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OBSTETRICAL SOCIETY OF LONDON

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461 to the cautery was that it was so apt to be followed by secondary hemorrhage, which was not so serious a matter in hospital cases, but might be in private, where there was no house-surgeon at hand. Nor was the cautery necessary, for with a thick wire-rope ecraseur, used very slowly, we might get rid of bleeding almost entirely. Mr. Hulke re- lated a case of ichthyosis, in which he had yielded to the opinion of others, and only removed a part of the tongue. Multiple recurrence ensued, and no second operation could be done, teaching the lesson of the importance of removing the entire organ early in cases of the kind. As to ligature of the lingual artery, Mr. Haward’s case did not appear to be a simple and un- mixedone; possibly the growth of the cancer was modi- fied by the erysipelas ; for Mr. D.e Morgan had observed that in widespread cancerous sores a sharp attack of erysi- pelas would often have a modifying and healthy effect. Division of the gustatory nerve sometimes had a beneficial effect upon the symptoms in cancer of the tongue. In reply to the President, Mr. Hulke said that the ichthvosis in the last case which he mentioned consisted in a large plaque on the side of the tongue, and also a number of small scattered patches on the upper and under surfaces.-Mr. BRYANT also agreed as to the desirability of complete extirpation of the tongue in epithelioma, and he thought it might be desirable to anticipate the formation of cancer in an ichthyotic tongue by extirpation. The virulence of this form of epi- thelioma was also evident. He had seen rapid recurrence in the glands-and not in the part itself. Even when the tongue was extensively implicated, he was in favour of its removal; for the glandular affection was a less painful mode of death than that of the tongue. As to the mode of re- moval, he disliked Paquelin’s cautery, preferring the galvano- ecraseur, with a thick wire. He had had no ill result from its use, the action being simply that of cauterising the wound after it had been cut. He had never had reason to tie the lingual unless for secondary haemorrhage.—Mr. MORRANT BAEEE observed, with reference to section of the gustatory nerve, that it was frequently difficult to get at, owing to cancerous infiltration of the tissues, and their section tended to excite swelling in the gland. A very simple operation would often be found to give great relief-viz., removal of all the teeth on the side in which the cancer existed, whether they were carious or no. This removed a hard body, and diminished the vascularity of the whole side of the mouth.- Mr. Pies, in reference to Mr. Haward’s recommendation as to the mode of ligaturing the lingual artery-viz., by exposing its origin from the carotid, stated that having seen the apparent benefit from the operation in Mr. Hay- ward’s case, he was led to tie the lingual at the same time as he removed the tongue with the écraseur. He had great difficulty in finding the lingual, but he found the external carotid, and then, as he thought, the lingual, which he tied. Secondary hasmorrhage ensued; it was checked with perchloride of iron. The man died of pysemia, and at the post-mortem he found that he had tied the superior thyroid, which came off high up.-Mr. CALLENDBB had never seen a case of cancer of the tongue in which the glands were not implicated, where the whole tongue could not be removed through the mouth with the ecraseur. This operation was much safer and easier than that from below or through the jaw. As to instruments, he had had the opportunity of testing the merits of various kinds, and had come to the conclusion that the ordinary écraseur was the best. He never had secondary haemorrhage, but he thought it more liable to occur after the galvanic écraseur. The difference appeared to be that after the galvanic ecraseur a slough was formed which had to be separated, this not being the case after the ordinary écraseur, and in a series of cases this separation caused the wound to take, on an average, a week longer to heal -Mr, HEATH thought that the method of ligature of the lingua] artery adopted by Mr. Haward would lead to difficulties, since the lingual and facial might arise together. Thf hyoid bone was not a good guide to the lingual; it waf better to go into the digastric triangle, when the arter3 would be readily found by division of the hyoglossus. Th( only precaution needed was to avoid cutting into thE pharynx. He agreed with Mr. Hulke as to the dangej of secondary hsemorrhage after the galvanic écraseur and his own experience and the weight of evidencE would induce him to give up the galvanic écraseur a.nc resort to the ordinary one.-Mr. HENRY MoBRis agreec with Mr. Heath as to the site for ligation of the lingual- viz., beneath the hyoglossus. He had seen the facial and the superior thyroid tied in the dead subject for the lingual. As to Mr. Haward’s case, he could not believe that ligation of the lingual could influence growth so near the root of the tongue, where other vessels also supplied it. Possibly the enlarged and inflamed cervical glands might have pressed on the carotid. Might the pysemia have been caused by necrosis of the hyoid bone ? He thought the operation through the jaw and that in the mouth were not to be contrasted, but were suited to different classes of cases.-Mr. BARWELL, in reply, said that he had no idea of using the cautery which he showed in removing the whole of the tongue; its advantage consisted in being kept at an equable heat, and it was useful for excision of small parts.- Mr. HAWARD said that the diminution in the tumour could not have been due, as Mr. Morris suggested, to the abscess, which had not arisen till some days after. Though the lingual did not entirely supply the tongue at its root, it supplied a good deal, and its ligature, therefore, diminished the vascularity. He did not suggest tying the artery at its origin from the carotid, but only tracing it from that point, and although the plan which Mr. Heath advocated might do very well in the dead subject, it was often impossible to see the hyoglossus when the parts were infiltrated with cancer. The erysipelas did not affect the cancerous sore.- Mr. BROWN made a few remarks in reply, and the meeting then adjourned. OBSTETRICAL SOCIETY OF LONDON. AT the meeting of this Society on the 7th inst. (Dr. West, President, in the chair), the following gentlemen were elected fellows :—Mr. A. de W. Baker (Dawlish), Dr. M. P. Dean (Toronto), Dr. S. Gell, Mr. W. W. Hardwicke (Rotherham), Mr. L. J. May, Mr. M. H. C. Palmer (Newbury), and Dr. A. L. Smith (Ottawa). Dr. MABEBLY showed two Flacentse with membranes at- tached, in which the bloodvessels, instead of uniting on the surface of the organ, ran for some distance along the membranes, and then united to form the umbilical cord. Dr. AvELING exhibited a Curved Needle, which, by a me- chanical contrivance, can be made to revolve, giving the operator the power of introducing its point in one direction and bringing it out in another exactly opposite. He had invented it for cases of vesico-vaginal fistula, and more especially where the wound to be closed was situated high up or transversely. The needle has a notch near its ex- tremity, in which a loop of the suture to be passed is placed. It is made by Messrs. Mayer and Meltzer. Dr. EDis read a paper on " The Forceps in Modern Mid- wifery." His object was more to provoke discussion upon the subject and elicit the opinion of the Fellows, than to define under what circumstances the forceps might or might not be employed. During the year 1874 the Registrar-General’s returns showed that there were nearly 6000 deaths from accidents in childbirth alone, many of which Dr. Edis believed were due to patients being allowed to remain too long in labour without timely assistance being rendered. Statistics bearing upon the question were given, but no definite conclusions could be drawn from them, as the high and low forceps operations were not dis- tinguished in these calculations. The point attempted to be elucidated was "the highest rate of frequency of appli- cation of the forceps coincident with the lowest rate of mortality to mother and child." The experience at the Rotunda Hospital, Dublin, during the last few years, threw some light upon this question. It was chiefly in reference to cases of tedious and difficult labour, more especially in primiparae, where the os uteri was not fully dilated, that the advisability of an early resort to the forceps was sug- gested. - Dr. AsHBURTON THOMPSON thought that the , numerical method Couhl not be applied to settle the ques- tion, nor could the result of personal practice. Different , practices offered different percentages of forceps delivery. Occupations would give rise to such differences. The causes , of difficult labour are not uniform. Forceps had recently
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to the cautery was that it was so apt to be followed bysecondary hemorrhage, which was not so serious a matterin hospital cases, but might be in private, where there wasno house-surgeon at hand. Nor was the cautery necessary,for with a thick wire-rope ecraseur, used very slowly, wemight get rid of bleeding almost entirely. Mr. Hulke re-lated a case of ichthyosis, in which he had yielded to theopinion of others, and only removed a part of the tongue.Multiple recurrence ensued, and no second operationcould be done, teaching the lesson of the importanceof removing the entire organ early in cases ofthe kind. As to ligature of the lingual artery, Mr.Haward’s case did not appear to be a simple and un-mixedone; possibly the growth of the cancer was modi-fied by the erysipelas ; for Mr. D.e Morgan had observedthat in widespread cancerous sores a sharp attack of erysi-pelas would often have a modifying and healthy effect.Division of the gustatory nerve sometimes had a beneficialeffect upon the symptoms in cancer of the tongue. In replyto the President, Mr. Hulke said that the ichthvosis in thelast case which he mentioned consisted in a large plaque onthe side of the tongue, and also a number of small scatteredpatches on the upper and under surfaces.-Mr. BRYANT alsoagreed as to the desirability of complete extirpation of thetongue in epithelioma, and he thought it might be desirableto anticipate the formation of cancer in an ichthyotictongue by extirpation. The virulence of this form of epi-thelioma was also evident. He had seen rapid recurrencein the glands-and not in the part itself. Even when thetongue was extensively implicated, he was in favour of itsremoval; for the glandular affection was a less painful modeof death than that of the tongue. As to the mode of re-

moval, he disliked Paquelin’s cautery, preferring the galvano-ecraseur, with a thick wire. He had had no ill result fromits use, the action being simply that of cauterising the woundafter it had been cut. He had never had reason to tie thelingual unless for secondary haemorrhage.—Mr. MORRANTBAEEE observed, with reference to section of the gustatorynerve, that it was frequently difficult to get at, owing tocancerous infiltration of the tissues, and their section tendedto excite swelling in the gland. A very simple operationwould often be found to give great relief-viz., removal ofall the teeth on the side in which the cancer existed, whetherthey were carious or no. This removed a hard body, anddiminished the vascularity of the whole side of the mouth.-Mr. Pies, in reference to Mr. Haward’s recommendationas to the mode of ligaturing the lingual artery-viz., byexposing its origin from the carotid, stated that havingseen the apparent benefit from the operation in Mr. Hay-ward’s case, he was led to tie the lingual at the same time ashe removed the tongue with the écraseur. He had greatdifficulty in finding the lingual, but he found the externalcarotid, and then, as he thought, the lingual, which hetied. Secondary hasmorrhage ensued; it was checked withperchloride of iron. The man died of pysemia, and at thepost-mortem he found that he had tied the superior thyroid,which came off high up.-Mr. CALLENDBB had never seen acase of cancer of the tongue in which the glands were notimplicated, where the whole tongue could not be removedthrough the mouth with the ecraseur. This operation wasmuch safer and easier than that from below or through the jaw.As to instruments, he had had the opportunity of testing themerits of various kinds, and had come to the conclusion thatthe ordinary écraseur was the best. He never had secondaryhaemorrhage, but he thought it more liable to occur afterthe galvanic écraseur. The difference appeared to be thatafter the galvanic ecraseur a slough was formed which hadto be separated, this not being the case after the ordinaryécraseur, and in a series of cases this separation caused thewound to take, on an average, a week longer to heal -Mr,HEATH thought that the method of ligature of the lingua]artery adopted by Mr. Haward would lead to difficulties,since the lingual and facial might arise together. Thfhyoid bone was not a good guide to the lingual; it wafbetter to go into the digastric triangle, when the arter3would be readily found by division of the hyoglossus. Th(only precaution needed was to avoid cutting into thEpharynx. He agreed with Mr. Hulke as to the dangejof secondary hsemorrhage after the galvanic écraseurand his own experience and the weight of evidencEwould induce him to give up the galvanic écraseur a.ncresort to the ordinary one.-Mr. HENRY MoBRis agreec

with Mr. Heath as to the site for ligation of the lingual-viz., beneath the hyoglossus. He had seen the facial andthe superior thyroid tied in the dead subject for the lingual.As to Mr. Haward’s case, he could not believe that ligationof the lingual could influence growth so near the root ofthe tongue, where other vessels also supplied it. Possiblythe enlarged and inflamed cervical glands might havepressed on the carotid. Might the pysemia have beencaused by necrosis of the hyoid bone ? He thought theoperation through the jaw and that in the mouth were notto be contrasted, but were suited to different classes ofcases.-Mr. BARWELL, in reply, said that he had no idea ofusing the cautery which he showed in removing the wholeof the tongue; its advantage consisted in being kept at anequable heat, and it was useful for excision of small parts.-Mr. HAWARD said that the diminution in the tumour couldnot have been due, as Mr. Morris suggested, to the abscess,which had not arisen till some days after. Though thelingual did not entirely supply the tongue at its root, it

supplied a good deal, and its ligature, therefore, diminishedthe vascularity. He did not suggest tying the artery at itsorigin from the carotid, but only tracing it from that point,and although the plan which Mr. Heath advocated mightdo very well in the dead subject, it was often impossible tosee the hyoglossus when the parts were infiltrated withcancer. The erysipelas did not affect the cancerous sore.-Mr. BROWN made a few remarks in reply, and the meetingthen adjourned.

OBSTETRICAL SOCIETY OF LONDON.

AT the meeting of this Society on the 7th inst. (Dr. West,President, in the chair), the following gentlemen were electedfellows :—Mr. A. de W. Baker (Dawlish), Dr. M. P. Dean(Toronto), Dr. S. Gell, Mr. W. W. Hardwicke (Rotherham),Mr. L. J. May, Mr. M. H. C. Palmer (Newbury), and Dr. A.L. Smith (Ottawa).

Dr. MABEBLY showed two Flacentse with membranes at-tached, in which the bloodvessels, instead of uniting onthe surface of the organ, ran for some distance along themembranes, and then united to form the umbilical cord.

Dr. AvELING exhibited a Curved Needle, which, by a me-chanical contrivance, can be made to revolve, giving theoperator the power of introducing its point in one directionand bringing it out in another exactly opposite. He hadinvented it for cases of vesico-vaginal fistula, and moreespecially where the wound to be closed was situated highup or transversely. The needle has a notch near its ex-

tremity, in which a loop of the suture to be passed isplaced. It is made by Messrs. Mayer and Meltzer.

Dr. EDis read a paper on " The Forceps in Modern Mid-wifery." His object was more to provoke discussion uponthe subject and elicit the opinion of the Fellows, than todefine under what circumstances the forceps might or

might not be employed. During the year 1874 theRegistrar-General’s returns showed that there were nearly6000 deaths from accidents in childbirth alone, many ofwhich Dr. Edis believed were due to patients being allowedto remain too long in labour without timely assistancebeing rendered. Statistics bearing upon the question weregiven, but no definite conclusions could be drawn fromthem, as the high and low forceps operations were not dis-tinguished in these calculations. The point attempted tobe elucidated was "the highest rate of frequency of appli-cation of the forceps coincident with the lowest rate ofmortality to mother and child." The experience at theRotunda Hospital, Dublin, during the last few years, threwsome light upon this question. It was chiefly in referenceto cases of tedious and difficult labour, more especially inprimiparae, where the os uteri was not fully dilated, that theadvisability of an early resort to the forceps was sug-gested. - Dr. AsHBURTON THOMPSON thought that the

, numerical method Couhl not be applied to settle the ques-tion, nor could the result of personal practice. Different

, practices offered different percentages of forceps delivery.. Occupations would give rise to such differences. The causes, of difficult labour are not uniform. Forceps had recently

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been used much more frequently than in former times. Hethought that difficult labours had not increased in propor-tion.-Dr. CLEVELAND said that in private practice he hadobtained excellent results from the use of the forceps, andbelieved that in judicious hands its employment was capableof further development. If one attempt at delivery by itsmeans failed, a second might prove successful. Howevervaluable statistics on a large scale in a lying-in hospital maybe, still in private practice we shall be mainly guided inthe use of the instrument by individual experience.-Dr.AVELING believed the determination of the question, howoften and when the forceps should be used, must for thepresent be decided by personal experience, and not bystatistics or the relation of individual cases. A scientificrule of practice might some day be obtained when readymethods had been found of measuring the expulsive force ofthe uterus and abdominal muscles, the dimensions of thefoetal head and pelvis, and the resistance of the soft struc-tures.-Dr. PLAYFAIR said that it was astonishing that theconservative instrument, the forceps, should have beenlooked upon with dread, while the perforator, until com-paratively recent years, had been used with appalling fre-quency. He had deliberately advised the use of the forcepsin lingering labour, and had done so after mature reflection.He had recommended a frequent use of the forceps when thehead was delayed low down in the pelvis by simple inertiauteri, and when only a slight vis à fronte was required tosupplement the deficient vis a tergo. The high forcepsoperation, when the head was at the brim, was in an entirelydifferent category. The advantages of frequent resort tothe forceps were the saving of suffering to the mother, theshortening of labour, better recovery of patients, and thesaving of infant life. Are there dangers associated with thefrequent use of the forceps which counterbalance theseadvantages ? It has been stated that ruptured perineum ismore common now than formerly, and that it is due to themore frequent use of this instrument. But supposing suchwere the case, it would not counterbalance the saving of asingle human life. On the other hand, the number of casesof vesico-vaginal fistula has diminished. He expressed hisopinion that in spite of the objections made to forceps,delivery by its means when the head was low in the pelviccavity was a more conservative practice than the use of itas a last resource. -Dr. GALABIN said he thought the sta-tistics of Dr. Kidd, based on the number of deaths afterprotracted labour, were unreliable, since there could be noexact criterion when a labour should be considered pro-tracted, especially when the observers were not the same.A comparison with the earlier records of the Rotunda Hos-pital gave a different result. The mortality in Dr. Johnston’smastership-namely, 21 per 1000-was more than half aslarge again as that from the foundation of the hospital in1745 to 1853, which was only 12-1 per 1000. In 88 caseswithin three years in which the forceps were applied beforefull dilatation of the os, simply on account of prematurerupture of the membranes, there were 4 deaths-a mortalityof no less than 46’6 per 1000. It was therefore at least notyet proved that such a use of forceps was free from risk.In the Guy’s Hospital Charity, out of 23,591 deliveries intwelve years, the forceps cases were only 5’2 per 1000, andthe maternal deaths only 4’4 per 1000, of which only ’8 per1000 occurred after protracted labour. The children still-born were 4-06 per cent. ; those still-born with a vertex pre-sentation 2-7 per cent., of which only about one, seventh weredecomposed or premature. He had always supposed thatmost of these children were sacrificed on account of the rulethat forceps should not be applied without sending for theassistant obstetric physician, but a comparison with theneighbouring charity of St. Thomas’s made this conclusiondoubtful; forceps were there used about ten times as often,but the ratio of still-births was almost exactly the same, theslight difference being in favour of Guy’s.-Dr. FITZPATRICKthought the discussion on the use of the forceps muchcalled for, and would be looked to with avidity by the pro-fession generally. The forceps had been weighted withrestrictions and conditions so as to materially diminish its ’

value. Our object is in many cases opposed to nature’s.Nature’s object is to repress feeble additions to the humanstock; ours, on the contrary, is to save life and relieve suf-fering, and for this object the forceps is an indispensablehelp.-Dr. PARR remarked, that however skilful in theuse of forceps a gentleman might be who related 400 and 1

700 consecutive cases without the loss of a single child, hecertainly was very fortunate. Dr. Parr in less than 400cases had four children still-born, from (two) mothers suf-fering from syphilis; not one of these labours exceededthree hours in duration. In a fifth case the child was borndead, suffocated by a short cord drawn tightly round theneck. No care could exclude such cases.-Dr. DALY saidthat in 800 cases he had used the forceps in 80, in 50of which the head was in the pelvis or in the perineum,and in 30 above or in the brim. Of the 800 cases four died.Of the 80 forceps cases two died; one was dying whencalled in of accidental haemorrhage, the other of puerperalfever; another of the forceps cases had pelvic cellulitis.There were ten still-births, two being forceps cases. Lacera-tion of the perineum occurred more frequently in first caseswhen the forceps was not used. Craniotomy was not resortedto in any case, while during an experience of five years,while a pupil in a country district in Ireland, the forcepswas not used once, but craniotomy was performed five times,and in every case with a fatal result to the mother.-Dr.POOLE thought that help might be given by other than in-strumental means-viz., by well-directed external pressure.He had used the forceps much less lately than formerly.-Dr. ROPER could not see the desirability of frequent use offorceps in lingering natural labour; he had never appliedforceps without ascertaining first that the natural powerswere insufficient to accomplish labour with safety to motherand child. The obstruction caused by a rigid os uteri andperineum slowly and naturally goes away, and there is onecondition which contra- indicates the use of the forceps-namely, the retrogression of the head on the cessation ofpain. In laborious labour it is only when uterine power isexhausted that rhythmic action of the uterus ceases, and be-comes one of persistent unremitting contraction, and thenimmediate delivery is indicated. The assertion that child-ren are frequently born dead from delay in lingeringlabour, who might be saved by timely use of the forceps, isnot borne out by statistics. In Dr. Hamilton’s 300 succes-sive cases without loss of a single child, the calculation ex-cludes all children known to have been dead before forcepswere applied. The number of these was eight, so

that really his mortality was equal to 1 in 37. He (Dr.Roper) thought that the application of the forcepswhen the os uteri was only 15/8 inch in diameter was

opposed to all propriety. His experience in the RoyalMaternity extended to 4377 cases, the forceps being usedonce in about 109 cases, still-births 1 in about 77, maternaldeaths 1 in about 463.-Dr. RoGERS thought that the use ofthe forceps was not required as often as it had been stated.Labour was a natural process, and terminated favourablywithout interference in the large majority of cases. - Dr.WALLACE thought that some expression of opinion by theSociety as to the length of time one should wait after im-paction or arrest before applying the forceps would be ofgreat value. He waited two hours, rarely longer; and in800 cases attended in the last two years he had applied theforceps 26 times. Amongst the forceps deliveries therewas one maternal death and one still-born child. - Dr.GRAILY HEWITT believed it to be impossible to lay down ahard and fast rule for the employment of the forceps. Forits employment education and a certain mechanical aptitudewere necessary, and mechanical aptitude was absent in someinstances. Hence a timidity and hesitation on the part ofsome to employ the instrument. Others, finding the ope-ration simple and easy, would naturally employ this meansof delivery more frequently. His view as to the expediencyof the employment of the forceps was practically the sameas Dr. Playfair’s—that is to say, considering the cases ofthe low operation. The high operation was undoubtedlydifficult and more dangerous. This distinction of forcepscases into high and low operation was Dr. M’Clintock’s,andthe distinction was a most important one to make. Hethought that the greater frequency of perineal lacerationwas partly due to too rapid extraction. The perineum mustbe allowed to expand. Nature’s method should be imitated.The importance of exercising traction in a forward directionwas sufficiently emphasised in the ordinary text-books.

THE Ayr Hospital and Dispensary is to be sold, anda new building, with fifty beds, and separate accommoda-tion for infectious diseases, erected upon a suitable site.


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