237

epidemics of diphtheria ; that milk sterilisation shouldalways be carried out with the whole of the supply, noportion being retained for the use of anyone in the institu-tion (at Forest Gate the officers’ portion was taken before themilk was boiled) ; that the method of sampling probablygave a sufficiently reliable result to determine the progressof the epidemic ; and that the unhealthy conditions, espe-cially hypertrophy of the faucial mucous membrane, was avery large factor in the persistence of the diphtheria bacillusin the throat.The SECRETARY, in the absence of Dr. F. H. BERRY

(Watford), read a paper narrating a similar experience at theLondon Orphan Asylum. Here the 350 boys and 200 girlshad little intercourse with the outer world except duringthe Christmas and midsummer holidays and were keptentirely apart, never seeing one another but in the dininghall and the chapel, where they were separated by widegangways. The cases occurred among the girls only,though the milk-supply was the same. There had beenno outbreak of diphtheria, and few if any cases formany years, when in January, 1898, after the holidaysseveral cases of feverish follicular tonsillitis appeared.On Feb. 25th a case of diphtheria was noticed so typical thatantitoxin was at once used before the Klebs-Lomer bacillushad been demonstrated. A series of mild sore-throats wasfollowed on March 27th by a case of diphtheria (clinical andbacteriological) and three sore-throats with the Klebs-Lomerbacillus which were at once isolated. A succession of"throats "lasted until April 30th when after an interval ofa week four cases of typical diphtheria and three suspiciousthroats, one of which developed into diphtheria, occurredbetween May 7th and 10th. All the cases were of a severe

type, but being treated promptly with antitoxin made rapidrecoveries. It was then resolved to isolate all childrenwith sore-throats in a vacant house in the grounds,but since these numbered 76 and the accommodation was notsufficient for more than 50 they were divided into dark redand pale red throats ; the former, as presumably the worst,were isolated and the latter were sent back to the school.Dr. Washbourn was then asked to examine the whole of thEgirls and the resident mistresses whose throats presentedanything amiss. These were 142 in number, eight beingmistresses. Diphtheria bacilli were found in those oi

three mistresses and 14 girls and Hoffmann’s in 33. Two oithe mistresses were teachers of music who gave their lesson;in glass-walled compartmeits just large enough to hold thepiano, teacher, and pupil, which might have assisted in thespread of the infection. All who, though not ill enouglfor the infirmary, presented the Klebs-Lomer bacillus weredetained in the isolation building for a fortnight, theithroats being sprayed with a disinfectant night and morning. A fresh examination showed that only two-onmistress and one girl-were still infective, and these afteanother week’s treatment were pronounced free and no morsore-throats appeared in the school from that time c

indeed from the exclusion of those in whom the Klebs.Löfflebacillus was found.

LEEDS AND WEST RIDING MEDICO-CHIRURGICAL SOCIETY.

Fœtid Expectoration.-Removal of a Submucous Fibroid bySection of the Uterus. - Volvulus associated withHernia.-Exhibition of Cases and Specimens.A MEETING of this society was held on Jan. 12th,

Dr. A. G. BARRS, the Vice-President, being in the chair.Dr. STANLEY DODGSON related the case of a woman, aged

30 years, who had Cough, Fostid Expectoration, and Occa-sional Hæmoptysis. The disease was of seven months’duration and dated from an extraction of teeth under ether.The patient had a temperature of 102° F. and was ex-

pectorating about 20 ounces of foetid sputum daily. The

only physical sign was impairment of resonance at the leftbase. Creasote inhalations on alternate days were given fortwo months, at the end of which time the temperature wasnormal and the cough and foul expectoration had disappeared,while the patient had put on weight. The patient had re-mained in good health during the three’succeeding months -A discussion followed in which Dr. H. J. CAMPBELL, Dr.C. M. CHADWICK, Dr. E. SOLLY, Dr. E. F. TREVELYAN, andDr. A. G. BARRS took part. The chief points raised were(1) the value of creasote given by the mouth as against theso-called creasote chamber; and (2) the difficulties of

diagnosis in some cases of foetid expectoration.-Dr.STANLEY DODGSOK replied.

Dr. J. BRAiTHWAiTE read a paper on the Removal of aSub-mucous Fibroid by Section of the Uterus. As the casewas possibly the first in this country in which the uterushad been opened by what might almost be called Cassareansection for the removal of a contained tumour it was ofsome interest. The patient was 41 years of age, a nullipara,and had suffered from exhausting hæmorrhage. The cervixwas extraordinarily rigid and could only be dilated by meansof Reid’s screw dilators under ether. It was then possibleto reach an internal fibroid near the fundus. The fibroidwas probably not larger than a big horse chestnut, but itwas impossible to remove it even morcellement as the vaginawas very small and the cervix was rigid and undilatable.On Dec. 29th last it was removed by making a centralincision in the anterior wall of the uterus, haemorrhagebeing prevented by a rubber tourniquet round the cervicalend. The tumour was easily turned out of the uterine cavitywith its mucous covering entire. The cavity was drained bya tube into the vagina. The wound in the uterine wall wasbrought accurately together with catgut sutures, about three tothe inch. The abdominal wound was closed with sutures inthree layers as usual, the peritoneal and middle layers withcatgut, and the skin with silkworm gut. The patientmade an uninterrupted recovery. It would be noticed thatthis was not abdominal section and enucleation of fibroidsin or on the uterine wall-a subject upon which variouspapers of great interest had been published.-Dr. E. 0.CROFT and Dr. J. B. HELLIER made some remarks and Dr.BRAITHWAITE replied.Mr. LAWFORD KNAGGS read a paper upon Volvulus in

Association with Hernia. Four distinct groups could be

recognised: (1) cases in which the neck of the volvulus waswithin the sac or close to the ring ; (2) cases in which thehernial contents were implicated in the volvulus but wherethe neck and some of the affected coils lay within theabdomen ; (3) cases in which the volvulus was producedwithin the abdomen upon the reduction of the hernia ; and(4) cases in which a volvulus occurred within the abdomenfrom some predisposing condition more or less directly con-nected with a hernia. All these groups possessed features ofmuch interest, but Mr. Knaggs only dealt with the secondgroup in which the cases were of unusual gravity andimportance.-Mr. H. LITTLEWOOD discussed the paper andMr. KNAGGS replied.The following cases and specimens were exhibited :-Dr. EDWARD WARD : (1) Ruptured Spleen and Kidney ;

and (2) Ovarian Tumour.Dr. A. G. BARRS: (1) Specimen of Amyotrophic Lateral

Sclerosis ; (2) Cancer of the Liver ; and (3) a case of Hydro-, pneumothorax with Typical Succussion Splash.

Mr. W. H. BROWN : (1) Mediastinal Growth ; (2) UnusualFracture of the Clavicle; and (3) Rupture of the CommonFeraoral. The patient in this case was shown.’ Dr. J. B. HELLIER: Carcinomatous Uterus removed per

vaginam.Mr. H. LITTLEWOOD : (1) A case of Suprapubic Lithotomy

with Prostatectomy in a patient, aged 70 years ; (2) a case ofCompound Depressed Fracture of the Skull in which thepatient had been violent and delirious for a month; and(3) Tonsil and Glands removed for Squamous Epithelioma.

Dr. GORDON SHARP: Four cases illustrating the After-effects of Diphtheria.

Mr. B. G. A. MOYNIHAN: A case of Extensive TuberculousDisease of the Ankle and Foot treated by Iodoform Injection.

, Dr. E. F. TREVELYAN : Specimen of Hemorrhage into thePons causing sudden death.

i Mr. MAYO ROBSON : (1) Adenoma of the Small Intestinecausing Intestinal Obstruction; (2) Sarcoma of the SoleusMuscle ; and (3) Tuberculous Kidney.

. Mr. LAWFORD KNAGGS : Case of Erasion of the Ankle forTuberculous Disease by Four Vertical Incisions (Glutton’s

e Method).

EDINBURGH MEDICO-CHIRURGICALSOCIETY.

Exhibition of Cases.—Salol in tlie Treatment of Small-pox.-Permanent Dislocation of the Patella.- Murder and

. Suicide by Cut Throat.THE fourth ordinary meeting of this society was held on

Jan. 17th, Mr. ALEXANDER MILLER, the President, being in, the chair.

238

Dr. NORMAN WALKER showed a man suffering from AcneVarioliformis which had lasted for two years. The disease,as it has been described, extended into the hair as true acnevery rarely did. The scarring was exactly like that seenafter small-pox. The patient had no syphilitic lesions andthough the condition had improved under the administrationof iodide of potassium Dr. Walker did not think that thatdisease was due to syphilis.

Dr. C. W. MACGILLIVRAY showed a boy who had beenStruck over the Left Parietal Bone by a piece of lead pipingwhich had fallen from a height of about 30 feet. The woundwas examined five hours after the injury and a piece of theleft parietal bone of about the size of a small oyster-shell wasfound entirely loose in the wound ; this was removed, leavingan area of about two and a half square inches of the duramater exposed. The boy was never insensible and the woundhealed perfectly without any febrile disturbance.

Dr. CHARLES BEGG communicated a paper on ClinicalExperience with Salol in the Treatment of Small-pox. Henarrated his experience of the disease in China and thoughtthat an explanation of the value which salol had had in hishands might be of value in view of the late spread of thedisease in England. Dr. Begg was not aware of any similarobservations to his own. The following case led him tothink of the use of salol in small-pox. A patient whosuffered from cystitis was taking a drachm of the drugdaily. This individual had previously suffered intenselyfrom the bites of mosquitoes. When taking salol a slightmental depression showed itself and the man did not evennotice the mosquitoes. He had hundreds of bites, yet noneof these showed the least appearance of swelling, redness, orirritation. This led Dr. Begg to think that salol might beuseful in other irritating skin affections and on trying thedrug its anaesthetic action was confirmed. Dr. Begg didnot think that the mental depression which salol producedhad anything to do with this sedative action on the skin.The drug was next tried in cases of small-pox and was foundto keep the patient free from all irritation. There was nodesire to scratch the skin and so the danger to the eyes wasgreatly avoided. This freedom from cutaneous irritationallowed of the patient sleeping and consequently exhaustionwas prevented. Salol also almost always prevented thevesicles from maturing into pustules. Nearly all vesiclesended as such. In one case, that of a European, who hadonly been once vaccinated in infancy, confluent small-poxoccurred and only two groups of vesicles ended as pustules.In almost every case the lymph dried up and the eruption soended. No dangerous effects from the use of the drug indaily doses of one drachm continued for a long periodmanifested themselves. The cases should be brought atan early period fully under the action of the drug, andwhen properly so treated little scarring resulted. The foulodour which small-pox patients exhibited was entirelymasked by the fruity odour which the drug manifested duringits elimination by the skin.-Dr. NORMAN WALKER statedthat his experience in the treatment of skin diseases bysalicine agreed with the observations of Dr. Begg and hethought that the absence of scarring was due to the non-formation of a hard scab and that the prevention ofsuppuration in the pocks accounted for this.Mr. SHAW McLAREN communicated a paper on Per-

manent Dislocation of the Patella. He said that thedislocation was a displacement of the patella outwards sothat it lay even in extension generally to the outside of themedian line, while in flexion it slipped outwards and back-wards until it lay on the outer surface of the externalcondyle, its anterior surface being directed to a certainextent outwards. The gait was thus rendered mostinsecure and the patient frequently fell, and attacksof synovitis were not infrequent. Mr. McLaren agreed withAppel that the condition was really a congenital defect, adeformity of the external condyle and trochlea of the femur,though a fall might first call attention to the malformation.In most of the recorded cases it had been noted either (1) IIthat the deformity was actually present at birth; (2) that the child learnt to walk at a late period or walked insecurely I,during later years ; (3) that there was rickets ; (4) or genuvalgum; (5) or outward rotation of the leg; (6) or ill-developedpatella; or (7) abnormal shape of the external condyle and ’Ipatella fossa of the femur. A case which he had met with I,was briefly as follows. It was that of a woman, aged 19years, who had never walked securely and did not really walk alone until the age of seven years. She could neverrun, was always falling, and had knock-knee on the left

side. She had presented evidences of rickets in childhood.On the left side there was marked genu valgum,the leg being rotated outwards. When the kneewas extended the patella lay to the outside of thenormal position ; when the joint was flexed it passedfurther and further out until it lay on the outer side of theexternal condyle. The fossa patellas of the trcchlear surfaceof the femur could be felt to be partially filled up on itsouter side as if the external condyle projected into it, whilethe outer edge of that condyle seemed to be entirelywanting. Mr. McLaren related the notes of Appel’s twocases and also several other cases which were not noted byhim. The quadriceps, in passing from its origin to itsinsertion, formed an obtuse angle at the point of which thepatella lay. During action the patella would be pulled out.wards unless this were prevented by the prominence of theexternal condyle, which kept the patella in the middle line.If the fossa patellae were too shallow or the ridge of theexternal condyle was not prominent enough the patella wouldlie dangerously far out on the trochlea. A slight accident ora severe contraction of the quadriceps was only necessary toshoot the patella off the front of the condyle altogether.In those cases where the condyle was markedly deficient thecomplete dislocation might exist from birth or very earlylife. In any case, the structures on the outer side of thepatella contract eventually and prevent the bone retainingits proper position. As regards treatment, various methodswhich had been adopted by different operators were related.The method which Mr. Shaw McLaren adopted in his caseconsisted in liberating the patella by dividing on the outsidewhatever contracted structures prevented it from assumingits normal position and then mooring it there by suturespassed through its inner border. Four years after theoperation the patella had retained its position slightlyexternal to and higher up than normal, and thepatient walked and went up and downstairs easily andcould also now run. This method of treatment seemedrational and effective and in most cases ought to be suc-cessful. The severer operation of opening the joint andenlarging the groove for the patella might be neces-

sary in some cases, whilst transplanting the ligamentumpatellae inwards should be reserved for those cases wherethere was a high degree of outward rotation of the leg.-ThePRESIDENT, Dr. MACGILLIVRAY, and Mr. CAIRD havingspoken, Mr. McLAREN replied.

Dr. HARVEY LITTLEJOHN narrated an interesting case OtMurder and Suicide by Cut Throat, showing how such casesought to be investigated and the difficulties to be encounteredin their elucidation.

ROYAL ACADEMY OF MEDICINE INIRELAND.

SECTION OF OBSTETRICS.

Deciduoma Malignum.- Ulceration in the Female Vrethra.

A MEETING of this section was held on Jan. 5th, Dr.A. V. MACAN, the President, being in the chair.

Dr. W. J. SMYLY read a paper on Deciduoma Malignum.Having reviewed the literature of the subject he said thatobservers were now almost unanimous in believing that thiswas a disease sufficiently distinct to merit separate considera-tion. They also agreed as to its clinical features, pathologicalappearances, and treatment ; also as to its connexion withpregnancy, and differed only as to their views concerning itshistogenesis. He inclined to Veit’s opinion that the diseasewas a sarcoma, modified by pregnancy. He also describeda case which had come under his own observation. Thepatient, a pluripara, was delivered of a hydatiform mole inDecember, 1898. She had repeated haemorrhages untilMay 10th when she had so profuse a haemorrhage that shewas reduced to a condition of profound anasmia. The uteruswas dilated and a quantity of material resembling placenta wasremoved which on microscopical examination proved to bedeciduoma malignum. Putrefaction and septic fever followedwith pulmonary symptoms and empyema preceding radicalmeasures. She lingered two months and then died. Therewas no post-mortem examination. Dr. Smyly showed themicroscopical specimens at the Edinburgh meeting of theBritish Medical Association, when they were pronounced byDr. Sanger to be typical examples of the disease which hehad described.-Dr. R. D. PUREFOY, Dr. SMITH, and thePRESIDENT discussed the case.