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abdomen was very tense and there was much respiratorydistress. Paracentesis was performed on Sept. 16th, 9 pintsof serum being removed. By Oct. 17th the abdomen wasagain tense and an attempt was made, by placing a

decalcified bone tube in the peritoneal cavity, to draininto the subcutaneous tissue of the lower thoracic region.Suppuration occurred in the integument and the bonetube was discharged, but the fluid remained in abeyancetill Dec. 17th. There was then a rapid accumulation and onJan. 5th, 1913, 11 pints were removed by tapping. She wasdischarged on Jan. 8th. She was readmitted on Jan. 22nd,and being very tense was tapped at once, but not satis-

factorily. On Jan. 24th the femoral ring was opened withthe aid of a cannula and probe passed through the abdominalwall above, a decalcified bone tube was inserted, and thewound closely sutured, about five pints of fluid escaping.During convalescence there was some oedema about thewound and a few drops of sanious fluid escaped, but theabdomen became smaller, and the patient recovered herstrength. By Feb. 2nd she was convalescent except for acontinued temperature of 1000 F., due to some tuberculoustrouble at the right apex, and dry pleurisy over the left front.She was discharged on March 22nd and there had been nooccasion to tap the abdomen since. The higher operationwas undertaken as a compromise, as at first the patientappeared too ill to stand the more complete femoral incisionor repeated tapping. Incidentally, it afforded an oppor-tunity for ocular demonstration of the cirrhotic liver.Sufficient improvement in the general condition followedto permit of the more radical operation, and the ultimateresult had been quite satisfactory in spite of the advancedstage of cirrhosis evident in the observed state of the liverand the obvious aspect. Ascites was present, but the needfor repeated tapping was obviated.

Dr. R. A. YouNG showed a case of Acquired Double MitralDisease in a Transposed Heart. The patient was a girl aged 10years and 10 months. She had suffered from rheumatic feverthree years ago followed by chorea, and came under observa-tion for a cough of ten weeks’ duration and headache. Thecardiac impulse was in the right axilla, and cardiac dulnessto the right of sternum. A sharp first sound and systolicmurmur were audible at the situation of the impulse. X raysconfirmed the diagnosis, and aided by a bismuth bolusshowed that the stomach was on the right side.

Dr. E. A. COCKAYNE showed a specimen of RheumaticNodules on the Heart.

NORTH LONDON MEDICAL ANDCHIRURGICAL SOCIETY.

Exhibition of Clinical Cases.A MEETING of this society was held in the board room of

the Great Northern Central Hospital on Feb. 12th, Dr.T. WILSON PARRY, the President, being in the chair.

Dr. ALEXANDER MORISON showed a girl, 11 years of age,who had had Epilepsy since she was 2 years old. Theattacks were at times of very frequent occurrence, as manyas 38 occurring in 24 hours. While under his care they werecharacterised by clonic convulsions affecting the right half ofthe body. At a former period (1909) they were stated to haveaffected the left side. Finding the bromides ineffectual inarresting the attacks, Dr. Morison used hypodermic injectionsof sulphate of atropine (1/200 gr.) three times a day withimmediate diminution of the frequency of the attacks and ina few days in their disappearance, when the atropine wasadministered by the mouth ultimately in doses of 1/100 gr.twice a day. With the abandonment of the drug there wasa tendency to recurrence of the attacks and at its resumptionthey disappeared for lengthened periods, only superveningoccasionally as a single attack. While recognising thisclinical fact that there are spontaneous periods of cessationof attacks in epilepsy, Dr. Morison felt inclined to regardatropine as having had a beneficial effect in this case and asaffording some support to the vaso-motor theory of the

origin of the attacks, at any rate in some cases of epilepsy.Dr. E. BELLINGHAM SMITH showed two cases of Aphasia.

The first was a case of Jacksonian Epilepsy-Right Hemi-anopia and Word Blindness. The patient was a man

who had contracted syphilis 28 years ago, and was now

being treated for convulsive movements affecting the

right side of the face and right arm, and also for difficultyin reading. The illness commenced in February, 1912, withan attack in which the patient suffered from sudden loss ofsight in the right eye and loss of speech and numbness inthe right arm. Since that date the patient had had attacks,recurring every two or three weeks, of convulsive movementsof the right side of the face and right arm ; these attackswere preceded by a "burning sensation" in the right eye,and were not associated with any loss of consciousness. Hecomplained that his sight was very imperfect in his righteye, and that to obtain a clear view of objects he must turnhis head to the right. In addition he had difficulty in

reading. He said that he could see the print, but had diffi-culty in understanding what he read. On examination itwas found that he recognised and named objects correctly,that he read very slowly and aloud, spelling eachletter deliberately ; he could then enunciate short wordsbut stumbled over or completely fell at long ones. The

difficulty with some letters was greater than with others.He wrote from dictation and copied quite well thoughslowly. When writing from dictation he repeated the wordsto himself. If, however, he was shown what he had writtenhe again had difficulty in reading it. Except for a con-siderable degree of contraction of his right field of vision hewas free from any other evidence of nervous disease. These

symptoms suggested that this man was suffering from agummatous meningitis, giving rise to epileptiform con-

vulsions of the Jacksonian type, while the hemianopia andword-blindness without agraphia could be explained on theassumption that he had some syphilitic obliteration of thevessels supplying the general visual centre in the occipitallobe and the region of the association fibres connecting thegeneral visual centre with the word-memory centre and theangular gyrus.-Dr. HARRY CAMPBELL was inclined to

accept Dr. Bellingham Smith’s explanation of the case-

namely, that the visual and aphasic phenomena were due tosoftening from endarteritis, and that the minor Jacksonianattacks were caused by a localised meningitis or actualgumma. He held that all cases of cerebral syphilis shouldbe treated without delay by the intravenous administrationof salvarsan, in conjunction with mercury. If this failedrecourse should be had to the intrathecal injection ofsalvarsanised serum. He incidentally referred to the goodresults be had obtained from this method of resuns ne naa obtained irom this metnoa OI Trearmenc in

tabes. He urged that in prescribing potassium iodide for

syphilis of the central nervous system not less than drachmdoses, three or four times a day, should be ordered.

Dr. BELLINGHAM SMITH’S second case was one of Motor

Aphasia and Partial Hemiplegia. The patient was a femaleaged 24. Nine weeks ago she was confined. The confine-ment was attended by a considerable loss of blood, whichleft the patient, in her own words, ’’ very weak and breath-less." Three weeks after the birth, while the patient wassitting at dinner, she felt a sudden numb feeling in the rightarm and found that both her right arm and the right side ofher face were paralysed. On attempting to speak she wasunable to utter a sound. Complete aphasia lasted for threedays ; since then her speech had been slowly and steadilyrecovering pari passu with her paralysis of arm and face.On examination it will be noticed that there is a slight weak-ness of the right side of the face, which is more marked onsmiling. The movements of the right arm appear normal,but the finer movements of the fingers, as required for

threading a needle or writing, are still very deficient. As

regards her speech, she hears well and understands what issaid to her ; she can also read readily and understands whatshe reads. She, however, says that when she wants to speakor reply she knows what she wants to say but can’t get itout without hesitating, stammering, clipping her words,or even occasionally using an entirely wrong expression."She can write so far as her paralysis admits, but is incapableof counting money. In this instance the inability to count,the difficulty in expressing herself, and the use of wrongwords, associated with her previous history of loss of bloodand resulting anasmla, suggest that this patient is sufferingfrom some cerebral thrombosis which has temporarily dis-organised her motor areas subserving the movements of faceand hand and also the kinæsthetic memory centre, whichcontrols intelligible speech.

Dr. H. L. TIDY showed a case of Tuberculide of the Handscombined with Bazin’s Disease. The patient was a girl

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aged 20. Eighteen months ago she noticed swellings on herhands, which have persisted with little change. Her handsache on exertion, but there is no definite pain. Occasionallya nodule will rupture and discharge slightly. About threemonths ago she noticed a few lumps under the skin abovethe right ankle, several of which have formed ulcers. Onboth hands are numerous cutaneous nodules, about the sizeof a sixpence, of bluish tint and very slightly indurated.The circulation is good. On the right calf are several ulcersof the same size with blue peripheries, and subcutaneousnodules can be felt. On the left calf are a few subcutaneousnodules. In both posterior triangles of the neck arenumerous small discrete glands. Otherwise there is nothingabnormal to be found.

Mr. GORDON TAYLOR showed a case of Osteitis Deformansin a man aged 56. The patient had sustained a fracture ofthe right femur in the middle of its shaft, and the applica-tion of splints and extension not proving successful in

keeping the ends in apposition the bone was plated by Mr.T. H. Kellock. This took place in May, 1913. Two monthslater it was noticed that he was suffering from osteitisdeformans, both femora and tibiae being bowed ; the upperpart of the spine also was seen to be fixed in a bowedposition. The clavicles were enlarged and the bones of theupper extremity were also slightly curved. None of thebones of the head were affected.-The PRESIDENT mentionedthat he had had an extremely interesting case of the samenature under his care some years ago. A lady of 63, whomhe had known some years before the onset of the disease,was the subject. The disease, from start to finish, lastedfour and a half years. It started after an operation forappendicitis, this being her second attack. The first attackoccurred six months previously, and the nurse who attendedher on both occasions noticed nothing abnormal with herbones. After the operation she complained of rheumaticpains in her legs and thighs, and it was noticed from time totime that she was getting shorter in stature. About four

years later the President was called urgently to see herand she had actually fractured her left femur whilein the act of stooping to put out a gas-ring. Thebone was carefully set and the fragments kept in appo-sition for six weeks all but two days. She died atthis time, and on examining the condition of the seat offracture after death it was found that no perfect union hadtaken place. Of the bones of the head none but the point ofthe chin was enlarged. The President added that Oslermentioned in his text-book that " of 8 cases traced to theend, 5 died with cancer or sarcoma."—Mr. CECIL ROWNTREEsaid that he had not heard that cases of osteitis deformanswere liable to cancer, but he could recall one in which cancernf the tongue occured What he had particularly noticed inthe occured what had particularly this case was the very high arterial tension and arterio-sclerosis that existed.-Mr. TAYLOR said that arterio-sclerosiswas not present in his case.

Dr. C. M. HINDS HOWELL showed a case of Paraplegia ina woman aged 60. The patient was well till nine monthsago, when she complained of pains in the legs and back andweakness of the left leg. Since the onset of symptoms thepains had ceased, but there had been progressive loss of

power in the legs combined with loss of sensation. The

patient now was unable to stand alone and presented all thesigns of spastic paraplegia. She also showed the Brown-

Sequard type of paralysis, muscular power being mostaffected in the left leg, whilst the sensory loss was mostnoticeable in the right leg. The upper limit of sensory loss

pointed to a focal lesion chiefly on the left side of the cordat the fourth thoracic segment. Its nature was almost

certainly a tumour. Considering the patient’s age Dr. HindsHowell did not think that he could advise operation unlessthe patient was very anxious to have it done.

Mr. - C. SHATTOCK showed a woman, aged 62 (under thecare of Mr. C. C. Choyce), with a Tumour in the Left Groin,noticed for three months, having caused discomfort inwalking but no actual pain. There was an elastic mass inthe upper part of Scarpa’s triangle, free from tenderness,not fixed to skin or bone, and lying behind and to the outerside of the femoral vessels, which were pushed forwards andnot involved in the mass. Examination of the hip-joint,spine, bones, and pelvis was negative. The mass was con-sidered to be probably a lipoma.—Mr. TAYLOR thought thediagnosis lay between a lipoma and a fibrous tumour.-Mr.ROWNTREE was in favour of its being a cyst.

Mr. SHATTOCK also showed a man (under the care ofMr. Arthur Edmunds) exhibiting an Aneurysm of the UpperPart of the Radial Artery. There was no history of trauma,but the patient had a positive Wassermann reaction. The

swelling had been noticed for three weeks, and was steadilyenlarging.-Dr. CAMPBELL remarked that arterial aneurysmdid not occur so long as the media remained intact. Hedrew attention to a function of the muscular elements in thearteries and veins which had been entirely overlooked in thiscountry-i. e., to prevent by their tonic contraction the vesselsfrom undergoing a progressive yielding before the intra-vascular pressure. Tonically contracted muscle fibre offereda resistance sui generis to a stretching force. Were thevessels divested of their muscular (and elastic) elements theywould speedily become aneurysmal. From this point of viewthe veins stood as much in need of muscular tissue as thearteries ; those of the lower extremities were rich in muscleon account of the hydrostatic pressure which they had tosustain ; the jugular veins contained but little muscle ;while the intraocular, intracranial, and interosseous veinswere wholly devoid of it, because in their case the intra-venous pressure never exceeded the pressure outside. Theinfluence of a tonically contracted media in preventing ayielding of the vessel wall was well shown in the case of thetemporal artery. Chronic hypotonus of this vessel led to ayielding of it in the transverse and longitudinal directions ;this was the explanation of the dilated and tortuous tem-porals which were quite frequently present in subjects of lowblood pressure.

ROYAL ACADEMY OF MEDICINE INIRELAND.

SECTION OF OBSTETRICS.

Fibromyoma.-Laceration of the Perineum and its OperativeTreatment.

A MEETING of this section was held on Feb. 6th, Sir’WILLIAM J. SMYLT being in the chair.

Sir WILLIAM SMYLY showed a specimen of Fibromyomaremoved from a girl aged 21 on whom he had been askedto do an ovariotomy. He did not see the patient until thetime’of the operation on Jan. 27th, but he did not think hecould have made a correct diagnosis even had she comeunder his observation sooner. When the abdomen was beingprepared he felt something like a soft flaccid cyst.On opening the abdomen the uterus and ovaries werefound to be healthy. On the right side was the tumour,which was shelled out of the broad ligament. Althoughit was cyst-like in appearance, on a knife being in-serted nothing came out. The tumour was entirely intra-ligamentous except a very small part embedded in the rightwall of the uterus. He had never seen such a large myomain a girl at such an early age. Pathological examinationshowed the specimen to be a myoma.

’ Dr. G. FITZGIBBON described a specimen of myoma whichhe had recently removed from a patient aged 29. Thetumour felt cystic, and on its removal proved to be so. Hehad considerable doubt at first as to whether it might not bea pregnancy, but after three weeks’ observation it wasdecided to operate. At the operation he felt that there wasconsiderable risk in not removing the whole uterus. One ofthe difficulties in these cases was the diagnosis, but a greaterdifficulty was to decide whether the tumour was sarcomatousor a fibroma. He suggested that a second operation wouldmeet the case if the tumour turned out to be a sarcoma, andtherefore one should do a myomectomy first.

Dr. E. HASTINGS TwEEDY, in a paper on Laceration of thePerineum and its Operative Treatment, said that in themajority of tears the levator fibres were not severed, butwere torn from their attachments to the mid-line of the

perineum. This dragging away preceded rupture of theskin and other superficial structures, so that vigorous efforts tosupport the perineum were often conducted at a time longafter its important elements had been torn away. Themethod of mass suturing with the patient lying on her sidecould be made an ideal operation. The lowest morbiditypercentage rate was seen in the practice of those whoconducted obstetrics with least surgical interference, and

1 THE LANCET, Feb. 26th, 1910, p. 590,