the Theory of Immunity.
SPINA BIFIDA OCCULTA.
Dr. J. O'CARROLL exhibited a patient suffering from a
fairly typical favus eruption on the head. She had also a
large tuft of hair on the sacral or lumbar region, and a
peculiar deformity about the left scapula at its superior
angle, looking like an exostosis. It was interesting to know
that a little sister of hers had a large meningocele in that
region. He thought that the one he exhibited would come
under the name of spina bifida occulta.
SPECIMENS.
Dr. J. WV. MOORE showed the heart of a police recruit,
aged 21, who died on the ninth day of Acute Rheumatism,
the axillary temperature rising to 108.6° shortly before and
to 1100 shortly after death. The heart was hypertrophied
but softened. The aortic valves were healthy, but a large
clot adhered to the mitral valve, blocking up its lumen to a
very serious extent. The sequence of pathological phenomena
probably was an attack of rheumatic endocarditis in

1106 Mrn CAL Jous I BIRMINGHAM AND NMIDLAND COUNTIES BRANCH. LNov. 18, 1893.
1891, involving the margin of the mitral valve, an escape and
consequent perishing of leucocytes, which excited fermentation
and caused coagulation of the blood, thus leading to the
formation of this great clot, which resembled a vast valvular
excrescence, outgrowth, or vegetation.-Dr. JAMES LITTLE
next exhibited a specimen of Mitral Narrowing due to atheromatous
change, taken from a man, aged 60, who had swelled
feet, short breathing, and the various signs of mechanical
congestion of the venous system.-Dr. M'WEENEY showed a
Round-celled Sarcoma removed on October 10th by Mr. Chance
from a woman, aged about 50. The tumour was situated on
the inner side of the thigh, a little below the knee, embedded
in the subcutaneous fat, and at the time of removal had
attained the size of a large orange. A nodule, about the size
of a walnut, was removed at the same time from a point a
few inches below the large tumour. Both growths were
rounid-cell sarcomata with distinctly alveolar arrangement.
The cells were large, witlh vesicular nuclei and an abundance
of protoplasm. The nuclei contained granules which exhibited
strong affinity for acid aniline stains, and bodies
closely resembling the so-called cancer parasites could be
seen. Numerous mitoses were visible, many of them being
asymmetrical, and hyperchromatosis was of frequent occurrence.-Mr.
STORY exhibited Sections of an Eye removed
from a healthy young man, who lhad subsequently lost the
sight of his second eye from a similar affection. The globe
was removed on account of secondary glaucoma, which lhad
not as yet shown itself in the second eye.-Dr. E. J.
M'WEENEY exhibited Urinary Organs from a case of Cystitis
witlh Surgical Kidneys.______
LEEDS AND WEST RIDING MEDICO-CHIRUR-
GICAL SOCIETY.
J, KILNER CLARKE, M.A., F.R.C.S., President, in the Chair.
Fr iday, Novemnber 3rd, 1893.
SURGERY OF THE SPINE.
MR. NORM[AN PORRITT read notes of a case of intraspinal
abscess, the result of caries of tlle posterior surface of the
lower cervical and first dorsal vertebrw, and of a case of dislocation
of the seventh cervical vertebra. In the first case
laminectomy was done, and the patient died eighteen hours
after the operation from hyperpyrexia; in the latter the patient
lived a year all but eleven days, although a fortnight
after the injury he nearly died from apyrexia, the temperature
sinking to 900 F., at the same time that the pulse and
respirations dropped to 31 and 7.1 respectively per minute.
Mr. MAYO ROBSON referred to the case of a little boy, suffering
from caries of the spine with paraplegia. In this case
he had removed some laminae, relieving the pressure, the
child making a good recovery. Some time after this, the
patient injured his back, and again became paraplegic. Some
bone was removed in the site of the old incision, which had
pressed on the cord. The patient's condition was somewhat
improved. He was still under observation.
Remarks were also made by the PRESIDENT, Mr. W. HALL,
and Dr. TREVELYAN.
TRAUIMATIC CYST OF THE PANCREAS.
Mr. W. H. BROWN read notes of this case. A lad, aged 17,
was struck violently in the abdomen by a buffer of an engine
on March 20th, 1893. He was removed to a hospital in North
Yorkshire. The abdonmen became swollen, and was tapped
on the left side; 70 ounces of blood-stained fluid removed.
Six weeks later 60 ounces were withdrawn. He was doing
well until January 27th,, when lhe fell from a horizontal bar,
immediately became velry ill, anid was admitted to the Leeds
Infirmary. On admission, he liad severe abdominal pain;
abdomen generally distended, tender, dull on percussion.
The symptoms becoming more marked, Mr. Brown made an
incision into thle abdomen, in the median line below the
umbilicus. About 3 pints of blood-stained fluid escaped; a
drainage tube inserted. None of the pancreatic ferments
could be found in this fluid. The patient improved for a few
days, but on July 4th a large swelling was noticed in the
'Ipper part of the abdomen: there was a good deal of pain
and some vomiting. The abdomen was now opened about
the umbilicus, the stoinach and omentum drawn up, and the
wall of the cyst exposed; this was punctured with a trocar, and
3 pints of dark-coloured, peculiar-smelling fluid withdrawin .
The opening in the cyst was enlarged, and the edges attached
to abdominal wall, and drainage tube inserted. The fluid
contained the pancreatic ferments. Seven weeks later the
boy was discharged, well. The author emphasised the advantage
of incision over tapping.
Mr. LITTLEWOOD referred to a case of traumatic cyst of the
pancreas he had read before the Clinical Society in 1892. He
found on introducing his finger into the cyst he could very
easily have opened it from behind on the left side, just below
the level of the twelfth rib, and urged that these cases should
be first explored in this region, and if fluid was found, to be
opened here, and so avoid a peritoneal operation. He remarked
that his case, and another he had seen, were certainly
effusions behind the ascending layer of the transverse mesocolon
in the neighbourhood of the pancreas, and not effusions
into the lesser peritoneal sac, for in both cases the layers of
the omentum did not form the cyst wall.
Dr. EDDISON thought some of these cases cleared up after
repeated tappings.
Mir. NORMAN PORRITT referred to a case under hiis care, in
which he had twice aspirated, the cyst again filling, so he
opened the cyst and stitched it to the abdominal wall; a
sinus still persisted.
RECURRENT APPENDICITIS.
Mr. MIAYO ROBSON related four cases of recurrent appendicitis,
in which he had successfully removed the appendix
in the quiescent period between the seizures.. Two of the
patients were women, aged 22 and 27 respectively, the other
two being men aged '23 and 31. In all the cases there had
been numerous seizures, and in some of them the symptoms
had been so severe as to threaten life. He also referred to a
number of other cases in which he had operated, and made
some remarks on the pathology of appendicitis, dwelling on
the anatomical structure of the appendix vermiformis as
being such as to predispose it to inflammation, there being
simply a layer of epithelial tissue protecting the underlying
adenoid tissue from infective organisms.
The paper was discussed by the PRIESIDENT, Mr. DRAPER,
Mr. W7. HALL, Dr. BRAITHWAITE, and Dr. EDDISON.
CASES AND SPECIMENS.
Mr. LITTLEWOOD showed a woman, aged 53, from whom he
had removed a AIalignant Mass from the Ascending Colon,
stitchling the divided ends of the colon by silk sutures after
Halstead's method. The patient made a good recovery.--
Dr. IRVING (Huddersfield) showed a successful case of Trephining
for Haemorrhage from the Middle Meningeal Artery.
-Mr. PICKLES showed a Fcetal Monstrosity.-Dr. E. SoLLY
(Harrogate) showed a specimen of Strongylus Gigas from the
Human Subject, passed per ?#rethram. - Dr. TREVELYAN:
Some microscopic and other specimens of Diseased Cerebral
Arteries.-Dr. WARPROP GRIFFITH: (1) Case of Congenital
Heart Disease. (2) Case of Unusual Cardiac Bruit.-
Mr. HARTLEY: Congenital Neevoid Lipoma in a Child, aged
4 years.
BIRMINGHAM AND MIDLAND COUNTIES
BRANCH OF THE BRITISH MEDICAL
ASSOCIATION.
PATHOLOGICAL AND CLINICAL SECTION.
BENfNETT MAY, MI.B., F.R.C.S., President, in the Chair.
Friday, October 27th, 1893.
CASES.
DR. E. N.\NASON showed a patient, aged 22, whom he had
trephined three years ago for Cerebral Abscess, which was
localised by focal symptoms to the centre of the left arm and
left side of face and tongue. An abscess was found in the
suspected area and drained, with the result of a complete recovery.
Some six or eight months later the patient had a
series of epileptiform seizures, in each case apparently determined
by a too free use of alcoholic stimulants. These
attacks were preceded by a sensory aura, consisting of apeculiar
taste sensation on the left side of the tongue. These
attacks had now ceased, and the young man seemed in perfect
health. I)r. Nason also showed apatient with symptoms

Nov. 18, 189S.] PLYMOUTH MEDICAL SOCIETY. TMii Biam 1107
Nov.18,1893.1 r..D.... OU..,L~~~~~~~~~~~~
of increased Intraorbital Pressure, probably due to a slowlygrowing
sarcoma of the orbit.-Mr. MORISON showed a boy,
aged 15, on whose right foot he had performed Tarsectomy.
The boy was born with a double congenital club foot. The
result of the operation was eminently successful. The contrast
between the two feet was very striking; and it was proposed
to deal with the left one similarly at an early date.
Mr. EALES showed a case of Hemianopsia in a woman, aged
33. Complete right homonymous hemianopia, with contraction
of remaining half fields. Central vision normal. Ophthalmoscopic
appearances normal. The contraction of remaining
half fields was probably functional, as it varied in
degree at different times of the day.-Dr. LESLIE PHILLIPS
presented a youth suffering from Lupus with Intercurrent
Syphilis.
SPECIMENS.
Dr. FOXWELL showed a Brain, with a glioma the size of a
hen's egg occupying the right motor area, but not involving
the basal ganglia. Its exact contour was impossible to determine,
but its centre occupied the ascending frontal convolution.
No abnormality was detected elsewhere within the
skull. The patient was a woman of 26, who, sixteen years
previously, had been knocked down by a hand cart, and received
a severe blow on the upper part of the left parietal
region. Three years ago she had a fit, beginning as a " cramp "
in the left leg. Similar attacks of Jacksonian epilepsy recurred
about once a month. When admitted to the Queen's
Hospital (in May, 1893) she was found to have double optic
neuritis, double ptosis, double facial paralysis, paresis of all
four limbs-much more marked on the left side-no sensory
change, ankle clonus on both sides, but patellar clonus on
the left side only. There did not appear to be sufficient
localisation to justify operation. Towards the end of September
she developed pneumonia, and died comatose.-Dr.
SIMON showed the Intestines from a case of Enteric Fever.-
Mr. MARSH showed: 1. An Adeno-sarcoma, the size of a
large walnut, removed from the left breast of a woman, aged
:32. Two months after the excision of the tumour she came
with a similar but smaller growth in the right breast, and
with distinctly enlarged glands in both axilla. There was no
recurrence in the left breast. 2. An Adeno-sarcoma, the size
of a Tangerine orange, removed from the left breast of a girl
aged 19. 3. A Proliferous Cystic Adeno-sarcoma, the size of
a large orange, removed with the breast of a woman, aged 51.
4. A Breast, with multiple cysts, removed from a woman,
aged 39, which, in some of its features, had clinically resembled
a scirrhous growth.
MANCHESTER MEDICAL SOCIETY.
C. E. GLASCOTT, M.D., President, in the Chair.
Wednesday, November lst, 1893.
ACROMEGALY.
DR. DRESCHFELD showed a patient, aged 30, who five years
ago began to present signs of acromegaly. The bones of the
skull and face were enlarged, especially the lower jaw; the
hands and feet showed the characteristic thickening and enlargement
which was manifest also to some extent in the
bones of the forearm and clavicles. There was atrophy of
both optic discs, with complete blindness of one eye and
diminished vision, but no hemianopsia of the other. The
thyroid could not be felt, but on each side was a well-defined
swelling dipping down into the thorax, and being apparently
connected with a mass there which gave rise to distinct dulness
on percussion over the upper part of the sternum. The
voice was hoarse, and the epiglottis was distinctly thickened,
but there was no paralysis of the vocal cords. The subjective
symptoms consisted in occasional pains in the head. There
was also marked sexual weakness. The patient sought admission
into hospital in consequence of excessive dyspncea,
which soon yielded to arsenic, with distinct diminution in
the size of the tumour masses in the neck. He was now
able to follow his work. Dr. Dreschfeld discussed the pathology
of the affection upon the evidence of the hitherto published
necropsies, Neither the persistence of the thymus nor
the enlargement of the pituitary body, which must be considered
as only one of the symptoms, could be looked upon as
the cause of the disease, which appeared to be more of a neurotrophic
nature.
HYDATIDS OF OMENTUM.
Mr. E. STAN MORE BISHOP mentioned a case of onental
hydatids, and showed the patient, together with microscopic
preparations of acephalocysts, scolices, and hooklets from the
tumour. Special attention was drawn to the fact of the extraordinary
mobility of the tumour under chloroform, as a
point of diagnostic importance between hepatic and omnental
forms.
RUPTURE OF URINARY BLADDER.
Mr. THOMAS JONES mentioned a case of intraperitoneal
rupture of the bladder, caused by falling against a wringing
machine while the bladder was full. Laparotomy was performed
forty hours afterwards, and the edges of the rent
brought together with twenty-one interrupted silk sutures.
Death occurred six days later, apparently from exlhaustion,
consequent on persistent diarrhcea. Post-mortemn examination
showed the rupture to be securely and perfectly watertight.
There was no peritonitis of post-operative origin.
SELF-RETAINING LARYNGOSCOPE.
l)r. MOIRITZ demonstrated a self-retaining laryngoscope.
NOTTINGHAM3 MEDICO-CHIRURGICAL SOCIETY.
WALTER HUNTE:R, M.B., President, in the Chlair.
Wednesday, November 1st, 1893.
PRESIDENTIAL ADDRESS.
THE PRESIDENT delivered an address on " The Comfort of the
Patient: Practical Hints Thereon.' He took as a text:
" What shall a man eat, what shall he drink, and wherewithal
shall he be clothed? " All indigestible food the sick
man should avoid, or whatever his idiosyncrasy dictated to
him as difficult of digestion. Alcohol had its proper place
among the drugs, but it was not a food. In drunken persons
and in delirium tremens he advocated kola wine. He laid
stress on the value of wool clotlhing next the skin, explaining
how cotton, becoming saturated with sweat, clings to the
skin, while the perspiration passes through wool, which not
only was non-coinductor of heat, but from its elasticity did
not cling to the skin; wool was, moreover, Nature's covering.
In all febrile conditions he advocated the use of woollen
night dresses and the patient to be in blankets with no
sheets. He expressed an abhorrence for feather beds. As
regards the relief of pain he dealt chiefly with facial neuralgia.
aud gastralgia; for the former lie advocated quinine, phosphorus,
or gelseminum; and he said that the latter could b6o
distinguished from dyspepsia by the presence.of actual pain,
whereas in dyspepsia there was swelling and discomfort but
no pain; gastralgia often existed with anaemia in young
women, and was best treated by quinine, and when anamnia
existed also by treating this. For eczema he recommen6de
an ointment composed of liq. carbonis detergens, vaseline,
and hydrarg. am., or Unna's zinc paste applied as a dressing
with several layers of butter cloth.
VOTE OF THANKS.
A vote of thanks to the President for his address was
proposed by Dr. BIRNIE. seconded by Dr. POWELL, ancl carried
by acclamation.
PLYMOUTH MEDICAL SOCIETY.
MARCuS BULTEEL, L.R.C.P., M.R.C.S., in the Chair.:
Wednesday, November Sth, 1893.
CASES.
MR. Lucy showed a patient, aged 52, in whom the head of thie
left Humerus was Excised three months ago for the relief of
pain, fixity, and paralysis of themusculo-spiral nerve following
a dislocation, which had remained unreduced three montlhs.
The wound was now healed, and movement good. MIr. Luicy
also exhibited a man, aged 21, in whom the Flexor Profunidus
Tendon going to the left mniddle finger was successfully
United with two chromic gut sutures. There was noW comnplete
power of flexion.-Mr. C. E. RUSSEL RENDLE denmonstrated
the result of a Mules's operation, performed sixteen
days previously, for Destructive Syphilitic Kerato-iritis of th-e
Right Eye. A silver-gilt globe was inserted and movements
of the stump were now excellent. Mr. Rendle also showed
a clay labourer, aged 35, with Myopia and Nyctalopia.
With antisyphilic treatment and suitable concave glasses

1108 Taw BLmJl ] REVIEWS. [Nov. 18, 1893.
NtsLICAL JOURNA^L]
some improvement was gained.--Mr. Licy showed a boy,
aged 18, invalided out of the navy nearly two years ago for
D)ouble Empyema following Influenza. The right side was
incised, and healed in three months. Resection of the ribs
w1s found necessary on the left side. There was good expansion
of the side, and the patient had gained flesh. Mr.
L ley exhibited a Slide of Fluid removed from an Encysted
Hydrocele of the Left Epididymis of a man, aged 53.
DIAGNOSIS OF SCARLET FEVER AND INFLUENZA.
Mr. HARLEY COUGH raised the question of diagnosis between
scarlet fever and influenza, more especially as regarded
desquanlation after each.
REVIEWS.
AN ELEFMET`.NTAiRY TEXTBOOK OF BIOLOGY, COMPRISING AVEGE-
TABIAE ANI) ANIMAL MORPHOLOGY AND PHYSIOLOGY. By J.
R. AINSWOwRTH DAVIS, B.A., Trinity. College, Cambridge,
Professor of B3iology and Geology in the University College
of WVales, Aberystwyth. London: Clhas. Griffin and Co.,
Limited. 1893. Second editionl, revised and enlarged.
(Vol. I, crown Svo, pp. 300. 8s. 6d. Vol. II, crown 8vo, pp.
416. lOs. 6d.).
IN this, the second, edition of Mr. DAVIS'S textbook there has
been imluclh addition of material and considerable alteration
in the text, so much so that the work is now divided into two
volumnes, the first dealing with vegetable, and the second
with animal morphology and physiology. The scope of the
work is much greater than that usually found in biological
textbooks, and in the second volume the author tells us he
lhas attempted to bridge over the gap between the courses of
z-)ology and humani anatomy as successively taken in a
medical curriculum.
A good feature of the work is that it justifies to a great
extent the appellation of a textbook of biology. Not only is
the structure of the types considered adequately given, but
muclh trouble lhas been devoted to the far more important
subjects of comparative morphology and physiology. No
attempt has been made to render the work a practical or
laboratory book; in this we think the author has acted wisely,
there being already an ample supply of excellent works in
this direction. Taking the two volumes together, they contain
an imnmiense amount of information in a very concise
forni; and although the amount of detailed description is
large, it is so correlated and woven into an organic whole by
means of repeated comparison, that the reader is ever reminded
that it is a co-ordinated science he is reading, and
not a mere collection of separate anatomies-an impression too
often carried away by a biological student after completing
the usual preliminary course in that subject.
In the first volume, the excellence of the illustrations,
many of which are drawn from the classical work
of Sachs, will be appreciated. The diagrams of lifehistories
are also noticeable, but their clearness would be
greatly increased by the freer use of various types, and a
more marked indication of the dominant phase in each. In
the secondl volume, although the description of the types is
correlated in many respects by the addition of the elements
of tlleir embryology, yet this characteristic, wlhich is so
marked in the first volume, is here not quite so well carried
out. That there are greater difficulties in this portion of the
orgaiiic kingdom we are well aware, and the autlhor is necessarily
somewhat cramped in his treatment by the requirements
of examining bodies.
In a book of this kind, which is a biological textbook and
not, as we have already said, a practical book, we could have
wishied for a little less detail and more generalisation. Still,
on the wlhole, it is certainly the best " biology " with which
we are acquainted, and it owes its pre-eminence to the fact
above stated, that it is an excellent attempt to present biology
to the studentas a correlatedand completescience. Iheiglossarial
index is a miost useful addition.
AN EXA-MINATION OF WNEISMANNISM[. By GEORGE JOHN
ROMANES, M.A., LL.D., F.R.S., Honoraly Fellow of Gonville
and Caius College, Cambridge. London: Longmans,
Green, and Co. 1893. (Cr. 8vo, pp. 934. 6s.)
TIHE facts of heredity and the doctrine of evolution have
bearings so important on medicine and pathology that any
biologist who pretends to deal with them on broad grounds is
sure of an attentive audience among members of the medical
profession. Professor Weismann's theories have been very
widely entertained in this country, and the interest which
his writings have excited has done much to increase the
amount of attention given to the fundamental questions of
heredity. His theories have been noticed from time to
time in these pages, and the changes which they have undergone
have been briefly indicated. In the volume before us
Mlr. ROMANES enters upon an elaborate criticism of the
scheme elaborated by Weismann both in its penultimate and
in its ultimate form.
Mr. Romanes compares and contrasts Weismann's theory of
heredity, and the extension of that theory to evolution, with
the tlheories as to heredity propounded by Darwin and by Mr.
Francis Galton. It may be convenient to reproduce here the
brief sunmmaries of the three theories which Mr. Romanes
gives. All three assume the existence of particulate elements
of heredity. Darwin held that these particulate elements " all
proceed centripetally from somatic cells to germ cells (gemmules);
the inheritance of acquired clharacters is, therefore,
habitual." Galton assumed that " these particulate elements
proceed, for the most part, though not exclusively, from
germ cells to somatic cells (stirp); the inheritance of acquired
characters is therefore but occasional." Weismann's theory
before its most recent modification was that " the elements
in question proceed exclusively in the centrifugal direction
last mentioned (germ plasm); the inheritance of acquired
characters is therefore impossible."
The first part of Mr. Romanes's book is directed to a criticism
of the proposition that the movement of the particulate elements
of heredity is exclusively in the centrifugal direction.
He argues that facts do not warrant the assertion that germ
plasm has shown an " absolute stability " since the first origin
of sexual propagation, but only a very high degree of stability,
as assumed by Galton.
In the concluding chapter in the book, Mr. Romanes examines
Weismann's latest work on The Germ, l'lasm, and
shows that in it the theory of the absolute stability is given
up, and the door is thus left open for the operation of
Lamarckian factors. The question, therefore, as to the possible
hereditary transmission of acquired characters remains
open.
The subjects discussed by Mr. Romanes are complex, and
involve the use of a terminology which is not familiar; moreover,
his style does not always contribute to the lucidity of
his arguments. But the work is well worth reading, and we
would recommend it to everyone who takes an interest in a
question of fundamental importance to all branches of
biology.
VENTILATION AND HEAT. By JOHN S. BILLINGS, M.D.,
D.C.L. New York: Tile EnDineering Record. 1893. (Demy
8vo, pp. 500, fig. 210.)
IN this volume Dr. BILLINGs treats all the imliportant matters
connected with ventilation and hleating in a masterly way;
his book will rank among the standard works on the subject.
An interesting account of the history of ventilation is given
at the commencement, and an extensive list of the general
literature. Dr. Billings tells us that the history of ventilation
began witlh tlle attempts to ventilate the Houses of Parliament
in 1660 by Wren, and adds: " The history of these
attempts would be almost equivalent to a hiistory of thle art
of ventilation in its entirety."
Several chapters are devoted to the chlemical and plhysical
properties of the atmosplhere, anid very completely are the
results of investigators collected and tabulated. This is
markedly the case in the chapter on carbonic acid in the air,
for no fewer than twenty-one tables are given, classifying the
results of publislhed researches into the amount of the gas
present under every variety of condition of the atmosphere.