1411LIVERPOOL MEDICAL INSTITUTION.

LIVERPOOL MEDICAL INSTITUTION.

A MEETING of this institution was held on Dec. 10th,with Prof. W. BLAIR BELL, the President, in the chair.

Attempted Abortion.

Dr. S. B. HERD read a note on two cases of attemptsto procure abortion.

The first was that of a woman who imagined herselfto be pregnant, having had three weeks’ amenorrhoea,although there were no other symptoms suggesting preg-nancy. She tried to induce abortion by injecting soapywater into the vagina with an enema syringe. There wasimmediate collapse and great pain across the lower abdomen,and slight bleeding from the vagina. The patient wasadmitted to hospital and on opening the abdomen lymphwas seen in appendages and intestines in the pelvis and therewas congestion of the tubes with semipurulent fluid oozingfrom the abdominal ostia and in the pouch of Douglas.A luteal retention cyst and a chronically infected appendixwere removed. No sign of pregnancy was present. Thepatient recovered normally and both tubes were patenttwo weeks later. The cyst in the ovary accounted for theamenorrhcea and menstruation followed its removal withina week.

The second patient gave a history of two abortions whichshe said were spontaneous, and said that, finding herselftwo months’ pregnant, she attempted to procure abortion bypassing a crochet-hook into the uterus. She passed thehook into the cervix but it went through the wall stid cameto be in the utero-vesical pouch. The hook was removedand the patient made a good recovery, having no rise oftemperature for seven days ; but she died suddenly on theeighth day from pulmonary embolism. The coroner wasinformed but no inquest was held.

In the first case, said Dr. Herd, there was, ofcourse, no criminal offence, for the patient was notpregnant, but in the second case it was difficultto say whether the police should have been told.The patient’s family doctor did not think thisadvisable.

In the subsequent discussion the PRESIDENT spokeof pseudo-pregnancy, in which, he said, there wasusually the fear of pregnancy with amenorrhcea.In these cases the corpus luteum of the precedingmenstruation was persistent and large as in Dr.Herd’s first case. Attempted abortion in suchcircumstances had come within his own experience,and the absence of pregnancy altered the medico-

legal aspect. He agreed that it was hard alwaysto believe that a woman, especially when nulliparous,could herself pass an instrument through the os uteri,and he usually suspected that she was shieldingsomeone else by her statement. He thought thatwhenever the practitioner was in doubt abouthis correct course he should report to the medicalofficer of health and throw the responsibility ofaction on him.

Prevention of Cancer.

Dr. GLYNN WHITTLE read a paper on the PreventiveTreatment of Cancer. In early post-graduate days,over 50 years ago, he said, he had formed an opinionof cancer at variance with what he had been taught.He was told that it came from an invading putrescence,but he came to believe that the germ which infectedwas itself a product of putrescent poison. Thepra-cancer, or weak spot, might be a tumour (hithertoinnocent), a fissure, ulcer, or other chronic inflam-mation, always marked by such poor circulationthat within its area the oxidising power of theblood was much diminished. The poison, swallowedor inhaled, was beaten off by the vitality of thepatient everywhere except in this precancerousarea.

The great majority of cases of cancer that had comeunder his care were in patients who had long neglectedlocal growths and chronic irritations, or persons whose-habits of diet had not been judicious, the chief faultsbeing a too large daily amount of animal or rich foods,.or alcoholic drinks regularly and too freely taken.-He had watched the old age of patients who had keptsufficiently in touch with him to follow closely hisrules of health. Those still living were free fromcancer, and those who had died had died of othercomplaints.

Dr. E. CRONIN LOWE emphasised the value ofcommunications which represented the careful observa-tions of men with prolonged clinical experience.The observations of others suggested that irritationalone could hardly be considered the only conditionnecessary for the production of malignancy, forwere this so, the problem would be why cancer did,not develop in everyone. The opinion was growing-that there must be an intrinsic factor which in certainpeople allowed the extrinsic irritant cause to producemalignant change.

Dr. C. 0. STALLYBRASS referred to the associationbetween alcoholism and cancer. The Registrar-General’s decennial supplements showed, he said,that all the occupations having high mortalitiesfrom alcoholism also had high mortalities fromcancer.

Intrathoracic New Growths.

Dr. LESLIE CUNNINGHAM, in the course of a paper,said that most intrathoracic tumours were carcinomatarising in the bronchi. There was one case of sarcomain a series of 17 primary growths ; the remainder were-mainly oat-cell carcinomata. Intrathoracic newgrowths deserved more attention than they receivedin text-books. The manifestations were definite-

enough to call for diagnosis tolerably early in the-condition. Dullness, with silence, and paralysis-of the left recurrent laryngeal nerve were signs which.should be regarded with the gravest suspicion.The PRESIDENT said that lead therapy had been-

withheld in such cases because of the fear of massivenecrosis, and but few had been treated. He recalled,however, at least one case in which life had beeni

greatly prolonged. He thought that, with the betterpreparations and methods now employed, it would b-worth while to reconsider the possibilities of lead

therapy, for there seemed to be no hope for these-patients otherwise.-Dr. R. E. ROBERTS showedradiograms to illustrate sources of error.-Mr. J. TpMORRISON pleaded for a more optimistic outlookeven in the case of tumours acknowledged to bemalignant. Radium treatment was still in itsinfancy, actual resection of such tumours was knownto have resulted in cure in a few reported cases,.and in certain cases of supposed unresolved pneumonia.surgery alone could elucidate the diagnosis. Earlierrecourse should be had to the radiologist, and thesurgeon should be called in to complete the team.-Dr. E. N. CHAMBERLAINS poke of the difficulty o-diagnosing pulmonary neoplasm from inflammatory--lesions, especially low-grade pneumonia with purulenttnnltration.—Dr* T. B.- DAViE referred to the histo--

logical basis of the types of bronchial carcinoma.described, and said that these types were ofterjL- °

all represented in the same tumour. In most,cases of oat-cell carcinoma,- if enough blockswere cut from different parts of the tumour, somesections would nweal epithelioma with typical;cell-nests.

1412 ROYAL ACADEMY OF MEDICINE IN IRELAND.

ROYAL ACADEMY OF MEDICINE INIRELAND.

SECTION OF SURGERY.

A MEETING of this section was held on Nov. 27thwith Mr. R. ATKINSON STONEY, the President, in thechair.

Transplan tation of the Fibula.Mr. F. GILL read notes about a girl, aged 10, who

was admitted to hospital on Nov. 27th, 1928, witha history of acute osteomyelitis of the left tibiaa year before. An operation had been performed inthe country, and she had attended a hospital fordressing over a long period.On examination there was a vertical scar eight inches long

on the antero-medial aspect of the left leg. There was lossof the greater portion of the shaft of the tibia, and twodischarging sinuses, one from the upper and one from thelower portion of the tibia. Genu recurvatum was present,with two inches of shortening in the leg, and marked muscularwasting of the thigh and calf. Radiography showed anabscess cavity, with a small sequestrum, in the upper partof the tibia, and a similar abscess cavity in the lower part.These cavities were opened, cleaned out, and packed, andwhen they were healed she was discharged from hospitalwith a request that she would return in six months.

On readmission in August, 1929, the upper part of thefibula was grafted into the upper part of the tibia. A seriesof radiograms showed the fibula in good position with newbone formation and increase in thickness. A walkingcalliper splint was fitted, and the patient discharged fromhospital and told to return in four months. Unfortunatelyshe did not come back until May, 1931, when she hadoutgrown the calliper and was walking with a markedvarus deformity. The only method of dealing with thepresent condition was to transplant the lower end of thefibula into the lower end of the tibia, after the varus deformityhad been corrected. A series of radiograms since then showthe lower end of the fibula in good position, and bonyunion has taken place. The fibula, as a whole, shows markedhypertrophy, and its lower end is beginning to thicken.

There is now two inches of shortening of the leg, genurecurvatum is still present, but the patient is able to walkwell and the functional result will be very satisfactory.

Several similar cases, said Mr. Gill, had previouslybeen recorded. In 1906, Goldman, of Freiburg,had reported a case of grafting of the upper end of thefibula, after the removal of the upper part of thetibia for sarcoma. Stone, in 1907, had describeda case where there was a loss of eight inches of tibia.He performed the operation in two stages ; the firstwas similar to that described, the second consistedin splitting the lower end of the fibula and graftingthe inner fragment to the lower part of the tibia.Mr. Atkinson Stoney had reported a case wherethe upper part of the tibial shaft was completelydestroyed, and where grafting of the upper part of thefibula was done with an excellent result.

The PRESIDENT, in congratulating Mr. Gill on hisresult, said that in the case he described there was notnearly such an extensive loss of bone. It was extra-

ordinary to watch the development of the fibula astime went on.-Mr. W. DooLIN mentioned two casesof acute osteomyelitis on which he had recentlyoperated, and condemned the procedure of primarydiaphysectomy.-Mr. H. STOKES said that if thetibia was taken out in a case of acute osteomyelitis,non-union always resulted. He regarded diaphy-sectomy as quite unjustifiable.-Mr. H. F. MACAuLEYthought that a primary diaphysectomy should onlybe done if radiography showed periosteal involvementof the bone.Parotid Tumour.

Mr. J. C. McMuLLiN read notes on a case of mixed

parotid tumour, and showed the patient, a woman48 years old, who had contracted mumps in 1895.

IA small lump persisted in the parotid region, and wasremoved three years later, but recurred immediately.

It was again removed in 1901, but again recurred, untilin 1913 it gave rise to facial paralysis, dysphagia, dyspnoea,and some pain, for which surgical intervention was againsought. It was not then thought possible to deal with thetumour successfully, and it continued to increase in sizeuntil in 1924 it had become as large as a melon, extendingfrom the zygoma to the angle of the mouth, over the lowerborder of the mandible, pushing the ear upwards andbackwards, spreading deeply into the neck, and envelopingthe ascending ramus and temporo-maxillary joint. Therewere neither metastases nor glandular involvement.

Complete extirpation of the whole gland was done inDecember, 1924. In the six years which have since elapsedthere has been no recurrence.

The outstanding features of the case, said Mr.McMullin, were the slowness of growth, the pre-

operative facial paralysis, and the repeated recurrenceswithout metastases or glandular involvement.

The PRESIDENT said that it was impossible to

remove tumours like this without the occurrence offacial paralysis. He had a somewhat similar caseat present, and felt encouraged to operate when hesaw Mr. McMullin’s good result.-Mr. STOKES saidhe had never seen such an extensive parotid tumoursuccessfully removed.-Mr. F. J. MORRIN said thatthese tumours were often said to follow injuries tothe parotid gland. He had recently seen a boy with atumour about the size of a tennis ball, who died insix weeks, when the growth had extended over theface. The injury in the present case might havebeen the original attack of mumps.

Percaine.

Dr. R. W. SHAW read a paper on his experienceswith percaine. He had used it, he said, in 30 casesnow reported, in 25 of which the operation wasabdominal, varying from gastrostomy to appendi-cectomy. There were two failures in the series,one of which was due to an insufficient dose. In theother case the patient was given a general arioes-

thetic, but it was afterwards realised that analgesiawas probably complete at the time, sensitiveness totouch only, and not pain, being tested. Anesthesiawas good in the 28 successful cases, and in muscularpeople there was greater relaxation and abdominalimmobility than could be obtained with generalanaesthesia. Eight patients developed headache,but in only one case-the one in which a generalanaesthetic was given besides percaine-was it severe,being eventually relieved by intravenous hypertonicsaline. There were 17 cases of vomiting, only two ofwhich were severe. In Dr. Shaw’s experience,percaine was the most satisfactory spinal anaestheticyet evolved.The PRESIDENT thought that in cases in which it

was impossible to give a general anaesthetic, percainewas extremely useful.-Mr. MORRIN, said he hadbeen an advocate of spinal anaesthesia for the last12 years. He had obtained excellent results fromnovocain. After percaine was used there was

sometimes a fall of blood pressure and rather severeheadache, and in one case he had seen a very severerectal paralysis.

Dr. SHAW replying to Dr. T. BOUCHIER-HAYES,said that better relaxation and immobility were

obtained with percaine than with spinocain. It wasadvisable to use percaine for prostatectomy, owingto the possibility of renal failure.

MANCHESTER EPILEPTIC COLONY.-The annualreport of the David Lewis Manchester Epileptic Colony, atWarford, near Alderley Edge, shows an increase from 381colonists to 407 during the year, the original houses havingbeen further enlarged.