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Temperature no substance ever came away. She has always felt ill since, and from that time has been irregular as to mensesAt 9 A.M. on the 15th the temperature rose to 106°, and sometimes once in three weeks, sometimes six weeks. at 9.20 death took place. From last June the discharge has been continuous, red, The post-mortem showed thrombosis of the cerebral slimy, and foul-smelling. Was losing flesh ; always weary sinuses. There were numerous small abscesses in the lungs, and sick. The sickness and retching came on every apparently from infarctions. The brain itself was normal. morning, with bringing up of sour fluid. Pain also began The longitudinal and lateral sinuses contained well-marked about June, chiefly over the sacrum, at first intermittent, decolourised thrombi. In the latter they were soft and but latterly much more frequent. The pain was mainly purulent looking; in the former firm. There was pus in localised about the sacrum and hypogastrium ; none during the left tympanum and in the mastoid sinuses; the mem- urination or defecation, but latterly she had been more brana tympani was not perforated, and there was no necrosis costive. of the petrous bone. Present condition.-There is a constant discharge of Remarks by Dr. TIRARD.-When the child was first seen, dirty, blood-stained, foul-smelling fluid from the vagina, although the diagnosis was obscure, it appeared to lie with nearly constant and intense pain, chiefly in the back, between tubercular meningitis and some meningeal irrita- but spreading down the thighs. With the speculum a, tion consecutive to the otorrhcea. It was noted, however, cauliflower growth is seen, filling the upper third of the that the discharge from the ear had preceded the measles, vagina and bleeding on touch. It can be defined as springing and that the symptoms had commenced with a fit after the from the os uteri and confined to it, but its upper limit child had been gradually failing. In favour of tubercular cannot be seen or felt. The uterus is movable bimanually, meningitis stood the history of wasting, fits, and measles; not freely. There is no fixation to bladder or rectum, and the symptoms, however, were rather against this and in the vaginal wall is smooth and apparently healthy. There 14th.-The

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favour of some more acute form of irritation. The freedom is a trace of albumen in the urine. She says that for the of the discharge from the ear formed an element difficult to last two days she has had some aching after micturition. reconcile with secondary infection from that source until The patient is dark, slight, 4 ft. 10 in. high, weight, three the occurrence of the pneumonia. The post-mortem appear- years since, 6 st. 7 lb. The diagnosis was epithelioma, That the springing from the cervix uteri. ances showed the correctness of this hypothesis. On Oct. 7th chloroform was given by Mr. Duckett and membrana tympani was not found to be perforated, Prof. middle in external and was both the Hare, and Mr. Boycott assisted. The pulpy growth although pus present ear, is worthy of note. Throughout it was curious there projecting from the os was first scraped away with Volkmann’s spoon, and then it was seen that it was conwere not more indications of pain. tinued high up the canal. When all within reach had been, cleared away but little was left of the cervical neck except the outer mucous membrane. Haemorrhage was free, but ANCOATS HOSPITAL. was easily kept under control by irrigation with hot saline CARCINOMA UTERI ; SUPRA-VAGINAL HYSTERECTOMY ; solution-irrigation with which was kept up throughout. RECOVERY ; REMARKS. The os was then temporarily plugged with sponge. The uterus was pushed well down from the front, and a fair hold! (Under the care of Mr. E. STANMORE BISHOP.) WITH such an operation as hysterectomy, every case, obtained by means of a strong silk ligature passed through the walls of the there not being enough tissue left for though in itself of no great importance, possesses an interest the vulsellum touterus, obtain a grip. The mucous membrane was, above that of many others, inasmuch as the relative merits divided all round the os, and the recto-vaginal septum opened of certain details in the technique required may still be con- oy scissors. As soon as the finger could be felt to enter the sidered sub judice. The general opinion may perhaps be peritoneum the opening was sufficiently enlarged, and a soft taken as fairly settled in favour of the supra-vaginal or sponge mounted on wire was passed in behind the uterus. The bladder was next carefully separated from the uterus Schroeder’s operation, as against the abdominal or Freund’s. the finger and scissors, and the vesico-uterine fold of the by Various tables of statistics exist which apparently show peritoneum opened. With care the opening was enlarged conclusively that the patient has a far better chance of life until only the two broad ligaments were undivided. Another with the former ; whilst, a priori, one would consider that sponge, mounted on wire, was pushed through this opening. the removal of a cancerous mass through the peritoneal The left broad ligament was then tied and divided. In down the uterus the right ligament began to’ cavity would be associated with great risk of infection of drawing that membrane by carcinomatous cells which might be dis. tear, the uterus to peel off from the peritoneum covering it, which remained attached to the side and was left. For lodged in transit, and thereby the chances of recurrence in some moments there was sharp right haemorrhage. The patient other parts be increased. In the earlier operations this became collapsed and the pulse thin and wEak. Hot flushadvantage was not obtained, as the uterus, after separating with saline solution improved the pulse, and a large it from bladder and rectum, was inverted, the fundus being ing Wells’ compression forceps arrested the bleeding. Spencer retroverted through the posterior opening, and consequently The process of tying and division was again commenced, but the ulcerated surface was directed upwards into the peri. the ligatures tore out, and, finally, the uterus tore away toneal cavity. Richelot in 1887 showed that this manoeuvre completely from its attachments on the right side. Two veins was not necessary, as also Leopold of Dresden and in which bled in consequence were clamped by a large Spencer 1888 Professor Sinclair3 described six cases, in two of which Wells’ forceps, which was left on, the whole flushed again’ the older method was followed, and in the four later ones with hot saline solution, and the cavity packed with iodothe uterus was removed without any such inversion. In form gauze. A self-retaining catheter was placed in thethe present case no inversion was attempted, nor did it bladder and the vulva surrounded by salicylic wool. appear that such a proceeding would have done anything After the operation there was so much shock that the but add to the difficulties to be encountered. was left on the table for a few hours, well covered M. G-, aged forty-two; married. Has had six patient with blankets, and placed before a good fire. Ether was children, two of whom were stillborn-the first and the also twice injected. She was then placed in bed. The last. Has always had easy labours, attended by a midwife, lasted two hours and a half. One ounce of beefand has quickly recovered after each. Her father she does operation tea and half an ounce of brandy were injected per rectum, Mother died of and not remember; he went to America. every two hours. At 3 P.M. collapse was still bronchitis, aged sixty. Two brothers, both dead ; one, aged veryrepeated marked. 97’8°; respiration 38. At forty-three, died of pleurisy; the other, aged twenty-three, of 6 P.M. there was Temperature an improvement. 988°; the phthisis. One sister living, aged forty-seven, in good health. pulse was stronger, 120. At 9 P.M.Temperature there has been very No one in her family or any of her relatives have had chloroform sickness. Collapse passing off; no pain, Had perfectly good health until slight cancer to her knowledge. but smarting. Has been dozing. Pulse is fuller, not slight the middle of February, 1888. Menstruation had stopped Urine drawn off by catheter. To have one grain of for three months, and as a severe flooding then came on, wiry. in a pill, and half a grain to be repeated every two opium with much pain, she considered that she had a miscarriage, in which opinion she was confirmed by the midwife; but’ hours. 12 P.M.: Pulse 116, improving both in volume and tone. Nothing but ice and soda-water given by the mouth. 1 Nouvelles Archives Oct. 8th.-1.20 A.M. : Essence of beef, half a teaspoonful, et de d’Obstétrique Gynécologie, Sept. 1887. 2 Archiv für 3 Med. Gynæcologie, Bd. xxx., Heft 3. Chron., vol. vii. by mouth ; repeated 2.50 A.M. ; very sick afterwards. .

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Again very sick ; has only slept a few minutes uneasiness in urination or defecation. Weight 6 st. 10 lb., 6.30 A. M. : Has slept since 5 A.M. 7.20 A.M. : an increase of 3 lb. on her weight three years ago. .Remar7,;s by Mr. Brsfior.-The case is interesting, first, Slight vomiting. 10 A. M. : Took a quarter of a teaspoonful of essence of beef ; feels much better; temperature 99 2° ; as showing the ease with which the uterus may be removed pulse 116 ; respiration 24. 11 A.M. :Has had half a cup of by following the modification of Schroeder’s operation, introtea, which was followed by slight vomiting of brown and duced by Leopold of Dresden, and emphasised by Professor flocculent material. 11.30 A.M. : Half a drachm of sulphonal Sinclair, who was, I believe, the first in England to point given; slept three-quarters of an hour; opium pills stopped; out its importance, which consists in the omission of the to wash mouth, which is rather dry, with diluted raspberry retroversion of the uterus through the posterior opening. vinegar and glycerine and water. 2.15 P.M. : Vomited Such a manoeuvre certainly was not necessary in this case, some bile and mucus. 12 P.M.: Urine quite clear; nutrient and its omission would appear to greatly diminish the risk of infecting the peritoneum by cancerous debris. Secondly, enemata are still continued every two hours.

4.40 A.M. : at a time.

9th.-10.30 A.M. : Complains of no pain and says she is very comfortable ; pulse fuller, not wiry ; under irrigation with creoline lotion the iodoform plug is removed, also the

the quick recovery from a state of profound collapse, which has been noted by Emmet and other observers as occurring in supra-vaginal operations, as contrasted with abdominal .clamp, causing some smarting, but nothing more; interior resections. Thirdly, the occurrence of typical menstruaof vagina is raw, as though blistered by the hot injection at tion six weeks after. Mayo Robson, Greathead, and the time of operation ; fresh iodoform strips are introduced Lawson Tait have also noted cases in which the same around a small drainage-tube; morphia suppository, quarter phenomena have been observed. of a grain, placed in the rectum; as the urine now begins to smell, and is cloudy with mucus, the bladder is washed out with a 5 per cent. solution of boracic acid. 12 A.M. : Complains of some pain over the hypogastrium; half a grain of opium pill to be given every two hours; nutrient enemata to be given every four hours. Temperature 99 ’8°; pulse 112; respiration 24. 1.30 P.M. : At her urgent request, the ROYAL MEDICAL & CHIRURGICAL SOCIETY. patient had a little tea, and at 3 P.M. two tablespoonfuls of

Medical Societies.

cornflour.

Removal of Upper Extremity for Osteo-chondroma.— Mechanism of Suspension in Locomotor Ataxy. AN ordinary meeeting of this Society was held on Jan. 14th, the President, Sir Edward Sieveking, in the chair. The PRESIDENT announced that a communication had been received from the builders stating that the new meeting room would be ready for occupation in about a fortnight’s now. llth.—Has slept best part of this day, only waking for time, and the resident librarian hoped to have the books food, which she takes well. Nutrient enemata discon- arranged ready for reference by a fortnight after that date. Mr. THOMAS F. CHAVASSE read a paper on Successful tinued. Is very comfortable, although once there was a of slight colic. No sickness. Outer wool changed ; Removal of the entire Upper Extremity for Osteo-chondroma. feeling inner iodoform dressing remains. The patient, a male aged forty, was admitted into the 12th.-Urine is ammoniacal, so the catheter is removed General Hospital, Birmingham, in January, 1889, for a large and the bladder well washed out with boracic solution. ossifying enchondroma of ten years’ duration growing from The iodoform plug is removed, and the vagina irrigated by the upper portion of the right humerus. The operation perhot creoline solution. A small drainage-tube is placed in formed was resection of the middle third of the clavicle, the canal, and an iodoform pessary. The vulva is plugged ligation of thefirst part of the axillary vessels with carbolised by iodoform gauze and covered by salicylic wool. The silk, the formation of oval skin flaps, and removal of the ligatures are not yet loose. After an enema the bowels remaining outer third of the clavicle, the scapula, and arm were comfortably opened. Patient has no pain except a en masse. Secondary haemorrhage, occurring on the sevenlittle during the vesical irrigation. Abdomen is flaccid ; teenth day, necessitated ligature of the subclavian artery in tongue slightly furred. She sleeps and eats well. Tempe- the second part of its course. Thepatient recovered, and is rature: 99’2° morning; 98’6° evening; pulse 101 ; respira- still living. The tumour itself after removal weighed 18 lib. Attention was directed to the systematic method of removal tion 24 13th.-The bladder was washed out, the vagina irrigated, of the entire upper extremity advocated by M. Paul and another iodoform pessary introduced. The bladder is Berger, and to the haemorrhage and shock occurring at rather irritable, requiring the catheter every three or four the time of and after the operation. A tabulated list hours. Took one pint of Benger’s food during the night of twenty-nine cases in which similar operations had and two pints during the day, with half a pint of milk. been performed was presented. A cast of the limb in its Has slept at intervals. Is to have fish or chicken and four entirety, prepared after his own method by Mr. Charles ounces of wine daily. Temperature normal; pulse 104; Cathcart, a portion of the original tumour showing its structure and attachment to the humerus, and photographs Tespiration 24. of thepatient before and afterthe operation were exhibited.A and bladder twice. of irrigated quarter 14th.-Vagina Mr. BOWREMAN JESSETT related a somewhat similar case a grain of morphia suppository was ordered, there being a good deal of vesical irriuation and some hypogastric pain. which had been under his own care. The patient, a man Takes food well. Temperature 98’4°; pulse 96; respira- aged twenty-two, had had amputation at the shoulder-joint tion 18. performed for sarcoma of the humerus. Three monthslater iuth.—JJressed morning and evening, with irrigation as a recurrence took place in the cicatrix, and this was rebefore. No pain, but considerable vesical irritation. moved, the growth being found to be slightly adherent to the in twenty-four hours two pints and a quarter of Benger’ss scapula and the tissues about it. A second recurrence was food, two pints of milk, fish, four ounces of port wine, found five weeks later, and then the scapula and outer half tea, and bread-and-butter. She was ordered simple enema of the clavicle were removed, an incision being made along the clavicle to the acromion, and another from this point and T 1-uth of a grain of atropine three times a day. 18th.-All ligatures but two removed. Irrigation and along the spine of the scapula. The flaps thus formed were iodoform only once a day. Patient sat up for the first time. dissected up, the clavicle divided, and, a V-shaped incision 21st.-Examination shows dome-shaped cavity coveredl being made on each side of the old wound, the skin and by mucous membrane with small red papille, soft, on theB subjacent tissues were reflected and the scapula removed. right side at upper extremity, probably orifice of the Fal- The subclavian artery was ligatured, comparatively little blood was lost, and the patient made a good recovery. The lopian tube. 22nd.-Catheter no longer required. Urine normal in1 growth was a myeloid sarcoma.-Mr. HEATH said it was character and quantity. Last stitches removed. important to distinguish between those cases in which the Nov. 2nd.-Discharged well. scapula had been removed with and those without ablation 27th.-After slight molimina had a small menstrual red1 of the upper extremity. He himself had once removed the discharge only lasting the day, and followed by no otherr entire upper limb. Heconsidered that removal of part of secretion. No pain after this had commenced. the clavicle complicated the operation, without offering comDec. 6th.-Is perfectly well and in good spirits. No3 pensatory advantages. It was impossible to lay down a set

IVth, -1. u A. M.: ;!51CR ana restiess. 4.10 . w. : met from 2.45 to 4 A.M. Half an ounce of Benger’s food. Vomited. 4.25 A.M. : Milk and soda-water at short intervals in small quantities. 11.15 AM. : Tea. 2 P.M. : Opium pills to be given every six hours. 10 P.M.: Has slept well, only waking for two ounces of food at 7 P.M. and

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