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there was considerable dilatation, with slight hypertrophy.There was a large effusion of blood under the serratus

magnus on the left side, containing 24 oz. of imperfectlyplotted blood. The liver weighed 193 oz., the spleen b7 oz.;there being some capsulitis of the spleen, with haemorrhageson the surface. Blood turbid, and of a.chocolate colour. No,change in marrow of sternum.

HOSPITAL FOR SICK CHILDREN, GREATORMOND-STREET.

DIFFUSE OSTITIS OF TIBIA.-CHEIRO-POMPHOLYX.

(Under the care of Mr. EDMUND OWEN.)FOR the notes of the following cases we are indebted to

Mr. R. C. Priestley, registrar.CAss 1. Di,use ostitis of tibia.-A boy of twelve years of

age has been in the Louise ward since March 20th withgeneral enlargement of the left tibia. His mother had sixweeks previously first noticed that the leg was swelling, butthe changes must have been going on much longer than that,for at the time of his admission there was not only generalthickening of the entire bone, but the bone was greatly bowedforwards, and was increased in length by at least a quarter ofan inch. There were slight redness, oedema, and elevation oftemperature in the skin over the shin, and the bone wasevidently tender. The patient was the youngest of seven.children, and was apparently the only unhealthy one in thefamily. He has suffered from otorrhoea and headaches at,various times. He has never hurt the diseased tibia. Hisfather died of some lung disease; his mother has had nomiscarriages. The boy certainly had not the characteristicappearance of inherited syphilis, though he did not lookhealthy. There were delicate white scar& of radiating linearulcerations at the corners of the mouth, and there was a.suspicious pegging of the left lateral incisor. In thecrescentic notch which its narrowed crown presented, how-ever, there was a small tubercle such as one does not expectto find in a Hutchinsonian tooth. As regards the centralincisors of the upper jaw-the "test-teeth,"—all that onecan affirm is that their long axes sloped downwards towards,each other.For a week or two the boy was kept in bed, and was

watched to see if he would improve without antisyphilitictreatment; but he made no progress until small doses of.grey powder were regularly administered. After this thelocal conditions became considerably improved; there wasless tenderness about the bone, whilst the skin was no longersmooth and shining, but its cuticular layer was thrown into’delicate wrinkles, showing a general diminution of vasculartension.Remarks by Mr. OwEN.-Diffuse interstitial osteitis in

children is generally the result of hereditary syphilis, butin this case no direct evidence of the congenital diseasecould be obtained. But the supicious obliquity of the,central incisors, the doubtful notch in the left lateralincisor, and, above all, the radiating linear scars at the

angles of the mouth, when taken together, afforded strong.circumstantial evidence of the specific nature of the disease.And to all this the improvement under the administrationof the small doses of grey powder added further con-firmation.

CASE 2. Cheiro-pompholyx.-Emily C-, aged ten years,healthy-looking and vigorous, was admitted on March 8thiaat, with a fairly good family history; at any rate, therewas no reason to suspect that she was the subject of anyhereditary taint. One Saturday last summer she went fora holiday to Hackney Downs, and, getting very hot, she’drank a large quantity of cold water. On her return homeshe complained of great pain in the feet, and the mother, onexamining them, found the soles studded with a crop ofblisters of various sizes, which she thought might possiblybe due to pressure from the boots. Since then, however,the child has had periodic attacks of blebs upon the palms 11,of the hands as well as on the feet. They last for abouta week, and, disappearing, leave the parts extremely z,tender.

’

On admission, there was one large bulla containing clearfluid on the plantar surface of the right great toe, andanother still larger over the second and third metatarsalbones. There was also a large bleb under the heel, andthera were some small ones on other parts of the sole. Thebleb3 wera tender, and the surrounding skin was red. A

day or two after admission the child developed a rash oflichen urticatus on the flexor aspect of the legs and arms.She was prescribed liquor arsenicalis, and in due course allher troubles disappeared. As, however, she affirmed thatthe blebs appeared upon the hands and feet regularly everymonth, she was, though apparently in excellent health, keptin the hospital for a week or two beyond the month; buther statement was not verified. She is still to be kept undersupervision.. ,Remarks.-Pemphigus of the hands andfeet is a sufficiently

rare disease, even in childhood, to justify the publication ofthis typical case. What may have been the cause of the firstoccurrence of the disease is uncertain. Although the childhad been running about all day, the blebs did not appear,merely because she was footsore-the fact of the handsbeing subsequently implicated is evidence of some generaldisturbing cause, which probably acted through the nervoussystem.

___________

BOLTON INFIRMARY.A CASE OF MULTIPLE SARCOMATA; DEATH; NECROPSY.

(Under the care of Dr. GILLIBRAND.)FOR the following notes we are indebted to Mr. E. C.

Kingsford.Rebecca R-, aged forty-five, was admitted on Jan. 9th,

1888, for persistent vomiting. The family history wasunimportant. She has been married fifteen years, and hadseven children, six of whom are living; one miscarriagebefore birth of second child. Menstruation had been regularup to the previous June; she had seen nothing since then,and at the time of admission again commenced to men-struate. She had always enjoyed good health, but at theend of October was seized with frequent vomiting, whichwas preceded by pain in the left side; this lasted for fivedays. There was then abatement of symptoms for threeweeks, after which they recommenced, and continued withmore or less severity up to the time of admission. Previouslyto October the patient had been comparatively stout, buthad since been getting rapidly thinner.On admission she was much emaciated, with dry shrivelled

skin, and some bright petechise scattered over the chest;these she had not noticed until her attention was drawnto them. Cardiac sounds normal. Dulness at left apex,with absence of respiratory murmur and vocal fremitus.Temperature normal. No headache. Optic discs normal.No abdominal tumour to be felt. Aortic pulsation quiteperceptible. Vaginal examination showed the os to berather low down, expanded in all directions, and quitesmooth. The uterus was freely movable, and the ovariescould not be felt. There was a small impressionabletumour on the upper surface of the left clavicle aboutits centre, painful on pressure; and a resistant mass in theposition of each thyroid lobe, that on the right side beingabout the size of a large horse bean, and that on the lefttwice as large; these were not painful on manipulation, andno other such tumours could be found about the body.Vomiting occurred frequently, quite irrespective of the inges-tion of food, and was always preceded by a sensation in thethroat in the neighbourhood of the thyroid. Urine normal.The vomiting continued, but varied considerably from day

to day, and was always more severe in the early morning.On Jan. 22nd she first complained of headache at the vertexand in the frontal region, and the next day had two epilepticseizures, the left arm being chiefly implicated; she hadnever been affected with anything like a fit before. On the24th the right optic disc was found to be slightly blurred,the left being normal, as were also the fundi and vessels.She was allowed to get up on the 31st, not having vomitedfor a week, but was immediately seized with headache and

sickness. From this time onward the headache persisted,being most severe in the upper occipital region; and she wastroubled with coughing, hiccough, and vomiting, althoughshe was able to take her food fairly well.-Feb. 9th: Rightpupil dUa.ted.—lOMi: Another epileptiform fit, followed byparesis of the left arm and slight bronzing of the skin, wasnoted, but it did not increase. Cardiac impulse felt outsidethe nipple line, and on the 19th it was reported as abové thelevel of the nipple, in a line with the anterior axillary fold.Pulse 136; temperature normal; respiration easy. A fewmore petechise had appeared on the abdomen, and albumenwas found in the urine for the first time, but not in any con-siderable quantity, and after three or four days it disappeared

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altogether. The patient now began to pass urine andfsecea in the bed.-March 1st: Both pupils dilated; bordersof optic discs very indistinct.-12th: Temperature "ene-rally subnormal; emaciation much increased; pulsation ofabdominal aorta clearly visible. No tumour could be felt;the pelvic region, however, was too tender to allow of pal-pation. Food taken freely, but only in small quantities ata time.-April 3rd: Extremely low; could not talk; gaped atfrequent intervals; perspired freely. Temperature 97°;pulse 140. Optic discs pale, ill-defined, and fluffy at

margins; small retinal haemorrhages in both eyes. Sherallied slightly after this for a day or two, and then graduallysank, dying on April 12th.Post-mortem examination revealed a large tumour in-

volving the base and upper part of the left lung; also threefirm tumours, about the size of horse chestnuts, in the bodyof the pancreas, the rest of the organ being narrow andshrunken; a white, softish mass, about the size of a hen’segg, replaced each suprarenal body; in place of the left ovary,there was another mass, made up of small, solid, and semi-fluctuating tumours, and a small cyst in connexion with theright ovary. The cerebral hemispheres were quite healthyin appearance, but in the cerebellum, at its junction withthe pons, was a soft tumour, about as large as a pigeon’segg, which extended to the surface at the under part of theleft lobe, having the appearance of a patch of softening;the fourth ventricle and commencement of the spinal canalwere much expanded, but communicated freely with thesubarachnoid space. All these tumours, as well as that ofthe clavicle and thyroid body, and one found on the innersurface of the second left rib, have been examined micro-scopically by Dr. Yates, and found to be small-celledsarcomata. The stomach was small and contracted, other-wise healthy, as were also the intestines. All the otherviscera were normal, and the liver weighed 48 oz ; no

enlarged glands found. Unfortunately the sympatheticsystem was not examined, nor was it noticed whether themediastinal growth pressed on the thoracic duct or involvedthe pneumogastric nerve.

e?Kr.—From the onset of symptoms it seems probablethat the ovarian trouble was of the longest standing, andthat the brain lesion occurred considerably later. Themediastinal growth existed at the time of admission, but,judging from the rapid emaciation, was in all probabilitypreceded by the post-peritoneal mischief.

Medical Societies.ROYAL ACADEMY OF MEDICINE IN IRELAND.

Treatment of Sterility and ObstructÌ1Je Dysmenorrhaea.-Five Cases of Abdominal Section.

A MEETING of the Obstetric Section of the Academy washeld on March 16th.

Dr. DUKE exhibited a Uterine Cervical Dilator, constructedon a new principle, and intended for rapid dilatation.-Dr. MORE MADDEN said he had seen Dr. Duke’s dilator usedwith good effect in some cases of stenosis of the cervix inhis hospital; and if members of the Section used it hebelieved they would admit its efficacy in appropriate cases.

Dr. MORE MADDEN read a paper on the Treatment ofSterility and Obstructive Dysmenorrhoea. He said that inthe recognition of stenosis, either of the uterine cervicalcanal or of the Fallopian tubes, will be found the best key tothe study of the pathology and to the successful treatmentof both these closely associated morbid conditions. Thefrequency of such cases is far greater than is generallyadmitted, and in his own hospital they furnished nearly11 per cent. of all the gynseoological cases there treated. Ofall the ailments of female life, few give rise to greater ormore persistent suffering, or produce more disastrous effects,not only on the general physical health, but also on the cere-bro-nervous system, and on the moral constitution of thepatient, than result from well-marked obstructive dysmenor-rhoea. The importance of the last-mentioned consequenceof dysmenorrhcea-to which he directed special attention inan article of his on the Disorders of the Female SexualFunctions, in Quain’s Dictionary of Medicine-is by no

means so generally recognised Be it should be. Theeffects of the second of the morbid conditions that form

the subject of this communication are certainly of no lessmoment in a practical aspect than the results to which hehad just referred as consequent on the first-named ailment;the latter involving, as they may do, not only the physicalhealth and well-being of t 1e patients, but also, in too manyinstances, intimately affecting their social interests and thehappiness of conjugal life.-Dr. W. J. SMYLY believed thatthe frequency of stenosis had been greatly exaggerated.-Dr. MASON said there was no doubt that obstructive dys-menorrhcea complicated with sterility was an exceedinglycommon complaint, and was a cause of great physicalsuffering and mental trouble. He held that, once the cervixwas divided bilaterally, there was no necessity for dividingit any more; and the use of Dr. Madden’s dilator was, hethought, calculated to cause a danger of pelvic inflammation.The treatment he (Dr. Mason) ordinarily followed was todivide the cervix bilaterally for its entire length, enlargethe opening of the os externally with a scalpel, and thento apply some astringent-perchloride of iron-in somecases, and to plug the vagina in others. A number of tb&women operated on for this disease became pregnant after-

! wards, but that number was not large in proportion to thenumber of operations. The number of cases relieved by opera-tion was, ho wever, large; a fair prospect of cure might be heldout to every patient operated on for dysmenorrhcea.—Dr.ATTHILL said the first question was, Did stenosis of the cervixever per se cause dysmenorrhoea? He was inclined toanswer that question in the negative. He had seen instances in which the os uteri was so small that he couldonly get an ordinary surgical probe into it, and in which,nevertheless, there was no dysmenorrhoea. But that theymight have cases of dysmenorrhaea indirectly depending ona small pinhole os uteri and a conical cervix was perfectlytrue. He also totally denied that a small cervix was per sea cause of sterility. In cases of small os uteri, where therewas no dysmenorrhoea, the uterus and cervical canal weranearly always what was termed infantile or rudimentary,and menstruation in those cases was nearly always scanty,but in the main perfectly painless. In nearly every case ofstenosis of the uterus in which pain existed there was amore or less unhealthy condition of the uterine mucousmembrane, which was vaguely termed uterine catarrh-the catarrh being a symptom and not a cause, the latterbeing some form of intra-uterine disease. He looked ondivision or dilatation of the cervix in those cases as

the first step towards the cure of the dysmenorrhoea, andconsequently the first step towards the cure of sterility.In many cases he divided the cervix, and treated the uterussecondarily for sterility, and very often with great success,where there was no dysmenorrhoea at all. It was his opinion,and had been for many years, that the cases of dysmenor-rhoea and sterility in which there were a conical cervix andsmall os could never be cured without first dividing thracervix. But division-or dilatation, if that were preferred-was a step towards completing the cure, the rationale beingthat by making the cervix uteri free the escape was allowedof the pent-up discharges, which otherwise caused irritationand pain. With respect to the modes of making the uteruswide, in the first place he entirely disapproved of dilatationas a cure. He had seen it tried over and over again, andthe patients pronounced to be cured because they were freefrom the dysmenorrhoea, and after a couple of months allthe symptoms would return.

Mr. O’CALLAGHAN read the following notes on five casesof Abdominal Section. Case 1: Pyosalpinx with Tumour(age twenty-six). On opening abdomen found tube on pointof rupture bound down with extensive adhesions, withintra-ligamentous tumour growing from uterus and fillingout the broad ligament. Aspirated tube and washed it outwith strong carbolic lotion. Dr. William Smyly agreedwith him that it would be wrong to attempt removal oftumour or the tube under the circumstances. Closed wound,which healed by first intention. Marked improvement inthis case; died in nine months after; tumour proved malig-nant.-Case 2: Fibro-sarcoma (age seventeen). Tumourpresented in right side, with history of rapid growth in sixmonths. On opening, found a large nodulated tumourattached to the ’outer margin of broad ligament. Heenucleated this, hmmorrhage at this stage being verybrisk; but the capsule being very thin from size oftumour, he was able to shell it out quickly; bleeding,easily controlled by pressure with sponges, and, tyingtube and bed of tumour with Chinese silk, as used by Mr.Tait, washed out peritoneum, closed wound without a drain,