THE
4 ustralian Medical oumal
AUGUST 20, 1895.
ntebical $orietp of Vittoria.
ORDINARY MONTHLY MEETING.
WEDNESDAY, AUGUST 7, 1895.
(Hall of the Society, 8 p.m.)
Dr. CHARLES RYAN in the chair, and twenty-one members were Present.
One gentleman was nominated for membership.
The following gentleman was elected a member of the Society:
Thomas Hugh Boyd, M.B. et B.S. Melb., F.R,C.S. Eng., of Richmond, proposed by Dr. Adam, seconded by Dr. A.
J. Wood.
Dr. J. W. BARRETT gave notice of the following motion :-
" That the Committee of the Medical Society of Victoria be Pequested to convene a conference of representatives of the Medical Society of Victoria, of the Victorian Branch of the British Medical Association, and of the Melbourne Medical Association, to devise some better method of electing the honorary medical officers of the Melbourne Hospital, than that at present adopted."
EXHIBITS.
Dr. DUNCAN, in exhibiting a patient whose penis and testicles he had removed, on account of malignant disease of the former klegan, said that he was impressed with the desirability in such eases of carrying out the operation in a thorough manner. In
the present instance, a large epithelmmatous ulcer existed, strange to say, on the root of the penis, and on its anterior aspect. A Prior operatidn had been performed without any decided result.
rthe penis was completely removed in the manner recommended by Pearce Gonld. Prior to this being done, both testicles were
l'emoved. In the present instance, a sufficient length of corpus 'Pongiosum was dissected off, and at the conclusion of the opera-
tion was brought up and fixed in front of the pubis. The object
of this was, to enable the patient to micturate in the erect position.
This was only partly successful. At the conclusion of micturition, the urine unfortunately was not projected far enough, and dribbled
Vol,. XVII. No. 8 AA
338 Australian Medical Journal. Arm. 20, 1895
oh to the clothing, thus rendering matters uncomfortable. It is not always possible, or even desirable, to save this particular part of the penis, but it was quite unaffected with disease in the present instance. Mr. 119;milton Russell suggested that a little tin trough might be employed during micturition, to carry the urine a sufficient distance from the person. He (Mr. Duncan) con- sidered the suggestion an excellent one, and promised to try it.
The patient was in excellent health, had regained his original weight, and micturated perfectly in the sitting position.
Mr. DUNCAN then showed an elderly patient on whom he had performed Kraske's Operation for Carcinoma of the Rectum.
The disease when first discovered occupied the posterior wall of the rectum, and could scarcely be reached by the finger. Left inguinal colotomy was first performed, and a fortnight afterwards, Kraske's operation. The coccyx was first removed, and then as much of the left side of the lower part of the sacrum as was sufficient to give free access to the disease. The rectum was then divided half an inch above the diseased segment, and the whole of it excised right to the anus. The opening of the upper bowel was then carefully stitched into the upper angle of the wound.
The rectal wound was then closed with strong buried sutures of catgut, and the superficial parts with fishing-gut. No soiling of the parts took place during healing, the colotomy wound acting admirably. The patient is now in good health, and the operation seems to have been of decided benefit so far.
Dr. E. A MACKAY showed a case of Sporadic Cretinism, and read the following notes :—N. F., male child, aged 2 years and 8 months, the subject of congenital myxcedema. The mother stated that the child had never seemed like an ordinary child since birth, being always very dull and quiet, but it was not until the child was twelve months old that she sought medical advice about it. She took it to a doctor because she thought the child was backward. She was then told that it had " water on the brain." The child has had no illnesses, but is unable to crawl or walk, but will try to stand if supported, seldom cries, smiles 11
attention is attracted, mouth open, tongue protruding, lower third of cornea covered by lower lid, countenance typical of congenital cretin - ism. Hair scanty, though fine and glossy ; growth of clown on forehead, eczema of eyelids ; skin harsh and dry ; extremities cold ; hands and feet short and broad, and very blue and wrinkled ; belly prominent ; large protrusion in the position of the umbilicus, part
AVG. 20, 1895 Exhibits. 339 of which is a reducible hernia, but most of it is myxcedematous tissue. Fatty lumps in the neck ; entire absence of thyroid gland, the rings of trachea being plainly to be felt. Has only two teeth, the lower incisors, which were cut at about two years old. The anterior fontanelle is widely open, measuring 3i inches laterally, and 4i- inches antero-posteriorly. The mother states that at birth the head was open right across, from the nose to the back of the head. The child's weight is 1 st. 4 lbs.;
its length 25 inches. The mother is a strong healthy woman, has no other children, no miscarriages, left her husband on account of his intemperate habits. Knows of no disease among his or her relatives. Had a great deal of worry and trouble during the pregnancy.
Dr. A. JEFFREYS WOOD showed a Sporadic Cretin, and read the following notes :-
E. F., a female aged 4 years, was first shown at this Society tw o years ago. At that time an unsuccessful attempt had been made to transplant a lamb's thyroid gland beneath the skin over the right chest. For a few months she was kept at the Children's Hospital, and fed with raw minced lambs' thyroids, and made Very good progress, being able to stand and walk with the help of a small chair she pushed in front of herself. I then lost sight of her for a year and nine months, during which time she became (lull and stupid, her face and body became puffy, lips thickened and kept apart, and skin dry and harsh. The pseudo-lipoma in th e right supra-clavicular region also returned (having disappeared when being fed with thyroids) ; the hair was scanty, dark brown in colour, and the scalp dry and scurfy. The umbilicus protruded very markedly ; she could not speak at all, and could only stand leaning against a chair. She was re-admitted into the Children's Hospital on the 15th September, 1894, and was allowed to lie in bed for a fortnight without any treatment ; during this time she would sit quietly in bed with mouth open and tongue protruding, without being attracted by passing events of the ward, or attempt- ing to talk or smile. Her height was 34 inches ; weight 26 pounds ; circumference of abdomen at level of umbilicus 2 4 inches ; whilst the anterior fontanelle measured x 1-1- inches.
On November 3, 1894, she began to take one of Burroughs Wellcome's thyroid tabloids daily, and the improvement was very 'narked from this time. At the end of the first week of treatment she had to be tethered to the top of her cot, for instead of being
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340 Australian Medical Journal. Aim 20, 1895
contented to sit in a torpid condition all day, she climbed up by the side of her cot, pulled her charts down and tore them up, and seemed thoroughly to enjoy herself. Her weight diminished from 1 lb. to
4
lb. a week ; her face, limbs, and body, instead, of look- ing fat and oedematous, became quite thin, and the skin quite lax, and amongst other things the prominent umbilicus disappeared, showing that its prominence was simply due to myxcedematous tissue, and not to the presence of any hernia as is usually described.She continued to lose weight for about twelve weeks, when she remained stationary for about a fortnight, and began to put on weight at the rate of four ounces a week . for a few weeks. The tabloids we: e increased to two a day in a fortnight, and were kept at that up to about six weeks ago. The effect of increasing the thyroids was to cause slight diarrhoea, profuse sweating, and fret- fulness. Urine was also passed very freely, but unfortunately no quantitative records were kept. She was sent to the seaside about six weeks ago where, owing to an oversight, she has been left with- out treatment. The absence of thyroid treatment has brought about a very obvious increase in her subcutaneous tissue, and caused her mental powers to become considerably dulled. The mother of this child has died recently of phthisis, and as her father has deserted her, she will be committed to the Schools. So I take this oppor- tunity of showing her to you before she is lost.
On March 26, 1895, or four months after beginning the thyroid treatment, the anterior fontanelle had closed, her weight was 19 lbs. instead of 26 lbs., and her abdominal circumference had been reduced from 24 inches to 18 inches. Now, after six weeks suspended treatment, the umbilicus is showing signs of prominence again, and the abdominal circumference is 21i inches. She has not grown in height since she was measured on March 26, when she was 32 inches, and the weight has increased to 29 lbs.
The following paper was then read :-
CASE OF HEMOPHILIA TREATED BY THE ADMINI - STRATION OF LIME.
By JAMES W. BARRETT, M.D., M.S.
Dr. Bryant, of Williamstown, has been good enough to furnish me with the following notes, and to allow me to place them on record :-
The patient was a boy aged 4+ years, about whom the follow - ing history was obtainable ;—When 12 months old, the child
Aug. 20, 895 Hcemophilia treated by Administration of Lime. 341 received a slight scratch upon the mucous membrane of the lower lip, and from this blood had been oozing continuously for eleven days when the patient was seen by Dr. Bryant. He was then blanched, pulse very small and fast. The bleeding was controlled by gentle pressure between two fingers, and the application of collodion on cotton-wool. Treatment had to be repeated several times during the next three days, on account of recurrence of hemorrhage. When 21 years old, the child fell and hurt the left knee-joint. The parts about the joint became very black, the joint swelled and became tense, and was apparently filled with blood-clot. The treatment adopted was rest and evaporating lotions, and complete recovery gradually ensued. The parents state that the slightest touch resulted in a black skin mark, and that the child almost always showed bruises. The boy was rather anemic in appearance, but had grown into a stout well-made child, and appeared quite healthy. On April 16, 1895, the child, being now 42 years old. Dr. Bryant was called out at midnight and found that he had been bleeding for fifteen hours from a small punctured wound over the right eyebrow, the result of a fall. All efforts to stop the bleeding had hitherto failed. Many remedies had been used—powdered alum, perchloride of iron, &c. The Child was almost pulseless, blanched, and transparent. The debris was cleared away from the wound, and a pad of cotton-wool soaked in very hot water was pressed to it for a few minutes. It was then replaced by a small piece of lint soaked in collodion, and Pressure was kept up for another five minutes. This controlled
the lirtiorrhage for the time being. No hemorrhage of any Consequence occurred for a few days, although slight oozing took Place, and the child gradually recovered its strength. On the fourth day the pad was removed, as there had been considerable hemorrhage during the night. A large clot was protruding from
the wound, the edges of which were sloughing and bleeding.
Another pad, soaked in styptic colloid, was applied and pressure kept up for a time. Slight oozing occurred every day until the eighth day after the injury, when free bleeding again occurred.
During this time perchloride of iron had been administered, and
the child had gained strength. The wound had now increased from a third of an inch to an inch in diameter, and the edges were undermined and gangrenous. The parts which were bleeding freely were powdered with iodoform and boric acid, and another Pad was applied, soaked in styptic colloid. On the tenth day, the
342 A ustraltan .11edical Journal. Au°. 20, 1895
oozing still continued, and the case seemed hopeless. The iron mixture was discontinued, and liquor ca]cis chloridi (15 minims) was administered for two hours. After this, there was no more haemorrhage. The pad was removed on the thirteenth day, and a clot was found firmly wedged into the wound. The child was rapidly gaining in strength. From the thirteenth to the twenty-third day there was no oozing, and the dose was reduced to ten minims three times a day. On the twenty-sixth day the pad was removed, and the case was practically at an end. The parents stated that the child, who had been allowed to get up and who had fallen a few days before and struck his head, had shown little or no bruising, but that before the illness he would have turned perfectly black in consequence of such an injury. There is no history of haemophilia in. the family.
This is a remarkable and instructive case, though it would not be fair to assume that every similar case will be controlled with equal ease. There is no doubt that the rational treat- ment to be adopted in any case of constant bleeding, is the free administration of a soluble salt of lime in large doses, and the application to the wound of pads soaked in a recent infusion of thymus glands, since the lime on the one hand, and the nucleo - albumen on the other, constitute together the most effective means known to us at present of inducing rapid blood-clotting•
Many cases of continuous bleeding occur, and in the great majority the haemorrhage ceases spontaneously. The teFort of the case is open to the post hoc propter hoc criticism, and despite previous unfavourable results, it certainly affords rational ground for an extensive trial of the administration of soluble lime salts in similar cases.
Mr. G. A. SYME thought that it was premature to draw con- clusions from this case, though the treatment was undoubtedly promising, and on scientific lines. No cases give more anxiety to medical men than hwmophilics, but there is undoubtedly in many cases a tendency for the haemorrhage to cease spontaneously' Some time ago he was unfortunate enough to perform excision 01
the knee in
a bleeder ; constantly recurring and free haemorrhag e occurred. Pressure was used, and sloughing occurred with fresh limmorrhage ; eventually, however, the haemorrhage gradually stopped.
Dr. GRANT had listened with interest to Dr. Barrett's case, an d thought that it was open to the criticism that one swallow does
AUG. 20, 1895 Hcemophilia treated by Administration of Lime. 343 not make a summer. A recent paper by Wright and Bruce demonstrated conclusively that the addition of chloride of calcium to blood increased its power of coagulation. And, in consequence, the administration of chloride of calcium was suggested in hmmophilia, and its administration was looked forward to with considerable interest, but the clinical results of the administration of this salt were extremely disappointing, thus demonstrating again the disappointment that frequently awaits laboratory experiments when put to the clinical test. The condition of the blood in bleeders might certainly be in either a plus or minus condition with regard to the contained lime salts, and it is quite conceivable that certain conditions exist in hzemophilia, where the administration of lime salts may be of value. But, on the other hand, if a ptomaine were responsible for the bleeding, it was hard to imagine that the administration of lime would be of any service. No one knows whether this peculiar condition is depen- dent on the condition of the blood or of the blood-vessels, and he thought light might possibly be thrown upon the subject if any member, who had such a case under his care, were to collect the blood in a watch glass or sealed vessel, and have it sent to the Physiological Laboratory at the University, to have the per- centage of lime salts estimated. The Society was indebted to Dr. Barrett for reporting this case.
Dr. BARRETT, in reply, said that if lime salts were abstracted from either blood or milk, clotting would not occur, and on the other hand, by replacing the lime, clotting again occurs. The question whether satisfactory results can be obtained from the internal administration of lime salts in the case of bleeders is still unanswered, and this case, when related to him by Dr. Bryant, seemed to be well worth reporting. If the blood in cases of haemophilia were found to be deficient in lime salts, he thought that the internal administration of those salts ought to be beneficial, and the additional use of an extract of the thymus gland locally ought theoretically to be the proper method of treat- /neut. He agreed with Dr. Grant, that an examination of haemophilic blood should be made with regard to the contained lime salts, and would willingly undertake to have the examination made if any specimen were forwarded to him at the University.
344 Australian Medical Journal. AUG. 20. 1895
The following paper was then read :-
TWO CASES OF MULTIPLE HYDATIDS OF THE ABDOMEN.
By CHARLES S. RYAN, M.B. Ed. et Melb., Ch.M. Ed.
Hon. Surgeon, Melbourne Hospital ; Hon. Surgeon, Children's Hospital.
CASE I.
J. N., Let. 36, first consulted me in September 1893. For some months previously he had suffered from an uncomfortable feeling in the lower bowel, and interference with defecation; in addition to this, he had suffered from obscure abdominal pains and dis- comfort, and was conscious of a general and progressive abdominal enlargement. He was a tall and athletic bushman, in excellent
health, but for his abdominal trouble.
On examination, I found distinct evidence of the presence of several intralabdominal swellings of varying size, distributed over the abdomen, which I concluded to be hydatid cysts. Examination per rectum revealed a large elastic tumour projecting downwards into the recto-vesical pouch ; and bimanual examination per rectum and abdomen led me to believe that the cyst telt per rectum was identical with the largest and most prominent cyst evident at the lower part of the left side of the abdomen. In this conclusion, as I shall have occasion to show, I was mistaken.
On October 15, 1893, assisted by Mr. Hamilton Russell and Mr. G. A. Syme,
I
operated. Under chloroform, I discovered the hyclatids to be divided roughly into two main groups, occupying respectively the lower portion of both sides of the abdomen, and filling the pelvis. The cyst which could be felt per rectum belonged to the left group. I determined to attack the left group only, leaving the other to be dealt with at a subsequent operation.I accordingly made an incision about four and a half inches in length into the left-band linea senoilunaris, commencing about two inches above Poupart's ligament, and extending upwards. On my hand into the opening so made, I found that the pelvis appeared to be packed with three or four good-sized cysts) and that the dependent portion of the omentum contained manY more. I was able to draw out of the wound a necklet containing thirteen cysts, the largest being about the size of a swan's egg, the smallest the size of a pullet's egg. The ornentum was ligatured
above the cysts, and they were removed en masse. The deepest cyst on the left side (that which I believed to be the one felt per
AtrO. 20, 1895 Multiple Hydatids of the Abdomen. 345 rectum), was aspirated, and seventeen ounces of clear hydatid fluid was drawn off ; the sac was then opened, and the cyst.
removed ; the cavity was well washed out and cleansed with sponges, and the opening in the sac was then closed :
a
la Bond, by a continuous chromicised catgut suture.On the evening of the day succeeding the operation, the temperature was 104.8°, but fell by the next morning to normal, For the next few days, however, the patient's condition was unsatisfactory, and suppuration of the wound took place, necessi- tating the removal of the stitches with about two ounces of pus.
Still the temperature remained high, and the patient's condition generally was unsatisfactory. A swelling now became visible in th e midline, just above the bladder, this increased day by day, until on. the 10th it was of a large size, resembling and in the position of a distended bladder. This I aspirated, and drew off sixteen ounces of serum tinged with blood, and becoming turbid.
Finding that it contained pus, I anaesthetised the patient, and laid the sac (for such it turned out to be) open, removing a good deal of debris, and a small portion of the cyst or endo-cyst, which had been left behind ; I placed a large drainage tube in. As a result of this his temperature fell, but he began to complain of bearing down pain in his rectum, and on examining him I was surprised to find that the cyst that I had felt before (and which I thought was the one on the left side already operated on, which had dropped down into the pelvis, and which I had treated by Bond's Method), had been untouched. I aspirated this, and drew off thirteen ounces of clear fluid. His condition for the next few days did not improve as I had anticipated, although the discharge from
the sac was not offensive, and the,sac itself appeared to be con- tracting and filling up.
It appeared evident to me that suppuration was taking place
somewhere, and as the general condition of the patient began to get serious, I determined that I would open up the abdomen on
the right side, and examine into the condition of three fixed cysts I knew by my former operation were there. When the patient was under chloroform, I examined again his rectum and found
that the cyst there I had aspirated a few days previously had filled
1-11) again, and on passing in a needle, I found it contained pus.
Au opening was now made in the right linea semilunaris sufficiently
large to admit my hand, which was passed all over the abdomen, especially examining the liver to ascertain whether there were any
346 Australian Medical Journal. AUG. 20, 1835
fi
hydatids to be felt there, or elsewhere in the omentum. Fortu - nately, there were none. The two large cysts which lay one on top of the other were converted into one sac by breaking down their septum ; the cysts were removed, and they were treated according to Lindemann's method. Their subsequent history is uneventful, as in the course of about five weeks the cavity had filled up, and the external wound had healed. I now put one finger in the rectum, and the other in the suppurating sac in the mid-line, and began to work it about when all at once I broke through into the lower cyst. I was able to evacuate about ten or eleven ounces of extremely fmtid pus, but I failed to remove the cyst itself. A long glass drainage-tube was passed in from above, quite seven inches in length. Its lower end could be felt through the rectum. The temperature after this never rose to any height, and in the course of a week became quite normal ; but for three weeks the patient was desperately ill, being violently delirious most of the time, on two occasions becoming alarmingly collapsed , vomiting and sweating frequently. His diet, during the time, consisted almost entirely of peptonised food and champagne . Eventually, however, he recovered, and by November 26, six weeks from the first operation, he was able to dispense with the tubes, and get up. The sinuses, which were plugged with gauze , took a few weeks to close, but his further progress was uneventful, and he recovered completely.
CASE II.
D. Mc., sat. 30, admitted to the Melbourne Hospital, January , 1894. For more than a year he had noticed a swelling in th e right hypochondriac region, and during this time he had three severe attacks of cramps, of which one attack was associated Wit h vomiting. There were three or four movable swellings to be felt which the exploratory needle showed to be hydatids.
On January 8, assisted by Mr. Syme, I operated through a fiveine b incision in the right linea semilunaris, extending from the costal mar"
gin downwards, and through this I removed eighteen cysts attache d to the omentum, further exploration revealed other cysts in t he left hypochondriac region, but these were not touched. The wound was closed without drainage, and healed without anY trouble. He left the hospital in four weeks, and six weeks late r
returned for further operation.
On March 29, through a three and a half inch incision to th e left of the median line, I was able to remove from the omentunl
AUG. 20, 1895 Multiple Hydatids of the Abdomen. 347 seven fair sized cysts, averaging about the size of an ordinary orange. Three of these cysts had to be tapped before I could bring them in situ. While endeavouring to bring down a cyst high up under the liver, it burst, and I was unable to again find it ; I could also feel two other cysts close to it. These all appeared to m e to be attached to the gastro-hepatic omentum. Before closing the wound, well over . towards the spleen I could feel several more cysts in the omentum. I re-opened the old incision on the right side, and drained two cysts on the free edge of the liver, which were firmly adherent to the abdominal wall, and were thus shut off from the peritoneal cavity.
During the succeeding week a great deal of constitutional disturbance was present, and on April 9, eleven days after the operation, a prominence in the epigastrium was noticed, having a somewhat dusky appearance. A needle was now passed into this, and through the liver towards its free margin ; pus being discovered, a knife was boldly plunged through it and into a suppurating hydatid cyst ; two other adjacent cysts, likewise suppurating, were also reached, and their contents were removed.
These cysts were beneath, but outside the under surface of the liver. Two tubes were inserted, and the cavities were drained.
From this out the recovery was uninterrupted, and in June the Patient left the hospital, to be re-admitted and operated on again for the third time.
On October 22, through an incision on the left side, two inches
external to the last one, I was able to remove entire a chain of five cysts attached to the mesentery ; three other cysts were so high up under the ribs that they could not be ligatured and removed. I pulled them down as far as I could, just managing to brin g about half of their substance into view. I then with a pair of scissors cut three-fourths of them away, leaving behind one- fourth of the three sacs, like the outside of an acorn. At the
same time I was able to feel a large cyst of the spleen or 1 its inner surface. The opening was sewn up without any drainage, but a week later I was obliged to remove some of the strtures and let out about two or three ounces of pus. After this the wound healed, and the patient was discharged a month after the operation.
He went home to near Mansfield, and did riot return until March 20, 1895, when he presented himself at the hospital, looking very much better and healthier in every way than we had
348 . Australian Medical Journal. Aua. 20, 1895
seen him before. I had previously ascertained by means of needle that he had a large hydatid cyst on the right upper surface of his liver. He had dulness extending high up into the axilla, and posteriorly as high up as the angle of the scapula. The splenic dulness was also increased. I operated by resetting portion of the seventh rib, in the axillary line. On opening into the pleural cavity, I stitched both layers of the pleura together before proceeding to open the abdominal cavity. The cyst was found just beneath the diaphragm. It was first aspirated, then incised, and the endo-cyst removed. The liver was pushed back, and the wound in the diaphragm closed with carbolisecl gut.
The thoracic muscles were then brought together with buried sutures, and the external skin wound then closed, adopting the method advocated by Mr. Hamilton Russell. Union took place by first intention, and without an ache, pain, or rise in the temperature. He made a perfect recovery from this operation.
He was able to get up on the tenth day, and a week later left the hospital.
On May 31, I operated on him for the fifth time. I made an incision in the neighbourhood of the spleen, parallel to the margin of the ribs. I found that the omentum was firmly adherent to the cyst in the spleen. With my finger nail I tore a hole through it, and exposed the surface of the hydatid ; I then drew off with an aspirator thirteen ounces of clear fluid. I then slit up the sac and removed the cyst ; I carefully sponged out the cavity, threw back the collapsed sac, and sewed up the abdominal wound. lIe made a perfect recovery, was out of bed on the tenth day, and uP and about on the fourteenth.
The account I have given you of these two cases, though I fear unavoidably a little bewildering, nevertheless tells its own tale.
But there are one or two matters to which, if you will bear wit h me for a few minutes, I should like to draw special attention, in order to invite discussion upon them. In the first place, I should like to call attention to the question of the operative treatment of multiple hydatids of the abdomen in general. My own experienc e prior to these two cases, both of such cases in my own practic e' and of similar cases observed in the practice of other surgeons , Ins been of a most unfavourable and disheartening nature. i n fact, I do not remember ever having seen recovery follow th e removal of such large numbers of cysts. The reason of this I no w
feel confident has been, to put it shortly, the attempt to do too
Aug. 20, 1895 Multiple Hydatids of the Abdomen. 349 ranch at a single operation. In either of these cases, to have adopted the heroic course of opening up the whole abdomen by an extensive incision, and then running " amuck" throughout the length and breadth of the cavity, sparing no organ that happened to harbour a cyst, in the endeavour to make a clean sweep of the disease, would, in my opinion, have been to court disaster. On th e other hand, I am certain that the secret of success lies in the judicious parcelling off of different regions for attack in successive operations, any one of which shall be fraught with comparatively trifling risk, for it is better for the patient to submit himself to half a dozen operations of trifling risk than to one which will Prove almost inevitably fatal. In the course of the first case, the Position which caused me most anxiety was that which obtained after the first operation, when I discovered that the abdominal cyst, which I had evacuated, was not identical with the pelvic cyst which pressed upon the rectum, and that the latter cyst was Ilppurating and causing much constitutional disturbance. Then I had to decide which was the better way to attack the pelvic cyst, Should I open it through the rectum, or should I plunge down through the cyst which had been evacuated, and get into the pelvic cyst that way ? Against this latter course was the fact that the path to the cyst was very deep and very narrow, and that the boundaries of this path was very indefinite and uncertain.
1'0 overstep the boundaries meant to burst through the peritoneal cavity, whereas to open the cyst through the rectum was very 'ouch easier, and would offer the great advantage of dependent drainage ; but against this method was the possibility of faecal contamination of the contents of the cyst. Eventually, I chose the former plan, and opened the cyst from above ; but I would venture to suggest in a similar case, that the cyst might be opened through the rectum, the mother-cyst removed, and the opening in the rectum stitched up, Of course this would entail elaborate Precautions for the avoidance of septic contamination. I lately noticed the report of a case of hydatid cyst opened through the rectum, by Mr. Reginald Harrison, in which the cavity was sUccessfully drained. In my case, trouble and delay in healing were certainly experienced, through the difficulty of draining With regard to the second of my two cases, .I should like to call attention to the brilliant results following the removal of the cyst (111 the convex surface of the liver, and the cyst of the spleen. In
350 .Australian Medical Journal. Ave. 20, 1895 the former case, as you will remember, I operated through an opening in the thoracic wall and the diaphragm. In both instances the fibrous sac was allowed to drop back unclosed after removal of the cyst and its contents, thus adopting the method advocated by Mr. Hamilton Russell in the February number of the Interco/on/a/
Quarterly Journal of Medicine and Surgery. I have no hesitation in expressing my emphatic opinion that the full recognition of the pathological significance of the fibrous adventitia, and its manage - ment on the principles laid down by Mr. Russell, will revolutionise the operative treatment of hydatid disease, and marks a most important epoch in the treatment of this affection. Thus in both instances in our second patient, after removal of the lower cyst through the diaphragm, and after the removal of the splenic cyst recovery was absolutely unmarred, and was completed in a few days, being exactly similar to the recovery which follows any simple abdominal incision, in which union by the first intention throughout takes place.
That this is an enormous advance on our former methods I need not say, indeed, it is hardly too much to say that the whole aspect of hydatid disease of the abbomen is changed by it, and I am con' fident that all other methods in dealing with simple uncomplicated cysts will rapidly fall into permanent disuse.
Dr. DUNCAN congratulated Mr. Ryan on his extremely interest - ing and original paper. If Australian surgeons had been some - what behind Lindemann and Bond in originality in the past in regard to the surgical treatment of hydatids, the paper just read would go far to retrieve the position. He had heard Mr. Ryan once say, that as surgeons we were quite satisfied with the recovery of our patients, even with the drawbacks our present treatment entailed. The speaker was entirely of the same opinion even when recovery entailed hernia and other evils. The paper just read would go far to impress on them the desirability' of following in the lines laid down by Mr. Hamilton Russell.
That these views were highly original, and would revolutionise our present operative procedures there could be no manner of doubt. In a paper that the speaker read before the Society on this Yell subject, he had been much impressed with the views expressed by Mr. Russell and Dr. Moore. If the theory which had received it practical illustration in the present paper should bear the test of further experience, then undoubtedly there could be no question
AUG. 20, 1895 Multiple ilydatids of the Abdomen. 351 of its immense superiority over our present methods of operating.
One of the cases alluded to in this paper was unquestionably unique in the annals of surgery. Mr. Ryan was to be heartily Congratulated in having brought such a case to a successful issue.
The paper altogether was highly thoughtful and suggestive, and would bear important results.
Dr. MooRE said he was sorry that he could not agree with one remark of Mr. Ryan's, which had been accepted by Dr. Duncan, and he was also sorry to appear to depreciate the value of a suggestion made by one of the members of the Society, but he Could not agree with the statement that the suggestion of not suturing the cyst before dropping it back would completely revolutionise the modern treatment of abdominal hydatids. It Was the intra-peritoneal or Bond's method, as against the extra- peritoneal or Lindemann's method, which was the great modern advance in the treatment of abdominal hydatids. The omission of the suturing of the sac was no doubt a valuable suggestion, but it was a mere detail, and it had been suggested independently by ond himself. He thought, therefore, that too much importance had been attached to what was really nothing more than a matter of detail, whilst the important principle, that of the intra-peritoneal treatment of the sac, as introduced by Bond, had been passed over, lie did not agree with Dr. Duncan in supposing that the peri- toneum had to stand the pouring into it of fluid from the cyst, for he did not believe that any fluid was poured into the peritoneuin in these cases. Mr. Ryan was certainly to be congratulated on the result in these two cases, and he quite agreed with his practice of doing a number of operations rather than attempting the treat- Inent of all the cysts at once. At the same time, remembering how ill both these patients were after operation, he thought surgeons would be disappointed if they expected . that such good results would generally be obtained in such cases.
Mr. HAMILTON RUSSELL said that, without desiring to claim any undue credit with regard to the intra-peritoneal method of treat- ing the adventitia of hydatid cysts, he certainly could claim that his paper on the subject was published coincidently with Bond's recent publication of a case so treated in the British Medical Journal. It was one thing to pipe a tune, but quite another thing to make the hearers dance, and for the last three or four Years the speaker had been urging surgeons to give his views a trial in dealing with the adventitious sac of hydatids, but they had
352. Australian Medical Journal. Aua 20, 180
been invariably received with scepticism. Among other surgeon!
to whom he remembered speaking was Dr. Moore, who rejecter the suggestion in toto.
Mr. SYME- said that a point yet to he determined was, what became of the fluid poured out by the adventitia, after the remove of the hydatid cyst treated intra-peritoneally. In the first place we had Dr. Moore's theory that, while the fluid which was 1,614 formed (probably, Mr, - Syme thought, by a process of osmosis) the edges of the incision became adherent to the nearest tissues
and so the fluid remained confined to the cavity originally
formed by the cyst, which it would gradually distend, and them]
be re-absorbed, or if not, and the sac became over full, the incision being in apposition with the abdominal wound the fluid would escape through it, and there was no risk of its entering the peritoneum, which was not a cavity. In th' second place, it was supposed . by others that the fluid would find
its way directly into the peritoneum, without distending the cyst and be at once absorbed. Both views were purely theoretical.
To the speaker, it seemed. largely a question of pressure. Dr.
Moore contended that there is no cavity or unoccupied space it
the abdomen, but it would not require much pressure to separate a place for fluid amongst the abdominal contents. This wriv
exemplified by a recent case of thole-cystotomy performed by the
speaker, the gall-bladder was firmly contracted round a large stone, and having removed the stone, it was found impossible V.
bring the edges of the wound in the gall-bladder in contact with
the abdominal wall, so it was brought as far as possible, and then
packed with iodeform gauze, the bile escaped freely from the
wound, but the patient progressed badly and died. At a post- mortem examination, the peritoneal cavity was found full of bile.
If fluid is secreted under pressure, it will find its way into the
cyst space first, and then either through the wound or into the
peritoneal cavity according to circumstances, but the facts before
the profession with regard to the behaviour of the fluid collecting
in the adventitial sac after operation, are not sufficient to permit
dogmatic statements at the present time. Mr. Ryan w as to be
congratulated on the success of both his cases, which were most
difficult ones. Regarding the treatment of cysts pressing on the
rectum, it seemed to him that it would be advisable to deal with
them from the rectum. It had been stated that it is useless to
attempt to be aseptic in operations about the rectum, but with
this he disagreed. At all events, the risk the surgeon runs by opening these cysts through the rectum, was much less than when he opened them through other cysts that were suppurating.
With reference to the treatment of cysts in the spleen, the choice of two operations presents itself—they may be reached through the thorax and diaphragm, or through the abdominal wall, and the way the cyst presents, and the nature of its contents, decides the surgeon in his choice. In the case read by Mr. Ryan, it was a simple matter to deal with it through the abdomen. Where You are dealing with a suppurating cyst without adhesions, there is less risk in approaching it through the diaphragm than through the abdominal wall. Mr. Ryan would not have been able to fix his splenic cyst to the abdominal wall after Lindemann's plan, and it would be hardly safe to drop it back as he had done if it had been suppurating. He heartily congratulated Mr. Ryan on these two most unique and successful cases.
Dr. BAGE thought that gravity would certainly tend to cause fluid, effused into the recently opened sac, to flow into the general peritoneal cavity if adhesions, such as Dr. Moore said were formed, were not fairly firm. He thought that Mr. Hamilton Russell's suggestion of omitting any sutures in the adventitia was a valuable one considering the uncertainty of having absolutely aseptic sutures.
Dr. CHAS. RYAN, in reply, thanked the members for the reception given to his paper, and expressed his pleasure at the interesting discussion to which it had given rise. Without in the least Wishing to withhold any of the credit due to Bond for being the first to suggest the intra-peritoneal treatment of the adventitious sae, he did not consider that this fact lessened the claims of 'r. Russell, who had been the first to formulate the principles, and to boldly advocate the best method by which this should be done. He narrated a case of hydatid of the liver in a boy of 10,
° 11 whom he operated at the Children's Hospital about two years 40. At the operation, Mr. Russell who was assisting him, so l''rsistently advised that the adventitia should be dropped back without suturing, that, half persuaded, he ended by putting in a few sutures which he felt were quite ineffective for complete closure of the sac. The boy made a perfect recovery, and left the hospital in a fortnight. Since this case, he had operated several times by the infra-peritoneal method without suturing the sac, in 411 cases successfully, and even in one or two cases in which bile
BB
Axe. 20,1895 Multiple Hydatids of the Abdomen. 353
had escaped into the sac, no harm had resulted, the bile finding its way to the abdominal wound, and escaping through an opening in the cicatrix In conclusion, he felt no hesitation in expressing the opinion that the intra-peritoneal method, as advocated by Mr. Russell, was the operation of the future, and would supersede all others in the treatment of uncomplicated hydatid cysts.
Melbourne gletritat Association.
The Annual Meeting of this Association was held on Friday, August 2, at the Association's Rooms in the Stock Exchange Club, Collins Street.
A very large number of members were present.
The following office-bearers were elected for the current year :—
President—Dr. C. P. Dyring ; Vice-Presidents—Drs. C. H. Molloy and P. B. Bennie ; Committee—Drs. A. V. Anderson, E. W Anderson, S. S. Argyle, W. R. Boyd, J. W. Springthorpe, G. A.
Syme; Hon. Secretaries—Drs. Charles Goodall and F. J. Owen;
Hon. Treasurer—Dr. R. R. Sta,well ; Hon. Steward—Dr. H. A.
Embling ; Hon. Auditors—Drs. J. R. Thomson and A. J. Wood.
The Committee reported a satisfactory year of original and important work by members, a substantial increase in the member's list, and a sound financial position.
The retiring President, Dr. E. W. Anderson, delivered an able and interesting address on "Recent Advances in Medicine and Surgery."
On the recommendation of the Committee, it was resolved
"That Resident Medical Officers of Victorian Hospitals may, on application and nomination by a member of the Committee, be elected by the Committee Honorary Members for one year."
Messrs. Burroughs, Wellcome and Co. have issued types for testing sigh t ' and also a chromatic dial for investigating the condition of colour vision . On the dial are apertures surrounded by the colour which is to be used as a test. The dial is moved over an underlying disc, on which are numerou s colours in segments of the same size as the apertures of the dial, and th e patient signifies when the matching colour appears. It forms a very ser' ice able and convenient little apparatus, and a useful colour test is obtainable.
354 Australian Medical Journal. AUG. 20, 1895
Aug. 0, 1895 Hospital' Reports. 355
ospitaJ 1etiorts.
EYE AND EAR HOSPITAL.
A Case of Detachment of the Retina.
Under the care of Dr. A. S. GRAY.
Senior Surgeon to the Eye and Ear Hospital.
Reported by Dr. PERCY WEBSTER.
Detachment of the retina is happily one of the rarer forms of eye disease ; when it does occur it is apt to be disastrous to vision, so that a case of recovery deserves to be recorded, more par- ticularly when the process of cure can be watched, and partakes more of a natural process than an artificial one. The result in this case was so successful as to lead to the restoration of perfectly useful and little short of normal vision.
I am much indebted to Dr. Gray for permission to publish this report.
A printer, aged 35, consulted Dr. Gray, and stated that on the Previous day whilst lifting some type, weighing about 200 lbs., he noticed something come across his sight, his vision became dim, but he experienced no pain, and had no Unusual sensation in the
eye. The sight remained dull and clouded, and when the lids were closed, there seemed to be clouds of smoke passing before the eye. Dr. Gray diagnosed a detachment of the retina and sent him to the hospital, and his condition was then as follows :- Right eye, V. = 5 c. + 5 cyl., ax. 90°; media clear ; fundus healthy ; pupil and tension normal. Left eye, V. .---. fingers at two feet; anterior media clear ; tension the same as the other
"ye. The vitreous was filled with fine rapidly moving opacities, obscuring the fundus, but not preventing a red reflex from its upper and nasal parts being seen. Below, and to the outer part was a flap of detached and torn retina, with a ragged edge flapping about with every movement of the eye.
The only portion of the patient's previous history of importance was, that eight years ago he had rheumatic fever, and that since then he has not seen so well with the left eye as with the right, and has occasionally had pain in it, and headache on that side of the head. He has not had syphilis or any injury to the eye.
Dr. Gray ordered the patient to bed with a compress bandage Over the eye, and he was given a mixture containing iodide of
BB 2
356 Australian Medical Journal. AuG. 20, 1895
potash. He was kept in bed for six weeks, being allowed, how- ever, to go to the water-closet. At the end of six weeks it was found that the retina had gone back in contact with the choroid, and that the vitreous had cleared, the vision having improved to
10, ths. The vision, now ten weeks after coming under treatment, is partly 6 + •5 cyl., axis 90°, and Cowel 2. The vitreous is free from opacities. The disc and macula are healthy, but out- ward from the latter the retina begins to assume a partly opaque appearance, and presents a few shining spots of degeneration;
further out still and downward is a star-shaped grey opaque patch, with blood-vessels and spots of haemorrhage in it, and having opaque grey lines radiating from it in different directions, the broadest of them having a direction parallel to the equator of the eye. Directly downward from the disc is a second similar patch, connected by fine lines with the first, and along these lines it looks as if a crease had been left in the retina, but nowhere is there any detachment, the retina being in close apposition to the choroid, which itself appears healthy.
Corresponding with this portion of the retina, the field shows a rather extensive defect above, its upper edge being limited by an irregular line running obliquely downward from the upper and temporal quadrant, to within five degrees of the mid-horizontal line at the nasal limit of the field, and passing within fifteen degrees of the fixation point.
One is unfortunately unable to say how long the detachment had been present, and can only speculate that it had been there for some time before the patient came to Dr. Gray, possibly from the t;me he had rheumatic fever, since when the sight has been defective in this eye ; that whilst he was lifting the weight the detachment ruptured, and the exudation behind it was diffused through the vitreous, and subsequently gradually absorbed ; that the retina fell back into its natural position, and formed some permanent attachment to the choroid.
If the sequence of events have been, as is supposed above, it would seem that some plan of operating which would produce a tear in the retina, and allow the escape of the exudation behind it to take place into the vitreous, would be the most successful method of operative treatment. It must be remembered, how - ever, that operative measures can so far claim but little success ,
and even where success has been attributed to them, it is more than likely that the rest in bed and general measures, are
Aug. 20, 1895 Hospital Reports. 357 responsible to a larger extent than the operation itself, for the improvement that has taken place.
I have to thank Dr. Orr for help with the notes, and informa- tion about the patient.
ST. VINCENT'S HOSPITAL, MELBOURNE.
Two Cases of Neuralgic Pain, Successfully Treated by Operation.
Under the care of Mr. G. A. SYME.
CASE I.
Pain along Intercostal Nerve, and Spasm of Abdominal Muscles, due to Exostosis of Rib.
J. H. S., get. 39, a horse trainer, was admitted on July 1, 1894, complaining of pain in the right side, more or less constant, but aggravated at times, when he was seized with violent cramps in th e abdomen. The pain had been present for six months, and was getting worse. Three and a half years ago he had a severe fall from a horse, injuring his left shoulder, but he does not think that had anything to do with his present trouble. On examination, the patient was a powerful well developed man. The pain was referred exactly to the course of the ninth intercostal nerve of the right side as regards its maximum intensity, though diffused more or less. During the severe paroxysm, there was marked spasm of the right rectus abdominis muscle, and of the oblique muscles.
On July 6, 1894, an incision was made along the ninth rib, Posterior to its mid point, and a portion of the rib, about two inches long, excised. The finger was passed back along the upper border of the tenth rib, and far back, near its articulation with the transverse process, a projecting portion of bone was felt. This Was removed with a gouge and cutting forceps, in piecemeal, and With some difficulty. It was spongy in character, and covered with Cartilage, and was evidently an exostosis, pressing on the nerve.
Some hemorrhage followed, which was arrested by plugging with iodoform gauze. The operation was conducted aseptically.
On July 11, the temperature rose to 103° F., and he complained Of pain in the right side and cough. On examination, some effusion was found in the right pleural cavity. On the 12th, he had a sudden attack of syncope, becoming almost pulseless, and
Collapsed. The pleuritic effusion became purulent, and was drained, and the cavity took some time to fill up, the lung expanding very slowly. However, it eventually filled up, and the patient was
358 Australian Medical Journal. AUG. 20, 1896 discharged perfectly well and free from all pain on September 3,
1894, and joined the circus troupe to which he belonged.
CASE II.
Persistent Headache, due to Inclusion of Occipital Serve in a Scalp Cicatrix.
M. D., aet. 17, single, was admitted on the 19th June, 1894, complaining of intense and persistent headache. When four years old, she fell from a fence six feet high on to her head, and became, according to her mother's statement, unconscious, vomiting as she recovered. She had also a scalp wound, which quickly healed.
When five years old she began to complain of headache, and has done so ever since. On examination, the patient was a bright intelligent girl, with no suspicion of hysteria. The pain was referred to the vertex and left side of the head, and also to the occipital region slightly, but was also diffused at times over the whole head. She had no vomiting, and no other symptoms of any kind. The head was shaved, and a scar discovered in the occipital region on the left side. An incision was made over the trunk of the left occipital nerve as it comes through the trapezias attachment, and the nerve dissected out, and traced into the scar in which it was found to be imbedded. A portion of the nerve and the scar were excised, and the wound closed. It healed by first intention, and the patient lost all pain, and has had no return of the headache since.
61inital Ectorbs.
THREE CLINICAL CASES.
I. LABIAL LIPOIVIA—II. COLLOID OVARIAN cysT- OMA--III. SUPPURATING HYDATID OF BROAD LIGAMENT, WITH ROTATION OF PEDICLE.
By J. W. DUNBAR HOOPER, L.R.C.P. et S. Ed.
Hon. Surgeon to the Women's Hospital, Melbourne.
CASE I.
In September 1893, I was consulted by Mrs. H., aged 48 years' for supposed right-sided inguinal hernia, for which she had been advised to wear a truss. The swelling gave a distinct impact Oil coughing, was painless, fluctuant, dull on percussion, transluce nt/
non-reducible, and non-lobulated.
AUG. 20, 1895 Clinical I, icords. 359
I diagnosed a lipoma, of right labium majus, and on September
23, 1893, dissected it out in a few minutes, tied the pedicle (in which were the two vessels) with carbolised gut, and closed the wound with silkworm-gut interrupted sutures. The wound healed perfectly. The patient was lately seen, and no further trouble was experienced. The lipoma weighed 1 lb.
Professor Howard Kelly, in the "Johns Hopkin's Gynaecological Reports for 1894," makes a special report on these tumours, and their great rarity is evidenced by the fact that he can only collect twenty cases culled from all sources, the largest specimen (24 lbs.) being reported in the Australian Medical Journal by Dr. Balls- Headley in 1888.
CASE II.
Mrs. A. B., 26 years old, never pregnant, was admitted to the Women's Hospital, on July 23, from the Out-Patient Depart- ment, where she came on the previous week, complaining of irregular, painless cata.menia, and a tumour in the right lumbar region, which, although noticed for eight months, caused no inconvenience. Purulent leucorrhma and frequent micturition distressed her. Per vaginam examination revealed an apparently Solid tumour, reaching to within two inches of the ensiforin cartilage. The fundus uteri was movable and in good position, and the urine was normal.
The diagnosis of colloid cystoma was confirmed by cceliotorny on July 25. There was no peritonitis, but the immense tumour was kidney-shaped, filling the right side of the abdomen, its highest surface being under the liver, while attached to its lower end, and deep in the pelvis, was the left ovary, from which the growth originated. A very broad pedicle required triple interlocking ligatures, and even then the left spermatic artery had to be Separately ligatured, and during this procedure the vessel slipped from the loop, the patient losing a great quantity of blood before it w as adequately secured. A glass drainage-tube was inserted, and the wound, after careful irrigation with saline solution, was Closed with twelve silkworm-gut sutures. The tube was removed in sixteen hours. On the eighth day, a large hmmatoma developed between the three upper sutures, and had to be freely laid open.
CASE III.
Mrs. J. W., aged 43 years, came to the out-patient department of the Women's Hospital on July 19. She stated that four days
vs"
360 Australian Medical Journal. Auu. 20,18 95
after her last (seventh) confinement, sixteen months ago, she noticed a tumour in the left iliac region, which had steadily increased in size, but gave her no inconvenience until two days ago, when she was suddenly seized with intense pain in the abdomen while engaged in household duties. She vomited and had to go to bed. Her temperature was mi., pulse 120, the abdomen distended and tympanitic. She was immediately admitted into my ward, and on further examination under anaesthesia the diagnosis was made of pelvic cystic tumour, with rotation of pedicle. There was no dysuria or menstrual irregu- larity, and she still nursed her baby.
Having quite recently operated on a suppurating pelvic hydatid where the history and physical signs were almost identical with this case, I was prepared to extend the present diagnosis in that direction. I performed cceliotorny on July 20, assisted by
Dr. Alsop, and found a good deal of bright fluid blood in abdominal cavity, with extensive peritonitis. The omentum was firmly adherent to the right lateral surface of an enormous fibro-cyst, and had to be ligatured in several places. The distal surface of the adventitious-sac was purple-black i1 1 colour, and was formed by the right half of the broad ligament, which was rotated five complete turns, and had torn some of the adherent omentum, thereby causing the haemorrhage.
Five and a half pints of hydatid fluid and daughter-cysts were removed, the last few ounces being purulent. The cyst had several firm adhesions to the bladder. ascending and descending colon, and vermiform appendix. The right ovary was converted into an hydatid cyst the size of a turkey's egg, and was removed, but the left appendages appeared normal. The wound was closed in the usual manner, and drainage-tube removed in twenty-four hours; but recovery was delayed by an abscess forming on the abdominal wall, though apparently unconnected with the sutures
I sent this specimen to Dn. Mollison for the purpose of searching for the bacterium coli commune in the suppurating hydatid the greater portion of the fibro-cyst being attached to bowel.
Unfortunately, the specimen was misdirected, but the point was an important one for investigation.
Dr. Farmer administered chloroform and then ether in th e is
and the preceding case without any subsequent vomiting.
AUG, 20, 1895 Clinical Records. 361 A. CASE OF ANEURISM OF THE HEART, AND A PROBABLE DIAGNOSTIC SIGN OF SUCH CON- DITION.
By E. H. EMBLEY, M.B., B.S. Melb.
Hon. Anesthetist, Melbourne Hospital.
This was the case of a well-nourished man, aged 60, a watch- Maker, whose work for years consisted in sitting at the bench for eight hours daily, and whose exercise was the walk to meals, a short distance, and a short evening walk. His habits of life were simple and temperate. I saw him in October last in reference to a loss of power in the right arm, which on investigation proved to be a slight hemiplegia.
In seeking for the cause of this, I found the following peculiar Condition of the heart :—The area of heart dulness was a good deal increased to the left, the apex beat was in the nipple line.
The heart sounds were with difficulty audible, in consequence of the thickness of the parietes, of their low pitch, but especially because of the presence of a musical sound, quite distinct from th e normal sounds, obscuring them. This sound was high- Pitched, humming, continuous throughout the entire cardiac cycle, rising in systole, and falling in diastole, audible from apex to base, but loudest at apex. The distinctly uninterrupted con- tinuity, the easy rise and fall, the absence of see-saw indications of backward and forward flow (as in certain incompetent valve cases), and the high pitch of the musical sound denoted a small thin tag of substance vibrating in a continuous current, increasing with increase of intra-cardiac pressure. He also complained of pain and numbness down the left arm, with pain and hyperaesthesia over the cardiac region.
By rest and quiet he was able, after the lapse of a little time, to resume his work. At the end of May, i.e., eight months later, he returned with much more marked indications of heart failure. He had now dyspncea on exertion, pain and numbness down both arms, flatulence, anorexia, sleeplessness, and more marked precordial Pain and hyperwsthesia. The abnormal humming was still present, and about as pronounced as before. He was still able to walk to see me, however. He again was advised rest and the usual
treatment. Three days later I saw him ; he was still the same.
On the morning of the following day he was found dead in the Closet, and was removed by a constable, at the request of the landlord, to the morgue, the landlord suggesting the possibility of poisoning.
