1542

tumour was subjected for about three months to the

rays, and clinically underwent diminution in size inaddition to becoming more moveable on the sub-

jacent parts. Examination after removal showed, how-ever, that no changes could be associated withthe treatment, either macroscopic or microscopic. Thestroma presented a variable amount of lymphocytic infiltra-tion and contained mast cells and a few groups of Unna’splasma cells. The epithelium, which was of the spheroidal-- celled kind, presented nowhere any necrosis, and the onlyfatty degeneration of any note concerned the cells ofthe few mammary lobules still remaining about the edgeof the growth. At no part of the margin was the

growth ceasing to extend. The "cancer body " occurredin groups or singly in certain of the epithelialcells and the arterioles around and in the stromawere normal. The results of the examination were

highly disappointing, for no degeneration of any kind or

- cell lysis had been induced by the treatment, no phagocyticinvasion of the epithelium was in progress, and on every sidethe growth was in an extending condition ; there was

nothing in the amount of lymphocytic infiltration, in themast cells, and in Unna’s plasma cells which might not be metwith in cases where no treatment had been carried out. Theclinical diminution in size of the mass and the loosening ofits deep connexions were difficult to explain ; possibly theywere due to the disappearance of a sub-inflammatory cedema.

Mr. STEPHEN MAYOU read a paper on the Effects of XRays on Rodent Ulcers. He first showed their probablerelation to ultra-violet light and thought that their effectswere closely allied to other forms of stimuli. With the

exception that their application was painless when appliedto healthy tissues they produced a superficial inflammationwhich was greatly increased by the application of otherforms of stimuli. This was instanced by cases, since he didnot think the fact was generally recognised. The dilatationof the vessels of the inflamed part seemed to be permanantin some cases after prolonged exposure. He thought thatthe rodent cells themselves acted as irritants and showed bysections that the leucocytosis was around these cells morethan in the neighbouring tissues. The greater part of thegrowth (that was to say, the nodular masses) disappeared bysloughing, but the outlying masses of rodent cells degene-rated, the degeneration taking place from without inwardstowards the centre of the clumps. The cells becomingvacuolated and the granules collecting around the cell-wallseemed to be making their way through it. The chromatinof the nuclei gradually ceased to take up the stain, leavingonly the cell-wall, which was subsequently removed byleucocytes. The removal of a small portion of the growthin order to examine it for the presence of active rodent cellswas found useful in determining when treatment shouldcease.-Mr. GODLEE asked if in the case of the rodentulcer the cure had been complete.-Mr. MAYOU replied thatcure had been complete in the case of the rodent ulcer. Hementioned two cases of carcinoma of the breast, in one ofwhich treatment by the x rays had had no beneficial effect,while in the other after a few weeks’ treatment a completecure seemed to be effected.

Dr. F. PARKES WEBER read a paper on Biliary Cirrhosiswith and without Cholelithiasis. He compared the cirrhosisof the liver resulting from chronic cholelithiasis to thechronic interstitial nephritis resulting from partial or inter-mittent obstruction to the outflow of urine. In both cases anacute suppurative ascenciing inflammation might superveneas the final cause of death. As a typical example of biliarycirrhosis from chronic cholelithiasis he quoted the case of awoman, 52 years of age, who suffered more or less from

jaundice during the last seven years of her life. In theearly part of 1896, about a year after the commencementof the jaundice, gall-stones were removed from her gall-bladder and her general condition was immensely improvedby a cholecystotomy, but it was supposed that a gall-stonehad remained in the common duct. Bad symptoms recurred.Besides the jaundice there were xanthoma of the eyelids,arms, and neck, and persistent pruritus. The liver andspleen were greatly enlarged and she became very cachectic.She had pulmonary infarction, pleuritic effusion, and

apparently commencing gangrene in one lower limb whenshe died in August, 1902. The liver was enlarged, greenish-yellow on section, and much cirrhosed. Microscopicalexamination showed the distribution of the fibrous tissueto be irregular and certainly not strictly ’’ unilobular." "

A similar case described by Dr. Weber in 1896 was

quoted as another example. It was that of a woman, 55years of age, with jaundice of four years’ duration. Other

examples were instanced from the literature of the subject.Dr. Weber proceeded to discuss the pathogeny and otherquestions regarding biliary cirrhosis without cholelithiasis.As a typical example of Hanot’s disease he referred to thecase of a girl, 14 years of age, described by him at the

Pathological Society in 1895. The child was thought tohave been more or less jaundiced all her life, but an eldersister, who had apparently suffered from the same disease,first became jaundiced at about 13 years of age and died at19. The case illustrated several points in regard to Hanot’sdisease : (1) the liver need not always be ’’ hypertrophic " ;(2) the cirrhosis need not be purely "unilobular"; (3) thegrowth of the whole body might be stunted when the diseasecommenced in early childhood ; (4) the splenic enlargementmight be excessive, especially in children ; and (5) occa-sionally there was a family tendency to the disease. Dr.Weber referred to cases of congenital biliary cirrhosis and toa clinical group of cases in which great enlargement of thespleen occurred in association with only occasional attacks ofjaundice, different members of the same family being some-times affected. He spoke of the probable causes of the

splenic enlargement in biliary cirrhosis and pointed out thatthere were cases of biliary cirrhosis with little enlargement ofthe liver and cases without much enlargement of the spleen.- Dr. H. D. ROLLESTON said that the paper raised so manypoints of interest that it was impossible to do justice to, or todiscuss, the paper. He considered that in the human subjectaseptic obstruction of the common bile-duct did not lead tocirrhosis of the liver but led to atrophy of the liver substanceand dilatation of the ducts, a condition analogous to hydro-nephrosis. Calculous obstruction of the ducts, which readilyallowed infection of the ducts to occur, gave rise to peri-cholangetic fibrosis for this reason. But in calculousobstruction multilobular cirrhosis might also be found. No oone anatomical type of cirrhosis was rigidly connected withobstruction.

Dr. HUGH THURSFIELD showed a specimen of Occlusion ofthe Orifice of the Innominate Artery by EndarteritisObliterans, with extreme narrowing of the orifice of the leftcarotid artery. Although the occlusion of the artery wascomplete there was no trace of thrombosis, and a probecould be passed down to the point of origin of the

artery from the aorta. The exact nature of the endarteritisand the reasons for the absence of thrombosis were questionsto which no answer could be given.-Dr. ROLLESTON sug-gested that the condition was an endarteritis similar to thatseen in the coronary arteries and thought that the conditionwas probably, syphilitic in origin.-Dr. F. J. POYNTONmentioned the case of a man in whom obliteration of thecarotid and brachial arteries gradually occurred so that nopulsation could be felt in these vessels. There was in thiscase a definite history of syphilis.

Mr. W. T. HILLIER showed a specimen of Thoracic Ductand Lymphatic Glands filled with New Growth taken fromthe body of a man who died from carcinoma of the rectumand had secondary growths in the liver, lungs, and lymphaticglands. During life there had been no chyluria or ascites.

CLINICAL SOCIETY OF LONDON.

Ruptured Crucial Ligaments and their Repair by Opera-tion.-Hepatic Abscess.-Strangulated Inguinal Herniareduced en masse by the Employment of Taxis.A MEETING of this society was held on Nov. 28th, Mr.

HOWARD MARSH, the President, being in the chair.Mr. A. W. MAYO ROBSON made a communication on

Ruptured Crucial Ligaments of the Knee-joint and theirRepair by Operation. The patient was a man, aged 41years, who was admitted into the Leeds General Infirmary inNovember, 1895, for lameness, the result of an accidentnine months before when he was almost buried by a fallof earth and sustained numerous injuries besides the oneto the joint in question. When admitted to the infirmarythe right knee was swollen but it was free from tendernesson manipulation. When the muscles were contracted thebones were in good position, but as soon as the muscles wererelaxed the tibia fell backward until stopped by the liga-mentum patellas, and on manipulation the head of the tibiacould be brought forward in front of the femur, there beingalso free lateral movement of the head of the tibia on the

1543

femur. It was manifest that not only were all the liga-ments relaxed but that the crucial ligaments had been rup-tured. On Nov. 21st the joint was opened by a semilunarincision carried across the front, dividing the ligamentumpatellae. The synovial membrane was found to be in-flamed and there was an excess of fluid in the joint. Bothcrucial ligaments were completely ruptured, having beentorn from their upper attachments, the ends being in ashreddy condition. They were stitched in position by meansof catgut ligatures, the anterior being stitched to the

synovial membrane and subjacent tissues on the inner sideof the external condyle and the posterior, which was tooshort and was split in order to lengthen it, was fixed bysutures to the synovial membrane and cartilage on the outerside of the inner condyle. The wound was then stitched upby means of buried catgut sutures and was closed super-ficially by interrupted silkworm-gut sutures. The result wasvery successful, complete restoration of the normal move-ments of the joint having occurred. The plaster-of-Pariswas removed in a month, after which movement graduallyreturned under massage. When seen on Oct. 24th, 1901, thepatient was walking without a limp and could run, and hecould work eight hours a day at his old employment. The

joint could be extended to the straight line and flexedjust beyond the right angle, there being no abnormallateral or antero-posterior mobility whatever. Mr. MayoRobson had not discovered any other case in which theseligaments had been repaired, which he trusted was a

sufficient excuse for his recording a single case.-ThePRESIDENT remarked on the interest of the case and onthe fact that these non-vascular structures should have beenrepaired in this way. He thought that as a rule it wasunwise to open a joint when it was actively inflamed and herelated an illustrative case. He had been struck by theremarkable way in which ligaments did in some cases

undergo repair and he referred to the case of a boy whoseknee-joint after injury was in a flail-like condition, yet sixmonths later the joint was found to be in a very fairlyserviceable condition.-Mr. W. G. SPENCER doubted if suchstrong ligaments could ever be perfectly repaired andwhether, if they were repaired, their attachments by scartissue would be sufficiently firm. In many cases there wasa plate of bone torn away with the ligament.-Mr. MAYOROBSON, in reply, concurred in the general view not to

operate upon joints in a state of acute inflammation. In hisown case the limb was absolutely useless nine months afterthe accident and the only alternative would have beenamputation.Lieutenant-Colonel W. K. HATCH, I.M. S., read a paper on

Hepatic Abscess, which he said he had had exceptionalopportunities of treating. Altogether, in the Sir JamsetjeeJejeebhoy Hospital and in private practice he had seenupwards of 1000 cases of this disease. He pointed out thatthe disease was common enough among natives and thoughalcohol was a factor the majority had suffered from

dysentery. In discussing the diagnosis, he insisted on thecharacteristic hepatic odour in the fluid derived from suchabscesses. Sometimes percussion gave a resonant note overthe abscess, due, no doubt, to the neighbouring colon. Ifsituated near the middle of the liver, near the ensiformcartilage, pulsation might be propagated from the aorta,thus complicating the diagnosis. He wished particularly tocall attention to the fact that aspiration was attendedwith considerable danger and ought, in fact, only to be

employed when the diagnosis had been established andit only remained to determine the precise locality ofthe abscess. The danger lay either in puncturing an

enlarged and highly congested liver or in wounding a largehepatic vessel. Dangerous and even fatal haemorrhagemight thus be caused and in some instances from punctureof the vena cava. His practice was to open the abdomen bya two-inch incision, exposing the liver, which enabled himto introduce the cannula with greater safety. As regardedsurgical treatment he thought that incision was unquestion-ably the proper treatment, and the earlier the better, thoughit might be well first, in large abscesses, to draw off part ofthe pus, making the incision a day or two later and thuslessening the chance of its becoming septic. He preferredto open between the ribs rather than below them. He

deprecated removal of ribs as being rarely necessary. Evenin cases where the abscess contents were being expectoratedhe preferred to incise. He never irrigated the abscess cavityunless it became septic. The mortality in hospital practicewas high, amounting in some years to 90 per cent. ; in

private practice it was probably only about 20 per cent.-The PRESIDENT asked whether Lieutenant-Colonel Hatch hndmade use ot the: umthod of diagnosis by leucocy Hecommented on the fact that apparently he (Lieutenant-Colonel Hatch) did not attach much importance to cuttinginto the abscess through the peritoneum, a procedure whichwas usually held to entail considerable risk. He himself,in such circumstances, preferred to expose the abscess andto pack gauze around the presenting part, so that in thecourse of a day or two adhesions might form and so shutoff the peritoneal cavity, and he mentioned a case inwhich he had adopted this procedure with success.-Mr.A. A. BowLBY, C.M.G., in some remarks on the subject ofattacking these abscesses through the pleura, recalled that ithad been alleged that as the pus was sterile there could beno objection to allowing it to escape through the pleura, buthe thought that it was generally held to be desirable to shutoff the pleural cavity. Even if the pus were originallysterile it probably did not remain so.-Mr. MAYO ROBS OKsaid that Lieutenant-Colonel Hatch had done good serviceif only by calling attention to the risks of indis-criminate blind exploration. This was still very widelypractised. The exploration of suspected distended gall-bladder, he trusted, was a thing of the past. It was

much safer in abscess of the liver to open the abdomen ;then they could see what they were doing and could themore easily arrest bleeding. He did not feel sure that itwas always desirable to perform the operation en deux tenapgbecause that prevented their exploring the region in order tofind out whether other abscesses were present. When explor-ing the liver he preferred to pack the wound with sponges andif pus were found it could be evacuated before making a freeincision.-Dr. A. E. T. LONGHURST expressed surprise atlearning that abscess of the liver was so common among thenatives of India and asked how Lieutenant-Colonel Hatch

explained this circumstance ?-Dr. J. P. ZUM BUSCH saidthat during the last 10 months he had opened four abscessesthrough the pleura ; in three he had made an exploratoryaspiration, and immediately afterwards he had excised tworibs, stitching the pleura to the diaphragm. The patients allrecovered without any trouble referable to the pleura. In thefourth case there had been a great many aspirations and nodoubt the needle had been pushed through the pleural cavity,for that patient developed an empyema from which he died.He pointed out that aspiration on suspicion of abscess of theliver might be attended by serious consequences.-Mr.STEPHEN PAGET asked what was the danger, if any, of

opening the abscess freely ? On two occasions he had foundit useful to pass a silver director down beside the trocar andthen with a probe-pointed gorget he had pushed aside theliver tissues, thus minimising the risk of wounding a vein.-Lieutenant-Colonel HATCH, in reply, said that he had notresorted to leucocytosis for diagnostic purposes. He thoughtthat there was a positive advantage in not pushing thesurface of the liver away from the abdominal parietes. Hehad never met with any bad results from the passage of thepus into the peritoneum, nor had the pathologist to the

hospital recorded any evidence of peritonitis from that cause.Beyond some dyspnoea he had not seen any danger fromopening through the pleura, yet he did not specially suturethe pleura to the surface of the thoracic wall. His objectwas to show that great care should be used in exploring,particularly in the cases in which there was no abscess atall, since it was in those cases that it might do most harm.The frequency of hepatic abscess among the natives in

Bombay might be explained by their unhygienic habits andsurroundings and the frequency of dysentery amongst them.

Mr. L. H. McGAVIN communicated a case of StrangulatedInguinal Hernia in which reduction en masse was obtainedby the employment of taxis. The patient, a man, aged 52years, was admitted into the Seamen’s Hospital, Royal AlbertDock, on Sept. 20th, 1902, with the following history. Fornine years he had suffered from a right inguinal herniawhich had always been easily reducible, no signs ofstrangulation having ever been present. On the night ofSept. 14th, however, the rupture suddenly came down and hewas unable to get it back. He immediately called in a

medical man who made several ineffectual attempts atreduction by the use of taxis. On the last attempt the masspartially disappeared and the patient at once experiencedgreat pain and almost immediately commenced to vomit.On the following day the vomit became stercoraceous andcontinued so till admission and the patient subsequentlydied. Mr. McGavin thought this case worthy of publication

1544

as much on account of its moral lesson as of its clinicalinterest, for it served to emphasise what had been so re-peatedly pointed out by many authorities, that the

attempt to reduce a strangulation of the intestineby taxis was unwise, and that when persisted in

repeatedly such treatment was quite unjustifiable.-Dr. E. G. L. GOFFE suggested the use of a local anaestheticin such cases, such as eucaine. He had witnessed very goodresults therefrom.-Mr. W. G. SPENCER observed that taxiswas largely resorted to and, perhaps, one only heard of theunsuccessful cases.-Mr. BOWLBY observed that many casesof reduction en masse were cases in which the taxis had beenapplied by the patient or his friends. He had never seen acase in hospital in which it had followed taxis applied in thehospital. It was quite possible that the measure of forceapplied by people outside the hospital may have been beyondanything that was reasonable and right. He opined that itwould lead to considerable loss of life if taxis were quiteabandoned. Even if the mortality from operation were only10 per cent. as alleged, the mortality of taxis applied within24 hours would not be nearly as much, for in the majority ofcases it was reduced with a minimum of force and a

reasonable amount of force was probably quite safe.-Mr. HORATIO P. SYMONDS said that as the surgeon of a

country hospital he had for 20 years always forbidden taxisto be applied, preferring to operate forthwith. The damagewas done in cases in which there was no omentum in the sac,in which event a comparatively small amount of pressuremight do great harm.-Mr. T. H. OPENSHAw agreed that infemoral herniæ, hernias with a tight neck, cases in whichthere was marked collapse and in which the symptoms hadlasted some time, taxis was inadvisable. Nevertheless, hehimself applied taxis in some cases, and not without success.He had not seen more than one or two cases in which taxishad done harm.

LIVERPOOL MEDICAL INSTITUTION.

Exhibition of Cases.-Salicylic Acid and Food.-ForeignBodies 7.n the Œsophagus.

A MEETING of this society was held on Nov. 20th, Mr.RUSHTON PARKER, the President, being in the chair.

Mr. T. H. BicxERTOa showed a case of SymmetricalCorneal Opacities, which was commented upon by Dr. K. A.GROSSMANN and Dr. F. H. BARENDT.

Mr. R W. MURRAY related the case of a lad, aged 16years, upon whom he had operated in April last for whatwas thought at the time to be Subacute Appendicitis. The

operation revealed a strictly limited hyperplasia of thecæcum and adjacent portions of the ileum with a smallabscess, probably glandular, behind the caacum. The abscesswas drained and ten days later a fæcal fistula formed. In

July, as the general health was failing, Mr. Murray openedthe abdomen away rom the affected area and short-circuited the inte-tine, joining the ileum to the transversecolon end to end by simple suture. The fsecal fistula closed,but the patient’s general condition was still far from

satisfactory. In this case, one probably of tuberculous

hyperplasia of the cæcum and ileum, Mr. Murray thoughtthat excision of the diseased portion of the intestines wasimpracticable.-Dr. W. BLAIR BELL gave the early historyof the case and could not agree with Mr. Murray as to thenature of the condition--in Dr Bell’s opinion it was nottuberculous. -The PRESIDENT, Mr. KEITH W. MONSARRAT,and Mr. G. G. HAMILTON spoke and Mr. MURRAY replied.

Dr. JOHN HAY showed a man, aged 38 years, sufferingfrom the tonic form of Progressive Muscular Atrophy whichhad commenced four months after an attack of lobar

pneumonia.-Dr. T. R. BRADSHAw remarked that the casewas of the type commonly known as amyotrophic scleros-ismore often seen in women and running a much more rapidcourse than the purely atrophic cases

Dr. C. J. MACALISTER and lir. BRADSHAW contributeda paper on the Influence of Small Doses of Salicylic Acidon Digestion and Nutrition, with special reference to its

employment as a preservative in food. Evidence had been

given in various courts and in Parliamentary committeeswhich was of the vaguest description, depending less uponactual observations upon the results of taking salicylic aciditself than upon the results of taking other antiseptics. Thewriters were strongly of opinion that the nature and amountef preservative employed ought’to be stated on the label.

They had found that it was contended that salicylic acidwas injurious for three principal reasons : (1) that it was

antiseptic and anti-fermentative and therefore liable tointerfere with the. digestive processes by destroying the

digestive ferments ; (2) that after absorption it was apt toinjure the general health and to interfere with nutrition ;and (3) that it was an irritant and therefore apt to

injure the mucous membrane of the stomach and in-testinal canal. They had reason to believe that manywho were opposed to the use of salicylic acid on the6rat ground did not distinguish between true digestionand decomposition. The writers had made numerous experi-ments on artificial digestion and they found that the

presence of salicylic acid even in saturated solution hadabout the same effect in retarding peptic digestion as thesame proportion of kitchen salt. In pancreatic digestion ofstarch it seemed to have no retarding influence at all afterneutralisation. As regard the second objection, one of themhad taken five grains of salicylic acid daily for a monthwithout any ill effect on the health ; they had given it tochildren in fruit juice preserved with it, and they hadwatched its effects on other persons, and they foundthat it exerted no recognisable bad effect whatever. As

regards the objection that salicylic acid was an irritant tothe mucous membrane, they denied that it could be so in

any such degree of concentration as it was possible to obtaineither in food or in the stomach contents. They maintainedthat salicylic acid as an antiseptic was of the greatest valueto the poorer classes in towns by enabling them to obtainluxuries, such as non-alcoholic wines, free from the riskof decomposition and at a moderate cost, and thus thepublic were able to obtain cheap, wholesome, and agreeablebeverages free from the risk of moral and physical evilwhich attended the use of alcoholic drinks. They challengedthe opponents to bring forward a single instance in whichit could be shown that bodily harm had resulted fromsalicylic acid employed as a preservative and they deniedthat it was possible for anyone to be injured by it inthe proportion in which it existed in any of the pre-served articles which had been brought to their notice.-Mr. F. T. PAUL bad supported the medical officer of healthin his endeavour to check the excessive use of salicylic acidas a food preservative on the grounds that (1) chemical pre-servatives were undesirable ; (2) salicylic acid was a poison ;and (3) it was unnecessary to preserve the articles in whichit was used. The first was an opinion shared by most medicalmen. The second point had been sufficiently proved at thetime that salicylic acid was largely given for acute rheu-matism, and he referred members to a paper he read beforethe society in 1876 As regards the third it was admitted bythe manufacturers of the fruit juices that they only used largequantities of salicylic acid in order to prevent alcoholic fer-mentation and the consequent presence of minute chemicaltraces of alcohol repugnant to the teetotaler ; otherwiseone or two grains to the pint would be sufficient. The otherfood substance for which salicylic acid was so largely usedwas bottled fruit, the flavour of which it completelydestroyed. Heat sterilisation in this case was alone neces-

sary, as he had proved by extensive experiments. He agreedwith other speakers that so small a quantity as one or twograins to the pint was probably harmless and need not beobjected to if stated on the label.-Mr. BICKERTON could notunderstand denouncing salicylic acid as a "poison." Heand his family had during the summer months drunk thespecial preparation around which controversy had ragedwith no appreciable effect one way or the other. Heunderstood that it had contained 19 grains to the pint.A little of the juice only was used at a time in a

tumblerful of water or soda water. The proof of the

pudding was in the eating. Salicylic acid in the strengthabove mentioned had done harm neither to himself norto his children, nor had he seen any ill effect producedon patients to whom he had prescribed it. As to the

reported injurious effects on the mucous membrane of thestomach, he doubted it. It was quite possible that the

symptom of irritation was due, not to the drug itself but toimpurities in its manufacture. He had applied a saturatedsolution of salicylic acid to his own eye and it had no effectwhatever, not even causing smarting or watering.-Dr. J. M.MOORE, Dr. J. BARR, Dr. A S. F. GRUNBAUM, Dr. R. J. M.BucHANAN, and Mr. DAMER HARRISSON spoke, and Dr.MACALISTER and Dr. BRADSHAW replied.

Mr. HAMILTON described a Method for removing ForeignBodies from the Œsophagus. The main point lay in searching