some cystitis ever since use of catheter. Takes some spirits of nitrous ether every day with relief. 11th. Was taken from her father's, where operation was done, to her own home to-day. Edema is much the same, though systolic bruit is less distinct. She is still pale-looking, and pulse is weak and easily quickened by exertion. 26th. Has been doing most of her own work of late. She has not to go up and down stairs, however, and is careful not to over-exert herself in lifting or otherwise. Legs are rather more swollen perhaps, but edema is no greater elsewhere. Little or no cardiac bruit to be heard now. Pulse 96, while up and about. Feb. 2d. Weighs one hundred and sixteen pounds, being a gain of twenty-eight pounds in a little more than eight weeks. March 29th. Doing well. Has suffered from a bad cold lately. Takes ten drops of tinct. of digitalis three times a day one week, and a pill of iron, nux vomica, and quinine the next. Goes out frequently for short walks. Edema is somewhat less than it has been. Patient feels well, and looks less pale. Weighs one hundred and twenty pounds. Remarks. The enormou ssize of the tumor, as well as the successful result in this case, make it worthy of record, and should encourage at least an attempt to relieve even the most desperate of such cases. Judging from the condition of the tumor, it could not have been long before the softened walls of the largest cyst in it would have broken down into pus, and then the end would have soon come. Besides, some intercurrent disease, such as the phlebitis which she had two years ago, might at any time have caused her death. There can be no doubt, we think, therefore, that under the circustances the operation was a perfectly justifiable one. The diarrhea, as also perhaps the mural abscess, and possibly the short attack of peritonitis, was doubtless due to septicemia. How the latter occurred may be open to question. It will be observed that every antiseptic precaution was taken, including the disinfection of the vagina, in order to prevent the entrance of any bacteria to the wound. I think that it is very important that the problem of shutting out diseased germs from access to the raw surfaces via the cervical canal should be satisfactorily solved so that we may get rid of one of the chief elements which make the operation of hysterectomy so much more fatal than ovariotomy. In a paper read last year before the Canadian Medical Association, I suggested that this purpose might be accomplished in cases where there was an absence of uterine discharge every month for a period of at least ten or fifteen days, by doing a preliminary operation for closure of the cervix. This procedure would be applicable to quite a large proportion of cases, and I see no good reason why it should not practically work well. In the instance reported above, I did not, however, put it to the test because I feared in her very feeble condition to subject the patient to an additional surgical procedure which would necessitate a confinement to bed for several days, especially as the size and weight of the tumor rendered rest in the recumbent position very irksome to her at all times, and obliged her to change her position frequently during the night in order to lie at all comfortably. I therefore chose to adopt the method of disinfecting the vaginal tract as the best alternative that presented itself. A NEW CURETTE. BY H. W. LONGYEAR, M.D., Gynecologist to Harper Hospital, Detroit, Mich. THE accompanying drawing represents a curette and intrauterine syringe which I have recently designed and successfully used for several weeks. As the drawing will show, I have two sizes fitted to one syringe by a screw-joint. The canula is made of pure silver, and the syringe of hard-rubber. The oval openings in the uterine end of the instrument are made with bevelled edges, the bevel sloping from without inward, thus forming a cutting edge encircling each opening, and parallel with the inner surface of the instrument. My manner of using it is to fill the syringe and canula with a one-per-cent solution of sulphate of copper, pass the instrument into the cavity of the uterus, inject a few drops of the fluid, then withdraw the piston of the syringe slightly, and move the end of the instrument back and forth in the uterus. I repeat this maneuvre several times, until the fluid in the syringe is exhausted, when the piston is withdrawn again slightly, and the instrument removed. If granulations be present in the cervical canal or uterine cavity, they will be drawn through the open ings and cut off, and can be washed out from the inside of the instrument on its removal. The copper solution acts as a styptic to prevent undue hemorrhage, beside being a tonic application to the parts. If much hemorrhage follows the withdrawal of the instrument, an injection of the copper solution will generally suffice to stop it. Care should be used in withdrawing the piston, and the afterintrauterine manipulation, as healthy tissue can be drawn in and lacerated if the instrument be carelessly used. If healthy tissue should be drawn in in this manner, the instrument, by slight traction, will be found to be held quite fast, when the piston should be pushed in gradually, until the grasp is felt to relax. The advantages I claim for this instrument over the ordinary curette are that it can be used with little or no pain to the patient, thus obviating the occasional necessity of giving an anesthetic, and lessening the danger of inflammatory action or nervous shock, which sometimes have, in the past, followed curetting of the uterine cavity; that it does its work in much less time and more thoroughly; and is, to a certain extent, a dilator, and can be passed through an os that at first may feel quite rigid and impervious. 31 PARSONS ST. CASE OF FIBROID POLYPUS OF THE UTERUS, WITH REMARKS ON SOME POINTS IN ETIOLOGY.1 BY THADDEUS A. REAMY, M.D., Cincinnati. MRS. M., of Indiana, age 45, came to consult me at the instance of her family physician, Dr. Fleming, on the 3d of March, 1886, on account of a troublesome, profuse, muco-serous discharge from the vagina which had existed for five years. She was a marked brunette, five feet four inches in height, weighing two hundred and eleven pounds, and, as may be imagined, was exceedingly fat. She was married at the age of 18 and is the mother of four living children, the youngest age 15; one abortion. There were no abnormal phenomena connected with the birth of the last child, and menstruation returned at the usual time and remained regular and healthy until five years ago. At that time her menses began to occur a few days earlier than usual, and while not losing more menstrual blood than normal, the intermenstrual periods were characterized by a profuse discharge of a watery fluid from the vagina. Three years ago, suffering for some days from bearing down which she compared to parturient pains, a body which she supposed was the uterus presented at the vulva, was pushed up by her at once, and never appeared so low down again. For two years nothing abnormal was noted save a sense of unusual fulness in the vagina and the discharge, which, however, was increasing in quantity. The menses were about the same in character as before. One year ago, she had rather profuse metrorrhagia on alternate days for two or three weeks. At this time she was examined per vaginam by her physician, a very competent man, and told that some sort of tumor was present, but as the hemorrhage ceased, nothing was done further until she came to consult me. By vaginal examination an ovoid body, considerably larger than the normal uterus, was found occupying the upper part of the vagina and entirely filling it; the lower extremity of the body being less than two inches from the vulvar outlet. Its surface was smooth to the touch, though somewhat irregular in outline, but it was so long that the examining finger was only able to detect that the upper part was smaller than the lower, while the point of attachment or upper continuation could not be reached. Further examination was deferred, and the patient sent to my private hospital for more complete examination and treatment. 1 Read before the Cincinnati Obstetrical Society, April 8th, 1886. Diagnosis. Either a fibroid polypus which had been extruded and remained attached to some part of the uterus, or a complete inverted uterus, most probably the former. On March 7th, she was placed upon the operating table in the lithotomy position, for the purpose of making accurate diagnosis, and an operation if necessary. Owing to the enormous amount of fat in the abdominal wall it was impossible to palpate the uterus above the pubes, and for the same reason combined with the large size of the tumor, conjoined manipulation per vaginam and abdomen gave no information as to the whereabouts of the uterus. A finger in the rectum could not be introduced far enough to make out any constriction in the tumor, or the presence of the uterus above. Digital examination of the vagina could not differentiate the uterus, for the cervix was beyond the field of the examining finger. (It was subsequently ascertained that the uterus was held by the tumor high in the pelvis.) Attempts to pass the uterine sound anterior to the tumor and to its left completely failed, but to the right and posterior to the tumor the sound was made to enter about two inches further than in any other quarter. I was now fully satisfied that I was dealing with a fibrous polypus, for the following reasons: 1. The uterine sound was made to enter two inches above what seemed, upon digital exploration, to be a constriction of the tumor. 2. The mass was entirely insensitive to the touch. 3. The absence, in the history of the case, of either anything abnormal connected with the last parturition, or any extensive or continued hemorrhage, which is a usual concomitant of inversion of the uterus. 4. The persistent watery discharge which is often noted in extruded polypi, though this sign may accompany a case of inver sion. 5. The absence of the clinical symptoms of pain, bearing-down sensations, loss of health, or the nervous manifestations usually marked in cases of inversion. The tumor, as noted above, was smooth on its surface, but its outline was not regular, for I could make out some slight protuberances, and general, though not marked, unevenness in its con tour. 7. The tumor, when grasped between the fingers in the vagina, could be easily rotated on its vertical axis, which could not occur to any marked extent in an inverted uterus. This was to me the most important diagnostic sign in this case, and as I have never seen it mentioned in the differentiation of these puzzling cases, I desire to call your especial attention to it. Emmet has called attention to this method of determining the size of the pedicle. Any additional points of diagnosis on this subject must be particularly valuable, for the fatal mistake of amputating an inverted uterus for an intrauterine polypus has been made several times. I confess myself to having had my écraseur chain around |