1340 OBSTETRICAL SOCIETY OF LONDON.

was very much less liable to be affected than the pyloric enHe considered that when the stomach was involved by u<

growth it was generally in the form of one of the folollowing varieties : in the first variety the growth wconfined to the pylorus and owing to the obstruction garise to enormous dilatation ; in the second, which wcommoner, the growth infiltrated the gastric wall to a greator lesser extent along both curvatures, involving sometimthe whole stomach and even spreading to the oesophagus ;the third the growth involved the cardiac end of tl

stomach, and in this situation was always loose and vc]

vascular so that haemorrhage was liable to occur from and in the fourth the growth began in an old ulcer and thwas commonly situated on the posterior wall of the stomaclOf secondary growths the most common situation was uidoubtedly the liver ; out of 30 cases it had been present ithe organ in no less than 14. Next to the liver it wmost usual to find the growth on the under surface c

the diaphragm, and next in frequency in the lumbar gland; With regard to the duration of the disease he had knowone case in which it had lasted for 60 months and in anotheit had lasted for 38 months. In most cases, however, thpatients died within 18 months of the first symptoms. H

thought that if the disease had lasted for seven months iwas probable that secondary deposits would be found iother organs.

Mr. CHARTERS J. SYMONDS said that these cases were verdisappointing so far as a cure was concerned ; out of about 2(cases there was only one in which he felt justified in performing the operation of pylorectomy. In this case n(

tumour could be detected on examination. The growth wa!so limited that it seemed possible to remove it completelywhen, however, further examination was made it was founc

impossible to remove the whole disease owing to theinvasion of the posterior wall. He thought that a gastro-enterostomy would give as much relief as a pylorectomy,and it was not attended with the danger of the latter opera.tion. He had seen cases which had extended over 12 monthsin which there were no secondary growths in the liver.

Mr. A. E. BARKER said the whole question turned uponthe early diagnosis of the disease. He did not think, how-ever, that the patients in whom the pylorus had beenremoved lived any longer than did those in whom a gastro-enterostomy had been performed. He referred to a case

reported by Kocher in which the patient had lived nine yearsafter the removal of the pylorus ; he thought that such afavourable result might depend upon the nature of thegrowth and be similar to the case recorded by Dr. NormanMoore, in which the patient had lived 60 months. Hereferred to the great risk in exploring the abdomen in casesof carcinoma as compared to the risk in cases of non-

malignant affections of the abdomen.Dr. S. H. HABERSHON divided the cases into two classes--

the first in which there were complete obstruction of thepylorus and dilatation of the stomach and the second inwhich the wall of the stomach was involved. These cases

usually gave ri>e to symptoms of gastric irritation. Notumour could as a rule be detected in the abdomen in thesecase<. In one case which owing to the small size of thetumour seemed suitable for operation the patient died soonafter its removal. The greatest difficulty in these cases wasto (listingui-h gastric catanh or simple ulceration frominvasion of the stomach by new growths.

Mr. C. A. BALLAKCE said that Mr. Moynihan had indi-cated the lines on which true advance in this branch of

surgery wonld take place. He had always regarded carci-noma as a local infection and if the cases could only bediagnosed early enough there was hope of a permanent cure.He mentioned a case in which, owing to the growth notbeing felt, operation had been postponed for some months,and had the operation been performed when the patient was first seen the chance- of a cure would have been far better.

Mr. G. H. MAKINS said that he should be interested tosee the results of further cases operated on in the mannersuggested by Mr. Moynihan. He mentioned the case of ayoung woman from whom he removed the pylorus as thegrowth seemed so limited. About seven months later the

patient died from recurrent e’rowth’-’ along the pancreas. Hewas of opinion that had he short-circuited the intestine thepatient would have lived as long. He would certainlyrecommencl short-circuiting rather than removal of the

pylorus in most cases .

M . MOYN-TIAN, in reply, pointed out that in 70 per cent.of the caes the growth was in a part of the stomach which

admitted of its removal. With respect to diagnosis he saidthat with a patient under medical treatment for gastric’trouble at an age when one might expect to meet with cancerof the stomach, and when there was an absence of free bydro-chloric acid in the stomach contents, then, whatever thephysical signs and clinical condition might be, it was

his practice to advise an exploratory incision. This had

permitted him to obtain cases at an earlier date thanelsewhere Even in the early stage, however, the radicaloperation might not be permissible, because the disease

might already have got beyond the limits of successfulremoval. He joined issue with Mr. Barker in respect of hisview that life after gastro-enterostomy was at all comparablewith life after partial gastrotomy or pylorectomy. Statisticsshowed at least one year’s clear gain in favour of thelatter. The improvement after gastro-enterostomy was greatand immediate, but was quite ephemeral. He suggested thatthe attitude of surgeons towards these operations was theirattitude of some years since towards operation for cancer ofthe breast. Gradually they had extended the limits of thatoperation, and no doubt as their knowledge increased theywould do the same in regard to operations for cancer of thestomach. He believed that if attacked early by an operationon the lines he had described, they might hope in the futureto obtain far better results than had been the case hitherto.

OBSTETRICAL SOCIETY OF LONDON.

Sloughing Fibroid of the Left Uterine Cornu showing AbnormalRelations. -Gonorrh&oelig;al Pelvic Peritonitis. -Tubal Mole.-Exhibition of Speccimens.A MEETING of this society was held on Nov. 6th,

Dr. PETER HORROCKS, the President, being in thechair.

Mr. ALBAN DORAN and Dr. CUTHBERT LocKYER, communi-cated a paper on Sloughing Fibroid of the Left Uterine Corn ushowing Abnormal Relations. The patient from whom thefibroid was removed, a single woman, aged 30 years, had beensubject for a month to symptoms of pelvic inflammation withfever. There was an irregular moveable mass in the leftfornix, rising into the left iliac fossa, and connected with asmall anteflexed uterus. Mr. Doran performed supra-vaginalhysterectomy, removing the uterus and tumour with theleft appendages ; the right tube and ovary were spared.The patient recovered. The tumour, five inches in longdiameter. was much larger than the uterus, projecting out-wards rather than upwards from that organ. It was a true

fibro-myoma in a necrotic condition, and adhered to the intes-tine and the omentum at its blunt-pointed outer extremity.This degenerative change apparently accounted for thefebrile symptoms. At first sight the tumour simulated afibroid in an undeveloped uterine cornu, but the Fallopiantube and ovarian ligament arose posteriorly, and not

externally, and were attached to a deep groove between theuterus and the tumour. The left round ligament arose fromthe under surface of the tumour somewhat posteriorly,passing under it and forwards to the inguinal canal. Atumour with somewhat similar relations to a uterus muchsmaller than itself had recently been figured without anyclinical history by Doederlein in Kiistner’s "KurzesLehrbuch der Gynakologie " (Fig. 146). This outwardgrowth of a fibroid of the cornu without outward displace-ment of the corresponding tube and ovary was very unusual.The sloughy state of the tumour demanded its removal,and the uterus could not possibly be separated from agrowth of this kind, so that it was also removed.--After some remarks by the PRESIDENT, Dr. A. H. N. LEWERSsaid that among other points of interest the case describedin the paper had an important bearing on the question ofthe mortality to be expected in cases of fibroid tumours of:he uterus. Statistics had been published according towhich the mortality from fibroids apart from operationappeared to be 0’000138 per cent., or about 3 in 2,000,000)ases. Now in such a case as Mr. Doran’s, one of sloughingsubperitoneal fibroid, which had already set up symptoms)f pelvic inflammation with fever, it could not be doubted,hat apart from operation the case must have ended fatally.Leaving out of the question the other possible causes ofleath in cases of fibroids, was sloughing such a very rarehing’? He had himself seen two cases comparativelyecently. One had been already published. The other wasne of the last cases in which he had removed the

1341OBSTETRICAL SOCIETY OF LONDON.-OPHTHALMOLOGICAL SOCIETY.

appendages for uterine fibroid. In that case tying thevessels in the pedicles appeared to have in some way cut offthe vascular supply of a fibroid near the fundus and causedit to slough. At all events, no evidence of sloughing (fever,foetid discharge, &c.) was present till after the opera-rioD. The patient died within a week, and at the post-mortem examination one of the fibroids near the funduswas found to have sloughed. Dr. Lewers called atten-

:ion to the frequency with which mucoid degeneration wasmet with in fibroids, and he would be glad to know Mr.Doran’s views as to the relation, if any, between mucoid

degeneration and sloughing.-After Dr. G. F. BLACKER hadjoined in the discussion Dr. CUTHBERT LocKYER drewattention to the fact that the term "suppurating fibroid" "

hardly conveyed the correct idea of the condition of thetumour at the time of removal, inasmuch as suppurationimplied the presence of pus and of pyogenic organisms, and.uch were not present in the tumour. In reply to a questionby Dr. Blacker as to the causation of the febrile condition ofthe patient Dr. Lockyer thought that it was possible for apyrexie state to result from the absorption of necrotic pro-ducts in which no organisms could be found, and mentioneddiat this had been proved in the case of blood clot.-Mr.ALBAN DORAN, in reply, regretted that none of the Fellows sof the society could offer any explanation of the abnormalrelations. The tumour was certainly in the left cornu,and the displacement of the left round ligament was

very unusual and seemed to indicate some malforma--cion of the cornu. The term " sloughing had beenused for convenience in the title of this communication,though there was not the typical moist, foetid gangrene’een in Dr. Lewers’s case, where the tumour was in close,’elation with the uterine cavity. In the present case thetumour and the cavity were far apart. The necrotic changeprobably came on because the shape of the tumour made itsblood-supply liable to interruption. He believed that mucoid

degeneration arose from similar causes assisted by feeblecirculation. This seemed certainly the case in two instances0f uterine fibroid in his own practice where menorrhagia wassevere and the tumour caused pain, rare in fibroid disease.Mr. Doran removed the uterus without the ovaries with

great benefit to the patients.Mr. J. BLAND-SuTTON read a communication on a case of

Gonorrh&oelig;al Pelvic Peritonitis.--Dr. DRUMMOND ROBINSONmade some observations with regard to the case.

Dr. W. S. HANDLEY read a communication on a case ofTubal Mole with Encysted H&aelig;matocele.&mdash;The case was dis-cussed by Mr. DORAN, Dr. HERBERT SPENCER, Dr. W. S. A.GRIFFITH, Dr. LEWERS, Mr. BLAND-SUTTON, and Dr.LOCKYER.The following specimens were shown :- ’

The PRESIDENT : Drawings of a case of Deciduoma

Malignum.Mr. DORAN: Fibroid of the Broad Ligament associated

with an Ovarian Cyst.Dr. LEWERS : Carcinomatous Uterus with Pyometra ; the

patient was well six years after the va,ginal hysterectomy.Dr. A. L. GALABIN: Papillomatous Cyst of (’’) an

Accessory Ovary.Dr. T. W. EDEN : Cyclops Arrhynchus.Dr. W. W. H. TATE : Fibro-myoma cf the Uterus com-

plicated with Double Salpingitis and Carcinoma of theCervix removed by Vagino-Abdominal Hysterectomy.The specimens were discussed by the PRESIDENT, Dr.

GRIFFITH, Dr. LEWERS, Dr. LOCKYER, Dr. SPENCER, andMr. J. H. TARGETT.

OPHTHALMOLOGICAL SOCIETY.

Mooren’s Ulcer.-Keratitis in the Newly-born. -Exhibition ofCases and Specimens.

AN ordinary meeting of this society was held on Nov. 8th,Dr. DAVID LITTLE, the President, being in the chair.Mr. E. NETTLESHIP read a paper on Chronic Serpiginous

Ulcer of the Cornea (Mooren’s Ulcer). The terms "chronicserpiginous ulcer," or ’’Mooren’s ulcer," were preferable to"ulcus rodens," which was another name for rodent epithe-:ioma. The paper was based upon an examination of 71.ases, 12 of which were Mr. Nettleship’s. Bowman was thefirst to describe a case in detail (1849), but Mooren rightlyhad the credit of discovering the disease as a clinically dis-rinct species in 1867. The ordinary characters and course of the disease were described. Its usual duration was from four

to 12 months, and no cases were included that lasted less thantwo months, though certain cases running a less chroniccourse might perhaps be of the same nature. The subjectswere adults from 23 to 71 years of age, rather less than a

quarter were under 40 years of age, just half between 40 and60 years, and rather more than a quart3r over 60 years. Adecided majority were males. In a large majority the attackin both sexes began in the winter half of the year, anddegenerative changes, perhaps merely senile, lowered surfacetemperature, and perhaps some congenital defect of qualityof the corneal tissue in certain persons were suggested aspredisposing causes. The course of the disease stronglysuggested infection, but no special micro-organism had a,yet been found. In more than one-fourth of the cases

both eyes suffered, sometimes with an interval of years, andthe disease was often exactly symmetrical in the two eyes.The prognosis was always grave and was far worse whenboth eyes were attacked, only one in four of the double casesbeing arrested short of total leucoma ; whilst of the singlecases more than half recovered with some untouched cornea.The deeper parts of the eye remained healthy and visionwas determined by the final state of the cornea and pupil.Treatment should begin with cutting away the overhangingand half-dead edge of the ulcer and applying an escharoticor strong germicide to the advancing border thus exposed ;the galvano-cautery was the best, pure carbolic acid andstrong tincture of iodine probably came next ; trans-plantation of conjunctiva over the ulcer appeared useful

occasionally. Though some cases were published as curedwhich would probably relapse, and though others wentto universal leucoma in spite of all possible treat-ment. the results had been much better since theintroduction of the cautery than before. Several old

patients had done well and several young ones very badly.Allusion was made to the "marginal atrophy" of cornearecently described by Fuchs and t) several other allied con-ditions of the cornea.-Mr. TREACHER COLLINS asked ifthere was any relation between the age of the Iatient andthe rate of progress of the disease. In two cases which hehad seen the ulceration of the cornea was most extensive,and yet the remaining opacity was not dense and remark-able good vision remained. In one case the patientdeveloped a crop of vesicles on the cornea and some patchesof infiltration, all of which cleared up upon his performingparacentesis and iridectomy.-Mr. J. B. LAWFORD relatedthe case of a woman, aged 69 years, with no very definitespecific history. In the right eye more than half the corneawas attacked ; there was severe iritis, but not much pain,the temperature being normal. He cauterised the advancingedge and after a second application it healed. Shcrtly after-wards it broke out again and he then applied nitric acidwithout much good resulting. He then used solution ofiodine daily, but it caused pain and did not do much good.Then the left eye became congested. An ulcer developedwhich he burnt with the cautery. The right eye had no un -attacked cornea and it was vascular and cicatrised. The leftwas again cauterised and strong glycerine of perchlorideof mercury was applied. After freely cutting away the edgeand applying the galvano-cautery it healed, but again brokedown and was cauterised. This was repeated and the patientstill remained under treatment. In another case, that of aman, aged 46 years, healing was obtained after one applica-tion of the galvano-cautery.-Mr. W. LANG on one occasionafter failure with the cautery did an iridectomy, when theulcer healed and the case did well. Since then he hadtreated others in the same way with good results in all butone case.-Dr. A. BRONNER thought that there were two dis-tinct classes of cases, one in which the ulceration was super-ficial and one in which it was deep.-Mr. SYDNEY STEPHEN-sort had published a case which occurred in a woman, aged60 years, where the ulcer healed after two applications of thecautery. He then looked upon it as malignant, but this viewhe did not now hold. This disease seemed to occur aboutonce in 17,000 cases, though more cases appeared tooccur in some countries than in others. He thought thename Mooren’s ulcer was a better term than serpiginous.Gifford had published a case in which the conjunctiva andsclera were involved in the ulcerative process, and last yearan Italian observer isolated a bacillus which caused a diseasewhen inoculated into the conjunctiva of rabbits.-ThePRESIDENT stated that he had only seen a few cases, andhe described one which occurred in a woman in which headvised an iridectomy, as it had when he first saw it resistedall kinds of treatment. The patient refused to have the