NORTHAMPTON GENERAL INFIRMARY.

1028

retching, disturbance of intellect, an intensified degree headache, and other forms of sympathetic pain. She was so irritable that the least worry upset her; in short, she had drifted into the state of chronic invalidism. Could only walk a few yards. Left leg drawn up somewhat to relieve shooting pain. Abdomen normal. On examination per vaginam, the patient was found to be wearing a Hodge’s elastic air-bag pessary. Cervix conical; retroflected uteri ; a convoluted coil, the thickness of the finger, in Douglas’s pouch, painful to touch. Sound passed normal depth, and on raising the with

NORTHAMPTON GENERAL INFIRMARY.

of

SURGICAL CASES.

fundus uteri, the retro-uterine mass, tubes, and ovaries were lifted with it, with intensified pain ; bimanual examination demonstrated and confirmed their attachment to the uterus. There was contraction of the left broad ligament. Abdominal section was performed on March 27th by Dr. Wallace, assisted by Mr. Laimbeer, ether having been administered by Dr. Briggs. The right ovary, which was four times its normal size, and contained a mass of cysts, in the midst of which was a hard fibroid mass the size of a marble, was ligatured with the right Fallopian tube and excised. The left ovary, also cystic, was left. Every cyst was punctured and the contents squeezed out. The left Fallopian tube was then catheterised from its fimbriated extremity, so that any catarrhal discharge might drain into the abdominal cavity.

difficulty

Drainage was adopted. The patient made an uninterrupted recovery. Temperature only twice at 100°, normal nearly all through; and pulse varying from 90 to 104, once 116 and 114. Drainage free. Abdominal wound closed by tenth day. She is now able to be up and about. Her health improves, and her neuroses have nearly all disappeared. Remarks.—It was at the patient’s request that the ovary least affected was left. Dr. Wallace lays great stress upon the impropriety of unsexing women unnecessarily, and points out that many cases of extirpation of the uterine appendages might be avoided by catheterisation of the Fallopian tubes, thorough puncturing of the cystic ovaries, followed by squeezing the organ like a piece of sponge in the hands, so as to complete the rupture of the cysts and the evacuation of their contents. Free drainage afterwards is a sine quâ non. For four or five days the sero-sanguineous drain in this case was profuse. The drainings were kept septic by Listerism, but Dr. Wallace does not apply the spray to the peritoneal surfaces. Catheterisation of the Fallopian tubes can sometimes be practised per uterum, and should always be tried, as !, there are cases which succeed, and the patient luckily

escapes the ordeal of abdominal section. CASE 2. Localised Peritonitis simulating a Parovarian Cyst;Exploratory Abdominal SectionDrainage;Cure.R. A-, aged twenty, unmarried, was admitted on Feb. 25th. The patient’s health had been good till April, 1883, when she noticed an enlargement of the abdomen, which rapidly increased. Since November menstruation had been regular until four months ago. No floodings. Slight abdominal pain occasionally. Bowels regular. No discharge per vaginam. On examination the abdomen was found to be

enlarged (umbilical measurement thirty-two inches) by a fluctuating tumour, dull on percussion, tympanitic in both iliac and lumbar regions, and the intestines pushed up into the epigastrium. The tumour had all the characteristics of

Uterus normal; was too distinct. to the left and forwards, and the vaginal portion of the cervix in the opposite direction. Abdominal section was performed on March 15th by Dr. Wallace, assisted by Mr. Laimbeer, the patient having been etherised by Dr. Briggs. The peritoneum, thickened to half an inch, was cut through, and eight pints and a half of greenii-h fluid, containing flakes of lymph, were evacuated. On passing the hand into the cavity, it was found to extend down to the floor of the pelvis, and to embrace the whole of the lower abdomen as high as the umbilicus, above which were imprisoned the intestines. Drainage and antiseptic dressings formed the treatment; and in four days the cavity was filled by the descent of the intestines, the whole abdomen being tympanitic. a

cyst, but fluctuation

fundus

displaced

April 27th : Discharge lessening ; dressings applied only improved ; able to walk about, and

every three days ; health is practically well.

pointed out that local peritoneal whether serous or purulent, are safely cured by abdominal section and antiseptic drainage. He referred to a case of enormous ascites permanently cured by abdominal section, which, in its early stage, had been pronounced Remarks.—Dr. Wallace

collections,

cystic.

FOR the notes of these cases we are indebted to Mr. J. Oswald Lane, M.B. Cantab,, &c., house-surgeon. CASE 1. Proctotom,y followed by Colotomy; Scirrhus of Rectum. (Under the care of Mr. G. H. Percival.)C. D-, aged thirty-two, a widow, was admitted on Feb. 3rd, 1883, with the following history : She belongs to a healthy family, having no evidence of malignant hereditary predisposition ; she is the mother of five children, all of whom are alive and enjoy good health, while she herself has had no. illness till three months ago, when she first experienced in defecation, with burning and gnawing pain in the lower spinal region, which at times destroyed her rest at night ; in addition, her bowels have generally been constipated, but occasionally she has had diarrhoea; she also noticed slime and blood in the motions, but never suffered from incontinence ; never had difficulty in micturition, and menstrual functions normal ; has lost flesh lately, combined with a feeling of lassitude and weakness; no Her present symptoms arcevidence of specific disease. as previously enumerated, except that hardly any motion is passed, and on examination per rectum a hard growth was found encircling the bowel, commencing just inside the anal orifice and extending upwards about two inches. The little finger could with difficulty be passed through the stricture formed by the growth. No evidence of ulceration. On February 8th, patient having been anaesthetised and tied in the lithotomy position, a deep incision was made in the middle line of the ischio-rectal fossa, reaching to the coccyx; the rectum was separated from its continuity with surrounding tissues by means of medium-sized curven scissors, first of all anteriorly separating it from the posterior vaginal wall, next laterally, and then from its posterior attachment. Two inches and a half of bowel having then been loosened throughout its whole circumference, it was then divided in its continuity above the growth by means o the thermo-cautere. The whole of the growth was by this means apparently removed, and there was very slight hæmorrhage.—9th : Patient seems very comfortable with no unfavourable symptoms ; catherisation necessary. Takes food well. Temperature, morning 99’2°; evening 1000. 10th : She complains of pain in sacral and lumbar region;a some abdominal tenderness ; no sickness. Bowels open three or four times involuntarily; micturition natural. -

Temperature, morning 99°; evening 99.6°.—13th: General improvement to-day. The case went on progressing till March 1st, when she left the hospital, being able to pass properly formed motions, though at times unable to restrain them. She presented herself from time to time as an outpatient, and in July she showed evidence of return of the growth ; symptoms of obstruction became more marked, though rectal bougies were frequently passed, and it became necessary on Oct. 1st to perform left lumbar colotomy. Her symptoms of obstruction were entirely relieved. The operation was very successful, as she progressed gradually after it and had little pain in the sacral region. She is now (April 1st, 1884) alive, but there is evidence of increase of growth and increasing cachectic symptoms. She has, however, lived more than thirteen months since the first operation. CASE 2. Obstruction of Bowels; Colotomy; Relief.— T. A-, aged forty-eight, shoemaker, was admitted on August 14th, 1883, with symptoms of partial obstruction of the bowels and marked appearance of malignant disease with an hereditary predisposition to such. On examination there was no evidence of rectal obstruction, but a growth could be felt in the position of the lower part of the descending colon, probably connected with it. The patient remained for about six weeks in a somewhat similar condition, at times passing some solid motions, though his general condition was becoming worse, and it was determined to perform right lumbar colotomy after his having had total obstruction five days. The patient was greatly relieved after the operation, and he progressed favourably in every way, having little pain, no distension, and free fsecal exit; the highest temperature was 99’6°. General condition much improved. He was discharged from the hospital five weeks ’

after operation, and has continued in very fair health up to the present time, but there is evidence of the growth having increased. CASE 3. Scirrhits of Rectum;Colotomy. (Under the care of Mr. Kirby Smith.)-H. W-, aged thirty-seven, shoemaker, was admitted with the following history :-He had

1029 suffered from pain in the back

during

the last

eighteen ing,

whilst in Southern Africa it had

lately

assumed

con-

months, but only since the last month had there been any siderable virulence.-Dr. SQUIRE had given some attention difficulty in defecation, but during the last seven daysthere to the general epidemiology of the subject. Whereas epihad been total obstruction, with continuous sickness. Never demics differ greatly in virulence, race does not constitute a passed blood, but frequently the motions had been of a slimy leading factor; that improved sanitation does not exercise

character. There was a cancerous history, and a hard growth could be felt per rectum, so that the smallest bougie could

any marked control

over

the merits of the disease its recent

aggravation in England furnishes clear proof. The imlumbar on him left He had colotomy munity of India was due to the comparative isolation of performed not be passed. the day of admission; he was immediately relieved by the the European element by which the disease was imported, operation, and his general health began gradually to improve. by the early removal of European children, and above all by He never had any had symptom; even his temperature was at the absence of most of the agencies which in this country the highest only 99’7°, and he was discharged four weeks bring about contagion from person to person. This pointed after the operation, "feeling quite himself again,"so that to the direction in which improvement might be effected. he was able to walk some considerable distance directly after In France children were systematically inspected before his discharge, and he resumed his work two weeks after- their admission into school ;but in England too frequently wards, and has continued to work till the present time, and attendance at school was enforced in the face of sanitary indications Although the shortened incubation of surgical his general health has been very good till two weeks ago. CASE 4. Encephaloid Disease of Rectum, &e. ; Colotomy.- scarlet fever had been adduced as proof of its inoculation M. G-, aged fifty-nine, admitted May 20th, 1883. She into wounds, this point was far from settled. A case was had all the symptoms and signs of malignant disease of the narrated in which the injury was received and scarlet fever rectum and uterus, as after three weeks there was total contracted three days after entrance into a new house, which obstruction to the passage of faecal matter, so that left could not have supplied any contagion. Hardly enough The patient seemed stress had in the previous discussion been laid upon desqualumbar colotomy was performed. greatly relieved from the operation, and progressed most mation as an infecting agent. In respect of treatment, lavourably for sixteen days, when her temperature, which mischief was likely to arise from the indiscriminate use of had been normal, rose to 102 6° ; there was abdominal pain the warm bath in the premonitory stage. This practice with tenderness. The next day the temperature rose to was well calculated to aggravate the pyrexia, and to 1032°, and there were all the signs of peritonitis. The favour the onset of convulsions in children.-Dr. HOPWOOD patient died the nineteenth day after the operation. had collected twelve good cases in which the duration of exposure had been limited to half an hour or an hour, Necropsy corroborated the previous diagnosis. and the onset bad followed in sixty-eight to seventy-eight hours. Surgical scarlet fever was not a distinct variety.

Medical Societies. HARVEIAN SOCIETY OF LONDON. A MEETING of this Society was held on the 15th ult., Mr. G, P. Field, President, in the chair. Hypospadias.-Mr. EDMUND OWEN showed a coloured drawing of a subject of hypospadias in which the sex had The child had been named been singularly mistaken. Florence Kate, but when Mr. Owen saw it, then sixteen months old, he discovered the testes near the crest of the pubis, and suggested that the name be changed. The boy was tberefore re-registered by the name of Sydney. He was now four years old, and was in every other respect well developed. If there were a doubt at any time about the determination of the sex of a child, it was much more likely to be

aa imperfectly developed boy than a girl. Mr. CRIPPS Adjourned Debate on Scarlet Fever. LAWRENCE, referring to the report of his opening remarks on April 3rd, which had appeared in the medical journals. stated that the expression "imperfect volatility" should have been used instead of "volatility"" in connexion with the poison of scarlet fever, in accordance with the drift of his observations on that subject.-Dr. CHEADLE, in reopening the debate, laid stress upon the specific nature of the virus. Its elaboration required a longer time than that of measles; the latter was contagious almost from its earliest manifestation, whereas the former was much less potent prior to the appearance of the rash than during desquamation. Families and individuals differed widely in their liability to the disease. The nature of this susceptibility was a subject well worthy of the attention of the Collective Investigation Committee. Again, the same persons showed very different vulnerability at different times. This was illustrated by the case of a former housesurgeon of the Hospital for Sick Children, who, after having -

resisted the concentrated infection of a scarlet fever ward, contracted the disease in the midst of the duties of a country practice. Surgical scarlet fever was probably contracted by contamination of the highly absorbent surface of recent wounds. In strict analogy with what happened in inoculated small-pox, the incubation was much shortened and the disease attenuated. Propagation by wound inoculation was not hitherto known in the case of measles or enteric fever; the influence of race as an etiological factor was open to some doubt. The variations were rather between epidemics than between countries. Climate, however, probably exercised an influence, although this was not necessarily based upon mere degree of temperature ; thus in India the disease, although repeatedly introduced, had never obtained a foot-

The disease had been contracted under the use of every antiseptic precaution, including the spray, and in cases where the wound had run an aseptic course.Mr. MALCOLM MORRIS deprecated harsh criticisms of the diagnoses of fellow-practitioners. In scarlet fever four prominent indications required consideration-the rash, the throat, the tongue, and the pyrexia. Any of these, or might fail us, and the rash was the most important, several, for in its complete absence diagnosis was at best but a guess. There were two typical varieties of eruption-the haemorrhagic variety special to severe cases, and the milder punctate form. Urticaria was often most difficult to diagnose from scarlet fever; but where any doubtful rash existed, isolation was the means to adopt, although the event might falsify our apprehensions. An extensive desquamation was an important guide, and of all the means proposed for checking the diffusion of contagious epidermic scales, constant bathing, as suggested by Dr. Jamieson in the Edin. Med. Journal, was the most promising ; yet better results might be expected from continuous immersion during two or three days at the height of desquamation. Continuous immersion was practised in Vienna, with good results in the case of burns. -Mr. MASON considered the question of the spontaneous development of the disease, and narrated a series of cases occurring in the same house. A child died in four days from the hsemorrhagic form of the fever, the nurse suffered from severe diphtheritic sorethroat, and the father acquired severe erysipelas before the dead body had been although inspection revealed no insanitary condition in the house, decaying vegetable refuse was discovered in the vaults opening into the area. Contagion was capable of clinging for long periods to articles of clothing. In the speaker’s experience, most of the parturient women infected by the disease were quite free from all abrasion. Diffuse peritonitis had generally ensued, abrupt in its inception, violent in its course. The desquamation stage was best treated by carbolised inunctions and warm baths. A case was adduced in support of the volatility of the contagium.Dr. DAWSON NESBITT suggested that the mildness of the in France might bear some relation to the lighter disease diet adopted in that country. The question whether practitioners engaged in midwifery should attend scarlet fever was one requiring serious consideration.—Dr. ALDERSON, after anxious investigation of the subject last mentioned, had arrived at the conclusion that very rarely could puerperal disorders be traced to scarlatinal infection. He had repeatedly attended parturient women when scarlet fever was Two instances were related in which the in the house. parturient mother escaped, although children were at the time suffering from the disease, in one case in a severe form. The danger from erysipelas was much more real.Mr. EDMUND OwEN related three cases of surgical scarlet

removed ;

A A 2