R O Y A L A C A D E M Y O F M E D I C I N E I N I R E L A N D .

Pres ident - -EI)wXRD H. BENNETT, M.D., F .R .C .S . I .

Genera l Sec re ta ry - - JOHN B. STORY, M.B., F .R .C .S . I .

S E C T I O N O F O B S T E T R I C S .

President--F. W. KIDD, M.D. Sectional Secretary--JoHl~ H. GLENN, M.D.

Friday. March 17, 1899.

DR. W. J. SmCLY in the Chair.

Exi~iblta.

DR. ALFRED SMITH exhibited three myomatous uteri removed by retro-peritoneal hysterectomy.

(1.) The first specimen was a large sof~ myoma which had been removed five days previously. The patient had given birLh to two children, and after the birth of the younger child, who was now three years old, the uterus in repose came down to the size of a three months' uterus. The tumour, which was considerably cedematous, and blocked up the pelvis completely, extended well into the broad ligament.

(2.) The second specimen was a very small fibroid, which he removed on account of the constant trouble which it gave to the patient during micturition. On cutting through the pedicle there was no h~emorrhage, and he found that there was only one uterine artery developed to any extent, and that was on the left side. The absence of a uterine artery on the right side was the chief point of interest in this specimen.

(3.) The third specimen which he had removed a fortnight ago was large, and appeared to him before operation as sub-peritoneal and pedunculated. Ou operating, however, he found a second pedicle intimately adherent to the promontory of the sacrum, and this gave him considerable trouble until he found out the condition. He then attempted to perform a myomectomy. He put a clamp round the cervix in the ordinary way in order to suppress hmmorrhage from it, and then proceeded to amputate the large tumour which he exhibited. On loosening the ligature, however,

140 Royal Academy of Medicine iu h,eland.

there was h~emorrhage everywhere. He tied several arteries, but notwithstanding this he could not arrest the hmmorrhag% 8o that he was obliged to perform hysterectomy. The patient did remark- ably well.

DR. PuR~'oY said that Dr. Smith's failure to find the uterine artery on one side was another illustration of the variations in size which one often observed in different cases in the uterine vessels. I t was very difficult to forecast what the behaviour of a fibroid would be. There were some harder than others, and the rate of growth in these cases was comparatively slow. The diffi- culty Dr. Smith had in controlling the h~morrhage in the case of myomeetomy showed that one ought to be prepared for an emergency, even in the case of a tumour with a small pedicle. He suggested that tying the ovarian arteries might have had some effect in checking the hmmorrhage in this case.

Dm S•rLY suggested that the small tumour might have been better removed per vaginam.

DR. S~nTH, replying, said there seemed to be a growing opinion that operation should be the treatment in the case of fibromata. tie looked upon these cases as strong arguments in favour of operative treatment. The uncertainty of the prognosis was another point in favour of operation. As regards the shock of removal of the uterus by the retro-peritoneal method, his experience was that patients suffered more pain and distress after removal of the tubes and ovaries only than when they removed the tumour and the uterus down to the level of the cervix. With reference to Dr. Smyly's suggestion~ the reason he removed the turnout from above was on account of the long pediele attached to it making this easy.

S ] E C T I O N O F P A T H O L O G Y .

President--J. M. PURSER, M.D. Sectional Secretary--E. J. ]I/[CWEENEY, M.D.

Friday, 24th March, 1899. PROF. E. H. BENNETT, M.D., President of the Academy~ in the

Chair.

Chronic (circumscribed) Abscess in Tibia (Brodie's). MR. H~NRY GRAY CROLY communicated several cases of Brodie's

abscess, and exhibited portions of bone removed by a small trephine and drawings of the cases; the bones were much thickened and diseased.

Section of Pathology. 141

(~ASE I. occurred in a young man, in the lower end of the tibia, admitted into the City of Dublin Hospital. The patient suffered from severe pain confined to a small spot about four inches above the ankle-joint. All treatment, constitutional and local, failed to give relief. Mr. Croly trephined the tibia at the most painful part ; a small quantity of pus escaped. The patient got immediate relief and made a rapid recovery.

CASE I I . - - A young lady, residing in the South of Ireland, suffered from pain at the junction of the middle and lower third of the tibia for about sixteen years. The pain at times was excruciating ; she got relief occasionally. All treatment having failed, amputation was proposed and refused. She came to Dublin. Mr. Croly trephined the tibia. A small quantity of pus escaped. The bone was very hard and thickened. The patient made a perfect recovery.

CASE I l I . m A young man, at present in the City of Dublin Hospital, suffered for ten years from very severe pain in the lower third of the right tibia. An incision was made through the perios- team some months previous to his coming under Mr. Croly's care. The symptoms were not relieved. There was thickening of the bone above the ankle-joint. Mr. Croly trephined, and about two drachms of healthy pus escaped as the portion of bone was being removed. The wound healed rapidly, and the patient got im- mediate and permanent relief.

CAsE I V . - - A young girl, at present in the City of Dublin Hospital, suffered for over three years from severe and constant pain in the upper third of the right tibia. She was operated on by a surgeon, but got no relief. Mr. Croly trephined the tibia. The portion of bone was diseased, and there was considerable thickening and density of the tibia. There were two (edematous and pouting granulations at the part affected. The patient got instant relief from pain.

l-~Ia. E. H. BESSETT said it was interesting to note that these abscesses were not confined to the epiphyses, as described by Brodie. He believed that they had nothing to do with tubercular disease of the bone, owing to their great chronicity, and the fact that they are relieved by emptying.

Mu. T. MYLES said that he had very recently operated on a boy for Brodie's abscess in the upper end of the tibia. He had operated on him three years previously for Brodie's abscess, and the boy went home well. He came back to him a few days ago with a superficial abscess over the site of the original Brodie's abscess, and operation showed that there had been no attempt whatever at the production of new bone in the cavity, and there was simply a

142 Royal Academy of Medicine in Ireland.

mass of granulation. Another case oa which he operated was remarkable in its recovery in that the skin dipped down into the recess, and patient had now a pocket extending backwards an inch in depth into the tibia. He presumed that the insufficiency of the new bony growth was due to the non-vascularity of the extremely dense tissue~ and that there was not room for the blood vessels to expand. He thought that the explanation of the alleged frequency of this condition in the tibia was that the disease was not re- cognised when occurring in other situations. Probably many cases of tubercular disease of the kuee-joint began as a tubercular process in the layer of bone immediately underlying the cartilage of the tibia.

DR. KNOtt had seen Mr. Croly's case in hospital~ and could bear testimony to the prolonged and intermittent character of the pain. In Brodie's cases, there was no external appearance that could lead to a suspicion of what the nature of the disease was.

MR. T. E. GORDON had a case recently. Patients forty-five years of age, had a very marked swelling of the upper third or more of the tibia~ and a sinus led down to this part of the bone. His tory was that patient had first noticed a swelling after an injury received twenty or th i r ty years previous. About twelve years ago a sinus had formed and closed~ and a second formed and closed, but a third sinus which formed persisted. A thick layer of dense bone was chiselled through with difficulty, and a large abscess found in the bone.

I~R. CROLY~ in reply to Mr. Myles, said that he had not meant to convey that circumscribed abscess of bone was confined to the tibia, but it was met much more frequently there. He could not see any analogy between a cartilage erosion and sub-cartilage trouble as described by Barnwel], who believed that the disease did not begin in the cartilage or bone, but in the cartilage under the bone. He had cut out the head of the humerus, but i t bore absolutely no analogy to circumscribed abscess of the tibia. Tubercular disease of the knee-joint had nothing to say to the condition.

Enteric Fever fatal through Embolic Itemiplegia. Da. J. W. MooaE reported a case of this disease, l i t will be

found in Vol. CVII . , page 350.] DR. E. J . MoWs.EIdEr asked Dr. Moore how he accounted for

the coagulation of the blood in the left side of the heart by myo- cardial changes. Apar t from some endocardial change, i t was not

Sectio~ of Pathology. 143

clear how he accounted for the formation of the thrombus. Was a microscopic examination of the spleen made with a view to dis- covering the typhoid bacillus? Was the sero-diagnostic test applied during life ? Regarding cerebral implication in the course of general infective diseases~ a most remarkable case which had come under his notice was that of a late distinguished Fellow of that Academy, in whose case the pneumococcus of Fraenkel became localised in the meninges after the morbid process to which it gave rise had been successfully overcome in the lung. He had seen a case of typhoid fever last winter, in which the symptoms which prevailed during the entire course of the attack were indis- tinguishable from meningitis~ and the real nature of the case was only ascertained by Widal's reaction.

DR. R. T~Av~as S~IT~ asked Dr. Moore if a microscopic ex- amination of the myocardium had been made, and did it exhibit parenchymatous or fatty degeneration ? Was it from clinical or post-mortem experience that he had made the statement that enteric fever is one of the fevers which most profoundly affects the myo- cardium ?

DR. J. W. MOORE, in reply to Dr. McWeeney, said that the endocardium was perfectly healthy, and in it there was nothing to account for the ante-mortem clotting. He attributed the clotting to the extremely feeble action of the heart which existed for the last ten or twelve hours of life. The spleen was not examined for Eberth's bacillus. Widal's reaction was positive. In reply to Dr. Smiths he said that in speaking of profound changes of the heart he was speaking generally and not with regard to the present case~ in which no minute examination of the heart muscle was made. Cardiac failure not infrequently did lead to death in enteric fever. He spoke solely from clinical experience on the subject.

_Primary Carcinoma of Liver, with Enormous Enlargement of Splee,. Da. D. F. RA~InAUT exhibited specimens.

Gall-stones with Multiple Abscess of Liver and Carcinoma of the JBladder.

THE SECRETARY (Prof. McWeeney) showed this specimen~ which was the liver of a woman: aged nearly seventy, who suffered from severe and persistent jaundice for several months before death, and was tho~Ight to have cancer of the liver. Post mortem the organ was not much enlarged (weighed 60 oz.), and was studded on the surface and throughout with hundreds of small abscesses: varying in size

14~ Royal Academy of Medicine in Ireland.

from a pin's head to a hazelnut, and containing a greenish pus, thick and inodorous. The larger bile ducts were greatly dilated and contained an inspissated bile mingled with soft gri t ty concre- tions. The common bile duct was large enough to hold the litt le finger, and contained several crumbling calculi, one of which quite blocked the passage into the duodenum. Of gall bladder there was no trace, its position being occupied by a solid white nodule about the size of a walnut, to which the duodenum was firmly adherent. On microscopic examination this proved to have tile structure of adeno-carcinoma~ and a gradual transition from normal bile duct to carcinoma structure could be distiuctly traced in the sections. There was no trace of the wall of the gall bladder to be detected with the microscope. The hepatic duct ran into this nodule, and the common bile duct ran from it to the duodenum. The cystic duct seemed to be represented by a solid cord about s 1 in. in diameter, consisting of cancerous tissue. The wall of the numerous small abscesses was composed of flattened layers of hepatic cells, which gradually became necrotic as the abscess was approached. The abscesses were not demonstrably contained in the bile ducts, or associated with the portal vein. They contained two varieties of Bacillus coli, distinguished by their appearance on gelatine plates and on potato. Both were highly virulent for animals (rabbits), and produced abundance of indol. The autopsy was made a few hours after death, so that post-mortera immigration need not be assumed. Exhibi tor was inclined to look upon the organisms as the primary mtiological factor, then came the calculi and finally the conversion of the gall bladder into a solid mass of neoplasm.

Dm EUSTACE asked, with reference to Dr. Rambaut 's specimen~ if there was any evidence of collateral circulation in the spleen.

DR. LITTLEVALE thought that there was no doubt about Dr. Rambaut 's specimen being one of pr imary cancer, as the normal liver tissues could be actually seen undergoing transformation into cancerous tissue. I-Ie thought that l iver abscesses, in Professor McWeeney's case, resembled kidney abscesses in that in the case of the kidney i t has been stated that when Bacterium cbli is found in the urine with symptoms of pain about the kidney, it was a pret ty certain sign of stone in the kidney, and it has been said that the presence of the stone in the kidney allows the Bacterium colt to get through the abraded membrane of the pelvis of the kidney.

DR. J. W. 1VIooRE said that the enlargement of the spleen in Dr. Rambaut 's case was most interesting and very unusual in c~rcinoma of the liver. There must have been very considerable

SectioT~ of Pathology. 145

pressure on the portal vein to cause the condition. The bacterio- logical origin of gall-stones was very interesting. I t has been observed that patients recovering from typhoid fever have become subject to gall-stones, and probably it is really a manifestation of the localisation of Eberth's bacillus producing a deposition of cholesterine and lime salts.

Dm KNo~'r asked if there was a large quantity of ascitic flui~ in Dr. Rambaut's case.

DR. R.~MBAUT, in reply to Dr. Eustace, said that there was a varicose condition of the gastric and (esophageal veins, and also the veins behind the peritoneum. In asylum post-mortems, only about one-twelfth of the cases of cancer of liver were primary. Perhaps the cirrhosis of the liver would account for the portal obstruction in this case. With reference to Dr. McWeeney's case he said that he had lately made a post-raortera examination on a woman who died of consumption, and found four abscesses in the liver. From the pus obtained he got almost a pure culture of Bacteriu,n colt.

DR. McWEENEY, in reply, said that he had lately seen a very large kidney completely riddled with small abscesses containing a creamy pus which contained one organism only--the Bacillus colt in prodigious numbers, and they could be seen easily filling up the urinary tubules. Without doubt the process had penetrated from the pelvis through the papillae along the straight tubules, and had excited suppuration from the interior of the urinary tubules out- wards. The same thing is constantly found in what are unjustly called "surgical" kidneys. In cases of typhoid fever, it was hi~ experience to find Eberth's. bacillus invariably present in the gall bladder. Cases are on record where, in cases of typhoid fever, the typhoid bacillus was found twenty years afterwards in the g~il bladder. In fact, the bile seemed to be an ideal medium for ~he long preservation of the life of various pathogenic speciea of bacteria.

Peculiar Clot from a Case of Eplstaxis.

Dm NINIAs FALKrNER reported the following case--M. C., aged seventy-six years, suffered from a chronic cough ; was a nat ive 'of Birr, King's County; a dressmaker; a widow ; had eight children, one living. On Sunday, 27th March, 1898, when coughing, blood commenced to flow from mouth and nose, and continued intermittingly until 29th March, 1898, when with a severe fit of coughing, accompanied by a feeling of suffocation, the clot was coughed up. The bleeding ceascd~ but patient sank anal

K

146 Royal Academy of Medicine iJ~ Ireland.

died April l l t h , 1898. The clot, which he was unable to break down with a spoon, is evidently a cast of the posterior nares, with a process about 8 inches in length, which probably extended down into the (esophagus; it is composed entirely of blood-clot and contains no organised tissue.

DR. MCWEENEu regarded Dr. Falkiner's explanation of the cases of rhinoliths as, at any rate, extremely suggestive.

THE WILr, IAM F. JENKS MEMORIAL PRIZE.

DR. JAMES V. INGHAM, Secretary of the Trustees of the College of Physicians of Philadelphia, informs us that the Fifth Triennial William F. Jenks Memorial Prize of Five Hundred Dollars, under the deed of trust of Mrs. William F. Jenks, will be awarded to the author of the best essay on " T h e Various Manifestations of Lith0emia in Infancy and Childhood, with the Etiology and Treatment." The conditions annexed by the founder of this prize ar% that the "prize or award must always be for some subject connected with Obstetrics, or the Diseases of Women, or the Diseases of Children ;" and that " t h e trustees, under this deed for the time being, can, in their discretion, publish the successful essay, or any paper written upon any subject for which they may offer a reward~ provided the income in their hands may, in their judgment, be sufficient for that purpose~ and the essay or paper be considered by them worthy of publication. I f published, the dis- tribution of said essay shall be entirely under the control of said trustees. In case they do not publish the said essay or paper, it shall be the property of the College of Physicians of Philadelphia." The prize is open for competition to the whole world, but the essay must be the production of a single person. The essay, which must be written in the English language, or if in a foreign language, accompanied by an English translation, must be sent to the College of Physicians of Philadelphia, Pennsylvania, U.S.A., before January 1, 1901, addressed to Richard C. Norris, M.D., Chairman of the William F. Jenks Prize Committee. Each essay must be typewritten, distinguished by a motto, and accompanied by a sealed envelope bearing the same motto and containing the name and address of the writer. ,No envelope will be opened except that which accompanies the successful essay. The Committee will return the unsuccessful essays if reclaimed by their respective writers, or their agents, within one year. The Committee reserves the right not to make an award if no essay submitted is considered worthy of the prize.