C.D.—This was a similar case of rodent ulcer, in the left side of the nose, extending to the corner of the eye. His age is 42, and the ulcer had existed for over six years. He did not receive more than a dozen applications from me in all. It healed without any difficulty; the only thing that occasioned him any trouble at all was the remedy, and you will see the effects in his case. Although he has quite recovered now, I would like to direct your attention to the present condition of the skin on that side of his face. This case should act as a warning to anyone who may imagine that X-rays are a mild sort of remedy.

E. F.-The patient, an old man over 70, came to me with a small suspicious growth forming just under the front of his tongue in the frænum. It was just in that doubtful stage that no one would care to say what it was, except, taking all the symptoms and facts of the case into consideration, it seemed most probably malignant. I only gave him one strong application of the rays, and that is more than a year ago, and not having the confidence in it then that I have now I did not care for the patient to run any risk, but sent him back to his medical adviser, Mr. Rudall, with a view to having it removed, intending to apply the X-rays again afterwards. Mr. Rudall took such a serious view of the case that he was inclined to remove the whole tongue, as he told me in his experience these partial operations on the tongue were always failures. The patient was so strongly adverse to losing his tongue that he consented merely to remove the growth, and he did so. I have never seen the patient since, but I learnt on enquiry a few days ago that there has been no return of it. I attached but little importance to it at the time, but I have had two very similar cases since, which, having only recently occurred, are not so suitable for my illustration; but in both these cases two or three applications seemed to quite clear up all appearance of the malignancy, and it quite disappeared, and I now can see nothing impossible in one strong application of X-rays to an early and doubtful malignancy and acting in this manner, especially if the growth was removed at the same time. Now, my moral is this, and this I take to be the key of the whole difficulty: I believe all cancers have an early stage in which the growth is very small and malignancy is in an undecided state, or rather, I mean, cannot be determined positively in diagnosis. Now, I am convinced that in all these cases where it is so situated that the X-rays can be effectively applied that an easy cure could be effected and the patient would never know for certain whether it was malignant or not; very unsatisfactory from a

diagnostic point of view, but a lucky thing for the patient. What I do feel keenly is this: the sad, hopeless cases that are sent to me of advanced cancer being operated on once and recurring badly-these I look upon now as quite hopeless, yet, perhaps, 12 months or two years ago what a very different result this treatment would probably have effected. A case of cancer cannot possibly be treated too early by X-rays, and if well advanced I must tell you it is well-nigh hopeless.

G.H.-This patient, a man of 65 years, had an ordinary epithelioma on the end of his nose completely removed by Dr. Schlessinger about two years ago. It returned in last December, and grew vigorously. His brother died of cancer, and he has a bad family history in this way. When sent to me by Dr. Schlessinger, at the beginning of July, he had an epithelioma growing strongly, although being treated with escharotics; the surface was partly burnt down, but it was still the size of half a walnut. It presented such a striking appearance that I asked him to have it photographed, which unfortunately was done by an amateur, and I fear the result a failure. I forgot to mention there were nodules of the disorder disseminated through to skin nearly over the nose, and barring the X-ray treatment there was no other course left but the removal of the entire nose, which probably would only postpone the usual inevitable end. In one or two ways it was not a favourable case, and was a recurrent case. On the other hand, it was most favourably situated for this treatment. I applied the rays on an average about three times a week, and at first for ten minutes each time, gradually reducing it as the desired reaction was acquired. It has behaved in the usual way of diseased tissue ; the cancerous growth broke down, and, as you will see, now has gradually perished. In a short time nothing but healthy tissue will be left, and I shall then allow it to heal up. I regard it as practically cured now.

It

H.I. This is a woman, aged 45, from whom Dr. Cooke removed a small epithelioma on the end of her tongue in February of this year. started to return about June, and I saw her first on July 12th. The scar of the former operation had healed well, but evidence of recurrence in this scar was unfortunately apparent, and the patient felt a return of the uneasiness in the tongue. I gave her a few preliminary exposures, and Dr. Cooke operated again in July, removing only a very small portion-nothing appreciable-and since then I have been treating her with the X-rays. Giving it her rather strong, the reaction has been somewhat severe, and it is too soon yet to be able to pronounce on the success or otherwise of the

treatment. I quote this as a typical case of what may be done if we can only succeed with this treatment; that is, instead of a serious operation of removal of the whole tongue, a comparatively trivial one of this nature. I will take this opportunity of saying that I do not at present take a too hopeful view of tongue cases; they are not the class of cases that I prefer for this treatment.

He

J.K.-This is a man aged 47. I was asked to see him by Mr. O'Hara on May 28. appeared to be suffering from a cancerous growth, inside on the lower jaw, on the left side. It was evidently of the nature of an epithelioma, and the glands were considerably enlarged. One point in his favour was that it had only existed a few months, but was rapidly spreading. Mr. O'Hara contemplated removing a portion of the jaw as evidently the best thing to be done, but before doing so asked me to give the X-rays a trial. Before commencing I took a small clipping of the growth, which was kindly examined for me by Dr. Kelvington, and pronounced to be epithelioma, and in a very active state. My own opinion is strongly that, if the case had been left to the usual course of events, at the rate it was progressing all doubts would be very soon removed. I gave him preliminary treatment with the X-rays, and it progressed most favourably. On June 12 Mr. O'Hara removed the enlarged and infected glands, and also scraped and curetted the jaw bone, and after a week I resumed the X-ray treatment. The case progressed most satisfactorily towards recovery, the mouth completely healing up, and the malignancy disappeared entirely.

It

H.I. This case was sent me by Dr. Hodson, a man about the same age as last, but the disease has existed nearly three year, and this has made the case almost a hopeless one. was epithelioma of the tongue. About onethird of the tongue on the left side was already gone, as if cut out by a gouge right down far back to the root of the tongue. I started the treatment on July 1st, and from the first it soon began to put on a healthier appearance, and the foul and characteristic smell disappeared almost entirely. This is a common and hopeful sign in these cases. I followed a similar line of treatment as I did in the previous case, and on July 24th Mr. O'Hara operated and removed the sub-maxillary glands, tied the lingual artery, which was nearly ulcerated through, and merely curetted the tongue. I resumed treatment a week after, and the present position is this: The wound has healed well, and the side of the tongue is now nearly healed up. I have here sections of the tongue and glands, kindly made for me and examined

by Dr. Kelvington. In his report both the tongue and glands give evidence of epithelioma of long standing, which exactly corresponds with his unfortunate history.

J.K. This is another similar case. A man aged 53 originally sustained a crushing accident on his head, and last year a small malignancy formed under his tongue, for which he was attended by Dr. Duncan in 1901. In October, Mr. O'Hara operated and removed it, but it returned so badly that he removed the entire floor of the mouth, dividing the jaw at the symphysis on May 19th. It returned again rapidly, and Mr. O'Hara sent him to me at the end of July. I then found him in a very hopeless state, and I hesitated to attempt to do anything for him, it looked so utterly hopeless. The whole of the region under the jaw. seemed a mass of malignant disease. Discharged large quantities of foetid pus and blood through the opening in the old wound of the last operation, which was breaking down, and small portions of malignant growth sprouting out through it. Apparently another month or two at the farthest would see the end of the case. However, at Mr. O'Hara's earnest request I said I would try the effect of the rays on it, and the improvement was immediate and decided from the very first. I started on July 21st and gave it to him every day. The discharge lessened, and to my surprise the growth steadily subsided and got smaller and smaller. Small pieces of bone came away. I took a skiagram of the symphysis of the jaw, which you can now see, and the condition disclosed and the improved state of affairs encouraged us to think the case was not so hopeless after all. Some days ago Mr. O'Hara again cut down on to the symphysis of the jaw, which seemed to locate the seat of the disease, and removed only the silver wire suture, which you see in the skiagram, and a small piece of necrosed bone, both which I have here. That is all that was done except that whilst under chloroform I gave the ends of the jaw a thorough exposure to powerful X-rays for about ten minutes, that is, right into what appeared now to be the seat of the disease, and the wound was then closed up. So far the result seems to have been most satisfactory; the wound has healed by primary union and has a healthy appearance, and there has been no discharge from it since; and the patient says he feels so much better that he feels as if he ought to go to work. this treatment one of the most striking facts I have noticed is how directly the advance of the disease is arrested, even although the difference cannot be seen by the patient. Now he expresses himself as feeling remarkably well and different to what he was for a long time pre

In

case.

viously. It is premature to say much about the future prospects of this case, but owing to the marked and steady improvement that has taken place since I commenced treatment in July, there are now reasonable grounds for hoping for a successful result. So far as I am aware this is quite a new method of applying the treatment as I used it in this Whereas at present the surgeon removes not only the malignant growth, but as large as possible an area beyond, in order to ensure a satisfactory result, in future what I advise is this: If the growth is only small, superficial, and has not existed for long, then it will probably clear up under the X-rays alone. If it does not, or if it has existed for long, and is of any appreciable size, then I advise cutting out the cancerous tissue only and exposing at the time of the operation the seat of the disease whilst under chloroform to as powerful a source of the X-rays as possible the open wound for ten minutes or even more, in fact up to the limit of safe endurance, and this is a point that can be only determined by actual experience of many cases, then closing up again and treating afterwards with daily and similar applications of the rays.

(Read before the Victorian Branch British Medical Association.)

A CASE OF COMPLETE ONE-SIDED GIGANTISM WITH ENLARGEMENT OF THE OPPOSITE SIDE OF THE BRAIN.

By C. Reissmann, M.A., M.D., B.C. (Camb.), B.Sc., M.R.C.P. (Lond.), M.R.C.S. (Eng.), Adelaide.

SEVERAL cases of defective growth of the whole of one side of the body are on record, and these have been found at the autopsy to have been associated with deficient development of the opposite side of the brain. But the reverse condition, that of one-sided overgrowth, including enlargement of the opposite cerebral hemisphere, is certainly one of the utmost rarity.

The subject of this condition, which is exhibited to the Branch to-night, is an infant aged seven months, a boy, the youngest of a family of three. His mother, who is a healthy woman, and is present with her child to-night, attributed her child's deformity to a shock which she received at the sight of a friend who had been accidentally killed. This occurred at the time when she was two months pregnant. Her nine months of pregnancy differed but little from the previous ones, with the exception that on this occasion her abdomen was unduly large-larger than it was during the previous pregnancies. At the fifth month, and again at the seventh month, the mother tells us there were some false labour pains, for which she obtained medical treatment.

There was some difficulty in labour owing to the large size of the child, who was delivered by forceps by Dr. Wigg, the mother having been in labour nine hours.

Beyond observing that he was a very large baby, nothing particular was noticed about the child at birth, but he weighed 14 lb. On the fifth day after birth the right leg was first seen to be rather larger than the left; then it was noticed that his right arm was larger than the left, and the right cheek larger than the left cheek. When five months old the child weighed 28 lb. The child is nursed by his mother, and is carried equally often in the right and left arm. Posture has nothing to do with the deformity.

At present he shows well-marked deformities (they are much more evident than appears from the accompanying photograph). The left side of the cranium (including the frontal, parietal, temporal and occipital regions) is much larger than the right side. The anterior fontanelle is widely patent, but it does not bulge externally. The posterior fontanelle is just patent. There appears to be slight proptosis of the left eye. The pupils are equal, and both react readily to light. The ears are of equal length. The right cheek, jaw and gums are distinctly larger than the left. There are no teeth. The right side of the tongue is very greatly enlarged, and when the tongue is protruded it deviates to the left, obviously owing to the great bulk of

G

its right half. The right shoulder, arm, forearm, wrist, hand, fingers and nails are much larger than the left. Deltoid tubercle of acromion to end of styloid process of ulna right side measures 20 cm.; on left side, 174 cm. The enlargement appears to include skin, subcutaneous tissue, muscle, and certainly also bone. Little difference is to be noted in the size of the two sides of the chest the chest appears to be well formed and normal. There is no transposition of viscera. The right side of the abdomen is slightly larger than the left; this is more particularly noticed in the skin and the subcutaneous tissue, which forms a loose fold above the right Poupart's ligament; not present on the left side. There is an umbilical hernia. The right buttock, leg, foot, toes and toenails are very much larger than the left. The difference in size of these parts is very striking. The right leg is not only larger but longer (by about, 5 cm.) than the left. The enlargement appears to affect skin, connective tissue, muscle and bone. There is no paralysis of any muscle, and the muscular tone is good and equal on the two sides. The child is, however, more clumsy with the right side, and if he attempts to reach out for an object with the right arm the movement is less decided than it would be if the left arm were used. The knee jerks are present, but are less readily obtained on the right side than on the left.

There is then an enlargement of almost the whole of the right side of the body, together with the opposite (left) side of the cranium, and, therefore, also of the left side of the brain; and, one may infer, also an enlargement of the right side of the spinal cord. For it is inconceivable that the enlargement of the brain is due merely to a neurolgia overgrowth; it is far more probable that the nerve cells and their axis cylinders-the upper neurones-are enlarged; and, if the upper neurones, probably also the lower ones.

(Read before the South Australian Branch of the British Medical Association.

RECORDS FROM GENERAL PRACTICE.-
CASES OF ABORTION.

By J. A. Cameron, M.B., B.C. (Camb.), Ipswich,
Queensland.

DURING those halcyon days of one's medical career, when one is walking the wards of a hospital as dresser, clerk and house officer, it appears to be vastly important to know all about the latest and most wonderful feats of surgery, and all the curiosities of medicine and bacteriology; but when one gets into general practice it is soon discovered that it is not these things that occupy much time and attention,

but the more homely questions of diagnosis of sore throats, of rashes, of phthisis, the treatment of broken limbs and so on, and one is sometimes tempted to wish that the years at the hospital had been somewhat differently spent. Among those common cases that frequently require careful consideration and treatment, and of which we see little at a general hospital, and with which we all have to deal, are miscarriages or abortions.

Doubtless my own experience is similar to that of many others. Shortly after getting my degree I went to act as locum tenens for a man with a large practice. One of my first experiences was to be called to one of his best patients, who was said to have miscarried at about the second month. I was shown, wrapped up in a diaper, what then appeared to me a very extraordinary-looking lump of tissue, as I had never seen anything of the kind before. The lady herself, probably more experienced than I then was, said she thought it had all come away. I readily agreed, and fortunately for both of us it had, and in a week's time she was well again.

On starting practice for myself, I soon found that such experiences multiplied, and I began after a time to make notes of these cases. In this I have collected short notes of 96 cases, way a brief analysis of which I bring before you for your consideration to-night.

In doing so, I may say that my object has not been to make out that my methods and results have always been the best, but simply to give my impressions founded upon the experience furnished by these cases, and not gathered at all from books, hoping to receive many valuable hints from members afterwards for my better guidance in the future. There are certain parts of our work of which this is one, such as the giving of anaesthetics and the management of labour, in which we all get considerable practice, and form decided opinions, even to each one thinking that he does these things better than most other men, so I hope to hear many opinions and suggestions to-night.

I take, then, abortion to mean, "the arrest of gestation, and the expulsion of the embryo at a period antecedent to its viability-that is, before the end of the sixth month."-Rentoul. And, of course, an abortion is said to be complete when both embryo and membranes are expelled, and incomplete when the embryo is expelled and the membranes are retained. An abortion is concealed when the embryo perishes in the uterus, and when both it and the membranes are retained, and expelled perhaps some months later. Four out of the 96 were of this nature.

Causation.-The causes divide into four groups-criminal and maternal, foetal and paternal causes. I do not, however, propose to enter into them in detail. I think there can be little doubt that the bougie or ladies' silent pills account for the greater number. Maternal causes may be general, such as fevers and other diseases, and local, for example, fibroids, endometritis following induction, inflammation following attempts at prevention, and lesions and displacements of the uterus. The foetal and paternal causes are many in number, but not so frequently met with as the two former groups. Herman gives 20 per cent. as the normal frequency of abortion to labours at term. An American writer, quoted by the Lancet, gives the proportion as ten miscarriages to 27 labours in native-born American women, and the same proportion among negro women. Other authorities variously estimate the frequency from 1 in 4 to 1 in 80. My figures are not sufficiently large to draw any conclusions of value, but I am inclined to think that 1 in 4 does not over-estimate the frequency here. Multiparæ abort more frequently than primiparæ, as is to be expected. Eleven of my series were first pregnancies. The second and third months seem to be the period at which most cases occur; 57 out of 96 took place then.

Symptoms.-The symptoms vary greatly with the stage of pregnancy, and the condition of the foetus and placenta. Shortly after the first month the bleeding is not usually great in amount; at the third and fourth month it usually continues from beginning to end of labour; at the fifth and sixth month a discharge of liquor amnii frequently takes place, and, generally speaking, the more advanced the pregnancy the more closely it resembles labour at term. If sudden violence causes abortion, there is often as a first symptom a great gush of blood, in which the ovum may escape, a sharp pain being felt at the time.

It is well to remember that before the end of the second month, the placenta not being formed, hæmorrhage is from the entire uterine surface, while at a later period it is from the placental site. This point ought to be borne in mind in treating the cases. Hæmorrhage may begin before or after the pains, and free hemorrhage is generally accompanied by strong contractions.

A fotus may die and be retained for several days or even weeks. In one of my cases the foetus apparently died at the fifth month and was retained till term. I will refer to this case again later. The expulsion of a dead foetus is generally slower, with less loss of blood, and with slower involution of uterus afterwards.

The ovum may be expelled in a mass during the second and third months, but after the fourth month the embryo is generally expelled and the membrane retained for some time after. I have known women at this stage to walk about for three or four days with the placenta in the womb after the foetus has been expelled. In any case the placenta is usually retained longer in abortion than in labour at term.

Having during the last five years known of three cases, in two of which extra-uterine gestation without severe symptoms was at first mistaken for a miscarriage, and another in which a miscarriage was diagnosed by two men as a tubal pregnancy till the embryo came away, I do not think it superfluous to mention that we should ever remember the possibility of confounding the two conditions; for in extrauterine gestation, also, bleeding from the vagina with expulsion of decidual tissue is often accompanied by the pain of uterine contraction, as in abortion.

Results and Treatment.-The two great immediate dangers to be apprehended are loss of blood and septic poisoning, with its long train of possible evils. The more remote dangers, such as subinvolution of the uterus, I do not intend to touch upon.

Bleeding may be profuse enough to cause grave primary anæmia, or if prolonged may in that manner undermine health. Primary severe hæmorrhage cannot always be prevented. Four of my cases were blanched from loss of blood from a sudden copious hæmorrhage before I was called in. I do not propose even to mention the various septic troubles that may arise, or their treatment, as I have been fortunate enough to have very little experience of them, and they were most thoroughly expounded here not long ago. In abortions even more than in labours at term I believe we ought to be free from the supervention of sepsis. Except in a few cases of criminal abortion instrumentally induced, we are free from what I believe is the chief cause of puerperal sepsis: the examining finger of a dirty midwife. Few doctors nowadays are so careless or ignorant as to neglect proper surgical cleanliness in their obstetric work, but in country practice, at least, it is almost impossible to prevent the woman in attendance from making vaginal examinations before sending for the doctor. Fortunately, she does not often do so in cases of abortion. Three of my cases had a bad-smelling discharge, with high temperatures, when I was called to them first.

I had reasons for suspecting that they had all been self-induced, but all improved rapidly when the uterus was emptied. Only one case of the 96 became septic after beginning treatment, and that was the case referred to