1568 PATHOLOGICAL SOCIETY OF LONDON.

be seen early, so that it is not postponed until the

patient is exhausted by protracted labour and injured byfruitless attempts at delivery in other ways. All of my cases inwhich the operation was performed on healthy patients at aselected time have recovered. Those who died were those inwhich the time of operation was dictated by the greater dangerof delaying it. As minor points I would remark-4. That Isee no advantage in making a long incision and turning theuterus out of the abdomen before opening it. If the abdominalwalls are kept closely applied to the uterus before opening it,and pressed together behind it after it has been opened, fluidsare kept out of the peritoneum quite as well as, and I thinkbetter than, if a long incision is made. 5. I would callattention to the desirability of washing the uterus with waterfrom time to time while it is being sutured. I did this simplyas a detail of cleanliness ; but I have since seen a paper byWalthard,7 who has found by laboratory experiments thatprolonged exposure of the peritoneum to air causes necrosisof superficial cells, and that this is indicated by the peri-toneum losing its shiny appearance and, can be prevented byflushing. 6. The remaining point on which I would comment isthe mode of sterilisation. I have heard of cases in the

practice of others in which pregnancy has occurred in spiteof ligature of each Fallopian tube ; for this reason I havein the later cases removed the tubes as close to the uterus as

possible consistently with secure ligature. The only mode ofsterilisation which it can be said is absolutely certain is theremoval of the ovaries; but this carries with it certain un-desirable effects. Removal of the oviducts is probably equallyeffective, and no ill consequence is known to follow as itsresult. I cannot, however, help some fear lest extra-uterinepregnancy may in some case follow it ; but till this fear hasbeen shown to have a foundation in fact I think it better notto deprive the patients of their ovaries.

Medical Societies.PATHOLOGICAL SOCIETY OF LONDON.

.Diphtheria of Stomaeh.-Der1Jwid Cyst of Face.-’eruel toCase of AnomalO1IS Tumour of Larynx.-Abscesses in cort-nexion with the (oesophagus.AN ordinary meeting of this society was held on Dec. 19th,

the President, Dr. PAVY, being in the chair.Dr. SOLTAU FBNTVIOK exhibited a specimen of Diphtheria

of the Stomach obtained from a child three years of age, whowas admitted into the London Hospital in 1891 for an attack ofcroup. The illness had commenced on the previous day withsymptoms of dyspnoea. On admission into the hospital therewas considerable difficulty of respiration, but no membranecould be observed. Absolute anorexia prevailed, andwhen food was administered through a stomach tube

vomiting invariably ensued. The vomited material nevercontained any trace of free hydrochloric acid. Tracheo-

tomy was subsequently performed, and the patient diedon the following day. At the post-mortem examination

primary laryngeal diphtheria was discovered, the membraneextending downwards into the finer ramifications of thebronchial tubes. The pharynx and oesophagus were freefrom disease. The stomach was completely lined withadherent membrane, which extended for one-third of an inchthrough the pylorus. On microscopic examination the tissuepresented the ordinary appearances of diphtheritic affectionof the stomach. Diphtheria of the stomach was a rare

disease, and occurred almost exclusively in children whowere the subjects of pharyngeal diphtheria. In such casesthe gastric affection was stated by Kalmus to be found asfrequently as 62 per cent., but in this country the complica-tion was not so often encountered. The chief points ofinterest in the case were: (1) the implication of the wholesurface of the stomach ; (2) the absence of membrane fromthe pharynx and oesophagus ; (3) the clinical features ofcomplete anorexia associated with vomiting and an absenceof free hydrochloric acid from the contents of the stomach.-Mr. SHATTOCK had seen a similar case, in which the entiregastric mucous surface was coated with membrane, thoughno exudation could be found in the oesophagus or in the

upper part of the respiratory tract.

7 Correspondenz-Blatt für Schweizerische Aerzte, 1893.

Mr. BOWLBY showed for Mr. PAUL (Liverpool) a Tooth-bearing Dermoid of the Face, which was removed from the-cheek of a boy aged five years. It was regarded by the parents.as a birth mark, and excited no special attention until five our-

six months ago, when a tooth appeared at the upper part.The tumour was situated on the left side of the nose a little:below the eye ; it had no connexion with the bone, and there.were no teeth missing from the jaws. At the time of removalthe tumour consisted of a soft pad of skin below, and above-of a little rim of gum-like tissue from which projected a left.upper lateral incisor tooth with its lingual surface upper-most. Beneath the erupted tooth was a small permanent.tooth of the same character. Attention was drawn to the-

following points : the rarity of teeth in true superficialdermoids ; the marked individual character of these teeth; .r,the association of a permanent with the temporary tooth ;the fact that the teeth belonged to the side on which thetumour was placed, and that, if these ought to be regardedas misplaced teeth, though the normal number were presentin the jaws, yet additional laterals were amongst the most.frequent of supernumerary teeth.

Dr. FELIx SEMON and Mr. S. G. SHATTOCK related theSequel of a case of Anomalous Tumour of the Larynx,which they had brought before that society on May 19th,1891. A growth sprang from the left arytseno-epiglottideanfold of a man aged forty-four, which presented all the

appearances of an angioma, and which was only afterremoval by means of the galvano-caustic loop recognised tobe a very delicate papilloma, encased in a shell of partlyfresh, partly organised, blood-clot. They had drawn atten-tion-(l) to the very unusual situation of the new growth ;.

(2) to the fact that the papilloma was in structure muchmore like the papillomata of the bladder than those of theupper air-passages ; and (3) to the unique fact of spon-.taneous haemorrhages occurring in connexion with and theformation of a blood-shell around the papillary growth.They now added that four months after operation the growthhad recurred, and that a month and a half later it was largerthan it had been originally. It was again removed by means.of the galvano-caustic loop, and, evidence of malignancybeing found on microscopic examination, subhyoid pharyngo-tomy was performed and the growth was excised. The patient,.who had, with the exception of some secondary haemorrhageon the first day after operation, been going on remarkablywell, suddenly became unconscious in the evening of the-third day, and his temperature began to rise, with graduallyincreasing coma, Cheyne-Stokes respiration, profuse per-spiration, and a temperature of 105 8° F. He died in the

morning of the fourth day after the operation. At the post-mortem examination oedema and intense congestion of the-brain were found, but no evidence was forthcoming to showthe ultimate cause of this condition. The tumour removed atthe second operation was a compact spheroidal mass nearlya centimetre in chief diameter, and of similar characters,both macroscopic and microscopic, to that before describedin the Transactions of the Pathological Society, vol. xlii. ; ,histologically it was a delicate papillary growth, thicklyencased with blood-clot, of which extensions passed betweenthe different processes composing the tumour. The investingepithelium of the mucous membrane was quite distinct fromthat of the growth, being of the stratified squamous-cellecSkind, and nowhere continuous with the other, which wascubical or cylindrical, and in places not more than a singlelayer in thickness. The growth not only projected beyondthe general surface but infiltrated the deep parts, after themanner of a columnar-celled or duct carcinoma of the breast,with which class of new formations they compared it,considering it probable that the tumour arose in the mucousglands. Assuming it to have so arisen, they supposed thatin process of time, part came to project from the surface,possibly after rupture of the thinned tissue enclosing it, and’so allowed of the removals recorded, whilst there remainedat these periods a deeper extension of the growth, infil-

trating the structures beiow the level of the mucous mem.-brane, and beyond the reach of endo-laryngeal operation. Thebsemorrhage which formed so marked a histological featurewas explained by the delicacy and vascularity of the growth,and was paralleled by the villous or duct carcinomas of thebreast, to which this tumour bore many resemblances. Do-

i Semon and Mr. Shattock further remarked on the obscure sym-! ptoms characterising the patient’s final days, and the want of

satisfactory explanation of the ultimate cause of death. Thiswas the first case ever described in which malignant disease ofthe larynx simulated in its initial stages the appearance of a

1569OBSTETRICAL SOCIETY OF LONDON.

pedunculated angioma of that part. That the disease was

primarily malignant in this case, and could in no sense beclaimed as an example of the transition of a benign growthinto a malignant one, did not, in their opinion, admit of anyreasonable doubt. All the facts, both clinical and histo-

logical, enumerated in the history admitted of one reasonableinterpretation only-viz., that the disease began in the deepertissues, and that the papillary excrescences were onlysecondary offshoots from it. Nevertheless, an attempt hadbeen made to utilise this case for a resurrection oftheories concerning the alleged special liability of benignlaryngeal growths to undergo malignant degeneration.-Mr. LBNNOX BROWNE thought it unusual to bring forward acase again for discussion after the main facts had been

already published. He was not clear from the descriptiongiven what was the exact situation of the growth. As to

haemorrhage, papillomatous growths springing from mucoussurfaces were very prone to bleeding, and credit was due toMr. Shattock for pointing out that the sheath of the growthwas composed of clot. The primary growth seemed to be freefrom any evidence of malignancy, and he had regarded thecase as one in which a primarily benign growth had been con-verted into a malignant one by the irritation of the galvano-cautery used to remove it. Early in the sixties Dr. MorellMackenzie exhibited at that society a number of specimens ofbenign laryngeal growths, and their microscopy was vouchedfor by the late Sir Andrew Clark. The removal of these benigngrowths became so common that the microscopical examina-tion of them fell into disuse. Dr. Mackenzie later showed agrowth which he thought to be benign, but the Morbid GrowthsCommittee pronounced it to be malignant. This induced theexhibitor to qualify his prognosis as to growths which wereto the naked eye apparently benign. The late Mr. CampbellDe Morgan opened a discussion at that society on cancer,and he dwelt on its purely local origin, the length of timeit might lie dormant, and on the part irritation might taketo convert a simple wart into cancer. He himself hadbeen under the impression that the conversion of benigninto malignant growths by irritation was of frequentoccurrence, but he now thought that it occurred onlyoccasionally. Mr. De Morgan had hinted at parasitism as theorigin of carcinoma, since then Sir James Paget had sup-ported the same view, and many workers had recently beenstriving to find a parasite. If this was its true pathology,all that was necessary for the production of malignantdisease was a breach of surface, the settlement of an

organism and its growth, development, and subsequentextension. What was there to preclude this happening in thelarynx ; it certainly did happen in the case of tubercle. Heclaimed to have proved that he was justified in the view he hadtaken, and that it was reasonable to believe that by irritationa benign might occasionally be converted into a malignantgrowth. The lesson to be drawn from such a discussion wasthat in dealing with certain benign growths of the larynxmilder measures should be pursued rather than resort shouldbe had to the use of unguarded instruments which mightprovoke irritation. He added later, after hearing a statementfrom Mr. Shattock, that he withdrew the suggestion that Dr.Semon and Mr. Shattock had become converts to his views.-Mr. BUTLIN saw the patient in consultation at a later period,when the question of a more serious operation had arisen,and then there was no doubt that the case was malignant,and the short duration of the symptoms, coupled with therapid recurrence and the extreme vascularity of the tumour,supported this view. The diagnosis of an innocent from amalignant growth in the larynx was excessively difficult.Only at most a small part of the tumour could be seen,and the p3.rt seized and removed for examination wasoften not characteristic of the disease. Such a diagnosiswas at best a mere reflection of the more perfectdiagnosis that could be made of an external tumour

by aid of sight and touch.-Mr. VICTOR HORSLEY

thought it not becoming the dignity of the PathologicalSociety to discuss the question of the possibility of the con-version of a benign into a malignant tumour, for almostevery published case was vitiated by the probability ofclinical error.-Mr. BOWLBY regarded the specimen as avillous carcinoma. If only a part of a papillomatous growthwas examined and that part projected from the surface, allthat probably could be said of it was that it was papillary,though it might in reality be carcinomatous, an ingrowthbeing present as well as an outgrowth. In duct cancer of thebreast it was not possible to decide as to its malignant natureby examination of the papillary growth ; a portion of the deeper

structure must also be examined. The error in the case shownwas originally one of diagnosis. He hoped that the specimenswould be referred to the Morbid Growths Committee.-Mr. SHATTOCK said that from the original histologicalexamination no one could say that the specimen was ductcarcinoma. The whole of the evidence as to the malignancyof the primary growth was clinical. The case in its entiretywas so remarkably like one of duct carcinoma that he regardedthat conclusion as the only one which would cover all thefacts, and this, therefore, made him believe that it was

malignant from the first.-Dr. SEMON, in reply, saidthat he felt it to be his duty to bring forward a clearaccount of his views on the case. As to the questionof the frequency with which benign growths became

malignant, he had assisted at an investigation, with the helpof 107 other laryngologists, and they found that of 10,747cases only 31 ended in malignancy, and a further strict

scrutiny reduced the number to 16.-The PRESIDENT,in referring the specimens to the Morbid Growths Committee,said that the question to decide was whether the case wasone of malignant disease during its entire course,or whether,as had been contended, it was an instance of benign growthpassing later into malignant disease.

Dr. ROLLESTON exhibited three specimens of Abscess inconnexion with the (Esophagus. 1. A localised abscess

arising outside the cesophagus on the right side of the neck,which discharged into the oesophagus, and proved fatal byeroding the inferior thyroid artery. The cause of thisabscess was obscure; its duration was about five weeks. The

specimen was from a woman aged thirty years. 2. Suppura-tion arising around a stricture of the middle and lower thirdsof the oesophagus. The stricture was apparently due toa corrosive poison taken thirty-three years before. Theremains of the mucous coat ran through a gangrenousabscess cavity in the posterior mediastinum. The muscularcoat was partly destroyed and partly blended with the outerwall of the abscess, as if the suppuration had begun in thesubmucous coat. This abscess cavity had burst into the leftpleura and set up a pyo-pneumothorax. The duration of theabscess appeared to be eleven days ; the onset was datedfrom a piece of meat sticking in the oesophagus of a managed forty-three years. 3. Suppuration in the posterior medias-tinum around the lower third of the oesophagus. This cavitycommunicated with the oesophagus just above the diaphragm,and opened into the left pleura, setting up pyo-pneumo-thorax. The symptoms developed quite suddenly duringmuscular exertion in a man aged fifty years two days beforedeath. The symptoms suggested rupture of the gullet andsuppuration as a result. The cause-straining-seemed in-adequate to bring about rupture ; but there was no evidence ..of epithelioma or of disease of the oesophagus.The following card specimens were shown :-Dr. FYFFE : (1) Broncho-pneumonic Phthisis occurring in

a diabetic patient; (2) Tubercle of Fallopian Tube.Dr. LEE DicKiNsoN : Calculous Obstruction of the Ureters.

OBSTETRICAL SOCIETY OF LONDON.l!

Exhibition of Specimens.-Intravea2ozcs Injection of Salinesolution in Cases of Severe genaorr7cage.

AT a meeting of this society, held on the 6th inst.,Dr. HERMAN, President, in the chair, the following specimens’were shown. Dr. W. DTTNCAN : Fibro-cystic Uterus removed byHysterectomy. Dr. H. SPENCER: (1) Transfusion Apparatus ;(2) Saturated Solution of Salt in Hermetically Sealed Tubes(for transfusion). Dr. HORROOKS: Transfusion Apparatus.Dr. LEITH NAPIER: Dermoid Cyst of Ovary.A paper was then read by Dr. P. HoRBOOKS, entitled

"Intravenous Injection of Saline Solution in Cases of Severe .H2emorrhage." After pointing out that transfusion had beenperformed for centuries, he mentioned experiments that hadbeen made abroad and in England to show that an injectionof saline solution into the veins of an animal bled to apparentdeath would revive it, and that recovery would take place.The late Dr. Wooldridge had done this, and had found itbest to inject as much saline fluid as blood lost. The fol-.

lowing propositions were then laid down : (1) when a personis dead from rapid heamorrhage there is still in the bodysufficient blood to carry on life if it can be circulated ;(2) theoretically, half the volume of blood could do thesame work if it were given double the velocity ; (3) deathfrom haemorrhage is due to failure of the heart, and this is,