1443

<oanthua of the eye to about two inches behind the ear, whichwas lifted clean away from its attachment to the skull ; itreached below to about half an inch below the zygomatic.arch and its upper margin, which was well defined, curvedround at an average distance of an inch and a half from thecentre line of the head. When seen with the face en

profile it bulged forwards, hiding the left eye and the

bridge of the nose. Seen from the front (Fig. 2) it drewthe left eyelids outwards to quite twice their normal length,thus leaving a mere slit through which the eye couldbe seen. The measurements of the tumour were as follows :The longest vertical surface measurement was 8 in., the

congest antero-posterior surface measurement was 82 in., andthe circumference round the base of the tumour was 18 in.The movements of the child’s face were not much affected,- except that the mouth could only be opened to the extentof half an inch. Two days after admission Mr. Hewetsondecided to aspirate the tumour in order to relieve thetension and to clear up the diagnosis between hasmatomaand sarcoma. A small-sized trocar was accordingly pushedinto the tumour, but beyond a few drops of blood nothingcame out of the cannula, which was therefore removed. Itwas found to be blocked by soft tissue, which was immedi-ately teased out, stained and examined under the micro-scope. It was found to consist almost entirely of smalla’ound cells, what little matrix there was being slightly ’,granular or homogeneous. There was no evidence of any fullyformed fibrous tissue and a diagnosis was made of smallfound-celled sarcoma, following injury. It was evident thatmothing could be done in the way of operation to relieve theohild, who remained in the hospital until its death onJan. 15th, 1893. The course of the disease was as follows. Atfirst the child was without pain, though as the tumour grewits weight became a source of great trouble to him. At rareintervals (only three or four times) the child had singleattacks of vomiting, not preceded by nausea and without.definite cause. Restlessness gradually set in, increasing day byday, so that the patient had to be kept more or less under theinfluence of chloral until about a week before his death, whenhe became quite apathetic, with an extremely weak pulse andslow respiration. The right eye became quite anaestheticand the pupil dilated and immobile. The right optic disc:soon showed evidence of neuritis, which passed rapidly intoatrophy. As the tumour increased in size it invaded moreand more of the forehead and left cheek until the left eyeballwas pushed well up against the inner wall of the orbit, andthen the cornea sloughed and the eyelids became affectedwith the disease. The only sounds the child uttered duringthe last fortnight were short, sharp, single cries. Four daysbefore death he scratched a sore over one of the large veins- coursing over the surface of the tumour and venous oozing- continued steadily afterwards. Between the eyelids thediseased tissue bulged out like an egg. This is shown wellin Fig. 3, which, with Fig. 4, was engraved from photo-graphs taken a few hours before death occurred. Themeasurements increased at the following rate :

Nov. 28. Dec. 5. Dec. 27. Jan. 10.longest vertical surface.. in. 1 in. 1 in. 3 in. = 1421 in.Longest antero - posterior

1 . 3 . 1 . 1 . - 1 .surface ......... 12 in. 14; Ill. 4 in. 4 in. == 16][ in.circumference round base 0 in. 4 in. 1 in. 4t in. = 25 in.

These figures show that the tumour developed a faster rateof growth during the last two weeks than the whole of thepreceding month.The post-mortem examination consisted merely in the

,removal of the tumour met situ by sawing through the skulloutside the disease. The right side of the brain was un-affected by disease ; the left side was almost undistinguish-able from the rest of the tumour, as it was almost entirely’diseased, the only free part being the upper-i.e., the

higher&mdash;parts of the white and grey matter of the cerebrum.In removing the tumour the cerebral portion of disease fell- entirely away, being extremely pulpy. The lower portionsof the frontal, parietal and temporal bones were quite eaten;away, and the disease, external and internal to the skull,was continuous. After being six weeks in spirit it weighed

<5 lb. On making a section through the tumour it was foundthat there was no cystic cavity. The tissues immediatelyunder the skin were reduced to blood-stained pulp, and the’mass of disease under it was pale, though in places the’vessels had ruptured and the blood and sarcomatous tissuewas not to be distinguished. All trace of the left eye hadvanished except a small portion of the sclerotic.

.Renmrks by Mr. LEKDRe:U.-The above case makes one

ask, In what way do sarcomata develop after injury ? It is

acknowledged that sarcomata develop after injury, but

according to Billroth no sarcoma "has ever been causedintentionally by mechanical influences. " In 99 cases out of100 the bruise after such a blow as this boy received wouldhave subsided and no ill results would have followed ; yetin this case after a hasmatoma had undoubtedly occurredsarcomatous disease set in with fatal results. I cannot find

any explanation of the fact that sarcomata follow injuries, butI think a distinct connexion can be traced between the ana-tomical structure of a sarcoma and of the reorganisation ofbruised tissues. The place of the blood-clot (Hamilton) is takenby new vascular loops and connective-tissue elements. Theselatter are at first small round cells, and only in the course of afew weeks do they become converted into fibrous tissue. Ifthis process of development from cells to full-grown tissue bedelayed or prevented have we not the very essence of sarcoma ? ’?I conclude that in this case the attempt at repair proceededto the stage of the formation of embryonic connective tissue,and that from some unascertainable cause, possibly someinherent predisposition, these small round cells remained intheir embryonic state, proliferating and increasing until deathoccurred.

Medical Societies.ROYAL MEDICAL AND CHIRURGICAL

SOCIETY.

The Use of Atropine in Chole1’a.-Oarcinorna of ThyroidGland.

If THE last ordinary meeting of this Society for the presentsession was held on June 13th, the President, Sir ANDREWCLARK, in the chair.

Dr. LAUDER BRUNTON read a communication on the Useof Atropine in Cholera. In 1873 he had drawn attention tothe close resemblance between the symptoms of cholera andthose of muscarine poisoning. The action of muscarine wasalmost completely antagonised by atropine, so that the sym-ptoms produced by the former poison were removed by sub-cutaneous injection of the latter. Dr. Brunton thereforecame to the conclusion that good results might be hopedfor in cases of cholera poisoning by the subcutaneous

injection of atropine ; but the first opportunity he gotof testing the supposition occurred a few months agoin the case of a patient who had come across fromHamburg. The father of this child died very shortlyafter admission into the hospital. The child was collapsedand appeared likely to die, but a subcutaneous injection ofatropine revived her for a time. This was followed by arelapse, but another injection was administered with goodresults and the child recovered. At no time either in thechild’s case or her father’s did the stools present an appearanceof rice water, but cholera bacilli were found by Dr. Kleinin the intestine of the father. Dr. Brunton suggested thatthere were various forms of cholera and that atropinewould probably be most useful in cases where cholera

appeared to have an action on the circulation and lessuseful in those cases where the intestine was chiefly affected,because Dr. Pye-Smith and he did not find in their experi-ments secretion from the intestine to be arrested by atropine.-The PRESIDENT remarked that Dr. Brunton possessed a highdegree of physiological and therapeutical instinct whichenabled him to anticipate much, not only in the way of ex-perimental research, but also in the field of clinical observa-tion. On these grounds, if on none other, he was entitled tobring his observations on a single case before the Societywithout apology.-Brigade-Surgeon SCRIYEN said that a

powerful remedy capable of hypodermic administration waswhat was wanted in the treatment of cholera. He regrettedhis ignorance of the physiological action of muscarine, butcertain of the symptoms of cholera-the cramps in the limbsand the spasm of the common bile duct-suggested that thecauses of these might be counteracted by atropine. The papernot only raised the question of the diagnosis of cholera, but sug-gested that there were various forms. During his twenty-eightyears’ service in India previously to 1879 he saw a vast numberof cases, but could only recognise one form, and he regardedthe rice-water evacuations as the most constant and cha-racteristic symptom. He admitted that there might be the

1444

greatest variety in intensity, from a mild diarrhoea to the for- e

midable and rapid collapse with early death, but the mild Scases were apt to pass into the severer forms. The diagnosis v

was impossible where there was no purging or where the tdiarrhoea was only bilious. In many organic poisons, such a

as those in decomposing fish and meat, and in the collapse r

after malarial fever there were produced symptoms like (cholera; but the urine did not appear usually to be sup- Ipressed and the stools were not of rice-water character.-Dr. kPYE-SMITH said there was a question whether these cases were c

instances of true Asiatic cholera. The finding of the commabacillus or vibrio he regarded as a good diagnostic mark whetherit was the cause of the disease or not. He held that it wasnot good to insist on any one pathognomonic sign in cholera;the fasces were colourless simply because all the food hadbeen washed away from the intestine and a precisely identicalcondition could be produced experimentally in animals byexciting an excessive secretion of succus entericus. If the

phenomena of cholera were only or chiefly due to excessive (diarrhoea it followed that though the atropine might not cure 1the diarrhoea, yet it might be valuable for the beneficialresults produced on the respiration and circulation, and it jcould be prescribed with advantage also in the cases of fvery severe diarrhoea such as were usually termed English ccholera.-Dr. PATTERSON said he had seen these cases ;on their first landing and had attended them until their Jadmission into hospital. He had had experience of asevere cholera epidemic in Chili in 1887-88 and he

. asserted that the first case described in the paper ex- Ihibited typical symptoms when he first saw it, there beinga constant passage of rice-water evacuations which were then

quite colourless ; the temperature was 966&deg; F. and the pulse110 ; the patient was blue and shrivelled and the urine sup-pressed. The child when he saw it was only suffering frompremonitory diarrhoea.&mdash;Dr. ORMEROD, who made the necropsyon the adult, said that the face was shrivelled, the bloodtarry, the lungs and internal organs shrunken and light ofweight. The intestinal contents were distinctly coloured andappeared to contain bile. He likewise examined a few daysago a man who died of violent diarrhoea, but the face andorgans were not shrivelled and the blood was liquid. Theintestinal contents were mucous in character and containedno comma bacilli.-Dr. LAUDER BRUNTON, in reply, said thatBrigade-Surgeon Scriven’s remarks to some extent bore outhis suggestion that there might be more than one variety ofcholera and in one at least of these atropine might be useful.In the case with rice-water stools no less than nine kinds ofbacilli had been found, varying so much that they werelooked on as distinct species.

Dr. FELIX SEMON then related the details of a case of

Malignant Disease of the Thyroid Gland, with most unusualcourse. The patient was a female aged fifty-two, who sufferedfrom dyspncea and occasional haemoptysis, supposed to bedue to the pressure of a hard goitre upon the trachea. On

laryngoscopic examination an ulcerating mass was seen inthe tube itself. Tracheotomy was performed, and after acurious attack of cardiac irregularity, rise of temperature,expectoration of brownish-red masses, and spasm of the

glottis, which occurred a week after the operation, the

patient recovered from the latter. Ten months after-wards she was greatly emaciated, but otherwise sur-

prisingly well, and the intra-tracheal tumour had so

completely disappeared that two other observers advisedremoval of the enlarged right lobe of the thyroid, whichthey supposed to merely press upon the trachea, withthe view of dispensing with the wearing of the cannula. Thisoperation, which was performed by Sir William MacCormac,could not be finished, because it was found that the centre ofthe goitre had undergone malignant degeneration and hadperforated into the trachea. From this exploratory operationthe patient again recovered and lived a full year afterwards,finally dying from intra-tracheal haemorrhage and suffocation.The post-mortem examination explained the unusual courseof the disease, there being, besides a large somewhat pedun-culated extension of the external tumour into the trachea, asecond smaller ulcerated tumour hanging down from athread-like pedicle more than one centimetre long and sepa-rated by a distinct interval of normal mucous membranefrom the upper limit of the pedicle of the larger growth. Heshowed the specimen. Had this smaller growth sloughedaway at the insertion of its pedicle, practioally no trace ofits existence would have been left, and a simiJar explanationno doubt obtained for the disappearance of the larger tumouroriginally seen during life. The growth, on microscopical

examination, proved to be an encephaloid carcinoma. Dr.Semon commented on the case and its unusual features-viz., (1) the temporary total disappearance of the intra.-tracheal extension of the thyroid growth ; (2) the curiousattack, probably due to irritation of the right pneumogastricnerve observed after the performance of tracheotomy; and(3) the fact that malignant growths of the thyroid, whenperforating into the trachea, appeared to have a tendency tobecome pedunculated, which he illustrated by another caseobserved by him.

OPHTHALMOLOGICAL SOCIETY.

Tumour of the Optic Nerve.-The Combined Method ofCataract -Extraction.

AN ordinary meeting of this Society was held on Thursday, June 8tb, the President, Mr. HENRY POWER, M.B.,F.R.C.S., in the chair.

Dr. ROCKLIFFE of Hull read notes of a case of Tumour ofthe Optic Nerve. The patient, a male aged twenty, wasshown to the Society in March, 1892, as a case of mon-ocular proptosis. In December, 1892, as he was emaciated,anasmic and losing weight, the eyeball and growth wereremoved en maasse. Mr. Treacher Collins examined the

specimen and reported as follows : "The tumour is situatedin the region of the optic nerve and is covered by a.

distinct thin capsule, which is continuous with the scleroticand is apparently the expanded dural sheath of the opticnerve. The tumour is oval in shape and about equal in

size to the eyeball itself. Its longest diameter measurestwenty-seven millimetres and its narrowest twenty-onemillimetres. It is of a greyish fawn colour. An antero-

posterior vertical section showed the parts of the eye in theirnormal position and apparently healthy; the vitreous is ofgood consistency, the optic disc not swollen. The growthcommences two millimetres behind the globe, expanding thedural and pial sheaths and pressing the lower portion of thenerve downwards ; this is seen as a distinct white bandrunning along the lower border of the growth." Micro-

scopically Mr. Collins describes the tumour as consisting ofnucleated cells, which have numerous delicate branching pro-cesses, interlacing with one another and forming a networkthe spaces of which are of very different shape and size ; inaddition, there are bundles of closely-packed nucleated fibresand a few thin-walled bloodvessels. Both pial and dura3sheaths encircle the growth. The appearances resemble veryclosely those seen in gliomatous tumours of the brain and thetumour probably originated in the neuroglia of the optic nerve.Dr. Rockliffe referred to the rarity of such tumours, quotedcases recorded by Brailey, Hulke, Lawson and others, and!considered the symptoms of tumour of the optic nerve to be.slowly but progressively increasing proptosis and loss ofvision, with absence of pain and constitutional derangement,the external appearances of the eye and fundus oculi beingnormal, with the exception of proptosis and dilated retinalveins and possibly some atrophy of the nerve, accompaniedwith symptoms of posterior pressure on the globe. If thetumour sprang from the sheath the displacement wouldprobably be forwards and non-central, and the movement ofthe globe limited ; but if from the nerve the proptosiswould be central, with no limitation of movement ofthe globe. He suggested the advisability of taking thefield of vision in such cases as likely to lead to moreexact diagnosis. The paper was illustrated by specimensand drawings.

Mr. SWANZY read a paper on the Combined Methodof Cataract Extraction. He advocated the combinedin preference to the single method for the extraction ofcataract and reported on 100 consecutive operations for

uncomplicated senile cataract by the former method. The