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the fundus, and tied a shanked button on the vaginal sideof it, and with counter-pressure on the inside made suchconsiderable traction that the gut broke; a piece of strongChinese silk was then substituted for the gut, passed throughone side of the fundus at the thinnest part, the buttonattached as before, and with strong pulling I hoped to re-invert the uterus like the finger of a glove. No responsewhatever succeeded this, although the traction was great, somuch so that the anaesthetist warned me that the conditionof the pulse and respiration was affected by it to such anextent as to cause alarm for the patient’s state. There wasno yielding of the uterus whatever. With this statement in

mind, 1 was obliged to desist for a time, subsequently re-newing the same plan of traction with counter-pressure.Again the same warning was given me, and, as upwards ofan hour had been spent in these efforts, I was reluctantlyconstrained to forego further interference in this way.

It remained open to me at this period either (1) to removethe ovaries, and so arrest the menstrual return in the lifeof the patient, trusting that by this course the uterusmight become smaller and less sensitive as time wenton; or (2) to close the wound and make additionalattempts at reduction in the future by other means.To the first proposal I could not bring myself to assent,because in a young married woman it appeared tome to be wrong to deprive her of the chances of subsequentmaternity in case the uterus could be replaced, and alsobecause, with the manipulative interference which had alreadytaken place, her prospect of recovery would be diminishedand made less secure by the increased shock entailed bysuch a procedure. I had not either placed this contingencybefore the patient or her friends. The wound was thereforeclosed, and the patient returned to bed. There was much

depression afterwards, the pulse was 140, and the tempera-ture next day 104°, and I was afraid that some peritonealmischief might cause her to elude our grasp. By the 38ththe temperature became normal, but the pulse remainedquick (120 to 130), and did not come below 100 for somedays after. There was a rise of temperature on the ninthday to 103°, manifestly from some faecal impaction. Afterthis the patient did well, slowly regained her spirits, andstill more so her strength. Some discharge of blood wasconstantly present, and at the end of three weeks a sharpattack of profuse haemorrhage brought her down much,rendering it evident that something more must be done if thepatient was to get well. I decided that the uterus itselfmust be taken away if recovery was to become complete andpermanent, and elected the elastic ligature as giving themost success in cases hitherto narrated. A modification ofGooch’s canula was used, with round elastic passed roundthe cervix in the vagina, but this in tightening broke severaltimes, and was given up in disgust. I then arranged to usea succession of indiarubber rings, such as are used roundumbrella handles; one was slipped over the fundus to thecervix, the site of its position having been previouslymarked out by the thermo-cautery drawn all round, so as toform a groove. A morphia suppository was put in therectum. This was done on December 21st. There wasmuch pain afterwards in the back and hips; very littlesleep; much restlessness and anxiety exhibited; and onthe second day the temperature reached 103°, falling againon the fourth day. The pulse in this stage did not risebeyond 124. Detergent injections were used every three orfour hours, the vagina being thoroughly washed each time, andquinine given internally. This ligature was not interferedwith for some days, and on examining it on January 1st I wasgratified to find that the body of the uterus had shrivelledup and become inert, being attached only by a thin band ofdark tissue, which was cut away with scissors. The patientimproved daily, and gained in strength much more rapidlythan heretofore; there was little soreness of the stump.She was discharged on January 14th, feeling very well.At this date there could be felt a small os uteri on a bit ofcervix, which to a casual observer might readily be inter-preted as an ordinary condition. The patient has been seenseveral times since, and lately expresses herself as feelingstrong and well, better in herself than she has ever beenbefore.There have been instances where an inverted uterus has

been replaced after a much longer period than this, and I amnot unacquainted with the numerous methods of restitutionwhich have been advocated, but each case must be con-sidered on its own merits where there exists so much

mobility of the uterus with a very flexible vagina, and such

complete involution of the inverted uterus, coupled "Withsevere constitutional strain. After failure of properly eon-ducted and repeated taxis, there is yet a field open for theway of cure, which in this instance was most effectuatraversed by the elastic ligature in the way I have described.Birmingham.

A MirrorOF

HOSPITAL PRACTICE,BRITISH AND FOREIGN.

ST. THOMAS’S HOSPITAL.TWO CASES OF LIGATURE OF THE SUBCLAVIAN FOR

AXILLARY ANEURYSM; CURE.

(Under the care of Mr. SYDNEY JONES.)

Nulla autem est alia pro certo noscendi via, nisi quamplmimae et mot-borum et dissectionum historias, tum aliorum tum proprias col1ect>$habere, et inter se oomparare.—MoRaAQNt De Sed. et Caus. dfor6.,lib. iv. Prooemium. -

THE following cases of aneurysm of the axillary arteryare interesting as well-marked and successfully treated

examples of this disease. The first case is more especially so,from the fact that the man had three years previously beencured of an aneurysm in the popliteal space, notes of whichwe published in THE LANCET at the time. In both thetumour was above the pectoralis minor and encroached onthe clavicle, and in the first case excessive use of the armhad probably to do with its seat, there being a specialliability to aneurysmal swelling. In the second case the

tearing of the diseased artery was a serious complication ofthe operation. But after the application of the ligaturesthe vessel was in a similar condition to what is produced bythe application of two ligatures and division of the arterybetween, a not unfrequent method of treatment. The strict

antiseptic precautions adopted, with the prevention of sup-puration, were undoubtedly great elements in the preven-tion of complications during the progress after ligature,and lessened the danger from secondary haemorrhage, whichwas feared might occur, as one ligature was applied not farfrom the aneurysmal sac, on an artery softened by disease.For the notes of this case we are indebted to Mr. C, S.Evans.CASE 1.-W. H. E-, aged thirty-three, a well and

powerfully built man, above the average height, of fair com-plexion, with red hair and of nervous disposition, wasadmitted on June 12th, 1885. The patient was a farmbailiff, apparently in robust health, but with a somewhatanxious expression, complaining of constant aching painin the right shoulder-blade that had existed for the pastseven months, and of a throbbing swelling under the rightcollar-bone, noticed three days before admission. This

swelling he supposed to be an aneurysm, having been underthe care of Mr. Sydney Jones in 1882 with a similar swellingin the ham, which had been successfully treated by digitalcompression. There was no history of aneurysm in thepatient’s family; a grandmother on the mother’s side was,however, believed to have had heart disease, and an uncleon the father’s side frequently suffered from gout. Both

parents are still living and in good health. The patient hadalways lived in the country, engaged in hard manual labourof a variable character, with occasional intervals of two orthree days at a time, when he used to come up to town, andadmits having indulged in alcoholic and sexual excesses.At the age of twenty he had chronically enlarged tonsils re-moved ; when twenty-three he contracted a chancre andbubo, but evidence of syphilitic sequelae was wanting. Fouryears later the right elbow was excised for chronic diseaseof the joint. Three years after this (in 1882) the poplitealaneurysm appeared, since which time, as advised, he has dis-continued the practice of drinking spirits, but still admitstaking three pints of beer daily on an average.’’ About amonth before last Christmas the patient woke one morningwith a pain in the right shoulder-blade, so acute that hereturned to bed shortly after getting up, finding the painless on lying down. He had been doing some heavy spade-work, carting manure, shortly before, but did not at the time

1 Vol. ii., 1882, p. 1030.

803

associate this with the pain, so that there was no definitehistory of an exciting cause of over-exertion, as in the formeraneurysm. He resumed work, however, attributing the pain,as before, to rheumatism, and took no further notice of thediscomfort until three nights before admission, when heput his hand by accident upon a pulsating swelling underthe right clavicle.On examination after admission, the hollow below the

outer third of the right clavicle internal to the deltoid wasfound filled up, but not replaced by any marked prominence.Over a corresponding area, extending two inches and threequarters down from the clavicle and two inches inwardsfrom the coracoid process, pulsation could be both seen andfelt, distinctly expansile, but unaccompanied by thrill. A

single systolic bruit was heard, most loudly just below theclavicle, of a soft, scraping character. The outlines of thetumour were not clearly defined, but corresponded with thevisible pulsation. Above the clavicle there was some increaseof pulsation, but no tumour to be made out. The axilla was,if anything, deeper than on the left side. Pulsation couldbe completely arrested by pressure on the subclavian abovethe clavicle. The right radial pulse at the wrist was

markedly weaker than on the other side. The heart’s apexbeat was an inch and a half below the nipple and justexternal to it, but without abnormality in the sounds. Thearteries were not anywhere obviously thickened. The liverappeared to be diminished in size, but the other organs werehealthy. There was nothing to be felt of the old leftpopliteal aneurysm, but the foot on that side was colder,and there was much less pulsation in the posterior tibialand dorsalis pedis on that side. The right popliteal could befelt beating. The femorals pulsated normally and apparentlyequally on both sides. The patient was ordered to keep hisbed, and was put on milk diet. The pain continued to increase,even with the arm elevated by a sling, and he slept badly.On June 17th Mr. Sydney Jones, after consultation with

his surgical colleagues, decided to tie the subclavian atonce, judging the patient unlikely to tolerate digitalcompression well, and taking into account the increaseddifficulty of the operation after an unsuccessful attempt.The patient was accordingly put under ether, which he tookbadly and in large quantity. The shoulder was washedwith carbolic acid (1 in 20), and the usual incision was thenmade for tying the subclavian in its third part. The arterywas exposed without any particular difficulty, lying ratherdeeply; it appeared so distinctly dilated at the distal endthat Mr. Sydney Jones prolonged the incision into the sterno-mastoid far enough to expose the scalecus, and then tied thevessel with thick catgut at the highest attainable point.The spray was not used. A small drainage-tube was inserted,the wound powdered with iodoform, and four or five suturesintroduced. Iodoform gauze, salicylic wool, and carbolicgauze bandages were used for the dressing, with sandbagsfor the fixation of the head, and a flannel bandage to securethe arm.June l8th.-10 A.3i. : Temperature normal. The patient

said that the old pain in the shoulder-blade was quite gone,and that he passed a better night than he had done lately.The temperature rose to 994°. Milk and ice only allowed.19th.-Temperature in the evening 99-2°. Slight aching

pain in the arm and hand is complained of. The patient isnot disposed to be restless.20th.-The temperature never subsequently rose above

98’8°. The wound was dressed in the evening for the firsttime, and found united by first intention all along. Thestitches were all removed, except one beyond the tube, andthis latter was shortened.

23rd.—Bfef-tea, and Brand’s essence were added to themilk for diet. The wound was dressed again, and thedrainage-tube removed.26th.-The wound has quite healed, except just at the

site of the drainage-tube. No pulsation has yet been feltin the sac of the aneurysm or in the radial at the wrist.The whole right arm is warmer, moister, and redder thanthe left; the nails have distinctly grown less rapidly; onpressure being applied sufficient to blanch one of the finger-nails, the blood returns more rapidly than on the left side.No pain is complained of. The patient sleeps well, andsays he feels quite well.28th.-The wound is now completely healed throughout.July 1st.-Pulsation could be felt to-day in the radial of

the right side. Fish and eggs were added to the diet. Thepatient had, in short, no bad symptom, and some days laterwas allowed to get up, keeping the arm still bound to the

side. Pulsation was just perceptible on several days sub-sequently, but did not persist.He was discharged on July 18th. When seen three

months later, there was no return of pulsation, either at thesite of the aneurysm, which was contracting, or in the radial.CASE 2.-The patient, a stoutish, thick-necked, well-

nourished, healthy-looking man, aged sixty-four, consultediNIr. Sydney Jones on Aug. 8th, 1885. He had suffered from

pain about his shoulder for from eight to ten years, and aswelling had appeared about two months previously belowhis left collar-bone. On examination this was found to bea rounded pulsating swelling below the outer third of theclavicle, pushing it upwards and partly overlapping itslower border ; it was almost the size of half an orange, wasfirm and elastic, not tender, but somewhat painful. The

pulsation in it was easily controlled by pressure applied tothe subclavian artery, this also arrested the pulse at thewrist. There was a distinct bruit to be detected in theswelling. There did not seem to be any difference in the twopulses. There was no evidence of cardiac disease.On August 15th Mr. Sydney Jones ligatured the sub-

clavian in its third part; this operation was somewhatdifficult on account of the shortness of the neck and theextent to which the clavicle was pushed upwards. Etherwas given, and the usual incision for ligature of the arterymade. There was much venous distension, and the externaljugular, being in the way, was ligatured in two places anddivided between. The subclavian was deeply placed, but,after a careful dissection, it was exposed and the aneurysmneedle passed from below upwards. The artery, which wasthinned, tore at this stage a short distance above the

aneurysm, and there was a sharp gush of blood. Arteryclamp forceps were quickly applied, and the vessel securedabove and below the opening; this opening was seen infront of the vessel, and was about three lines in extent.Chromic acid ligatures were then passed carefully round andtied on each side of the tear in the artery. The pulsationquite ceased in the aneurysm. The operation was performedunder the spray, and antiseptic dressings were applied afterthe insertion of a drainage-tube and the closure of the wound.The subsequent progress of the case was most satisfactory.

The dressings were changed on Aug. 20th, when the woundhad healed, excepting at the ends of the incision throughwhich the drainage-tube passed. There was hardly anydischarge. It was dressed again without the spray on the24th, 27th, and 31st, and on Sept. 2nd and 5th. The left radialpulse could be felt on Aug. 26th. The patient complainedof no pain. During the first night he was rather restlessand suffered from dryness of the mouth and thirst, butbeyond this had nothing to complain of excepting constipa-tion later on, for which he required frequent aperients.The highest temperature after the operation was 988°, andthe lowest 962°; the average would be H7’5°.He was last seen on Oct. Jth. He had lost all trace of

the pain which he had suffered from previous to the appli-cation of the ligature. The aneurysmal swelling was rapidlycontracting and firm, though still connected with the lowermargin of the clavicle ; of course all pulsation had ceased.

LIVERPOOL EYE AND EAR INFIRMARY.GUMMA OF THE OCULAR CONJUNCTIVA ; CURE ; REMARKS.

(Under the care of Mr. CHARLES G. LEE.)A. W-, aged forty-four, single, by occupation a

labourer, applied for advice at the out-patient depart-ment on July 18th, 1885, and gave the following history:-Fourteen days ago he got very wet while working in thesewers, and in a day or two subsequently noticed that hisright eye became inflamed, especially at the inner corner,but, supposing it to be a simple cold, paid no attention to ituntil three days before coming to the infirmary, when alittle discharge came away. He has not, however, had anytreatment up to the present time. He has always had goodhealth with the exception of an attack of venereal diseasecontracted twenty years ago, which consisted of a chancre,followed by a rash on the skin ; about this time also his haircame off in large quantities. He was treated by a herbalist,and persistently denies any venereal complaint since this.Last Christmas he commenced to suffer with a sore-throat,and this continues to the present.Present condition.—The patient is a tall spare man of only

poor muscular development considering his occupation ;