1464

filters. Irradiation of healthy tissues was dangerous.-SirFELIX SEMON related an instance where radium caused

sloughing with fatal mediastinitis.-Mr. W. D. HARMER hadfound that external insertions of 150 mgm. of radium for18 hours resulted in a wound which did not heal. -Dr. HILLlaid great stress on the filtration. He had employed 150 mgm.with a screen of 2 mm. of platinum covered with rubber for18 hours without injurious effect.-Mr. S. HASTINGS in18 cases had found sloughing in one case where septic teethwere present. He placed the radium in a Symonds’ funnel andinserted it by means of an cesophagoscope.

Mr. E. A. PETERS brought forward a case previouslyexhibited with left unilateral abductor paralysis, but whichnow had progressed to complete paralysis with the cord in acadaveric position.

Dr. J. DONELAN’S two cases of Papilloma of the VocalCords, in which he had found it easier to employ the indirectinstead of the direct method, were discussed by Sir STCLAIRTHOMSON, who related that both Killian and von Eicken

preferred the indirect method where this could be employed.Indeed, by the old principle of cito, tuto et jucunde theindirect method came first.-Sir FELIX SEMON remarkedthat the need for good technique in the application of theindirect method had constituted laryngological work as aspecialty, accordingly he regretted the disuse of thismethod by the younger men.-Dr. HILL pleaded for thesimplicity of direct laryngoscopy, and mentioned thetolerance of chronic tuberculous patients to its use. He alsoconsidered that suspension laryngoscopy would still furtherdiminish the fiéld of theindirect method.-Mr. E. B. WAGGETT

upheld indirect laryngoscopy.-The PRESIDEKT consideredthat where a general anaesthetic had to be employed thedirect method was preferable, in other cases the indirect.The advance from the days of Hartmann’s direct spatula tothe present duck-billed tubes was remarkable.

Dr. W. JoBSON HORNE showed a case of Laryngeal Neoplasmwhich Mr. H. C. Fox and Mr. J. F. O’MALLEY consideredto be attached to the anterior commissure ; also an extremecase of Congenital Webbing of the Palate.

Dr. L. H. PEGLER brought a case with an ŒdematousFibroma depending from the left vocal cord.

Mr. C. I. GRAHAM exhibited a case of Chondro-Sarcomaof the Pharynx.

Mr. P. R. W. DE SANTI’s case of Lupus of the Nose, Ear, andTongue and Pharynx was discussed. The Wassermann reac-tion was only partially positive on one occasion ; giant cells,but no tubercle bacilli, were recognised in a microscopicalpreparation.

Mr. C. POTTER’S case of Perithelioma of the Pharynx, whichwas enucleated with the capsule by an incision through themucous membrane, was referred to Mr. S. G. Shattock.

In Dr. HILL’s case of Carcinoma of the Base of the

Tongue and Epiglottis Mr. DE SAXTi recommended a

subhyoid pharyngotomy through a central incision.

SECTION OF OTOLOGY.

Primary Tu.bercnlosis of the Ear.-Exhibition of Cases.A MEETING of this section was held on May 15th, Mr

RICHARD LAKE being in the chair.Dr. W. JOBSON HORNE described a case of Primary Tuber-

culosis of the Ear in a child aged 13, in which the diagnosiswas established by the finding of tubercle bacilli in thetissues over the necrosed portion of the temporal bone,which he exhibited. There had been a coueh for three

months, and the child had been wasting seven months ;there had been measles two months ago. Fifteen days beforedeath facial paralysis developed, and the child died withsigns of cerebral disease. There had been a discharge fromthe right ear for about four months. Post mortem the

temporal bone and membrana tympani were found to havebeen destroyed, the ossicles had perished, and the middleear was disorganised. The antrum and middle ear werefilled with débris and caseous matter, and the cancellous

portion of the mastoid was involved. Above and behind theexternal auditory meatus a subperiosteal abscess was found,and at its site a sharply defined area of necrosed bone corre-sponding to the outer wall of the antrum. On deflecting thedura mater from the cranial surface of the bone an extra-dural abscess was found and some tuberculous deposits. Therewere also found extensive disease of the lymphatic glands,general miliary tuberculosis, tuberculous meningitis, and

tuberculous nodules in the brain. Dr. Horne expressed theopinion that primary tuberculosis of the ear presented suchdefinite clinical and pathological features that it could easilybe distinguished from the secondary form of the disease.Primary tuberculosis of the ear was essentially a disease ofchildhood, if not even of infant life. This case also illus-trated the exhibitor’s contention that in the primary formthe stress of the disease was, in the first instance,on the mastoid bone.-Mr. C. E. WEST, in discussingthe case, said that bone tubercle was very rarelyprimary in the sense of being the site for the first depositionof tubercle in the body; it was nearly always preceded by afocus, generally a caseating one, in the lymphatic glands.Supposed tubercle of the temporal bone in children hebelieved to be much rarer than was generally supposed.The operative results on these cases, though good at thetime, were unfavourable later, for 50 per cent. died fromtuberculous meningitis three or four years afterwards.

Dr. E. A. PETERS and Dr. H. J. DAVIS showed interestingcases of Exostoses of the External Meatus, and the advisabilityof operation in such instances was discussed. Dr. Davis alsoshowed a remarkable case of Recovery from Operations, atdifferent dates, on two large temporo-sphenoidal abscesses.The patient, a girl aged 16, was shown a year ago afterrecovery from an abscess on the right side, and three monthsago she again presented herself with similar symptoms onthe left side-namely, earache, vomiting, and vertigo-andan aural polypus was protruding from the meatus. Owing togreat restlessness, aphasia, and rapid unconsciousness, withrotatory nystagmus to the right, and signs of meningitis, he,with the assistance of illr. Addison, opened and drained alarge temporo-sphenoidal abscess. The brain was motionlessand on incision pus and a quantity of sanious fluid streamedfrom the lobe, which then commenced to pulsate. Salineswere continuously administered, and Mr. Addison performedlumbar puncture. As the pathologist reported that pus wasfound in the cerebro-spinal fluid the prognosis was regardedas hopeless. Dr. J. M. Bernstein and Dr. Elworthy, whoalso saw the case, recommended intraspinal injections of

antistreptococcus serum, and 10 c. c. were given twice at24-hour intervals. She also had three vaccine injections inthe flank, and was kept alive on champagne, pituitrin extract,&c., and her recovery, though slow, was uneventful. Shewas now bright and the aphasia had disappeared, but shecould only hear the tuning fork on contact.

EDINBURGH MEDICO-CHIRURGICALSOCIETY.

Empyema in Children.-The Pathology and Etiology ofDuodenal Ulcer

, A MEETING of this society was held on May 6th, Dr. JO’HVPLAYFAIR, the President, being in the chair.

Dr. NORMAN WALKER showed a case of advanced

Myccsis Fungoides apparently cured by the application ofX rays, onlv pigmented areas remaining.

Dr. G. ft. MELVILLE DuNLOP contributed a paper on

Empyema in Children, based upon 98 cases treated in his wardin the Sick Children’s Hospital. He pointed out that duringthe same period in which these empyema cases occurred therehad been 861 cases of pneumonia, or 1 case of empyema to

every 8 or 9 cases of pneumonia. The pleural fluid effusedduring childhood showed a marked tendency to become

purulent, and the younger the child the more pronouncedwas this tendency. The effusion in a child under 3 yearswould almost certainly be of a purulent character. In 59cases of pleural effusion in such young children the fluid waspurulent in 53. The tendency of the fluid to become purulentgradually lessened from 3 years till the age of 10, when theformation of a serous effusion was usual in the great majoiityof cases. Of 149 cases of pleural effusion the following wasthe analysis:-

Under 6 months of age........ 3 cases, all purulent.13etweeti 6 months and 12 months 9 " 8 " 1 serous.

" 1 and 2 ears ......... 26 24 " 2 "

" 2 3 3 ., ......... 21 18 " 3 "

" 3 5 5 " ......... 23 18 " 5 "

" 5 10 " ......... 57 " 27 " 30 "Over 10 years ............... 10 " 1 " 9 "

The following shows the percentage distribution of infectingorganisms : In 53 per cent. the pneumococcus was present

1465

alone; in 16 per cent. the streptococcus was present alone ;in 14 per cent. the pneumococcus and streptococcus weremixed; in 3 per cent. the staphylococcus and streptococcuswere alone ; in 1 per cent. staphylococcus and pneumococcuswere mixed; in 2 per cent. the staphylococcus, pneumococcus,and streptococcus were mixed ; in 3 per cent. the tuberclebacillus and streptococcus were alone ; and in 6 per cent.there were no growths. As to the causation of empyema inchildren, while admitting the occurrence of primary formsdue either to cold or injury, Dr. Dunlop believed that in themajority of cases the condition was secondary. In only7 per cent. of the cases was a history of lung or otherantecedent history lacking. In the majority of cases theeffusion either occurred with or followed lobar pneumonia,and then the fluid was invariably purulent. Empyemain his experience was much less frequently associatedwith bronchopneumonia. It frequently developed afterscarlet fever, measles, or whooping-cough, and occasionallyafter influenza. Any suppurative process, such as purulentarthritis or osteomyelitis, might account for it, andin young infants septicaemia was a common cause.

In striking contrast to empyema in the adult, a

very small proportion in children was due to tubercle.Of his cases, lobar pneumonia accounted for 69

per cent. ; infectious diseases, 11 per cent. ; broncho-

pneumonia, 5 ; suppurative processes, 3 ; tubercle, 3 ;influenza, 2 ; causes unknown, 7. In most instances theeffusion in cases of pneumonia occurred within a few

days of the crisis. Sometimes the symptoms heralding theonset of empyema were acute and violent ; in others they ’iwere insidious and indefinite. He cordially agreed withthe writer who :said that latency in pneumonia was

synonymous with carelessness in the physician. The childwas often sent into the hospital with a diagnosis of atrophyor miliary tuberculosis, and the general appearance went farto confirm such a diagnosis. In six of his cases convulsionswere the earliest manifestation of empyema, while theother symptoms in the order of frequency were fever, cough,vomiting, quick breathing, sweating, restlessness, anddelirium. In older children, and especially after infectiousdiseases, the foregoing symptoms were less pronounced, butthe child gradually assumed a languid appearance, sufferedfrom a short paroxysmal cough, and emaciated rapidly.As regarded sex, 53 were boys and 45 girls. The left sidewas involved 45 times, the right 39, which was not at all theusual proportion or what would have been expected fromthe frequency with which left-sided pneumonia occurred.Both sides were involved in four cases. The amount of fluidvaried greatly both in quantity (3/4 oz. to 40 oz.) and in thetime it took to collect. In some cases he found one side ofthe chest filled with pus in a few days. A number of

symptoms were very suggestive of empyema. First, inalmost every (case Liic UUiiU 100K.t;U. Seriously in, had au

anxious, pinched. and frightened expression, and was

profoundly anæmic. The face was earthy or yellow incolour with sometimes puffiness under the eyes. There wasa very rapid and sometimes extreme emaciation. When achild was suffering from marasmus he invariably excludedthree diseases-viz., tuberculosis, congenital syphilis, andempyema-before concluding that the diagnosis was correct.There was usually some cough, either suppressed or

paroxysmal, and the breathing was quick, but never so quickas in pneumonia. Even when the pleura was full of pusthere might be little real dyspnoea. The temperature wasusually raised from 30 to 4°, and it might be very high orsubnormal. In ten of his cases it was either normal or

subnormal during the whole period of observation. Clubbingof the fingers might be observed when the empyema hadlasted a long time. When the fluid was present therewas generally a leucocytosis of from 20,000 to 30,000.His experience did not bear out the statement thatdiarrhoea might be present. Clinically, whenever abso-lute dulness of a board-like character at the basewith a boxy percussion note at the apex was noteda pleural effusion should be suspected. The sense ofresistance to the percussing finger also was of great value.It was quite common to get loud tubular breathing over apurulent effusion in the child-a misleading point to thoseaccustomed to investigate empyema in the adult. Vocalfremitus was of little help, but displacement of the heart’sapex was a very valuable aid in diagnosing fluid in the chest.It might be found in the epigastrium, or even as far as the

right mammary line. The complications of empyema were

generally due to further pneumococcal infection, and thecommonest was purulent pericarditis, present in 40 per cent.of his fatal cases. This complication, often altogetherundiagnosed during life, for friction was seldom if ever

detected, should always be suspected if after draining thepleura freely the child continued ill with a rapid pulse.Purulent meningitis and peritonitis also occurred, but notsuppurative arthritis or general septicaemia. Diagnosis wasoften difficult without the aid of an exploring needle ; it

might have to be passed repeatedly before the collection wasreached, and even then if the fluid were thick it might notpass, or large masses of lymph might block the lumen. Itwas often said that a hectic temperature indicated pus, buthe had found as high temperatures in serous as in purulentcases. The prognosis of pleural effusion was difficult, as themortality was largely determined by the cause and durationof the illness and the age of the child. In the 98 cases therewere 20 deaths, or 19 per cent. Under 2 years the prognosiswas very grave ; in 30 cases he had 11 deaths (36 per cent.).After 2 years 68 cases with 9 deaths (13 per cent). With adouble effusion, of 4 cases only 1 recovered. Pneumococcalcases over 2 years almost invariably recovered, but in strepto-coccal and mixed infections the prognosis was not nearly sogood. Tuberculous empyema was fortunately rare in thechild, but the prognosis was not nearly so grave as in theadult. Pus in the pleural cavity should be evacuated assoon as diagnosed, for if the drainage was good and sepsisavoided the risks of complication were greatly diminished.In most cases any attempt to relieve the effusion byaspiration was a dangerous waste of time. and itwas not very efficient. Where the exploring syringe haddrawn off merely turbid serum aspiration had often givenhim good results, and it should be tried in very younginfants unable to stand a serious operation. Aspiration wasuseful also, when the effusion was very large, to draw off aquantity of pus the day previous to operation. It did notdraw off all the pus ; large masses of fibrin were left, andno drainage being possible resection was usually neededlater. In operation either resection of the rib or simpleincision of the pleura formed the choice. The former gavebetter drainage and less risk of sepsis but was a moreserious operation. Simple incision was better for younginfants. Of his cases, 8 were aspirated, with 1 death ;61 were resected, with 14 deaths ; and 29 were incised, with5 deaths. The main danger of the operation being syncopeand death from the anaesthetic, local anaesthesia was

preferable in young infants. The incision, 2 or 3 inches

long, should be made in the sixth interspace in the mid-axillary line. To avoid syncope the pus should be allowedto escape very gradually. The tube might be removed in 7-10days and should seldom be retained longer than 3 or 4 weeks.-Professor F. M. UAIRD alluded to the value of Truby King’s suggestion of having a few drops of sterile water in the

exploring syringe, so that if the needle became blocked afew drops could be injected and then withdrawn. If puswere present it could easily be detected in the syringe.-Dr. JOHN THOMSON said that he had never been able to hearfriction in pericarditis in children. He attached importanceto the child’s general health in determining whether a

pleurisy were serous or purulent. If the child was healthythere was much less risk of empyema than if it were weak.As a preliminary measure he favoured aspiration, and hehad had two or three dozen cases where a single aspirationhad been sufficient to effect a cure. -Dr. ALEXANDER GOODALLhad found auscultation very misleading in empyema inadults, and bronchial breathing was often marked and loudover an effusion.-Dr. DUNLOP replied.Mr. D. P. D. WILKIE read a communication entitled

" Observations on the Pathology and Etiology of DuodenalUioer,"with an epidiascope demonstration. He said thatthe credit of recognising that this ulcer was of frequentoccurrence was due to W. J. Mayo, Moynihan, and MayoRobson. He wished to demonstrate certain facts gainedchiefly from the post-mortem room. During the past threeyears he had investigated the condition of 490 cadavers,and he had met with 41 cases of duodenal ulcer, andin only 6 of these had the ulcer any direct connexionwith the death of the patient. In only 6 cases

had a diagnosis of duodenal ulcer been made beforedeath, and all of them had been operated on. In one ortwo cases where a chronic ulcer had been found it had

1466

caused during life none of the typical symptoms. Such" silent" " ulcers might attain considerable size and causedeath from haemorrhage or perforation without producingany noteworthy symptoms. The subjects of these " silent "

types of duodenal ulcer were generally old people witharterio-sclerosis. The ° ° syndrome pylorique" described bySoupault and resembling the Moynihan’s symptom-complexof duodenal ulcer might be, but was not invariably, associatedwith a duodenal ulcer. It appeared to be the clinicalexpression of an irritable condition of the pyloric muscula-ture favouring spasmodic contraction. It might, however,be associated with an ulcer on the gastric side of the pylorus.Morbid anatomy: : In the 41 cases the lesions were situatedon the first part of the duodenum and with two exceptionswithin one inch of the pylorus. In 9 cases the ulcer wason the anterior wall from half to three-quarters of an inchbeyond the pylorus ; in 12 it was on the posterior, and inother 12 there was an ulcer on both anterior and posteriorwalls directly opposite one another (the so-called kissingulcers" of Moynihan). In 5 cases the ulcer was at the

upper part or roof of the duodenum ]ust beyond the pylorus,whilst in one female case a large ulcer occupied the lowerwall of the duodenum, extended to the posterior wall, andinvaded the pylorus. In 21 cases there was but one ulcer,in 16 two ulcers, and in 4 more than two ulcers. Insome of the cases where a fair-sized ulcer was found on the

posterior wall no suspicion of its presence had been arousedby a careful examination of the unopened gut. The im-

pression left by such cases was that this type of ulcer must befrequently overlooked at operation, and the question arosewhether the duodenum should not be opened in doubtfulcases. In 5 cases besides the duodenal lesion one or more

gastric ulcers situated on the lesser curvature some distancefrom the pylorus were found. Of acute and chronic ulcer it wasnot so easy to speak with assurance as in the case of gastriculcer. With ulcers on the anterior wall, many which from theouter surface of the intestine showed evidence of chronicityclosely resembled acute ulcers when viewed from the mucousaspect. Chronic ulcers of the posterior and postero-superiorwalls were usually more easily recognised, resembling as

they often did the large crater-like ulcers of the stomach.The essential factor for the formation of a duodenal as of a

gastric ulcer, was that a portion of the mucosa became sodevitalised that it might be digested and leave a breach ofsurface. This devitalisation might be brought about by(1) the lodging of an embolus in an arteriole of the duodenalwall; (2) venous embolism ; (3) the circulating of toxin in theblood, causing a degeneration not only of the liningepithelium of the bowel but of the endothelium of the

capillary blood-vessels, so that small hæmorrhages took

place and determined local areas of lowered resist-

ance ; and (4) reflex nervous spasm of the vessels or

of the muscularis mucosæ causing small hæmorrhagesinto the mucous membrane. He discussed these causes at

length, and said that toxic degeneration or necrosis of themucosa or of lymph follicles of the duodenum followed bydigestion was probably the most frequent cause of acuteulceration. The source and nature of the toxin mightvary widely ; thus the products of tissue autolysis circu-lating in the blood caused degeneration in the parenchymaof various organs, and in the stomach and duodenum diges-tion of the devitalised tissue followed with the forma-tion of ulcers. In two of his cases death resultedfrom widespread superficial burns, in one case fiveand in the other 12 days after the accident. Mr.Wilkie was convinced that some definite relationshipexisted between morbid conditions in the lower boweland duodenal ulcer. The relationship between themwas not clear, but he was inclined to think that theulcer was due to a combined action through the bloodand through the autonomic nervous system. Rosslehad been struck by the frequent association of chronicappendicitis and duodenal ulcer. There was some evidenceto show that toxic absorption from the colon had a

definite vago-tonic influence. The periodicity of the sym-ptoms of duodenal ulcer, the effect of worry, over-fatigueand chills, and vaso-motor disturbances in determiningthe onset of a fresh attack all pointel to the importanceof the nervous factor in duodenal ulcer. After dis-

cussing the site of £ the ulcer and the sex incidencehe drew the following conclusions : 1. Duodenal ulcer is a

disease of frequent occurrence and one which often passes

unrecognised. 2. Although as a rule readily recognised, achronic ulcer may occasionally exist and give rise to none ofthe characteristic symptoms, the first evidence of such a"silent " ulcer being sometimes its perforation. 3. Silent" duodenal ulcers are met with most frequently in the subjectsof arterio-sclerosis and are found for the most part on theposterior wall. 4. Some toxic or irritative factor, usuallywithin the abdomen and most often associated with the colonor appendix, is found in a large proportion of cases. 5.Probably many acute duodenal ulcers are primarily follicularulcers from the breaking down of inflamed lymph follicles.6. Whatever be the primary cause of a gastric or duodenalulcer, spasm of the muscular coats of the viscus is an

important factor in determining its chronicity. 7. Thesituation of the opposing ulcers on the anterior and

posterior walls on the boundary zone of the areas suppliedby the anterior and posterior branchea of the supra-duodenal artery suggests that a common vascular

deficiency, rather than a contact infection, accountsfor the peculiar tendency to chronicity and recurrence.

8. This vascular deficiency may be due to arterio-

sclerosis, but probably it is usually due to spasmof the muscular coats of the duodenum, inducedby a slight local anasmia consequent on strain on

the supraduodenal vessels, this muscular spasm beingfavoured by the increased vago-tonus and the irritable con-dition of the autonomic nervous system which exist in suchcases. 9. The sex incidence of duodenal ulcer is to be

explained on anatomical grounds. The relatively highpylorus and short fixed duodenum of the male allow of itsvascular supporting ligament, the hepato-duodenal ligament,being exposed to strain, which in the female with her

relatively low pylorus and lax duodenum is borne by the leftborder of the gastro-hepatic omentum and lesser curvature ofthe stomach. 10. The fixity of the male duodenum furtherpredisposes to kinking at the first duodenal angle, and thusto an unduly long exposure of its first part to the acid chymefrom the stomach. -Professor CAIRD said that the lateProfessor Hamilton, of Aberdeen, believed that there was norelation between burns and duodenal ulcers, and personallyhe had found no such association.-Professor WILLIAMRussELL alluded to the relation which existed between con-ditions in the lower part of the intestinal tract and duodenalUlcer. He WCLS glad to Know that Mr. wilke old UUU

believe in the view of embolism as a cause ofbelieve in the viecv of embolism as a cause ofduodenal ulcer. He had taught for long that local

spasm caused anæmia and this led to acute erosion.Both duodenal and gastric ulcers were very frequentlyassociated with hyperchlorhydria. Duodenal ulcer was

very difficult to diagnose if there was hyperchlor-hydria present, and one ought never to diagnose itunless there was melfcna or occult blood present.-Professor ALEXIS THOMSON thought we should be chary inaccepting the theory of the bands in connexion with thestomach and duodenum as causal agents as well as aboutthe condition of the lower bowel. The toxic factors whichunderlay the production of appendicitis might be the causeof duodenal ulcer also. The stasis of the bowel in womenrather was antagonistic to the sex relationship of the disease,and the ulcer was often present in young men who hadno intestinal stasis.-Dr. D. CHALMERS WATSON, Mr. J.WHEELER DOWDEN, and Mr. J. W. STRUTHERS also tookpart in the discussion.

ROYAL ACADEMY OF MEDICINE INIRELAND.

SECTION OF PATHOLCGY.

Wassermann Reaction,A MEETING of this section was held on May lst, Dr.

J. B. COLEMAN, C.M.G., the President, being in the chair.Professor E. J. McWEENEY read a communication on

Experiences with the Wassermann lieaction. He hadinvariably carried out the original technique with theexception that he used a non-specific antigen and adoptedthe quantities and general procedure laid down by M’Intoshand Fildes in their valuable text-book on syphilis. Thenumber of cases lie had tested so far was 240, of which182 wore available for statistics. From the Lock Hos-

pital he had examined 54, of which 47 were undoubtedly