Royal Academy of Medicine in Ireland

PART III.

MEDICAL MISCELLANY.

R~ports, Tra~.nsactions, a~d Scientific TreteUigence.

ROYAL A C A D E M Y OF M E D I C I N E I N I I ~ E L A N D .

Pres ident - -WALTER G. SMITH, M . D . , F . R . C . P . t .

Genera l S e c r e t ~ r y - - J . A. SCOTT, M . D . , F . I ~ . C . S . I .

SECTION OF PATHOLOGY.

President,--J. B. COLEMAN, M.D., F.R.C.P.I. Sectional Secretary----T. T. O'FARRELL, ~.I~.C.S.I.

Friday, January 22, 1915.

THE PRESIDENT in the Chair.

Exhibits.

Two Cases o] Lymphangeioma of the Con]unctiva. DR. EU~HAN MAXWELL said tha t in the first case the pat ient could not be shown as she had developed scarlatina. The patient was a girl aged three and a half years, whose parents noticed that she had a cold in the right eye since birth. The lower half of the conjunctiva was raised, and when touched with a probe had a boggy feeling. A piece of the growth was removed for examination, and the whole tissue then became diffused with blood and remained bright red for some days. The child was taken from hospital by t~he parents. The section showed several spaces lined with endothelial, epithelial, and a few round cells. The child was brought~ back to hospital with a purulent discharge from the conjunctiva. The growt~h had increased, and now involved not only the lower half of the conjunctiva but the inner half as well. A boggi- ness Mso appeared above the right eyebrow, but there seemed

8evtion o/ Pathology. 129

to be no communication between it and the conjunctival growth. Trea tment by electrolysis was commenced, but it was interrupted by the development of broncho-pneumonia, and now the child had scarlatina.

DR. MAXWELL said the pat ient in the second case (who was brought forward) was a l ~ a girl aged three and a half years. The appearance was somewhat similar to tha t described in the previous case, but the growth seemed to involve the orbit. The history was that the parents had noticed that the left eye protruded since the child was ten months old. The fundus was examined and found to be normal, and the vision was the same in both eyes. The eye was displaced downwards and outwards and the motion was slightly limited. The orbit was explored under an ansesthetic, but nothing could be seen or felt from the outer side. The con- junetival growth appeared to go backwards indefinitely. The t rea tment adopted in this case also was electrolysis. The proptosis had lessened by one m.m. , the original amount of proptosis being 3 m.m. , and tlhe conjunctiva had shown considerable improvement.

The proptometer was shown and its use demonstrated. Dr. Maxwell said tha t according to the literature on the

subject it seemed tha t the predisposition to these lympb- angciomata is present at birth, but that the earlier stages of their growth was gradual. The first case certainly bore out the s ta tement as to their early appearance, and probably in the second case the growth had been in the orbit some time before it had caused sufficient protrusion of the eye-ball to be noticeable. Lymphange iomata of the conjunetiva do not seem to be so very uncommon, but they are extremely so in the orbit (according to Parsons only five such cases are recorded). All authors are agreed as to electrolysis being likely to produce the best results.

Trm PRESIDENT remarked tha t the condition appeared to be rare, but that possibly they all saw cases of it from time to Lime without making a correct diagnosis. He thought it would be of interest if Dr. Maxwell explained the way in whittle the electrolysis was applied, and also the length of t ime for which the t rea tment is necessary.

Dm MAXWelL, replying, said the method of electrolysis was- -A needle is attached to the negative pole and inserted for about half a minute into the tumour, and this was r e .

I

130 Royal Academy o/ Medicine in Ireland.

pealed every ten days. The patient was pug under an anaesthetic. She could not say how long ~he treatment would require to be carried on, but she presumed that this would depend on how the patient reacted.

Enlarged Thymus.

DR. A. R. PARSOSS said ~hat in Sir Patrick Dun 's Hos- pital he had met witch five cases in young children, aged from two to five years, in whic~h death occurred suddenly, and on examining them he was struck by the size of t~he solitary follicles of the intestine and of ~he mesenterie glands. Dr. Walter Smith had exhibited these cases before the British Medical Association in 1891, and no one was able to ~hrow any light on the pathology. The exhibi~ now shown was taken from a child aged nine, who was admitted to hospital at two o'clock on Christmas Day. The history was that the child was well until 5 p.m. on t~he previous day, when it became delirious. I t was found impossible to make a satisfactory examination on admission on account of t~he rest- lessness of tJhe child. He was extremely emaciated, and the pulse was uncountable. The first impression was that it was meningitis. I t was impossible to obtain a specimen of the urine. The child died at 7 o'clock, or five hours after admission. At the autopsy some of the urine was obtained, and, except for a slight trace of albumen, was normal. Enlarge- ment of the thymus gland was ~hc only thing found. In this case there was no enlargement of t~he mesenteric gland or of the solitary follicles of the intestine.

Acidosis in a Case o] Typhoid Fever. DR. A. R. PARSONS said that this was a case of a boy, aged

eleven years, who was ricke~ty almost~ from his birth, and he was admitted to hospital as probably a case of Friedreich's ataxia. He had difficulty in walking, and swayed from side to side. For the first, two or three days he had no idea of what was wrong. There was no nystagmus, and the knee-jerks were only slightly exaggerated. On the ~hird morning after admission a marked change was noticeable. He was stupid, cold, and his hands were bluish; he also vomited. I t wa.~ thought that~ he was suffering from acidosis, and on examination of the urine an amount of aceto-acetie acid and acetone was discovered, Next evening his respirations were laboured,

Section of Pathology. 131

He was cold, barely conscious, and the clinical pictmre was like that of a boy in diabetic coma. The fundus was examined and found to be perfectly normal. On the following morning some members of the class noticed a sweet odour from the breath. On free administration of alkali by the mout~h t.he lad gradually recovered, and after some days the aceto-aeetic acid and acetone disappeared from tile urine. An at tempt was made to get him ~ walk, but he was very weak on the limbs. After three or four weeks in hospital the tem- perature, which was previously normal, rapidly rose, and he then died. In the same ward there had been three cases which developed typhoid fever, and when the post-mortem examination was made, evidence of typhoid was found. There was marked enlargement of the solitary gland, and the typhoid bacillus was isola$ed from the spleen. There were two points of interest in the case--/.e., for a boy of eleven, who had never taken vigorous exercise, the heart was very large, and his liver also was enlarged. No explanagion of the acidosis in the first instance was forthcoming. In the second instance it might have been a febrile acidosis.

PROFESSOR A. C. 0'Sur,LIVAN 'had satisfied himself that there was ulceration of the intestine glands.

Malignant Disease o] the Stomach. DR. A. R. PARSONS said this specimen was removed from

a man, aged forty-five, who was admitted last September complaining of abdominal pain and weakness, l ie was extremely emaciated, and weighed only 5 st. 12 lbs. Notwii~h- standing his condition, the always said he was gett4ng on well. During his time in hospital he took a fair amount of food, but had no desire for meat. l ie was practically free from vomit- ing. Physical examination revealed nothing beyond some slight crepitus in the hmgs. The upper part of the abdomen was a little resistant, but it was impossible to find any tumour. He was given a test meal, and a very small quan- tity of fluid was obtained and a small clot of blood. The fluid was acid in reaction, but contained no free hydrochloric acid. I t was suspected ghat the man was probably suffering from cancer of the pancreas or growt.h on the anterior wall of the stomach, which could not be got at. l ie was under obser- vation three months, and died a fortnight ago. On post- mortem examination t'hc liver was found absolutely normal.

132 Royal Academy o/Medicin~ in lreland.

I n the stomach was found a mass all mat ted together. The omen tum was all infiltrated with malignant~ disease, and along the greater curvature of the stomach there were enlarged glands. On opening the stomach a malignant growth was found where the cesop'hagus entered the stomach. On examining the thorax a 'hard mass was found in the lungs which at first sight looked like a secondary deposit, but was found to be tubercular. The heart was very small in size, and he looked upon it as the best specimen of brown atrophy of She heart that~ he had seen.

TrlE PRESIDENT, referring to the condition of acidosis, said he was quite satisfied from his experience that it occurred in all sorts of patients, and he had been in She habit of teaching students to detect it by the odour of acetone from the pat ient ' s breath.

DR. WmHAM said the first case was one of a kind that was always interesting, because these cases of lmyphat ism were found only occasionally. He mentioned tha t he had great faith in an opinion that had been expressed by a friend of .'his thab lympha t i sm was caused by sudden death, and not the cause of it. He had himself come across lymphat ism in a case where sudden death was due to being run over by a motor car. He suggested the possibility of lymphatic changes nob being always connected with sudden death.

DR. HENRY STOKES said he would like to know what size Dr. Parsons considered the thymus gland ought to have been. He had little experience of patients of the age referred to, but he suggested tha t he had seen as large a thymus as the one shown in children of nine. He inquired as to the structure of the thymus gland. He thought that if the thymus gland was nob altogether composed of lymphoid tissue ib could scarcely be the cause of lymphat ism.

DR. PARSONS said he agreed tha t acidosis occurred in a variety of conditions, and tha t children got acetone on slight provocation, but in this case the amount was extraordinary. He could not quite agree wibh Dr. Wigham, because he (Dr. Parsons) thought, w~hen looking at that thymus gland, tha t it was hard to see how sudden death could have caused it. He had never seen a thymus of the size shown in a child of nine years old, except in a case of thymus dea.bh. He would look upon the specimen as an extremely pathological one as re- gards its size. He mentioned f, hat Osler did nob draw any

Section o/ Pathology. 133

very sharp distinction between this condition and that of lymphatism.

Brain ]rom a Case of Hemiplcgia. Da. W. BOXWELL showed a brain removed from a woman,

aged fifty, who was suffering for years from mitral disease and a certain amount of sbenosis as well as mitral regurgita- tion. She was well on Vhe mend when one day, while sitting up in bed taking her dinner, she fell back, and it was noticed 6hat she was paralysed. There was a complete paralysis of the left arm,. leg and face. She survived tha t attack, never lost consciousness, and after a day or two could speak. The heart, however, gave way afterwards and she died. The brain was taken out, as it was expected fihat a specimen of hemiplegia due to embolism would be obtained, and tha t a lesion would have been encapsuled. When 6he specimen was cut the only lesion to be seen was a small hmmorrhage on the frontal lobe and here and there small spots. The pat ient had had only one attack with cerebral symptoms, and in that. sh(' had complete hemiplegia. I t was not quite clear why she had complete hemiplegia with a lesion in the situation m which the one shown was found.

THE :PI~ESIDENT inquired how long the patient lived after the onset of the hemiplegia. There seemed to him to be some difficulty in attributing the hemiplegia to the h~emorrhage shown as ifi appeared small, comparatively limited, and corfiical.

DR. BOXWET.L, replying, said about a week elapsed between the onset of the hemiplegia and death. I I e had looked for embolism, but found none.

Pituitary Tumo,ar. Da. W. G. HAavEY said the pat ient from whom the spcei-

men was removed was a woman, aged about sixty, who was admit ted to the Adelaide Hospital complaining of a severe headache which had been troubling her for about a fortnight. She also complained of giddiness, but never vomited. Shortly after admission she became suddenly unconscious. An a t t empt was made to get her discs examined, but she died before this could be done. There were no signs of acrome-

galy. The autopsy revealed a ~umour of the piSuitary body about

134 Royal Academy of Medicine in Ireland.

t~he size of a walnut. This tumour consisted of masses of cells, epithelial in type, with clear protoplasm and large nuclei. The cells were arranged in a papillo-adenomatous manner, and lay in a matrix of lightly staining connective tissue. The epithelium in places formed solid cell masses in which were numerous glandular and cystic spaces. :Round these spaces, the epithelium, elsewhere irregularly cubicle, had a columnar ar rangement~- the cells lying more closely packed together and their nuclei staining more deeply than those of other parts. The spaces were sometimes empty, and in s.ome places their walls surrounded tissue which was obviously identical with the above-mentioned connective tissue matrix. This quite clearly represented part of the matrix enveloped by the papillomatous growths of the epithelium. In other parts were to be seen apparently cysts containing a homogeneous light pink staining colloid material devoid of visible cells or nuclei.

In termedia te eondigions, however, appeared to be fre- quent, for in one part of the space, fairly well formed connective tissue was seen, its nuclei staining well, while at another was a pink homogeneous vaeuolated material. Here and there lying loose in these spaces were large swollen cedematous cells with well-marked nuclei, and containing a finely granular pink protoplasm. In places, large, oval, yellowis'h-colourcd cells with the nucleus at one end were seen; elsewhere were similar looking globular yellowish masses, ghe nucleus having apparently disappeared. I-Iere and ghere, also, were plasmodial masses appaYently derived from the epithelium, and in these were several nuclei--sometimes arranged as in t~he giant cells, sometimes seen in tuberculous masses. Throughout the tumour were large blood spaces.

He inquired what the homogeneous " colloid " material was, and if it~ was derived from the eedematous degenerated epithelial cells. H e suggested that some of it certainly seemed to be, but pointed out t;hat in many of the spaces a very similar, if not identical, pink homogeneous substance appeared to take origin, in par~ at~ least, from the degenerated connective tissue.

MR. W. D. O':KELLu recalled a case of pituitary tumour in which the patient had eye symptoms by which Dr. Wcrner was able to diagnosticate the position of bhe ~umour. The tumour was malignant.

Section o] Pathology. 135

DR. PARSONS inquired if ~here was any affection of the thyroid. :Hie suggested tha t a section should be examined by Professor Scott to ascertain if there was any thyroid iodine in it.

DR. ROWLETTE said he would like a little more information as to the difference between the s~rueture of the tumour and the appearance of the normal pituitary body. H e also asked whether the tumour was regarded as malignant.

DR. HARVEY, replying, said the thyroid was nob very cave- fully exaanined, but as far as could be made ou~ ib was normal. There were curious yellowish bodies in ~he section which would almost suggesr iodine content, but he understood from the literature tha t colloid had never been found in r pituitary body. As far as he could make out this tumour was to be regarded as a tumour of the intermediate part of the thyroid. The proliferating papilliform and adenomatous structure was different from the ordinary pituitary body in this part. He considered it difficult to say whether it was malignant or not. I t seemed to be a pedunculated tumour, which did not infiltrate t;he surrounding parts.

Friday, February 19, 1915.

DR. BRONT~ in the Chair.

Blood Films ]rom a Case o] Trypanosomlasls ]rom West A]rica.

DR. T. Wm~AM s~howed blood films from a ease of Trypano- somiasis. The history was Vhat about November last Dr. Jellett , of Waterford, brought him ~ pat ient to Trinity College, saying tha t the man had been having malaria, and did not seem to be able to get rid of it, at tacks of fever thaving recurred from time to time. Specimens of the blood were examined, but no malaria parasites could be found. A~ the t ime he was not in a febrile condition, and it was decided to make another examination when the fever came on. This was done, but the result was also negative for malavia. On inquiry he found tha~ the patient had been in Nigeria. A search was made of the blood, and the t rypanosoma wan discovered.

136 Royal Academy o] Medicine in lreland.

Th~ only symptoms of trypanosomiasis was tha$ the man had some enlargement of the glands in the posterior triangle of the neck. He had some attacks of fever, but ~hought he was getting betf~r. He was, however, losing strength. This seemed typical of trypanosomiasis.

I~ was remarked $hat it was a practice in the Tropics to call all fevers malaria.

Some illustrations by Miss Robinson demonstrating the changes the Trypanosoma gambiense undergoes in the fly were shown.

DR. O'FARRELL considered that the interesting point about the case was tha t there appeared to be no marked symptoms. He inquired if the glands in the posterior part of the neck had been punctured for diagnosis. Referring to the motility of the trypanosomata, he pointed out that at one time it was considered that they only moved towards the flagellum.

DR. METTA~ inquired whether there was any difference in symptoms between infection by this trypanosoma and the T. rhodiense, and if t~here was any likelihood of Trypanosoma rhodiense setting up sleeping sickness.

DR. W. W. LAW said the more these cases were worked at the more it was found that they 'had a wider geographical range than was originally supposed. He had experience of the practice in the Tropics of calling all classes of fevers malaria. All the newer things that had been found, such as trypanosomat~, &c., helped to clear up doubtful points.

DR. WmHAM, replying to the remarks, said that the methods of diagnosis tha t were open to him were--Firs t , to examine the blood, and if after prolonged examination no result was obtained, the second step would be to puncture the gland. In the later stages of the disease one did not. often find more in the gland t~han in the blood. The next proce- dure would be to remove some of the blood from the patient and inject it into a susceptible animal. The rat was not so good for this purpose, and a monkey was difficult to obtain. The symptoms in T. rhodiense were more severe than in T. gambiense. In the former the trouble generally went to the brain, and patients were more likely to succumb. The difference between the tsetse fly disease and trypanosomiasis of Wes~ Africa was small.


(a) Inlcztive Sarcoma (dog). PROFESSOR A. E. METTAM showed a specimen taken from

a dog suffering from t'his condition. The condition was said to be found most frequently in bulldogs in this country, and on ~he Continen$ in St. Bernards. The specimen exhibited was obtained from a fox terrier. The growt~h sometimes reproduced vegetatively. In great Danes and St. Bernaxds it reproduced metastat ical ly in the lungs. I t was easily trans- planted and the structure was a sarcoma.

(b) Cystic Kidney (dog). PROFESSOR A. E. •ETTAM said this specimen was obtained

from the same animal as the previous one, in which the kidneys were found to be cystic. I t ~had been previously shown tha t in dogs suffering from lesions of sarcoma the kidneys had also interstitial nephritis. He was not sure whether the condition was of congenital origin or t)hat the specimen shown was in the nature of a new growth.

(e) Endocarditis (pig). PROFESSOR A. E. METTAM exhibited the 'heart of a pig

showing endocaxdit, is. On examination of the heart he found unexpectedly that the lesion was due to a streptococcus. So far as he was aware, there was no fibrous tissue.

(d) Endocarditis (ox). PROFESSOR A. E. METTAM showed a specimen of this con-

dition taken from an ox. He pointed out that the only aper- ture which persisted for the passage of blood would scarcely admit a small spatula. Air cysts were numerous in the lungs.

(e) Disscctlng Aneurysm of the Pulmonary Artery (sheep). PROFESSOR A. E. METTA~, in showing the specimen, said

hc found the puhnonary artery enclosed apparently in a huge blood clot, The hBemorrhage was into the wall o~ the pulmonary artery, and on following the course of the pulmonary artery the hmmorrhage could be seen. I t was easily demon- strafed that the h~emorrhage was in the wall and not external.

(/) T~berculosis of tl~c Udder (cow). PROFESSOR A. E. METTAM, in showing this specimen, said

that the animal from which it was removed gave milk re- Cently in the city. The whole of t~e specimen was on~ huge

138 Royal Academy o] Medicine in ireland

tuberculous mass. He understood that the milk given by the animal was actually swarming with tubercle bacilli. The animal showed generalised tuberculosis, and there were miliary tubercles in the lungs. He presumed that the animal was free from tuberculosis twelv~ months before.

(g) Tuberculosis of the Udder (sow). PROFESSOR A. E. 1V[ETTAM said that the tubercles found in

this specimen were more of the classical type. There was acute inflammation present.

(h) Tuberculosis o] Udder (sow). PROFESSOR A. E. METTAM showed two small pieces of ~he

udder of a sow which contained a growth about Che size of the finger. I~ was thought to be a ease of actinomycosis, but, on examination t~he ~umour was found to be tubercular. He had not seen the carcase of ~he pig, but on inquiry found that it was suffering from gcneralised tuberculosis. I t showed tuberculosis of the spinal column.

(i) Turnout o] Kid~ey (ox). PROFESSOR A. E. METT~.M showed portion of the right

kidney of an ox, which was apparently in a great i~umour- like mass. The entire mass would weigh abou~ 50 lbs. On splitting $he organ he found cysts, the tumour spreading into the pelvic substance, and involving the vena cava. The posterior vena cava was enormously dilated. The carcase was t:hin and emaciated. The diaphragm, lungs, and pleurae con- rained metastatic deposits. The tumour appeared to be a sarcoma, but of what kind he was ye~ unable to say. The section of the secondary growth was true to type.

DR. MATSON complimented Professor Mettam upon the variety and in~eresting nature of the exhibits, and made reference to the importance of veterinary pat~hology to public health work.

DR. O'FARRELL, referring to the case of infective sarcoma, said it was rare in humans to get secondary deposits in the testes. The case of tuberculosis of the udder he thought was an extreme one. He had examined a good many specimens of milk and had not yet found tubercle. He pointed ou~ thar a number of leucocytes were te be found in milk, and it would, he considered, be of interest t~ know when She leuco-


cytes in milk might be looked upon as normal, and when should they be called pus. He looked for information as to what was the relation of tubercle bacilli to the amount of pus in a sample of milk.

DR. W. D. O'KELLY suggested that infective granuloma would have been a better term than infective sarcoma.

Aneurysm of tile P~dmona,ry Artery.--There a ppear(,d to be one vessel which suggested a sheath of l~lood round it, but not through the wall.

Tuberculosis of the Udde,r.--He inquired what percentage of cattle showed tuberculosis in the abattoir, and how many were condemned.

DR. WmItAM said the case of infective sarcoma was of interest, as it was known that other conditions in the nagure of t umodrs were infective--for instance, " warts." He did not know what dourine was like, but was anxious to know if it produced granuloma. He was anxious to know the best way for examining milk in order to discover tubercle, as frequently acid-fast bacilli are met with which axe not tubercle.

PROFESSOg METTAM, replying, said, as to how the infection reached the testes he could not say, unless it was along the course of the lymphatics. Very many secondary growths are not found. Infective sarcoma indicated the structure of the growth.

Dourine is met with only at stud, and is transmitted at coitus. The main symptoms of infect~ion axe paralysis, para- plegia and hemiplegia, and the changes occurring are somewhat similar to the changes in syphilis.

He considered that in every case where the leucocyte count of milk was large it suggested mastiffs, not neces- sarily tuberculosis. There was much difference of opinion as to the proper leucocyte count in milk. He was ag present not in a position to suggest what would be a count to con- demn milk. His practice for examination of milk was fo centrifuge it and examine the deposit, spending half an hour over the microscopic examination; and the next step was animal experiment. The presence of numerous acid-fast bacilli in milk was not sufficiently taken into account by those examining it. He suggested that washing with alcohol should be tried where acid-fast bacilli were found, as of course tubercle was alcohol-fast. The " strippings," or milk lasg drawn, was the best for examination purposes.

140 t~oyal Academy o/Medicine in Ireland.

An Unusual Case o] Sarcoma. Da. T. T. O'FARaE-.L, in showing the specimen, said it was

one of ordinary spindle-celled sarcoma, but tha t the position w a s unusual.

The history was Four years ago the patient, who was a labourer aged fifty-four, got a fall on his back, and afterwards passed blood mixed with the urine. H e stated tha t he was drinking heavily at the time. Three months ago he complained of pain, which he referred to the region between the last rib and the erector spin~e muscle. The pain at night prevented him sleeping. He also referred to ~he bad attacks of pain a t the right external abdominal ring, and these very bad at tacks lasted from one to two hours, and at times he felt very thirsty alter them. After Vhe at tacks the urine was said to be red or brown. He never suffered from incontinence, but .'had become very emaciated and weak latterly. Albumen was never found in the urine.

The abdomen was opened, aa~d the kidney on tha t side was found apparent ly normal. The pat ient afterwards died. Part ial post-mortem was done. The specimen consisted of liver and kidney. The other kidney was normal, as was the suprarenal. There was a tumour between ~he liver and kidney. Sections of it were msAe from different parts, and showed it to be a spindle-celled saxcoma. The interest in the ease was tha t the growth was perfectly outside the capsule of the kidney, and distinct from the liver and suprarenal. Some par~ of it was external to the peritoneum, but the large bulk of t~he tumour h~ixl pushed the peritoneum in front~ of it. He thought there could be no doubt that it originated outside the peritoneum.

DR. WI(}~AM said the t, umour was of a very large size, but where it originated was hard to say.

DR. O'KELLu said the specimen reminded him of one shown las~ year. The supraxenal was said to be normal, but there appeared to be some giant cells, and he suggested that it was quite possible t~hat the growth was from some of the chromophil bodies in the neighbourhood. Some of the cells he thought suggested a nervous relationship.

Da. O'FARa~LL, replying, said Shut he had noticed the large cells in the specimen, and the same point occurred to him, but, as Dr. Wighan, had said, it was difficult to give a definite opinion as to its actual origin.

Section of Obstetrics. 141

SECTION OF O B S T E T R I C S .

President---M. J. GIBSON~ M.D. Sectional Secretary--GIBB6~ FITZGIBBON, ~[.D., F.R.C.P . I .

Friday, February 12, 1915.

THE PRESIDENT in the Chair.

Exhibits.

Myomatous Uterus cemoved during Parturition. S1a WmL~AM SMYLY said this uterus was removed from a woman who had been in labour twenty hours. The labour was obstructed by a large fibro-myomatous tumour which occupied the pelvic cavity. I t was an extra-peritoneal tumour, si tuated in the triangle bounded in front and below by the cervix and vaginal wall, behind by the rectum, and above by per i toneum; it was fixed in the pelvis. The walls of the uterus were enormously thickened, and the lower uterine segment was very much thinned out.

The pat ient was aged forty-five, and this was the sixth pregnancy. On the 5th of January, 1915, at 2 p.m., the mem- branes ruptured, the local midwife was called in, and she sent for Dr. Murray, who, after consultation with Dr. Wallace, determined to bring her to Dublin from Roscrea, in the County Tipperary. He (Sir William) considered that Dr. Murray, who was in attendance, deserved the, highest credit for his courage and ,hmnanity in bringing this patient, who had been many hours in obstructed labour, a long railway journey from Roscrea to Dublin. She arrived at the Rotunda Hospital at 5 a.m. When examined there it was found tha t the head was freely movable above the brim, but no foetal heart could be heard. On vaginal examination, the pelvis was found to be blocked by a large tumour, and the foetal head could be reached only with difficulty. The child was dead. The pat ient had already been examined by three different people, and the case was therefore not cer t~nly in an aseptic condition. There was not room to perforate, and extraction by version or by forceps was out of the question. It. being impossible to pus, h up the tumour, it was at first determined to wai~ to see what nature would do. Morphine and scopolamine were given. However, at 10 a.m. there was no alteration in the condition, and it became necessary to deliver. I t was then decided to do

142 Royal Academy of Medicine in Ireland.

C~esarean section and to remove the uterus and tumour. Cervical C~esarean section offered no advantage, so the classical operation was done, and the ~umour and uterus were removed. The pat ient made a normal recovery.

Ruptured Horn of a Two-boomed Uterus. SIR WILLIAM SMYLu said this specimen was removed from

a young married woman, who was four montJhs pregnant. On the morning of the 20th of January, 1915, she was in per- fect health, and had arranged with a friend who was a trained nurse to call for her to go to Mass at 8 o 'clock; but just as the friend came in she felt w%at she described as if a knife had been thrus t into her umbilicus, and then fainted. After a t ime she recovered, and fainted again, and spent the whole day going from one fainting fit to another until 4 p.m. Dr. Winder was then called in, and sent her to the Rotunda Hospital at about 6 30 p.m. , so tha t she had been bleeding from 8 a.m. until 7 p.m., before operation. When admitded, she was blanched and pulseless, and there was no doubt about the diagnosis of ruptured ectopic pregnancy. When tJhe abdomen was opened, a two-horned uterus was found. The foetus had escaped into the abdominal cavity, and the placenta was extruding ~hrough the opening. The horn was removed, and the pat ient recovered.

Dm PUREFOY said he was fortunage in having seen both the eases brought forward by Sir William Smyly. They illus- trate most forcibly the demands which may sometimes be made on the surgical skill and knowledge of the obstetrician. The thickening of the uterine wall was very observable, and he was not sure tha t it was due only to t~he uterine action which had for so many hours preceded the operation.

In the second case the collapse was such as to leave only the slenderest hope of the pat ient ' s recovery, and as the operation proceeded the patient, was to all appearance moribund: The hypodermic injection of ether proved most help- ful in rallying her. The urgent need for speedily concluding the operation furnished one very cogent reason for omitting wha~ some of us regard as an important detail in such cases--viz . ; t~he removal of the free blood from ~he peritoneal cavity by flushing with hot saline; on this point, however, opinions vary. I t is interesting to recall tha t in several cases of spontaneous uterine rupture in the early months, such as-t~hat recorded by Dr. M'Kinley in 1850, by


Dr. Hooper, Dr. Harrison, and Dr. Scott, as well as one recorded by Dr. Collins, a former Master of the Rotunda Hos- pital, the lesion was situated in the fundus. No satisfactory explanation of this fact has yet been offered. The placenta is so rarely attached in this area, the action of the trophoblast, cannot be accepted as a solution of the problem.

Da. SPENCER SHEILL asked if very much difficulty was ex- perienced in removing the tumour without separating the uterus from it first. He suggested that it might have been possible to push the tumour up. l ie was recently consulted by a patient who has a tumour about half as large again as the one shown, but not quite so fixed, and he was, therefore, anxious to know if this case had been seen in t;he third month of pregnancy, what course would have been adopted. Would it be considered desirable to recommend, as he did in 'his own case, the removal of the tumour, or to advise waiting until labour occurred.

THE PRESIDENT said he would like to know if hysterectomy had been done in the first case on account of risk of infection before the patient came into hospital. The case appeared to hdve been suitable for the operation of C~esarean myo- rneetomy; but, of course, if there was doubt about the management of the case before ii~ came into h~)spital, it was wiser to remove the probably infected uterus.

In the second case the important point was t~he situation of the placental site; where the specimen had given way, the wall was much Vhinner than anywhere else. I t would be of interes~ to know what information the microscopical examination had given regarding the decidual reaction, and whether the thinning was due to ~he trophoblast.

SIR WILLIAM SMYLY, replying to the remarks, said no marked contraction ring was felt, but ~he lower uterine segment was very thin. He had no~ examined t~he posterior wall, but thought it was the same as the anterior one. l ie considered the point as to whether it was safer to leave or remo~e the blood of much importance; but Lhought that wasthing out the blood in a very bad case jus~ made the difference between life and death, l ie had never before tried leaving it. He agreed with ~he President~ as to myomectomy being Lhe ideal operation. The reasons why he did a hysterectomy in this case were given by the President himself, but in addition the distance from the fundus down to where the tumour wa~ situated was very considerable, and he thought

144 Royal Academy o/ Medicine in Ireland.

a myomectomy would have been difficult; but if the patient had been younger, and the uterus aseptic, he believed myomectomy would have been the ideal operation. Had 'he met wi~h the woman earlier in pregnancy, and knew what was going to happen, he certainly would have advised enu- cleation; but, of course, the tumour would have been very small, and it might have been difficult to determine whether it was intra- or extra-peritoneal; so the necessity for operation might not have been evident.

DR. ROWLETTE had microscopic sections made through t:he torn par~, which showed ~ha.t the wall was eroded by the chorionic trophoblast.

Pathological Rcport o/Broad Ligament Specimens. TtIE PRESIDENT said that the microscopical examination o!

the large tumour which he had shown at the last meeting of the Section had proved it to be a fibro-myoma. The hlmour weighed seven thousand and twenty grams. The more cen- tral portions of it exhibited some myxomatous degenerative changes.

The second specimen shown at the same meeting was a case of fibroid uterus with a large cyst. Complete examination s.howed the cyst to be p~rovarian.

Fata~ Gasfro-intestinal Heemorrhage in the New-born. DR. SPENCER SrIEILL differentiated between ordinary

mel~ena neonatorum and the very fatal type of which so little appears to be ]~nown regarding its pathology. Havin~ alluded to whab has been published regarding the causation and treatment, he proceeded to relate details of a case rmde~ his own care. The child, aged two days, passed and vomited so much blood as to be almost moribund. The treatment he adopted was the subcutaneous injection of horse se rum--a treatment, so far as he was aware, hitherto untried in such a case. The result was rapid and successful, and the child did well and remained so.

SIR WILLIAM SMYLY said he had used horse serum with an infant some monVhs old, and it certainly appeared to do some good, but the case did not terminate so satisfactorily as the one now rep'orted. I t was administered hypodermically and hy the mouth. ]:[is case was not, however, a similar one to that of Dr. Sheill, but the treatrrmnt was the same. I$ was a case of purpura htemorrhagica,


DR. TIERNEu recalled three such cases. The first was rapidly fatal. In the second he tried the gelatine prescription mentioned in Dr. Sheill's paper, using commercial gelatine instead of Mcrek's gelatine. This was given by the mouth in drachm doses every hour, and the patient gradually got better. The third ease was a milder one, and, with similar treatment to the second case, ~he result was quite good.

THE PRESIDENT said he remembered two eases such as Dr. Sheill had reported, but of a less severe type ; both recovered without any special treatment. In a bad ease he had no doubt the serum would be of the greatest benefit. He inquired as to Dr. Sheill's impressions regarding the injection of saline into a patient who was bleeding.

Da. SPENCER SEEmL, replying to the remarks, said, w'hether the result was due to the treatmen~ or not he could not say. The patient might have go~ weIl in any event. He did not like to claim definite results fi-om a single instance. The disease he looked upon as comparatively rare. He had seen a good many cases of melsena neonatorum which might be looked upon as the same disease, but in a lesser degree. He was interested in the use of horse serum in typhoid. He thoughb t~hat t;he presumption was that it increased the coagulability of the blood by increasing leucoeygosis. Saline injections were given to prevent collapse from the want of blood, and gelatine was given to prevent furtJher loss, whether it was absolutely scientific to administer both together he could not say. The child had, he considered, reached t;he limit. The pulse could not be felt at the wrist, so he thought it would be safe to use saline injections to prevent the c:hild from dying, in spite of the chance of raising the blood pressure. The same applied to adrenMin. The serum injected stlowed a dgfinite result within two and a half hours. He had no experience of human serum; but he could find nothing in the literature to suggest t~hat it had a better effect than the horse serum, and the lat~t.er was more readily obtained. As go ~n ounce of human serum being necessary, that might be so, but his case, he thought, tended to show that such an amount of horse serum was not required, he considered that the horse serum had more than an effect on t~he coagulability of the blood. I t acted as a hormone. His ease could hardly be considered parallel go Sir William Smyly's if the latter was one of purpura h~emorrhagica.

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Royal Academy of Medicine in Ireland