1326

vessels, so that the existence of such a tone as Dr. West haddescribed was possible. The pulmonary vessels had greatpower of absorption and this was greatly favoured by themovements of the lungs. The collapse of the lung in casesof pneumothorax was partly due to the rapid absorption ofthe air in it by its own blood-vessels. The valve theory heconsidered hypothetical.

Mr. PEABCB GOULD asked for an explanation of the dis-placement of the heart and mediastinum in cases of pleuraleffusion. The presence of a small quantity of fluid hadbeen mentioned as necessary for increase of intra-pleuralpressure in cases of pneumothorax. He mentioned a case ofa boy admitted to hospital with pneumothorax due to injuryof the chest, from whose chest air escaped with a rush onparacentesis, but in whom there were no signs of any fluid inthe pleural cavity.

Dr. WEST, in reply, said that he did not think that it wasany more difficult to conceive of pulmonary hypertrophy thanof hypertrophy of the kidney which was so common. He wasaware of Cohnheim’s experiments on dogs, but it did notfollow that the same conditions obtained in man. Severalspeakers had spoken of the absorption of serous fluidthrough the vessels, but he thought that the lymphatics alsoplayed an important part.

MEDICAL SOCIETY OF LONDON.A

Treatment of Tuberculous -Disease of the Bladder.-Recurrent Hæmatemesis due to Hepatovtosis. í

A MEETING of this society was held on May 9th, the I

President, Dr. SANSOM. being in the chair. J

Mr. MANSELL MOULLIN read a paper on the Treatment of ITuberculous Disease of the Bladder. He called attention tothe present very unsatisfactory methods of treating tuber- aculous cystitis. If constitutional methods failed or were impracticable from a patient’s position in life or from other reasons there was nothing left. Local applications 1were condemned on various grounds. They increased the risk of septic cystitis. They helped to extend the tuber- c

culous disease by the way in which they bruised and 1

injured the still healthy portion of the mucous mem-

brane ; and they were of no use, for they never reached 1their mark. The bacilli were much too well protected by the depth at which they lay in the tissues and the coating of caseous déb’J’is that formed upon the floor of the ulcers to be affected by iodoform or lactic acid or any othersubstance that could be injected into the bladder,Drainage at best was only a palliative and in manycases made matters worse, as the tuberculous disease ’grew down and infected the track of the drainage-tube. Forcases such as these if constitutional measures failed therewas nothing left, and the question Mr. Mansell Moullin wished to raise was whether some might not be relieved, andperhaps even cured, by adopting much more energeticmeasures at a much earlier date ; whether, in short,the local treatment of tuberculous cystitis had not falleninto its present state of disrepute because it had beentoo feeble and too late. Suprapubic cystotomy was an opera-tion almost devoid of risk, at any rate in the earlier stagesof tuberculous cystitis. Removal of the growth either byexcision or erasion under such conditions was a perfectlyfeasible measure whatever it might be later. The only argu-ment against operation was that the disease in the bladderwas nearly always secondary and therefore its removal would-not really benefit the case. Mr. Mansell Moullin pointed outthat the mucous membrane of the bladder rarely becameinfected through the epithelial surface. This, unless it wasinjured in some way, was an efficient protection. Nearlyalways the bacilli invaded it either by direct continuity fromome neigfibouring organ or through the medium of theblood-vessels or the lymphatics. In the case of tuberculous

,pyelitis this was undoubtedly easy as there was a free commu-nication between the lymphatics of the pelvis of the kidneyand those of the mucous membrane of the bladder, andwhen the ulceration began at or around the orifice of oneof the ureters the presumption was in favour of its beingsecondary. But when the disease commenced in other partsof the bladder, or even of the trigone, this was by nomeans so certain. Tuberculous disease usually began inthe trigone of the bladder, not because this was in relationwith the generative orgarHc’l, but because this was the most

vascular and physiologically the most active part of thebladder. The bacilli infected it first for the same reasonthat they attacked the growing epiphyseal line of a bone andnot the shaft; and, further, the communication between thelymphatics of the genital organs and those of the mucousmembrane of the bladder is by no means free. Especiallyin the case of women, whose generative organs were not soprone to tuberculous disease as those of men, the tuberculouscystitis, if not secondary to pyelitis, was nearly certain tobe primary ; and even in men, judging from the extremefrequency of tuberculous epididymitis and the comparativerarity of tuberculous cystitis, the extension of the diseasefrom one to the other would not be so easy as it was usuallyimagined. Everything depended upon early diagnosis andnow that the cystoscope and centrifugalisation of the urinewere in common use there ought to be no difficulty in diagnos-ing the beginning of tuberculous cystitis and eradicating itthoroughly. Mr. Mansell Moullin brought forward particularsof various cases in support of this view. He had operatedthree times himself and seen two other cases in which opera-tion might have been performed with advantage. One patientwas operated upon in January, 1891, and was still well. Twoothers had been operated upon by Mr. Battle, one, the firstin England, so long ago as 1889. Five years afterwards thepatient had had no recurrence. And there were upwards of30 cases recorded as having been operated upon abroad.In most of these the disease was primary, but in 3, otherorgans were involved as well and yet the patients had beenbenefited very materially. Reverdin’s patient, for example,had suffered two years before from tuberculous epididymitisand was well two years after the operation in spite ofhaving had a perinephritic abscess; Greiffenhagen’s patienthad a caseous abscess in the perineum, probably in con-nexion with one of the vesiculæ seminales ; and Bellhas reported a third case in which, in spite of thepresence of tuberculous epididymitis, the bladder symptomsalmost disappeared after the ulcers had been scraped with aVolkmann’s spoon and cauterised. Tv.o years later, whenthe testis was removed, the man was described as well withthe exception of some incontinence of urine. Mr. MansellMoullin agreed that it was of no use attempting a radicalcure when the bladder had become so rigid and contractedthat suprapubic cystotomy was almost out of the question.But he urged that if the diagnosis was made at the

beginning, as it should be, and the patient did not

rapidly improve under constitutional measures, suprapubiccystotomy followed by excision or erasion of the growthoffered a fair prospect of cure in cases in which theinfection of the bladder was primary, and that even inthose cases in which other organs were involved as wellthe operation would, with very little ri,3k to life, provide ameans by which much of the suffering which inevitablyfollows in those cases might be successfully prevented.-Mr. FRBYBR observed that there were great difficulties in thediagnosis of tuberculous disease of the bladder. Thehsematuria, pain, and increased frequency of micturitionwhich were usually present often suggested the presence of astone, but, whereas the increased frequency of micturition inthe case of calculus diminished when the patient was

recumbent and during the night, there was no such remissionin the case of tuberculous cystitis. Primary tuberculousdisease of the bladder was very rare. He thought that it wasalmost always secondary to tuberculous disease in some otherpart of the genito-urinary tract, the site of primary diseasebeing, in order of frequency, (1) epididymis, (2) vesicul2aseminales, (3) prostate gland, (4) testicle, and (5) kidney.He himself had opened the bladder in six cases for tuberculouscystitis and he had regretted it in every case but one, and hethought that constitutional medical treatment did more forthe patient. The local mischief appeared to increase after theerasion and months elapsed before the guprapubic incisioncould be closed. He could not agree that the operationwas free from risk seeing that Mr. Barling had shownthat out of about 50 children on whom suprn,bubic cystotomywas performed for stone no fewer traan 20 per cent. suc-cumbed. As regards the site of the disease he thought fromcystoscopic examination that most of the !esions were at theneck of the bladder or at the trigone owing to the proximityof the vesiculæ seminales. &c.-Mr. BATTLE observed that

it was worth while trying to give surgical relief to these! cases as the state of the patient was such an extremelymiserable one. There were two classes of cases, the first inwhich there was a definite ulcer which might be easy tobreach aud a second in ’which the mucous membrane was

1327

studded all over with tuberculous granulations, these being tl:most numerous at the trigone. He agreed that primary picases were very rare, but when they occurred they were very amenable to surgical treatment if they were attacked tl

"early. He mentioned five cases in which he had operated difor tuberculous cystitis, one in a woman, the other four in tlmen. 1. A woman, thirty years of age. who was extremely exhausted from chronic cystitis. She improved very much si

after scraping, but died from hemiplegia due to cerebral e:

thrombosis. 2. A man who got well and continued well five D

-years after operation. 3. Another who refused to continue p1treatment after the operation and yet was free from sign of tubercle elsewhere and the local condition had greatly improved. 4. A patient who had had hæmaturia for four Tr

months. The mucous membrane was found covered with tl

oranulations which were scraped away, but he did not li

’improve much, although the suprapubic opening was L

kept open for six weeks. 5. A man in whom no im- tl

provement occurred. He had not seen the evil results from li

’suprapubic cystotomy which had been referred to unless ban attempt were made to close the wound too early.- Dr. CLIFFORD BEALE said that the statistics of the Victoria dPark Hospital for Diseases of the Chest showed how rare wasthe association of tuberculous vesical disease with that of o

’the lungs. Dr. Beale mentioned one obscure case in which bthere was much pain, with intermittent escape of pus in the I urine, which relieved the pain. At the necropsy this was o

’found to be due to tuberculous disease of the vesiculm semi- tnales.—Mr. MANSELL MOULLIN, in reply, said that he did not fclaim that every case could be benefited by cystotomy. He c

was surprised to hear it said that cystitis was so often v

secondary to tuberculous vesicular disease. It occurred in a

women in a large proportion of cases, and here this explana- r

tion could not hold good. Even if the primary disease were iin the genito-urinary tract all parts of it, including the f;seminal vesicles, could now be easily reached by operation. I

Dr. MACNAUGHTON-JONES read a paper on Recurrent 1Hæmatemesis due to Complete Hepatoptosis discovered by Laparotomy. The patient, aged thirty-eight years, the (

mother of seven children, had been very delicate in child- (

hood and had suffered from severe gastrodynia, with vomit- ing, amenorrhoea, and anæmia during puberty. At the age ,of nineteen years there was hæmatemesis, supposed to be i

’due to either gastric ulcer or vicarious menstruation. She was married at the age of twenty-three years and five months aafter her first labour there was recurrence of the hmmatemesis. sFollowing a miscarriage in 1895 there was severe metror-rhagia and in December of the same year there was 1

again hæmatemesis. The metrorrhagia recurred in 1896,when she had an attack of typhlitis. In 1897 gastro- ,dynia and vomiting occurred after eating some shell- rfish and continued on and off until July, when severe hæma-temesis again set in. On July 14th she was seen with Dr.William Barter. She then was blanched, extremely weak,with rapid pulse, nourishment being administered by’enemata, as no food could be retained by the stomach.There was no pain. The abdominal percussion note wasu’esonant in every direction save in the right hypochondriac,lumbar, and inguinal regions, in which a fairly large moveable,mass extending from the lower ribs to the inguinal region’could be defined. Its edge gave the tactile impressionusually experienced on feeling an enlarged spleen. There wasneither a renal nor hepatic line of demarcation. Diagnosisresolved itself into the question of hepatic or renal enlarge-ment and the view was taken that it was an enlarged andmoveable renal tumonr. The condition of the patientwas most alarming and precluded abdominal section. Her,condition having improved abdominal exploration was

’carried out on September 17th in the presence of Mr.Bland Sutton. The tumour was reached by the ordinary’Langenbuch’s incision for nephrectomy, but when theabdominal cavity was opened it was found that it was the’edge of the liver which extended from the costal cartilagesto the iliac fossa, the right lobe being in the latter position.The gall-bladder was exposed and was found a few inches

,

below and to the right of its natural position. On passing the4ia,nd under the diaphragm the vault was found to be empty.The liver was darker than usual and the surface was somewhat- deeply injected. The spleen and both kidneys were examinedand found to be normal. The liver was resting directly onthe right kidney. It was replaced in the same position andthe stomach was taken out, laid on the abdominal wall, andin its turn closely examined. It was somewhat enlargedand its vessels were rather distended, but nothing abnormalto touch was found. After careful readjustment of the parts

the abdominal wound was closed in the usual manner. Thepatient made an uninterrupted recovery without any compli-cation. There was no sickness after the operation nor hasthere been any since. She gradually returned to ordinarydiet and left on Oct. 10th for the aeaside. " Sincethen," Dr. Barter writes, "the patient has gone on im-proving and now, with the help of an abdominalsupport and with due regard to careful dieting andexercise, is better than she has been for years."Dr. Macnaughton-Jones reviewed the literature of dis-placements of the liver hitherto published, quotingMariano Semmola’s and Giofredi’a exhaustive paper on thesubject in 1895, and the condition "hepatoptosis," or

migratory or moveable liver, the term applied by Glenard tothis condition, in contra-distinction to transposition of theliver, of which but a few cases have been recorded. In 1754Laurent Hiester demonstrated a laterally displaced liver onthe cadaver and Catani in 1866 for the first time on theliving subject. In the majority of cases only a lobe hasbeen displaced. No such complete displacement as occurredin this case had, so far as he was aware, been described ordiscovered during life by operation. Out of 70 cases

which had been collected up to 1895 by Graham, inonly 8 was there any certainty of diagnosis, and inbut 4 was the condition discovered by operation. Peters,Richelot, Terrier and Baudain, and Binnie were the

operators. Billroth first sutured the lobe of the liverto the abdominal wall and h patopexy had been success-fully performed by Marchand and Ischering and other

operators. The particulars of these cases and of otherswere given where the liver was found in an umbilical orabdominal hernia. The association of bepatoptosis withmoveable and enlarged kidney was frequent, hence the errorinto which some had fallen of mistaking the hepatic tumourfor a renal one. The assigned causes, as congenital mal-position, enlargement of the kidney, injuries, tight lacing, andlengthy ligaments, were considered, and the more commonsymptoms to which hepatoptosis gave rise. In manycases hepatopexy was out of the question, as in thecase brought forward, but its feasibility had beenproved in the instance of partial lobular displacements.-Mr. BATTLE said that during the last few weeks he had met

! with a case which he thought to be of the same nature. The: patient came to him on account of severe right-sided: abdominal pain. She was forty-five years of age and had

a lax, pendulous abdomen. A mass, believed to be the liver,was felt lying transversely just below the umbilicus. When

ithe patient stood up the mass sank down to the level of, Poupart’s ligament. The application of a flannel bandage. had entirely relieved her symptoms.-The PRESIDENT said. that the association of hasmatemesis with hepatoptosis was a. very unusual one. It was curious that although there was so. much dislocation of the organ and interference with the, position of the vessels ascites had been present in so fewr of the recorded cases.-Dr. MACNAUGHTON-JONES, in reply,. said that the mass exactly simulated a renal tumour and was9 only discovered to be the liver at the operation. In another, case its nature might be suspected if there were absence ofa the hepatic dulness in its normal position.i The following is the list of officers elected for the ensuingyear:—President: Mr. Edmund Owen. Vice-Presidents :s Dr. J. Kingston Fowler, Mr. John H. Morgan, Dr. J.s Mitchell Bruce, aind Mr. George R. Turner. Treasurer : Mr.- David H. Goodsall. Librarian : Dr. William Henry Allchin.1 Honorary secretaries : Mr. William H. Battle and Dr. Jamest Calvert. Honorary secretary for foreign correspondence:r Mr. Alban H. G. Doran. Council : Dr. John Anderson,s C.I.E., Mr. William H. Baker, Dr. E. Clifford Beale, Dr.. Frederick L. Benham, Dr. Robert L. Bowles, Mr. Stanleyr Boyd, Dr. William Ewart, Mr. A. Pearce Gould, Dr. Con-estantine Holman, Dr. Hector W. G. Mackenzie, Dr. Roberte Maguire, Dr. Sidney H. C. Martin, F.R.S,, Dr. J. Baldwins Nias, Dr. Humphry D. Rolleston, Dr. Amaud Routh, Dr. A.. Erneat Sansom, Mr. Morton Smale, Dr. John C. Thcrowgood,s Mr. Frederick C. Wallis, and Mr. Arthur K. Willis.a I _--_____ ___ _

OBSTETRICAL SOCIETY OF LONDON.

Primary Carcinoma af the Fallopian Tube Exhibition ofSpecimens

A MEETING of this society was held on May 4th, Dr.C. J. CULLINGWORTH, President, being in the chair.

Dr. HUBERT ROBERTS read a paper on a case of Primary