303

Mr. OPENSHAW also exhibited a child, aged six months, n

presenting congenital absence of the lower two-thirds of the n

tibia, evidently due to an intra-uterine fracture, the mother f;

having fallen over the back of a chair during pregnancy.- bThe relative advantages of the manipulative and the p’’open" methods of operating on cases of congenital dis- o

location of the hip-joint were discussed by Mr. KEETLEY f4and Mr. BALLANCE, both of whom expressed a general ppreference for the latter.-Mr. OPENSHAW replied, o

,4 Mr. JAMES SHERREN exhibited a case of Ankylosis of the s

Hip following Gonorrhoeal Arthritis occurring in a man, aged t

20 years. 14 days before the onset of the pain in the joint he phad had an attack of urethritis. The right hip was fixed in t

extension and there were marked wasting of the thigh and 1=slight wasting of the muscles of the calf. c

Mr. SHERREN also exhibited a case of Secondary f

Syphilitic Synovitis of the Elbows. The patient, a man, c

aged 24 years, had contracted a venereal sore six months i

previously and about a month previously he noticed that his (left elbow had become swollen and painful and a week later .Jthe right became similarly affected. Both elbow-joints were anow held in a flexed position, all movements being resisted Jand painful, and there was a considerable amount of effusion t

into both joint cavities. t

Dr. F. J. POYNTON exhibited a case of Atavism occurring 4

in a child, aged three years, who had been admitted to the IHospital for Sick Children, Great Ormond-street, under thecare of Dr. F. G. Penrose for inability to walk properly. Whenfirst set down on his feet he stood erect, but when he com-menced to walk he crouched and assumed a posture likethat of a chimpanzee. The whole body was bent forwardand the head was bent, the chin pointing to the right. Thehands were held in front and the upper extremities were bentat the wrists and elbow. The hips and knees were flexedand the feet were turned in, the pressure coming upon theirouter borders. The crouching attitude became more markedas the child became tired.-The case was discussed by Mr.E. MUIRHEAD LITTLE, Dr. EDMUND CAUTLEY, and Dr.A. F. VOELCKER.

Mr. HUTCHINSON, jun., exhibited a case of Macro-

dactylism in a man, aged 54 years. The digits involvedwere the right thumb and index finger, the latter being thelarger. All the bones of the right index finger were the siteof rounded knobs and a skiagram showed that the jointswere almost completely ankylosed. The soft tissues werealso hypertrophied. The hand, in spite of its ungainlydigits, was useful and the patient had worked hard as acooper. The other hand and both feet were of normal size.The condition had existed since birth. The patient had comeunder care for an oesophageal stricture.

Dr. H. D. ROLLESTON showed a man, aged 44 years,paffering from Aortic Disease and presenting a musicaldiastolic aortic murmur resembling that heard in cases of

ruptured valve. There was, however, no other reason to sus-pect rupture of a valve in this case and Dr. Rolleston did notregard it as an instance of that lesion. The patient had nothad 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 theFingers of doubtful origin.

CLINICAL SOCIETY OF LONDON.

Bx7tibitio,n øl C/fl,S88.A MEETING of this society was held on Jan. 23rd, Mr.

HOWARD MARSH, the President, being in the chair.Dr. T. D. SAVILL exhibited a case of Facial Hemiatrophy

(Morphcea or Localised Scleroderma of the Face). Thepatient was a man, aged 50 years. In 1880 he had a severeblow on the top of the head and thereafter suffered fromneuralgic pains in the vertex and face, sometimes of greatseverity, until 1895, when they subsided under treatment.In 1885 or 1886 he first noticed that the hair of theleft side of the scalp and left eyebrow was coming offand that the face on the left side was becoming wasted.The wasting of the face at first gradually increased, butit had remained stationary for some years. On the leftside of the face the whole of the skin was thin, shiny,and smooth, and the subcutaneous tissue was considerablyatrophied. The hair was almost absent from the left.anterior quarter of the scalp and was also wanting in theinner half of the left eyebrow. The temporal and masseter

muscles were apparently atrophied but the other facialmuscles did not seem to be wasted. The distribution of thefacial atrophy corresponded roughly to the cutaneous distri-bution of the left fifth cranial nerve. There were three otherpatches of atrophied skin upon the body, one upon the middleof the back of about the size of the hand which presented afew dilated venulfs characteristic of morphoea, and in thisposition there appeared to be a slight tendency to excessof pigment. Another patch of atrophied skin might beseen behind the right ear and a third over the outer side ofthe left knee. These, like the facial atrophy, caused thepatient no unpleasant sensations. Microscopic sections ofthe skin of the atrophied side of the face and of the

patch on the back were shown ; also sections from anothercase of morphosa and of healthy skin for comparison.-Sir DYCE DUCKWORTH agreed with Dr. Savill in regardingcases such as the one before the society as identical withmorpboea and referred to a paper on the subject which he(Sir Dyce Duckworth) had communicated to the L1’cinburghMedical Journal in 1883,1 dealing with different forms ofatrophy. Facial hemiatropby represented the most extremeform of atrophy, not only the skin but the muscles and eventhe bones being sometimes involved. No one could doubtthat these lesions were of nerve origin, and in Dr. Savill’scase the fifth nerve and the Gasserian ganglion had probablybeen damaged by the accident. All of these atrophic skinlesions were, in his view, of neuro-trophic origin, and hereferred to cases in which a fall upon the head had beenfollowed by rapid and total loss of hair from all parts ofthe body.

Dr. SEYMOUR TAYLOR exhibited a case of Ruptured AorticValve. The patient, a "hammerman" by occupation, aged50 years, was admitted to the West London Hospital onOct. 16th, 1902, complaining of giddiness, prascordial pain,and dyspnoea which had come on somewhat suddenly in July,1902, after a long da,y’s heavy work. On admission he wasfound to have a loud aortic obstructive murmur and a louderdiastolic murmur. The latter was musical and was so loudthat it could be distinctly heard at a distance of two inchesfrom the chest, and with the aid of the stethoscope it couldbe heard all over the thorax, in the abdomen as low as the ’

umbilicus, and down the arm. The left ventricle was hyper-trophied and probably dilated. The diagnosis of rupturedvalve was made on the following grounds-viz.: (1) A historyof syphilis ; (2) the sudden oncoming of urgent symptoms ;(3) the patient’s occupation ; (4) the musical diastolicmurmur ; (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 caseas one of aortic regurgitation in which loss of compensationhad occurred rather than as a case of ruptured aortic valve.The latter was a very rare condition in which the symptomssupervened very suddenly and were continuous and cumula-tive. He referred to a case which he had observed in whichthe patient after sudden and violent exertion took to bed and

, died six or eight months later, ruptured aortic valve beingverified 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 com-

pensation. A musical murmur and a marked diastolic thrillwere not, he thought, altogether trustworthy as a means ofdiagnosing ruptured aortic valve.-Dr. S. VERE PEARSONreferred to a case which he had observed at St. George’sHospital resembling Dr. Taylor’s case which proved at thepost-mortem examination to be one of dilated aortic orificewith failure of compensation.-Dr. A. E. GARROD discussed

.

the significance of the systolic murmur in the case.-Dr.TAYLOR, in replying, admitted that the diagnosis was open

yto doubt, but emphasised the history of syphilis, the occupa-tion of the patient, and the loudness of the musical murmurein support of his view.

Mr. STEPHEN PAGET exhibited a case of Removal of the

t Scapula of a boy, aged nine years. The patient was a thin,

and delicate-looking but healthy boy. Swelling of the bone.e was first noticed one month before ; there was no pain or

history of injury. A hard nodular rounded mass with a broadbase sprang from the rght supraspinous fossa and passed

t forwards beneath the clavicle. No signs of pressure on thet vessels and nerves of the arm and no enlarged glands were

present. On April 30th, 1902, the scapula was excised andthe growth found to be cartilaginous. The patient made aft good recovery and the movements of the arm were good.

1 Edinburgh Medical Journal, January, 1883, p. 616.

304

The sutures were removed on May 12th and the patient wasdischarged from hospital on the 21st, wearing a support toprevent the arm from dropping.-The PRESIDENT regardedthe case as an exhibition of the wonderful compensatorypowers of the human body and as a lesson in conservativesurgery.-Mr. PAGET, in replying, explained why he hadremoved the whole instead of only a part of the scapula.

Dr. H. D. B.OLLESTON exhibited a case of Charcot’s Diseaseof the Knee-joint and Spontaneous Fracture of the Tibia inthe same limb. The patient was a widow, 46 years of age,who had had seven miscarriages. She had suffered from" lightning pains " eight years, and visceral crises six years,previously. There had been a sudden onset of painlessswelling of the left knee after a long walk five years before,and three years before, while going upstairs, the left tibiahad fractured painlessly. The menopause came on a yearpreviously and was accompanied by incontinence of urine.Altered character of voice was noticed 11 months previously.On Dec. 3rd, 1902, after an attack of diarrhoea lasting forthree days, she lot power in the right leg. In addition to

arthropathy of the left knee the left tibia, about the middle,showed a projection the result of the old fracture. Therewere also paresis of the right lower extremity, complete para-lysis of the left third nerve, and altered speech. She had hadoccasional choking fits and was subject to attacks duringwhich she felt faint. The optic discs were pale and the pupilswere contracted and did not react to light or accommodation.- Mr. A. A. BOWLBY remarked on the spontaneous fracture ofthe tibia and referred to two cases of tabes dorsalis in whichsimilar fractures had occurred. One was that of a manwhose leading symptom was incontinence of urine andanother was that of a woman who successively fractured oneof the bones in all four of her extremities. In Mr. Bowlby’sexperience these fractures united very well, though this did notcorrespond with the opinion generally held.-Mr. J. R. LUNNconcurred in the view that tabetic fractures readily unitedand emphasised the point that the patients suffered little orno pain at the time of the fracture.-Dr. ROLLESTON, in

replying, remarked that the paralysis of the right leg, whichwas evidently an upper-neuron paralysis, was possibly ofsyphilitic origin.Mr. J. R. LUNN exhibited a case of Traumatic Stricture of

the Œsophagus treated by Gastrostomy. The patient, a sea-man, aged 63 years, had always enjoyed good health until1898, when he met with an accident whilst at cea. Two

years afterwards (in 1900) he began to lose weight andexperienced some difficulty in swallowing and was able totake liquid food only. He went to the London Hospital andMr. C. W. Mansell Moullin performed gastrostomy. He wasdischarged four weeks afterwards, when he returned to sea,feeding himself by the abdominal opening into the stomach.About 15 months after the operation the wound healed. The

patient went into hospital in Boston, U.S.A., and had it

reopened. In 1902 the wound began to heal again and ashe could not pass the tube he tried to dilate the orifice witha piece of wood, which caused pain and bleeding. At Havre,in September, 1902, a surgeon trimmed the edges of thewound in the abdomen and stitched them together. Whenhe arrived at the St. Marylebone Infirmary in October, 1902,the stitches were removed and the wound was healed. Sincehis admission he had gained in weight and had been able totake solid food, though he had occasionally had some

dysphagia and he still had some obstruction (spasmodic) ofthe oesophagus. About seven inches from the teeth therewas some doubtful thickening around the larynx. The patientseemed very well in health with the exception of a ventralhernia which occasionally caused him some pain and for whichhe wore an abdominal support.-Mr. BOWLBY commentedon the length of time-two years-during which the patienthad lived since the operation.-The PRESIDENT thought thatstricture of the gullet might quite possibly be due to theinjury, and he referred to a case in which the left lung hadbeen wrenched off from its root during an accident.

Dr. F. PARKES ’VEBER exhibited a case of Persistent

Slight Jaundice of four years’ duration in a girl, aged 182years, without obvious alteration in size of the liver or spleenand without marked impairment of the general health. The

patient was the youngest child of Polish Jewish parents.The patient’s mother, who was living and healthy,had had 13 children altogether (of whom eight diedearly) and two miscarriages. The patient had beenunder observation since the beginning of November,1902, and about that time there was slight irregular fever, which passed off in little more than a week. (

The fseces had generally been well coloured, though some-times pale. The urine, which was free from albumin andsugar, had varied in colour but was generally not very dark;sometimes a slight Gmelin’s reaction had been obtained.The serum obtained from a blister gave a Gmelin’s reaction.Iodide of potassium in five-grain doses three times daily wasgiven during nine days but was discontinued owing to a

pustular eruption. Occlusion of one or more of the smallerhepatic ducts by a process of obliterative cholangitis wassuggested by Dr. Weber as a possible explanation of theclinical features of the case.-Sir DYCE DUCKWORTH

suggested that the jaundice might be of syphilitic origin.-Dr. ROLLESTON agreed with Dr. Weber that a condition ofchronic cholangitis might exist in this case akin to chronicbronchitis.-Dr. WEBER, in reply, stated that urobilin hadnot been detected by the spectroscopic examination of theurine.

Mr. LEONARD S. DUDGEON exhibited a case of TabesDorsalis in which the chief points of interest were-(1) atabetic arthritis affecting the astragalo-scaphoid joint; (2)atrophy of the small muscles of the right hand ; and (3)paralysis of the first nerve.

Dr. PERCY KIDD exhibited a case of Pneumothorax in achild, aged 23 months, resulting in recovery. The child wasadmitted into the London Hospital on Sept. 22nd, 1902, witha history of cough and wasting and with all the signs ofpneumothorax on the right side. No tubercle bacilli werefound. The signs of pneumothorax gradually disappeared,but in November a localised empyema was operated on. The

patient made a good recovery and was now steadily gainingin weight.

MEDICO-CHIRURGICAL SOCIETY OFEDINBURGH.

Exhibition of Cases. - 4 rrhinal. --Rectal Growths.-Retinal Hæmorrhages.

THE fifth ordinary meeting of this society was held onJan. 21st, Sir THOMAS R. FRASER, F.R.S., the President,being in the chair.

Before commencing the business of the evening, thePRESIDENT asked the members to agree in offering the heartycongratulations of the society to Sir William Turner onaccount of the high and unprecedented honour which hadbeen conferred upon him in his election to the principal-ship of the University of Edinburgh. This was unanimouslyagreed to.

Mr. H A. THOMSON showed a case of Successful Treat-ment of an Ununited Fracture of the Tibia and Fibula inwhich the fracture had been induced to unite by means of arigid metal plate and screws which were imbedded in thetissues for eight months.

Mr. THOMSON also showed (for Dr. NORMAN WALKER) acase of a large Ulcerating Surface over the Site of the LeftBreast in a woman, aged 45 years, which had been treatedby x rays during a period of 75 minutes by successive sittingsof five minutes each. Marked improvement ensued.

Mr. H. J. STILES showed a boy in whom he had success-fully Transplanted the Ureters into the Rectum for Extro-version of the Bladder. The boy was comfortable and couldhold his urine for three hours.

Mr. C. W. CATHCART showed a patient after operation forSuppuration in the Frontal Sinuses.The PRESIDENT read a paper entitled ’ The Inefficiency

of the Di-sodic-methyl-arsenate (Arrhenal) as a Thera-

peutic Agent." He said that in a former paper dealingwith the recently introduced and much lauded cacody-lates he had stated the proposition that the thera-peutic effects of arsenic were caused by its pharmaco-logical action and that if arsenic were so united with otherbodies as to be incapable of producing any pharmaco-logical action or of inducing in excessive quantities the toxiceffects that represented an extreme degree of pharmaco-logical action, it could no longer be capable of producing thetherapeutic effects in disease which were the recognisedeffects of arsenic. If, therefore, any compound of arsenicsuch as the methyl-arsenates or cacodylates were found tobe so inert that they might be given without produc-ing, in doses considerably above the minimum-lethal ofthe ordinary active compounds of arsenic, any symptomsof the action of arsenic, it must be because the arsenichad become emasculated and inert and probably because