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March 21st. He has had all along a very distinct blue line onlower gum.

In this case it was impossible to apply pressure on accountof the position of the tumour. Dr. Wilks therefore prescribedlead, influenced, he said, in some measure by the success whichappeared to have followed that treatment in a case reported byDr. Daly in the London Hospital Reports, vol. iii. He con-fessed, however, the difficulty of explaining in what way im-provement is produced by the use of this drug. Lead has noinfluence in coagulating the blood. It acts probably throughthe nerves, constringing the smaller arteries. " Is it possible,therefore," Dr. Wilks suggested, "that the modus operaradimay really resemble that which Brasdor had in view whenpropounding his principle, and that deposit of fibrin takesplace in the aneurismal sac, because the circulation is dimin-ished by reason of the contracted state of vessels on the distalside of the tumour ? " The suggestion is a novel one, and, itseems to us, well worthy of careful consideration.

Clinical RecordsOF

THE PARIS HOSPITALS.

HÔPITAL BEAUJON.

CIRRHOSIS; ASCITES, MISTAKEN FOR AN OVARIAN CYST ; PUNC-TURE OF THE ABDOMEN, AND INJECTION WITH A SOLUTIONOF IODINE, FOLLOWED BY SYMPTOMS OF PERITONITIS; ŒDEMAOF THE LEGS ; PUNCTURE OF BOTH LEGS, PERFORMED WITH ALANCET ; GANGRENE OF THE RIGHT LIMB; DEATH.

(Under the care of M. DOLBEAU.)AN account of the above case will doubtless be found of

interest, because of the many important points of practicewhich it involves. No local or general symptoms of hepaticdisease were observed during life. Two distinguished noso-comial surgeons of Paris, Prof. Gosselin and M. Leon Lefort,mistook the affection for an ovarian cyst; and, acting uponthis opinion, the former punctured the abdomen, and intro-duced an injection of iodine into its cavity. Symptoms pro-bably of peritonitis, but which were not of a very decidedcharacter, then manifested themselves; they, however, gra-dually subsided, and the patient recovered from the attack.At a later period both legs became swollen. Puncture of thesurface was resorted to as a means of giving relief, whengangrene of the right limb ensued and carried off the patient-showing the risk of the proceeding under such circumstances.The patient was a woman aged thirty-nine, and mother of

a girl of fifteen. She had miscarried some years ago, throughthe ill-treatment of her husband, who had given her a kick in Ithe belly. Since then no symptom of illness had presented ’,itself. In the beginning of 1864 the abdomen became swollen,and distended so speedily that she was forced to seek admit-tance into M. Gosselin’s wards about the month of July.After having carefully examined the patient, M. Gosselincame to the conclusion that the case was one of ovarian cyst,and, under this impression, he punctured the abdomen andinjected a solution of iodine. Symptoms apparently of perito-nitis supervened, but gradually subsided. Nineteen days after-wards a second puncture was made, but this time without theemployment of any injection. A clear limpid fluid was ob-tained. The abdomen remained as large as formerly, and thepatient left the wards at her own request. She resumed herusual occupations without suffering any distress or notable in-convenience. The size of the abdomen diminished little bylittle, and three months later there was scarcely any tym-panitis. The physiological functions of the body were per-formed regularly, menstruation being quite normal.

In February or March, 1867, the legs became swollen ; theabdomen had gradually enlarged; yet the patient continuedher business, and could take long walks without any consider-able fatigue. In the month of November following, however,the enormous distension which the abdomen had then attainedcompelled her to seek for some medical succour, and she en-tered the wards of M. Dolbeau at Cochin. On November 19tha first puncture was made, and drew forth about eight litres offluid. On December 5th a second puncture became necessary,and about as much fluid ran out. M. Dolbeau then left the

service, and M. Leon Lefort, who succeeded him, diagnosedan ovarian cyst, thus confirming M. Gosselin’s view of thecase. On the 29th the patient left Cochin to follow M. Dolbeauto Beaujon. On the 31st puncture of the abdomen was made,and at the same time both legs were punctured in variousparts with a lancet, in order to give an outlet to the fluidwhich painfully distended the surface. In the evening ofJanuary 3rd the patient complained of intense pain in theright leg. The next morning the limb was covered with darkspots; the thigh was larger than the other. Diarrhcea andrigor on the same evening. The next day the countenance wasmost anxious, and the patient suffered intense pain in the leg.Application of compresses steeped in camphorated spirits ; ex-tract of bark, four grammes; sulphate of quinine fifty centi-grammes. On January 5th gangrenous patches appeared onthe legs. On the 6th the inner surface of the thigh showedsimilar spots. Diarrhcoa; intense pain; the patient sufferedgreat distress. On the 7th the mortified patches involved theposterior and outer surfaces of the thigh. The patient diedthe same evening.On examination of the body, the following morbid changes

were discovered :-Ascites, with the presence of about tenlitres of a clear fluid ; numerous adhesions between the omen-tum and anterior abdominal walls, between the transverse colonand the anterior edge and inferior surface of the liver. Theliver was much larger than in its normal state, and presenteda peculiar shape ; it was covered with round eminences; thesurface was rough ; the tissue tough and granular; the wholeformed a type of hypertrophic cirrhosis. The liver and bothlungs were closely adherent to the diaphragm. The ovarieswere quite healthy; the uterus occupied its natural situation.The internal saphena vein of the right extremity showed nosigns of inflammation.

A CASE OF SIMPLE CONTUSION OF THE THIGH, PRODUCED BYTHE PASSAGE OF A WHEEL ; SUBSEQUENT GANGRENE, DUE,PROBABLY, TO SOME INJURY OF THE FEMORAL ARTERY.

On February 28th, the patient, who is a carter, was broughtinto M. Dolbeau’s wards. The next morning, on being ex-amined, he said he was leading his horses, when he slippedunder the cart, and the wheel had merely grazed the limb. Hewas not then in a state of drunkenness. A large ecchymosissituated at the distance of a few centimetres above the kneesuggested the idea that the wheel had actually passed overthe limb in that situation. There was no fracture of thethigh-bone, however, nor any laceration of the soft parts. Thewhole of the thigh was enormously swollen, and at the injuredpart considerable tension and some slight fluctuation wereobserved. On making a puncture with a needle, a smallquantity of blood exuded. Proceeding with the examinationof the patient, M. Dolbeau’s attention was then struck by theexistence of other and important phenomena. The lower partof the leg had lost all sensibility, and was quite cold, whereasthere existed considerable hyperasstbesia of the parts whichhad preserved their sensibility. The beatings of the arterywere quite distinct, but ceased to be felt in the foot andeven at the posterior tibial artery. M. Dolbeau concluded thatthe artery had sustained some injury, and that mortificationmight be the result.

Since then the symptoms of the disease have been becominggradually more marked, and at the time we write all the partswhich at first showed signs of sensibility and of loss of heat, arecovered with mortified patches; the skin slips off under theslightest pressure of the finger; the surface is speckled withlivid spots. The question of immediate amputation of theleg presents some difficulty, as the ecchymosis above the kneealso shows signs of mortification, and a subsequent operationmight become necessary. The general state of the patient istolerably good. M. Dolbeau is of opinion that an obliterationof the artery has taken place at some indefinite point.

TUMOUR AT THE UPPER PART OF THE STERNUM, SUPPOSED TOBE OF A CANCEROUS CHARACTER.

The patient is a robust man, and was never ill before.Three months since he discovered the existence of a tumourwhich he bears at the upper part of the sternum. At presentthe tumour is about as large as a small apple. It cannot bereduced, is quite hard, and yet presents some fluctuation inthe centre. The skin does not adhere to it, and has preservedits natural appearance. Furthermore, the morbid growth isimmovable, and adheres very certainly to the sternum. The

patient says he has never been affected with syphilis, nor doeshe present any sign of this disease. His parents are healthy.

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Treatment with iodine, intus et extus, has as yet produced no favourable results. The notes of the above cases have been obligingly furnished

by MM. Bourgeois and Magdelain, M. Dolbeau’s house-surgeons.

___

MEDICAL SOCIETIES.OBSTETRICAL SOCIETY OF LONDON.

WEDNESDAY, MARCH 4TH, 1868.DR. BRAXTON HICKS, VICE-PRESIDENT, IN THE CHAIR.

THE following gentlemen were elected Fellows :-Mr. W. F.Butt, Dr. R. Dyce (Aberdeen), Dr. James Ellis, Dr. R. Fegan(Charlton), Dr. A. Godwin, Mr. G. A. Kenyon, Mr. J. R.Lynch, Dr. J. Nicholls (Chelmsford), Dr. G. J. Sealy (Wey-bridge), and Dr. C. W. Turner.

Dr. MURRAY exhibited for Professor Byford, of Cbicago, anew Pelvimeter. The instrument is a modification of Baude-locque’s Callipers, and by its aid the different diameters of thepelvis can easily and accurately be taken.

Dr. MEADOWS exhibited for Dr. Tanner two Ovarian Cysts,which had been removed by ovariotomy ; and although theywere believed to constitute the right and left ovaries, yet thepatient had menstruated regularly up to the time of theirremoval, the last period having ceased about a week before theoperation.A discussion ensued, in which Dr. Barnes, Dr. Hewitt, Dr.

Tyler Smith, Dr. Snow Beck, Mr. Chambers, and Dr. Murraytook part. It was generally considered either that a portionof one of the ovaries must still remain and be in a healthystate, or that the cysts removed and exhibited were reallycysts of the broad ligament separate and distinct from the Iovaries themselves. Dr. Meadows was requested kindly towatch the case, and report if menstruation again took place.

Dr. AvELiNC, of Sheffield, exhibited a new form of ShortForceps, the peculiarity being that the handles were muchcurved backwards, by which modification they were more outof the way of the operator, and a better grasp was obtainable.

Dr. MURRAY communicated for Mr. E. ASBURY aCASE OF RUPTURE OF THE UTERUS OCCURRING DURING

LABOUR.

This was the patient’s third confinement, and the two pre-ceding ones had been easy and natural. She had been inlabour but a few hours when the accident happened. Thelabour had been without complication, and the only differencebetween her condition on the present occasion and in her pre-vious confinements was, that there was now a much greaterabdominal enlargement than existed then. The rent in theuterus was transverse, about four inches in length, situatedlaterally and not far from the fundus. The edges of the lace-ration were inverted, and at the seat of rupture the walls werevery much thinned. The author considered the cause of rup-ture to be over-distension of the uterine walls, whereby theyhad become thinned and weakened, and that possibly degene-ration of muscular fibre had also taken place.

Dr. BARNES believed that Dr. Murphy was one of the firstto describe a softening or other alteration of the uterine tissuesas the cause of rupture. Since then the tissues had been oftenexamined. He himself had carefully examined the tissues inthree cases of rupture, and he had found no more degenerationthan that normal amount of granular change of the fibre-cellswhich always existed towards the end of pregnancy as a prepa-ration for solution of the tissues about to become superfluous ;certainly, then, although degeneration of tissue might some-times be present, it was not a constant or a nenessary condition.He had asked if the child in the case related had been deadsome time before the rupture. He had known this to be thecause of rupture. Where the child was long dead, it had lostits resiliency and its fitness for being driven through the pelvis,and thus might become as efficient a cause of obstruction aseven a narrow pelvis.

Dr. GRAILY HEWITT thought it likely that the abortionwhich had occurred had an influence in producing the irregu-larity in the thickness of the uterine walls in the case related.The undue size of the head was also an important element inthe case. As a matter of practice he believed it very difficultto ascertain in the early part of a labour whether the headwas unduly large or not, but it was a matter of some moment

in reference to cases such as this. The rupture of the uteruswhich occurred in this instance could not have been antici-pated, and it would appear that the treatment adopted wasmost prompt and appropriate.

A CASE OF CÆSAREAN SECTION.

BY J. BRAXTON HICKS, M.D., F.R.S.

The operation was performed by Dr. Hicks on a deformedwoman, aged thirty-seven, who did not come under his obser-vation till past the seventh month of pregnancy. The pelviswas found to be of the malacosteon type ; and although thebrim was much distorted, yet, had the outlet been good, de-livery might have been effected through it. Yet, as the bonyoutlet was very much narrowed, the parts very rigid evenwhen examined under chloroform, Dr. Hicks, after carefulconsideration, thought that the balance of chances was infavour of Cæsarean section rather than craniotomy, because itmight have necessitated Caesarean section after all. The lengthof the abdomen was very small, pushing the fundus of theuterus forward, and this would have added to the difficulty ofemploying the crotchet, which would have been the onlytractor capable of being used. The operation was done in theusual way under chloroform at the eighth and a half month,two doses of secale preceding it. No difficulty arose duringits performance. The uterus contracted well without hæmor-rha.ge. The wound was not closed with sutures. Vomitingcame on immediately, which caused expulsion of the uterinedischarges through the wound. This subsided, gradually tillthirty-six hours after the operation, when the discharges ceasedto flow per vaginam ; but vomiting having recurred, theywere extruded through the lower part of the external wound.From this time tympanitis came on, and rapid pulse withvomiting. A catheter was passed up the os uteri, and then atent, but no further secretion took place per vaginam. Shesank about ninety-six hours after the operation. Abouttwelve hours before death, the tympanitis having distressedher exceedingly, Dr. Hicks tapped the flatulent intestine witha very fine trocar and canula, letting off a large quantity offlatus to her great relief, so much so, that when it had reac-cumulated, she begged to have the tapping repeated, whichwas done with the same result. The child lived a month, anddied of thrush. The post-mortem showed a general blushover the peritoneum; no blood in cavity ; a trace in the linefrom uterine opening to the external wound; a patulouseverted wound in uterus ; a long cervical canal, not impervi-ous ; the uterine cavity entirely clear and healthy. Dr. Hicksdwelt in his remarks-first, upon one disadvantage of opera-ting before labour had set in, from the tendency to closure ofthe cervix; and, secondly, on the question of closing theuterine wound or not. He thought that had the wound beenclosed in this case, the serious complications would not haveoccurred. If it were found practically that the stitches weretorn out, perhaps one might take a hint from some of the suc-cessful cases where the uterus had adhered to the parietalwound, and suggested that we might carry the same suturethrough the external and uterine walls, whereby the intrusionof the uterine secretions into the peritoneal cavity would beprevented ; at any rate, it could not make matters worse thanthey now are. He then considered the state of the uteruswith two holes in it, one three times the size of the other.There was, when any pressure, as of vomiting, occurred, threetimes at the least greater tendency to flow out of the woundthan from the cervix, and there was much more tendency inthe cervix to contract than the wound. He thought thevomiting from chloroform a great danger in these cases, andinclined with Dr. Greenhalgh to the use of the ether spray.He finally remarked upon the mode of tapping the bowel inextreme tympanitis, that he had employed it in four cases withgreat relief, and without any mark of the operation afterwards,either by inflammation or extravasation of nuid or gas.Mr. SPENCER WELLS said that when he first suggested the

use of sutures to close the opening made in the uterine walls,at a meeting of the Society in 1883, as a means of preventingthe escape of blood or other fluid into the peritoneal cavity,and thereby lessening mortality after Cæsarean section, he badnot tried the plan, nor had it ever been tried, so far as heknew. And some speakers at that meeting thought thesutures not only unnecessary, as the uterine contractionswould close the opening, but might be injurious by setting upmetritis. But in 1865 he had put the plan into practice in theonly case in which he had performed Caesarean section. Thecase was published in the journals of that year, and he had

recently seen the woman quite well. He used a long piece ofsilk as an uninterrupted suture, leaving one end hanging out