663

away so as to expose its tubes, was demonstrated; Gaertner’sduct appeared like a small nerve running a straightcourse towards the uterus. Cysts springing from thevertical tubes of the parovarium are multilocular, andbear papillary contents lined with epithelium, which maybe ciliated, but is often made up of cubical cells not

bearing cilia. The normal epithelial lining of the par-ovarian tubes is not invariably ciliated, and if so, oftentends to degenerate into its original cubical form. Theouter end of the horizontal tube of the parovarium generallyhears a small cyst, the lining of which resembles endothelium.Between the parovarium and the Fallopian tube, small cysts,lined with endothelium, are very common. It is these, orthe terminal cyst of the parovu’ium, that form the starting

point of the so-called " parovarian cyst," which is thin-walled, unilocular, and filled with clear fluid, but no papil-lary growths. There is no evidence that any of these cvstsspring from the Fallopian tube, the terminal "hydatid" ofwhich never attains large proportions. The multilocularpapillary cysts of the hilum of the ovary, and of the neigh-bourhood of Gaertner’s duct, are identical with those arisingfrom the vertical tubes of the parovarium. all these struc-tures containing relics of the Wolflian body, the source ofcysts of this kind.Mr. HUTCHINSON showed, as a living specimen, a man

who had lost the ends of nearly all the digits of his hands.The gangrene was brought on from exposure to cold. Hewas at work on a snowy night, and afterwards the ends ofhis fingers inflamed and became gangrenous; they havenever recovered, for on any change of temperature theyswell and become cedematous. The toes were not affected.There was a threatening of gangrene of the ears. Before thisoccurred, on any exposure to cold his fingers would " die

"

very readily. It was a case of peculiar constitutional weak-ness of circulation with liability to gangrene, and differingfrom common cases of frostbite in the slight intensity of thecold causing the death of the parts -Dr. WILKS said he hada boy in the hospital last year with gangrene of fingers, ears,and toes, and haematinuria. All had healed up. Thehooma-tinuria pointed to some blood condition.

Dr. S. WEST showed a specimen of Mediastinal Tumourfrom a boy aged fifteen, who had been ill for only twomonths. For three weeks he had a swelling in front of thechest, with brassy cough and dyspnoea, and pain down theside of the chest, and inner side of the left arm. After a fewdays in hospital the swelling increased and appeared abovethe sternum. A needle was inserted, but nothing wasobtained. A day before his death the left pulse was foundunequal. He died in an attack of dyspnoea. At the autopsythe tumour was found to be very large and growing from themediastinal glands, pressing upon and over the heart, flat-tening it down against the diaphragm. The vessels andand nerves on the left side were quite embedded in thetumour, but were all free on the right side. The onlysecondary growths were in the kidneys, but the primarygrowths had extended down to both front and back ofthe heart, under the pericardium, without implicating themuscular tissue. The growth was a small round-celled sar-coma. The nerves in the tumour were found to be greatlythickened, owing to infiltration with tumour tissue. Thecase was interesting on account of the age of the patient ;out of fifty-five similar cases only five occurred between tenand twenty years of age. Dr. Douglas Powell had giventhe average age as twenty-four. The whole mass hadalso grown with extreme rapidity; the shortest time givenby Walsh was three months and a half. He had neverseen the nerves thus thickened ; but Dr. Quain had re-corded a case in which thickening was due, however,to inflammation, and not to infiltration of the tumour.Dr. S. WEST also showed two specimens of PerforatingUlcers of the Large Intestine from Typhoid Fever. In bothcases the disease was of long duration, and in both therewere cicatrices of typhoid ulcers in the ileum. In one thepatient died suddenly, with signs of peritonitis, and afterdeath a collection of puriform fluid was found in the pelvis,and a perforation of the lower end of the sigmoid flexure.In the other the liver and intestines were found mattedtogether in the right hypochondrium, where a collection ofpus was found, and a perforation of the colon at the junctionof its ascending and transverse portions. In this case thefever ran a mild course throughout; but there was all alongone symptom which he had always observed to be attendedwith a fatal termination to the case-a scarcely audible firstsound of the heart.

Dr. HENEAGE GiBBES showed microscopical sections ofa specimen of Cirrhosis of the Liver in a child of sevenmonths, following congenital absence of the common bile duct.The case was under the care of Dr. Steel of Abergavenny.A male infant, eighth child of healthy parents, bornDecember 3rd, 1881, first began to show symptoms ofjaundice a few days after birth; was treated with castoroil in mild doses, afterwards with iridin in doses oftwo to three grains thrice daily. This seemed to have aslight effect on the stools and skin ; other remedies hadalso been tried without any result. Nutrition was main-tained tolerably well till the sixth month, when wastingand ascites set in, and the child died on the 10th of July.The liver was found to be hard and smooth, and weighedfour ounces after hardening in spirit. No common ductcould be found in connexion with the duodenum. Underthe microscope dense bunches of fibrous tissue were foundbetween the lobules, in the interstices of which werethe dilated bile ducts filled with ble. The cells in thelobules seemed broken down, and did not stain. Thisseemed to be a case of cirrhosis following on congenitalabsence of the common duct. The jaundice not appearingfor the first few days might be explained by the small amountsecreted at that early stage having filled the diverticula ofthe bile ducts. After these were fully distended jaundicewould he set up.The Society then adjourned.

CLINICAL SOCIETY OF LONDON.

Treatment of Phthisis by Residence cet High Altitudes.—Excision of Cancer of the Tonsil,

THE first meeting of the present session of this Societywas held on Friday, Oct. 13th, J. Lister, Esq., F.R.S., inthe chair. The new volume of the Transactions was statedto be ready for distribution, which is a fact very creditableto the hon. secretaries. The President read the new rulesin reference to the exhibition of living specimens. He alsoshowed the form of diploma of hon. membership, and statedthat most of the hon. members recently elected had ex-pressed in warm language their sense of the honour thusconferred upon them.

Dr. THEODORE WILLIAMS communicated a case ofPhthisis treated by Residence at High Altitudes, the

patient having been exhibited at a former meeting of theSociety. A medical man aged thirty had cough and ex-pectoration of three years’ standing, followed by hæmo-

ptysis, wasting, elevation of temperature, and great prostra-tion ; and when seen by Dr. Williams in consultation withDr. Vereker Benden, on Aug. 30th, 1881, he presented thephysical signs of consolidation of the upper lobe of theleft lung. After five months’ residence at Davos, in-cluding a walking tour of seventeen days in the Engadine,during the whole of which period he took exercise largely,he gained a stone in weight, and found his strength andpower of climbing greatly improved. On first arriving atDavos he had dyspnoea from the rarefaction of the air, butthis passed off, and his respiratory powers became greaterthan previously. On his return, Dr. Williams found an in-crease in the cyrtometric and other chest measurements,especially in the upper regions of the thorax ; and the phy-sical signs denoted the development of emphysema aroundthe old consolidation and hypertrophy of the healthy lung.Dr. Williams stated that while he ascribed the generalimprovement of the patient to the dry form of antisepticatmosphere and the sun’s powerful influence, he assignedthe arrest of the tubercular changes to the local effects on thelungs of breathing rarefied air, which by inducing emphy-sema caused an expansion of the thorax, at the same timeopposing a barrier to the encroachment of further infectiveprocesses in these organs. With regard to the durability ofthe good results of mountain climates, Dr. Williams’s expe-rience was that in well-selected cases one or two winterssufficed to produce permanent arrest of consumptive dis-ease, though in many instances a prolonged stay of atleast two years was desirable. Dr. Williams exhibitedcyrtometric tracings of similar cases that had resided atDavos and Colorado for several months to illustrate the

664

widening of the chest through breathing mountain air.- lymphatic glands existed, and where the faucial growth wasDr. ALTHAUS was much interested in this subject, as he had circumscribed, or nearly so, operation was called for; butrecently sent a case of advanced phtbisis to Colorado, and that in other cases feeding with tubes with subsequentlythe improvement that had followed was most marked. The gastrostomy was the treatment. The operation was itselfpatient referred to was a young lady with a cavity in one far easier than many of daily occurrence, and seemed tolung, hectic, and great wasting. All European climates had offer no special risk to the patient. Of the four cases men.proved ineffectual ; but after being at Colorado (8000 feet tioned it was considered by Mr. Golding Bird that the dis.above the sea) a week, there was a marked change in her ease was primary in the tonsil in three, in all four it was thestate, and she was able to be out in the open air all day left side that suffered.long. Patients were able to stay in Colorado all the year Mr. CLEMENT LucAS related a case of Excision of theround; the weather was so fine that there was no need Base of the Tongue, Right Tonsil, and part of the Leftto send them into the lower levels at any time; the air Palate for Epithelioma. The patient, aged sixty-four, a

was extremely dry. A residence of two years was con- coalporter on the riverside, who had drunk freely, first camesidered desirable by Drs. Solly and Norman, who resided under Mr. Lucas’s care in Guy’s Hospital onFeb. 13th, 1880.there, and with whom he had been in correspondence on He was at that time suffering from a large aneurism of thethe subject. - Dr. BROADBENT could not quite see the right popliteal artery, causing pain and œdema, of the legpoint of the paper. Such a case as that related was not and foot, and from a smaller aneurism of the left popliteal.an infrequent experience, and the change noted was such Digital compression of the right femoral artery was com.as was often observed after residence in any of the usual menced on Feb. l7th, and continued for sixteen hours, whenwinter resorts. He wanted to know whether in a large num. the aneurism appeared to have consolidated, and pulsationber of cases the results were better from residence at high could no longer be detected. On the following day somealtitudes than from residence in the south of France or pulsation was re-established, and on the 20th digital com.Egypt. - Dr. MACLAGAN asked how far the arrest of pression was again commenced, and continued for eleventhe disease was due to residence in a germless atmo- and a half hours, when pulsation ceased and did not recur,sphere, such as was known to exist in such high alti- the tumour afterwards gradually shrinking. An attempt wastudes, and how far to the general healthiness of the life made about a fortnight later to cure the small aneurism inat Davos. How far also was the enlargement of the the left popliteal space by digital compression, but thischest peculiar to cure of a case of phthisis, or common to failed, and as the tumour caused him little inconvenience,anyone moving to such a latitude.-Mr. LISTER said that no further treatment was suggested, and he left the hospital.Dr. Williams’q case was an example of improvement under He was readmitted on August 2nd, 1881, suffering frommany favourable conditions. If high altitudes were useful, it epithelioma of the base of the tongue and right tonsil. Onwas important to know how the good effects were brought the right side of the tongue, opposite the last molar teeth, wasabout. If the air was germless or aseptic, he failed to see a small ulcer, grey in colour, and irregular on the surface.how that circumstance could interfere with the organisations The ulceration extended along the anterior pillar of the fauces,already present in the lung. Possibly the absence of dust and involved the right tonsil as well as the tissue betweenin the air might be one cause of the beneficial result. He the tongue and the jaw. The surface of the tongue near thehad recently himself experienced in high altitudes an un- base was raised and indurated for about half an inch fromsatisfied desire for taking deep inspirations, and this must the margin of the ulcer. The movements of his tongue wereafter a time cause enlargement of the chest. But he asked interfered with, so that mastication and deglutition werewhether there was any benefit in this ; the deeper breaths painful, and there was an increase of salivary secretion. Nowere merely efforts to take in the same amount of oxygen enlarged glands were felt beneath or behind the jaw. Theas in lower altitudes. But how far was this desirable ? If this operation was performed on Augut 9th. The patient beingremained permanent, on returning to the lower levels of placed under the influence of chloroform, the cheek wascourse it would be useful. Residence in these high alti. first divided by an incision from the angle of the mouth totudes certainly did exercise a beneficial influence. -Dr. the masseter muscle, and the facial artery was twisted. AWiLBERFORCE SMITH remarked that a very small gain of gag was then inserted on the left side of the mouth whilstflesh makes a great difference in the measurement of the the tongue was drawn forward with forceps, and the flaps oichest. He suggested that an aseptic atmosphere might the cheek were held back by retractors. The back ot the

prevent the intercnrrent inflammatory attacks which in- tongue and tonsil were in this way easily reached. The softcrease the phthisical state. - ]Dr. WILLIAMS, in reply, palate was next divided near the middle line by means ofreferred to his paper in the International Congress Trans- Paquelin’s cautery, and dissected down with the anterioractions. In reply to Dr. Broadbent, he said that as pillar and the tonsil. Attention was now paid to the tongue,a specialty of mountain climate he found he got ex- which was divided in the median line with a scalpel, and care’pansion of the chest and change in the percussion note fully dissected outwards till the lingual artery was reached.from dulness to resonance to hyper-resonance. In this This was seized with two pairs of torsion forceps, dividedrespect this treatment differed in its effects from sea between, and the ends twisted without loss of blood. The

voyages, or residence in Egypt or the Cape. He was tissue between the tongue and jaw was next dissected up,not himself sure that the air at Davos was germless; the cautery being used to stop any bleeding points, andthe air had never been analysed. He thought the expan- finally the growth, with the base of the tongue, right tonsil,sion of the chest was a distinct advantage; he also sug- and half the soft palate, was removed in one mass. The

gested that in these patients the lungs were often not fully cheek was brought together with three harelip pins, and itdeveloped, and residence at these high altitudes caused an united primarily. The patient recovered rapidly after theenormous development of the lung. Almost all the natives operation, and sixteen days later was again subjected toof high regions have large lungs. He did not think Davos digital compression for the cure of the left popliteal aneu-and such places were very successful in staving off inter- rism, which was about the size of a pigeon’s egg. Pressurecurrent inflammations. was kept up with the aid of opium for fortY-tight hours,

Mr. GOLDING BIRD detailed a case in which he had but soon after this, though much consolidated, the tumourremoved an Epitheliomatous Tonsil in the manner adopted still pulsated. He left the hospital, with the tongue quiteby Cheever (1871), and referred to three other cases of the healed, on September 16th. He was readmitted into thesame disease in which he had determined not to operate. hospital on February 13tb, 1882. There was no return of theThe operation consisted in an external incision from the disease in the tongue or palate, which were united by a firmear tothehyoid bone, through which the wall of the pharynx and sound cicatrix. There was a large mass on the rightwas reached with the greatest ease, and the tonsil with the side of his neck below and behind the jaw, which com-adjacent pharyngeal tissue removedwith the galvanic cautery. menced six weeks before, and grew rapidly, extending cut-The later stages of the operation were aided by an additional wards beneath the sterno-mastoid. An operation for theincision through the cheek from the angle of the mouth. removal of this growth was undertaken on the followingThe disease having also affected the tongue, part of that day. A vertical incision about four inches in length wasorgan was removed as well as an enlarged gland at the made, commencing behind the jaw, and the growth dis-angle of the jaw. Until the wound closed an oesophagus sected round. It was found necessary afterwards to enlargetube was used for feeding, and though great relief was given the wound transversely. In the course of the operation theto the patient, yet he soon succumbed to recurrence, not in lower part of the parotid gland, a portion of the stemo,the site of the excised organ, but in the tongue and in the mastoid, the posterior belly of the digastric and stylo-hvoid,lymphatics of the neck. The conclusions arrived at by the and a portion of the submaxillary gland were removed, allauthor were that where only a limited infection of the of which were infiltrated. The facial artery was twisted,

665

and the facial and lingual veins ligatured with catgut. Atthe bottom of the wound the internal jugular vein and thetwo carotids, with the hypoglossal nerve, were exposed.Two enlarged glands were also removed from beneath thesterno-mastoid. The patient recovered without a bad sym-ptom, and left the hospital on March 24th. He was agmnseen in July last with a recurrence of the growth on bothsides of the neck, but there was still no sign of disease inthe original site. It was not then thought advisable tointerfere further. Mr. Lucas said that, by the operationdescribed, it was evident a cancerous tonsil, with the

adjacent structures, can be completely removed from withinthe mouth, and when this was practicable, it had the advan-tage over the external operation of avoiding the fistuloustrack, through which saliva was apt to ooze. For the rest, thetreatment of cancer here did not differ from the treatmentof it elsewhere. The treatment-and the only treatment-was to operate early, and to operate late ; to operate, indeed,so long as it was possible to remove a loathsome outgrowthwithout great immediate danger; to operate to keep itlocal; to operate on the earliest return; and though wemight often be disappointed in our attempts to eradicate thedisease, we might still prolong life, or, as in the case beforeus, succeed in driving the disease from its original site toone where it was less offensive, and more easy for the patientto bear.Mr. C. HEATH congratulated Mr. Golding Bird and Mr.

Lucas on their bold procedure. Dr. Cheever’s operationmust of necessity be of great difficulty, but was successfulin his and Mr. Golding Bird’s hands. But the questionarose as to whether good was done by such an operation.His own view was that, whenever the surgeon can getbeyond the cancerous disease, an operation was justifiable,even when the growth was in the lymphatic gland ; but theopinion was often given by eminent surgeons that cancerousdisease of lymphatic glands was a bar to operation. He shouldtherefore be glad to know what the general opinion was.-Mr. MORRAXT BAKER thought that Mr. Lucas was verysuccessful in the long period that elapsed without localrecurrence. He asked if the part was removed with theecraseur, or with the scissors, after Mr. Whitehead’s method.He had himself used in many cases the ecraseur, to preventhaemorrhage and lessen pain. He quite concurred with Mr.Heath in advocating the removal of cancerous lymphaticglands where they could be completely removed.-Mr.Bl-’"TLI}i thought removal of the tonsil through a deepwound on the neck was hardly worth doing, althoughpossibly justifiable. Cheever had had two cases, andCzermak had had one, but in all there was rapid recurrence.As a result of his researches, he found that the only caseof malignant disease of the tonsil really improved by opera-tion was one of lympho-sarcoma, removed through themouth, in which there was freedom from recurrence for twoyears at least ; and he rather doubted whether there wasnot some error in the diagnosis in this case, as it was ex-tremely difficult to distinguish a lympho-sarcoma from anordinary enlargement of the tonsil.-Mr. LISTER said therewas no doubt of the boldness and skill of the operators inthe cases related. But he feared that, on the average, opera-tive interference was more likely to be harmful than bene-ficial. Mr. Lucas’s case was very successful and favourable.He asked for a more detailed account of the last step of thisoperation. He was glad to know that surgeons nowgenerally removed cancerous lymphatic glands when accessi-ble ; this was quite a change since he was a student. Hebelieved he was the first person to clear out an axilla incases of scirrhus of the mamma, and he had had reason tobe very well pleased with his results. In a case of epithe-lioma of the lip and a single enlarged gland underthe chin Mr. Syme used to operate, and with goodresults, although at the time he deprecated such opera-tions where glands were affected in other situations.-Mr. GOLDING BIRD’s opinion was distinctly in favour of notoperating in cases of cancer of the tonsil.-Mr. CLEMENTLuCAS said that in his case the tongue was divided entirelywith the knife. The soft palate and tonsil were first dis-sected down, then the tongue was dissected up, and themass to be removed was carefully divided, and any bleeding

point was touched with a Paquelin’s cautery. He thoughthis case showed that such operations were not hopeless, forhe had freed the man from the loathsome disease in themouth, and he was now suffering from a far more tolerableaffection in the neck.The Society then adjourned

OPHTHALMOLOGICAL SOCIETY OF THEUNITED KINGDOM.

Chronic Me’lnbranous Inflammation of Conjunctiva. -Chronic Tubercle of the Choroid and Brain. -.41iliaryTicbercle of the Choroid and Lung without Meningitis.-Large Tubercle growing near the Optic Disc.-DestructiveOphthalmitis in Children.THIS Society met for the first time this session on

October 12th, Mr. W. Bowman, F.R.S., President, in thechair. The President laid on the table a copy of the

Society’s Transactions, vol. ii.Mr. ANDERSON CRITCHETT and Mr. JuLER showed a case

of Rare Affection of the Conjunctiva, which they consideredto be one of chronic membranous or so called "diphtheritic"conjunctivitis. The patient was a young woman aged seven-teen. Ten months ago she had local suppurating (soft) soreson the vulva and anus, for which she was treated at theLock Hospital. There were no symptoms of constitutionalsyphilis. No mercury was given, and she was dischargedcured in two months. Five months ago she had an attackof what appeared to be inflammation of the ocular conjunc-tiva in both eyes. This was treated first with alum andthen with zinc lotions, and was almost cured when a whitepatch appeared in the left eye near the lower cul-de-sac. Itwas a white, opaque, non-vascular, diphtheritic-lookinggrowth, unattended by pain and without suppuration. Sincethat time it has gradually extended and now appears as adirty-white shreddy mass, seated on a semi-induratedvascular base of the conjunctiva. The lower part of theocular conjunctiva, the lower cul-de-sac, and the innersurface of the lower lid are the parts now attacked. Tendays ago the right eye became similarly affected, a whitepatch appearing in the lower part of the ocular conjunctivasurrounded by vascular injection. It is now (10th day)about 1 ’5 centimetres in length and 0 ’5 centimetres in width,situated horizontally between the cornea and the lowercul-de-sac. The cornea is clear and the vision normal.There is no suppuration and only slight pain and photo-phobia ; iodoform lotion, quinine lotion, &c., have been applied,and mercury given internally without any improvement.-Mr. POWER remembered a similar case in a man thirtyyears old who had a growth at the lower part of the outerconjunctiva. The growth increased, and eventually pro-jected as a horny mass from the surface of the cornea. Theeye was excised.-Mr. NETTLESHIP saw about two yearsago a girl with a patch of adherent membrane on an in-filtrated base on the ocular conjunctiva, which had lastedabout six or seven weeks when she was first seen. Therewas no surrounding inflammation, and he regarded it as alocalised chronic diphtheritic patch. He touched it withlapis divinus several times, and it disappeared, leaving a scar.Other cases of chronic diphtheritic conjunctivitis had beenpublished, one by Dr. Businelli of Rome, where masses ofmembrane kept reforming and protruding between the lids.Another case is recorded by Mr. Mason of Bath, and othersby Mr. Hulme and Mr. Hutchinson. It, therefore, seemedas if in certain cases diphtheritic conjunctivitis tended tobecome chronic.-Mr. POWER added that in his case therewas a distinct specific history.

Dr. S. WEST showed a case of Leucocythaemia with RetinalChanges (dilated veins, &c.)

Dr. S. MACKENZIE read notes of a case of ChronicTubercle of the Choroid and Brain. The disease occurred ina girl aged fourteen. There was no tubercular history. Shehad never been well since she had whooping-cough, eighteenmonths before her death, suffering from frontal headache,feverish attacks, diarrhoea, and occasional vomiting, andloss of appetite and flesh. Following this was white swellingof the right knee. She then rapidly lost sight, whilst the othersymptoms continued. When first observed she was flushedand feverish ; there were no abnormal signs in chest or ab-domen. She was quite blind. Ophthalmoscopic examinationshowed double papillitis. In the left eye there was a patch ofchoroidal disease, larger than the disc, to the outer side ofit. It was opaque and yellow in the centre, with a zone ofblack pigment, and an outer margin of pigment. A smallercircular patch was below the disc, over which coursedretinal vessels. One small patch existed in the right eye.The diagnosis was chronic tubercle of choroid and brain.