675OBSTETRICAL SOCIETY OF LONDON.

and there seemed to be signs of the presence of gas in theperitoneal cavity. The conditions appeared to be favourablefor operative interference ; though the fever had ran

rather a protracted course, the type had been mild,and before the perforation the patient’s strength hadbeen well maintained. From the absence throughout ofdiarrhoea or other intestinal symptoms, it might be inferredthat the ulceration was slight in amount and probably chieflysituated rather high up in the ileum, where it would be moreeasily accessible. The lower down the ulcers the more severewas the diarrhoea. It was usually most severe when theulceration extended into the large intestine, next when itwas chiefly about the ileo-cascal valve, and least when, as wassometimes the case, it was mainly in the higher part of theileum, though these ulcers were very liable to perforate.Moreover, as this was about the twenty-fourth day of the ill-ness, it was hoped that the fever was drawing to its termina-tion. Accordingly, five and a half hours after the acces-sion of the symptoms, the collapse having passed off, Mr.Bland Sutton, who was assisted by Dr. Berkeley, opened theabdominal cavity by an incision 8 cm. long in the linea alba,between the umbilicus and symphysis pubis; the recto-vesicalpouch was found to be full of a brown turbid fluid which hadescaped from the bowel, and bubbles of gas were being givenoff. On withdrawing a coil of intestine from the pelvis aperforation was found in the centre of an oval ulcer, the out-line of which was plainly apparent through the intestinalwall. In the adjacent mesentery a large pink gland wasvisible, no other ulcers being seen. The ulcer was excised byan oval incision, the cut edges of the mucous membranewere drawn into apposition by a continuous silk suture, andthen the serous surfaces were brought together by eleven Lem-bert’s sutures; the peritoneal cavity was freely irrigated withwarm water, and the stitched portion of the gut was laidimmediately under the wound in the abdominal wall, which wasthen closed in the usual manner. The operation lasted nearlyan hour, a considerable portion of which time was occupied inwashing out the peritoneum. At the end of the operationthe patient was much collapsed, but gradually rallied andlived till the sixth day, passing ultimately into a typhoidstate, with great prostration and rambling delirium. Someleakage of gas took place, and consequently the central stitchof the abdominal incision was removed in order to allow a freevent. He was at first fed by nutrient suppositories andenemata, but subsequently took liquid food by the mouth andhad a craving for solid food. He suffered a good deal from hic-cough. He passed urine and motions without difficulty andduring the last two days had diarrhoea, which seemed to be onechief cause of the final fatal prostration. He suffered no

pain, and there was no sign of peritonitis. Permission wasobtained for a partial examination. The sutured section ofbowel was found to be adherent to the edges of the incisionthrough the abdominal wall. Fluid could readily be made togurgle through this portion of the gut by pressure on the intes-tine above without any leakage taking place. The escape of gaswas due to the sloughing of a stitch exactly in the middle ofthe suture. The perforation was situated twelve inchesabove the ileo-meal valve. The shock of the prolonged opera-tion no doubt diminished the patient’s chances of rallying,and in any future attempt it would probably be better notto excise and suture the ulcer, but, after washing out theperitoneal cavity, to attach the perforated bowel to theabdominal incision and leave a fistula which could be dealtwith subsequently.-Mr. HERBERT ALLINGHAM said that hehad operated some time previously on a case of typhoid fever inwhich perforation had occurred. The ileum was adherent tothe sigmoid flexure, and on touching the small intestine ittore to pieces, so that it was impossible to suture the perfora-tion. The small intestine was therefore stitched to theabdominal wall, but the patient died twenty-four hourslater.-Mr. EVE remarked that in a paper read in 1888 beforethe Congress of American Surgeons notes were given of fivesimilar cases, all of which had proved fatal.-Mr. BATTLEwondered what was the mortality of perforation occurringin enteric fever if left to itself. There were at present records Iof about twenty cases of typhoid perforation which had beensubmitted to operation. Of seventeen cases which Senn 1had collected, four were said to have been saved. "-Dr. 1

GOODALL said that the case related was a favourable favourable

one for operation. It was often extremely difficult to 1

say when perforation had taken place, and if the operator adelayed until the fact was made evident by the onset ’.of peritonitis the case was by that time hopeless. Looking Iback at the last twelve cases which he had seen of perforation. ,

during typhoid fever he was sure that in not one would surgicalintervention hase had the slightest chance of success. Asmany cases of perforation recovered under medical treatmentalone, this made hesitation necessary before deciding to inter-fere.-Dr. BURNEY YEO thought that if the patient had livedthere would have probably been a stricture of the intestine,for its lumen had been so much narrowed by the suture.-Mr. BLAND SUTTON, in reply, said that he operated becausethe conditions appeared to be so very favourable. The propertime for the operation was when the patient had rallied fromthe shock of the perforation. He thought that if a temporaryartificial anus had been made the patient would have hada better chance of recovery. The patient must have diedif left, for the pelvis was full of extravasated fsecep. In

endeavouring to discover the portion of gut which had per-forated it should be remembered that when deflated the guttended to sink into the pelvis, and that was where he hadfound the perforation.—Dr. CAYLEY, in reply, said that,though patients might recover after perforation, he did notthink that recovery was possible when there had been muchextravasation.

OBSTETRICAL SOCIETY OF LONDON.

Exhibition of Specimens.-Symphysiotomy.-The Relation ofJICa?t Disease to Menst’l’uat’ion.

A MEETING of this society was held on Wednesday,March 7th, Dr. G. E. HERMAN, President, being in the chair.The following specimens were shown :-Dr. DUNCAN: (1) Ruptured Tubal Gestation-sac, with

Embryo in sitii,, and a Drawing of the same ; and (2) Poly-poid Myoma of Cervix. Dr. LEITH NAPIER : (1) Foetnswith Ectopia Viscerum and Retroflexion of Spine (referredto subcommittee) ; and (2) Anencephalic Fcetus.

Dr. ROBERT P. HARRIS of Philadelphia read a paperentitled I I A Plea for the Practice of Symphysiotomy, basedupon its record for the past eight years." He mentioned theunfavourable statistics of the operation of symphysiotomyduring the period 1777 to 1858, and the great reduc-tion of mortality in both mothers and children since itsrevival by Morisain in 1866, and pointed out that the successobtained by this operator, and by Novi and others in Italy,showed that the operation is founded on a rational basis. Heconsidered that the results obtained in other countries were

very encouraging, and mentioned, as the best conditions forthe performance of symphysiotomy in view of saving thechild’s life, that the woman should be operated on in goodseason ; that the size of her pelvis should be accurately ascer-tained ; and that the true conjugate should not measure lessthan 2 in. The child should be very carefully, not hurriedly,delivered by the forceps applied to the sides of the head; andif asphyxiated it should be carefully treated for its restora-tion.-Dr. LBWERS said that Dr. Harris had inquired whatstopped the progress of symphysiotomy in England. Dr.Lewers’ own case, operated on last year, was the only one : ’.published in England since the revival of the operation. Hethought some of the early mortality was due to the operationhaving been performed in extreme cases of pelvic contraction,and much to the want of asepsis. He pointed out thedifference in rigidity of the pelvic joints in pregnant and innon-pregnant women, and that in the former a gain of three-quarters of an inch in the conjugate was possible. He con-sidered the indications for operation were failure to deliverwith forceps in a slightly contracted pelvis, and that strictasepsis was necessary. He estimated the present mortalityof symphysiotomy at 7 per cent.-Dr. HORROCKS, after men-tioning the three alternatives in the case of a living child whichcould not be delivered alive-namely, craniotomy, Caesareansection, and symphysiotomy-said that craniotomy shouldhave a mortality of nil, and he believed the mortality of thesecond alternative to be less than that of the third-certainlymore children were saved. He mentioned theunfavouraMeafter-effects of Cassarean section, and related two cases where con-ception had occurred after this operation when the tubes hadbeen ligatured. Sterility would be best obtained by removing,the ovaries or by excising a piece of tube. He had wit-nessed one case of symphysiotomy, and was astonished at the.wide separation of the halves of the symphysis ; he was onlyable to surmise what state the sacro-iliac joints must be in.The woman had been unable to work since, and was now, liehad heard, in an infirmary. He would like to know if this swas common, and instanced Dr. Lewers’ case, when the

T,

676 OPHTHALMOLOGICAL SOCIETY.

patient could not do her work so well as before operation.He should recommend a patient, under the conditions named,to have craniotomy performed ; or if she was anxious to havea living child, and willing to incur the extra risk, Cassareansection, in preference to employing symphysiotomy.-Dr.GRIFFITH thought the reason why symphysiotomy was notmore frequently done in this country was because the opera-tion was a very serious one for the patient. He had not yetfound, although he had about 3000 cases of labour annuallyunder his charge, the conditions necessary for its performancepresent-namely, the pain in labour, a moderate degree of con-traction (conjugate vera not less than 3 in.), the foetus alive,and delivery impossible with forceps properly applied. Hebelieved the total risks of Caesarean section were less than thoseef symphysiotomy.-The PRESIDENT said that obstetricalscience was much indebted to Dr. Harris and others who hadput their results before the profession. The percentagemortality appeared to be about 10, not lower than that offavourable Caesarean section. The latter operation could becombined with sterilisation, but the best way of doing thishad not yet been established. Symphysiotomy, in whichoperation the patient could not be sterilised, might be requiredmany times in the same patient. There was no informationas to whether frequent division of the symphysis could bedone on the same woman with good union each time, and theafter-histories of symphysiotomy cases were as yet wanting.In one recorded case the patient could not do her work so wellas before, and in another laceration of the urethra occurred.He was inclined to think Csesarean section preferable tosymphysiotomy.—Remarks were also made by Dr. CULLING-WORTH and Dr. LEITH NAPIER.A paper was then read by Dr. Gow on the Relation of

Aeart Disease to Menstruation. Particulars with regard tomenstruation were given of 50 cases. In 28 the menstruallow was unaltered; in 17 the flow was absent or scantier thanbefore; in 5 the flow was either more profuse or recurred morefrequently than before ; in no case was there good evidencethat heart disease gave rise to severe menorrhagia. It wouldseem that either amenorrhcea or scanty menstruation was afar more common accompaniment of heart disease than

menorrhagia. A further analysis of these cases seemed topoint to the fact that heart disease led to relative sterility,and also that it greatly increased the tendency to premature3’K,pmlsion of the ovum. In conclusion, it was pointed outthat a large number of women suffering from valvular diseaseof the heart pass safely through the period of pregnancy andlabour. The cases were further analysed as follows :1. Mitral stenosis (22 cases) : in 9 cases menstruation was

regular and the amount lost unaltered, in 5 cases menstruationwas regular but more scanty, in 4 cases there was amenorrhoea,and in 4 cases menstruation was either more frequent or moreprofuse. 2. Mitral incompetence (15 cases) : in 10 casesmenstruation was unaltered, in 4 cases menstruation was morescanty, and in 1 case there was amenorrhcea. 3 Mitralstenosis and incompetence (7 cases) : in 4 cases menstruationwas unaltered, in 1 case menstruation was more scanty, inl case there was amenorrhcea, and in 1 case there wassJightly increased menstrual loss. 4. Aortic incompetencea,nd obstruction (2 cases) : in both cases menstruation wasanaltered. 5. Aortic and mitral incompetence (3 cases) :in all cases menstruation was unaltered. 6. Aortic incom-petence and obstruction and mitral incompetence (1case) : menstrual loss was more scanty than before. - Dr.JOHN PHILLIPS was much interested in the paper, as hehad for some time been investigating the subject. He com-mented on the want of reference to the subject in the wholeliterature of the past twenty years. He had examined thehearts of 656 women consecutively, whose ages varied betweeneighteen and forty-four, in the out-patient room at King’sCollege Hospital, and had observed fifteen cases of organicheart disease. In none was there menorrhagia, in most a

tendency to amenorrhcea, and in two aortic cases the patientsattended in consequence of amenorrhoea and breathlessness.He agreed with Dr. Gow in all his conclusions, except thathe thought, perhaps, a woman conceived as readily with adamaged heart as with a healthy one. The tendency toabortion was undoubted. -Dr. HORROCKS recognised thevalue of the paper. He thought, however, that more

accurate knowledge could be obtained by comparing themenstrual history of a patient with the condition ofbhe heart found post mortem. Records of the men-

strual function were rare in medical and surgicalteports. He pointed out that most of Dr. Gow’s cases

were instances of mitral stenosis and that it was only when

tricuspid regurgitation occurred that any marked effectcould be expected in the uterus. In the cases where thetricuspid valves were incompetent there was no menorrhagia.He thought all the facts were in favour of Dr. Gow’s con-clusions,-The PRESIDENT called attention to the admirablemethods of Dr. Gow’s research. Instead of taking patientswho came to a hospital for their special diseases, and inwhom there would appear a greater frequency of functionaldisturbances of the genital organs associated with heartdisease than was actually the case, he took patients withheart disease and inquired into the frequency of menstrualdisturbance in them. He (the President) had made someobservations on the effect of venous congestion from heart,lung, and liver diseases on menstruation, and his results inthe main agreed with those of Dr. Gow.-Dr. GRIFFITHhad met with an instance of menorrhagia coexisting withmitral regurgitation.—Dr. Gow replied.

OPHTHALMOLOGICAL SOCIETY.

Orbital Tumours.-Adjourned, Discussion on SchoolOp7ithalntia. --Exhibition of Specimens.

AN ordinary meeting of this society was held on Thursday,March 8th, the President, D. ARGYLL ROBERTSON, M.D.F.R S.E., being in the chair.

Dr. HILL GRIFFITH (Manchester) related some cases ofOrbital Growth, showing photographs and preparations. Thefirst represented the successful removal from the upper partof the orbit of a man aged thirty-five of an encapsuledadeno-sarcoma which was causing repression and downwarddisplacement of the eye. The second was the removal ofwhat afterwards proved to be a hypertrophied lacrymal glandfrom the orbit of a young girl. When seen six years later alarge irregular bony exostosis (?) filled the space betweenthe frontal arch and the eyeball. Probably the lacrymalgland had been pushed out of position by the slowly growingmass, and had been erroneously regarded as the cause of thetrouble. The third was a symmetrical tumour in a similarposition in an otherwise healthy young man, which wasregarded as an acute hypertrophic inflammation of the

lacrymal glands. The fourth case was one of very slow and

painless protrusion of the eyeball in an otherwise healthyyoung woman in whom a portion of growth could be felt inthe upper and outer part of the orbit. Seventeen monthsafter the first visit the tumour was removed, together withthe orbital contents, the nature of the growth being doubtful.The last two cases were malignant growths in which theorbital contents were removed, death occurring in one casetwelve months later from extension of what had proved tobe sarcoma, and in the other from meningitis on the

twenty-fourth day after operation. Dr. Griffith statedthat in all such cases he had found pressure sufficient forthe arrest of hemorrhage, and he warned others againstthe use of the actual cautery with this object.-Mr.MCHARDY questioned the value of the horseshoe incisionin these cases, involving as it did so much more stitching.-Mr. JULER stated that he had exhibited a similar case, inwhich a portion of the growth had been removed and subjectedto microscopic examination, the opinion being expressedthat it was sarcoma. A suspicion of syphilis, however, wasaroused, and the patient recovered completely under

mercury.-Mr. ADAMS FROST mentioned a similar case, inwhich a growth had been removed as sarcoma, but turnedout subsequently to be syphiloma.-The PRESIDENT describeda case of symmetrical orbital tumours, both of which hadbeen removed at different times and places, but recurred andfinally disappeared under iodide of potassium.-Dr. LITTLEdwelt on the difficulty of diagnosing orbital tumours, andmentioned a case similar to the foregoing in a male patientfifty-five years of age. The tumours had existed two months,and on removal looked like sarcoma.-Dr. HILL GRIFFITH,in reply, said that the horseshoe incision was only adopted inorder to give more room where the tumour was very extensive.The adjourned discussion on Mr. Hutchinson’s paper on

School Ophthalmia was then resumed. .

Mr. HuTCHlNSON said that in his paper, so far fromexaggerating the frequency and severity of the attacks, hehad rather understated them. At the school with which hewas mainly concerned many of the cases had fulfilled theexact tests of workhouse ophthalmia, having frequentlyrelapsed and lasted for frcm six to eight months, developing