220

been emptied for some hours, and was probably distended.He could not tell us if he had passed urine since, nor wasthere anyone who knew ; however, the introduction of acatheter showed that the bladder was intact. Free heemor-

rhage into the peritoneum without external wound aftertraumatism is most likely dependent upon laceration of theliver, and such lacerations, especially if of small size, arevery difficult to diagnose, sometimes indeed impossible.Rupture of a healthy spleen is almost unknown at thisage. Laceration of the mesentery suggested itself, or

laceration of the omentum, and of these the former is themore likely to tear. There was a complete absence ofsymptoms of ruptured liver or spleen, and the small amountof abdominal pain, the slight vomiting, and the absenceof rigidity of the abdominal wall made me regard the caseas probably one of slight rupture of the mesentery withoutinjury to the intestine. Abdominal section should, I think,be performed if the shock from which the patient is

suffering is considerable and the amount of blood in the

peritoneum large, or if the shock, whatever its degree, is

increasing in spite of the employment of the usualremedies, and continued escape of blood into the peri-toneum is taking place. When there is no evidencethat the source of the blood is a rupture of one

of the viscera, it is permissible to make a longerdelay. Here, also, there should be distinct evidence ofincreasinq effusion, and it is got always necessary to searchfor the Meeaicer point, although it is desirable that such shouldbe secured if found easily. It is not easy to measure theamount of fluid in the peritoneal cavity and its rate ofincrease unless the patient be examined always on the side.In this position the pelvis is emptied to a great extent, andit is easy to mark the line of advancing dulness dueto the effusion on the abdominal wall and estimate therapidity of its escape from the lesion. It has on formeroccasions been pointed out that excessive shock should notbe considered as contraindicating operation, as by means ofsaline infusion the patient may be brought into a conditionfor the necessary procedures when it is a question of vital im-portance that the hsemorrhage should be arrested by surgicalmeans. I do not think that the question of operation is settledwhen the haemorrhage has stopped, though there is generallyrapid absorption of the effusion, for a quantity of blood in theperitoneum may cause inflammation from the changes whichensue. One of the first signs which may be called unfavourablewill then be a commencing distension of the abdomen, andthis should be regarded as an important indication for inter-ference. The constant desire of the boy to lie on the leftside was difficult of explanation, until the onset of the

pneumonia made it evident that there had been injury to theleft side of the chest in addition to the injury of theabdomen. There were no symptoms of laceration of the lungwhen he was admitted, but the presence of the hsemato-thorax and the later inflammatory attack make it evidentthat such must have occurred, although probably of limitedextent.

Medical Societies.ROYAL MEDICAL AND CHIRURGICAL

SOCIETY.

Varieties of Intestinal Obstruction dependent on Gall-stones,with a series of cases.

AN ordinary meeting of this society was held on Jan. 22nd,the President, Mr. HUTCHISON, F.R.S., being in the chair.

Mr. MAYO ROBSON read a paper on the Varieties of In-testinal Obstruction dependent on Gall-stones. He remarkedthat the usually accepted form of obstruction was only oneof four varieties of intestinal obstruction depending on gall-stones, which he proposed to classify as follows :-1. Theform dependent on local peritonitis in the region of thegall-bladder, leading to paralysis of the bowel. Twoillustrative cases were related, both of which yielded to

general treatment without operation. 2 Volvulus of thesmall intestine dependent either on the violence of the coliccaused by an attack of cholelithiasis or on the contortionsinduced by the passage of a large concretion through thesmall intestine. Two cases were related in which Mr. Robson

performed laparotomy and untwisted the volvulus, recoveryfollowing in each case. 3. Mechanical obstruction due to the

passage of a large concretion through the small intestine.Two instances were given in which enterotomy with removeof the concretion was followed by recovery. 4. Obstruction

depending on adhesions or on stricture, the result of pastgall-stone attacks, or of healing nstu]se. As this form was

specific only in the antecedent cause instances were only re-ferred to and not related, since cases of this kind could be morefully discussed in a paper dealing with the subject generally.Mr. Robson, in answer to questions addressed to members ofthe staff or to the registrars of a number of large metro-politan and provincial hospitals, had received communica-tions from institutions representing about 80,000 patients,and out of this number only four cases of intestinal obstruc-tion from gall-stones had been recorded during the pasttwelve months, proving that this form of obstruction is farfrom common, and all the four cases coming under thethird form described in his paper seem to prove that it isthe commonest.

Mr. ARBUTHNOT LANE, in connexion with the first classof cases, quoted an instance in which he had operated foracute intestinal obstruction in which he found the distendedgall-bladder pressing upon the colon and duodenum.

Mr. ARTHUR BARKER cited a case seen by him post mortemin which copious diarrhoea preceded for some time thevomiting which ushered in the fatal termination. Theobstruction was in the lower part of the ileum. and the casewas recorded in the Transactions of the Clinical Societyabout sixteen years ago. The only other case with which he-was familiar was one operated upon by Mr. Thomas Smith,who cut into the bowel and removed the stone, the

patient making an excellent recovery. He did not approveof needling the stone through the bowel wall, and con-

sidered that shyness about opening either the lareor small bowel was carried a great deal too far. Hethen recounted a case of volvulus, the cause of which wasobscure, upon which he had operated with a good result. He.had thought since that this might be due to gall-stones, ancaasked Mr. Robson whether in these cases he had met witheffusion into the peritoneal cavity, it being a point of greatpractical and pathological importance whether the bowelmight be so long twisted as to allow the passage of septicmatter through its walls.Mr. EDGAR WILLETT said that in the St, Bartholomew’s,

Hospital Museum there was preserved a gall-stone four inchesin circumference impacted in intestÍJae; also the suturedportion from which a stone had been removed in a patientwho subsequently died from a second obstruction. The

specimen showed excellent union along the line of suture.Mr. J. JACKSON CLARKE said that out of 800 post-mortem

examinations he could recall only one in which he had seen agall-stone impacted in the small intestine. It was two inche&long and half an inch across.

Mr. F. S. EVE referred to one case of gall-stone impactedin the large intestine in the Museum of the Royal College ofSurgeons of England, and suggested that some of the casescited might have recovered if left alone. He quoted 20 casescollected by Mr. Treves which had not been operated upon, ofwhich 6 recovered and 14 died. Of 26 cases which had beenoperated on 10 recovered and 16 died. Up to 1889. of 8 casesoperated upon 7 died ; whereas subsequently to that date, of18 cases operated upon 9 recovered, showing a very greatimprovement in recent years.

Mr. CROFT said cases of obstruction from gall stone werevery rare. His own observations had not led him to differfrom the opinion expressed.The PRESIDENT said he was disappointed that no attempt

had been made by Mr. Robson to collate the successful casesin recent years. For himself he would say that up to thepresent time one half the ca8es died after operation, and hedid not think the subject had advanced to the point at whichit could be said that "delay in such a case is criminal." ’Even in cases where death was threatening he thought thechances of recovery were about equal to those of a fata)issue if operation was decided against. In his own expe-rience of obstruction a large number of cases exhibitingvery severe symptoms improved spontaneously, and largegall-stones could be shown which had passed the bowel’without assistance. He quoted one case which en the’ninth day when apparently in extrentis was relieved bythe passage of the stone ; while one operated on undersimilar conditions died. Another objection to the rule infavour of operating in these cases was that in the hands of lessexperienced surgeons the mortality would probably be greatlyin excess of what it was at present. The third class of caseQ

221

he thought did not support the contention in favour ofoperating. There was one important class which had notbeen alluded to-viz., cases in which a gall-stone remainedfor months in the intestine, giving rise to repeated attacks ofobstruction. He mentioned two cases of this kind, both ofwhich recovered, passing the stone without assistance. Hefurther stated that he had never yet in the post-mortem roomseen a case where an impacted stone had caused death.3ir. iAyo ROBSON, in reply, said that the statement to which

the President had taken exception only applied to a particularinstance, and was not intended for a general rule. Thatdesperate cases of impaction did recover he freely admitted,bat thought that some cases which died might have beensaved if operated upon before tympanites appeared. Withregard to the second class, in which volvulus occurred,recovery was scarcely possible without operation. He thoughtthat statistics prior to the last two years could not be acceptedas giving any idea of results as they might be obtained now,and still iess as representing what he anticipated in the nearfuture. He quite agreed that were the operation performedby all surgeons as a routine treatment there might be anincreased mortality. In answer to Mr. Lane, he thoughtvolvulus was due to the violence of intestinal contractionwhen a large stone was passing or obstructing the bowel.He had operated on four cases, in two of which a stone wasobstructing the small intestine and was associated withEome peritoneal effusion.

HUNTERIAN SOCIETY.

The Operative Treatment of Perityphlitis.AN ordinary meeting of this society was held at the London

Institution on Jan. 9th, Mr. CHARTERS J. SYMONDS, Pre-sident, being in the chair.Mr. SYMONDS read a paper entitled "The Operative Treat-

ment of Perityphlitis." The paper was founded upontwenty-three cases which had come under his care for

surgical treatment. Questions of surgical import only weredealt with, and the important question, When should opera-tion be undertaken? llr. Symonds stated that the cases werenecessarily divided into two groups : (1) those in which

operation had been performed in the quiescent stage for

relapsing typhlitis, and (2) those in the acute suppuratingcondition. The first group included six cases. The followingare briefly the notes of each. Case A is reported in fullin the Clinical Society’s Transactions for 1885. The

patient bad had several attacks of colic during the sixmonths before the removal by operation of a calculusfrom a cavity outside the appendix. The peritoneal cavitywas not opened. Mr. Symonds now exhibited the calculusremoved in July, 1883, and stated his belief that this was thefirst case of perityphlitis operated upon in the quiescentstage, The calculus was composed of calcium phospbate andfaecal matter, and the question was whether such a calculuscould have formed in six months. In two other of thesix cases a calculus was also found on operation. In one,Case B, there had been symptoms of colic for two years.The calculus rested in a cavity outside the appendix andpresented a laminated appearance similar to that of Case A.In Case C a calculus of similar size and form was removed froma cavity in the iliac fossa. In this case the caecum was adhe-rent to the abdominal walls, and a faecal fistula resulted fromsloughing of ;the intestinal walls and still persisted. The

patient had suffered from typhoid fever one year and ent e-ritis three months before admission. Before operationthere was a small area of exquisite tenderness in thelower part of the right rectus muscle. The symptoms inthese three cases were of three, six, and twenty-four months’duration respectively from the first attack. Case D, a female,had had two attacks, the first twelve and the second twomonths before admission, with an ill-defined right iliacswelling and pain on walking. The abdomen was opened,the appendix removed, and perfect recovery resulted. Case E,a girl aged eight, had had a first attack five years ago, whenthree years of age. With quiet and care she had no secondattack till 1893. The patient came under Mr. Symonds’ carednring a third attack, when a tumour could be felt at thebrim of the pelvis. The appendix at the operation was foundto be hanging down into the pelvis and adherent to the rectum.It was removed, and the patient did well. Case F was astudent who had had two attacks and in whom at opera-tion a mass of white lymph was found adherent to the

iliacus muscle and to two coils of ileum. The appendix andomentum were removed, and recovery resulted. Thus in thesesix cases four had had two attacks, one bad had greatpain and inability to work after a first attack, and in onethe attacks had been frequent. Mr. Symonds would askthe questions-Ought we to operate after one attack, even ifsevere ? Ought we to advise operation after a second attack?And, thirdly, if in suppurating cases the appendix could notbe found, should the peritoneal cavity be opened if necessaryin order to find and remove the appendix ? 7 He next

detailed the method of closure of the divided appendix.Operation had been performed in fleventeen acute cases. Hestated it was important to estimate the initial severity. He-considered that if the attack was not very severe or verysudden the prognosis was good so long as the swelling con-tinued firm. Many cases recovered from the first and fromthe second attack. Mr. Symonds drew attention to thefact that the quantity of pus was in no way propor-tionate to the amount of swelling, and narrated one

of his cases where the swelling was enormous, reaching.above the umbilicus, and contained only one drachm of foulpus. The usual symptoms were sudden onset of pain, withor without sickness, or diarrhoea, with or without pain,with or without sickness, and with subsequent development oftumour. Case G, a female, experienced sudden pain in theright hypochondriac-and inguinal regions one month after con-finement. The temperature varied between 99" and 102° F.On the tenth day there was a well-defined swelling in theright inguinal region, with hectic symptoms. An incision,

yielded one ounce of pus, and an entire detached appendix,contained in a large cavity. Mr. Symonds said that five outof the twenty-three cases presented hectic temperature withanorexia and gradual development of the swelling. Of thesefive cases all but one recovered, and in that case the abscessruptured on the thirteenth day. This patient was at firstnot very acutely ill, but was suddenly taken with severe

pain and diarrhoea and collapse. Mr. Symonds advisedoperation where a tumour existed which continued to increasein spite of rest, and where the temperature rose and thetumour continued to increase in size. In another group ofcases there might be an abscess in an abnormal position.The notes were read of a case where, with violent abdominalpain and tenderness, there appeared on the fifth day a smalltender swelling in the cascal region, which was demonstrated.by operation to be an abscess between the ileum andcascum. He next referred to a fourth group of cases where,with abdominal distension and septic pyrexia, no tumour was.palpable. He pointed out the great value of the presence ofslight cedema over the loin as an indication of the presenceof deep-seated suppuration. In two cases a large abscesshad been completely masked by the abdominal tympanites.He therefore advised operation where the symptoms weresevere and persisted if the abdomen was tympanitic. As tothe justifiability of operation during the early stages of thedisease, Mr. Symonds pointed out that in two of his casesoperation had been performed twenty-two and twenty-ninehours after the onset of symptoms. In one purulent peri-tonitis was found and death resulted. The other was admittedinto hospital in a state of collapse, and operation revealed alocalised abscess, which was drained with good result. Mr.

Symonds considered that the danger of operation was muchincreased by the removal of the appendix when an abscessexisted. In none of his cases of abscess pas the appendixsearched for.

Mr. COTMAN asked the President to what extent be was inthe habit of prescribing opium in these cases, and stated hisopinion that opium merely masked the symptoms.

Dr. FORTESCUE Fox asked whether Mr. Symonds con-sidered it possible that a distended appendix might dis--

charge itself into the caecum and so the abscess be dis-

charged per anum, and narrated a case which supported this-hypothesis.

Dr. F. J. SMITH said he had never yet seen a calculus inan appendix vermiformis at all resembling the one shown.He considered that the sudden onset of abdominal pain with’vomiting and iliac tumour was an absolutely certain sign ofpus and compelled operation.

Sir HUGH BEEVOR said he had seen six cases wheresudden pain, vomiting, and tumour had all been present andthe patients were all living although no operation had been.performed. ,

Mr. SYMONDS said that in his opinion the less opium giventhe better. In a few cases he advised five grains of Dover’spowder to be taken three times daily. He could not explain