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MEETINGS OF SOCIETIES.

GLASGOW MEDICO-CHIRURGICAL SOCIETY.

SESSION 1902-1903.

MEETING VII.-9TH JANUARY, 1903.

The President, DR. W. G. DUN, in the Chair.

I. CASE OF INTUSSUSCEPTION OF JEJUNUM.

BY DR. W. F. GIBB.

Andrew B., æt. 29, admitted to the Royal Alexandra Infirmary, Paisley, on 3rd May, 1902. Previously he was in good. health, but always constipated. Four days ago he was seized with severe abdominal pain, with bilious vomiting. No movement of the bowels has occurred, and no flatus has passed, neither has there been any appearance of blood or mucus. When admitted he was collapsed, and vomited green fluid incessantly. The abdomen was quite flat, and he complained of great pain in the epigastrium. In the left iliac region there was an area of dulness and slight fulness. Rectal examination gave no information.

4th May.-On opening abdomen an irreducible intussusception of the small intestine into small intestine was found, estimated to be about 3 feet below duodenum; it was greatly congested, but not gangrenous. Enterectomy and end to end.

anastomosis by suture was done, and 1 pint saline injected subcutaneously. Vomiting began soon after, and he died next morning.

II. CANCER OF SMALL INTESTINE REMOVED BY

ENTERECTOMY.

BY DR. W. F. Gibb.

Mrs. H., æt. 27, admitted to the Royal Alexandra Infirmary, Paisley, on 20th June, 1902. Up till April last she had enjoyed good health; she had had several children, and when admitted was three months pregnant. About two months ago she began to suffer from abdominal pain, persistent vomiting, emaciation, and difficulty in getting bowels to move. She was found when admitted to be much emaciated and somewhat collapsed, temperature subnormal, the abdomen distended and tympanitic. Severe colicky pains occurred every few minutes, with gurgling and visible movements of bowel coils in epigastric and umbilical regions. The colon was not distended. The vomiting was bilious, not fæcal. No abdominal tenderness, no tumour felt, liver dulness normal, rectal examination negative.

On following day a median incision was made, and a tumour of ileum found within a few feet of the cæcum, causing partial obstruction. The affected portion was fixed outside with a few inches of healthy gut, and, as fæcal vomiting occurred shortly after the operation, the bowel was opened at once and drained.

On 3rd July the tumour and a few affected glands were removed, end to end union effected by suture, and the abdominal cavity filled with saline fluid.

On 7th August she was dismissed well, and was delivered safely on 25th December.

Dr. Ferguson's report on the examination of the tumour:"The tumour is a colloid carcinoma. Over a considerable part of its extent the whole thickness of the bowel has been replaced by tumour substance, and in one or two regions the serous coat has been infiltrated, although no evidence of further peritoneal invasion exists."

E. C., æt. 2 years, admitted to the Royal Alexandra Infirmary, Paisley, on 1st November, 1902, on account of an

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abdominal tumour observed about three months previously. The tumour was firm, painless, movable, and dull to percussion; it extended from pubes to centre of epigastric region. Patient's general condition fairly good. Urine-acid, scanty, specific gravity, 1030; large deposit of urates; albumen, sugar, and blood absent.

On 7th November the abdomen was opened by median incision, and over a pint of clear yellow fluid escaped, and a solid tumour studded with cysts presented. After division of adhesions to small intestine, the tumour was delivered and removed by ligaturing its remaining attachment, a pedicle half an inch in diameter arising from the pelvis.

2nd December. The child's father reported her as keeping well.

Dr. Ferguson's report on the examination of the tumour:"The tumour may be described as a myxochondrosarcoma. The greater part is distinctly myxomatous, and consists of amorphous cells and fibrous bands embedded in a hyaline matrix. There is a wide deviation in the amount of cellular elements in different parts of the growth, and in several large areas the preponderance of cells is very great and the type of cell is distinctly sarcomatous.

"Throughout the whole mass, also, there are interspersed nodules and plaques of hyaline cartilage.

No trace of ovarian tissue is noted."

IV. ON A CASE OF CONGENITAL DEFORMITY OF THE NOSE ASSOCIATED WITH A DEGREE OF MEDIAN HARELIP.

BY DR. ALEX. MACLENNAN.

Defects in the development of the median parts of the face and head are somewhat rare, for it is owing to an arrest in the growth of the lateral maxillary processes that the very common deformity of so-called harelip is due. At one time it was doubted if a median cleft could occur in the upper lip, but the occurrence of a number of this rare condition has settled the question, and it is generally admitted that the deformity occasionally is seen. It is the explanation of the facts which still give rise to the diversity of opinion. The deformity about to be reported has a number of points of interest which will be referred to after the case has been described.

P. M., æt. 7 months, was brought to the out-patient department of the Western Infirmary, Glasgow, suffering from a deformity of the nose which was congenital. The acconipanying photographs give a much better idea of the condition

than any description can do, but there are one or two points which the photographs do not bring out with sufficient clearness. The protuberance on the nose was covered with normallooking skin, and on section the normal structures of skin were found to be present. The small tubercle seen about the middle of the swelling was somewhat more hairy than the other parts, which were covered with the usual fine down. The internal anatomy of the nose was normal, with the exception that the septum was much thickened in the region of the external deformity. There was no trace on the protuberance of the red part of the lip. That part of the lip which ought to form the lunula was thinned in the middle,

and it was quite apparent that the lip had escaped further deformity owing to a compensatory expansion of the lateral maxillary processes. The continuation, from the borders of the nostrils of the normal structures which form the upper lip, could be clearly traced downwards from either side, sweeping in a curved manner to bridge over the gap left by the missing fronto-nasal process, and curving away from each other again, so as to leave a small notch in the upper lip. The palate and mouth were normal.

I would offer the following explanation of the malformation:-The deformity has arisen from an error in the growth of the fronto-nasal process, either in direction or in punctuality. The defect inight conceivably be attributed to the

lateral maxillary processes, which by their excessive growth united in the middle line and caused the median process to become diverted from its proper course. This, however, was unlikely, for the amount of union below the protuberance was not sufficient to lead to the belief that the lateral maxillary processes possessed such an exuberant growth. In all probability, then, the growth of the lateral maxillary processes was compensatory, and they attempted to fill in the gap caused by the failure of the fronto-nasal process to do its proper share; and just because the union was so slender, the error in the growth of the nasal process was one of direction rather than one of punctuality. The maxillary processes possessing a normal formative power grew on till they met in the middle. line, and in a similar way the misplaced fronto-nasal process exceeded its normal dimensions-perhaps in an attempt to reach its proper situation.

From a scrutiny of other examples of this malformation, it seems evident that the error lies in the fronto-nasal process, which takes on a wrong direction of growth, for in certain cases the same deformity of the nose may be present while the gap in the lip is retained; thus showing that to produce this deformity no barrier to the downward growth of the median process is required.

On the assumption that the defect is due to the median process growing forwards instead of directly downwards, the deformity is quite explicable. The nasal process turned forwards and left a gap, which, in the present case, became filled in by a compensatory growth of the lateral maxillary processes, but these left enough trace of their action to indicate the origin and nature of the deformity.

The description of the deformity as a tumour has been carefully avoided, for this is an example of growth which can in no sense be called a neoplasm, being merely a piece of tissue, normal in every respect save its position, and it is questionable if this tissue would ever have taken on such an excessive growth as to warrant the term tumour being applied to it. Still less can it be described as a teratoma, for the mass neither formed part of another ovum nor of a blighted twin. In an ordinary double harelip the misplaced or normally placed fronto-nasal process is never called a tumour, and this swelling is merely the misplaced nasal process, or part of it. This aspect of the subject has been discussed by Kredel 1

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1 Kredel, Die angeborenen Nasenspaltung und ihre Operation," Deutsche Zeitschrift für Chirurgie, 1898, Bd. xlvii, S. 237. (Literature here appended.)