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less pain and distension, and he was altogether more com-fortable. A nutrient enema was given every four hours andhot water only by the mouth for forty-eight hours moreOn the llth the stitches were removed and he was allowedone ounce of milk with water every three hours, in additionto the nutrient enemas. Slow but steady improvementfollowed, a little pus occasionally escaping by the wound.On the 17th fascal matter passed by the rectum and he wasallowed eggs and light puddings. On the 19th a small col-lection of pus was evacuated from the smaller wound on the

right side, which then quickly healed. On the 21st thebowels were acting regularly, whilst fsecal matter still flowedfreely from the wound, which was contracting and granu-lating. The temperature was subnormal, the pulse was 74and the patient was gaining strength daily. On the 26th hewas allowed to get up and my note-book records : " Woundsmaller, appetite good, bowels open daily with simple enema,fsoal discharge through wound much less, dressings changedonly three times a day, walks outfor half an hour and sits in thesun." " On April 10th he had a sudden relapse ; bilious vomitingset in with pain in the epigastrium, the bowels became con-stipated, and there was a slight rise of temperature, followedby a fall to 956°F., with a weak pulse of 62, and no fsecalmatter escaped by the wound. These symptoms persisted inspite of active treatment till the 13th, when the vomit becamestercoraceous and he had much hiccough. It was clear thatsome obstruction existed above the wound, due probably tosome twisting of the gut. Mr. Bruce-Clarke, who sawthe patienton the 13th, was of this opinion, and thought that a secondoperation would be necessary, but he decided to try warm waterinjections through a tube passed some distance into thewound whilst the patient was turned over from side to sideand the abdomen was briskly massaged. These measureswere successful ; some fsecal matter through the wound,fol-lowed, and in the evening there was an action per rectum.The abdominal pain ceased and the vomiting and hiccoughdisappeared. From this time the improvement was steadyand continued. The wound closed, the bowels actednaturally, and the patient’s strength increased daily. Onthe 22nd he was able to walk a mile and on the 24th he leftthe College for the seaside on sick leave. A month after-wards he was able to walk ten miles and was reported tobe in general good health.Remarks.-This case is one of considerable interest, illus-

trating the value of enterotomy as an aid to the evacuationof pus from the peritoneum. Before the operation thebowels were all but paralysed, and there was great reasonto believe that the patient would sink from intestinalstasis. The immediate relief which the incision affordedwas very marked. The intestines were too much mattedtogether to allow of the exact cause of the abscess beingmade out ; it seemed to be most probable, however, thata strain acting on a piece of adherent bowel had torn itand had caused some of its contents to become extravasatedand so had given rise to the formation of pus.

CASE OF ACUTE INVERSION OF THEUTERUS.

BY W. R. ORR, M.D., M.CH., M.A.O. R.U.I.

THE extreme rarity of this accident-it having occurredbut once in over 190,000 cases of labour in the Rotunda

Hospital since 1745-and the fact that it has a bearing onthe proposed registration of midwives constitute my apologyfor recording the case. On Aug. 15th I was hurriedly calledto see a young woman aged twenty, who had just given birthto her first child. I arrived on the scene about an hour after

delivery and found the patient in a state of great collapseand quite unconscious, the pulse being small and rapid, theskin cold and clammy and the breath coming in gasps. Themidwife informed me that it was a case of "false con-ception "; whatever she meant by the phrase I cannot

say. On examination I found the uterus completely in-verted and beyond the vulva, with the placenta stilladherent. The uterus was quite flaccid, and there had beenbut a small quantity of blood lost. I stripped off theplacenta, a matter of little difficulty, and replaced the uteruswith ease. The patient, however, died some two minutes after-wards, altogether about an hour after the accident. I think Ithere can be no doubt as to the immediate cause of the acci- I

dent. The woman had had a tiring day and was much fatiguedwhen labour commenced. After the expulsion of the foetusthe midwife-according to her own account and that of abystander-pulled strongly on the cord, and almost simul-taneously the uterus and its contents were protruded. Herethe primary cause seemed mechanical, but as there was astrong expulsive effort on the part of the patient it was pro-bably assisted by muscular contraction. I think I am safein saying that the presence of a medical man would haveprevented the occurrence of such an accident.Wanstead, N. E.

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A MirrorOF

HOSPITAL PRACTICE,BRITISH AND FOREIGN.

Nulla autem est alia pro certo noscendi via, nisi quamplurimas et mor-borum et dissectionum historias, tum aliorum tum proprias collectashabere, et inter se comparare.—MORGAGNI De Sed. et Caus. Morb.,lib. iv. Proœmium.

ROYAL FREE HOSPITAL.CEREBRAL ABSCESS DUE TO OTITIS MEDIA ; REMARKS.

(Under the care of Dr. SAINSBURY and Mr. ROUGHTON.)THE relation between disease of the middle ear, with its

bony annexes, the mastoid antrum and mastoid cells, andcerebral or head symptoms is well recognised and is suffi-

ciently puzzling. - The association of this disease withwell-marked head symptoms, including optic neuritis, suck

as, apart from the ear disease, would unhesitatingly beascribed to intra-cranial mischief is well-known. How far

the symptoms are actually due to concurrent intra-cranialdisease it is perhaps impossible to decide, but we are

certainly familiar with the presence of the symptoms to apronounced degree and with their complete and rapid sub-sidence on treatment of the bone disease only. For thisreason it has been urged that in the above class of cases theminor operation of removal of the diseased bone in the wallsof the middle ear and around it should be first performedand, in case of subsidence of the head symptoms not occurring,that the major operation of opening the skull should be thenentertained. The following case suggests that it is best notto be too systematic in procedure, that each case should betreated on its own merits, and that perhaps the majoroperation should in some be performed at once.A man aged fifty was admitted into the Wynn Ellis

Ward of the Royal Free Hospital on Saturday, Aug. 12th.of this year. The patient was sent in for the associa-tion of head symptoms with deafness of, and discharge from,.the left ear. The family history had no bearing on the,case. The personal history recorded a discharge from theleft ear extending back to youth. At the age of thirtythis seems to have ceased. The patient’s habits were intem--perate. On Saturday, Aug. 5th, he was exposed to a draughtwhilst travelling in a railway carriage. He seems to have’.noticed a slight deafness in the left ear the same day, and inthe evening he vomited. On the 9th the deafness was notedas being worse, there was a complaint of pain in the ear, andin the afternoon of this day there was some discharge ofblood from it. On the 10th there was less pain, but some -discharge of matter. He consulted a medical practitioner on this.day, and whilst at his house he had a convulsive fit. He seems.to have recovered partially and was removed to his home,but there lapsed into an unconscious state, which lasted somehours. After recovery from this fit and during the next day,he was distinctly not himself ; his memory was bad, he couldnot find words and he described his feeling as being one ofvacancy. At one time he appears to have been distinctlyaphasic. After admission into hospital on the 12th his,

speech was noted as being thick, and the face on the right.side as weak. The arms and legs were moved equally by the-.patient, the knee-jerks were absent on both sides, there were.no sensory symptoms. On further examination the deafness.in the left ear was found to depend on disease of the middleear. At the time of the patient’s admission there was mode-rate fever, the maximum temperature being 101 ’2° F. On,the following day the temperature fell to normal and it-remained so till the 18th. During this time there was decided

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improvement in every respect. The ear was syringed daily withboracic lotion. On the 17th there was some return of pain inthe ear and there was also some frontal headache. On the18th the temperature rose to 100° F. and the frontal headachewas exchanged for pain in the temporal region. On the19th the temperature was 101° F. ; the pupils were slightlyunequal, the left being smaller than the right. At this stageMr. Roughton was consulted. A granulation polypus wasdiscovered by him, and he advised the operation of scraping.This was performed on the 23rd, but in the interval the

patient became decidedly worse; he was more drowsy andwas delirious at night. On the 22nd there was a return ofthe aphasia. At the operation Mr. Roughton found pus inthe external meatus, but the mastoid antrum appeared to behealthy, and the mastoid process, though it was sclerosed,with practical obliteration of the cells, did not show anycarious bone. The temperature had reached normal beforethe operation, but on the next day, with a deepening of thecerebral symptoms, it began to rise again. Unconsciousnesswas practically unbroken ; there was vomiting once during thenight and there were slight convulsive movements, beginningin the right arm, but affecting also in slight degree the right legandthelettarm. It was now determined to trephine over thetemporal region, but the patient died the same evening, havingbecome suddenly worse late in the afternoon. An attempt wasmade to take him into the operating theatre, but the end cametoo quickly. At the post-mortem examination the dura materwas found to be slightly raised over the roof of the tympanum.A large abscess involved and distended nearly the whole ofthe left temporo-sphenoidal lobe.Remarks by Dr. SAINSBURY.- The comment upon this case

is that the major operation ought to have been undertakenin the first instance ; but upon what indications ? Was theaphasia, in itself an unusual symptom, an indication of thiskind ? How was it produced ? The suggestion was madebefore the operation that the aphasia might be produced bythe pressure of an abscess in the temporo-sphenoidal lobeupon the convolution of Broca or upon the fibres leading fromit, and the size of the abscess found at the necropsy and itsprobable tension make this not unlikely; but still, was thissufficient ground to go upon ? Optic neuritis has not beenmentioned, because there was some difference of opinionabout it ; in any case it must have been in the earliest stagesand it did not exceed slight congestive swelling of the disc.It has been mentioned that the knee-jerks were absent on thepatient’s admission; of this there was no doubt, but on the24th (the day of his death) they were found to be present.

DINORWIC QUARRIES HOSPITAL,LLANBERIS.

A CASE OF PHLEGMONOUS CELLULITIS OF FOREARM

FOLLOWING AN INCISED WOUND OF THUMB ; SECONDARYINFECTION OF KNEE-JOINT, LUNG AND THROAT ;

PYÆMIA (?) ; RECOVERY.(Under the care of Mr. R. H. MILLS-ROBERTS.)

THE question as to whether the following case of septicinfection was a true pyaemia or not will probably be answereddifferently according to the opinion held by our readers as tothe meaning of that term. Clinically as regards symptomsit was not pyaemia, as Mr. Mills-Roberts points out; the tem-perature was not characteristic in its course, colliquativesweats were absent, there were no rigors from first to last andthere was very little gastro-intestinal disturbance. Still the

patient became rapidly emaciated, jaundiced, and therewere suppuration in the knee-joint, evidence of lung in-flammation, and glandular inflammation in the neck. Weare inclined to ascribe the recovery of the knee-jointto the treatment, which was well adapted to the particularcase and was not too long delayed, as so very muchdepends on the period at which the purulent contents of ajoint are evacuated. Mr. Stephen Paget wrote an interestingpaper which we published in THE LANCETl a few years agoon the Distribution of Pyasmic Abscesses, in which he came tothe conclusion that the distribution of these abscesses was nothaphazard, but was subject to certain rules and combinations.The parts’ affected were, however, not limited to one side ofthe body3in any lesions, although after some injuries there

1 THE LANCET, July 31st, 1886.

was a greater tendency for certain viscera or systems to beinvolved.A man aged thirty-eight was admitted into the Dinorwic

Quarries Hospital on Oct. 3rd, 1892, with the followinghistory. On the previous Saturday, whilst cutting bread,the knife slipped into the patient’s thumb, making a

small wound which was thought nothing of; he wrappeda piece of linen round it and went about as usual.Next day he complained of considerable throbbing painin his thumb and applied a linseed poultice. On Monday(Oct. 3rd) he went to his work at 7.30 All as usual,but returned home about 10 A.M. feeling very ill,shivering violently and complaining of great pain in histhumb. After reaching home he went to bed and

applied another linseed poultice. On the following day hewas seen by a medical man, who lanced his thumb, poulticesbeing continued until the following Saturday, Oct. 8th, whenhe was seen by Mr. Mills-Roberts. He was then looking veryill ; he had a sallow complexion, with a haggard and anxiousexpression, and he was delirious, but he answered questionsrationally. His voice was husky and he complained of sore-throat, but there was nothing to be seen on examination beyonda little congestion of the fauces. His temperature was 104° F.and the pulse was 130. He was in great agony with his hand,which was much swollen, the swelling extending to the bendof the elbow. No distinct fluctuation could be found, but thewhole forearm was tense and brawny. The axillary glandswere swollen and tender. On the palmar aspect of theterminal phalanx of the thumb there was a small wound,from which a little pus oozed. He was recommendedas an in-patient. After admission ether was administeredand several deep and superficial incisions were made in thehand and forearm ; a great deal of serum but very little pusescaped, the latter coming from a deep incision which was madealong the palmar aspect of the thumb, and a counter-openingwas made above the anterior annular ligament to the inner sideof the radial artery, a director being easily passed betweenthe latter incisions, and carbolic lotion was syringed through.Carbolic fomentations and poultices were afterwards applied.The temperature in the morning was 104° F., and in the even-ing it was 100° F. Next day (Oct. 9th) the following notes weretaken : "Feels better. Hand is comfortable and swelling ismuch less. Still complains of sore-throat. On examinationthere is considerable congestion, most marked on the rightside ; there is also tenderness on pressure behind the rightangle of the jaw. The appetite is very bad." The tempera-ture in the morning was 100 6° F., and in the evening it was103’6° F. -Oct. 10th: " Hand looks better; swelling diminish-ing ; no tension. Throat is very painful. A few glands canbe felt under the right angle of the jaw; they are very tender.Patient complains of pain behind the right knee-joint, buton examination no tender spot can be felt and there is noswelling. " The temperature in the morning was 99° F., and inthe evening it was 102 ’20 F.-Oct. llth : "Hand and arm stillimproving. Throat is better. The right knee is very painfuland tender to touch; tenderness is most marked in the

popliteal space. There is no swelling or effusion into thejoint. Patient is considerably thinner than he was on admis-sion. He has a slight cough, but no expectoration." The

temperature in the morning was 101° F., and in the evening itwas 101’6° F.-Oct. 12th "Hand and throat improving. Thereis a little effusion in the right knee-joint, but the pain is lessand tenderness is not so marked." Later, at 8 P.M.: "Effusionis increasing ; a syringe was introduced into the joint and aboutone drachm of slightly turbid, oily fluid withdrawn. Under themicroscope there are numerous leucocytes to be seen, many ofwhich are in a condition of granular, fatty degeneration.Patient’s cough is worse. There is no expectoration and thereare no abnormal physical signs. He is evidently wasting rapidlyand is slightly jaundiced, with a flushed face. His pulse is120, weak and irregular; it is inclined to run." The tempera-ture in the morning was 100° F., and in the evening it was102° F.-Oct. 13th : " Cough is worse. There is considerablefrothy expectoration, with streaks of blood (first noticedabout 8 A 1B’1:.), rapidly increasing in amount, until at 12 noonsputum is well mixed with blood. On auscultation afew crepitations are heard below the angle of the rightscapula. Pain has disappeared from the throat and there isno visible congestion. Hand is looking well. Patient ismuch more jaundiced than he was last night, and he is attimes very flushed.’’ Dr. Lloyd Williams administered ananaesthetic and Mr. Mills-Roberts freely opened the knee-joint,making an incision about two inches long on either side of thepatella as far back as possible. About six ounces of thick