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OBSTETRICAL SOCIETY OF LONDON.

Temperature, Pitlse, and Respirat’ion during Labour andLying-in.-Ovariotomy in Women over the age of EightyYercrs.-Exlaibztion ot Specimens.A MEETING of this society was held on April 3rd, Dr.

F. H. CHAMPNEYS, President, being in the chair.The following abstract of a paper by Dr. PEOBYN-

WILLIAMS and Mr. LENNARD CUTLER upon Temperature,Pulse, and Respiration during Labour and Lying-in was read.The writers first considered the effect of labour. With regardto temperature they find that their results coincide withthose of Dr. Giles. With regard to pulse they find : 1. -Rate: :The low rate of the pulse after delivery, as given in the text-books, is exaggerated. In one hundred cases of normal labourobserved in connexion with this point they found that in76 the rate was diminished, in 11 it remained stationary, andin 13 it was increased after the end of the third stage. Inthis serif the average decrease between the rates during thefirst stage, and half an hour after the end of the third, waseleven beats per minute (from eighty-nine in the first stage toseventy-eight after delivery). Parity and the length oflabour have some influence on this fall ; and after theadministration of chloroform during labour it is common tofind the pulse remaining high after delivery. In 19cases of post-partum haemorrhage there was an averagerise of nineteen beats per minute (seventy-eight duringlabour, ninety-seven after delivery). 2. lension This,as estimated by tracings made with Dudgeon’s sphygmo-graph, is usually above normal during labour, but is

occasionally low, notably in one case in which delivery wasfollowed by considerable haemorrhage. Respiration.-Afterdelivery there was on the average a fall of one respiration perminute (23 during labour, 22 after delivery). After theadministration of chloroform this decrease was not observed.The effects observed in connexion with lying-in were as

follows :- Tem2)ercit u,,Pe. -The average temperature of 100cases varied between 98° and 99’F., being higher in the eveningthan in the morning. The highest average temperature wasreached on the first day and was higher in primiparæ than inmultiparæ. ’Rupture of the perineum had no appreciableeffect, on the temperature during the puerperium. Pulse.-

(1) Rite. The writers do not agree with the statements inthe text-books that the pulse is normally very slow duringthe first week, but found that the average rate of 100 caseswas never lower than 72. The pulse-rate was fasterin the morning than in the evening throughout this series.

(2) Tension. In a few cases the tension is diminished

by delivery ; but in the majority it is increased. Whatever

may be the tension of the artery during labour, and whetherit rise or fall after delivery, within twenty-four hours it hasalways increased so much that it is at least as great as, andgenerally greater than, the tension during labour. This in- !creased tension may persist throughout the puerperinm,and commonly lasts longer in multiparas than in primi-paræ. Respiration.-The rate of respiration was foundto vary between twenty and twenty-two per minute. Ittends to follow the pulse-rate in being higher in the

morning, and not the temperature, which is higher in theevening.-Dr. DAKIN congratulated Dr. Probyn-Williamsand Mr. Lennard Cutler on their very important paper.Their observations on the temperature, which were madeunder circumstances most favourable for accuracy, showedwhat was the typical chart of a lying-in woman-namely,one differing in no way, except for some slight exag-geration of the evening rise and morning fall, from thatof a person in ordinary health. The chart of the caseswhere perineal rupture was present showed the efficacy ofthe antiseptic methods in use at the General Lying-in Hospi-tal at the present time, for it did not differ practically fromthat of cases where there was no rupture. The pulse-ratewhich they found to be the average was perhaps more inte-resting, as it was opposed in some degree to what was statedin the text-books. Their results were, however, what mostof those who had large experience of lying-in women wouldexpect. As regarded the tension of the pulse, they againwere at variance with what had been hitherto accepted.Fritsch and Meybnrg found that the tension was diminished ;and it became difficult to reconcile this with the slower rate.Dr. Probyn-Williams and Mr. Cutler’s results showed thaithe pulse obeyed the ordinary laws of the circulation irthese circumstances, and explained the tendency to a slom

pulse by the high tension always present. Their results

explained also the frequency of pulse which often pre-ceded post-partum haemorrhage, if it were assumed, as it

fairly might be, that the suddenly increased arterial ten-sion which normally occurred was due to a retraction ofthe vessels in unison with the retraction of the uterus

Then, if retraction of neither uterus nor arteries were com.plete, there would be, as happened in the cases in the paper, alow tension and rapid pulse on the one hand and a relaxedandbleeding uterus on the other. It is possible that the increasedrapidity observed by Dr. Probyn-Williams and Mr. Cutlerafter the administration of chloroform was due to diminishedtension, and the tendency to post-partum haemorrhage,believed by some to exist in women who have had chloroformduring their labour, might be thus explained. Dr. Dakinhad never seen this effect from the drug. One effect ofits administration was that the child at birth was oftenvery lethargic, and did not begin to cry vigorously atonce without considerable stimulation.-Dr. REMFRY con-sidered that the rise in pulse-rate after chloroform mightbe due to the fact that in the cases recorded chloroformhad only been given in tedious labours and when instru.mental or other manipulations had been necessary.-Dr. HORROCKS thought the increased rate of the pulsein post-partum, as in any other form of haemorrhage, wasphysiological. Theoretically, half the amount of blood in thebody could do the same work in a given time if it were cir-culated with double the velocity. The increase in number ofheart beats was an attempt to increase this velocity pari passicwith the loss. The precise way in which the loss of bloodset up the increased rate was not perhaps known, but nodoubt it was through the vaso-motor system. He could notagree with Dr. Dakin regarding retraction of the heart andarteries. A3 a matter of fact, so long as the heart was com-pletely refilled with blood there was no retraction. If it wereunder-filled there would be some retraction, and if it were notrefilled at all there would be complete retraction during eachdiastole. The increased size of the left ventricle durin!!’pregnancy was a hypertrophy, and its subsequent diminutionwas an involution.-Dr. AMAND ROUTH asked for more

information as to the effect of chloroform upon the tem-perature of the lying-in woman. He thought the admin-istration of chloroform by lowering the heat of the bodymight in a measure account for the difficulty in revivingchildren after its use, which, as Dr. Dakin had stated,was not infrequently observed.-Dr. DUNCAN agreed withDr. Probyn-Williams and Mr. Cutler in questioning the

accuracy of the statement made in text-books that the

pulse-rate became slower after delivery. In years goneby he (Dr. Duncan) used to dread post-partum hoemor-rhage if the pulse kept up to 110 ; but he found his fearswere groundless, as he had never had a case of this accident,whilst a good many of his patients had a pulse of over 100for some hours after delivery. He thought a high pulse-ratewas met with most often in the upper classes of society,where a neurotic temperament was not rare.-The PRESIDENTsaid that a paper of this kind was much needed to test andcorrect accepted views, which were apt to be quoted frombook to book without sifting. The chief point in debateseemed to be the pulse. In his experience this was oftenrapid, especially after excitement, either mental or bodily,without any undue loss of blood. But in this case the beatswere distinct and the tension good. The pulse of hmmor-rhage was running, the beats not well separated, and thetension low. Such a pulse often preceded haemorrhage andbetokened a general vaso-motor condition affecting the heart,arteries, and uterus.

Dr. LEONARD REMFRY read a paper on Ovariotomy inWomen over the Age of Eighty Years. Ten cases were

recorded, all of whom had recovered. The list includedoperations in England, America, Australia, and Germany.One patient, aged eighty-three years, suffered also from

, epithelioma of the vulva. Dr. Remfry saw her in August,’ 1894, and the epithelioma was at once freely removed.l In November there were no signs of recurrence, and,

the internal tumour being larger, ovariotomy was per-1 formed ; her convalescence was satisfactory. The paperi concluded with some details of the various cases and. remarks on the powers of resistance in aged people.-; Mr. BUTLER SMYTHE congratulated Dr. Remfry on the. success of his case complicated with epithelioma, and askedt if any mental symptoms had been observed previously to thea operation. The patient had been under his care on twov occasions, but had absolutely declined to have the tumour

933

removed. Her mind then seemed to be exceedingly weak,and her conduct and language extraordinary. She had beento several hospitals "to show herself to the doctors," butwould not submit to any operative measures beyond aspira-tion of the cyst, which was twice performed. It was most

gratifying to hear from Dr. Remfry that up to the presenttime there had been no recurrence of the epithelial growth.-Dr. LEWERS hoped that the after-history of the case as

regards the vulvar epithelioma would be given to the society, !,as in his experience recurrence was much more likely to occurearly than in cases of epithelioma of the cervix. Dr. Lewersmentioned a case under his care where, after apparently com-plete removal, recurrence took place in the inguinal glandsfive months after operation.-Dr. HEYWOOD SMITH saidthat in his case, referred to in the paper, the tumourwas of enormous size (47 lb. ), and prevented the patientfrom moving freely about. The adhesions to the abdominalwall were very strong, so that he had to leave a pieceof the cyst wall the size of a dinner plate attachedto the inside of the abdomen.-The PRESIDENT saidthat it must be remembered that people of eightyyears and upwards were selected cases ; they had out-lived their contemporaries, and might be expected to beunusually sound. Dr. Remfry’s paper illustrated the factthat cases which would not seem favourable often turnedout well, and that a selection of ovarian cases on a priorigrounds was unsatisfactory. The good results of operationfor ovarian tumour with pregnancy illustrated the same

fact.-Dr. REMFRY, in reply, said that the mental conditionof the patient with epithelioma was perfectly satisfactoryduring her stay in hospital, except during convalescence,when she was irritable and difficult to manage for three orfour days. There had been no recurrence of the epithe-lioma, which was excised in August, 1894. It was alwaysnecessary to verify a patient’s age by obtaining if possiblethe birth certificate. He considered that after ovariotomyin old women nutrient enemata should be administered inorder to prevent shock.The following specimens were shown :—

Dr. CULLINGWORTH: (1) Embryo and Clot from a TubalAbortion ; (2) Diff use Uterine Myoma.Dr. DUNCAN: (1) Myoma undergoing Myxomatous De-

generation removed by Hysterectomy; (2) Œdematous

Myoma removed by Hysterectomy ; (3) Double Tabo-ovarianCysts; (4) Dilated Tubes and Cystic Ovaries (early stage oftubo-ovarian cysts).Dr. LEWERS: Tubal Gestation of Three Months operated

on before Rupture.

VEST LONDON MEDICO-CHIRURGICALSOCIETY.

Treatment of Empyema in Children.-Secondary Malignant Ibtsease oj the Lung or Pleura. A MEETING of this society was held on April 5th, the

President, Dr. BANNING, being in the chair.Dr. COUTTS read a paper on the Treatment of Empyema in !,

Ohildren. He considered that there was a chance of cure byaspiration in cases with small cavities that are recognised intheir early stages. If there were no improvement after twoaspirations he thought that the method was inadvisable.Statistics were given of twenty-seven cases treated by simpleincision, and of sixty-one cases treated by rib resection. Not-withstanding the unfavourable results of the former as

compared with the latter, Dr. Coutts thought it should betried in the more debilitated cases. After opening the chesthe advocated washing out not only in cases with offensivedischarge but in those of large dimensions with hightemperature. He gave statistics of forty-three cases ofempyema in children under the age of two years with twenty-seven deaths. Empyema is in itself so fatal at an early agethat the responsibility for the high mortality does not rest onone operation or another. Although here again the statisticswere favourable to the method of rib resection, Dr. Couttswas, on the whole, inclined to the opinion that simpleincision was preferable in these infants.-Dr. MAY referredto the treatment of empyema after operation by immersingthe patient in a warm bath.-Mr. BIDWELL mentioned that hehad known caries of rib to follow resection for empyema inchildren, and therefore he was inclined to recommend simpleincision in any case where the pus was not fetid; he thought,too, that the patient’s stay in hospital was shorter after

simple incision than after resection of rib. Washing out wasonly employed when the pus was offensive, and in childrenhe bad found a warm bath of bichloride of mercury (1 in10,000) very satisfactory. He had treated two cases bywashing out combined with immediate closure of the wound ; ;in one case the result was satisfactory after a second opera-tion, and in the other resection of rib was subsequentlyrequired.-Dr. COUTTS replied.

Mr. STEPHEN PAGET read notes of three cases of SecondaryMalignant Disease of the Lung or Pleura. Case 1 : Earlystage of cancer of the pleura, secondary to cancer of thebreast, with a note on the removal of the whole mammarygland without removal of the nipple. Case 2: Advancedcancer of the pleura with pleural effusion, secondary to cancerof the breast, with a note on the value of repeated aspirationin such cases, and on the sudden sleep that sometimes followsthe sudden return of the lungs to their natural action.Case 3: Huge sarcoma of the lung secondary to subperi-osteal sarcoma of the femur, with a note on the possibilityof making a diagnosis in this case between a solidgrowth and an effuaion ; and on the influence, if any,of amputation at the hip-joint in preventing recurrence

of the disease in these cases, the value of the inhala-tion of oxygen, and the use of Dr. Coley’s erysipelastoxin. He said that the cases showed the value of a medicalopinion in a surgical case, and of a surgical opinion in amedical case. They also raised important questions as to thediagnosis of these cases, and as to their treatment, both pre-ventive and palliative.-Mr. MACADAM ECCLES pointed outthe frequency with which recurrence occurred above the lineof incision after amputation of the breast for cancer. Withregard to the utility of amputation at the hip-joint forsarcoma of the thigh, he referred to two cases which werefree from recurrence two and a half years after operation.-Mr. BIDWELL deprecated the practice of leaving the nipplewhen amputating the breast for cancer ; he also advocatedthe complete removal of the pectoral muscle in all caseswhere the growth invaded the muscle.-Mr. PAGET replied.

NOTTINGHAM MEDICO-CHIRURGICALSOCIETY.

Three Cases of Laryngeal Paralysis. - Graves’ Disease.Three Cases of La Chronic Pharyngitis.A MEETING of this society was held on March 20th, Dr.

J. S. TEW, President, being in the chair.Mr. GRAY read a paper for Mr. STEWART and himself on

Three Cases of Laryngeal Paralysis, They divided laryngealparalysis into : (1) neuropathic paralysis-(a) from centrallesions, (b) from lesions of the superior laryngeal nerve, and(e) from lesions of the recurrent laryngeal nerve ; and (2) myo-pathic paralysis. They illustrated this division by cases ofparalysis of the superior and recurrent laryngeal nervesrespectively and also a case of bilateral abductor palsy,which they claimed for the myopathic variety. - Theyalso read a short communication on the Surgical Treat-ment of Graves’ Disease, with some Considerations on

its Pathology. They narrated two cases of Graves’ diseasefor which isthmoidectomy had been performed, with veryrapid improvement in the patients’ symptoms. They discussedthe alternative operation of removing half the gland with theisthmus, and claimed for isthmoidectomy equal efficacy andmuch less risk. Referring to the pathology ot Graves’ diseasethey passed in review the various theories laid down andarrived at the conclusion that the theory that answered allthe facts best was the one which held that Graves’ diseaseis a primary disease of the thyroid gland, and that thesymptoms are due to a hyperplasia with exaggeratedfunctions of the gland-in short, to hyperthyrea, justas those of myxoedema are now universally agreed tobe due to the opposite condition of the thyroid, athyrea.They gave all the arguments for this view-especiallythe appearances seen microscopically in the gland (assummarised by Professor Greenfield in the BradshaweLecture of 1893) - the known symptoms of overdoseof any of the thyroid preparations and the result ofoperations.Mr. MACKIE read a paper on Chronic Pharyngitis and

claimed that in the causation and maintenance of this con-dition the gouty and rheumatic diathesis was in the majorityof cases the most prominent factor,-The President. Misa