1364

of Extra-uterine Foetation and these were discussed by Dr. u

HORROUKS, Dr. CULLINGWORTH, and Dr. G. E HERMAN. 0T7MANCHESTER MEDICAL SOCIETY.

Rheumatic Hyperpyrexia.-Post,-operative Hæmatemesis-Acid Auto intoxication.

A MEETING of this society was held on Nov. 4th, Dr. A. MEDGE, the President, being in the chair.The PRESIDENT related a fatal case of Rheumatic Hyper

pyrexia treated by cold baths. The highest temperaturereached was 110° F. Quinine in large doses, cold sponging.continuous application of ice, and even ruhbing with ice ha(failed to reduce the temperature, but immersion in the col(bath was always successful in bringing it down temporarilto a normal or subnormal point. Eight baths were used

during the hyperpyrexial period, which lasted seven daysdeath being preceded by the signs of hypostatic pneumoniaAlthough the patient was always removed from the battbefore the temperature had fallen to 102° collapse frequentl3ensued, requiring the use of stimulants and hot applicationsThere were very well-marked nervous symptoms, includingpain and stiffness in the neck, delirium, clonic convulsions,internal strabismus of the right eye, spasm of the leftfacial muscles, spasm of the masseters interfering with theopening of the mouth, and protrusion of the tongue. Refer-ence was made to the tetaniform nature of many of thesesymptoms. The necropsy proved the case to have been oneof pure hyperpyrexia without complication except theterminal pulmonary congestion.

Mr. CHARLES ROBERTS read a paper on Post-operativeHasmatemesis with illustrative cases. He described 12cases, dividing them into two groups. In the first thecondition was associated with profound toxaemia and wassatisfactorily explained on the theory that it was due to

sepsis, the operation acting only as a possible predisposingfactor. In the second group the condition occurred apartfrom sepsis. Three cases were described in detail. Thevarious theories as to the cause of post-operative hasmat-emesis were discussed.

Dr. F. CRAVEN MooRE read a communication on the sub-ject of Acid Auto-intoxication sui generis. After referring tothe clinical and experimental basis of the modern concep-tion of acid intoxication, the prototype of which obtained inconnexion with diabetes mellitus, the occurrence of suchintoxication apart from diabetes was dealt with and a

division of such cases into two groups was adopted-viz : (1)those in which m’mifestations of acid intoxication occurredin association with. and probably secondary to, some generalmorbid state; and (2) those in which they occurred apartfrom any general disease to which they might be regarded assecondary and apart from any lesions post mortem whichwould afford adequate explanation of their obtaining to thisgroup, the term acid intoxication sui generis being hereproperly applicable. As illustrative of this condition thefollowing cases from the hospital practice of Professor J.Dreschfeld were described. the first case was that of afemale, aged 30 years, who bad for some two months sufferedfrom attacks of vomiting, gastralgia, constipation, pallor,.and weakness. Four days before death she suffered fromdrowsiness, prostration, air hunger, and exhibited a strongodour of acetone. The urine gave no reaction for glucose.On admission to hospital the vomiting ceased, the patientbecame rather excitable, and then lapsed into a comatosecondition which terminated fatally in about 20 hours. Theurine was highly acid, contained a trace of albumin and nosugar, gave well-marked reactions for acetone and aceto-acetic acid, and also for ß-oxybutyric acid. A filtered speci-men gave a rotation ot -- 3° (2 dm. tube) ; an etherealextract exhibited negative rotation and crotonic acid wasobtained on distillation with H2SO4. The second case wasthat of a female, aged 14 years, who had suffered fromrecurrent attacks of vomiting and constipation withoutindications oc gastro- intestinal lesion, the condition beingapparently "hysterical" vomiting. The breath and urinecontained acetone ; the latter also contained aceto-aceticacid and &bgr;-oxybutyric acid (a = 0 46° in 2 dm. tube).With suitable dieting, evacuant enemata, and alkalies

internally these manifestations disappeared. The third casewas that of a female suffering from mitral disea-e withbroken compensation she exhibited for a few days acetone,aceto-acetic acid, and &bgr;-oxybutyric acid (a = - 0.2°) in the

urine. Of these cases the first represented the severe formof acid intoxication sui generis; the second to some extentsimulated the condition of cyclical vomiting regarded byEdsall as an acid intoxication ; and the last was apparentlyacid intoxication of slight degree and secondary.

LIVERPOOL MEDICAL INSTITUTION.

’

Pleural Effusion. - Pylorectomy. -Suprapubic Prostat-- eetomzy.-Rlte2cmatoid Arthritis.e A MEETING of this society was held on Nov. 5th, Mr., J. RLSHTON PARKER, the President, being in the chair.1 Dr. JAMES BARR described his method of treating pleurali effusions. After removal of the fluid from 40 to 60 minims7 of adrenalin chloride, 1 in 1000, were injected. He had usedi it in many cases with invariable success. In ascites the, method was not so successful. He also described an. apparatus for the introduction of aseptic air into the pleurali cavity.r Mr. F. T. PAUL reported several cases of Pylorectomy.

Two patients operated upon in extremis died. The otherthree recovered-(l) a woman, aged 56 years, with extensive

, cancer of the pyloric end of the stomach who died 16 months; later from recurrence; (2) a man, aged 46 years, with an! early cancer; and (3) a woman, aged 56 years, in whom

the tumour proved to be an inflammatory mass. The twolatter patients were so far in excellent health. Mr. Paulalso showed a man with Carcinoma of the Pylorus whohad improved so much after gastro-enterostomy that he

proposed to excise the growth.-Sir WILLIAM M. BANKS said: that his experience of removing the pyolrus for cancer was! but slight, as he never had any great opinion of the opera-

tion owing to the impossibility of removing completelythe affected lymphatic glands lying in the curve of theduodenum and embedded in the head of the pancreas. Hehad operated in about half a dozen cases. They allrecovered and for a while appetite returned, weightincreased and so on, only to be followed by death in everycase. He was not sure whether patients did not live as longand as comfortably with a successful gastro-enterostomy aswith excision of the cancer.-Mr. R W. MURRAY said thatif a radical cure was to be hoped for in cases of carcinomaof the pylorus the growth must be more freely excised thanpylorectomy with union of duodenum and stomach permittedof. In such cases he advocated gastro enterostomy withremoval of about one-half of the stomach.-The PRESIDENTremarked that cases suitable for pylorectomy were quiteexceptional among cases of malignant disease When hehad performed a pylorectomy the narrow duodenal tube hadbeen sewn to the upper part of the wider opening in thestomach and then the redundant remainder of the latterclo<-ed.&mdash;Mr PAUL replied.

Mr. G P. NEWBOLT read notes of two cases of EnlargedProbtate treated by Suprapubic Prostatectomy. One patient,aged 70 years, from whom a prostate weighing five and

three-quarter ounces was removed in May, 1903, was

shown in good health, being troubled only by frequencyof micturition. The other patient, aged 62 years, diedfrom uraemia four days after operation. His bladder wasshown, the space from which the prostate, weighingone and a quarter ounces, was removed being demonstrated ;its base was formed by a well-marked layer of recto-

vesical fascia. In both cases the prostatic urethra wastorn away together with the ejaculatory ducts.-ThePRESIDENT said that he had devoted what attention hecould to the perineal method described by their Americancolleagues, Professor Alexander and Dr. Parker Sims ofNew York, at the Manchester meeting, 1902. The operationhad proved satisfactory to him and to his patients.-Mr. D.DOUGLAS CRAWFORD recognised Freyer’s operation as theideal one. Although easy in adenomatous cases it wasdifficult in the fibroid form, and he preferred to punch outportions of the prostate in the latter cases.

Dr. C. J. MACALISTER read a paper on Rheumatoid Arthritisand its Relation to other Diseases. He pointed out that thedisease as generally seen in institutions was in the stage ofdeformity and that very often the active processes had beenarrested, and he indicated that it was very necessary to treatthe disease during its very earliest and acute stages if anyreal benefit was to ensue. Having referred to the fact thatacute rheumatoid arthritis frequently resulted from infec-tions from the nasal, gastro-intestinal, and other mucous

1365

membranes, he proceeded to cite a number of examples Iwhere rheumatoid conditions had been associated with some 12

perversion of the thyroid functions and stated that the sypsymptoms in these cases had disappeared altogether or wa!

bad been greatly ameliorated by the administration of abs

thyroid gland. Dr Macalister then proceeded to deal with the early symptoms of rheumatoid arthritis and he pointed legout how frequently vascular spasms of the extremities th{

precede the joint affections and also that muscular Th

cramps were of frequent occurrence as initial symptoms hoand he suggested that the poison was very like ergot in its lef

general effects. He considered that there was a close griassociation between Raynaud’s disease and some cases of rheumatoid arthritis and, furthermore, that he had seen titcases of Graves’s disease which suggested that a relationship thexisted between all three diseases. After referring to thefact that iodine might possibly produce its occasional Wbeneficial effects through the thyroid gland which normally 52contained iodine, he proceeded to suggest that the toxin of tbrheumatoid arthritis was not eliminated from the body owing. Tlto the fact that it either paralysed the organs of elimination b(or failed to stimulate them, so that however freely the skin or 01

kidneys might appear to be acting they could not remove ttthis particular poison from the blood and that in order to be cleliminated the constitution of the poison had to be changed, pIn support of this hypothesis he quoted a case where kin the acute stage a patient with intensely swollen and j(painful joints remained unrelieved in spite of the fact n

that the kidneys and skin were acting profusely until n

(all other drugs having failed) large doses of quinine bwere given which caused the poison to be poured out through r

the skin in the form of a horribly smelling, volatile matter r

which was so offensive that the patient could not be kept inthe ward and that with this elimination there were an imme- diate subsidence of the pains and swellings and a speedy <

convalescence.-Dr. R. LLEWELLYN JONES (Bath) regarded rheumatoid arthritis as a symptom-complex and thought that igiven any source of auto-intoxication the resulting toxaemia might through its action on the cord segments produce what was called rheumatoid arthritis. He emphasised theimportance of the gastro-intestinal tract as a source

for such poisons. He alluded to the occurrence ofrecurrent attacks of local syncope and asphyxia in thesecases and also to the presence of muscular cramps affectingmainly the extremities and in others also the musclesof the head and neck. This might suggest a commonparent origin, a cerebro-spinal toxsemia, for Raynaud’sdisease, tetany, and early rheumatoid arthritis. He hadalso noted the connexion of Graves’s disease. Dr. Macalister’sgratifying results with thyroid feeding afforded him muchpleasure, all the more so as he was able to confirm it fromhis own experience.-The PRESIDENT said he knew from thepractice of a friend that feeding was a most important factorin the treatment of these cases. His friend advised theconsumption of three pints of milk in addition to theordinary meals and the President had seen benefit accrueeven in some well advanced cases.-Dr. BARR, Dr. G. G.&TOPFORD TAYLOR, Dr. S. A. GILL, and Dr. W. B.WARRiNGTON spoke, and Dr. MACALISTER replied.

EDINBURGH MEDICO-CHIRURGICALSOCIETY.

Exhibition of Cases and Specimens.-Enterectomy for Tuber-culous Strictucre of the Intestine.- Valedictory Address.-1!.leotion of Office-bearers.THE first meeting of the eighty-third session of this society

was held on Nov. 4th, Sir THOMAS R. FRASER, F.R.S., theretiring President, being in the chair.

Dr. NORMAN WALKER demonstrated a case of MultipleRodent Ulcers on the face of a female patient. The

original ulcer on the usual site had healed under the in-fluence of the x rays. At present there were about a dozensmall ulcers scattered over the forehead and the face. This

multiplicity was important from a diagnostic point of view.Mr. HAROLD J. STILES showed a boy after Transplantation

of Tendons for Paralytic Equino-varus. The long extensorsof the leg were paralysed with the exception of the extensorlongus hallucis. The peroneal and superficial muscles ofthe calf were likewise paralysed. The deep calf muscleswere active. In the leg both in front and behind the tendonswere transplanted into active muscles and the boy nowpossessed a little movement of the ankle-joint.

Dr. EDWIN BRAMWELL showed a case of Hemiplegia of12 months’ standing in a man, aged 51 years, who had hadsyphilis 24 years previously. The Argyll-Robertson pupilwas present on both sides. The right Achilles jerk wasabsent, although the knee-jerk on that side was markedlyexaggerated. The patient had had shooting pains in hislegs for several years. Dr. Bramwell was of opinion thatthese facts justified a diagnosis of associated pre-ataxic tabes.There was a bilateral extensor response, most pronounced,however, on the right side. Stimulation of the sole of theleft foot was followed by a flexor movement of the rightgreat toe. The sign of "flexion of the thigh on the trunk,"described by Babinski, was present on the right side ; thetibialis phenomenon of Strumpell was also well marked onthis side.

! Mr. A. A. SCOT SKIRVING showed two patients afterL Wound of the Knee Joint. The first patient was a man, agedr52 years, who fell through a glass plate, partially dividingE the quadriceps extensor and opening into the knee-joint.The wound was very dirty. After the application of a car-i bolic poultice the wound was enlarged and two large piecesr of glass were removed ten hours after the injurv. Aftere thorough cleansing of the wound the capsule of the joint wase closed and the wound healed by first intention. The second

. patient was a boy who suffered from acute suppuration of thee knee-joint as a result of a wound from a dirty needle. Thed joint was freely drained and extension was applied. Passive;tj movements were commenced fairly early. The usual state-il ment in text-books was that the best result which could be

hoped for in such cases was ankylosis. It might be that ah more hopeful result was to be expected in children. At any

rate the boy shown had very free movement in the knee-joint.Ln Mr. DAVID WALLACE showed : 1. A lad, aged 19 years,e- who suffered from a Congenital Hypertrophy of the Left Half

Iy of the Tongue. The left half was twice the size of thed right and had a papillomatous appearance and varied inat size from time to time. The latter condition was noted in aia case recorded by Hutchinson. 2. A man who had a Disloca-ce tion of the Acromial End of the Clavicle which had beenhe treated by wiring. Though the movement was very good thece bcne was not in proper position.of Dr. W. ALLAN JAMIESON showed : 1. A case of Para-de keratosis Variegata in a woman, aged 35 years. The disease

ng commenced eight years ago and at present the whole bodyles was more or less affected, the skin of the trunk and limbsLon being of a deep crimson-red colour shading into brown ind’s places and dotted over with white spots. The epidermislad seemed to be looker on the cutis than normally. The surfacer’s was glossy like silk and itchiness was complained of. Muchich improvement had resulted from the use of glycerine of starchom with 40 grains of resorcin to each ounce. 2. A case ofthe Mycosis Fungoides in the erythrodermic stage. The patient;tor was a woman, aged 49 years, and almost the whole bodythe was covered with ill-defined brick-red patches or slightlythe roughened yellow areas, on parts of which were crusts. The;rue inguinal and cervical glands were enlarged. As yet there

were no tumours. Exposure at a distance of ten inches toB. the x rays was being tried as treatment. 3. A patient to

show the Results of Treatment in a severe case of Ichthyosis.The lad, aged 16 years, had been treated by daily washingwith a resorcin and salicylic soap, followed by inuncticntwice in 24 hours with glycerine of starch containing adrachm of resorcin to the ounce and with marked benefit.4. A case of Ichthyosis showing unusual distribution. Thegirl, aged 13 years, showed on the palms and the

iber- soles great thickening of the epidermis, that on the solesbeirg more than a quarter of an inch in thickness. At thebend of each elbow and in the axill&aelig; large areas were

ciety covered by an almost black filiform growth interspersed with, the fine hairs. The same condition was present on the nipples

and their areolae, the flanks, the front of the abdomen, the.tiple groins, the patellar area, the popliteal spaces, the ankles, andThe the front of the toes. The appearances were those ofe in- ichthyosis hystrix.lozen Mr. J. M. COTTERILL exhibited a man with a Sarcoma ofThis the Shoulder at present being treated with the x rays.ew. The following card specimens were shown :&mdash;

ation Dr. A. HILL BuCHAN: Two Microscopical Preparationsmsors from a case of Asthma.,ensor Mr. SCOT SKIRVING: (1) Stereoscopic Photographs of ales of series of Extragenital Chancres ; and (2) S1 ecimen andiscles Photograph of a peculiar Foreign Body (Extremity of andons Locust Bean) impacted in the Left Bronchus.now Mr. COTTERILL: (1) a Large Multiform Ovarian Cyst;

(2) a Kidney removed from a child, aged five years, for