pale and the extremities cold. The pulse was feeble. Onthe in ier side of the left limb there was a deep wound com-mencing about the junction of the middle and lower thirdsof the leg which ran along the posterior border of the tibiaround the external malleolus and across the ankle to theouter side of the foot. The ankle-joint was opened into ;the tarsal bones were comminuted ; the vessels were tornacross, and the tendons dragged out of their sheaths.

The patient having been placed under chloroform, Dr. Fossamputated through the upper third of the leg. The posteriorflap was made by transfixion, and the anterior by cuttingfrom without inwards, and consisted chiefly of skin. Thelimb having been removed, it was noticed that there was nobleeding from the flaps. The pulse could not be felt eitherin the femoral or radial artery. The breathing was regular.The surface of the body was cold. In a little time the pulsereturned at the wrist, and a few seconds later could be felt inthe groin. But still there was no hæmorrhage from thestump, so the flaps were brought together with silver suturesand the patient removed to bed.

She made a steady recovery, somewhat delayed by twogranulating patches, which relused to heal until skin graftswere placed on them.



(Under the care of Dr. Foss.)J. T-, aged forty-six years, was admitted to the

hospital on March 24th, 1881, at 3 A.M. The patient’sright leg bad been caught in some machinery and severelycrushed. The tibia and fibula were comminuted fromthe upper third downwards. The vessels were torn across,and these, together with the skin, were torn and con-

tused. Chloroform having been administered, Dr. Fossamputated the thigh at a little above the condyles. Theflaps being formed according to Teale’s method, only thefemoral artery required a ligature. The flaps were broughttogether by silver wire sutures. Not much blood was lostduring the operation, but apparently before being broughtin he had lost some, and at this time was suffering from thisand a good amount of shock. The same morning, at nineo’clock, the temperature was 98.2°. In the evening thetemperature was the same ; the pulse was 116. A sedativedraught was prescribed. He slept during the night and nextmorning. Pulse 120 ; temperature 100 4°. The dressingswere stained with blood. Complained of pain in the stump,also in the other leg. ’

On the 27th the wound was dressed for the first time.The wound looked well ; there was no tension or sloughingof flaps ; no hæmorrhaee.About 10 A.lV!:. next day the nurse noticed that he had

fainted, and it was discovered that there was bleeding fromthe stump. Notwithstanding stimulants, he went into astate of collapse, and died in about half an hour. Thequantity of blood lost was not large, but considering hiscondition, it was sufficient to cause death. A hurriedexamination of the stump was made after death, but nopoint from which the haemorrhage could have come wasobserved. The ligature was firmly fixed in the femoralartery, and there was an organised clot inside it.

THE LEVEE. -The following members of themedical profession were present at the levée held atSt. James’s Palace on Monday last :-Surgeon R. F. Adams,Surgeon T. Archer, Surgeon J. Battersby, Surgeon E. Butt,Surgeon L. H. Carter. Surgeon G. J. Coates, Surgeon S. A.Crick, Surgeon-MajorJ. S. Comyn, M.B., Surgeon-Major A. F.Churchill, Surgeon J. G. Crofts, Surgeon G. W. H. Cook,Surgeon A. B. Cottell, Surgeon F. A. B. Daly, Surgeon J.R. Dodd, Dr. Peter Eade (Sheriff of Norwich), Surgeon-Major B. Franklin, Surgeon-General S. H. Fasson, SurgeonR. W. Ford, Surgeon W. Deane-Freeman, Surgeon S. G.Hamilton, Surgeon-Major H. F. Hensrnan, Surgeon-MajorE. Hoile, Deputy Surgeon-General F. Holton, Surgeon A. G.Kay, Surgeon R. C. K. Laffan, Surgeon G. S. Lewis, SurgeonC. A. P. Mittchell, Surgeon R. E. R. Morse, Surgeon H. J.R. Moberly, Surgeon-Major S. Moore, Surgeon-Major E.M’Crystal, Surgeon T. Mayne, Surgeon T. C. Nugeut, Dr.Ord, Surgeon George Turner Phillips, Surgeon - MajorWilliam H. Pickford, M.B , Surgeon A. S. Rose, SurgeonS. Salaman, Surgeon A. T. Sloggett, Surgeon G. E. Twiss,Surgeon T. B. A. Tuckey, and Surgeon T. P. Woodhouse.


Hepatotomy.—Removal of the Uterine Appendages.THE ordinary meeting of the Medical and Chirurgical

Society was held on Tuesday, May 24th, Dr. Barclay,President, in the chair. Two papers, by Mr. Lawson Tait,on subjects of considerable interest in connexion with ah.dominal surgery, were read. Mr. Morrant Baker exhibiteda case of bromide of potassium rash.

" On Three Cases of Hepatotomy," by Mr. LAWSON TAIT(Birmingham). This paper contains the narration of threecases in which the author performed operations on the liversimilar to those in two cases already received by the Society.Abdominal section was performed in all three. The liverwas found not to be adherent to the parietes in any of them;the contents of the tumours were removed, and the edges ofthe wounds in the liver were stitched by continuous sutureto the edges of the wounds in the abdominal wall, anddrainage-tubes were fastened in. Two of the cases weleoperated upon for hydatids of the liver, and the otherfor a large cystic abscess enclosing a loose piece of livertissue, weighing about an ounce, and which had apparentlybeen a slough. All three patients made good recoveries.

—Mr. H. MORRIS was surprised to hear that Mr. LawsonTait preferred abdominal section to aspiration for unilocularhydatid cyst. During the last few months he had had twocases in which two aspirations had been successful. In onecase eighteen and twenty ounces respectively were drawnoff; in the other, under Dr. Powell’s care, three or fourounces were drawn off by him on the second occasion, anllboth were, up to the present, cured. He should certainlyhesitate to resort to abdominal section at first in such cases.There are no doubt other cases in which aspiration is quitehopeless.-Dr. HEYWOOD SMITH asked if there was anytroublesome haemorrhage from the incision through theliver, and whether pressure was sufficient to control it,or whether the vessels could be taken up. He wished toknow if sinuses followed the use of drainage-tubes insuch cases.—Mr. HULKE thought the great risk was theescape of the contents of the cyst into the peritonealcavity, and he asked how Mr. Tait quite prevented this. Hethought all surgeons must at times have regretted notmaking freer incisions into hydatids of the liver, especiallywhen suppurating.—Mr. LAWSON TAIT replied that the

haemorrhage was stopped by pressure. He had had notrouble in now six cases of operation on the liver. Hewould never again aspirate liver hydatids ; he had no fearof abdominal section, but he had fear of aspiration, and hehad heard that aspiration rarely cured hydatid cysts. Styriansurgeons especially had this experience. The tapfing does notaffect the cyst at all, which may at any time reall. In hismonocystic case he believed the patient was cured. Hisassistant seized the cyst with forceps on each side, andplaced a sponge on each side, and so prevented any escapeinto the peritoneum.On Removal of Uterine Appendages for the Arrest of

Uterine Hæmorrhages," by Mr. LAWSON TAIT. The authorcommenced his paper by referring to the use of the statis-tical method in testing the real value of operations, andespecially instanced ovariotomy as one which would not haveobtained the complete acceptance it has received had not thecareful statistical method of Mr. Spencer Wells shown thatits results could be favourably compared with those ot everyother major operation in surgery. Mr. Lawson Tait wishedto lay his experience in another portion of the department ofabdominal surgery before the Society, in order to obtain itsdecision as a guide for the future for himself and others.After protracted trials of drugs for the arrest of uterinehaemorrhage, he had come to the conclusion that all wereabsolutely without effect, save ergot and two salts of potash,the chlorate and the bromide, and these were by no meansuniformly successful in giving permanent relief. In all thecases he had to relate these drugs had been fallytried beforethe question of operating was discussed. He had entitledhis paper "The Removal of the Uterine Appendages," be-cause his experience seemed to show that the removalof the ovaries was not a certain method of arresting



menstruation, while removal of the tubes as well seemed Ito be so. The author then related thirty-one cases, ofwhich four were fatal, twenty-seven recovering from theoperation. A summary table was appended to the paper,which was a complete list of the operations and results.The author summed up with the following conclusions,which he considered might be legitimately drawn fromthem. 1. That, so far as its primary results are concerned,removal of the uterine appendages for the arrest of in-tractable uterine haemorrhage is an operation which is quiteas easily justified as any of the major operations of surgery.2. That so far as its secondary results are yet known it is anoperation which yields abundant encouragement for itsfurther trial; as conclusions which are indicated but uotwholly ’vproved, he thought he might formulate a statement thatremoval of the ovaries alone is not sufficient to arrest men-struation, but that removal of both tubes and ovaries doesat once arrest it. So far as some of these cases have gonethe arrest would seem to be permanent. This conclusion is

quite in harmony with what is known of removal of bothovaries for large cystomata, for in such cases the tubes arealmost uniformly included in the clamp or ligature. Threeat least of the cases, and probably two others, show that thearrest of menstruation by this means leads or may lead tothe atrophy of uterine myoma. Finally, there is some closeconnexion, here pointed out, he believed, for the first time,and worthy of very close study, between uterine myoma andits accompanying haemorrhages and cystic disease of theovaries. In two of the cases cystic disease seemed to bethe cause of the haemorrhage without any myoma inter-vening. One other conclusion, he thought, was justified,that the whole subject is worthy of careful study, and shouldnot be made the subject of premature and hostile conclusions.Dr. GRAILY HEWITT remarked that the subject was worthyof the closest possible study. He did not consider that Mr.Tait was in the habit of allowing due importance to condi-tions, often observed by him to be of moment in these cases,especially the causation of the haemorrhages. Mr. Taitappearednot to assign any importance to the uterus in cases of hmmor-rhage, but takes for granted that when any difficulties arisein the treatment of uterine disease, flexions, &c., the ovariesshould be removed.-Mr. TAIT protested that his paper didnot give any sanction to such a statement.-Dr. HEWITTsaid he gathered that from the paper; cases were regardedas incurable except by removal of the ovary, but his ownexperience was that haemorrhage is very frequent in cases ofuterine displacement, and is curable without removal of theovary. Two classes of cases are grouped together in thepaper : those in which there are tumours of the uterus, andthose in which there are not uterine tumours, and in many ofwhich there are displacements and cystic disease of ovary.In the cases of uterine myoma there are some in which thisoperation is justifiable, although he had seen cure by othermeans in cases as bad as any quoted. He had seen the otherclass of cases treated with success without this operation,by dealing with the uterus itself. One of Mr. Tait’s caseswas under his own care at one time ; the patient came tohim in a state of intense prostration, great vomiting,emaciation, and was threatened with phthisis ; locomotionwas impossible ; the uterus was decidedly anteflexed. Shewas three times under his care, and was much better whenshe left his care, and he hoped to get her quite well ; it wasanteflexion of uterus with a very soft, relaxed condition ofthe organ. He could conceive of cases in which this operationwas justifiable, but giving Mr. Tait full credit for his skilland for his record, he was sure there were many caseswhere correction of displacement of the uterus cured thesymptoms.-Mr. TAIT said only two cases had flexion,both of which had been under Dr. Hewitt’s own care.-Dr. HEWITT thought he heard four or five such cases readout.-Mr. TAIT said in only two cases was the uterus foundflexed and replaced and stitched to the wound.-Dr. BAR-CLAY asked if Mr. Tait wished to recommend the operationwhere the ovaries were healthy, or only where they werediseased.-Dr. HEYWOOD SMITH said it was very importantto recognise the condition of the ovary before the operation.In about sixteen of the cases the ovaries were cystic; thequestion arose as to whether there was not more tendencyto haemorrhage with commencing cysts in both ovaries thanin advanced cystoma. He asked if the haemorrhage wasslight or great in separating the pelvic adhesions of diseasedovaries. He thought very slight alterations in the size, shape,and texture of the ovaries could be recognised before opera-tion, and he thought normal ovaries were very rarely

removed in this operation. The cure of flexions no

doubt relieved the symptoms directly due to the uterus,but did not affect the ovarian trouble.-Dr. HICKIN-BOTHAM had seen many of Mr. Tait’s cases. He thoughtsufficient stress had not been laid upon the previous treat-ment these patients had undergone before the operation.At first he had great doubt about the operation, and shrankfrom countenancing it ; but he felt there were cases, in whichhaemorrhage persists and threatens life after all other meanshave been tried, in which this operation promises a certainand tolerably safe cure. This operation, of course, ought tobe hedged about with many precautions.—Mr. LAWSONTAIT replied that he had been told that the operation wasliable to abuse, which meant that it would be performedsimply for the sake of the fee, or that it would bedone to protect women from the posibitity of gettingchildren. He thought no surgeon would be found thus toabuse it. This argument, too, was very dangerous. Hewould like to know bow many unnecessary pessaries wereapplied ; and it could be applied in the same manner to manyother forms of treatment. The operation will alwaysremain a hospital operation, and it has been quite the mostunremunerative of all in his practice. Again, it hasbeen said that it unsexes a woman ; but the ovaries removedshow that they are so diseased as to prevent bearingchildren, and the majority of the patients had either beenquite barren, or had not had any children for many years,while it do3s not unfit women for marriage. The patientalluded to by Dr. Hewitt came to him sutl’eriug from a severeretroflexion. There could be no real division between ovario-tomy and oophorectomy, as none can say where one endsand the other begins. In one case only had he severehaemorrhage, which was, however, controlled by pres-sure of sponges; no adhesions add to the danger of theoperation. He never used drainage-tubes in the pelvis.The meeting then adjourned.


AT the meeting on April 2lst, Mr. Henry Power, Pre.sident, in the chair, Mr. HENRY MORRIS read a paper onNaso-pharyngeal Polypi. He selected six cases which hadcome under his care within the last few years to illustrate-1. The different kinds of naso-pharyngeal or suffocatingpolypi. 2. The effects of these growths at different periodsof their progress. 3. The various operations which aresuitable to the different cases. Of these cases three have eoccurred in females and three in males. In four of the

patients the affection commenced either before or just aboutthe period of puberty. In three of these the polypus was ofthe firm fibrous variety, two of the patients being boys andone a girl. In the fourth the polypus was of the fibro-cellular kind, being somewhat firmer and tougher than thenasal gelatinous variety. The other two cases (4 and 5)were cancerous in character and occurred in adults. InCase 4 the patient was a man in whom the disease beganabout the fortieth year, and though of a cancerous nature,and persistently recurring after removal, he continued alivefor more than five years; the operations, if they did not curehim, nevertheless kept off death from time to time andrestored him, for lengthened periods, to a condition ofcomfort. Case 5 was also cancerous, and the diseaseaffected a woman when in her fifty-eighth year. It wasvery rapid in its progress, and ended fatally within ayear, the operation having had but little effect in pro-longing life, but much in relieving her of very greatsuffering during the last months of her existence. Fourof these cases support the view that the fibrous varietiesattack generally young adults, though they do not givecolour to the opinion that they are peculiar to the malesex, or that they always exist singly. Case 1, for instance,is opposed to both these views, the patient being a younggirl and the tumours being multiple. Nor does this casegive any support to the idea, that if these polypi have beenpersistently removed up to the age at which one no longerfinds them commencing, they may be permanently ex-terminated, unless, indeed, this age is much beyondpuberty. For this patient, in whom the disease beganwhen fifteen years and a half old, has now, in her

twenty-second year, a recurrence severe enough to preventher lying down to sleep, and which before the last opera-