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development, which he had observed in 1869 (Boston Medical and Surgical Journal). He was sure that the development of the lower extremities in the present child had been arrested, since there was no case of spontaneous amputation on record in which these small sprouts remained at the ends of the limbs. Virchow had first called attention to this important difference.

INCLUSION OF A PIECE OF OMENTUM IN A PERFORATED GLASS DRAIN

AGE-TUBE.

DR. HUNTER Showed a glass tube, used for draining the abdominal cavity after laparotomy, the lower fourth of which was filled with omentum that had entered the lumen through one of the small perforations in its side. Tait's operation had been performed four days before at St. Elizabeth's Hospital, and a drainage-tube was inserted on account of hemorrhage. The patient was doing perfectly well, her temperature being normal. He endeavored to remove the tube the previous evening, but was unable to do so. That morning he used some force, twisting the tube entirely around, when it was withdrawn, carrying a piece of omentum with it. The patient had a good deal of pain at the time, and there was slight bleeding, but no ill effects had followed the manipulation. The accident was a forcible illustration of the danger attending the use of perforated tubes.

DR. GILLETTE thought that the holes in the tube were unusually large.

DR. WYLIE said that he preferred straight tubes either without perforations, or with very minute openings.

DR. SKENE, in reply to a question from Dr. Hunter, said that the present tube was not one of Keith's drainage tubes, since the openings were three times as large as those used by that surgeon. DR. HUNTER said that his tube had been purchased in Edinburgh as the variety recommended by Dr. Keith.

THE PRESIDENT asked if Dr. Skene preferred perforated tubes. The latter replied that he did not, unless the holes were very small.

DR. HUNTER replied that he had frequently used such tubes, and had never before had such an accident as the present one.

THE PRESIDENT did not believe that any particular object was gained by using perforated tubes. If a tube was sufficiently long to reach to the bottom of Douglas' pouch, it was enough for any ordinary purposes of drainage.

ATTEMPTED REMOVAL OF A SESSILE INTRAUTERINE FIBROID-DEATH FROM SEPTICEMIA.

THE PRESIDENT showed a uterus which had been removed postmortem from a patient at Mt. Sinai Hospital. She was admitted into the hospital October 22d, on account of profuse metrorrhagia. She was 40 years of age, had been married twenty years, and was last pregnant fourteen years before. She had been flowing profusely for three years. On examination, the fingers could be passed through the os and almost to the fundus, where a sessile mass was detected. An attempt was made on four successive days to dilate the internal os by means of tupelo tents.

These

latter unfortunately did not remain in position, so that when the last were removed just before the operation on October 28th, only the external os and cervix were found dilated. Hoping to secure sufficient dilatation during the operation, the capsule of the tumor was freely excised, and an attempt was made to remove the growth with a spoon-saw. The tissue was so soft that it was impossible to grasp it with volsella-forceps, as they tore out. After working for an hour, it was found that the tumor was so firmly attached to the uterine wall, that its complete removal could only be effected at an imminent risk of perforating the uterus. He accordingly decided to leave the rest of the mass to slough out. The patient, who was previously in very bad condition, rapidly developed septicemia and general peritonitis, and died on November 8th, ten days after the operation. The case was cited because it illustrated the extreme difficulty of removing soft intrauterine fibroids, which were high up in the uterus and were firmly attached to its wall. The President had repeatedly removed similar growths from points lower in the uterine cavity with perfect success.

DR. HUNTER asked if the uterine wall was not very thin near the base of the tumor.

THE PRESIDENT replied that it was, but that there had certainly been no perforation.

DR. GILLETTE thought that the uterine wall, as well as the tumor, was sloughing.

DR. COE said that on examining the growth he was inclined to believe that it was not a suitable subject for removal with the spoon-saw. He referred to Dr. Thomas' practice of excising such sessile tumors piece-meal with scissors, especially if they were quite soft. There was less danger of perforation with this

method.

DR. WYLIE thought that the septic infection was not due merely to the manipulation of the uterus during the operation, but possibly to the prolonged use of tents. He thought that twelve hours was long enough to leave each set of tents in position.

DR. JANVRIN believed that the septic poison was transmitted from the uterine wall to the peritoneum. The septicemia was certainly due to the operation, and not to the tents.

DR. SKENE said that it was very difficult to decide upon the proper treatment of such cases as the one under discussion. According to his observation, whenever the cervical canal was so contracted as to require artificial dilatation, it was safer to remove the ovaries or to perform hysterectomy, than to attempt the enucleation of the intrauterine tumor. He had seen four fatal cases of enucleation, and if he had to deal with a case of obstinate hemorrhage, he felt that he would offer the patient a better chance by Hegar's operation or hysterectomy; that is, unless the uterus had contracted so much as to force the tumor downwards into the internal os. When the growth was as near the peritoneum as in the present specimen, enucleation was a most unsafe procedure. We should administer ergot, and see if the uterus had the power to partially expel the tumor. He disagreed with Dr. Wylie in his statement that septicemia did not result from injury to the uterus during the operation. It could hardly have resulted from the use of tents.

THE PRESIDENT desired to correct the impression that he ever used sponge-tents. He invariably employed the tupelo variety. He acknowledged that in such a thin-walled uterus as the one shown by him, enucleation was difficult, and the spoon-saw was a dangerous instrument. But the thickness of the uterine wall at the site of the tumor could not be determined before the operation. He certainly should hesitate before operating on a similar case again.

SUPPOSED PAPILLOMATOUS DEGENERATION OF THE OVARY.

THE PRESIDENT exhibited a mass having the size and shape of a large almond, the whole exterior of which was studded with small papillary projections. He had removed it two weeks previously from a woman 33 years of age, upon whom he performed ovariotomy for the removal of a large polycyst, weighing thirty-five pounds, and who had since made a perfect recovery. Finding on the right side what he supposed to be the ovary, and seeing on exposing it that it had undergone a peculiar papillomatous degeneration, he removed it and submitted the specimen to Dr. Heitzmann for microscopical examination. His opinion was expressed in the following letter:

Dr. Paul F. Mundé.

NEW YORK, November 16th, 1885.

DEAR DOCTOR:-The discoid body, about 11" in length, and 11′′ in breadth, that you removed during ovariotomy, contains a central cavity, found empty. Around the cavity the wall consists of two distinctly marked layers, the innermost being solid, varying in its transverse diameter from to ", and here and there is slightly pigmented. The outer portion is papillary or villous in character, also greatly varying in breadth, only a small portion of the solid wall being destitute of villosities. Under the microscope the solid portion appears to be composed of a delicate fibrous and myxomatous tissue, richly supplied with medullary or embryonal corpuscles. The most striking feature is the large number of large and tortuous arteries, with perfectly well developed endothelial and muscular walls, partly in a state of slight waxy degeneration. In a few places there is a deposit of brown pigment, caused by previous hemorrhage. The villous portion consists of very well developed villosities, characteristic of embryonal chorion. The villi are made up of delicate fibrous and myxomatous tissue, and are lined in the lower portions with flat epithelium. The upper portions show columnar epithelia, and numerous offshoots, almost entirely composed of such epithelia.

I do not know whether or not such findings were made before. The case certainly deserves accurate microscopical study, and several illustrations for publication.

Diagnosis.-Chorion of an embryo in waxy degeneration.

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From this examination it would appear that the specimen was one of a very rare inclusion tumor, that is, a dermoid cyst in its

initial stage. The President acknowledged that he was surprised at this diagnosis, as he had regarded the growth as an ovary similar to one which he had removed some time ago, but had not. had examined, believing it to be a proliferating papilloma.

DR. COE did not pretend to question Dr. Heitzmann's diagnosis, but he thought that the specimen resembled in its gross appearance an ovary which he had in his possession, one-half of which was normal, while the other half was papillomatous,

A SUCCESSFUL CASE OF SECONDARY OPERATION FOR ACUTE PERITONITIS, FOLLOWING OVARIOTOMY.

DR. HUNTER reported the case of a patient from whom he removed a small tubo-ovarian cyst on November 11th. Soon after the operation she developed peritonitis, as evidenced by general tenderness over the abdomen, marked tympanites, rapid, wiry pulse, and elevation of temperature. Her condition became so serious that he resolved as a last resort to re-open the abdomen. This was done at twelve o'clock on the third night following the operation. The peritoneal wound had been closed separately with catgut; the edges were firmly united. A small quantity of blood serum was found in the cavity. A glass drainagetube was inserted, and the cavity was irrigated thrice daily with warm carbolized water. The patient began to improve at once, the tenderness and tympanites disappeared, and she was then convalescing. The marked improvement was entirely out of proportion to the small amount of fluid removed.

DR. WYLIE had found, as a rule, that there were so many adhesions in cases of peritonitis, that it was impossible to secure perfect irrigation.

THE PRESIDENT asked what the precise indication for the secondary operation had been; was it simply proposed to relieve the tympanites?

DR. HUNTER replied that he had expected to relieve the peritonitis, which was evidently present. As soon as this was arrested the tympanites disappeared.

EXTRA-PERITONEAL INCISION OF A SMALL PELVIC ABSCESS.

DR. POLK stated that two months before a woman had entered his service at Bellevue Hospital with a pelvic abscess, which pointed in the posterior cul-de-sac. He opened and drained the abscess per vaginam, but, although the patient at first improved, she began to have hectic, and speedily lapsed into a condition resembling the last stage of phthisis. Thinking that there was another accumulation of pus which had not been reached, the speaker introduced his finger into the abscess and explored it thoroughly, but could detect nothing. After waiting two weeks longer, the patient was anesthetized, and a thorough examination was made. With a finger in the abscess-cavity, one in the vagina, and another in the rectum, a suspiciously soft, but not fluctuating mass, about the size of a pigeon's egg, could be felt behind the

left broad ligament, between it and the rectum, and apparently attached to the pelvic wall just above the level of the spine of the ischium. There was no pointing or even bulging in the direction of either the rectum or the vagina. The problem was how to reach it. To go down through the cavity of the abdomen, meant that the pus would have free access to the peritoneum, as from the position of the supposed abscess and its size, its walls could not be attached to the abdominal opening so as to drain its cavity, and at the same time exclude its contents from the abdominal cavity. The enucleation of the entire abscess contents and walls seemed too serious an undertaking in the patient's weakened state, so the idea of reaching the mass by laparotomy was abandoned. The next suggestion was naturally that an attempt should be made to reach the pus through the vagina, or rectum, or old abscess-cavity. Its remoteness from the walls of all these cavities, the number of the vessels in the involved region, with the presence of the ureter, made him hesitate to attempt evacuation through either of these cavities. There remained but one other path and that was outside the peritoneal cavity, by going down between that cavity and the pelvic wall. The incision for ligating the common iliac artery was made, the peritoneum was easily pushed back till the brim of the pelvis was reached, then the index finger was carefully and easily worked down along the pelvic wall toward the abscess until the resistance to further progress showed that he had reached the region of adhesions usually surrounding such spots; gently forcing the finger onward, the abscess-cavity was reached, and about one ounce of fetid pus was evacuated. A drainage tube was put in and the cavity cleansed. This cleansing has been done twice daily, and to date the patient has been well. It was three weeks since the operation.

DR. JANVRIN had never seen a parallel case. He thought that Dr. Polk was most fortunate in being able to detach, and afterwards to open the peritoneum, because it was generally thickened and adherent in such cases.

DR. WYLIE said that he had frequently removed by laparotomy abscesses connected with the tubes and ovaries. He washed out the cavity afterwards with a solution of carbolic acid, 1 to 100, or of corrosive sublimate, 1 to 10,000, and afterwards with water which had been purified by boiling.

THE PRESIDENT called attention to the fact that the discussion turned upon fixed, and not upon removable, abscesses.

DR. WYLIE thought that the tubes were generally the centres of suppuration.

THE PRESIDENT asked if the speaker would open and drain a pelvic abscess through an abdomino-peritoneal incision.

DR. WYLIE replied that he would drain such an abscess through the vagina if it could be reached, but that if it re-formed, it was probably due to pyo-salpinx, and hence laparotomy was necessary. DR. JANVRIN did not believe that the speaker was discussing Dr. Polk's case at all, since he was speaking of an abscess which could be extirpated as if it were an ovarian cyst.

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