No. 2472.

JANUARY 14, 1871.

AddressON

THE ADVANCES IN OBSTETRIC MEDICINEDURING THE LAST TWELVE YEARS.

Delivered at the Annual Meeting of the Obstetrical SocietyJanuary 5th, 1871,

BY GRAILY HEWITT, M.D., F.R.C.P.

GENTLEMEN,—The present appears to me an appropriateoccasion for reviewing the advances in obstetric medicineduring the last twelve years. I think it can be shown thatthis Society has, so far, most completely fulfilled its objectsin respect to the advances it has made and the improve-ments it has introduced in the practice of obstetrics.

Embracing the whole field of obstetric work, my observa-tions must necessarily be brief, and, as regards particularsubjects, of an extremely summary character. Necessarily,also, my individual judgment on the progress made inspecial departments or subjects is simply an indivicdl djudgment. I must ask, therefore, for your kind indulgewhile I endeavour to pourtray what appear to me twosome of the more important advances in our scions ob-tained during these twelve years of the Society’s ex’ ence.Much valuable information concerning the statistics of

midwifery practice has been afforded by the

papers of Mr.

Bailey, Mr. Dunn, Mr. Mitchell, and Dr. Granville ; whilenew and curious facts concerning the practice of midwiferyin our Indian possessions have been furnished by the papersof Dr. Jackson and Dr. Shortt. /The general features of labour, and its management, have

been the subject of several thoughtful essays. Dr. Hicks’s

paper on the condition of the uterus in obstructed labourwill assist the practitioner in determining more accuratelywhen and how to give assistance. Women perish as a con.sequence of labour more often from want of appreciation onthe part of the attendant of the actual condition presentthan from any want of skill on his part.Then we have had a philosophical inquiry as to the seat

of the pain in labour by Dr. Sansom; a paper by Dr. East-lake enforcing the practice of delivery of the placenta bymeans of external pressure-a real advance in practice;also a valuable and interesting account of the manner inwhich double monsters are usually delivered, by Dr.Playfair.That valuable anaesthetic, chloroform, was introduced by

our lamented colleague Sir J. Simpson before this Societywas founded, but the proper and safe limitations to its usein midwifery practice have been discussed by us on severaloccasions. We have come-some of us, at all events-torecognise the fact that chloroform has a tendency to makelabour lingering," that it sometimes enfeebles the uterus,and may thus cause haemorrhage. This tendency it is pro-posed to do away with by diluting the chloroform by mixtureof alcohol or other vapours, or by accurate mixture withair. Dr. Sansom has pointed out the great liability to theinhalation of poisonously high percentages of chloroformat high temperatures unless proper care be exercised. Mr.Ellis has given us new inhalers for effecting such mixtures.Dr. Kidd has given us, and has been the means of eliciting,much valuable information. The general conclusion I taketo be, that in ordinary midwifery practice the anaesthetic.should be diluted, that it should not be given to producethe full effect, and that in all cases rather excessive pre-cautions against haemorrhage are required when chloroformis given.The vexed question as to the influence of ergot on the

fcetus has been discussed in an elaborate paper by Dr.TJvedale West.The very important subject of distortion of the pelvis-

a condition so full of danger to mother and child-hasfrequently incidentally been before us. Since the formationof this Society, a new form of distortion has been added tothe previous list-the spondylolisthesis, or projection for-

wards of the last lumbar vertebra from caries or other dis-ease of the bones beneath; first described in 1853 by Kilian,of Bonn. Dr. Barnes has contributed in our Transactionsan exhaustive paper on this new and interesting deformity,detailing the particulars of thirteen cases. The disease israre; but we shall probably hear of it more commonly nowattention has been directed to its existence.Of the great obstetric operations, most of which we can

happily designate as conservative ones, the forceps is thechief and the foremost. What has this Society done tofurther the use and efficiency of this instrument ? In thefirst place, this Society has on several occasions expresseditself strongly on the great impolicy of postponing the em-ployment of the forceps when the labour is not a progressiveone, and when it is delayed. We have endorsed the opinionput forward by Dr. Tyler Smith in a very able paper, thatthe head ought not to rest on the perineum some hoursbefore the instrument is applied; we in the same way re-pudiate the old maxim that it is necessary to feel the earsbefore using the instrument we no longer insist on theos uteri being fully dilated in order to employ it; we donot consider the entrance of the blades into the uterus asprejudicial; nor do we object to the employment of slightdegrees of compression to the fcetal head when necessary.

These various questions require the use of discrimination onhe part of the attendant in particular cases; but the ques-ion is generally one of mechanics. In Dr. Tyler Smith’saper, and in a very forcible one by Mr. Harper, the ad-

visability of more frequently using this life-saving instru-ment is most strenuously insisted on. Unquestionably,however, this Society has still work to do in urging thispoint on the attention of the profession.Then, with reference to the form of the forceps, something

must be said. The tendency has been, in this country atleast, to employ an instrument too short in the blades. Oa.the Continent they have not fallen into this error. Atten-tion has been directed to this point in this Society; and ournoble exhibition of obstetrical instruments has contributedfacts of moment. There can be no doubt that the forcepsshould have tolerably long blades, and that it should havehandles giving the operator some little power.The last twelve years have seen much that is new in the

operation of turning. The true value and place of thisgreat operation has been more accurately defined. Our es-teemed honorary Fellow, Dr. McClintock, discussed thematter in a very able paper. The question between thehigh forceps operation and the operation of turning is hardto determine in a general way, and it is quite evident thatthe individual difficulty will always have to determine theindividual choice. Respecting the method of performingthis operation, Dr. Braxton Hicks has introduced a noveltya.nd a great improvement. It is hardly necessary for me tostate to you that the bi-manual method of turning, whichwe owe to Dr. Hicks, enables us to turn in many caseswhere it would be otherwise difficult or impossible. It is areal addition to our armamentarium. The new operationwill not, of course, supersede the old one, which must stillbe practised in many cases.Passing for a moment now to the destructive operations,

intended, however, to save the mother, we come to themethods of diminishing the size of the foetal head. Heremuch has been done in our Society in the way of improve-ment. Dr. Braxton Hicks has revived and developed a factreally stated by Hull and Burns many years ago, but lostsight of till now-viz., that the foetal head can be broughtthrough a very small aperture, when tilted so that the faceshall be first presented at the aperture, the cranial bonesand the lower jaw being first removed. The practical ap-plication of this fact will aid extraction in certain otherwisevery difficult cases. Another novelty in the same directionis the suggestion of Dr. Barnes’s to cut the head into seg-ments by means of a very strong wire, worked by anadaptation of the ecraseur mechanism.Next we come to the operation of cephalotripsy. Before

this Society was founded the cephalotribe was hardlyknown of at all in this country. We have now, in the in-strument of Dr. Braxton Hicks, a most portable and prae-tical instrument. Dr. Barnes, Dr. Matthews Duucan, andDr. Kidd, of Dublin, may be mentioned among those whohave in this Society done much to develop the use of theinstrument. Many cases admit of the extremely advan-tageous employment of this method of delivery, with the

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effect of saving the mother from possible lacerations inotherwise difficult craniotomy cases ; in fact, there is a greatdeal to be done with it. Short of this operation, we havehad a much improved craniotomy forceps from Dr. Barnesand Dr. Hall Davis.The vexed question of the Caesarean section has come

before us on as many as eight occasions. Dr. Greenhalghhas argued strongly in favour of the operation. Dr. BraxtonHicks, Mr. Bryant, Dr. Swayne, Dr. Newman, and Dr.Roberts have brought cases before us, all of which offerdata of importance. It must be said, I think, that the nu-merous improvements, which I have already adverted to, inthe method of extracting the foetus, very much lessen thefrequency of the necessity for recourse to this severe opera-tion, and that expert operators will in future succeed inextracting the foetus in cases formerly incapable of beingthus treated. On the other hand, the improvements insevere abdominal operations, such as ovariotomy, contributein some degree to lessen the danger of the Caesareansection. The general current of English thought is, andhas generally been, adverse to the Caesarean section ; butyet we cannot afford to put it on one side. Cases will nowand then occur calling for it, and we must be prepared ac-cordingly. Dr. Barnes has recently suggested an improvedmethod of suture for the uterine wound.The induction of premature labour is an operation whic

has engaged our attention on many occasions. We havefrequently discussed the relation which this child-savingoperation bears to other methods of delivery. It must bestated, I think, at the present time, that we are not yet de-cided as to what is actually the best method of inducingpremature labour. There is a. very remarkable paper inthe Transactions, by Professor Lazarewitch, of Charkov, inwhich twelve cases are related wherein the method of in-

jecting water to the fundus of the uterus was employed ;and no one can read the account of these cases without being struck with the safety and completeness with whichlabour was induced. Then we have the method of inducingpremature labour now known as Dr. Barnes’s method. Thisis unquestionably an exceedingly good, and it may be cha-racterised as being the best, method we have in our posses-sion for bringing labour to an end within a certain definitetime. Looking, however, to the great difficulty of conduct-ing the labour through its various periods safely to thechild, which is an important consideration in most of these.cases, it must, I think, be stated that we have not yet quitedecided as to what is the best method ; and there are stillsome, including myself, who think very highly indeed of’the method of simple puncture of the membranes.The curious subject of missed labour has been brought

before us by Dr. Wynn Williams, who has detailed addi-tional cases.

Every practical physician of the present day attachesgreat value to the thermometer. It was very importantthat we should know what changes the temperature of the’body underwent after the occurrence of parturition, in orderthat we might have some data to go upon in estimatingthe value of changes of temperature. That information hasbeen given to us in a valuable paper on puerperal tempera-tures by Mr. Squire.The diet which is proper during the puerperal state is a

subject which was brought before us in a very forcible man-ner by a late president of this Society, Dr. Oldham. And,so far as I have been able to see, Dr. Oldham’s statements’have produced a great effect in the practice of the profes-sion in this respect. Dr. Oldham contended strongly forthe adoption of a more liberal diet after labour. This is amatter which must be regarded as of great importance.A new term in reference to haemorrhage has been added

to medical obstetric literature since the formation of this’Society. We now recognise the existence of a form termed‘’°concealed accidental hæmorrhage,"—hæmorrhage, that isto say, occurring concealed in the uterus itself, capable ofimperilling the patient without necessarily causing a greatexternal loss,-a very dangerous complication of labour.This subject was brought before the Society, and severalcases were detailed, by Dr. Hicks. This is an actual additionto our knowledge.

I next allude to what has been put forward by thisSociety on the subject of placenta praevia. In a very inter-esting paper, Dr. Greenhalgh laid down, for the first timepublicly, so far as I am aware, this proposition, that in

a case of placenta prrovia the patient should not be allowedto go on to the full term of pregnancy ; that a woman withplacenta prrovia is constantly in danger of losing her life;and that the practitioner should exercise a special controlover that patient, if he does not think it advisable to in-duce the continuance of the labour at the time the difficultyis first observed. With reference to the methods of treat-ment of this complication, I think that the general currentof feeling in this Society is in favour of an eclectic method.I imagine there are few gentlemen of position in this Societywho would tie themselves to any one procedure in referenceto placenta prævia. On the whole, I think the Society hasexpressed itself in favour of rupturing the membranes, com-bined with turning, as generally the best procedure. The

partial separation of the placenta in certain cases, whichhas been suggested by Dr. Barnes, doubtless will be valu-able with the limitation which he himself describes.With reference to post-partum haemorrhage, I have little

doubt that, if the treatment of the third stage of labour pre-viously alluded to were generally practised and insisted upon,we should have very slight occasion to treat post-partumhaemorrhage at all. As tothe actual treatment of post-partumhaemorrhage, an important addition has been made to ourpractice in the injection of perchloride of iron into theterus in cases where other methods fail. This we owe to

Barnes. It may be said, I think, with reference to thissubject, that we have not yet determined that this remedyis entirely devoid of danger. I mention it therefore withthis slight qualification. Certainly the most importantthing we have to do is to prevent the patient from actuallydying under our hands from haemorrhage; but, in adoptingany remedy under such circumstances, we have to consideralso the possible secondary effects of this treatment. I donot state this, however, with any wish to discourage theuse of the remedy.With reference to transfusion, a remedy which we have

at hand in certain cases where other methods fail, we havehad valuable papers from Dr. Waller and Dr. Aveling. Itseems that the best method of performing this operationhas not yet been decided, although the matter has under-gone discussion over and over again. It must be admittedthat it is a remedy which is the only one capable of resusci-tating a patient in certain cases; and it is a remedy whichmust always be considered in alluding to the subject of thetreatment of hæmorrhage. It has saved many patients, andwill probably save many more. The difficulties in decidingon the adoption of the operation are always very great.

It has been pointed out that adhesions of the uterus onits peritoneal surface may give rise to post-partum hsemor-rhage, by preventing the contraction of the uterus. Caseshave been brought before this Society proving patho-logically the existence of this condition.With reference to rupture of the uterus, we have had a

very valuable paper from Dr. Radford, a well-known con-tributor. One of the chief values of this paper appears tome to be this, that it proves conclusively that the two chiefcauses of rupture of the uterus are, a slightly contractedpelvic brim, and a rather long labour. It is not cases ofsevere deformity in which rupture occurs, but a case ofslight pelvic deformity, and in which the labour has beenrather more prolonged than usual. Other causes have beenmentioned as inducing rupture of the uterus, but they arenot so certainly causes of this grave accident as those Ihave mentioned.With reference to inversion of the uterus, we have had

a paper from Dr. Tyler Smith alluding more particularlyto the mechanism of its occurrence. From the same gen-tleman we have also had a new explanation of retroflexionof the gravid uterus. Dr. Tyler Smith has pointed outthat, in the cases in which the gravid uterus is retroflexed,the retroflexion has generally existed previous to the occur-rence of pregnancy.On the subject of embolism and thrombosis we have had

some interesting papers from Dr. Barnes, Mr. Wade, andDr. Playfair. Women are liable to suddenly die during thefirst two or three weeks after labour; and the pathologicalexplanation is a very interesting one. The conclusion, asit seems to me, to be drawn from the cases brought beforethis Society, is the duty of preventing such an occurrence;and it would certainly appear that the condition which hasbeen most usually at fault has been a general weaknessof the system, making it, therefore, extremely advisable, as

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prophylactic, to sustain the strength of the lying-in womanin every possible way.On the subject of phlegmasia dolens we have had three

valuable papers from Dr. Tilbury Fox, in which the matteris fully considered.With regard to puerperal fever, whieh has been so

fruitful of discussion in obstetric history, we have had manypapers from Dr.Tilbury Fox, Mr. Mitchell, Dr. Beck, Dr. Hicks,Dr. Tyler Smith, and myself. Dr. Tilbury Fox has pointed outto us the close alliance between the occurrence of erysipelasin lying-in hospitals and puerperal fever, a connexion whichwas demonstrated by the figures he brought before us. Dr.Beck has pointed out the pathological fact of the uterusbeing found very large in cases where death occurred frompuerperal fever. Dr. Hicks has developed the relationwhich scarlet fever bears to puerperal fever, in privatepractice especially, with the effect of showing the great fre-quency of the connexion between these two. Next, a paperwas brought before us containing an account of the expe-rience of the Nightingale ward in King’s College Hospital,which has demonstrated, if it required demonstration, thegreat danger of placing puerperal patients in contiguitywith other patients, especially those suffering from surgicalaffections. Dr. Tyler Smith has brought before us a case inwhich he injected ammonia into the blood in the treat-ment of puerperal fever. With reference to the treatmentof puerperal fever in general, I think it has come out, fromthe discussions that have occurred in this Society, that,whatever may be necessary by way of prophylaxis, it is adisease in which copious stimulation is most important, ifthe patient is to recover.We come next to the subject of puerperal convulsions. In

this department Dr. Hicks has given us a novel patho-logical fact-namely, that in certain cases convulsions areapparently a prelude to the albuminuria. This is a matterwhich requires much further investigation. Dr. Hall Davishas given us a most valuable paper, containing the wholeof his experience of puerperal convulsions, treated mostsuccessfully on what may be called the eclectic method.Chorea in pregnancy has formed the subject of a valuable

paper by Dr. Barnes. The result was that, of the cases col-lected. 39 patients recovered and 17 died. Dr. Barnes, onthe whole, discountenances the theory which has been putforward of late years with reference to the etiology ofchorea-namely, the embolic theory; according to which itis held that the disease arises from the transportation ofcertain minute particles of fibrin from the valves of theheart to certain cerebral centres.

Eighteen cases of extra-uterine pregnancy have beenrecorded. In one or two of these the patients narrowlyescaped having an operation performed on them, whichmight possibly have saved their lives-namely, opening theabdomen and arresting the haemorrhage by surgical means.The diagnosis in these cases is so difficult that it will per-haps be still some little time before the operation is per-formed.With reference to abortions, Dr. Priestley has contributed

a paper in which he has urged on the Society the desir-ability of almost invariably endeavouring to remove thesecundines instead of leaving them in the uterus; arguingthat this is safer, on the whole, even in cases where the re-moval is somewhat difficult.We next come, gentlemen, to the consideration of what

has been done in the department of the diseases peculiar towomen. The various subjects pertaining to this have beendiscussed at great length and with great frequency in thisSociety, and various opinions have been expressed with re-ference to points many of which must be considered asbeing still debatable.On dysmenorrhcea, on flexions of the uterus, on inflam-

mation of the uterus, and on irritable uterus we have hadpapers read from Dr. Marion Sims, Dr. Greenhalgh, Dr.Barnes, Dr. Tilt, Dr. Meadows, and myself. Dr. Savageand others have also contributed valuable observations.It is certain that of late years great advances havebeen made in our knowledge of what may be termedthe mechanical diseases of the uterus, and in the rela-tion which exists between these mechanical diseasesand functional diseases, such as inflammation. I wouldnot presume on this occasion to speak dogmatically on thesubject, holding as I do views which are not quite sharedin by gentlemen very eminent indeed in this Society; but

I think we have come to recognise this, that the uterus isliable to be affected with certain important alterations inregard to its shape-alterations capable of exercising avery important influence upon other conditions which, per-haps, some might consider even more important-namely,the inflammations of the uterus. With reference to thesubject of dysmenorrhoea, I think it may be said that anoperation which some time since was very much vauntedfor the cure of this condition has come to be rather dis-countenanced-I mean the making of large incisions intothe uterus. I cannot say more, however, on this subject.The discussions which have taken place may be read withgreat advantage by anyone who chooses to inquire mto it.On the subject of ovarian tumours we have passed over a,

great deal of ground since the Society was first formed,twelve years ago. We have had as many as twenty-threepapers or contributions of various kinds relating to ovariantumours. Although ovariotomy was not first practised inthis country, yet it has come to be practised very largely;and the operation has afforded an instance of the fact, thatwhen the British mind does take up a thing it takes it upvery efficiently indeed. The success of this great operationhas, in fact, obtained for English surgeons and physiciansan extreme notoriety throughout the civilised globe. Theoperation is now performed in Stockholm, it is performed inGermany, and it has been performed in Australia and inIndia with success. This Society has unquestionably donevery much indeed te settle various points connected withthe performance of this operation.On fibroid tumours of the uterus and polypi of the uterus

we have had a multitude of papers, discussing various pointsin pathology connected with this subject, and describing-various methods of removing these tumours ; and many in-genious appliances have been brought forward for perform-ing the operations. At present, however, I suppose it canhardly be said that we have discovered how to prevent theformation of these curious growths in the uterus. We cancontrol their development in certain cases, but, unless wecan act upon them surgically and mechanically removethem, we cannot be absolutely certain of being able to dealwith them satisfactorily.With regard to cancer of the uterus we can say, unfor-

tunately, very little. Dr. Wynn Williams and Dr. Routhhave brought before us cases in which bromine has beenused as a remedial agent, and unquestionably with a goodresult in many cases which have been detailed to us. ButI am afraid we are not yet in a position to say that we havea remedy which will cure the disease.On the subject of retention of the menses, and the ope-

ration for relieving this condition, we have had some veryinteresting papers; also on the subject of vaginal operations,as well as some on the operations for the relief of prolapseof the uterus.

We come, in the next place, to the subject of the diseasesof children. The time of the Society was so much engrossedotherwise in the early part of its career that it must beconfessed that this subject was a little neglected. We had,however, a most interesting paper some years ago from Dr.Little, proving the connexion between difficulties in labourand the production of certain impairments of motor powerin the limbs. This paper has attracted comparatively littleattention.

’ Mr. Squire has given us a good account of the normal’ temperature of new-born children-very valuable indeed,

from the same point of view as the observation of the tem-perature of the mothers.

Dr. Tilbury Fox, in a paper on the etiology of rickets,propounded a theory in reference to the production of thisdisease deserving of a more attentive consideration and

’ extended investigation than it has hitherto received. Dr.Fox believes that in cases of rickets the child has beensuckled by a woman who has menstruated while suckling.her infant. This is a question which should be solved byinvestigation and further observation.On the subject of malformations we have had before us

as many as fifty cases, specimens and drawings of various.’ kinds, and the Society has collected valuable material on

the subject.In the next place, the Society has, on the suggestion of

Dr. Farr, entered on a serious and extensive investigation’into the subject of infant mortality in England, its causes

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and prevention. That work it has been engaged on duringthe last two years, and the general results of the investi-gation were communicated to you at the last meeting. Partof the result of the work of the Committee who conductedthe investigation is the production of the set of rules forthe general management of infants, now produced. Theserules have been very carefully drawn up and revised atseveral meetings of the Committee and Council, and arenow before you in a complete form. They will speedily becirculated by the Society as widely as possible. Followingother recommendations of the Committee, attempts willnow.be made to procure better enactments in reference toinfanticide, to the registration of midwives, and to enforcetheir better education.We have had a large number of papers before us on mis-

cellaneous subjects, which it is difficult to bring into theforegoing list of the work of this Society. We have had upwards of fifty instruments of various kinds exhibited atour meetings, to say nothing of the well-known great publicexhibition of instruments some time since held at the Royal,College of Physicians.

I say nothing of the indirect effect which this Societyhas produced upon the profession in reference to obstetriceducation. Many gentlemen have, through this Society,roceived what has been virtually their obstetric education.

I now, gentlemen, take leave of you as your President,tanking you very cordially for the manner in which youhave assisted me in performing my duties, and wishing theSociety an equally prosperous career in the future.

Clinical LectureON

CHRONIC HYGROMA OF THEBURSA PATELLÆ.

Delivered at the Queen’s Hospital, Birmingham.

BY JAMES F. WEST, F. R. C. S.,SENIOR SURGEON TO THE HOSPITAL, AND PROFESSOR OF ANATOMY IN

QUEEN’S COLLEGE.

GENTLEMEN,—The case we shall consider to-day is oneof considerable interest, and presents many peculiar fea-tures. It not only serves to illustrate a very common con-dition—housemaid’s knee,—and so affords me an oppor-tunity of briefly describing the varieties of that disease and their treatment; but it also enables me to bring under your-notice a pathological specimen of great value from its mag-nitude, and of no little surgical importance from the infre-quence of the successful removal of such growths. The

term " hygroma" means a hypertrophy of a bursa, whether caused by pressure or by acute or chronic inflammation. It

may occur to any synovial bursa, but is most commonlymet with in the bursa patellæ, and in that which overliesthe olecranon process.

I will read the notes as taken by my dresser, Mr. Hunt,and then notice the chief points of interest which arise outof the case.Mary H-, aged thirty, housewife, admitted into the

Queen’s Hospital, under Mr. West, Oct. 27th, 1869.History. - Eleven years ago she came to Birmingham

-from the country, and began to work as a charwoman.Whilst following this employment she had to kneel a greatdeal and she soon noticed a small swelling about the size’of a marble over the front of the left knee. She had no

:pain. in the tumour at first, but it soon got larger and be-came painful. It has continued increasing up to the pre--aer-t time, and has been very inconvenient to her, especiallyduring the past six months, not only on account of its size,but because of the pain it gives her to kneel. She is a veryhealthy woman in all respects except this, and she hasnever had any illness in her life. She cannot assign anycause for the disease, never having received any blow orilljury to the knee.

State on admission.—There is a ls,rge, globular, semi-solid

swelling over the front of the left knee, in the situation. ofthe bursa patellæ. The tumour is slightly movable in all

creased temperature of body, and no emaciation. She com-plains but little of pain in the tumour, except when sheis kneeling. The following are its dimension s :-Verticalmeasurement, 7 in. ; transverse ditto, 8 in. ; circumferenceat base, 12 in.Mr. West, judging the case to be one of hygroma, deter-

mined to relieve the patient by operation. On Nov. 1stshe was placed under the influence of chloroform. A trocarwas first thrust into the swelling, partly to ascertain thenature of its contents, and partly to reduce its bulk. Onlya small quantity of yellow opaque fluid escaped; and Mr.West then proceeded to remove the tumour. A vertical in-cision was made over the whole of the tumour, and it was

[Note.-These drawings were made by one of the students,Mr. Priestley Smith, who is now a dresser in the hospitalfor the sick and wounded at Bingen.]

carefully dissected out. It was found to be very adherentto the patella, and to have abundant vascular connexions