271

of the muscles of the left side of the larynx was a similarfatty degeneration, dependent usually on an affection ofthe left recurrent nerve.-Mr. WAGSTAFFE thought thatmicroscopic examination of the muscles would be of interest,to see whether it was really fatty degeneration, which wasrare, or fatty infiltration, which was comparatively common.- Mr. CRIPPS replied that on teasing out a piece of the sub-stance of the muscle, no trace of muscular fibre was visibleunder the microscope.-Mr. MORRIS remarked that he hadobserved a similar condition in the rectus femoris on bothsides in a subject dissected, and no traces of muscular fibrecould be found.

Dr. GREENFIELD exhibited a specimen of Occlusion ofCoronary Arteries by atheroma of the aorta. The patient wasa married woman twenty-seven years of age, who was broughtinto St. Thomas’s Hospital dead. She had been in good healthtill the day of her death, when she suddenly complained offeeling queer, and whilst out walking, became faint, vomited,and died in less than half an hour. The commencement ofthe aorta, immediately above the sinuses of Valsalva, wasconsiderably thickened for about half an inch ; the orificesof the coronary arteries extremely narrowed, just admittinga bristle. There were a few patches of atheroma in the coro-nary arteries themselves, but these were not prominent; thecalibre of these vessels was normal, and they were free fromclot. The heart was of normal size, weighing eight ounces;the muscular substance firm and the valves healthy. Therewas also one small patch of atheroma in the wall of the archof the aorta, but none elsewhere. Microscopically, the diseasein the aorta presented the ordinary characters of endarte-ritic deformans, with very slight atheromatous change ; themuscular substance of the heart showed only slight fattydegeneration. The interest of the case appeared tobe in the early age of the patient, the absence of previoussymptoms, the great thickening of the coat of the aorta, andthe slight change in the heart tissue. From a comparisonof this with other cases, Dr. Greenfield was inclined tobelieve that the hypothesis of Dr. Dickinson must be true,and that the muscular substance of the heart must benourished in great measure by imbibition from the cavities.The disease might possibly be syphilitic, but there was

nothing definitely to show that it was so.-Dr. HILTON FAGGEinquired whether Dr. Greenfield had found that fatty dege-neration of the heart was usually associated with obstructionof the coronary arteries; or whether, when branches wereobstructed, the corresponding portions of the heart weredegenerated. In his own experience he had not found theseconditions necessarily associated.-Dr. GREENFIELD said hecould not state from his own experience whether fatty de-generation accompanied the obstruction of branches of thecoronary arteries; as a general rule, the complete ob-struction of the arterial supply of any organ would lead tofatty degeneration, but from the present case, and thoserelated by Dr. Dickinson, he was inclined to believe thatthe fatty degeneration of the heart was only a conditionassociated with, but not necessarily dependent upon, theobstruction of the coronary arteries.-Mr. MORRIS inquiredwhy, in the case of obstruction of one coronary artery, theblood should not pass into its branches from the branchesof the other. Although it is said that there are no com-munications, Mr. Morris had seen a specimen in which in-jection had passed from one into the other.

Dr. GREEN FIELD also showed two specimens of Obstruc-tion of the Renal Artery by Atheroma, with consequent de-generation of the kidney. In one of these cases-a male,forty-nine years of age-the obstruction was not complete,but the artery was greatly thickened by atheroma close toits origin from the aorta. The corresponding kidney wasgreatly atrophied, weighing only an ounce and a half,whilst the other weighed ten ounces and a half, and was oflarge size. In the other case-a female fifty-three yearsold, who had been under treatment for ovarian tumour withascites-no symptom referable to the renal condition hadbeen observed. The left renal artery was much obstructedby considerable atheromatous thickening, and also firmlyplugged by coagula, which extended into the ultimate divi-sions. The corresponding kidney was enlarged, weighingfour ounces and a half, one ounce more than the right ; itscapsule was somewhat adherent ; the substance of an opaqueyellow colour, resembling a wax model, showing greatlythickened and obstructed vessels. Microscopically, in addi-tion to chronic changes similar to those found in the other

kidney, there was extreme fatty degeneration of the epi-thelium, and exudation of white blood-corpuscles aroundthe obstructed vessels. Dr. Greenfield remarked that thecases were of interest as showing the changes which occurin organs as a result of partial and entire arterial obstruc-tion, and also as illustrating a somewhat rar.e condition.

Dr. GREENFIELD exhibited a specimen of Fibroid Diseaseof the Heart. The patient, forty-three years of age, diedsoon after admission to the hospital, and very little could beascertained of his history. The heart was very large, mea-suring twelve inches in circumference at the base; the leftventricle greatly dilated, thickened, and of globular shape ;in its posterior wall was a large fibrous patch, which was.continuous with a similar one at the apex. These extendedthrough the whole thickness of the wall, and at the posterioraspect of the cavity of the ventricle there was a roughenedpatch, to which coagula were firmly adherent. The cavityof the ventricle was lined by a thick layer of honeycombedclot which appeared to have started from this point. Thekidneys presented very numerous small infarcts, the size ofa mustard-seed, due to small coagula carried from the heart.The case was of interest as showing a mode of terminationof fibroid disease, of which there was no case on record in

! the Society’s Transactions.Mr. BUTLIN exhibited a Fatty Tumour removed by

Herniotomy. The patient was an elderly woman who had! suffered from hernia for some years, which came down

at times, but was usually easily reducible. On the daybefore the operation it could not be reduced; there was no

. vomiting, but some pain and nausea. When seen by Mr.Butlin there was a tumour the size of a cocoa-nut in the

’ left inguinal region, which gave no impulse on coughing,, but was slightly resonant. In operating it was found ne-

cessary to open the sac, when the tumour was found to

occupy it. The tumour, which was smooth and of a verydark colour, almost black in the centre, from hæmorrhage

) into its substance, was attached by a thin membranous, pedicle inside the abdomen; it was tied and separated with-

out difficulty. Its connexions in the abdomen could not be.

discovered. Microscopically the tumour was composed of! fatty tissue, but with more nuclei than usual. Mr. Butlins thought he was justified in operating at once in this case.-. Mr. WAGSTAFFE inquired whether the sac was really con-l tinuous with the peritoneal cavity, and whether it was> not a low form of connective-tissue growth developing> into true fatty tissue.-Mr. BUTLIN replied that he was, able to feel along the pedicle into the abdomen for some; distance, but could not feel the attachment. He at first- believed it to be a diseased ovary, but there was no trace of; ovarian structure ; and he thought it now probably omental.. —Mr. MORRIS thought it would decide the point whether it) was an appendix epiploic if the intestine could be felt on

feeling along the pedicle.-Mr. BUTLIN had not been ableto distinguish the contents of the abdomen.The meeting then adjourned.

CLINICAL SOCIETY OF LONDON.

AT the meeting of this Society on the 12th inst. thechair was occupied by Sir William Jenner, who deliveredan inaugural address (which will be found in another

column). The attendance of members was unusually large,this probably being due to the fact that the newly electedPresident was about to take the chair for the first time.The papers read were also of unusual interest.A vote of thanks to the President for his address was

moved by Dr. GREENHOW, who, in the course of his re-marks, said that the Society had been fortunate in alwayshaving its chair filled by men in the very first rank of theprofession; and although he had at times felt that it mightbe unwise to call upon their presidents to deliver inauguraladdresses, yet he might say that from the day that SirThomas Watson took the chair at the first meeting of theSociety to the present occasion every address had been ofthe highest value, marked as each was by the originalityand character of its author.-The motion was seconded byMr. BARWELL, and carried by acclamation.

Dr. PooRE then read notes of a Case of Paralysis of the

272

Serratus Magnus Muscle, the patient being afterwardsexhibited. The patient, a man forty-three years of age,strained his right arm while unloading a timber waggon inMay, 1874. The same evening he felt pain and numbnessin the thumb and forefinger, which prevented him fol-

.owing his occupation, and compelled him to seek relief atvarious hospitals without success. He was first seen byDr. Poore on July 24th, when there was no sign of paralysis,but only considerable pain down the arm and hand, espe-cially on exertion. Jarring movements increased the pain, so:that he dreaded travelling on railways. There was distinctbenderness over the brachial plexus, and over the mediannerve at the bend of the elbow, and pain and numbness werecomplained of in the right thumb and forefinger, whilemarked redness existed at the back of the band and wrist.its regards muscular irritability, both faradaism andvoltaism were negative in their results; but the cutaneoussensibility at the back of the hand was increased to thecurrent. The patient stated that he had at first experiencedpain up the right side of the neck and over the rightscapula, but this had disappeared. At that time he couldnot raise his arm above his head without pain ; in fact, allmovements of the right arm were painful and difficult. Hisprevious treatment consisted chiefly in the application ofliniments, without benefit, a hypodermic injection of

morphia on one occasion alone giving relief. Dr. Pooretried the effect of the constant galvanic current, to-

gether with exercise of the painful muscles, andwith marked success; the first application affordedhim temporary relief, and after the fifth time he ceasedattending, believing himself to be well, all pain having dis-appeared, and only redness of the hand with numbness ofthe forefinger and thumb persisting; but there was then nosign of palsy of the serratus. Three weeks later he re-turned, because the pain had recurred on the outer side ofthe arm and round the shoulder-blade. On examination he !,was then found to be suffering from paralysis of the serratusmagnus. Dr. Poore, who was leaving town, transferred thepatient to the care of Dr. Gowers, and did not see him againuntil the end of October. His condition has remainedalmost unchanged up to the present time. When the armsare at rest there is hardly any obvious deformity; close in-spection, however, showing that the lower angle of the rightscapula is a trifle nearer the middle line than that of theleft. Marked deformity is produced when the serratus isbrought into play by raising the arms at right angles to andin advance of the trunk; the spinal border of the rightscapula forming a projection about two inches high to theright of the vertebral column ; the lower angle is station-ary, but the upper end of the spinal border approaches themiddle line in a slight degree. The digitations of the leftserratus are plainly visible, but those of the right cannot bedetected. The shape of the thorax is remarkably altered,as shown by tracings obtained by the use of the cyrtometer.There is nearly bilateral symmetry when the arms are atrest, but when the serrati are put into action there ismarked bulging of the left side, while the tracing of theright side shows the backward projection of the scapula.When the arms are held forward, and a deep inspirationis taken, the want of expansion of the right side isnotable, while the restoration of the sternum from itsrecession, due to the position of the arms, is effected bythetrapezius and sterno-mastoids. The patient has a curioushabit of sighing, which may possibly depend on the impair-ment of the serratus. It is doubtful if the palsied musclereacts to either form of electricity, but there is, perhaps,slight movement of the spinal border of the scapula on fara-disation of the axilla. There seems to have been slightmprovement during the last month or six weeks. Dr.Poore commented upon the late appearance of the paralysisafter the receipt of the injury ; this may have been due tothe strain inducing a subacute inflllrrimation of some of thecords of the brachial plexus, probably the median ; hencethe pain on movement which was so marked a feature atthe onset. It is possible that the galvanism which curedthe pain may have led to the too early use of the muscles,and that thus the pain was literally converted into paralysis.There can be no doubt that in this case the serratus magnusis the sole muscle affected, and it is completely paralysed;but the phenomena observed here differ in important

respects from those attributed to palsy of the serratus bywriters on the subject. Thus Duchenne (Electr. Local., 3rded., p. 939) says of this affection that when the arms areheld in front of the body the scapula of the affected sideundergoes a movement of rotation, so that the spinal borderof the bone moves away from the vertebral column, and a see-saw movement is induced, in which the lower angle is raisedand brought inwards, while the external angle is depressed.In the present case, on the contrary, the upper end of thespinal border is pulled up and in by the action of the levatoranguli scapulse, the trapezius, and rhomboids. Niemeyer’sstatement, that patients with paralysis of the serratus cannotraise the arm above the shoulder, as this is the chief musclesharing in that movement, is not borne out by the presentcase; for although there is obvious paralysis of the serratus,yet he can readily raise his arm above his shoulder. Para-lysis of the serratus magnus alone is infinitely rare, althoughit is not uncommon to find this muscle affected in pro-gressive muscular atrophy associated with other of thescapular or arm muscles.

Dr. SOUTHEY then brought forward a well-marked exampleof Lepra Aneastbetica. The patient, who was shown to themeeting, is a male, twenty-five years of age, well nourished,and of fairly healthy complexion. His hands are cold andwasted, the fingers semiflexed in the " bird-talon" position,and skin shrivelled. At first the case was thought to be oneof locomotor ataxy, with muscular paralysis. There isanaesthesia of the greater part of the hands, the tactile senseis also lost, the skin of the finger-tips appearing smooth andatrophied. In places there are scars of old burns and in-juries, which he has received without being aware of it, theonly reason why he objects to their infliction being that thesores produced are so long in healing. There is now a soreplace, nearly healed, on the sole of the right foot, near theball of the great toe. This maybe the result of injuryfromhis boot, but in situation and character it resembles the true"spedalkshed" plantar ulcer. Such an ulcer arises as acentral yellow patch, which, sloughing, leaves an irregularulcer extending so deeply as to cause necrosis of the bone;its intractability is its peculiar character, lasting generallythe patient’s life-time, while its cicatrisation or completedrying up is mostly of bad omen, life even being endangered.In this case the ulcer one time was nearly healed, withoutany effect on the man’s general health, but it thn brokeout again. The patient was born in Southern India, ofEnglish parents, and he had lived in that country up to theyear 1873. In 1869 he contracted a venereal affection, whichwas followed by " crops of boils " and " whitlows " on thefingers. Shortly after, he began to experience less of sensa-tion, first in the limited patch over the right knee, theanaesthesia being preceded by slight itching, but no markedperverted sensibility or hypersesthesia. Similar aneastheticpatches appeared later over the lobe of the right ear andeyebrows, that on the ear having gone since be left India.The loss of sensation in the hands and feet has occurredgradually, and almost pari passu, while the deformities ofthe hands have taken place during the last year. He hasbeen taking iodide of potassium and mercury, and latelygalvanism has been employed, but the progress of themalady has been hardly at all stayed. It is interesting thatbut two generations of Europeans resident in India have

! sufficed in this case to render him liable to the affection, his! grandfather having been the original settler, and both his

parents having been born and lived in India.I The exhibition of these two cases excited considerable

interest, but time not allowing any discussion to take placeon them, this was, on the motion of Mr. Morrant Baker, ad-

, journed to the next meeting.

THE MEDICAL PROFESSION IN JERSEY. - The! Jersey British Press of Saturday last contains the memorial. of the Mpdical Society of Jersey, addressed to the Sanitary! Committee of the States on the 26th of December. A copy> was also presented to the Governor. This memorial showsb that the profession urged on the States the immediatei passing of a compulsory Vaccination Act, the establish-, ment of a hospital for infectious cases, and cf a place for. disinfecting bedding, articles of clothing, &c. In others words, the petition shows that the responsibility of the

; disaster involved in this epidemic does not rest on thet members of the medical profession.