Nov. 25th.-Returned to-day. Humerus firmly united by strong bony union. Splints removed. Owing to the long period the man had been under treatment he had some stiffness of the elbow, but could move his fingers freely.

Remarks. In this case non-union was due to the presence of muscular tissue between the ends of the bones, and union could not have possibly taken place by other than operative means. The pain which was supposed to be due to the "knitting of the bones," was caused by the pressure on the musculospiral nerve, which was between the ends of two fragments. The wire suture which united the sawn ends of the fractured bone was cut short and hammered down on the bone and left there. It did not cause the slightest inconvenience. This operation is one which, if performed with a strict regard to antisepticism, is devoid of danger and gives most satisfactory results, but it should not be resorted to till other measures (as drilling and rubbing the ends of the bones together) have been tried.

MONTREAL DISPENSARY-DEPARTMENT OF

GYNECOLOGY.

CASES UNDER THE CARE OF DR. ALLOWAY.

CASE I.-C. D., aged 44, married 22 years. Has had five children at full term and four miscarriages. The last miscarriage was supposed to have been due to a fall at fourth month of gestation, but contents of uterus did not escape until the ninth month. Has a metrostaxis every two weeks, sometimes going as far as the third week, and lasting six days. Discharge sometimes profuse, and accompanied with pain in back and sides. Intermenstrual leucorrhoea. The menorrhagia has existed for the last five or six years, and has reduced her much in strength. She complains of constant headache and facial neuralgia, frequent micturition, and constipation.

Examination.-Perineum intact; vagina relaxed and spacious with uterus and pelvic floor low down. No para- nor perimetritis. Uterus enlarged +1 in., but not retroverted. Cervix hypertrophied, intravaginal portion measuring two inches in length and one inch and a half across at external os.

It is the seat of

extensive cystic hypertrophy, the hypertrophic disease extending half an inch back on the posterior lip. An old bilateral laceration is evidently here the cause of the hypertrophy. The corners have become cicatrized up, giving the cervix a truncated mushroom appearance. To do Emmet's operation of trachelorraphy in this case would be useless, as it would leave a considerable amount of diseased tissue still in the anterior and posterior lips. I therefore decided to do Hegar's operation (Fig. 1) or a modification of it (Fig. 2) of exsection of a portion of the cervix,

removing all of the diseased portion, as, by so doing the cervix is reduced in size, the nutrition of the organ is effected by reducing its blood supply, and involution of the whole organ is induced. Fig. 2 shows the manner in which the sutures are passed, the three centre ones in the anterior and posterior lips uniting the mucous membrane of the cervical canal to that covering the portio-vaginalis, and in this way retaining the patency of the os. One week before the operation the uterus is thoroughly curetted with the sharp instrument, after which carbolic acid is applied to the entire endometrium on an applicator wrapped with cotton.

The operation is done under ether, with the patient on her back in the lithotomy position, a Sims or Simons' speculum pulling the perineum well downwards in the hands of an assistant.

A Museaux double tenaculum is fixed high up in the cervical canal and the uterus drawn down to the vulva. With straight scissors the cervix is slit up on each side to a point where you wish to begin the exsection. With a scalpel the posterior lip is carefully dissected off; the anterior or upper lip is then rapidly removed in the same manner. These lips are trimmed off with rectangular curved scissors. The centre sutures are then passed and the corners closed by two sutures each, as shown in Fig. 2. Of the sutures I have used in this operation I prefer the silk-worm gut shotted, but silk or wire will do. It is well to perform this operation under constant irrigation of a weak antiseptic solution, no sponges or like material being necessary. After the operation the vagina is irrigated night and morning with an antiseptic hot solution and the patient kept in bed. On the eighth or ninth day afterwards the sutures are carefully removed and the patient further kept in bed for five or six days. In all such long-standing cervical laceration cases as the one I have described, we get much better results in the more perfect involution of the whole organ than from Emmet's operation.

CASE II. A patient attending my clinic asked me to see a friend of hers at her house with the following short history:

Aged 26. Has had three children, the last one born fourteen days ago. She was attended by a midwife. Labor was normal; did very well until the tenth day, when she became chilly, complained of slight headache, loss of appetite, pain in back, and intense prostration. The feeling of prostration was what concerned the patient and her friends most. She could scarcely walk from her bed to the sofa without being thoroughly exhausted. She was very anæmic; had a rapid pulse and slight elevation of temperature (101°); tongue dry, and was constantly thirsty; bowels very loose, amounting to troublesome diarrhoea. She also complained of night sweats. On examining the abdomen there was not the slightest tenderness on firm pressure over fundus of uterus or broad ligaments. In fact her whole condition seemed to point anywhere but to the region of the pelvis for explanation of symptoms. As, however, I had

uterus.

seen other cases of a similar nature during the second and third week of puerperal convalescence, I assisted the patient to place herself on a kitchen table in front of a good light. Placing her in Sims' position and retracting the perineum I got the odor of an infective purulent discharge. The cervix was small, seemed well involuted, and was neither lacerated nor eroded, showing that absorption could not be taking place from the vagina. I then fixed a volsella in the anterior lip of cervix and drew down the As I did so a gush of the most foetid greenish pus escaped. Relaxing my hold on the volsella, the uterus went back to its anteflexed position and the flow of fluid from the uterus stopped as if a controlling cock had been turned. I then prepared a 1-2000 solution of corrosive sublimate in a fountain irrigator with a return-stream tube, and looking about for one of the two women who were with me a few moments before, to hold up the bag of the irrigator, I found myself and patient the only occupants of the room. The horrid stench of this pent-up pus was too much for them, and out of dire necessity they ran from the apartment, which was, I must say, a small and miserably ventilated one. With the aid of a nail in the window-sash

I managed to wash out the uterus thoroughly until the return fluid was clear. I then removed the speculum and passed my left fore-finger into the uterus, at the same time pulling the organ well down with the volsella. At the position of the internal os I could feel a strong band or ridge stretching across the anterior wall. Over this ridge my finger passed directly forwards and downwards into the cavity of the body of the uterus, on the anterior wall of which I could distinctly feel two small velvety elevations about the size and thickness of a five-cent piece. The smoothness of the surrounding mucosa of the uterus within reach was very marked and interesting. These small elevations were no doubt the remains of portions of placental tufts left behind attached to the wall of uterus, but which would have done no harm in their melting-down process had there been free drainage. The fibrous ridge spoken of on the anterior wall almost invariably exists in these cases of extreme anteflexion. It acts as a most complete valve, preventing the ingress and egress of

fluids.

This band was, together with the extreme anteflexion (Fig 3), undoubtedly the cause of retention of the discharge.

The uterus was converted into a veritable abscess which could discharge its contents only by a process of overflow, and occasional contraction of the body of the organ overcoming the valve-like obstruction at the cervix. (Fig. 4.)

FIG. 4.-Showing retained discharge converting uterus into pus-dilated cavity.

The symptoms complained of by the patient were those of a chronic septicemia due to constant absorption of a very small quantity of ptomäines from the cavity of the uterus. The skin and bowels were, by their over-action, endeavoring to maintain the balance between health and a serious explosion. The nervous system was giving evidence of distress in the headache, cardiac irritation, and slight elevation of temperature.

Sims on Treatment of Stenosis of Cervix. Am. Gynæ. Trans., 1878.