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in hospital ranged from 99 4° to 99’8° F. with one exception.On May 28th he complained of severe pain in his side. Themorning temperature was 1028° and the evening temperaturewas 1034°. His breathing during the whole of this day untilabout 5 A.M. on the 29th had a distinct Cheyne-Stokescharacter. On the night of the 28th he had severe diapho-resis. By 8 A.M. on the 28th his breathing had becomenormal and the pain had disappeared. This condition wasin all probability due to the injuries his body had receivedfrom the different falls of debris. Taking his tuberculoushistory into account I felt greatly tempted to give him a stiffknee, but the inflammatory condition of the knee was soamenable to treatment that I decided to try passive move-ments and massage and to give him a moveable knee.

Medical Societies.CLINICAL SOCIETY OF LONDON.

Primary Resection of Gangrenous Intestine. -PriviaryAbdominal Section for Wounds of the Abdonzen.

A MEETING of this society was held on Jan. 26th, SirR. DOUGLAS POWELL, Bart., the President, being in thechair.The PRESIDENT referred in graceful terms to the loss

which the society had sustained by the death of Sir JamesPaget who had been not only an honorary member of thesociety but was the first surgeon to occupy the presidentialchair.Mr. JONATHAN HUTCHINSON, jun., read a paper on

Resection of Gangrenous Intestine in Cases of Hernia basedon a comparison of 42 cases. He related two cases of success-ful primary resection of small intestine during herniotomy,both operations being performed by simple enterorraphywithout mechanical aids. One case was that of a womanwith a strangulated femoral hernia on whom he had operatedin 1893, removing five inches of damaged gut; she was ingood health six years later. The second case was that of aman with strangulated inguinal hernia in which it was neces-sary to excise ten inches of intestine ; this was done byMaunsell’s method-that is, one in which an artificialintussusception was made. The patient made a per-fect recovery, but died three years later from ulcera-tive colitis, and the specimen was fortunately obtainedfor Mr. Hutchinson by Mr. H. L. Barnard. It was

shown at the meeting and proved that there had not beenthe slightest narrowing at the site of the resection. Mr.Hutchinson remarked that it was probably the generalimpression that the use of Murphy’s button had renderedresection of intestine not only quicker but safer. To testthis belief he had collected from hospital records (includingall the cases he had himself operated on both with andwithout this apparatus) 15 examples of primary resectionfor gangrenous gut performed with Murphy’s button and 16cases in which suturing alone was employed. Of the formeronly one (7 per cent.) had recovered and of the latter six (37per cent.). 11 cases treated by conservative measures (e.g., ’,formation of an artificial anus) without resection had all died.None of these cases were included in Dr. Kendal Franks’spaper published in 1893, and they were not selected in anyway excepting that they had all been under the care ofhospital surgeons. This was a very striking comparison, butbesides this the fatal cases treated by suturing alone hadlived on an average twice as long as those in which Murphy’sbutton had been used; in other words, they had given muchmore promise of survival. Three out of the 10 fatal cases ofsimple suturing would probably have recovered but foraccidental complications (multiple strictures of small intes-tine, obstruction of intestine by an omental band, and tuber-culous phthisis causing constant cough). Moreover, thepost-mortem records showed, on the whole, better union ofthe divided ends after suturing than after the use of Murphy’sbutton. The latter was apt to cause acute congestion by itsbulk ; its weight was also a disadvantage, and even shouldthe patient recover it was probable that a stricture mightresult. At any rate, the openings made by operations withMurphy’s button in gastro-jejunostomy sometimes showed amarked tendency to contract. The greater time required forthe accurate performance of suturing did not appear to be

of much practical importance-it had probably been a littleexaggerated. The after-shock had not been dangerous inhis experience. Whilst primary resection of gangrenous,perforated, or irretrievably damaged intestine in a herniamust always be attended with high mortality, yet itoffered the best chance of recovery. This agreedwith the results previously brought forward by Dr.Kendal Franks, Mr. C. B. Lockwood, and other surgeons.Turning to the details of the operation in performing resec-tion it was of great importance to excise enough of the

damaged intestine so that the sutures might be placed inhealthy tissue, and it was nearly always advisable to do itthrough a median abdominal wound. Special care had tobe taken with the mesenteric edges of the two ends, forleakage most readily occurred at this point. Maunsell’emethod was probably one of the best to employ. If theintestine could be emptied and made to contract this wouldfavour sound union and tend to prevent infection of thestitch apertures by the septic contents. It was probablethat the administration of an aperient immediately after theoperation would lead to better results than in the past. Mr.Hutchinson had operated on 140 cases of strangulated herniawith a total mortality of 25 per cent. 65 were inguinalhernia, of which 54 recovered ; 54 were femoral, and of these40 recovered ; whilst 21 were umbilical, and of these 12recovered; 34 deaths in all. The great majority were

due to the gangrenous or acutely inflamed condition ofthe intestine and omentum at the time of operation.Five of the fatal cases were possibly due to theemployment of too conservative methods.-Mr. ARTHURBARKER remarked that the question of how to dealwith the intestine during operation was a very importantone. He did not think that Mr. Hutchinson had resectedthe gut too lavishly. He quite agreed that primary resec-tion was preferable to Murphy’s button. He mentioned acase in which the weight of the button had dragged the-paralysed bowel down into the pelvis and caused death. Hehad given it a very fair trial and had had considerablesuccess with it, but there was no better method than thesimple suture. As to the question of time occupied in

suturing as compared with the use of the button, thatdepended very much on the operator. The condition of theintestine was the key to the position and it was of thegreatest importance to remove sufficient and suture

healthy tissues to healthy intestine beyond the stran-

gulation. In one case he had removed 35 inches ofthe gut and the case had made a perfect recovery.Oat of 11 "anastomosis" operations which he had recentlyperformed he had used the Murphy’s button on three

occasions. Two of these 11 were gastro-enterectomies inboth of which the button was used and both recovered ; twowere pylorectomies, both were sutured, one recovered andone died; three were resections for gangrenous intestine, onewith the button died and two with suture recovered. Threewere lateral anastomosis operations, all with suture, and allthree recovered ; one was a case of excision of the caecum inwhich the suture was used and this recovered. Thus, out ofeight cases in which a simple suture was used one died, andout of three in which the button was used one died, result&which supported the method of simply suturing the bowel.-Mr. HOWARD MARSH referred to the great difficulty in

deciding as to the true condition of a piece of intestine.It was often impossible to say if the intestine would recoveror not. The bowel was often completely paralysed andobstruction resulted from this. On the whole, it was betterto excise the piece of gut if in doubt. Resection was notnearly such a dangerous procedure as was formerly believed..It was most important, he thought, to remove it freely, andhe quoted cases in illustration. He had no doubt that thecontinuous suture was better than Murphy’s button. He con-

gratulated Mr. Hutchinson on the excellent results that he hadachieved which were a distinct advance on previous statistics.-Mr. CHARTERS J. SYMONDS hoped they should save manymore lives by modern methods and by dealing more boldlywith the intestine. He referred to the difficulty of emptyingthe intestine at the time of the operation. This was veryimportant, for in this way it was possible to prevent sym--ptoms of paralysis of the bowel. He quite agreed with theadvantages claimed for the direct suture as compared with’the use of the button.-Mr. HUTCHINSON, in reply, said thathe had used interrupted sutures of fine silk passed through allthe tissues of the intestinal wall. The sutures becameabsorbed or at any rate disappeared. He wished to drawattention to the fact that in the specimen exhibited there

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were no adhesions around the bit of intestine and the serous csurface was perfectly smooth. This patient had died from s

ulcerative colitis, wholly unconnected with the illness for 1which the operation had been performed some years before. (

He wished to refer to the advantage of sewing up the aabdominal wound layer by layer. He quite agreed with the importance of emptying the bowel at the time of the opera- tion and he saw no harm in , the use of a mild aperientafterwards. In gastro-jejunostomy he had been equally l

impressed with the advantage of direct suture. lMr. A. PEABOE GOULD read a paper on a case of Bullet

Wound of the Abdomen, with four wounds of the smallIntestine and two of the Mesentery; Operation; Recovery.The patient was a young man, aged 20 years, who wasaccidentally shot with a small revolver on the evening ofOct. 30th, 1899. A medical man who was called to himfound him in great pain and at once administered a hypo-dermic injection of morphia, and then took him to theMiddlesex Hospital where he was seen by Mr. Pearce Gouldabout an hour after the accident. The wound in the abdo-men was two inches below the navel and one inch to the leftof the middle line. There was still some pain, the respira-tion was easy, the abdomen moved freely, and the pulsewas 96. The liver dulness was not obliterated and there was nodulness in either flank. There was no paralysis. Six ouncesof clear normal urine were drawn off by catheter. Under ananaesthetic the wound was explored and was found to extendinto the peritoneal cavity. This was freely opened and bloodflowed out from it, but neither gas nor intestinal contentswere observed. The intestine was examined and four woundsapparently in the jejunum were found; three of these wereperforating and the other involved the serous and muscularcoats only. There was no visible escape of intestinalmatter. These wounds were closed with Halsted’s suturesof sterilised silk and two wounds of the mesentery whichwere close by were also sutured. No other lesion was found.The peritoneal cavity was cleansed, the bowel was returned,and the abdominal wound was closed. The man made an un-interrupted recovery and left the hospital well on Dec. 4th.The bullet was found lying deep in the left buttock and wasallowed to remain. In commenting on this case Mr. PearceGould drew attention to the following points: (1) the multiplelesions produced by a single bullet; (2) the absence of serioussymptoms ; and (3) the necessity for exploration, even inspite of the absence of all symptoms, to determine whetherthe wound was perforative, whether any viscus or largevessel was injured, and, if so, to treat them. He emphasisedthe importance of the hypodermic injection of morphiaimmediately after the accident, both in relieving painand shock and in controlling the movements of theintestine, and so lessening the chance of fouling of theperitoneum with germ-laden intestinal contents. The caseillustrated the necessity for careful and thorough explora-tion of the abdomen (by operation) in all cases of perforat-ing wound and severe contusion of the abdominal wall.-The PRESIDENT, referring to the use of opium in abdominalinjuries and wounds, said that although it had been discarded,not without reason in these cases, it was ont; thing to giveit before diagnosis and another to give it after the diagnosiswas made. The morphia syringe might be of great use onthe battle-field. When gangrene of the intestine had beendiagnosed there might be no harm in giving morphia. As tothe absence of symptoms in Mr. Gould’s case this waspossibly due to the narcotism of morphia.-Mr. ARTHURBARKER remarked that there was no more difficultclass of case to deal with than that narrated. Theamount of shock in such cases varied very considerably,and he mentioned the case of a patient shot throughthe abdomen who walked downstairs and professedhimself as feeling quite well. In another case with the samekind of wound there had been great shock. As to the pro-cedure adopted that must vary with the time which hadelapsed since injury. If seen early the abdomen should besearched, but if not seen till later it might be well towait. The velocity of the bullet was another factor. If the

speed was great then the intestinal wounds would be verysmall. In general an operation might well be undertakenin any doubtful case. He quite agreed with the remarksmade on the value of opium.-Mr. HOWARD MARSHreferred to the possible absence of symptoms even withvery grave internal lesions and mentioned a case

in point of ruptured colon. In another case of injuryin the hunting field the patient went to the city and waswell for two days. Then he passed into a state of shock and

died. The necropsy revealed rupture of the super-mesentericartery as a consequence of which part of the small intestinehad become gangrenous. He certainly thought it well tooperate more freely. An exploratory operation was notattended with much risk. He believed in saline injections asa most valuable method for the treatment of shock.-Dr.NEWTON PITT referred to the remarkable way in which a" cow-doctor" would puncture a distended intestine with alarge trocar. He inferred from this that small bullets with

high velocity would not do great damage to the intestine.-Mr. PEARCE GOULD, in reply, said that the patient was notnarcotised but he was only relieved from pain by themorphia. The amount of shock in such cases seemed to

depend very much on the parts which were damaged. If thegreat sympathetic plexuses were injured then probably therewould be great shock. In his case the shock at the end ofoperation was not great enough to call for saline injection.His main object in bringing forward this case was to

emphasise the importance of operation in all perforating

injuries of the abdomen.

OPHTHALMOLOGICAL SOCIETY.

Experimental Exophthalmos and Enophthalmaos.-CicatrixHorn growing frona the Cornea.-Glau.coma following theuse of Homatropine.-Exhibition of Cases and CardSpecimens.AN ordinary meeting of this society was held on Jan. 25th,

Mr. G. ANDERSON CRITCHETT, being in the chairDr. WALTER EDMUNDS read a paper on Experimental

Exophthalmos and Enophthalmos in which he remarked thatthere were three ways in which prominence of the eyescould be affected experimentally: (1) by acting on thesympathetic, either stimulating it or dividing it; (2) bythe administration of certain preparations or drugs ; and(3) by operations conducted on the thyroid gland. Withregard to the first, stimulation of the cervical sympatheticproduced: (1) prominence of the eye; (2) widening of thepalpebral fissure; (3) at first increase and later decreaseof the intra-ocular tension ; and (4) erection of the hairsof the head. Division of the sympathetic produced theopposite effect. Cocaine was one of those drugs whichproduced proptosis, widening of the palpebral fissure, dilata-tion of the pupil, and decrease in the intraocular tension.Cunningham had shown that feeding a healthy animal onthyroid extract produced similar results. Dr. Edmunds thenshowed photographs of monkeys and rabbits both before andafter feeding on this substance. Exophthalmos after theadministration of thyroid had once been observed in man byBeclere, where it appeared after excessive doses had accident-ally been taken by a patient suffering from myxoedema. Thethird method of effecting the prominence of the eyes was byoperations on the thyroid. Removal of the thyroid might pro-duce either exophthalmos or enophthalmos, but in the monkeyusually the latter. Numerous lantern slides were shownof animals in which this had been done, as well as drawingsof animals in which the sympathetic had been divided.Dr. Edmunds summed up his results by saying that the dis-cussion of these phenomena was particularly interesting inits bearing on the pathology and treatment of Graves’sdisease ; the fact that the most important eye symptom ofGraves’s disease could be produced by the administrationof thyroid preparations certainly suggested that the eyeaffection was secondary to the goitre. He had not triedthe effect of division of the sympathetic in feeding withthyroid extract, but with the administration of cocaine itdiminished the effect produced. It therefore suggesteditself that the exophthalmos might be benefited by divi-sion of the cervical sympathetic, and, indeed, the opera-tion had been tried several times in man. The resultswere said, however, not to be very satisfactory, at leastas far as the general disease was concerned.-Mr. J. B.LAWFORD referred to a case reported by him in whichexophthalmos had resulted from thyroid-feeding in a woman.aged 34 years, who had suffered from myxcedema for fiveyears. She was treated with the extract with great benefit ;but relapsing four and a half years later the treatment wasresumed, this time with the development of severe exoph-thalmos. Her subsequent history was unknown.-Mr.G. MACKAY described a case in which exophthalmosfollowed an operation on the cervical glands in which thesympathetic had evidently been divided. He also quoted a