231

The case was of interest on account of the unusual physicalsigns presented. The patient was 51 years cf age, and hadsuffered from caries of the spine when he was 32 years old.Twelve weeks before he was admitted into the London Hos-

pital (under the care of Mr. F. S. Eve) the left testis hadbecome swollen and painful. Nine weeks after the swellingfirst appeared a soft red spot was discovered in the front ofthe scrotum which enlarged and eventually burst, dischargingpus. On examination in hospital there was an abscess witha sinus in the anterior wall of the scrotum. Behind theabscess a hard nodular mass was felt which later was foundto be the tuberculous epididymis and behind that a soft

globular structure which was the body of the testis. The !,vas could be felt in the spermatic cord ; it was not beaded. ’,On examination by the rectum the left vesicula was found to

’’

be swollen and hard.Orchidectomy was performed 12 weeks after the first

symptoms and as much of the vas as possible was removed.The epididymis was quite destroyed by tuberculous depositsand many nodules of tubercle were scattered through thebody of the testis. The abscess cavity opened into theglobus major of the epididymis. The wound healed by thefirst intention.

I am indebted to Mr. Eve for kindly allowing me to

publish the case.Weymouth-street, W.

Medical Societies.ROYAL SOCIETY OF MEDICINE.

OBSTETRICAL AND GYNÆCOLOGICAL SECTION.

Enucleation of a Uterine Fibro-myoma during the SeventhMonth of Pregnancy.-Hæmorrhage into the Pons Varoliias the Immediate Cause of Death in the .Eclampsia ofPregnancy.-Exhibition of Specimens.A MEETING of this section was held on Jan. 9th, Dr.

HERBERT R. SPENCER, the President, being in the chair.Dr. HERBERT NVILLIAMSON read a short communication on

a case of Enucleation, during the seventh month of pregnancy,of a Uterine Fibro-myoma weighing 172 pounds, which was fol-lowed by premature labour two days later. The patient wasa primigravida, aged 32 years. When four months pregnantshe suffered from repeated attacks of acute abdominal painand became emaciated with some fever, and the distension ofthe abdomen was so great that she was unable to lie down inbed. At the time of the operation the tumour, which couldbe felt distinct from the gravid uterus, was thought to bea malignant growth of the ovary, but it was found to be a iuterine fibro-myoma undergoing necrotic degeneration. The area of attachment of the tumour to the uterus was rather narrow but required enucleation. A premature child wasexpelled three days later but the patient made an uninter-rupted recovery.

Dr. NORMAN C. CARVER and Dr. JOHN S. FAIRBAIRNcommunicated a case of Heamorrhage into the Pons Varoliias the Immediate Cause of Death in the Eclampsia ofPregnancy, with illustrative cases. The patient was a

primigravida, aged 24 years, who, after exhibiting signs ofimpending eclampsia, was found unconscious and straight-way admitted to hospital. In view of the history of theillness and the presence of cedema and a high degree ofalbuminuria the case was thought to be one of eclampsia,and as the patient was in a state of deep coma, withCheyne-Stokes respiration, rapid dilatation of the cervixwas done, followed by the extraction of a fcetus ofbetween five and six months’ development. The patientdied a few hours later and at the necropsy death wasfound to be due to an extensive haemorrhage into the

pons Varolii. Dr. Carver and Dr. Fairbairn argued that

although the immediate cause of death was a pontinehaemorrhage the case was primarily one of eclampsia,and in support of this quoted four recorded cases

of a similar nature, in which an unsuspected cerebralhaemorrhage was found post mortem. Details of thesecases were given and, from an analysis of the symptomspresented by them and the above case, attention was

drawn to such features in them as might serve to arouse asuspicion of the occurrence of apoplexy in the course of an eclamptic attack. These were, briefly, deep coma andcyanosis, with marked respiratory disturbance, occurring in

a young patient presenting the urinary and other signs ofeclampsia, and they were especially suggestive when theattack was unaccompanied by the usual eclamptic con-vulsions.-The PRESIDENT thanked Dr. Carver and Dr.Fairbairn for the interesting paper. He had not metwith a case of hæmorrhage into the pons Varolii in

eclampsia but he could recall two cases of haemorrhageinto the substance of the brain, one observed at a post-mortem examination and the other in which hemiplegiaoccurred, from which the patient slowly recovered. He thoughtthat apoplexy was a well-known cause of death in eclampsia,and was surprised that Dr. Carver and Dr. Fairbairn had notfound more cases recorded, although they did not claim thattheir paper was exhaustive. In view of the possibility of theoccurrence of cerebral hsemorrhage in eclampsia, the intra-venous injection of a large quantity of saline fluidwould appear to be not unattended with risk.-Dr.MACNAUGHTON-JONES recalled the fact that the " apo-plectiform " was one of the old writers’ divisions ofeclampsia in which sanguineous and serous effusionoccurred into the ventricles. The symptoms were such asdescribed in this case. He dwelt on the importance of earlyanticipation of the eclampsia, especially through the ocularsymptoms and signs which were often present, and in whichan ophthalmoscopic examination afforded most valuableevidence of the approaching danger. One of the mostvaluable therapeutical means they possessed to control theincreased blood pressure in these cases of threateningcerebral haemorrhage he believed to be the employment ofweak doses of pilocarpine which was also useful in checkingthe convulsions. If necessary, its full physiological actionmight be neutralised by Thth of a grain of atropine. He hadknown eclampsia ending fatally to occur as early as the fourthmonth of pregnancy.-Mr. A. LIONEL HALL SMITH said hehad seen three cases of cerebral hmmorrhage complicatingeclampsia or toxaemia of pregnancy, in all of which thediagnosis was confirmed at the necropsy. In one of themthe hæmorrhage occurred in association with eclamptic con-vulsions after delivery, but in the other two the patientswere not in labour and had only reached about the thirtiethweek of pregnancy.-Dr. AMAND J. M. RouTH had nothad an opportunity of seeing a post-mortem examina-tion of any case dying from puerperal eclampsia wherecerebral haemorrhage had been found, but thought thatDr. Carver and Dr. Fairbairn had shown how oftensuch hsemorrhage might supervene and be the immediatecause of death. He thought it unwise to increase arterialtension, as must have been done in the first case reported,when 10 ounces of blood were removed and 40 ounces ofsaline infusion injected. This may well have increased thetendency to hæmorrhage. He presumed that saline infusionin these cases was given to dilute the toxins at each givenpoint and to increase the leucocytosis to combat the toxins ;but it was doubtful if it should be given when it increasedarterial pressure. He considered that the suggestion to givepilocarpine (at all events in the doses usually prescribed-viz., sth grain) was fraught with grave danger. He con-.ideredthat it should never be given in cases where apoplectic sym-ptoms were present or where there was coma, for he hadseen patients under its influence suffocated by the enormousquantity of ropy mucus secreted by their salivary andbroncho-pharyngeal glands. He was interested in the factthat epigastric pain had been mentioned as a precursor ofeclampsia in some of these cases of albuminuria ofpregnancy. He considered this sign, following ocularevidences of high arterial tension, increasing albuminuria,and diminishing excretion of urea, a valuable indicationthat eclampsia was impending and that steps should betaken to induce labour without needless delay.-Mr.D. C. RAYNER referred to a case of eclampsia underhis care in which a fatal termination was due tocerebral haemorrhage. The patient was in the eighth monthof her third pregnancy when convulsions set in. They werefrequent and seemed more marked on the right sir;e. The

pupils were also noticed to be unequal. The urine containedalbumin and the patient was not in labour. Coma deepenedand the patient died in a few hours. There was extensive

hæmorrbage into the right corpus striatum anti opticthalamus.-Dr. R. H. HoDGSON said that he thought thelesson to be learnt from this instructive paper wa, in alcases of eclampsia in pregnant women empty the uterusHe had done so in six cases and in all the women

recovered, five very rapidly, and one in whom some slighconvulsions continued for five days was quite well arter one

232

injection of pilocarpine. Emptying the uterus caused theblood to flow to the portal system and thus lessenedthe danger of cerebral haemorrhage. He did not under-stand the object of the saline injection.-Dr. FAm-BAIRN, in reply, said no attempt had been made tomake an exhaustive collection of cases of apoplexy as thecause of death in eclampsia, and the cases collectedwere those of haemorrhage into the pons or base of the brainwithout unilateral symptoms to suggest apoplexy. Largecerebral haemorrhages were not frequent in eclampsia, as wasshown by the statistics quoted in the paper. The cases re-corded were undoubtedly rare but the possibility of a deeplycomatose and cyanosed eclamptic patient having also acerebral hasmorrhage ought not to be lost sight of, especiallyin giving a prognosis.The following specimens were shown :-Dr. J. P. HEDLEY : (1) Hydrosalpinx with Torsion of the

Pedicle ; and (2) Double Hæmorrhagic Cysts of the Ovaries. IMr. HAROLD S. SINGTON: Tumour of the Fcetal Head.Dr. A. H. N. LBWERS : Cancer of the Cervix (advanced) ;

hysterectomy by Wertheim’s method.

MEDICAL SOCIETY OF LONDON.

Graduated Labour in Pulmonary Tuberculosis.-The OpsonicIndex in Tuberoulous Patients engaged in PhysicalExcerise. A MEETING of this society was held on Jan. 13th, Dr.

J. KINGSTON FOWLER, the President, being in the chair.Dr. M. S. PATERSON read a paper on Graduated Labour in

Pulmonary Tuberculosis, which is printed at p. 216 of thisissue of THE LANCET.

Dr. A. C. INMAN read a paper on the Effect of Exerciseon the Opsonic Index of Patients suffering from PulmonaryTuberculosis ; this also is printed in this issue of THE LANCET(p. 220).The PRESIDENT said that the two papers which they had

just heard marked an epoch in the treatment of pulmonarytuberculosis. He contrasted the work done at the Hospital forConsumption and Diseases of the Chest at Brompton 15 to20 years ago with the work demonstrated by the two papersread that evening, and pointed out the difference between thegroping in the dark then and the light which was now shedon pulmonary tuberculosis.

Sir A. E. WRIGHT, whilst admitting the possibility of theauto-inoculation method being useful, observed that byemploying tuberculin they could begin with minimum dosesand increase the amount as required, thus insuring morecontrol than in auto-inoculation.

Dr. C. THEODORE WILLIAMS mentioned that when FrimleySanatorium was opened there was no idea of startinggraduated exercises which were begun by Dr. Paterson.

Dr. R. MAGUIRE said that the auto-inoculation treatmentmust not be applied to every case of pulmonary tuberculosis.,Success depended on the careful selection of fit cases forthat treatment at the sanatorium ; if the method were to becarried out indiscriminately it would soon be found to failwhen comoared with artificial inoculation.

Dr. F. J. POYNTON emphasised the importance of recog-nising that there was more in the sanatorium treatment atFrimley than mere auto inoculation. He did not think thatthe patients whom they had heard about that evening wouldhave done so well as they did on the tuberculin treatment.

Dr. PATERSON, in reply, dwelt on the necessity of dis-charging patients from the sanatorium ready to return totheir usual work without fear of relapse.

Dr. INMAN, in his reply, said that the advantages of sana-torium life were of inestimable value in the treatment of

pulmonary tuberculosis. He did not think that the injectionof tuberculin would ever replace artificially induced auto-inoculation.

EDINBURGH MEDICO-CHIRURGICALSOCIETY.

Exhibition of Cases.-Appendi]citis.-The Optic Nerve inCases of Intracranial Tumour.

A MEETING of this society was held on Jan. 15th, Dr.JAMES RITCHIE. the President, being in the chair.

Dr. ROBERT A. FLEMING showed a case of Spastic Diplegiaof Infantile Origin in a man aged 45 years. The tendon

reflexes were greatly exaggerated, as was also Baginsky’ssign. Athetoid movements were present, chiefly in the leftarm which was paralysed. Nearly all the muscles were

hypertrophied, including those of the neck ; when he spokethere was a marked spasm of the platysma myoides. Thepatient’s intellectual power was good ; there was no familyhistory of nervous disease, but one brother stammeredgreatly; the athetoid movements and spasticity had beenpresent as long as the patient could remember. The lesionmust have been either a meningo encephalitis or a meningealhaemorrhage.

Mr. J. W. DOWDEN showed a man after operation forPerforated Duodenal Ulcer as illustrating the good resultsof early complete suture of the abdominal wounds. The ulcerwas situated towards the gastric end of the duodenum; itwas excised by a longitudinal incision, the cavity of theabdomen was washed out with saline solution, and drainageopenings were made at the lower part of the abdomen. Onaccount of the giving way of the sutures the bowels pro-lapsed two days later ; they were replaced and all the abdo-minal openings were then securely sutured and healed byfirst intention.Mr. F. M. CAIRD showed a man after Removal of Half of

the Tongue. The operation was done under cocaine, thetongue being snipped out by scissors. No gag was neces-sary and the man walked back to bed. A few hours afterthe operation he could articulate perfectly and thewound healed much more satisfactorily than in cases doneunder a general anxsthetic. All the glands in the front ofthe neck were subsequently dissfcted out, and though eachwas microscopically examined no trace of malignant diseasewas found in them.

Dr. EDWIN BRAMWELL snowea a DOy sunenng trom

Poliencephalomyelitis. He had been healthy until threemonths ago when he felt sick, vomited, and had pain at theback of the neck. On the following day he could not move hishead. The movements of the arms and legs were normal,showing that the spinal cord was unaflected, but his head washeld stiffiy and this was not due to rigidity of the musclesbut to excessive weakness of the deep cervical muscles aswell as the sternomastoid and trapezius muscles, which weremuch wasted and exhibited the reaction of degeneration. A

general improvement was taking place and the prognosis wasfavourable.’ Mr. H. ALEXIS THOMSON showed a case after OsteoplasticAmputation through the Middle of the Leg, in which aportion of the tibia was retained in the anterior flap andbrought into contact with the sawn section.

Dr. D. CHALMERS WATSON showed two cases of ChronicPancreatitis. He said that the disease was much morecommon than was supposed. One of the patients had beentreated for catarrhal jaundice in August, 1906 ; on account ofthe pain a neoplasm at the head of the gall-bladder wasdiagnosed and an operation was performed. He was now

pale, sallow, and emaciated and subject to severe paroxysmalattacks of ague-like severity every six weeks. The secondpatient had suffered for ten years with indigestion, jaundice,and emaciation.

Mr. DOWDEN read a communication entitled °° Deductionsfrom 100 Consecutive Operations for Appendicitis." Hecon-fined his statements almost entirely to acute attacks. Hesaid that the appendix was dependent on a single artery as arule for its blood-supply and was consequently unable to copesatisfactorily with the urgent demands for blood caused bysevere inflammation. In his series of 100 operations 82 wereacute cases (52 males and 30 females), while the so-called"interval operation" was performed on 14 males and fourfemales. Recurrent attacks were noted in 37 cases. Amongthe 82 acute cases there were 16 deaths, while among the 18"interval cases " there were no deaths. A classification ofthe acute cases according to age showed that 16 cases withsix deaths were under 16 years of age ; 50 cases with 9deaths were from 16 to 30 years of age ; and 16 cases,with one death, were over 30 years. On the first day of theillness there were 11 operations performed with no death;on the second day there were 16 operations withtwo deaths ; on the third day there were 18 opera-tions with seven deaths; and at later periods therewere 37 operations with seven deaths. The sym-ptoms were often treated as those of acute in-digestion. It could not be sufficiently emphasised thatevery attack of so-called acute or subacute indigestion calledfor a careful local examination, including, if in doubt, arectal examination. The presence of pain to the left of, and