637

the autoplastic flap became necrosed, sometimes over a thirdof its surface. Such an inconvenience, though it did no tinjure the value of the operation, greatly diminished its

1

utility, especially because it delayed healing. ProfessorTansini found out a way to avoid this inconvenience and

published the modifications to be made in his originalmethod. Studying the vessels of supply to the pedicle of theflap he noticed in them some important branches comingfrom the dorsalis scapulae (see Fig. 3), which is an

important branch of the subscapular artery. The dorsalis

scapulse runs between the teres major and the teresminor and sends branches to the latissimus dorsi and to theskin; the latissimus dorsi, besides the branches of thedorsalis scapulse, receives some branches straight fromthe subscapular artery. Tansini therefore proposed to includein the flap the latissimus dorsi and in order to insure a richblood-supply for the flap he proposed also to include a

portion of the teres major. In this way the flap becomesperfectly vital and compensates with the teres major for theloss of the pectoralis major muscle, while at the same timethe loss of substance of the latissimus dorsi makes it mucheasier to join the edges of the back wound.

Tansini’s directions for making the flap are as follows: "Thepedicle is to be about two inches and a half or two inches andthree-quarters wide and in order to include in it the most im-portant arterial branches its centre is to correspond to a pointwhich must be at one inch and a quarter from the posterioraxillary line and two inches from the spine of the scapula,and four inches from the inferior angle of the scapula. The

flap is of a long oval shape and of dimensions proportional tothe wound which is to be covered and is to be directed fromabove down and rather obliquely towards the median line ofthe back. The anterior edge of the pedicle is to start fromthe extremity of the axillary wound and afterwards when theflap is brought forwards it joins the anterior edge of thewound itself ; the posterior edge, which is cut into the skinof the back at about two and a quarter inches from theanterior edge so as to include the emerging point of thearterial branches above mentioned, is to join the posterioredge of the axillary wound." .

Professor Tansini applied this modified method to manypatients and obtained excellent results, so that both he andother surgeons have continued to adopt this method withgreat success. An accurate study of the different pro-cedures for the cure of cancer of the breast has been

published this year by Dr. Marzagalia, and clearly showsthe excellence of Tansini’s method; it also gives photo-graphic illustrations of the first two cases on which he

performed the modified operation. I have myself seen Iin the operative surgery clinic of the Royal Universityof Pavia the excellent results obtained by the newmethod and I give here the figures of two patients operatedon by Professor Tansini. From these figures the practicalvalue of the operation may be easily seen.To sum up, Tansini’s method consists first in removing

all the skin of the breast, compensating the loss of substanceby,the provision of a perfectly nourished flap which makes itpossible to approximate the skin edges in the region whenceit is taken by a lineal suture; the flap is formed fromskin rarely invaded by cancer and with its large pedicleabundantly covers the loss of skin of the axilla. The flapallows the arms to move freely. These points are made clearin the accompanying illustrations which represent actualcases on whom the operation has been done. (See Figs. 4

and 5, 6 and 7, 8 and 9, and 10 and 11.) .

YefeKCM.—Assaky : Ueber breiter Amputation mit NachMgenderAutoplastie, Miinchener Medicinische Wochenschrift, No. 10. 1899.Cestan : De l’Opportunité des Ablations Larges et du CurageAxillaire dans les Cancers du Sein, Archives Medicales deToulouse, Aout, 1902 Fantino: Sul Carcinoma della Mammella,Riforma Medica. 1898, Tome ii., p. 567. Guleke : Beitrag zur

Statistik des Mammacareinoms, Berlin, 1902. Tansini: NuovoProcesso per 1’Amputazione della Mammella per Cancro, RiformaMedica, No. 1, 1896 ; Sopra il mio Nuovo Processo rli

Amputazione della Mammella. Riforma Medica, No. 15. 1906.Kortweg : Die Statistiscben Resultate der Amputation des Brustkrebs,Langenbeck’s Archiv, 1888. Arbutbnot Lane : An Effectual Methodof Treating Extensive Malignant Disease of the Breast, THE LaNCFm,Oct. 12t.h. 1895. p. 904. Legueu: De l’Autoplastie par Glissement duSein, XII. Congres Francais de Chirurgie. Paris. 1898. Le Dentu :Le Cancer du Sein, Paris, 1902. Maiss : Zur Plastik nach Amputa-tion einer Carcinom Mamma, Munchener Medicinische Wochenschrift.No. 40, 1899. Meriel: L’Extirpation du Cancer du Sein, Paris, 1903.

1 Professor Purpura alludes to the dorsalis scapula as the circum-flexa scapulæ. We have thought it better to adopt the English nomen-clature to avoid the risk of confusion with the posterior circumflexbranch of the axillary artery.—ED. L.

Rotter: Zur Topographie des Mammacarcinoms, Archiv fiir KlinischeChirurgie, 1899, Tome ii., p. 58. Rodmann The Best Incision, in Opera-tion for Mammary Carcinoma, Annals of Surgery, 1901.

Pavia. ___________________

’

Medical Societies.ROYAL SOCIETY OF MEDICINE.

PATHOLOGICAL SECTION.

Acidosis in P’I’egnancy.A MEETING of this section was held on Feb. 18th, Mr.

S. G. SHATTOCK, the President, being in the chair.Mr. J. B. LEATHES read a paper on the subject of Acidosis

in Pregnancy which had come into prominence recently inpapers by Zweifel,l Williams,2 and Ewing and Wolf.3 In 18successive cases of eclampsia Zweifel found that there wasa smaller proportion of the nitrogen in the urine excretedin the form of urea than was normal ; the percentage ofthe total nitrogen excretion that was accounted for byurea varied in different cases from 27 to 70 per cent. ; theammonia nitrogen was, on the other hand, always high,and in one case amounted to 16’5 per cent. of the totalnitrogen. To account for the high ammonia coefficient Zweifelfound the urine frequently contained lactic acid. Largeramounts of lactic acid were generally found in the bloodand more in the placental and fce.al blood than inthe maternal. On those and other grounds the lactic acidwas regarded by him as the cause of the eclampsia. It hadbeen rightly pointed out that lactic acid might be present inthe blood in far larger amounts than those found by Zweifeland cause no inconvenience or symptoms of any kend,4 andthat after epileptic seizures, though not in the intervalsbetween them, far larger amounts were found in the urinewhich were fairly clearly the result of the convulsions and notthe cause.5 The muscles, it was known, produced and con-tained lactic acid when the supply of oxygen was deficient.6 Butthe high ammonia coefficients given by Zweifel’s patients, andconsiderably higher ones still, had been found by others indisorders of pregnancy. Williams described cases oftoxa3mic vomiting in the early months of pregnancy inwhich the ammonia in the urine accounted for 32, 35, and45 per cent. of the total nitrogen excreted, and in one

clinically identical case the liver showed central necrosis ofthe lobules similar to that found in acute yellow atrophy.Those cases had no jaundice, no albuminuria or other signsof renal disease and in two of them the liver dulness wasnormal, while in the third it was somewhat diminished.Such cases as those, and besides the three described fullythree others were referred to, Williams regarded as allied toyellow atrophy. The high ammonia coefficient was cbarac-teristic. It was not found in cases of neurotic or reflexhyperemesis, nor in the pre eclamptic toxasmia accon paniedby albuminuria, and therefore was an important diagnosticsign of a dangerous condition. A coefficient o’ 10 or 15 percent. he says would seem to justify the diagnosis of toxasmicvomiting and to afford an urgent indication for the prompttermination of the pregnancy." Ewing and Wolf gave amost valuable series of analyses of the urine in more than30 cases of pregnancy. he first six ca-es showed no !-ym-ptoms of abnormality except that in the urine of four of themthe ammonia coefficient was somewhat raised, in one case upto 11 per cent., and the urea was low ; and in all six the"undetermined" " nitrogen (urea, NHs. uric acid, andkreatinine were determined as well as the total N) gave highfigures, 14 and 15 per cent. even when the NH3 wasnot above the normal, and 24 per cent. in one case

when the NHJ coefficient was 11 per cent. The normal"undetermined" N coc-fficient was according to Folin’sestimations not more than about 6 per cent. Thenext six cases, characterised by very severe vomitingheginning early in pregnancy, were grouped together byEwing and Wolf as toxasmia. In four bf these the

1 Zweifel: Archiv für Gynäkologie, Band lxxii., p. 1, and Bandlxxvi , p. 536.

2 Williams : Johns Hopkins Hospital Bulletin. 1906, p 71.3 Ewing and Wolf : American Journal of Obstetrics, vol lv., No. 3.

4 Donath : Berliner Klinische Wechenschrift, 1907 p. 241.5 Mouze and Saiki: Zeitschrift für Physiologische Chemie, Band

xxxvii., p. 203.6 Hopkins and Fletcher : Journal of Physiology, vol. xxxv., p 247.

I3

638

urine was found to contain large amounts of ammonia,forming from 20 to 43 per cent. of the total nitrogenexcreted in one case. In the other two the ammonia co-efficient was normal but in all six the undetermined nitrogenwas at least doubled. Similarly, in the other three groups ofcases of pre-eclamptic toxaemia, eclampsia, and acute yellowatrophy, low urea and high ammonia coefficients were theTule and large amounts of undetermined nitrogen werecommon. The authors were disposed to regard the alterationin the proportion of the nitrogenous constituents of the urinewhich was common to all those conditions as a sign that theywere all results of the same underlying disturbance of themetabolism of the body. The point raised for discussionbefore the section was whether, with the data as yet available,it was justifiable to conclude that the abnormal compositionof the urine was in any way causally connected with thegrave conditions referred to. It was pointed out thatammonia coefficients such as those described were commonin starvation, in severe vomiting and diarrhoea., with dietsfrom which carbohydrates were excluded, in diabetes, andamongst other conditions in certain diseases of the liver. Inthose last cases there was some evidence that the associationof high ammonia coefficients with hepatic disease was

incidental rather than causal, and the same sort of connexionhas not yet been proved not to hold in the disorders ofpregnancy. More striking than the high ammonia coefficientwas the large amount of nitrogen in unknown combinations,for to account for that there were fewer possible knowncauses. It was particularly noteworthy that in completestarvation, so far as the available data went, there was noevidence for a similar phenomenon. But, on the other hand,there was some difficulty in attributing greater significance z,to that sign, as all the six cases described by Ewing andWolf as being free from symptoms of any grave disturbanceexcreted more than twice the normal amount of nitrogen in.such unknown combinations.

OBSTETRICAL AND GYNÆCOLOGICAL SECTION.

rlvarian .Dermoid with Secondary Cysts connected with the I07nentum. -Exhibition of 8pecimens. IA MEETING of this section was held on Feb. 13th, Dr.

HERBERT R. SPENCER, the President, being in the chair. ,

Dr. MARTIN RANDALL read a paper on Ovarian Dermoidwith Secondary Cysts connected with the Omentum, in-

cluding a pathological report by Mr. T. W. P. Lawrence. Dr.Randall described the case of a young woman who had apelvic tumour of the size of a hen’s egg situated in the rightposterior quarter of the pelvis rather high up. There were

symptoms of inflammation and the tumour was opened in theright iliac region and purulent-looking fluid with somevernix-like material escaped. The cavity was drained butsubsequently the cyst was removed by operation. Theomentum was observed to be studded with a large numberof small cysts containing cheesy material and hair and a

large piece of this structure was removed. Mr. Lawrencereported that the main tumour was a dermoid of the rightovary. As many as 50 minute cysts were found in theomentum. They were for the most part lined with cubicalepithelium and contained sebaceous material. The patientmade a good recovery but died a year later with symptomsof apoplexy.The PRESIDENT thanked Dr. Randall and Mr. Lawrence

for their valuable and interesting paper. He thought therewas little doubt that the fluid at the first operation wassebaceous and not purulent. He had been surprised to findhow frequently some operators met with " suppuratingdermoids." The explanation, he thought, was that thesebaceous material, fluid at the temperature of the body,closely resembled pus to the naked eye. In his experiencesuppuration rarely occurred in dermoids. A practical deduc.tion from this paper was the importance of removing theseand other ovarian tumours entire if they were not too large.This had been his practice for many years. He did not go sofar as Mr. J. Bland-Sutton, who removed all tumours, howeverlarge, entire, sometimes making an incision extending fromthe ensiform cartilage to the pubes. Such a long incisioncertainly to some extent increased the risk of omental andintestinal adhesions and of hernia.

Dr. A. L. GALABIN said that he had met with one

somewhat similar case in which there had been a furtherdevelopment of the metastases than in any of thosecollected by Dr. Randall. An unmarried lady, agedbetween 40 and 50 years, came with a large tumour

the history of the duration of which was quite indefinite.She said that her abdomen had been large for as longas she could remember. An ovarian tumour was dia-gnosed. At the operation it turned out to be a dermoid andwas removed with difficulty on account of universal adhe-sions. Among the adhesions and over the peritoneum werescattered very numerous thin-walled cysts containingsebaceous fluid like that in the main cyst. These existedalso in the cellular tissue of the abdominal wall and pelvisso that a number of them were divided in the abdominalincision. No skin-like structure was seen in the secondarycysts. Those on the peritoneum were thin-walled but in thecellular tissue no definite cyst wall could be detected. A

good deal of sebaceous matter had to be left unremoved butthe incision healed well in the first instance. After someweeks it broke down again and a discharge of oily fluidbegan which later became semi-purulent. The patientremained ill many months and it was feared that the con.dition might run a malignant course, but eventually the sinusclosed, she recovered completely, and was well after severalyears. Dr. Galabin agreed with the President that it wasdesirable if possible to remove a small or medium-sizeddermoid cyst entire.

Dr. R. H. HODGSON remarked on the fact that someof the cases alluded to died with septic symptoms.He suggested that they might have been saved had hexa-methylene-tetramine been used. He bad experimented withit in large and small quantities in many and varied diseases,and had found it most valuable in septic diseases, but itneeded to be used with caution. The kidneys afforded thefirst and most marked signs that the drug was in excess.He strongly suggested its use to those who had much opera-tive work on the peritoneum.

Dr. H. MACNAUGHTON-JONES said that there must havebeen some thousands of ruptured dermoid cysts and yet onlythe cases mentioned had been recorded. It did not appeartherefore that there was any great danger of metastasis orimplantation in the case of simple dermoids.

Dr. AMAND J. M. RouTH had seen several cases wheredermoid cysts of the ovary had ruptured before or duringthe operation without such sequelae as had been described.Were Dr. Randall and Mr. Lawrence able to discriminatebetween dermoids which were innocent and those the cellsof which were liable to be transplanted and to develop intoproliferating cysts as in the cases recorded by them ? 1The following specimens were exhibited :-The PRESIDENT : Caseating Carcinoma of the Corpus Uteri.Dr. MACNAUGHTON JONES : Hasmatosalpinx complicating

a Myomatous Uterus.Mr. EARDLEY L. HOLLAND: A Melanotic Tumour of the

Vulva.Dr. AJlfAND ROUTH: A Placenta Diffusa.

MEDICAL SOCIETY OF LONDON.

Chemical Examination of the Gastric Contents after a TestMeal. -Tlte Eaeperimental Produetion of Oast’J’1,C Uloerationby Injection of Gastrotoxin.A MEETING of this society was held on Feb. 24th, Dr. J.

KINGSTON FOWLER, the President, being in the chair.Dr. W. H. WILLCOX read a paper on the Importance and

Significance of the Chemical Examination of the GastricContents after a Test Meal. He emphasised the importanceand necessity of the thorough and systematic examinationof the gastric contents in cases presenting persistentdyspeptic symptoms. It was only by that means thata trustworthy diagnosis could be arrived at in manycases. The lack of information as to the nature ofthe gastric contents in the different forms of dyspepsiaand gastric diseases was deplored, and it was pointed outhow necessary it was that cases of that class should besystematically investigated in order that more accurateknowledge might be obtained of the condition of the gastriccontents. The importance of the investigation in directingtreatment along the right lines was insisted upon. It was

pointed out that in every case it was necessary that both theclinical history and symptoms should be fully considered inconjunction with the result of the analysis of the gastric con-tents. An analysis alone was not sufficient to enable one toform a trustworthy diagnosis. The chemical evidenceand the clinical evidence were supplementary to one another.The results of a complete analysis of the gastric contents