CLINICAL SOCIETY OF LONDON.

162 future to be content with similar procedures and then to trust to general treatment and hygienic surroundings to assist in the cure. If in the future operativetreatment should be thought advisable in acute cases he anticipated that short-circuiting the diseased area would be found to be the more useful procedure, as it was the easier and safer method to pursue, but experience alone would show whether the suggestions would prove of as much service in acute as they were in chronic cases. It was bladder. interesting to note that in his first and seventh Mr. A. E. BARKER said that from time to time cases were cases, in which a condition of tuberculous peritonitis met with which were believed to be cancer and in which coexisted with tuberculous ulceration of the intestine, the patients made good recoveries. He referred to the case the mere exploratory operation had not cured or even arrested of a woman in whom he had explored the abdomen and had the tuberculous process, but that the radical operation of found what he considered to be cancer and accordingly had removing the principal focus of disease or, as in his third given a grave prognosis. The patient made a good recovery case, the short-circuiting and so setting at rest the diseased and was well a year after the operation. He thought that bowel, was in all three cases effectual in putting a stop to the celerity in operating and protection to the patient from tuberculous peritonitis and, so far as could be seen without cold did most to eliminate shock. the parts being exposed, in curing the more diffuse Mr. W. G. SPENCER suggested that the duration of the disease. All surgeons must have had the experience of disease was an important factor in the diagnosis, for in those curing tuberculous peritonitis by simple abdominal section, with or without drainage, and probably many of them had cases which ran a rapid course the disease was commonly situated in the head of the pancreas, whereas in those of more also experienced disappointment in other cases where the chronic course the growth might be secondary to the irrita- effusion had returned after a longer or shorter interval. He tion caused by gall-stones. He suggested that some cases suggested that the explanation of these recurrent cases lay in might be due to the occurrence of gumma of the liver and the fact that the original focus of disease in the ovaries, deprecated operation in such cases. Fallopian tubes, or bowel, had not been removed and had again Mr. J. HUTCHINSON, jun., did not consider that rapidity been the starting-point for a further effusion of the tubercle of operation was so important as Mr. Mayo Robson considered, throughout the peritoneal cavity. If that were the correct for in operations on the lower abdomen the most successful explanation the remedy was quite clear-viz., that wherever results were obtained by the slower operators. In comparing the original disease might be it should be removed, if that cases of intestinal obstruction in which a Murphy’s button were possible without adding seriously to the risk of operahad been used with those which had been sutured, the mor- tion.-Dr. W. EWART asked what were the early symptoms tality was less in those sutured (although a longer operation) which led to the diagnosis of tuberculous ulceration of the than it was in those in which a Murphy’s button was used. intestine and what were the indications for operation. He He asked if in the treatment of cases of ascites stitching the also asked if tuberculin had been used as a means omentum to the abdominal wall had been shown to be of any of diagnosis.—Mr. CHARTERS J. SYMONDS pointed out service. With regard to those cases in which cancer was that the symptom which in the cases recorded had seen at the time of the operation and yet the patient led to operation was obstruction and that operation recovered he said that he did not believe that it was the effect had been performed rather for the relief of obstrucof the operation, and he mentioned the case of a man with tion than for the treatment of ulceration of the intestine. ascites, jaundice, and lumps in the liver who recovered He quoted the case of a female, aged 25 years, who had without any operation. recurring attacks of mild appendicitis. The appendix had Dr. A. F. VOELCKER asked what dose of calcium chloride been removed and a faecal fistula had formed when she first had been used in these cases. came under observation. The cæcum was excised and an Mr. MAYO ROBSON, in reply, said that he gave 30 grains of end-to-end union of the intestine was made. At the time of calcium chloride three times a day for from two to the operation tuberculous ulceration of the intestine was three days before operating and one-drachm doses with seen to be present. He mentioned two other cases of .saline solution per rectum subsequently to the operation. possibly tuberculous stricture of the small intestine in men. He mentioned a case in which chloride of calcium had proved One of these patients had been subject to symptoms of of good service in arresting hæmorrhage. He was convinced obstruction for 20 years. In this case two feet of enorthat it was inadvisable to operate in cases of cancer of the mously distended intestine were excised. In the other case a man, aged 40 years, was too ill to stand the excision head of the pancreas. He of the intestine but the gut was short-circuited. thought that Mr. Mayo Robson’s suggestion of removing CLINICAL SOCIETY OF LONDON. the localised focus of tubercles was a good one.-Mr. W. WATSON CHEYNE said that there were two important points for discussion : the first was the treatment Treatment Chronic Tuberculosis The Radical of of the In- of tuberculous ulceration by excision or short-circuiting, and testine. -A Case of Hair Ball removed from the the second was whether the focus of the tuberculous disease Stomack of a Child, aged Nine Years. should be searched for and removed. He quoted the case of A MEETING of this society was held on Jan. 10th, an infant with extensive tuberculous disease of the periMr. HOWARD MARSH, the President, being in the chair. toneum with symptoms of obstruction. In this case he shortMr. A. W. MAYO ROBSON (Leeds) read a paper on the circuited the intestine and at the time of the operation Radical Treatment of Chronic Intestinal Tuberculosis, in tubercles were seen all over the peritoneum. The which he observed that whatever might be their views child made an excellent recovery. He was convinced regarding the treatment of acute intestinal ulceration surgical that the treatment of tuberculous ulceration of the treatment was generally advisable in chronic intestinal tuber- intestine by short-circuiting was sound practice, but he culosis. He related seven cases (one male and six females) considered it debateable whether the searching for and in which he had operated with only one death, and removal of the original focus were advisable, though, remarked that while in the first and seventh of his of course, where the disease was strictly limited-as, for cases the adhesions to adjoining parts were very in- instance, to the Fallopian tubes-these should be retimate in the other cases the affected part of the bowel moved. In diffuse tuberculous peritonitis it was inwas quite free, thus rendering operative measures easy advisable to search for the focus as the patient could and simple. In the first, second, third, and fifth of his seldom stand the prolonged operation.-Dr. G. NEWTON cases he bad employed a decalcified bone bobbin as a temPITT thought that the operation in the cases recorded porary splint over which to apply sutures, a method which was performed rather for obstruction than for ulcerahe had described on numerous occasions and which he still tion of the intestine. He considered it inadvisable to employed and advocated as being simple and efficient. The interfere with cases in which there was "matting" of the physiological rest to the diseased parts secured by short- intestines. Although tuberculous affections of the appendix circuiting, as in his third case, and by colotomy, as in his sixth were not uncommon at post-mortem examinations he case, seemed to answer so well that where the radical opera- thought that tuberculous appendicitis was decidedly rare.tion of excision involved serious difficulties or the patient Mr. A. E. BARKER said that he had removed a tuberculous mass f i o m 1 he abdomen of a little girl in the region of the was not in a condition to bear it he would not hesitate in

any doubtful case, and especially those cases in which the patients were still comparatively young. He did not think that all cases of chronic enlargement of the head of the pancreas did well, and he referred to one case of a man who at the time of operation was thought to be the subject of malignant disease, but at the necropsy the head of the pancreas was found to be the seat of chronic inflammation. He did nut think that it was possible in many cases to push a gall-stone back along the common duct into the gall-

163 and the child had made a good recovery. He occurrence of chorio-epithelioma following immediately on the removal of hydatidiform mole was given, and the paper was inadvisable to interfere with those was followed by a lantern demonstration on the close cases in which there was " matting" of the intestines and in such of these cases on which he had operated he had always association between vesicular mole and chorio-epithelioma.regretted it, as the wound had opened up and faecal The PRESIDENT remarked that it was quite impossible to fistulæ had formed, the final condition of the patient prove definitely whether these malignant growths were of thereby being rendered very distressing. The cases most ’ maternal or of foetal origin. Even if it could be shown that suitable for operation were those with a considerable amount they were developed from the outer epithelial layer of the He did not think that tuberculous disease of villi of the chorion, that would not settle the question, of fluid. the appendix was of common occurrence. He then entered because it was still disputed whether that layer was maternal or foetal. It was for this reason that he had named his own on the question of how much of the intestine might be safely removed and mentioned a case in which the specimen, shown at the society some months ago, "deciduoma malignum,"the name given by Sanger who cæcum, the ascending, the transverse, and the descending colon had all been successively removed for tuber- first described the condition. He could not help leaning to culous ulceration and the patient after the final operation the view that it was foetal in origin, and he did not see how remained in excellent health.-Mr. C. R. B. KEETLEY thosewho believed in its maternal origin could get over the thought that it was important in all cases of tuber- fact that it so often followed upon hydatidiform mole. The culous peritonitis to find the point from which the point raised by Dr. Lockyer that there were two sorts, one He classified the cases under three without syncytial elements, probably maternal in origin, to disease had arisen. headings-the first, cases in which a tumour could be felt which the term deciduoma malignum" would be appro(this, he said, was always glandular) ; the second, cases in priate, and one with syncytial elements of foetal origin, to which there was a tuberculous appendicitis ; and the third, which the term "chorio-epithelioma"would be better in which there was diffuse tuberculous peritonitis. He applied, was no doubt very important. But it had to be
appendix

considered that it

I

syncytial

,

RITCHIIE, ,