1386mouth to a less extent, receded by a general feverish condi-tion and accompanieq. by swollen and painful joints.Traumatic bleeding in their case is also very persistent. Theremaining two daughters, aged 17 years and 19 years respec-tively, are subject to very frequent and serious epistaxis aswell as oozing of blood iroca the gums around decayed teeth.For some days previously to the onset they complain offrontal headache, feeling languid and faint, loss of appetite,and pains in the back. The joints become swollen and pain-ful ; the knees, ank’es, and wrists are those principally in-volved. Perspiration starts with the bleeding, steam actuallyrising from their bodies. The loss of blood leaves them veryweak, anasmic, and short of breath, but they seem rapidly toregain their health and strength again until another attacklays them prostrate. Menstruation is excessive in both casesand haemorrhage from a cut or wound is extremely resistantto treatment. The mother of these children has told me sheis kept constantly busy washing blood-stained clothsas it rarely happens for even a few days to pass withoutsome member of her household bleeding. There can be nodoubt that the disposition has been transmitted through Ithe male line, the mothers of the two families having Ino history whatever of any tendency from either side tothis affection.When the patients have come under treatment the usual

remedies have been tried with varying success, such as ergot,tinctura ferri perchloridi and calcium chloride internally,adrenalin externally, with rest and compression. I amrather anxious to know if there is any recognised form oftreatment which would tend to counteract this tendency toabnormal bleeding.The comparative rarity of these cases, together with the

sense of helplessness in regard to treatment which confrontsthe ordinary practitioner, are my reasons for bringing themunder notice.

Attercliffe, Sheffield.

Medical Societies.ROYAL SOCIETY OF MEDICINE.

MEDICAL SECTION.

Oomplioations of Pne?lmonia.A MEETING of this section was held on Nov. 5th, Dr. S. J.

GEE, the President, being in the chair.Dr. W. J. HADLEY, in reopening the adjourned dis-

cussion on the Complications of Pneumonia, said thatthe statistics supplied by the medical registrars of theLondon Hospital referred to the last ten years, andthey must remember that those figures came from theworking classes and he thought that they would differin many ways from those collected from the well-to-do.In the first place it was noticeable that pneumonia wasthree times as common in the male as in the female. Thatdifference held in all the returns except where children wereconcerned (East London Hospital for Children) where thefigures stood at 443 males to 316 females. Secondly, thefigures showed that mortality increased with age fromabout 5 per cent. to 49 per cent. Thirdly, it wasseen that the mortality was rather higher in femalesthan in males, males being 23-21 per cent, andfemales 25’45 per cent. In considering complications,it was most important to separate antecedent conditionsfrom those which resulted from the disease itself. Manyantecedent conditions considerably influenced the mortality.With alcohol as an antecedent condition the death-rate was66· 66 per cent. out of 105 cases. With cardio vasculardisease (including aneurysm) as an antecedent the death-ratewas 46 ’ 14 per cent. out of 91 cases. In the case of chronicnephritis it was 82 6 per cent. out of 23 cases, andwith chronic pulmonary troubles as an antecedentcondition the death-rate was 31’ 64 per cent. outof 79 cases. In many of those cases the deathwas not due to the pneumonia at all but to the originaldisease, whilst in others it was simply a modus moriendi,At the same time it was most important to remember thegreatly increased danger of pneumonia occurring in thecourse of some chronic diseases. Of complications as aresult of pneumonia itself empyema, delirium, and peri-carditis were the most important, and gangrene, abscess,

endocarditis, and pericarditis were the most fatal. Peri-carditis in a bad case of pneumonia was a difficult thing todiagnose and was often unsuspected ; it should be most care-fully watched for, as there was but little chance for the patientunless the pericarditis was opened and drained. It should benoted that, especially in the young, a pericardium distendedwith fluid pushed directly backwards and gave rise to markeddulness at the left base posteriorly simulating consolidation orfluid of the left lung and showed very little in front unlesscarefully searched for, when the displaced apex beat, hiddenheart, and muffled sounds could generally be made out. Inregard to abscess as a complication of pneumonia it was

frequently an interlobar empyema. Concerning meningitis itmust be borne in mind that meningeal symptoms were oftenpresent as a result of toxasmia. without any meningitis. Re-traction, headache, vomiting, irregularity of pupils, squint,fits, and twitchings might be observed, and he had seen themastoids explored in such circumstances. Referring to

peritonitis and colitis complicating pneumonia, Dr. Hadleysaid that abdominal pneumonia " was a condition whichthey must recognise. They were quite familiar with thecase admitted as appendicitis which after or before

operation was transferred to the medical side as a pneu-monia. They had probably all read the accounts ofoutbreaks of pneumonia in an institution where it wasnoticeable that many of the cases were purely abdominal,resembling enteric fever. He had seen an epidemic in acountry village where nearly half the cases were abdominal,resembling enteric fever but of shorter duration, and severaloccurring in the same house, some being abdominal andothers pulmonary. Sometimes acute paralytic distension ofthe stomach occurred which was apparently toxic, but it wasoften seen in lesser degree in the intestines, especially thecolon. He knew nothing which embarrassed the heart somuch in pneumonia and it was most important to get rid ofit by enemas or by using a long tube. He had left the tubein sometimes as the condition recurred so frequently.Gentle massage would often enable the patients to pass theilatua through the tube readily. In regard to arthritis as acomplication of pneumonia, he noted that most of thecases were in patients younger than ten years of age. Thetreatment by inoculations was hindered by the difficulty ofgetting cultures. The acuteness of the disease made it hardto get vaccine before the crisis occurred and many cases wereadmitted to hospital only a short time before the crisis. Inhis opinion the more chronic complications would give thebest chance for inoculations such as arthritis and empyema.Pneumonia, rheumatism, and tubercle formed a group of

which it could be said that one attack appeared to predisposeto subsequent ones. With such a characteristic how couldthey expect a preventive inoculation; at any rate the

immunity must be very short-lived.Dr. N. DALTON considered that when lysis was observed it

could be explained by the fact that there was some latentcomplication or some secondary infection interfering withthe ordinary course of the pneumonia. With reference todilatation of the stomach he did not think that it was anuncommon complication.

Dr. A. M. GOSSAGE thought that the complications ofpneumonia were more important in childhood than in adultlife and the death-rate in children from complications washigher than in adults. In children under the age of one yearit was found that there was great mortality from thetoxoamia of pneumonia. In children a’large number of casesoccurred of primary pneumococcic empyema.

Dr. A. C. LATHAM said that, judging from the monthly re-turns made at St. George’s Hospital, the maximum incidenceof pneumonia was in May and in October. About May peoplewere prone to take to their thin clothes too soon and aboutOctober people sometimes failed to take to their warmerclothing soon enough. He had been told that the Bulawayohospital statistics showed that in the rainy season the bedswere full of cases of malaria and in the cold season the hos-pital was crowded with cases of pneumonia. In regard to theknee-jerk in pneumonia, out of 120 cases investigated it waspresent in 90, and it was sluggish or absent in the remainingbO. Referring to the treatment of pneumonia by anti-diphtheritic serum he said that it had been tried in severecases where the prognosis was grave and in no case in whichthe serum had been given had the temperature reached thepoint where it stood before the introduction of the serum.

Dr. J. FAWCETT stated that the Guy’s Hospital cases did notinclude " terminal pneumonias and that probably accountedfor the fact that the mortality-ratio was only 15 - 6 per cent. ;

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if "terminal" cases were included the mortality-ratio was19’9 per cent. It seemed of importance for the propercollation of those cases that the statistics should be correctedin that particular. He then drew attention to Dr. HectorMackenzie’s statement in reference to the fact that no caseof pleural effnsion requiring paracentesis had occurred inthe figures of ten years from St. Thomas’s Hospital. The

rarity of that complication was well known, but at the sametime his experience seemed somewhat exceptional. In the15 cases recorded from Gay’s Hospital only three requiredtapping and even in those the quantities removed were small-namely, a pint, half a pint, and a pint respectively. Therewas no case of chronic pneumonia among the Guy’s Hospitalcases and in looking over the records for 23 years there wasno case of the kind which without doubt followed lobar

pneumonia.Dr. H. A. CALEY said the occurrence of empyema

materially influenced the gravity of a case of pneumoniabut not to so great an extent as some of the hospitalstatistics suggested. After commenting on the myocardialweakness recognised in cases of pneumonia he went on todescribe the toxsemia, pyrexia, and deficient oxygenationwhich were usually present in grave cases of pneumonia.He thought that primary muscular weakness due to those Ithree factors was very important. There were certain casesof pneumonia following influenza in which death ensuedvery rapidly with symptoms of cardiac and respiratoryfailure and the question arose as to whether those deathswere not due to a toxsemic depression of the medullarycentres.Dr. S. WEST said that in regard to knee-jerks in pneumonia

they were important from the point of view of prognosis. Inthose cases where the knee-jerks disappeared late the

prognosis was more favourable than in those cases where

they disappeared early. It was probable that furtherresearch would lead them to take the same view about the

pneumococcus as they held about the streptococcus, of whichthere were several kinds producing different pathogenicresults.

After Dr. W. LANGDON BROWN had spoken Dr. MACKENZIEwound up the debate. He remarked that it showed the

comparative rarity of the complications of pneumonia and hesuggested that the Royal Society of Medicine shouldapproach the hospitals with the view of obtaining statisticsconcerning the cases of pneumonia treated by vaccines.

SURGICAL SECTION.

Removal of Goitre by Operation.A meeting of this section was held on Nov. 12th, Mr.

J. WARRINGTON HAWARD being in the chair.Mr. JAMES BERRY read a paper entitled "An Analysis

of 274 Additional Cases of Removal of Goitre by Opera.tion," which will be found printed in full in this issue ofTHE LANCET, p. 1366.Mr. WARRINGTON HAWARD said that ether had not been

used in the operation. The cause of death in the smallmortality in the series of cases was ascribed to cardiacfailure. If some more stimulating anesthetic than chloro-form had been used, such as ether, cardiac failure mighthave been lessened.

Sir VICTOR HORSLEY said that he believed Kocher did notuse drainage in the majority of cases at the present time buthe (Sir Victor Horsley) agreed with Mr. Berry in draining for ’a brief period. He had never allowed anaesthetists to give

I

ether in those operations for the last ten years because thepatient secreted mucus freely. If dyspnoea was observed inthe patient on the operating table the anaesthetist was eithergiving too much chloroform or he was not giving the right Ikind of anaesthetic.Mr. W. G. SPENCER said that quite apart from cases of

exophthalmic goitre where there was dyspnoea there werecases without enlargement suffering from extreme rapidityof pulse in which he thought a small operation was beneficial-that is to say, dividing the isthmus and taking away alittle thyroid gland on each side. He advocated operatingon patients late in life with enlargement of the thyroid glandbecause the tumour might become malignant.

Mr. H. J. PATERSON described the use of the open methodof giving ether in operations on the thyroid and said that itdid not cause any increased secretion of mucus.Mr. BERRY, in reply, said that ether by the open method

was well worthy of a trial.

CLINICAL SECTION.

Exhibition of Cases.A MEETING of this section was held on Nov. 8th, Sir

THOMAS BARLOW, the President, being in the chair.Mr. JONATHAN HUTCHINSON, jun., showed a case of

Trigeminal Neuralgia. The patient was a man who hadsuffered for five years from epileptiform neuralgia. An intra-cranial neurotomy of the second and third divisions of thefifth nerve had proved unsuccessful, so Mr. Hutchinsonremoved the Gasserian ganglion leaving the ophthalmicdivision, with the result that there was complete relief frompain. The case showed that intracranial neurotomy in suchcases was not followed by permanent cessation of thesymptoms.

Dr. BERTRAM L. ABRAHAMS showed a case of Myopathy.The patient was a man, aged 43 years. There was wastingof the pectoralis major, quadriceps, gluteus maximus, andsupraspinatus on both sides, and to a less extent of thepronato-flexors of the left wrist, right hypothenar muscles,and both latissimi dorsi, together with the abductor andadductor muscles of the thighs. The calf muscles wereflabby. There was hypertrophy of the deltoids and serratimagni, and to a less degree of the infraspinatus and rectusabdominis. The erect posture was only maintained byviolent lordosis ; the ascent from the horizontal was effectedby "climbing up" the legs. The gait was straddling, on awide base, and the patient walked entirely on his toes, theheels never touching the ground. Dr. Abrahams pointedout the unusual features in the case and showed that it wasmost nearly allied to Erb’s juvenile form of muscular

atrophy but that the anomalies presented lent support tothe view that all the true myopathies were varieties of thesame disease.Mr. T. H. OPENSHAW showed a case of Recurrent Disloca-

tion of the Shoulders cured by operation. The patient wasaged 27 years. He had been the subject of recurrent dis-locations of the shoulders, the result of epileptic fits since1896. He had been treated with injections into the joint,rest, and splinting without avail. The right shoulder-jointhad been dislocated 50 times. Removal of a small portionof cartilage from the surfaces of the joint had proved ineffec-tual. Division of the pectoralis major was also ineffectual inpreventing re-dislocation. The successful operation con-

sisted in detaching the insertion of the subscapuiaris fromthe humerus and attaching it to a portion of the deltoidmuscle. Mr. Openshaw had performed that operation threetimes, with a permanent cure in each case. The cases hadbeen watched for six years, two years, and 16 monthsrespectively.

Dr. W. P. HERRINGHAM showed a case of Pigmentationwith Enlarged Spleen and Leucopenia. The patient was aman, aged 40 years, of hitherto excellent health andphysique, who had never left England or suffered fromsyphilis. For two years he had noticed pigmentation overthe body ; he had lost two stones of weight in the lastyear; for six months he had been feeling languid, and forfive months had felt too weak to work. He began to vomitabout five months ago in periodic attacks which lasted some.times as long as three days and the vomit had thrice con-tained blood. The whole of the body was pigmented, withpatches of lighter colour at the sides. The penis and scrotumwere parti-coloured, some parts being very dark and otherslighter than natural. The neck was very dark also. Therewere light patches, which appeared even lighter than natural,on the cheeks, and there were normal patches on the hands.The spleen was much enlarged, nearly to the umbilical leveland nearly to the middle line. The man had greatly im-proved in strength and had had no vomiting since admissionto hospital. He had been treated with liquor arsenicalis in10-minim doses.

Dr. HERRINGHAM also showed a case of Neuritis of the

Right Brachial Plexus following an attack of rheumatism.The patient was a lad, aged 17 years, who on August 23rdwas suffering from a swelling of the right wrist-joint. Therewas no evidence of endocarditis, old or recent. After two orthree days’ treatment with salicylate of sodium the swellingin the wrist had gone and he was free from pain. But on

Sept. 3rd he again complained of pain in the right shoulder,and on the 7th some wasting was visible in the deltoid.There was considerable tenderness on pressure of the soft partsin the axilla against the head of the humerus. Completereaction of degeneration was found in the deltoid on

Sept. 18bb. Patches of anaesthesia, some slight and others

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marked, made their appearance in areas involving almostevery root in the plexus. The musculo-spiral could be feltthickened and tender on the outer side of the humerus. Thelesions spread. On Oct. 3rd there was reaction of degenera-tion in the spinati, deltoid, biceps, and brachialis anticus,and weakness in the extensors and flexors in the forearm.The flexor carpi ulnaris and the intrinsic muscles of thehands were normal. On Nov. 5th he had regained a littlepower in the movements of the wrist. He had been treatedat first by salicylate of sodium in 20-grain doses and latelyby electricity, intra-muscular injections of strychnine, andthyroid extract.-In reply to some remarks of Dr. SIDNEYPHILLIPS Dr. HERRINGHAM said the neuritis might bedescribed as perineuritis.

Dr. R. MURRAY LESLIE showed two cases of CongenitalHeart Disease in adults. The first was that of a woman,aged 22 years, who had cyanosis and clubbing of thefingers from birth. She was intensely cyanosed, the

lips, the ears, the nose, and the tongue being of a

dark bluish-violet colour. A soft blowing systolic murmurwas audible over the left margin of the sternum, the

point of maximum intensity being the fourth left costalcartilage. There were probably a patent ventricular septumand other associated abnormalities. The main interestof the case lay in the fact that the patient had been.able to reach adult life in spite of the extreme degree ofcyanosis. The second case was that of a woman, aged30 years, who had been under observation for the past tenyears. At the age of nine years the case was diagnosedas pulmonary stenosis. The patient was a well-nourished,almost adipose, woman and complained principally ofattacks of giddiness and breathlessness. There was a

moderate degree of cyanosis, most noticeable in the lips. Thefingers were clubbed and the nails were livid. The tempera-ture was subnormal. The skiagram showed marked enlarge-ment of the right ventricle. There was a loud harsh systolicmurmur audible over the praecordia but loudest in the

pulmonary area. The principal lesion in this case was

undoubtedly pulmonary stenosis although there was probablyalso some patency of the septum. The interest of the caselay in the fact that the patient had now entered her fourthdecade and appeared to be in better health than ever.

Dr. A. M. H. GRAY (introduced by Dr. H. BATTY SHAW)showed a woman, aged 41 years, with typical signs ofMyxcedema who gave a history of having suffered 16 yearspreviously from exophthalmic goitre. When first seen threeyears ago she had a considerable quantity of fluid in theabdomen and had been tapped on two occasions within theprevious two years ; the history and physical signs suggestedthe possibility of a ruptured ovarian cyst. The ascites, how- I

ever, cleared up completely after giving thyroid extract bythe mouth but recurred to a slight degree when the treat-ment was discontinued and again disappeared on resumingtreatment. The thyroid gland could not now be felt but asmall papillary growth of the size of a pea was present on thedorsum of the tongue near the foramen casoum and thequestion was raised as to whether this might be a lingualgoitre or a papilloma of the tongue.-In reply to Dr. L. GGLOVER, the PRESIDENT observed that in Vols. XXXI. andXXXII. of the Transactions of the Clinical Society a caseof myxoedema supervening on Graves’s disease was de-scribed.

Dr. JOHN FAWCETT read a paper on Pneumothorax treatedby Aspiration under the X Rays. The patient, a man, aged22 years, was admitted into Guy’s Hospital on June 5th, 1907,with a pneumothorax on the right side. 19 days after theonset of the pain the condition of the chest was found to bemuch the same as on admission, very little absorption of airhaving taken place. The patient was placed on his back onthe couch in the x ray room. The screen was put over

the front of the chest and a trocar and cannula of the usualform employed in aspirating the pleural cavity were theninserted into the pleural sac in front of the posterior axillaryfold in the sixth or seventh space. The lung was seen com-pressed towards the spine and therefore the distance that thetrocar could be passed so as not to touch the lung could bedetermined. As the lung expanded the cannula was graduallywithdrawn until it was flush with the inner surface of thechest wall; when the lung appeared to be expanded fullythe cannula was withdrawn and the puncture sealed. The

lung was seen to remain expanded and to expand and to re-tract with the respiratory movements. The improvement andrelief produced by aspiration were immediate and persistent.The patient was seen again on Nov. 6th last; he locked in

excellent health and said he felt so well that he had con-tinued his work regularly. _LARYNGOLOGICAL SECTION.

I Exhibition of Cases and 60MMM.The first meeting of this section was held on Nov. lst,

Dr. J. BARRY BALL, the President, being in the chair.After the PRESIDENT had announced the receipt of

messages wishing success to the section the following com-munications were made :-Mr. ALEXANDER R. TWEEDIE exhibited a microscopic

specimen of a Localised Pulsating Growth of the MiddleTurbinal which had given rise to recurrent severe epistaxis.

Dr. DAN MCKENZIE showed a case of Paresis of the RightVocal Cord and a case of Fistulous Opening in the middleline of the neck ; the latter was considered to be a persistentthyro-glossal duct.

Mr. F. A. ROSE exhibited a Chicken Bone which wasremoved after nearly 48 hours’ impaction in the larynx butwhich had caused neither dyspnoea nor cough.Mr. HAROLD S. BARWELL showed a case of an extreme form

of Septal Deviation ; various opinions were expressed as totreatment. He also showed a case in which Thyrotomy hasbeen performed one year and nine months before for Tuber-culous Laryngitis ; the larynx remained soundly healed andthe lung disease was quiescent and in an early stage; therehad been aphonia for 15 months before operation but thevoice had now returned.

Dr. L. H. PEGLER showed a case of Tumour Attached tothe Entire Length of the Vocal Cord ; opinions as to itsnature differed.

Dr. STCLAIR THOMSON showed (1) a case of DoubleFrontal Sinus Operation allowing comparison between theOgston-Luc and the Killian methods; and (2) a woman,aged 40 years, in whom Extensive Tuberculous Laryngitishad become healed after tracheotomy and galvano-cauterisa-tion.-Discussing the latter case Dr. J. DUNDAS GRANTagreed in recommending the cautery.

Dr. E. FURNISS POTTER exhibited a Tumour removed fromthe Naso-pharynx 15 weeks after operation for adenoids ; itwas considered that it consisted of blood-clot with a remnantof the adenoid vegetation.Dr. PETER H. ABERCROMBIE made a further report on a case

of Cellulitis of the Neck shown before the LaryngologicalSociety in January, 1907 ; the case had proved to be one ofepithelioma of the right side of the epiglottis, half of whichhad now been removed.-Mr. P. R. W. DE SANTI thoughtthat a more extensive operation should be performed.

Dr. E. A. PETERS showed a case of Functional Paresis ofthe Palate and Cords.

Dr. F. SPICER showed a case of Ulceration of the LeftCord in a man, aged 40 years, who had been treated forhoarseness in 1903; there was a general opinion that thedisease was malignant and farther exploration was

recommended.Mr. H. CLAYTON Fox showed a case of Crusting in the

Nose without Atrophy of the Turbinals.Dr. W. JOBSON HORNE showed a case of Symmetrical

Tumours on the Vocal Processes and a case of InflammatoryNasal Obstruction apparently due to Syphilis.

Dr. HERBERT TILLEY exhibited a patient suffering fromNasal Syphilis.

MEDICAL SOCIETY OF LONDON.

Exhibition of Cases.A MEETING of this society was held on Nov. llth, Dr.

J. KINGSTON FOWLER, the President, being in the chair.Dr. G. F. STILL showed a case of Cleido-cranial Dysostosis.

The patient was a boy aged six years. He was backward inwalking and was only beginning to talk at three years andten months. His thumbs were remarkable, the terminalphalanx of each appearing unduly short, with the nail curvedantero-posteriorly. In the position of the anterior fontanelleossification had failed, so that there was a widely openfontanelle which measured 44 inches antero-posteriorly and3 inches laterally ; its margins were not quite regular inoutline. The clavicles showed a deficiency of the outer part.- Dr. F. J. POYNTON described a case in which the Clavicleswere Absent but the Fontanelles were Closed.—Dr. STILL saidthat in these cases general dwarfing of the whole skeletonsometimes occurred.