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CLINICAL SOCIETY OF LONDON.

CLINICAL SOCIETY OF LONDON.

574 of two portions, the larger of which involving the whole aortic arch, was globular in shape, and compressing the trachea, oesophagus, right v...

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574 of two portions, the larger of which involving the whole aortic arch,

was

globular

in

shape,

and compressing the trachea, oesophagus, right vagus nerve, which was stretched over it, and the descending cava, which was, however, pervious. The gullet and trachea were displaced to the left. This portion of the aneurism had eroded the sternum and formed the tumour observed during life; it was nearly entirely filled up by laminated clot. Immediately succeeding this, and separated from it by a constriction, was the smaller portion of the aneurism, involving the upper part of the descending aorta, which had compressed the bronchus almost to occlusion, and had ruptured into the tube. Dr. Irvine remarked that had the aneurism been limited to the descending aorta the symptoms during life would have been wholly ascribed to changes in the lung, which, from the compression of its brouchus, was riddled with abscesses. He referred to a somewhat parallel case recorded by Dr. Burney Yeo in the last volume of the Society’s Transactions, where, as here, death was occasioned by a posterior aneurism, one on the ascending aorta being also present and alone diagnosed. He contended that the pulmonary disorganisation must have been due to the pressure on the bronchus, and not on the nerves in the root of the lung. Mr. BuTLIN showed a specimen of Scirrhus Cancer of the Bladder, remarkable on account of its rarity, and by its infiltrating uniformly all the coats of the viscus, causing gradual diminution of the size of the organ, and rendering it unable to admit either of contraction or dilatation. The late Mr. Travers, in his paper on Cancer of the Bladder, states that he bad never seen an instance of scirrhus disease ; and Gross, of Philadelphia, has only met with one case in the course of twenty-five years. A specimen exhibited by Dr. Bastian at the Society, and reported on by Dr. Cayley and Mr. Hulke, appeared to be of this nature. The bladder now shown was extremely hard ; it was adherent to the surrounding tissues, and the growth had infiltrated the os pubis. Internally it was inflamed and sloughing. There was suppurative nephritis of the left side. Microscopically it proved to be typical scirrhus, and Mr. Butlin sent round drawings ofsections taken from various parts. He remarked that the absence of a tumour in the viscus was not uncommon when scirrhus invades hollow organs, infiltration and thickening of the walls being the chief features. The patient was a man, forty-five years of age, who at first exhibited only the haematuria common to all forms of vesical cancer ; but during the last four or five weeks he was unable either to bold his water or to pass any quantity at a time. In reply to Dr. Coupland, Mr. Butlin added that the prostate was healthy, the disease of the bladder being primary with secondary infiltration of lymphatic glands, peritoneum, and liver. Dr. F. ROBINSON brought forward a recent specimen of a Lung from a case of fatal haemoptysis, the subject being a soldier, twenty-nine years of age. Both lungs were studded with tubercle in various stages, and at the apex of one of them were two vomicse, the size of walnuts, and filled with blood-clot. Although the patient had contracted syphilis, there was no indication of gummata &c. in any organ, and Dr. Robinson questioned the statement in some quarters as to syphilis playing a main part in the production of phthisis.-Dr. POWELL suggesting that specimens such as this should be referred to a committee for investigation, in order, if possible, to arrive at a definite conclusion as to the existence of a special syphilitic phthisis," Dr. EoBiNSON said that he did not bring the specimen forward as a case of syphilitic lung-disease; and Dr. MURCHISON pointed out that in no other organ of the body was there any indication of the effects of constitutional syphilis. Dr. GOODHART exhibited two specimens of Tumour of the Lip containing Cartilage, one of which contained also osseous material and fibro-cellular growth, the other myxomatous and yellow elastic tissue. He referred to two other instances in which a tumour in the lip was made up of adipose and of fibrous tissue, and did not consider that the term applied to them by Sir James Paget-namely, "labio-glandular"correctly described their structure, which was that of a connective-tissue growth, containing hardly any glandular tissue. The vicinity of glands was a likely place for the development of such tumours; and he instanced the similarity between the present specimens and those from the parotid gland.-Mr. HULKE did not think these growths were so very uncommon, although they seldom attained H

such a size as to require removal. They are so frequently met with in the neighbourhood of the muciparous glands on the inner surface of the lip that he was disposed to agree with Sir James Paget in regard to their nomenclature. He had examined several, and believed them in their early stage to be myxomatous, later cartilaginous, sometimes with Mr. BuTLIN contended that the specks of ossification. small amount of glandular tissue found in these growths afforded no argument against their origin within the glands, but was in favour of it, judging from the analogy of mammary and parotid tumours. As the connective tissue of these growths increases the gland-elements disappear, and in the case of mammary tumours a recurrent nodule may have no glandular tissue in it at all.-Dr. GOODHART quite admitted that such tumours may grow in the midst of the gland, but from the connective tissue, and not the secreting structure. If the tumours were principally glandular, the gland-tissue would be likely to surpass the connective tissue in amount. Mr. HULKE did not mean that gland-tissue could be transformed into myxomatous tissue, but that all glands contained a certain amount of connective tissue, which in these cases was probably the starting-point of the growth. Dr. GREENFIELD referred to a case of a similar tumour in the neighbourhood of the parotid, in which undoubtedly a new formation of glandular tissue had taken place. It seemed as if in the neighbourhood of glands there was a tendency to develop into myxomatous and then into cartilaginous tissue. Quite recently he had met with a glandular tumour of the testis which had recurred as such. Mr. BARKER related a case of Popliteal Aneurism, and exhibited a preparation of the aorta and great vessels which was remarkable for the symmetrical disposition of endarteritic patches on the two sides. The aorta was almost wholly free from disease, but raised patches of translucent material occurred on the posterior wall of the right common iliac artery, on each external iliac trunk as it passes over the pubic bone, and throughout the femoral artery; and in the popliteal the lesions were on the anterior wall, the left vessel being the seat of a small aneurism blocked by clot. The change in the lining membrane of the vessels disappearcd in the tibiala of each side at about the same level. Mr. Barker considered the specimen to show the existence -

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of another factor in the production of these inflammatory changes (which in no part had yet become atheromatous)viz., the friction orjarringof thevessel against hard structures. It was curious that the left common iliac artery, which, unlike the right, is not supported by the lumbar vertebra, should have escaped these changes. He thought he had seen atheroma of the basilar artery limited to the under surface of the vessel ; and he remarked upon the frequent occurrence of aneurism in situations where arteries are applied to bone. The tibial arteries are rarely the seat of aneurism, and it would be interesting to know whether aneurism of the right or left common iliac was the more frequent,-Mr. MORRis remarked that in this specimen the aorta, which in its whole length pulsates against the vertebral column, was quite free from disease. The occurrence of popliteal aneurism was much more easily explained by the strain thrown on the artery in the movement of the joint.-Dr. CRISP could not accept Mr. Barker’s hypothesis without further evidence.-Mr. HULKE pointed out that if a flexible tube be bent, the strain is greatest upon the convex side of the bend. The Society then adjourned.

CLINICAL SOCIETY OF LONDON. THE first meeting of the Clinical Society for the present session took place on Friday, the 13th inst., and there was a very good attendance of the members, the surgical element being the most strongly represented. In the absence of the President, the chair was occupied by Mr. Bryant. It was announced that the volume of the Transactions for the past session was nearly ready. The greater part of the meeting was occupied by the relation of an interesting case of intestinal obstruction and the discussion thereon, which elicited very diverse experience on important diagnostic points. Dr. WOLSTON read the notes of a " Case of Intestinal which occurred under his care, Mr. Maunder

some

Obstruction "

575 with him in the treatment of ealthy, and only the lower portions of the bowel had It illustrated, the author observed, the great become emptied. The lungs and brain were not examined. that surgical interference would only difficulty of diagnosis in such cases and how little the have accelerated theany fatal issue, There was no great course of symptoms might point to the cause of the occlusion of the bowel. The patient was a young lady, twenty-five the existence of tuberculosis. In conclusion, the authors years of age, who, up to the time of her attack, had been in inquired whether there were any elements in the case robust health. She was mentally deficient, but fully capable which might have led to a diagnosis of the cause of the of expressing her feelings, and had no lack of sensibility. obstruction, and whether there were any grounds for a cause.-Mr. MAUNDER who The only point in her history which seemed important was belief that was associated with Dr. Wolston in bringing forward the that when ten years of age she suffered from pain in the left case observed that it was a further illustration of the hypochondrium, occurring paroxysmally, which lasted for difficulty of diagnosis attending abdominal disease. He did some time. There had been no complaint, however, for ten not at any time think operation desirable-the patient seemed too well for it. Doubtless, had she not been years past, though she had stooped and limped ever since the time of the pain. The illness commenced on Feb. 20th imbecile, the symptoms might have given a clearer idea of the nature of the disease.—Dr. HILTON F AGGE stated that, with headache, sickness, and slight pain in the bowels; searched the records of Gay’s Hospital, he the bowels were confined at the time. She continued to could find no case on record where tubercular peritonitis suffer from constipation, loss of appetite, slight vomiting, was the cause of intestinal obstruction; the case in that and some pain until March 3rd, when Dr. Wolston was respect seemed to him unique. But he could not agree with called to her, and she was said to be suffering from a slight the authors that the diagnosis was so impossible as it seemed to be regarded, and the symptoms as recorded attack of gastric fever. When seen, the tongue was coated ; would, he believed, have justified a different diagnosis. face apathetic; some fever; urine thick. The abdomen was Indeed, they would have led him to the opinion that the tympanitic; no tumour could be felt; there was no pain or case was one, not of intestinal obstruction properly so called, tenderness on pressure. The bowels had been slightly but of something affecting the general peritoneal surface moved the day before, and there was no sickness that day; and causing constriction at several points. He referred to his paper on the subject in the Guy’sHospital Reports, no headache; temperature 99.5° F.; pulse 80. Copious in which he described a group of cases in which several enemata and fomentations to the abdomen were ordered. different parts of the bowels were affected, with no great On March 4th there was paroxysmal pain and in- obstruction at any one point. The characteristic feature of creased tympanites, but no tenderness. Another enema these cases is the gradual onset; in the cases of obstruction at one point the onset is usually sudden. His diagnosis was given of water with castor oil, and the bowels were freely opened, but great pain and sickness followed would, therefore, have been that of obstruction, either the injection. The pain continued, with frequent vomiting of the small intestine by chronic peritonitis, or enlarged through the night. Next day the vomit was stercoraceous ; mesenteric glands, or possibly tubercular disease, or else the abdomen very tympanitic. A long tube was passed, a chronic stricture of the large intestine. A question of and water injected, the operation being repeated several importance as regarded diagnosis was, were the peristaltic times. Nutrient enemata were also given. On March 7th movements observed when purgatives were not givenf A she was seen by Dr. Sutton, who thought there was con- characteristic feature of the form of obstruction under constriction by a twist or band, but did not consider operation sideration was the paroxysmal pain coming on at intervals advisable. On the 9th there was no pain or sickness, and apart from purgatives, and accompanied by perceptible periinversion and shaking were practised, but with no benefit. staltic action at certain parts of the bowels. Dr. SILVER The abdomen, however, became flattened below the um- referred to the-importance of attempting to relieve the disbilious. On the llth, the distension being considerable, it tension of the bowels in such cases, if only to give some rewas thought desirable to puncture the bowel by a small lief. He had employed with this object the aspirator needle trocar, to allow of the escape of flatus, which was done, but in cases of distension from malignant stricture at the juncwithout much relief. The patient was seen in the afternoon ture of the sigmoid flexure with the rectum, and also in by Mr. Maunder, who kneaded and manipulated the distension of the stomach from pyloric stricture, with great abdomen. But little change was observed during the next relief. Scarcely a trace of the entrance of the needle could ten days ; the pain continued pretty constantly, and a good be discovered after death.—Dr. SOUTHEY would have objected deal of flatus was passed, but the abdominal distension con- to the diagnosis made; but he had never seen an instance tinued considerable. On March 28th there was much sick- of obstruction due to tubercular peritonitis, though several ness, and emaciation had become very marked. Galvanism of complete obstruction from chronic peritonitis. His exwas applied over the abdominal parietes, and also with one perience as to the occurrence of peristalsis was just the pole on the tongue, the other at the anus, and was pro- reverse of Dr. Hilton Fagge’s.-Dr. BUZZARD inquired what ductive of free peristaltic action, but gave no relief. This was meant by the term "galvanism" in the report of the A large case.-Dr. COUPLAND inquired whether in any case of puncwas repeated several times a day until the 30th. dose of watery extract of aloes was given at Mr. Maunder’s ture of the intestines any oozing of faeces had been observed. suggestion, and caused a motion, but also much pain. On In experiments on the dead body he had found that the April 1st the condition was much the same. On April 10th openings remained patent.-Dr. SILVER had seen in one there was great weakness, constant sickness, and a good case, where the distension was great, some escape of faeces. deal of flatus passed. On the 14th, after kneading the -Mr. FURNEAUX JORDAN observed that there were some bowels, and giving an enema, a large dark stool of very symptoms of cerebral disease, and suggested that tuberoffensive fæces was passed. The distension of the abdomen cular disease of the brain might give rise to obstruction Mr. GEORGE diminished, but there was still much vomiting and pain. of the bowels, which was not complete. On the 16th a strange look of the eyes was observed, BROWN thought the question of peristalsis one which the face was red, and on the 19th there was slight should be discussed. He agreed with Dr. Southey as to the strabismus. Death occurred suddenly and unexpectedly; greater liability to peristaltic movement when there was it was ushered in by convulsive movements in the not chronic peritonitis, in which the muscular tone must right hand and strabismus, breathing became difficult, be diminished and reflex movements less readily excited.and death occurred in about an hour, without any Dr. SOUTHEY added that the cases in which peristalsis was general convulsion or loss of£ consciousness. At the most marked in his experience were those of cancerous post-mortem, the peritoneal surface of the intestines was stricture of the colon; where least, those of chronic perifound to be covered with tubercular granulations resembling tonitis. Mr. BRYANT had had some experience in tapping grains of boiled sago and yellowish-white nodular masses, the intestine for distension. In two cases which he rethickly scattered over their surface, the intestines matted called fseoal extravasation resulted: one a case of great together, and in places held down by puckered fibrous- tympanites in a man with compound fracture of the leg; the looking adhesions apparently of old date. The bowels were other a case of sloughing umbilical hernia. Both patients tightly contracted in some places, but there was no sign of died within a few hours of the punctures, which were done recent inflammatory action. The mucous membrane was merely to give temporary relief ;and in both cases there

being subsequently associated the

case.

It was evident

emaciation, andnothinginthe general condition tosuggest tuberculosis was the

having carefully

seemed to believed, have and the symptomsdiagnosis.

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576 fseoa.1 extravasation at the seat of some of the punctures. This indicated a necessity for caution. He was not aware that tubercular peritonitis was so rare a cause of intestinal obstruction ; but, at any rate, in this case there were none of the features either of a sudden occlusion by band or stricture, or of a chronic stricture of the colon. The symptoms were those of marked chronic disease affecting the small intestines. He agreed with Dr. Southey, as to the occurrence of peristalsis, that it was most marked in chronic contraction near the lower end of the small or in the large bowel, and also in the early stages of acute obstruction, where, however, it was soon paralysed. In only two cases of chronic peritonitis had he seen the same ; both were cases complicated with abdominal tumour, and here the peristalsis was limited to certain parts of the abdoDr. men, where it was readily excited by slight pressure. WOLSTON expressed his willingness to submit to correction of the diagnosis, but pointed out that the absence of tenderAs ness was opposed to the view of tubercular peritonitis. regarded peristalsis, there was no appearance of peristaltic action, except on rubbing the abdomen with castor oil or on galvanising it. The puncture was performed to give relief ; it gave little, and was not repeated; and it was evident from the post-mortem that but little good could have been done unless by very numerous punctures at different points. The " galvanism" was a rotatory magnetoelectric machine. Mr. MAUNDER gave an account of the sequel of a case of Gastro-enterotomy related by himself and Mr. Gordon Brown in the previous session. (See THE LANCET, 18th March, p. 425.) The operation was performed in November, 1875, and in March the patient, who was sixty-eight years of age, was in fair general health. The abdominal tumours, however, increased in size, and hiccough occurred. The artificial anus continued healthy. To avoid inconvenience the patient was advised to have an enema of half-a-pint of water daily, which answered perfectly. A sponge tent was worn in the aperture as a plug. The patient died from exhaustion seven months after the operation. A postmortem was obstinately refused by the friends. The operation had only been performed successfully three times in the country-once by his colleague, Mr. McCarthy, once by Mr. Wagstaffe at St. Thomas’s, and by himself.-Dr. CouPLAND inquired whether Mr. Maunder knew what part of the intestine was opened in his case. He mentioned that in examining one body he found that the jejunum would have been opened; had this occurred nutrition would have been greatly interfered with.-Dr. GREENFIELD said that he had been led by Mr. Maunder’s case to make some investigations as to the part of the intestine usually found in the situation recommended by Trousseau for the operation, and adopted by Mr. Maunder-viz., a little below the midpoint of a line drawn from the umbilicus to the right anterior superior iliac spine. He had examined a number of bodies, in many of which there was distension of the bowels from various causes, by making an incision at the point named, and seizing the protruding bowel, before the contents of the abdomen were disturbed. In at least four or five cases the csecum was opened, in one the sigmoid flexure, and in one the small intestine, more than eight feet above the ileo-cseoal valve. He could not at the moment give exact statistics. These facts showed, however, that Trousseau’s statement could not be accepted as of universal application. Still, the operation was none the less valuable, resting, as it did, upon the fact that distended bowel-i.e., bowel above the seat of stricture-would be opened, and no other situation could be selected for incision more favourable, or more likely to open the intestine as low as possible.-Mr. MAUNDER said that Mr. McCarthy had similarly examined between sixty and seventy bodies, and had told him that in a very large majority of cases the ileum was opened near the ileo-cseoal valve.-Mr. HEATH inquired whether the patients in the other two cases were still living.—Mr. WAGSTAFFE said that his case was still alive. Mr. TEEVAN related a case of Traumatic Stricture, with The numerous fistulæ, cured by Internal Urethrotomy. patient, who had been a sailor, in 1854, whilst engaged in the rigging, slipped and fell astride a spar, causing rupture of the urethra, displayed by the usual symptoms, and followed by extravasation of urine. Three years later abscesses formed around the urethra. When seen by Mr. Teevan there was great thickening of the corpus spongiosum;

was

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the scrotum

were marks of sixteen The fistulae were treated and bougies tried to dilate the at first by caustics &c., stricture; but all these measures failing, internal urethrotomy was performed, and with complete success. Mr. Teevan insisted on the following points in the case as of First, that the stricture was traumatic; importance : secondly, that it had lasted for twenty-one years ; thirdly, that the fistulae were penile, and therefore difficult to close ; fourthly, that three different methods, drawing off the water, cauterisation, &c., had been tried without success ; and, fifthly, that all were cured by Otis’s method, on the principle of making the passage normally free. He insisted also upon the fact that a catheter was not leftin the bladder after the operation.-Mr. HEATH said that the case appeared to him to be one of very ordinary nature, and the treatment in no respect differed in principle from that taught at every modern medical school. If the stricture is dilated the case gets well. If it had been cut into, split, or dilated, the wound would have healed. He thought that causticpointed probes were exploded long ago, and as to keeping a catheter in the bladder it was against the teaching at every general hospital. Dr. Gouley, who had strongly advocated the practice of not keeping it in, thought he had made a discovery, but it was really no discovery at all, as it was was

puckered;

there

fistulae, five of which were patent.

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Mr. MAUNDER remarked that Mr. very interesting, but the treatment not novel, except that Otis’s operation was used. The object was to dilate the urethra to a greater degree than was thought needful or practised in England. As to the keeping in of a catheter, it should only be kept in when haemorrhage was dreaded; he had never had reason to keep it in after a splitting operation. -Mr. TEEVAN still thought sixteen nstulse a rare number, and he did not know of a case where five were open. Dilatation was carried as far as No. !} without success. He thought, too, that English surgical works advocated leaving a catheter in the bladder. He inquired what Mr. Heath would have done in such a case.Mr. HEATH said he should have passed a Holt’s dilator, and split to the full size. Cases of four, five, or six 6stu!M were not uncommon. He did not speak of the statements of books, but of the practice in general hospitals. A report of a case of Hydatid Tumour of the Orbit, by Mr. Higgens, was read by the Secretary. The patient, a girl, aged fourteen, who had always been delicate, came to Guy’s Hospital, having for a month had pain in the right eyeball, which had then begun to protrude. It was pushed downwards and forwards, but the lids could be easily closed. Movement of the eyeball upwards was impossible, but other movements were perfect. There was diplopia when vision The optic was directed upwards; the eye read Snellen 10. disc was red, greatly swollen, and bulging into the vitreous; the retinal veins were large and tortuous, and their visible number was greatly increased. The arteries were of about the normal calibre. There was no pulsation in or about the orbit, and no bruit could be detected; but there was some fulness deep in the orbit beneath its roof. It was thought there was a growth situated between the globe and the superior rectus muscle, passing backwards, and involving the optic nerve. Twelve days after being first seen the eye became inflamed and paintul; there was swelling of the upper lid, oedema, of the conjunctiva, and increased impairmentof mobility of the globe. There were no rigors and no constitutional disturbance. An abscess of the orbit being suspected, an incision was made through the conjunctiva beneath upper lid, and a director passed backwards came against a firm substance at the back of the orbit, which was incised, and blood only escaped. A fortnight subsequently the protrusion was increasing. An incision was then made through the soft parts in a line parallel with the upper border of the orbit. The lachrymal gland was found pushed forward and was removed. Behind it was a firm growth, which was torn away with the fingers and the handle of the scalpel. The growth collapsed, and was then found to extend to the apex of the orbit and to be closely connected with the optic nerve, whence it was scraped away. It was an extremely thick-walled cyst, composed of inflammatory tissue, inside which was a thin pellucid cyst, which separated easily, and which the microscope demonstrated to be made up of a delicate membrane presenting an appearance of serrated fibres. The contents of the cyst had escaped, no hooklets nor daughter cyst were

practised everywhere. Teevan’s

case was

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577 associated with a high fceta.1 mortality, and had advocated an increased frequency of forceps operations as calration, the wound was stitched up and the edges of the lids culated to lessen the fcetal deaths. He had then alluded to were pared and united so as to prevent subsequent damage the remarkable results ot Dr. Hamilton, of Falkirk, who had to the eyeball from exposure. Some suppuration occurred two successive series of cases of 800 and 700 without a single at the site of the wound, but the patient made a good reco- still-birth. He himself (Dr. Playfair) had attended nearly In very. A month after the operation, the eye was found to 300 consecutive cases without losing a single child. deviate downwards; there was no mobility upwards ; the Mr. Godson’s practice forceps were used once in 66 cases, lid could be raised to a very limited extent. The patient and in the other once in 9, and yet in both almost one out read Snellen 2a easily; she had double vision when attempt- of every 20 children were still-born. He would ask the exing to look upwards. There was a plentiful secretion of planation of this.-Dr. BICKS, in reference to an allusion as moisture, notwithstanding the absence of the lachrymal to hospital statistics not being so reliable as those of private gland. The swelling of the optic disc had quite subsided, practice, stated that at Guy’s patients were under observabut there was some haziness of its inner border. The retinal tion for a month after the confinement, and that the deathvessels were quite normal. rate could be relied upon. It varied between 2 and 7 per thousand. Before we could fairly estimate the death-rate from forceps we must first ascertain how frequently ergot had been given.-Dr. CHALMERS thought Dr. Hamilton’s statistics OBSTETRICAL SOCIETY OF LONDON. were quite as likely to require explanation as Dr. Godson’s. AT the first meeting of this Society, October 4th, 1876, He doubted the accuracy of so low a rate of mortality as Dr. ROPER remarked Alfred Meadows, M.D., F.R.C.P., Vice-President, in the Dr. Hamilton’s statistics gave. the foetal mortality might be diminished, the that, although chair, Dr. WILTSHIRE showed a specimen of Utero-Vaginal maternal mortality was probably increased from the freRupture, removed post mortem from a patient who had quent resort to forceps. Dr. ROUTH stated that he had died during labour. A fibroid tumour the size of a large gone closely into the question as regards operative midorange had interfered with the progress of labour. The wifery among the London poor and those of the manufacdistricts. Long forceps were more frequently used rupture occurred at the junction of the cervix uteri with turing on account of deformities of the pelvis, and in these cases rewere the vagina posteriorly. The walls of the uterus the risk to both mother and child was increased. Dr. Playmarkably thick. Ergot had been given.-Dr. PLAYFAIR fair stated that we are justified in using them once in five inquired why the forceps had not been applied. A large cases. The late Professor Simpson had shown that the proportion of cases of rupture followed the use of ergot. An mortality during childbirth was greater in proportion to the of hours women were left in labour.-Dr. PLATFAIR early application of forceps might have averted the catas- number observed that he had not said that he himself advocated so trophe. He would further ask why gastrotomy was not frequent an application of the forceps. He would strongly performed when the child had escaped into the abdomen. insist upon the importance of distinguishing between the It would have given the patient a better chance of recovery. high and low forceps operations. The former he considered - Dr. BRAXTON HicES inquired as to the size of the os uteri, to be a serious matter, not to be lightly undertaken, nor and where it was at the time of rupture. If the cervix were without grave risk to the mother. His remarks applied drawn over the head, how was it that the child escaped solely to the low forceps operation, when the head was on the perineum, and merely delayed by the want of vis a tergo. into the peritoneum ?-Dr. AvELING inquired how soon after Under such circumstances the operation was perfectly easy, death the post-mortem had been made. Sometimes dis- quite safe, and highly conservative both to the mother and placement occurred from the effect of decomposition after child-far better than giving ergot. Mr. GODSON said, death.-Dr. MEADOWS suggested that possibly the tumour when he commenced practice operative midwifery was looked had been mistaken for the head, the former being so large upon by the public in a very different light from what it as to interfere with the descent of the head.-Dr. ROPER was now. Had he used the forceps often, he would soon asked as to the relation of the tumour to the rupture.-Dr. have had no midwifery practice at all. He never applied WILTSHIRE thought that the accident would possibly have forceps so long as there was a prospect of labour being been averted if forceps had been used, but there were ob- completed naturally, without injury to either mother or jections to their employment in this case, which altogether child.He believed that the large number of premature was a very painful one. births accounted in a great measure for the still-births. Dr. DALY related the particulars of a case of Intra-Uterine Had forceps been more frequently resorted to, the mortality Tumour, where death ensued two hours after removal. The would probably have only been very slightly diminished. Dr. A. L. GALABIN related the histories of two cases of patient had been confined six weeks. Violent and continued pain set in. A tumour was detected, and enucleation at- Pregnancy complicated by extensive Malignant Disease of tempted by the fingers. Rupture of the uterus ensued; the Cervix Uteri. In the first haemorrhage at irregular there was no hæmorrhage; but the patient died from shock intervals had taken place during the whole term of pregtwo hours afterwards. Rupture seemed due to softening of nancy. Labour came on at full term; the cervix was dilated the uterus.-Dr. H. SMITH inquired whether any incision by Barnes’s bags. Perforation was then resorted to, and the had been made across the face of the tumour before enuclea- head extracted by the cephalotribe. The patient recovered; resulted from sloughing. a vesico-vaginal fistula The tion was attempted.-Dr. DALY replied in the negative. Dr. BANTOCK exhibited a specimen of a Two-headed second case was interesting also, inasmuch as amputation Monster, where the bodies were united from the breast. of the cervix by the galvano-caustic was resorted to five downwards. There were but two legs, with a third rudi- months after labour, the patient then being four weeks mentary one.-Dr. MEADOWS suggested that it would be well pregnant. She carried the child to full term, when dilatation of the cervix was effected, and bipolar version perto present it to the museum. Dr. CLEMENT GODSON contributed a paper entitled, formed, and the child extracted living. Peritonitis set in, "Midwifery Statistics of Thirty-five years’ Practice," com- but the patient recovered. The two cases showed that piled from the records of his father’s practice in Barnet, delivery might sometimes be effected by the natural passincluding the wealthy and the poorest. The results were ages, when, at first sight, Caesarean section seemed the only shown in tables drawn up indicating the percentage of resource.-Dr. MEADQws thought, as a rule, it was better ordinary normal presentations, placental and compound. to resort to Caesarean section, as, although in these two cases In the single practice of Mr. Godson there were 2203 de- the patients fortunately recovered, the maternal risk was liveries, and in the compound practice of himself and a so great, and there was an almost uniform death of the partner 1020. The records were kept separate so as to child, when delivery was attempted per vias naturales. In compare the results of the combined and single practice, the first case the dilating bags changed the position of the forceps having been applied more frequently of late years. presenting head. This fact he had noticed in another case, The maternal mortality amounted only to 8 in the 3223 and it would be interesting to know the experience of cases. The percentage of still-born children was slightly others on this point.-Dr. GoDSON thought the first case over 5 per cent.-Dr. PLAYFAIR remarked that he had confirmed the opinion he had previously stated, as to the of amputating the cervix uteri in cases of recently pointed out that a low ratio of forceps operations

found. The whole tumour was nearly as large as the eye. ball, but its central cavity was very small. After the ope-

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