773NORTH LONDON MEDICAL AND CHIRURGICAL SOCIETY.

not for the saving of life, four points of view had to be con-sidered : (1) their necessity, (2) their safety, (3) theirefficiency, and (4) whether they left a patient less fitted forlife in other ways. The operations for the relief of symptomsdependent on retroflexion of the uterus with or without

adhesions, or on severe prolapsus uteri, which, though notdangerous to life, caused the patients to seek relief, were tobe classed as operations of expediency. A parallel was tobe found in the radical cure of non-strangulated hernia,removal of the vermiform appendix in recurrent appen-dicitis, osteotomy for deformities, and laparotomy for theremoval of adhesions in recurrent abdominal pains, allof which were sanctioned by professional opinion anddemanded by suffering humanity. 1. Necessity . -Afterall minor procedures had been tried and accidental

complications had been treated, when operation seemedlikely to give the desired relief, and the risks had beenexplained to the patient, it seemed to him that the necessityfor operation had been fully established. 2. Safety.-Thesixteen cases of ventro-fixation which he had performed hadgiven him no anxiety, and he thought that the experience ofothers would corroborate the view that when all proper pre-cautions were adopted there was practically no risk. At thesame time, the accidental complications which might attendany operation, however slight, had to be taken into account.3. Efficiency.-This was a point which the discussion shouldhelp to eztablish. There could be no doubt about theimmediate relief to pain and pelvic distress or as to thebeneficial effect on the patient’s general health in nearlyevery case ; but what they wanted to ascertain was, Didthe relief last, or was there a tendency to relapse ? 7 Theywould expect information also as to the influence on

subsequent pregnancies and the tendencies to abortion ; andwould wish to know whether after parturition there was aliability to resumption of the old displacement. His colleague,Dr. Braithwaite, had related to him one case in which abor-tion followed, but in which after the abortion the uterus wasin good position ; and a second case in which the patienthad a normal delivery at term. He could himself vouch forthe permanent beneficial effects on some of his patients, asshown by the complete restoration to health, the resumptionof marital relations previously impracticable on account ofdyspareunia, the loss of all pelvic discomfort, and theabsence of the necessity of further medical attention.4. Results.-The question whether the patient was left lessfitted for life was best answered by considering the possiblecomplications such as hernia or intestinal obstruction. A herniacould be prevented by proper care in suturing the abdominalwalls. Intestinal obstruction was a possibility, but so far nocase had been reported. There were two classes of operationto be considered: the extra-peritoneal, such as Alexander’soperation and its modifications, and the intra-peritoneal.Alexander’s operation, as modified by Kocher of Berne, wasvery satisfactory from an anatomical point of view, but hehad been disappointed with it in that when undertakenfor prolapse it generally required plastic operations inaddition, whilst in retroflexion with adherent appendages itwas useless, and in the absence of adhesions other procedureswere as efficient. He had performed the operation five timesand in only one case had been quite satisfied with it. Inthree cases the relief was only temporary, whilst he hadlost sight of the fifth case. When it was necessaryto lift up and fix forward the uterus and to separatepelvic adhesions ventro-fixation was probably the bestmethod, and it might then be regarded as a con-

servative measure. In such cases he had been much

gratified with the results. In complete procidentia he wasnot satisfied with it, as it required supplementary plasticprocedures. He regarded hysterectomy for procidentia asunjustifiable. A modification of ventro-fixation consistedin the combination of hysterorrhaphy with other opera-tions, such as ovariotomy or the removal of diseased

appendages. Keith’s operation came under this category.He concluded (1) that in the treatment of retroflexionor retroversion, after the failure of other means, ventro- I,fixation offered a means of treatment leading in so many . 1cases to permanent relief that the operation was likely ’to have a permanent place in surgery ; (2) that the

necessity for the operation usually only arose when adhe-sions were present, other cases generally yielding to lessheroic measures, including Alexander’s operation ; and(3) that in the treatment of procidentia ventro-fixationwithout other supplementary measures usually resulted indisappointment; but that in certain cases, when combined

with colporrhaphy or perineorrhaphy, the results were suffi-ciently good to encourage the gynaecologist to advise opera-tion where all the ordinary methods had failed to give relief.

Dr. LEITH NAPIER stated that an important paper hadrecently appeared in the Zeitschrift für Geburtshülfe undGynilkologie, in which the results of 154 operations weregiven: in 63 cases pregnancy had followed, 54 beingdelivered at term. It had been objected that cases of

pregnancy after the operation required artificial delivery in alarger proportion than usual, and that cross-births were morefrequent. But the objection was greatly weakened by thefact that most of these patients would not have becomepregnant at all except for the operation. He then gave theafter-histories of the cases he had read before the societyin 1893 and subsequently published in conjunction withDr. Schacht. One patient had two subsequent labours atterm, one had one pregnancy going on to term, one abortedat two months, one had an early menopause, and this one,with the fifth, presented no subsequent return of her badsymptoms.

Dr. GEORGE KEITH observed that his father never removedboth ovaries unless diseased, though this impression wasconveyed in Mr. Mayo Robson’s paper. His practice was toremove the appendages of one side only in such a case andsuture the stump to the wound.Mr. J. W. TAYLOR (Birmingham) had performed Alexander’s

operation in about a dozen cases and two of his patientssubsequently became pregnant; but it had two drawbacks-firstly, the abdomen had to be opened on both sides, in-creasing the risk of hernia ; and, secondly, it was uselesswhen there were adhesions, and these could not always bediagnosed before operation. He therefore gave it up infavour of ventro-fixation ; the first three cases relapsed,owing to the sutures not being buried ; the remaining seven-teen were cured. But in view of the necessity of anadditional plastic operation in cases of prolapse he hadadopted vagino-fixation, which he had now done in seventeencases with most satisfactory results. It presented the

advantage that it could be combined with other procedures,such as removal of diseased appendages.

Mr. FRED. EDGE (Wolverhampton) had had an experiencevery similar to Mr. Taylor’s. He first tried Kocher’s modifica-tion of Alexander’s operation, but gave it up for the samereasons. He had had twelve cases of ventro-fixation, but notfinding his results as satisfactory as he wished had given itup in favour of vagino-fixation, with which he had been morethan satisfied. He had performed this operation twentytimes, and thought it was of special advantage in cases ofretroversion associated with cystocele, for by the conditionsof the operation the fundus could not fall back withoutdrawing up the cystocele, and the latter could not comedown without dragging forward the fundus, so the twotendencies balanced each other.

Dr. SCHACHT’S experience led him to endorse ProfessorMayo Robson’s views. He had had two cases of ventro-fixation recorded in the paper to which Dr. Napier hadreferred. In one the results were very good at the time ofthe last report, and in the other case the patient became twicepregnant after the operation, the first pregnancy ending inabortion at the fourth month and the second going on toterm. In the latter case he had an opportunity of seeing thepatient at the time of her confinement, and when the labourwas over he could feel the uterus closely applied to theabdominal wall. He thought that the possibility of sub-

sequent pregnancy should influence the method of suturingthe uterus.The discussion was then adjourned to the next meeting.The following specimens were exhibited :-Dr. PURCELL showed three specimens of Carcinomatous

Uteri removed by Vaginal Hysterectomy.Dr. HEYWOOD SMITH, Dr. BANTOCK, Mr. BOWREMAN

JESSETT, and Mr. J. W. TAYLOR joined in the discussion.

NORTH LONDON MEDICAL ANDCHIRURGICAL SOCIETY.

Rheumatic Fever associated with Delirium and Coma.-TheDiagnosis and Treatment of General Septic Peritonitis.A MEETING of this society was held at the Great Northern

Central Hospital on March 12th, Mr. CHARLES KING beingin the chair.

774 WEST LONDON MEDICO-CHIRURGICAL SOCIETY.

Dr. ROBERT BURNET read the case of a man aged forty-two years who was admitted under his care into the GreatNorthern Central Hospital on Sept. 26th, 1895, suffering froma Second Attack of Acute Rheumatism. He stated that he hadexperienced slight attacks of the disease since his firstsevere attack at the age of fourteen and that his mother alsohad had rheumatic fever. There was no history of mental°instability, of alcoholism, or of syphilis. He had been in bedfor three weeks before his admission, and there was intensepain in the joints and he was quite unable to move. Heseemed well-nourished, intelligent, and perfectly rational.-In spite of the pain in the joints there was comparatively’little swelling. Beyond slight enlargement of the area of- cardiac dulness, the apex beat being one inch outside thenipple line, and some indistinctness of the first sound at the.apex, there seemed to be no affection of the thoracic viscera.The pulse was regular, at the rate of 120, and the temperature102° F. The tongue was furred and the bowels were consti-pated. He was given a calomel purge and a mixture containingtwenty grains of salicylate of soda every two hours. The jointpains had all subsided at the end of twenty-four hours andthe salicylate of soda was discontinued. On Sept. 28th hehad slight delirium, although there was no recurrence of jointpain or other signs of serious import. He slept after a

- draught of chloral and bromide. In the morning he was- quite rational, although the temperature was 102°. Thenext day he was very delirious and violent, but stilltook nourishment well, the diet consisting of milk withsix ounces of whiskey in twenty-four hours. At 11 P.M.he was given a hypodermic injection of morphia andwas quiet till 5 A.M. The day following he was very noisyand violent, the temperature was 102° and the pulse 90.Towards evening the temperature rose to 103°, the breathingbecame stertorous, the face cyanosed, and the pulse running.He died on the evening of that day. The temperature after- death rose to lOaD. The necropsy was made by Dr. Frey-berger. The brain was found to be very hyperaemic,although there was no effusion of blood within the cranium.The intra-ventricular fluid was very turbid. Along thecourse of the larger vessels of the pia mater occurredwhite fibrous thickenings from the size of a millet-seedto that of a split pea. There was slight cedema of thelungs, but no other morbid condition of any of the otherorgans was visible to the naked eye. Dr. Burnet alludedto the fact that formerly cerebral symptoms occurringin the course of rheumatic fever were attributed to peri-carditis or to meningitis and hyperpyrexia ; but in somecases the cerebral symptoms were found without either

pericarditis or meningitis, and therefore it was admittedthat cerebral symptoms might be present with pericarditisalone or with hyperpyrexia alone. He also remarked thatalienists recognised a true alternation between rheumaticfever and mental disorder without hyperpyrexia where, as inthe case under notice, the patient suddenly lost all joint tpains and became delirious. Dr. Burnet’s patient had nohigh temperatures, there were no signs during life ofpericarditis, or of endocarditis, and the necropsy showedhyperaemia of the brain without meningitis and without anysign of inflammation in or around the heart. He therefore,considered this case as allied to the latter group.

Mr. C. B. LOCKWOOD read a paper, illustrated by theintern, on the Diagnosis and Treatment of General SepticPeritonitis. After referring to the extreme fatality of

general septic peritonitis Mr. Lockwood said that of latesome cases had been saved by surgical measures. Also, thatsuccess might be greater if an earlier diagnosis was made. Asthe greatest difficulty of diagnosis was met with in peritonitis.due to internal causes that class of ease was mainly referredto. The clinical symptoms were discussed in turn, and it was- argued that clinical experience showed that reliance couldnot be placed upon the appearance, general condition ofthe patient, on the temperature, upon the condition ofthe abdomen, and so forth. In the vast majority ofcases the symptoms of general septic peritonitis wore ! I,the symptoms of acute intestinal obstruction due to ’imechanical causes. The leading features of acute intes- Itinal obstruction were mentioned. In peritonitis themost reliance was to be placed upon (1) the non-passageof flatus and of faeces; (2) the abdominal distension; (3) theabsence of vermicular movement; (4) the collection of fluidin the pelvis ; (5) upon evidences of inflammation above thecaecum, Fallopian tubes, gall-bladder, or elsewhere ; (6) thepulse ; (7) the vomiting; and (8) the previous history. in-most cases it is impossible with our present means to diagnose

acute general septic peritonitis from acute mechanicalobstruction. The operation of laparotomy in general septicperitonitis was discussed. Especial stress was laid uponrapidity and precision in operating, upon the thoroughemptying of the distended intestines, and upon the preven-tion of shock and collapse. Lastly, the influence of thekinds of peritonitis upon the prognosis was mentioned. In

bacillary peritonitis the effects upon the serous membranewere superficial and capable of recovery. In streptococcusperitonitis the bacteria had penetrated the depth of theperitoneum and could not be assailed by ordinary measures.Since November, 1893, Mr. Lockwood had operated upon tencases of acute general septic peritonitis, of which three hadrecovered. Of the latter, one was due to gangrene or

ulceration of the vermiform appendix, one to a perforationof the ileum, and one to salpingitis. In considering thefatality in these cases the inevitably deadly nature of thedisease has to be remembered.

WEST LONDON MEDICO-CHIRURGICALSOCIETY.

L?i,17vi.,q’s Angina. - Sporadic Cretinism. -Multiple Lipo-mata.-Bronzed Skin.-General Paralysis in the Early.Stage. - Cardiac Bruits. -Salivary Fistula. -Adenomaqf the Tongue.-Gummata of the Arms.--Car.d Specimens.A CLINICAL meeting of this society was held on March 6th,

Dr. A. SYMONS ECCLES, President, being in the chair.Dr. SEYMOUR TAYLOR showed a case of Ludwig’s Angina.

The patient, a man aged thirty years, had passed through asevere attack and recovered save for a small amount ofresidual induration on the right side of the neck under theuse of iodide of potassium. No incisions were found to benecessary. The case was one of a series which occurred asif epidemically in the Hammersmith district.

Dr. CHAPMAN brought forward a case of SporadicCretinism. The patient was a girl aged eighteen yearswho presented most of the typical features of the disease.She had never been able to stand and had no control overthe sphincters. Her father had been a very heavy drinker.-Dr. CHAPMAN also showed a man aged forty-seven yearswho had a large number of lobulated subcutaneous growthspresenting the physical characteristics of Lipomata or

fibro-lipomata, in size varying from a nut to an orange.The first one appeared about four years ago during anattack of malarial fever in which there was a markedshrinkage of his normal subcutaneous fat. The onlyparts of the body now free from the growths were

those subjected to pressure. There was no evidence ofvisceral disease and no history of syphilis ; none of thetumours had been excised for examination.-The PRESIDENTconjectured that the growths might be of lymphatic origin.He had seen similar cases in the near east which werebelieved to be of that nature.-Dr. S. TAYLOR and Dr.ALDERSON believed that the growths were lipomatous.

Dr. H. SUTHERLAND exhibited a case of Bronzed Skin. The

patient was a middle-aged woman whose symptoms hadlasted about eight years and were those usually found inAddison’s disease. The bronzing was most marked on theface, breasts, axillae, elbows, buttocks, and linea alba. Supra-renal extract had been tried for six weeks without benefit.Dr. Sutherland asked for opinions as to diagnosis and treat-ment.-Dr. ABRAHAM was unable to offer a definite diagnosis,as the bronzing was very indistinct by artificial light.-ThePRESIDENT cited cases of bronzing in which there was alsodebility in which the rest cure had been efficacious.-Dr.CAMPBELL POPE narrated a case of marked bronzing inwhich extensive disease of the spleen had been the chieflesion found post mortem.

Dr. SUTHERLAND also showed a case of General Paralysis inthe Early Stage. The patient was a man aged thirty-threeyears who had some loss of power in the arms, partial loss ofmemory, slight tremulousness of the tongue, and inequalityof the pupils. The knee-jerks were exaggerated, but thishad not previously been noticed. He had been muchexposed to the weather and was addicted to alcoholic andother excesses.---Dr. SEYMOUR TuKE said that he had nodoubt that this case was one of general paralysis, though ina stage not often seen. He alluded to the frequency inwhich the disease arose in cases of untreated or badly treatedsyphilis..