l)haryngeal wall wlich was directly invading the larynx in the immediate
vicinity of the riglht vocal cord, and considerably diminishing the air passage.
Mr. HANDLEY, in reply, said that Mr. Tilley's remarks applied rather to
cancer of the larynx than to cancer of the pharynx.
Dr. Solis Cohen's case involved the removal of the whole cross-section of the
pharynx or whether only the anterior part of the pharynx was removed.
Mr. TILLEY replied that the lateral wall of the pharynx on one side was
removed, and there was a very extensive growth within the larynx.
Mr. HANDLEY said the case referred to was therefore not entirely analogous
to the present one, in which the whole cross-section was removed over the
lower half. The patient was in the ordinary position, but with the shoulders
raised on a pillow, and he was very careful to plug the trachea above the tracheo-
tomy tube, so that he was not afraid of blood getting into the lungs.
sidering the severity of the operation, there was very little shock.
extended so low that it would have been impossible to do a high tracheotomy.
It involved the upper end of the csophagus, and he had to divide the cesophagus
as low as he could reach, almost down to the suprasternal notch.
same reason it was impossible to bring the cesophagus ul) to the skin.
thought Dr. Swan's case was a more unfavourable case than his own because
of the number of enlarged glands.
The prognosis after,such operations was
largely dependent upon whether the carotid sheath had to be opened or not.
He had done the same operation in a second case, but with a fatal result.
patient died on the table, apparently from the irritation of the vagus, after the
operation was practically complete.
He believed that it was due to a defect in
his technique, and that if he had frozen the two vagi below the point at which
he was working, death would not have occurred.
anl oval-shaped epitheliomatous ulcer of the right lateral
He did not know whether
Congenital Absence of Left Pectoral Muscles.
By J. GRAHAm FORBES, M.D.
MALE, aged 47, stickmiiaker;
Until a year ago his attention had never been
drawn to the defective mrluscular developmiient of the left side of the
chest, and his parents noticed nothing abnornial.
When young he was able to take part in the usual gamrles,
but was not athletic.
Has apparently experienced no inconvenience
from the loss of the left pectoral muscles, and attributes the greater
strength of the right armn to its almnost exclusive use in his work.
Patient is below medium height and of spare build.
mnarked want of symmetry of the two sides, owing to the absence of
the sternal portion of the left pectoralis major and the whole of the
under treatm-ient since childhood for
No history of infantile
sisters and children
The chest shows
Forbes: Conigentital Absence of Left Pectoral Muscles
left pectoralis miiinor.
mlajor and a small band passing to the
abduction of the armii and flexion at the elbow.
The left side is munch flattened, the first and sixth ribs and intercostal
s,paces are only covered by a layer of thin smiioothl skin, and the anterior
fold of the axilla
Extension and abduction of the armiis
bring the pterygoid fold of skin into proim-inence as a fine ridge running
downwards along the line of the muissing axillary fold, disappearing on
bringing the arms to the side, and apparently not comnposed of imluscle
The left nipple is normial in appearance and position.
sternum is deviated slightly to the right and forwards, the lower end
formins a sharl) projection with the xiphoid cartilage directed backwards.
defect in formiiation
muscles thanthe left
mluscular development of the left armii and hand is probably due to the
almost exclusive use of the right in the course of work; at the same
time the mliovemiients of the left upper limlb are perfect.
the thorax show hyper-resonance of the left side, and on auscultation
sibili are audible over both lungs.
Though his attention has only been
(drawn to the absence of the left pectoral im-uscles during the last y-ear,
the defect is probably congenital.
to point to infantile paralysis, and, as no other miiuscles are Nanting, the
condition is not likely to be a forimi of myopathy.
of soime 65 to 70 cases of unilateral 'absence
shown, the hypertrophied clavicular portion of pectoralis miiajor only
relmains, with occasionall1
The skin covering the
changes, being slmooth and thinned and somtietiimies adhlerent to the ribs,
and the nipple imay be undeveloped.
and seems to occur more often in miiales.
laborious occupation and athletic pursuits, such as boxing and swimmliing.
In several cases recorded in France the patients were able to performl
ilitary service without exemption
may pass unnoticed until medical advice is sought for some ordinary
Associated Anownalies.-(1) Absence of other mluscles, such as latis-
sinus dorsi, serratus imiagnus and teres miiajor.
of costal cartilages sufficient to allow hernia of the lung on forced
Only the clavicular attachment of the pectoralis
first costal cartilage persist.
is hypertrophied and both
are broug,ht into relief by
There is no evidence in the histor-
In the mlajority,
in the case
a few rudimnentary fascicles of the sternal
side often shows trophic
The deficiency is usually on the left,
It proves no hindrance to
(2) Defective development
inspiration, as in case recorded by Jonathan Hutchinson.'
and inial-development of the corresponding arm and hand.
A rellmarkable case described by Reboul 2 is the onlv one recorded of
bilatesral absence of pectoral muscles, associated with undeveloped sterno-
mnastoid and anterior neck muscles.
The patient, in other respects a powerful, mnuscular miian, was capable
of liftino, and supporting heavv weights.
the head being carried well forward in the attitude characteristic of the
chimpanzee, while the front of the chest was miiuch sunken.
Etiology.-Several explanations have been put forward
for this rare anom-laly.
(1) Arrest of developm--ent of the blood-vessels
and nerve supply (peripheral or central) to affected mnuscles; not supported
by dissections made of cases post ml-ortem.
(Widal and Leinirel).
Unsupported by the good physique presented in
This view cannot be applied to the imajority of cases
showingp)ersistenceof the clavicular head of pectoralis mlaj'or.
uterine foetal paralysis (Berger), only affecting the pectoral m1luscles;
in 1839 ascribed the anomiialy to the influence
intra-uterine pressure, which, by forcibly comiipressing the foetal upper
liml-b against the thorax, prevented the development of the underlying
muscles.As a further result grooving of the chest wall by the apposed
limb, together with imialforimiation of the arm and hand, have been recorded
in a few cases imiet with in infancy and early childhood.3
of a thoracic depression in adults may be due to obliteration of the groove
by the further growth of the chest wall.
for atrophy of the skin and nipple and defective development of the
This explanation of Froriep receives the support of the mnajority of
Reboul adopts it to explain his case of bilateral absence of the
pectoral mnuscles; he supposes that, in addition to compression of both
sides of the thorax by the upper limnbs, the pressure of the chin of the
foetal head inclined forwards accounts for the undeveloped condition of
the anterior neck miuscles.
It is reasonable to apply this theory to
explain other congenital
There was mnarked kyphosis,
('2) Physical deterioration
(3) Retrogression to the normiial state existing in certain
e.g., the porcupine and guenon mionkey, which have no
Pressure would also account
Arch. Surg., Lond., 1894, v., p. 342.
'Re. d'orthopedie, Paris, 1905, vi., p. 353.
3Souques, A., Rev. nteutrol., Paris, 1902, x., p. 159.
Barker: Meningitis complicating Otitis media
.abdonminal muscles, possibly produced by pressure of the flexed lower
linbs on the abdomen of the foetus in utero.
AMIr. RAYMOND JOHNSON said that he had shown a similar case before the
Clinical Society five years ago, the patient being a boy witlh absence of the
pectoral muscles on the right side.
The case differed from the present one in
two respects: (1) that there was a very broad fold of skin from the side of
the chest down the inner side of the arm to the internal condyle, with
a band of muscle in its free edge, a so-called chondro-epitrochlaris.
it as a case of webbed arm and fingers associated with absence of pectoral
There were a few fibres of the clavicular portion present.
a considerable number of cases had been recorded in which there was an absence
of pectoral muscles associated with webbing of the fingers and the presence of
a fold of skin from the chest to the inner side of the arm.
the left scapula was higher than the right; in his own case the difference in
that respect was very striking.
It was difficult to imagine that such a defect
was the result of pressure, especially when the absence of muscles was asso-
ciated with webbing.
Dr. G. A. SlJTHERLAND thlought that the pressure theory was probably the
correct one in the present case, and that one might exclude a nervous or
vascular lesion because the atrophy was so limited to a certain area of the
b)ody, and involved all the structures of the part.
of the cases was there an affection of hands or fingers, and if there was
pressure of the hand sufficient to cause such injury, on the principle that
pressure and counter-pressure were equal and opposite, one would expect that
the part pressing on the chest ought
interesting parallel in a certain condition of the abdomen in which there
was a congenital absence of certain parts of the muscular wall in the right or
left hypochondrium, which had been traced to pressure upwards of one or
All the structures in the abdominal wall were atrophied, and as a
result, when the patient coughed or strained there was a ballooning of the
abdominal wall at the part affected.
Dr. FORBES, in reply, said there were one or two cases on record in wlich
there was a definite grooving of the chest wall corresponding to the position of
the limb in ittero.
In the present case
In only a small proportion
to be affected also.
Meningitis complicating Otitis media, with Lumbar Puncture.
By A. E. BARKER, F.R.C.S.
THE case of C. W., aged 31, is shown to einiphasise the point that
lumbar puncture may be of remedial as well as of diagnostic value.
patient's condition at the time when the im-eningitis was found in the