1515 and another case in which Pean removed one weighing 18 pounds from the root of the mesentery. In discussing the etiology of these fibro-myomata Mr. Anderson points out the existence of unstriped muscular tissue in different parts of the retro-peritoneal tissue, especially between the layers of the broad ligaments and in the suspensory fibres of the mesentery. Amongst the more recent literature is an inter- esting paper by Mr. Marmaduke Sheild read before the Royal Medical and Chirurgical Society in which he gives an excellent description of a large fibro-myoma which was successfully removed from the retro-peritoneal space. My own case appears to resemble Mr. Sheild’s except that it had undergone cystic degeneration and I am inclined to think that it arose from the muscular tissue found at the root of the mesentery. Medical Societies. ROYAL MEDICAL AND CHIRURGICAL SOCIETY. The Wounded in the Present War. A MEETING of this society was held on May 22nd, Dr. F. W. PAVY, the President, being in the chair. Mr. CLINTON T. DENT gave an address on the Wounded in the Present War. He commenced by referring to the large scope of the surgical field which had been afforded by the present’ war ; he would, however, confine his remarks to certain questions relating to the accommodation and to one or two classes of gunshot wounds. He much preferred tent hospitals to huts. The patients in them certainly did better. The only objection was in case of wet weather, but this objection was more apparent than real. The tents were more sanitary and the ventilation was more perfect, No. 4 Hospital on the Mooi river was, on the whole, the most satisfactory institution he saw in the whole campaign. It was about 4000 feet above the sea-level and had 500 and afterwards 800 beds. Churches, schools, and public build- ings were generally ill-adapted for surgical cases, though they appeared charming to the casual visitor. Of the latter there were too many and their absence would have been an advantage. The additional air-space in a marquee was very desirable. There should be always some kind of flooring. The regulation pattern of bed was too wide. The operating theatres should be of a more permanent kind than a tent. In this campaign the climate, altitude, and environment were all very favourable to the medical department, quite as much as the small-bore and high velocity arms. The question of the extraction of bullets had assumed quite a different aspect in modern times. When retained a bullet had very often struck a bone, but it nevertheless went a straight course. The rapidity of rotation was enormous and that was one of the reasons why it had an expanding effect on bone. A fair proportion of bullets were lodged. When retained a bullet might after a time become a source of irritation, physical or psychical. If the bullet were sterile it did but little harm by being retained, but if septic it made itself known in that way. One of the most remarkable cases he had met with was that of a man who was shot through the frontal bone from side to side, the bullet lodging in the helmet on the other side. Under certain circumstances a bullet should be removed-viz., (1) when it was subcutaneous ; (2) when it was pressing on nerves or important or vital structures ; (3) when it was much deformed, especially if the mantle was split; (4) when it was likely to interfere with the union of a bone which it had split; and (5) generally shrapnel bullets should be removed. On the other hand, a bullet might very well be left unremoved when in the abdominal or thoracic cavity, or when lodged deep in cancellous tissue of bone or deep in muscular tissue, or, again, when the division of im- portant muscular tissue was necessary for its removal. He bad never advocated that all bullets should be left. The effect of range was very uncertain. Less injury would be done in a living than in a dead body. In the dead body subcutaneous bullets were rare, but in the living body they were not at all uncommon. The nearest 1 Transactions of the Royal Medical and Chirurgical Society, vol. lxxx. escape he had seen was the case of an officer who was struck by a bullet precisely in the centre of the sternum which it perforated excepting the inner table. Long bones were rarely drilled but often fissured and splintered. The bone became slightly expanded and it might remain expanded. A feature of small-bore wounds was the large amount of callus afterwards thrown out, and therefore a neighbouring joint might become fixed. As to the effect of transport on fractures he (Mr. Dent) could fully indorse Mr. Treves’s remarks. He thought that injuries to nerves were more common with high velocity bullets. The nerve might be engaged in the callus. He had seen three cases where Mauser bullets had gone clean through a nerve trunk. The function of the nerve might be disturbed when the bullet went quite close to the nerve trunk without actually cutting it. Nerves might be involved in cicatrices and he mentioned cases in illustration. Head injuries were some of the most successful surgical cases he had met with. "Gutter fractures of the skull should always be trephined ; the injury of the diploe in such cases was often very great. That old dictum of Guthrie that injuries of equal extent were more serious in the frontal than in the mid-cerebral region, and in the latter than in the post-cerebral region, was certainly not borne out by the experience of the present war. Mr. Dent exhibited lantern slides of skiagrams and of Mooi river hospital and Boer trenches. Sir WiLLlAM MAC CORMAC also gave an address on the Wounded in the Present War, which appears in full at p. 1485 of the present issue of THE LANCET. He exhi bited a 100-pound shell which had been presented to him by Colonel Downing and the officers of the Royal Artillery. It was fired from the Boer Long Tom gun, "Umbulwano Bill," and 20 of such shells were fired into Ladysmith during the siege daily excepting Sundays. This gun was mounted on a disappearing carriage and it was capable of carrying 10,000 yards (six miles). Another smaller shell, the first fired by the Boers into the English lines at the battle of Colenso, was also shown. Major WILLIAM DicK, R.A.M.C. (Netley), had only had experience of wounds after the men came back from the seat of war. There had been a large number of cases of paralysis of the musculo-spiral nerve. In one case he thought the nerve was divided, but he found at the operation that it was intact. It was only damaged, and the patient com- pletely recovered. He believed small-bore bullets were more often deflected than was supposed, and he mentioned cases in point. He also mentioned several cases of abdominal wounds, and he believed that their successful issue had been favoured by the fact of the patients having been wounded when starving. OTOLOGICAL SOCIETY OF THE UNITED KINGDOM. Exhibit’ion of Cases and Spechnena. AN ordinary meeting of this society was held on May 7th,. Sir WILLIAM DALBY, the President, being in the chair. The PRESIDENT announced that Professor Politzer of Vienna had been elected an honorary member by the council. Mr. C. A. BALLANCE showed a case of Epithelial Grafting of the Labyrinth after Removal of the Semi- circular Canals. A woman, aged 54 years, had had a dis- charge from the left ear since childhood. On May 7th, 1898, she was admitted into St. Thomas’s Hospital with a large masto-squamous abscess, foul otorrhcea, and extreme vert,igo. The old mastoid operation was performed, but discharge from the ear and vertigo still persisted and deafness was absolute. On Feb. 6th, 1900, Mr. Ballance found a sinus leading into the petrous portion. The semicircular canals were in part removed, and the vestibule was opened, the remaining cavity being repeatedly swabbed out with absolute phenol. For several days the patient was very sick and giddy. On the 17th the cavity was grafted. No giddiness or sickness occurred after the grafting. On removing the plug on the 22nd the patient at once said that she could hear well. When shown at the meeting the wound was soundly healed, the hearing being good, and the patient could run, being free from giddiness and also from tinnitus. Mr. Ballance pointed out that the
Transcript
1515
and another case in which Pean removed one weighing18 pounds from the root of the mesentery. In discussing theetiology of these fibro-myomata Mr. Anderson points out theexistence of unstriped muscular tissue in different parts ofthe retro-peritoneal tissue, especially between the layers ofthe broad ligaments and in the suspensory fibres of the
mesentery. Amongst the more recent literature is an inter-esting paper by Mr. Marmaduke Sheild read before the RoyalMedical and Chirurgical Society in which he gives an
excellent description of a large fibro-myoma which wassuccessfully removed from the retro-peritoneal space. Myown case appears to resemble Mr. Sheild’s except that it hadundergone cystic degeneration and I am inclined to thinkthat it arose from the muscular tissue found at the root ofthe mesentery.
Medical Societies.ROYAL MEDICAL AND CHIRURGICAL
SOCIETY.
The Wounded in the Present War.
A MEETING of this society was held on May 22nd, Dr.F. W. PAVY, the President, being in the chair.Mr. CLINTON T. DENT gave an address on the Wounded in
the Present War. He commenced by referring to the largescope of the surgical field which had been afforded by thepresent’ war ; he would, however, confine his remarks tocertain questions relating to the accommodation and to oneor two classes of gunshot wounds. He much preferredtent hospitals to huts. The patients in them certainlydid better. The only objection was in case of wet weather,but this objection was more apparent than real. The tentswere more sanitary and the ventilation was more perfect,No. 4 Hospital on the Mooi river was, on the whole, the mostsatisfactory institution he saw in the whole campaign. Itwas about 4000 feet above the sea-level and had 500 andafterwards 800 beds. Churches, schools, and public build-ings were generally ill-adapted for surgical cases, thoughthey appeared charming to the casual visitor. Of the latterthere were too many and their absence would have been an
advantage. The additional air-space in a marquee was verydesirable. There should be always some kind of flooring.The regulation pattern of bed was too wide. The operatingtheatres should be of a more permanent kind than a tent.In this campaign the climate, altitude, and environmentwere all very favourable to the medical department, quiteas much as the small-bore and high velocity arms.
The question of the extraction of bullets had assumed quitea different aspect in modern times. When retained a bullethad very often struck a bone, but it nevertheless went a
straight course. The rapidity of rotation was enormous andthat was one of the reasons why it had an expanding effecton bone. A fair proportion of bullets were lodged. Whenretained a bullet might after a time become a source ofirritation, physical or psychical. If the bullet were
sterile it did but little harm by being retained, butif septic it made itself known in that way. One ofthe most remarkable cases he had met with was thatof a man who was shot through the frontal bone fromside to side, the bullet lodging in the helmet on theother side. Under certain circumstances a bullet should beremoved-viz., (1) when it was subcutaneous ; (2) when itwas pressing on nerves or important or vital structures ; (3)when it was much deformed, especially if the mantle wassplit; (4) when it was likely to interfere with the union of abone which it had split; and (5) generally shrapnel bulletsshould be removed. On the other hand, a bullet might verywell be left unremoved when in the abdominal or thoraciccavity, or when lodged deep in cancellous tissue of bone ordeep in muscular tissue, or, again, when the division of im-portant muscular tissue was necessary for its removal. Hebad never advocated that all bullets should be left. Theeffect of range was very uncertain. Less injury wouldbe done in a living than in a dead body. In the deadbody subcutaneous bullets were rare, but in the livingbody they were not at all uncommon. The nearest
1 Transactions of the Royal Medical and Chirurgical Society, vol. lxxx.
escape he had seen was the case of an officer whowas struck by a bullet precisely in the centre of thesternum which it perforated excepting the inner table.Long bones were rarely drilled but often fissured andsplintered. The bone became slightly expanded and itmight remain expanded. A feature of small-bore woundswas the large amount of callus afterwards thrown out,and therefore a neighbouring joint might becomefixed. As to the effect of transport on fractures he(Mr. Dent) could fully indorse Mr. Treves’s remarks. Hethought that injuries to nerves were more common with highvelocity bullets. The nerve might be engaged in the callus.He had seen three cases where Mauser bullets had goneclean through a nerve trunk. The function of the nervemight be disturbed when the bullet went quite close to thenerve trunk without actually cutting it. Nerves might beinvolved in cicatrices and he mentioned cases in illustration.Head injuries were some of the most successful surgicalcases he had met with. "Gutter fractures of the skullshould always be trephined ; the injury of the diploe insuch cases was often very great. That old dictum ofGuthrie that injuries of equal extent were more serious in thefrontal than in the mid-cerebral region, and in the latterthan in the post-cerebral region, was certainly not borne outby the experience of the present war. Mr. Dent exhibitedlantern slides of skiagrams and of Mooi river hospital andBoer trenches.
Sir WiLLlAM MAC CORMAC also gave an address on theWounded in the Present War, which appears in full at
p. 1485 of the present issue of THE LANCET. He exhibited a 100-pound shell which had been presented to himby Colonel Downing and the officers of the Royal Artillery.It was fired from the Boer Long Tom gun, "UmbulwanoBill," and 20 of such shells were fired into Ladysmith duringthe siege daily excepting Sundays. This gun was mountedon a disappearing carriage and it was capable of carrying10,000 yards (six miles). Another smaller shell, the firstfired by the Boers into the English lines at the battle ofColenso, was also shown.Major WILLIAM DicK, R.A.M.C. (Netley), had only had
experience of wounds after the men came back from the seatof war. There had been a large number of cases of paralysisof the musculo-spiral nerve. In one case he thought thenerve was divided, but he found at the operation that itwas intact. It was only damaged, and the patient com-pletely recovered. He believed small-bore bullets were moreoften deflected than was supposed, and he mentioned casesin point. He also mentioned several cases of abdominalwounds, and he believed that their successful issue had beenfavoured by the fact of the patients having been woundedwhen starving.
OTOLOGICAL SOCIETY OF THE UNITEDKINGDOM.
Exhibit’ion of Cases and Spechnena.AN ordinary meeting of this society was held on May 7th,.
Sir WILLIAM DALBY, the President, being in the chair.The PRESIDENT announced that Professor Politzer of
Vienna had been elected an honorary member by thecouncil.Mr. C. A. BALLANCE showed a case of Epithelial
Grafting of the Labyrinth after Removal of the Semi-circular Canals. A woman, aged 54 years, had had a dis-charge from the left ear since childhood. On May 7th, 1898,she was admitted into St. Thomas’s Hospital with a
large masto-squamous abscess, foul otorrhcea, and extremevert,igo. The old mastoid operation was performed, butdischarge from the ear and vertigo still persisted anddeafness was absolute. On Feb. 6th, 1900, Mr. Ballancefound a sinus leading into the petrous portion.The semicircular canals were in part removed, and thevestibule was opened, the remaining cavity being repeatedlyswabbed out with absolute phenol. For several days thepatient was very sick and giddy. On the 17th the cavitywas grafted. No giddiness or sickness occurred after thegrafting. On removing the plug on the 22nd the patientat once said that she could hear well. When shown at the
meeting the wound was soundly healed, the hearing beinggood, and the patient could run, being free from giddinessand also from tinnitus. Mr. Ballance pointed out that the
1516
case illustrated the boundless possibilities of epithelialgrafting when applied to the labyrinth for the cure of deaf-- ness.-The PRESIDENT thought that Mr. Ballance’s procedureopened up an enormous field for the future.-Dr. WJLLiAMMILLIGAN thought that the procedure could be adapted to all,cases of dry catarrh of the middle-ear, and for certain cases ofpost-suppurative fixation of the stapes ; he had accordinglyoperated on three cases of advanced dry catarrh in
which long previous treatment had been tried. He first
performed the complete post-aural operation and thenendeavoured to remove the stapes, or if the foot-platewas too ankylosed for removal he burred through it andthe adjacent part of the promontory, thus exposing thevestibule and providing a path for the direct transmission ofsonorous vibration to the internal ear. The final measureconsisted in grafting, as in Mr. Ballance’s suppurative cases.In one case the hearing had been somewhat improved. Themarked tinnitus had been to a great extent relieved.-Mr.HUGH JONES had performed Malherbe’s operation in one case,but the result was disappointing.-Mr. ARTHUR CHEATLEthought that opening the posterior labyrinth would be ofuse in all cases of increased tension as indicated by giddi-ness and tinnitus. In cases of dry catarrh of the middle-earhe suggested that the promontory should be opened throughthe meatus.-Mr. ERNEST WAGGETT thought that in allcases of increased labyrinthine tension the seals should betapped through the round window before attempting Mr.Ballance’s operation.-Dr. URBAN PRITCHARD, Mr. CUMBER-BATCH, Dr. DUNDAS GRANT, Dr. MACNAUGHTON JONES, andMr. C. H. FAGGE joined in the discussion.Mr. BALLANCE also showed a case in which an
Alveolar Sarcoma had involved the Petrous Bone, paralysingthe seventh, eighth, ninth, tenth, eleventh, and twelfthnerves and on which he had operated with success. Awoman, aged 32 years, was admitted into the NationalHospital, Queen-square, on Feb. 7th, with left facialparalysis, severe pain in the left ear, and difficulty in
swallowing. A polypus filled the meatus and there was somefoul discharge from the ear. The left side of the tongue waswasted and it was protruded to the left. Taste was absent onthe same side. The voice was nasal, the left side of the softpalate was paralysed, and fluids regurgitated through thenose. The left side of the pharynx was insensitive. Theleft vocal cord was fixed in the cadaveric position. Completeparalysis of the trapezius and sterno-mastoid muscles withatrophy was also present. On March 9th on opening thebone behind the ear a tumour was found which had destroyed
.
4the mastoid and petrous portions. Rapid enucleation of thetumour was performed, very considerable haemorrhage result-ing. The growth was adherent to the dura mater in theregion corresponding to the anterior and posterior surfaces ofthe petrous portion. On May 7th sound healing hadoccurred.Mr. ARTHUR CHEATLE showed (1) a case of Epithelioma
of the Meatus which had involved the Middle-ear and theParotid Region ; and (2) a case of Chronic Middle-earSuppuration with loss of the Head of the Malleus, the Incus,and the Crura of the Stapes.
Mr. C. H. FAGGE showed (1) a case in which Healing hadoccurred after Ossiculectomy (discharge had been presentfor 18 years) ; and (2) a case of Functional Nerve Deafness.
Dr. DUNDAS GRANT showed a case of Old-standingPerforation healed by the Application of TrichloraceticAcid.
Dr. MACNAUGHTON JONES showed a case of ContractedMeatus arising out of Chronic Otitis Media.
Dr. JOBSON HORNE exhibited the specimens and read thenotes of a case of Septic Thrombosis of the Right Lateraland the Superior Longitudinal Sinuses occurring with
broncho-pneumonia, associated with pus in the middle-ears,the membranes being intact. The diplococcus of pneumonia iamd pyogenic organisms were cultivated from the clot in the 1sinuses and from the middle-ear. It was suggested that the cinfection of the sinuses had occurred by way of the petro- 1squamosal sinus (which was very marked) from the middle- iear.-Mr. ARTHUR CHEATLE in discussing the case alluded ito Dr. Still’s investigations on the presence of infective pus tin the intact middle-ear of infants. He thought that if f
pathological changes in the lining membrane were present t
the condition could not be considered normal, and he ishowed a drawing and specimen of an illustrative case.- tMr. BALLANCE stated that the middle-ear of every child tunder five years of age contained muco-pus, but he was a
not prepared to say that the presence of an infective r
organism was normal. c c
EDINBURGH OBSTETRICAL SOCIETY.
Ex7tibition of Specirnens.-Ncrv Handle for Axis-traction
Mlroeps.- Vaporisation of the Endometrium - V1llva’l’ITaematoma in Lab01tr.A MEETING of this society was held on May 9th, Dr. R.
Mir,Nr MURRAY, the President, being in the chair.Professor A. R. SiMPSON showed (1) an Anencephalic
Fcetus and (2) a Bi-partite Placenta with a Single Amnionand a Single Uhild.
Dr. J. LAMOND LACKIE showed the Bladder and Kidneysfrom a case of Suppression of Urine in which there had beenevidence of tuberculous kidney for nine years.
Dr. G. MATHESON CULLEN showed (1) the Cervix and Partof the Vagina which had been thrown off after separation ina syphilitic patient, the cause not being known; and (2)Radiograms of Polydactyly. Out of a family of 13 childrenthree had deformed thumbs and the mother had also doublethumbs on both hands.
Dr. R. MILNE MURRAY showed a Cyclops Foetus whichlived a few hours.
Dr. J. FOULIS showed a New Handle for Axis-tractionForceps.
Professor A. R. Simpson read, a paper on Vaporisation ofthe Endometrium. In 1895 Dr. Neugebauer of Warsaw gavea preliminary notice of a paper by Professor Sneguiveff ofMoscow, who had for some years previously been makingobservations on the effect of steam as a basmostatic. It hadproved serviceable in various bmmorrhages and when appliedto the endometrium acted as a caustic, haemostatic, anees-thetic, and antiseptic. The apparatus consisted of a smallboiler for generating steam and a double catheter for con-veying the steam in and out of the uterine cavity. Dr.Ludwig Pincus of Danzig had tested the applicability of thisapparatus to a variety of cases and had studied the con-
ditions under which it might be employed. The operationwith the fenestrated catheter, where steam came directlyinto contact with the endometrium, he termed "atmo.kausis." Another operation with a non-fenestratedcatheter, the steam not being allowed to escape, hetermed "zestokausis." Pincus gave the following con-
clusions regarding the method of treatment:-1. Atmo-kausis and zestokausis were both effective and serviceabletherapeutic methods ; they were not more dangerous thanother intra-uterine procedures if the rules were carefullyfollowed. 2. The technique might be regarded as settled.3. The best results were obtained when it was applied apartfrom curetting, without narcosis, and with previous dilata-tion and protection of the cervix. The patient should restin bed till the slough separated, in slight cases till the thirdor the fourth day. 4. A dosage of the cauterisation from asuperficial influence to the most complete destruction of themucous membrane was absolutely possible. The dosagedepended on the temperature of the steam (which wasregulated by a thermometer attached to the boiler) and theconsistence of the uterus. The higher temperatures from110° to 115° C. were to be preferred. The shortest possibleduration with the highest temperature was best, especiallytill experience was gained in its use. 5. Both pro-cedures might replace or supplement curettage, andthey were indispensable when the curette failed. 6. Themethod acted as a specific against uterine haemorrhagesfrom whatever cause, and it gave good and rapid resultsin all forms of endometritis, metritis, and sub-involution.7. Obliteration or atrophy of the uterus could be obtained totake the place of extirpation by applying it for a longerperiod. 8. When atmokausis fails or produces only a
transitory effect the contractile elements of the uterus havebeen quite lost. 9. It was the best palliative in inoperableintra-uterine cancer. 10. It produced excellent results inthe early stage of sepsis following abortion or labour. Itxmid also be used for preliminary disinfection of the uterusDefore total extirpation and abdominal operations. 11. Sub-mucous myomata and malignant neoplasms must be excluded’rom the treatment 12. It was absolutely necessary thatjhe adnexa should be quite free from disease. Professor3impson bad, he said, employed this vaporisation in 14 cases;the application was continued in some cases for 45 seconds,n others for 60 seconds, and in one for 90 seconds. All ofhe patients in these cafes were under chloroform at theime, but only one patient complained of any sufferingafter it. The cases were all those of endometritis withmenorrhagia or metrorrhagia. Out of 14 cases 11 wereiured and the rest improved. Against atmokausis was
