Medical Society of Victoria.

ORDINARY MONTHLY MEETING.

WEDNESDAY, JUNE 5, 1895.

(Hall of the Society, 8 p.m.)

The President, Dr. ROTHWELL ADAM, occupied the chair, and twenty-two members were present.

EXHIBITS.

Mr. HAMILTON RUSSELL showed two cases of Plastic Surgery :(1) Case of severe burn of axilla and surrounding region in a boy æt. 4 years. At the time of operation, there was a granulating surface in the axilla, of the size of the palm of the hand, very painful, and making no progress towards healing; abduction of the arm was impossible. The operation consisted in bridging the axilla with skin, by means of a broad flap raised from the chest, which was made to meet two flaps brought forward from the back. The raw surface left on the chest was allowed to heal by granulation, and the ultimate result was perfect restoration of the movements of the arm. [Photos were shown taken immediately before operation.]

(2) Compound comminuted fracture of the lower extremity of the humerus, involving the elbow-joint, with sloughing of the soft parts in the flexure of the elbow. The patient, a girl, æt. 6 years, was run over by a tram. Three weeks after the accident, the raw surface was covered over with a flap of skin raised from the side of the thorax, and the arm fixed to the side in plaster of Paris bandages. The denuded area on the chest was at the same time covered in turn by the gliding method. Complete healing of both flaps resulted, and by the tenth day the first-mentioned flap was severed from its root, and the final result, as shown, was perfect restoration of the arm.

Dr. A. JEFFREYS WOOD showed two cases of Congenital Syphilis from the same family :

The eldest child, A. B., æt. 9 years, was treated for syphilis when a baby at the Children's Hospital, and now has just cut her four central incisor teeth, which are typically pegged, separated by well-marked spaces, and the two upper and the left lower central incisor are notched.

The younger child, P. B., æt. 3 years and 8 months, was treated for congenital syphilis at the Children's Hospital when 3 weeks old, and also developed well-marked post-nasal growths when 4 months old. She is now suffering from an ulcerative condition of the gum of the lower jaw, which has exposed the upper half of the roots of the central and lateral incisors of the lower jaw. This ulceration has been present for six weeks, and is now clearing up under mercurial treatment. No mercury has been given since eight weeks of age up to the present time.

The family consists of eight children; the first five children were strong and healthy, without any sign of snuffles or rash about the buttocks. The sixth child was the elder of the two shown. The next child was a boy who was apparently healthy; his birth was followed by two miscarriages-one at nine months, and the other at four months, while our younger patient was born six years after the birth of the elder patient, and presented all the signs of congenital syphilis.

In considering the question of marriage with relation to patients who have had syphilis, these cases occurring in the same family with an interval of six years between them are very interesting.

Dr. W. A. WOOD said that a possible explanation of the length of time between the birth of the two syphilitic children from the same mother, might be that the mother herself became infected subsequent to the birth of the first syphilitic child.

Mr. G. A. SYME said that he did not agree with the last speaker. When so many children were infected in a family, the mother was almost certainly infected, either from the father in the first instance, or from the first child, and a second attack of syphilis within the period mentioned was very unlikely.

Mr. KENT HUGHES said he had under his care a family where the mother confessed that she had been infected with syphilis. before marriage, and she had continued to give birth to syphilitic children considerably over a period of six years.

Dr. MOORE said that these cases of congenital syphilis had always presented to him many points of interest. He thought that the cases presented to-night were probably explained by an infected husband, the wife then became infected and continued to bear syphilitic children for the six years. With regard to the length of time, it is not an unusual thing to find mothers continuing

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to give birth to syphilitic children over a period of six years. From notes taken in the out-patient department at the Melbourne Hospital, he thought five years was an average time for the infection to last. He thought that the question of treatment modified considerably the length of time over which infection lasted. During the period in which syphilitic children are born, it is interesting to note the occurrence of miscarriages between infected children: With reference to Mr. Hamilton Russell's cases, he congratulated him on the success of both his cases, and felt certain that this procedure should be more generally adopted in large granulating wounds.

Dr. NIHILL showed & Fibrous Polypus removed from the naso-pharynx, and read the following paper :

A CASE OF FIBROUS POLYPUS OF THE NASO

PHARYNX.

The patient, from whom the growth I now show you was removed, illustrated so well some of the characteristics of fibrous polypus of the naso-pharynx, that I thought the notes of the case might be of interest.

D. R., a male, aged 25 years, consulted me complaining of complete nasal obstruction on both sides, of ten years' duration; of a troublesome muco-purulent discharge, and of having suffered from repeated attacks of epistaxis.

On examination, by means of the anterior rhinoscope, several mucous polypi were detected. These having been removed, the septum nasi was found to be deviated to the right side, and presented several irregular, cartilaginous, and bony outgrowths. But the chief cause, however, of all the symptoms was found by the posterior rhinoscope, and by digital examination, to be a smooth, globular swelling of firm consistence, almost completely blocking the posterior nares.

In order to thoroughly examine and remove the growth, the patient was placed fully under the influence of an anesthetic. It was only when the patient was under chloroform that a correct idea of the size and relations of the growth was formed. It then appeared to be springing from the right posterior naris, and invading the left posterior naris. So much having been ascertained, the ordinary nasal wire polypus snare was passed through the right anterior naris, and by means of the finger passed behind the soft palate, the loop of the snare was made to encircle the

growth, and by gradually tightening the wire, the successful removal of the tumour was accomplished. The chief difficulty experienced during the operation was in applying the loop. The hæmorrhage was free, was easily controlled, and soon stopped. When removed, the growth measured about two inches in length, one inch in diameter at its widest part, and proved to be of fibrous hardness.

nose.

The patient, on recovering from the effects of the anesthetic, was delighted to find how freely he could breathe through the His recovery was uninterrupted, and he now says he is as well as ever he was. It was difficult to state the exact origin of the growth, but I am inclined to think it arose from the upper part of the septum, or from the superior turbinated bone on the right side.

Most authorities, including Sajous, Lennox Browne, Greville MacDonald, De Havilland Hall, Ball, and others, are agreed as to the rarity of occurrence of these growths. The roof of the naso-pharynx appears to be their favourite site, but they have been found to arise from the septum, the inferior turbinated bones, or the floor of the nose. They occur much more commonly in males of from 15 to 25 years of age. They are extremely rare in females. The symptoms commonly produced are-complete nasal stenosis, epistaxis, and nasal discharge. They grow rapidly, and tend (by pressure) to displace surrounding parts, giving rise to the deformity called frog face. Repeated hæmorrhages, and the tendency to degenerate into sarcoma, are the most serious consequences to be feared.

With regard to treatment, most authorities recommend that efforts should be made to remove the growth by means of the cold wire snare, the galvano-caustic snare, or electrolysis, before resorting to more serious, and in many cases, unnecessarily dangerous operations.

Mr. Walsham, in St. Bartholomew's Hospital Reports for 1892, expresses the opinion, that division of the soft palate will be all the operative interference required in most of these cases. If a more extensive operation appear necessary, the procedure described by Annandale, of Edinburgh, seems worthy of adoption. The steps of this operation are as follows :

:

(1) The exposure of the anterior nares, by freely dividing the mucous membrane connecting the upper lip and upper jaws, according to the plan of Rougé.

(2) The division of the bony septum of the nose, along its attachment to the jaw.

(3) Incising the soft parts along the middle line of the hard palate, and then sawing through the alveolar margin of the upper jaw, and through the entire hard palate along the middle line.

(4) The forcible separation of the two jaws, and the introduction through the gap of the finger, periosteal scraper, or other similar instrument, with the view of separating secondary connections of the growth to surrounding parts.

(5) The removal of the growth from its primary site of origin by forceps, sharp spoon, cold snare, or the galvanic wire.

(6) When the tumour has been removed, the introduction of some antiseptic plug. The jaws are brought together and secured by one wire suture, and two or more horsehair sutures through the soft part of the palate.

Annandale relates three cases in which this operation was performed, and they all proved, so far as the removal of the growth was concerned, most satisfactory.

Mr. HUGHES showed a specimen of a Fibrous Polypus that he had also removed from the naso-pharynx. It was almost sessile in its attachment, and its removal lasted over an hour and a half. With reference to Dr. Nihill's remarks about the production of frog face by these tumours, he was of opinion that this type of face was almost unknown, except in the case of malignant tumours of the naso-pharynx.

Dr. NIHILL, in reply to Mr. Kent Hughes, said, though he had been fortunate enough to see three cases of this kind within the last three months, his personal experience of the progress of these growths was limited. Hence, he had merely followed the description of the course of fibrous growths in the nose as it is given by authorities on the throat and nose. The specimen removed by Mr. Hughes, and shown you to-night, has shrunk to a third of its original size.

The following paper was then read :—

RADICAL CURE OF INGUINAL HERNIA, ESPECIALLY IN REGARD TO BASSINI'S OPERATION.

By W. MOORE, M.D., M.S. Melb.

Surgeon to Out-patients, Melbourne Hospital.

I think that no apology is needed for bringing this subject before members for their consideration; for it is somewhat