32

two. clenched fists placed end to end, and was firmly fixed Ito the posterior abdominal wall by the mesentery of theascending colon. Reduction was not difficult when a starthad been made, and an unknown but considerable lengthof small bowel was pulled out and set free in the cavity.Finally, a little effort was wanted to pull what seemed to bea lump through the ileo-caecal valve. This could be deliveredthrough ; the parietal wound and on examination proved tobe another intussusception at the end of the ileum with whatseemed to be a tumour at its apex. This intussusceptioncould not be reduced, and as it seemed necessary to resectthe tumour no prolonged efforts were made to reduce it. The

receiving bowel, therefore, was incised longitudinally, andthe tumour was pulled through the incision and removedwith scissors. The parts removed were practically the apexof the intussusception and involved about three inches ofthe length of the bowel in its whole circumference. The

growth was as large as a hen’s egg, was much congested onits free surface, and was white and oedematous on section.The invaginated bowel was now easily drawn out; the actualseat of resection was found to be only nine inches above theseat of incision in the bowel, and the situation of the growthin the ileum was about eighteen inches distant from theileo-csocal junction. The primary incision was closed by a

double continuous Dupuytren’s suture. The divided ends ofintestine left by the removal of the growth were joined bymeans of a large Murphy’s button. The large size of buttonwas used, even though it was in the small intestine, becausethe gut was so distended and hypertrophied that the smallbutton would have been inefficient, and also because the ileo-csecal valve was already so much dilated that it was not

likely to prevent its subsequent passage. The operationwas concluded by cleansing and returning the gut and sutur-ing the parietal wound in the ordinary way. As regardsthe subsequent progress of the patient, no vomiting occurredtill 8 P.M., when it persisted till the early morning. Nutrientenemata were given. She had no sleep during the nightowing to abdominal pain, which was only partially relievedby two hypodermic injections of morphine. On Nov. 2ndthe sickness was less, though she vomited several timesduring the night. There was an occasional intestinal

cramp, which ceased towards the right iliac region. Onthe 3rd the patient had occasional hiccough, but wasmuch more comfortable, having passed flatus freely. Theabdomen was somewhat distended, but not tense. Painful

peristalsis was still visible. The temperature had nowreached its highest point-viz., 1010 F. On the 4th vomitinghad ceased, much flatus had been passed, and the abdomenwas no longer distended. She was given sulphate of mag-nesia. in drachm doses twice daily to keep the bowels acting.She continued to make progress. On the 7th the bowelswere opened, and she had a good appetite. She got up on

the 25th for two hours. On the 30th she passed fourmotions. With the last of these she had very acute pain inthe " lower part of her bowels " for about five minutes andperspired profusely. The Murphy’s button was then expelledwith a little blood and a loose motion. The button was fullyclosed, blackened, and surrounded by unaltered silk thread,but there was no intestinal slough. The patient was dis-charged recovered on Dec. 2nd, a month after the operation.

Microscopically the tumour presented the characters of afibro-myxoma with numerous well-formed vessels traversingits substance.

Medical Societies.EPIDEMIOLOGICAL SOCIETY.

-Dip4theria in Older and Newer Bristol.A MEETING of this society was held on Dec. 13th, Mr.

SHIRLEY F. MURPHY, President, being in the chair.Dr. WALTER Dowsorl read a paper on Diphtheria in

Older and Newer Bristol, the first comprising the registrationsub-districts of St. Mary Redcliffe, the Castle precincts, St.Paul’s, St. James’s, and St. Augustine’s, being the Bristol ofthe Charter of Henry VIII.; and newer Bristol, comprisingthose of Clifton, Bedminster, Westbury, Ashley, and St.Philip’s, added to the borough in 1835. In 1891 the popula-tion of the whole was 221,000, and of the two sections 55,000and 166,000 respectively. To these numbers might be addeda population of over 60,000 in districts such as Stapleton,Horfield, and St. George’s, outside the city boundaries, butin brick and mortar continuity with Newer Bristol,with which they had many conditions in common, andwhich, forming an organic whole, practically made upa Greater Bristol, with 280,000 to 300,000 inhabitants.During the five years 1890-94 the cases of diphtherianotified were 501, with 162 deaths ; none were removed tohospital, nor was there any disinfection of the excreta.The suggestions of Dr. Newsholme and Dr. Sidney Daviesat the Newcastle meeting of the British Medical Associa-tion in 1893 as to the influence of the ventilation or non-ventilation of sewers by street grids, or of the defectiveconstruction of sewers and drains in newly-built districts,had led Dr. Dowson to turn his attention to the possibleinfluence of those factors in the causation of diphtheriain Bristol, as well as to the agency of personal contagion, as inschools, to which Dr. Newsholme and Mr. Shirley Murphyattached considerable importance. The sewers of Bristolwere tide-locked twice in every twenty-four hours, the out-falls being protected by tidal valves. Storm waters wereadmitted by road gulleys, but there was absolutely no pro-vision for ventilation, and the manholes were air-tight. In

by far the greatest number of the new streets the drainswere laid under the houses without concrete or disconnexionfrom the sewer, and the hopper closets in the backyardswere without flushing apparatus, so that, with the verydefective construction of many of the drains, the escape ofsewer-gas in and around the dwellings was inevitable. Thecharacter of the drainwork might be judged from the

i fact that during these five years the drains of over 9000,. or one-fourth, of the 37,000 houses in Bristol had to be3 wholly or partly leconstructed, and three-fourths of these. were in the newer districts. He might call these 9000j "sewer air," and the other 28,000 "non-sewer air" houses.j The 501 cases of diphtheria occurred in 437 houses, of which. 125, or 28’6 per cent., presented sanitary defects, and 711 were I I sewer air " houses. Thus the percentage of "seweri air " houses attacked was 8, and of " non-sewer air " houses1 13 (1). In times of heavy rainfall the low-lying districts werel for many consecutive days flooded to a depth of several feet,s and the sewage, forcing w.c.’s, traps, and gulleys, rose into the houses, leaving when it subsided a deposit of foul mud.l This happened in 1889, and again in 1893, when it wasr followed by a sudden outburst of diphtheria. Thus, in the latter year 22 of the 27 cases occurring during the six weeksL following the flood were in the districts affected ; this was- but natural, yet he did not think that on the whole these. special outbreaks could be held to outweigh the absence ofs evidence of sewer air playing any appreciable part at otheri times and places. The districts of Newer Bristol in which

33

the incidence of diphtheria was heaviest were those whichwere continuous with the most populous outlying rural dis-tricts, rural in name only, but really integral parts of GreaterBristol--districts where, since they had adopted notification,diphtheria was found to be very rife, and which did notpossess means for disinfection or exercise any stringentsanitary administration.

BRITISH GYNÆCOLOGICAL SOCIETY.

Exhibition of Specimens. - Utero-ovarian Irritation as a

Factor in the Oausation of Rheumatoid Arthritis, and theSpeaial Treatment necessitated thereby.A MEETING of this society took place on Dec. 12th, 1895,

Dr. CLEMENT GODSON, President, being in the chair.Dr. SMYLY (Dublin) showed the following specimens :-

(1) Pyosalpinx removed by Vaginal Colporrhaphy ; (2) ThreeMyomatous Uteri removed per vaginam by Morcellement ;and (3) Ectopic Gestation operated on at Term; all the

patients recovered.-Dr. BANTOCK hoped that Dr. Smyly didnot advocate colpotomy for all cases of pyosalpinx, for inmany it would be almost impossible to get good results

by that method. In support of this statement herelated cases of pyosalpinx operated on by laparotomy, wherethe complications could not have been dealt with bycolpotomy. With regard to the vaginal operation for fibroidshe did not think it was so good as the abdominal. Heconsidered it most important that the integrity of the pelvicfloor should be preserved, even if the uterus were representedonly by the cervix. Compared to this the prolongation ofconvalescence by one or two weeks was of little importance.-Dr. HEYWOOD SMITH thought they should keep an openmind on the subject of the relative merits of the vaginal andabdominal operations ; the former were being done exten-sively on the Continent and in America, and the results wereso far very good.-Dr. RouTH considered that the propertreatment of adherent pyosalpinx was aspiration per vaginamand injection of iodine. Similarly, for fibroids, neither theuterus nor the ovaries should be removed, but the uterinearteries should be tied, as was done in America.-Dr. SMYLY,in reply, said he thought it was wrong to perform a newoperation unless it seemed to be the best one for the patient,and this rule had guided him in all his cases. Many casesof pyosalpinx were rendered unsuitable for colpotomy by thefact that the uterus could not be pulled down, for this wasan essential point in the performance of the operation.Briefly, the principal advantages of vaginal over abdominaloperations were: firstly, the risk of hernia was obviated ;secondly, convalescence was shorter; and thirdly, andchiefly, the shock of operation was much less, and themortality was proportionately diminished.

Mr. W. ARMSTRONG, J.P., of Buxton, read a paper onUtero-Ovarian Irritation as a Factor in the Causation ofRheumatoid Arthritis, and the Special Treatment necessi-tated thereby.-The PRESIDENT thanked Mr. Armstrong in thename of the society for his valuable and interesting paper.-Dr. LEITH NAPIER said that Dr. Halliday Croom had pointedout some years ago the association of inherited rheumatismwith a form of dysmenorrheea which he was the first to

designate as the rheumatic type. It was possible forrheumatism to remain long latent and to show itself whenuterine disturbance occurred, as in a case he had seen wherethe patient developed an attack of acute rheumatism twoweeks after her first confinement and again three weeksafter the second confinement, whilst in the interval sheremained free.-Dr. ELDER thought that Mr. Armstrong’sinteresting paper was not conclusive, because all the factsmentioned therein were consistent with the view thatrheumatoid arthritis was neither the cause nor the effectof utero - ovarian disturbance, but that both were alikethe effects of a common cause.-Dr. ROUTH observed thatmany years ago Mr. Druitt had read a paper before theMedical Society of London showing that many uterinetroubles remained intractable until they were treated as ofrheumatic origin.-Dr. FORTESCUE Fox said his experienceagreed closely with that of Mr. Armstrong, and he hadbeen led to very similar results ; but he felt inclined,following Dr. W. M. Ord, to lay more stress on the causalinfluence of the nervous system, and he was glad tonote that Mr. Armstrong gave considerable importance tor medies directed to that system. Other factors enteredinto the etiology of rheumatoid arthritis, of which

perhaps the most important was climate. Inherited tubercu-

losistand shock occurring at the menopause also played apart. He agreed with Mr. Armstrong that very hot bathswere not so effectual as cooler ones.-Mr. ARMSTRONG brieflyreplied.

NOTTINGHAM MEDICO-CHIRURGICALSOCIETY.

Medical Aid Societies.-Prevention of Phthisis.A MEETING of this society was held on Dec. 18th, 1895,

Dr. MUTCH, President, being in the chair.Dr. COULBY called attention to the abuses of certain

so-called Medical Aid Societies, and it was decided to discussthe subject at the next meeting of the society.

Dr. C. WILLS, medical officer of health of the Newark,Southwell, Worksop, and Mansfield district councils, read a,paper on the Prevention of Phthisis. It was illustrated withfifty-five lantern slides, many of which were prepared for theoccasion. The causes of phthisis assigned by eminentauthorities on the subject, such as the late Dr. Parker, thelate Sir G. Buchanan, Dr. Ogle, Dr. Sims Woodhead, Dr.Martin, Dr. Squire, Dr. Cornet, Professor Bang, and M. Nocard,were enumerated in their order ; and it was pointed outthat dusty air with damp subsoil appeared to be the greatcause of phthisis in man and easily accounted for its pre-sence in cows, which were often kept in foul, unventilatedcowsheds, whence the disease was transferred to children.These causes explained infection carried by dusty air con-taining the bacillus in close, unventilated rooms and wouldaccount for the disease prevailing in those engaged inthe dusty occupations of steel-grinding and pottery manu-facture, and among Cornish miners, as well as its rarityamong those engaged in occupations in pure air, on thesea or land, or living in mountainous districts, wherethere is comparatively little dust or stagnant subsoilwater. Inheritance, as seen by the light of Koch’s experi-ments with guinea-pigs and those of Professor Bang withthe calves of tuberculous cows, as related to the Buda*pest Congress, appeared to mean inheritance of dusty homes,dusty clothing, infected handkerchiefs, dusty bedding, andinfected mother’s milk. The remarkable example of theOldham Medical Society was fully quoted to indicate thelines upon which notification was desirable. The treat-ment of incipient cases in the mountain regions ofGermany, Switzerland, and America was illustrated, andthe results collected by Dr. Williams and Dr. Tonclear wereshown on the screen. Illustrations of grates for ventilatingand warming were exhibited, and the method of extractingfoul air, introduced by Buchan of Glasgow, was shown.The better ventilation of factories, workshops, schools, andcowhouses was insisted on as being very important.

LEEDS AND WEST RIDING MEDICO-CHIRURGICAL SOCIETY.

Pathology of -Dip7itheria.-Ex7tibition of Cases and Speeil1wns.A PATHOLOGICAL meeting of this society was held on

Dec. 3rd, Mr. MAYO ROBSON being in the chair.Dr. TREVELYAN read a paper on the Pathology of Diph-

theria. It was chiefly based upon the minute morbidanatomy of a case of diphtheria and upon the examinationof the diphtheria culture boxes under the scheme adoptedby the Leeds Corporation at the instance of Dr. Spottis-woode Cameron. The case was of some interest, as deathoccurred from cardiac paralysis, and an intense degenerativemyocarditis was found. There was evidence of a well-marked

tubulo-glomerular nephritis, and during life albuminuria hadbeen persistently present. The local diphtheritic lesion wasfirst described, then the changes in the various organsand tissues were explained, and finally some points inthe bacteriology. The question as to whether the serumcould in any way be made responsible for some of thevisceral lesions was discussed, the opinion being ex-

pressed that there was no evidence in support of thatview. The bacillus itself as well as its staining andcultivation were briefly described. The question as towhether dahlia methyl-green produced a characteristic stain-ing of the bacillus was discussed. The method of preserving-cylinders of nutrient medium with growth on them in