a good deal to getting the patient into a proper condition; made her live quietly for some time beforehand; and kept her in bed for two or three days after the application, which measures he found to secure success invariably. He thought that the application should be delayed after menstruation. He should hesitate to make an application of nitric acid to the uterus in a case where the canal and mouth of that organ was very much diminished in size; and he did not believe that these were the class of cases to which it was applicable. This treatment should be succeeded by more constitutional means. He used glycerine and extract of belladonna.--Brit. Med. Journal. FACIAL PALSY. CLINIC BY PROF. H. C, WOOD, JR., M.D., UNIVERSITY HOSPITAL, PHILADELPHIA. I bring before you gentlemen, a case which offers a great deal of interest in regard to the diagnosis of its cause. This young woman has been out of health for three months. Her first symptom was severe headache, referred chiefly to the region of the mastoid process of the temporal bone of the right side, and accompanied by occasional spells of giddiness. About six weeks ago she noticed for the first time that she would stagger, or even fall, on attempting to walk. To-day she complains of weakness in her limbs and inability to direct their movements. Her right ear cannot appreciate the tick of the watch even when it is applied close against the head; she has lost the sense of taste on the tip of the tongue of the side affected. She has a tumor under the lower angle of the left scap la which I believe to be a neuroma, on account of its exquisite tenderness on pressure. By looking at her face you can at once detect that her right side is paralyzed; her mouth is drawn a little towards the sound side; if I told her to blow, her right cheek would bulge out, and, in eating, food accumulates between the gum and the buccinator muscle. If I tell her to close her eyes, her right eye remains open, and her forehead is utterly expressionless. would suggest a centric origin of the palsy, but these symptoms can be explained otherwise. The loss of hearing is nervous in its character, and not due to a disease of the ear membrane, for we know that if the vibrations of a tuning-fork are not appreciated when we place it upon the side of the head it means either that the nerve of that side is absent or has been incapacitated by disease to perform its function. The loss of taste can be accounted for by remembering that in facial palsy, when the lesion is so far back as to affect the nerve-trunk before the chorda tympani is given off, through paralysis of that nerve the secretion of saliva is interfered with and the function of taste is lost upon the anterior portion of the tongue on that side. The fact that the loss of taste in this woman is on the same side as the palsy is a very strong indication that the paralysis is of peripheral origin, for a centric lesion destroying taste and motion on the same side in the localized manner here present is an almost unheard-of rarity, if indeed it be at all possible. The symptoms that would suggest a centric origin are staggering, giddiness, and inco-ordination of movements; but these may be due to a local peripheral lesion. In the internal ear we have the organs known as the semicircular canals, which probably are not connected simply with the function of hearing, for experimental as well as clinical evidence shows that they are largely engaged in maintaining the equilibrium between the individual and the external world. Thus, if in a bird we destroy these canals we will see it turning around and around, always towards the injured side, or, in other words, performing what are called circus movements. In frog, wounds of the ear produce a similar loss of power on the injured side. In Meniere's disease, you know, apoplexy into the labyrinth is at once followed by staggering, giddiness, etc. Two or three years ago I witnessed a case in which, the man having been shot in the face, a bullet was lodged near the foramen through which the portio dura and the portio mollis enter together; thus pressing on these nerves, it affected profoundly their functional powers, producing phenomena precisely parallel to those which are seen in the animal whose semicircular canals have been injured. Most probably in this young woman we have a similar condition; not that the semicircular canals are destroyed, but possibly the function of the portio mollis is in some way interfered with by pressure. Another proof that the paralysis is a peripheral one is that the muscles answer much more readily to the continued current than to the galvano-faradic one. What is the origin of this palsy ? Have we to deal with a paralysis of peripheral or of centric origin? I believe it to be peripheral, because we have an entire and uniform paralysis of this side of the face. If it were of centric origin we should have scattered face-areas affected, because the portio dura arises by several disseminated centres, and some fibres would probably escape the lesion. It Considering it proven that the paralysis is of is by reason of this manifold origin of the facial peripheral origin, what is the nature of the lesion? nerve that complete facial palsy is never centric. It may be rheumatic, or due to disease of the petIt is true that there are in this patient certain symp-rous portion of the temporal bone, or to thickentoms-as the staggering and giddiness-which ing of the membrane lining the aqueduct of Fall 1 of a number of symptoms which seemed to indicate peritonitis. There was obstinate constipation, stercoraceous vomiting and other signs of intestinal obstruction. M. Duleard decided to perform ovariotomy, as perhaps the ovarian cyst might be the cause of the obstruction. The abdomen having been opened along the median line, the peritoneum was found covered with false membrane, and the cavity contained flakes of lymph in serum. The cyst was removed with some difficulty, and a deep opius, or to an injury, or to a chronic tuberculous inflammation of the brain, or, lastly, to pressure by a tumor. We can at once exclude number four, for there is no history of a blow having been received; so can we also exclude number five, for the general appearance and general health of the patient are good, and there is no tenderness or any other local indication of disease of this bone. If the palsy were rheumatic it would have come on suddenly; and in this case the disease has been progressive. It is not due to disease of the pet-seated red tumor was found, which was the point rous portion of the temporal bone, for we have no local tenderness, no signs of suppuration or history of long-standing disease of the ear. We cannot entirely exclude the thickening of the membrane lining the aqueductus Fallopii, but it is doubtful whether this thickening would be such as completely to obliterate the canal and paralyze the nerves. Moreover, there is no apparent cause for this thickening, and the history of the case is altogether too acute for such a supposition, although not acute enough for the theory of a rheumatic attack. The most plausible explanation of the present phenomena is, according to my views, pressure exerted by a growth, with which, it may be, co-operates some thickening of the membrane lining the aqueduct; the character of this foreign body I believe to be specific, although there is no absolute proof of such origin. Treatment. We will give our patient the benefit of the doubt, and will place her on large doses of the iodide of potassium combined with the bichloride of mercury. If the trouble were rheumatic, we would place her on the salicylates, although in our hands they have proven of much less service in the chronic or subacute forms of rheumatism than in the acute forms of the disease. If this trouble is rheumatic in its origin it will be benefitted by doses of iodide of potassium, smaller, however, than those given for syphilis. The use of electricity is advisable, not to cure the disease, but to keep up the tone and proper nutrition of the muscles. We have not used any blisters behind the ear. The patient is improving under the specific treatment; the tumor at the angle of the scapula is less tender on pressure. [Under specific and local treatment the patient continued to improve, and was subsequently shown to the class almost recovered.]-Med. Times. of the internal strangulation. This was liberated with much trouble and only by making several liberating incisions, which allowed a double flexure of intestine to be drawn out and straightened. The cure was rapid and complete, the temperature never obtaining 38°C. This is an example of gastrotomy performed during full peritonitis, and demonstrates how many cases given up as hopeless could be easily and quickly relieved. ENTERORAPHY FOR THE CURE OF ARTIFICIAL ANUS. In a report of a clinical lecture by Prof. M. Schede (Deutsche Medicinische Wochenschrift), Western Lancet, details are given of a case of artificial anus, in which, as cure could not be effected through the usual means, the portion of intestine involved in the disease was removed, and enteroraphy performed. This report is of much interest as a contribution to the statistics of an operation to which much attention has recently been directed by German surgeons, and also as describing certain modifications in the operative method, and in the after-treatment, applied by the author in dealing with his cases. The operative treatment was carried out with strict attention to antiseptic precautions. The subject was a very feeble woman, aged forty-three, who, three weeks before she came under the notice of Prof. Schede, had suffered from strangulation of the femoral hernia on the left side. An operation performed for the relief of this condition had exposed a coil of gangrenous intestine, and resulted in the establishing of an artificial anus. In the left inguinal region was an opening into which the little finger could be passed, and from which there was a constant discharge of fluid feces. No fecal matter was discharged by the anus. There was a free opening into the portion of the intestine GASTROTOMY FOR THE RELIEF OF IN- above the opening in the groin, but neither a finger TESTINAL OBSTRUCTION. The following from the Progres Medicale for July appears in the Western Lancet:-A woman aged 48 years was affected with an ovarian cyst, which was about to be operated on, when in the few days preceding the operation she complained nor a probe could be passed into the lower segment. After the patient had for two days been subjected to a preliminary treatment, consisting in evacuation of the portion of bowel above the false anus, in exclusive feeding by clysters, and in frequent administration of opium, the following operation was performed: A vertical incision was first UTERUS FOLLOWING THE REMOVAL Robert Barnes, M.D., F.R.C.P., Obstetric physician to St. George's Hospital, reports the following case in the British Medical Fournal, Sept. 6, '79 : Seeing that the subject of inversion of the uterus was to come before the Obstetric Section, and feel ing that the collation of clinical illustrations affords the most useful means for a right understanding of pathological and therapeutical problems, I have been induced to submit the following case. inversion. Two or three preliminary observations I may be pardoned for obtruding. In discussing inversion of the uterus, especially with reference to treatment, it is essential to bear in mind the distinction I have laid down elsewhere between recent and chronic An inversion may be described as recent, so long as the due involution of the uterus This process following labor is not completed. takes about a month. During its progress, the uterine muscular fibre still retains more or less of the contractility, dilatability, and vascularity of the made through the abdominal wall, commencing CHRONIC SENILE INVERSION OF THE just above the upper margin of the false anus and carried upwards for a distance of about three inches. The portion of intestine above the opening was then exposed, drawn outwards through the wound, and inclosed temporarily in a stout catgut ligature in order to prevent any flow of intestinal contents during the subsequent steps of the operation. The short piece of intestinal canal between this ligature and the artificial anus having been washed with a five per cent. solution of carbolic acid, the upper margin of the outer orifice was cut through and the adhesions of the upper segment of gut were carefully divided. The contracted extremity of the lower segment of gut was then dissected out of a bed of cicatricial tissue and also secured by a ligaature of catgut. A wedge-shaped portion of mesentery, corresponding to the interspace between the portions of gut, having been excised, the edges of this membrane were first brought together and fixed by sutures, and afterwards the margins of the two portions of intestinal canal. The catgut ligatures were now removed. These had served their purpose so well that not a drop of fecal fluid had been observed during the operation. Fearing that there might result a failure of uninterrupted prim-pregnant organ. ary union between the two applied portions of in testine, and in order to prevent any discharge of intestinal fluid into the abdominal cavity and consequent fatal peritonitis, Prof. Schede did not at once return the sutured portion of the intestinal canal. The upper and lower portions of the external wound having been closed by sutures, this portion of gut was retained without the middle portion of the wound, and prevented from slipping inwards by a large bent needle passed through the mesentery and the opposite margins of abdominal wall. This exposed portion of gut and the whole seat of the operation was then covered by Lister's dressing. No indications of febrile reaction were manifested during the subsequent progress of this case. When the process is complete, the muscular wall of the uterus has lost much of the contractility, dilatability, and vascularity which are developed under pregnancy. Those methods of reduction which are comparatively easy if tried within a month after labor may fail if tried at a later period. In the case I am about to relate, the inversion was first noticed ten years after the woman's last labour. It was discovered after the removal of a fibro-myoma; and the inversion was probably-not certainly-independent of the process of labor. Beginning with the classical case of John Hunter, the preparation of which is in the Hunterian Museum, I have collected in my Obstetric Operations and Diseases of Women several cases of inversion caused by fibroid tumors. I now describe an interThe patient vomited soon after the operation, but only once. The dressing was changed esting case of this kind. Although, in these cases, on the second day, and again on the sixth day. On the growth of a tumor in the uterus may induce the fifth day there was a free discharge of fluid muscular development in the proper uterine walls feces by the anus. Subsequently, defecation was analogous to that observed in pregnancy, still the regular and normal. On the tenth day the bent condition of the uterus, as it comes under obserneedle was removed, and the exposed coil of in-vation, much more closely resembles that of chronic testine, then covered by healthy granulations, al- inversion. We may, therefore, class the case I lowed to fall back into the abdominal cavity. the end of the fifth week the patient was discharged as cured. At now describe as one of chronic inversion. We might, perhaps, even with stricter propriety, refer it to a third order of cases; namely, to one which includes chronic cases observed in women who have reached or passed the climacteric. In these "Doctor, I am very much troubled with these pains, but I find considerable relief from a band-cases, the uterus has gone beyond the involution age over the region of the liver." which follows pregnancy. It has been still further "Then by all means wear a belt. A simple affected by the involution of senility or decrepitude. strip of flannel will answer every purpose, only be careful to draw it a little tighter on the side where your liver is than on the other." *Read in the Section of Obstetric Medicine at the Annual Meeting of the British Medical Association in Cork, August 1879. These, then, may be classed as "senile chronic inversion." The uterine tissue is more dense; the muscular element is disappearing, the fibrous predominating. Hence reduction by taxis or the various manœuvres found effective in the recent and ordinary chronic inversions is more difficult. My present case falls under this order. The woman was near fifty, and senile changes had set in. extremities of the Fallopian tubes and of the round ligaments are drawn into the inverted cavity. The question arises, When was the inversion produced? It might have arisen before the removal of the tumor in the first operation, or during that operation, or at some subsequent time. Which is the more probable? It is difficult to understand how the uterus could turn itself inside out after the tumor was removed. But it is not impossible that the stump left behind might be so large and projecting as to excite uterine expulsive action, and that thus the inversion was completed soon after the first operation; the stump meanwhile undergoing disintegration and disappearing. But I am more inclined to conclude that the inversion was produced or completed during the operation or immediately after it. I had no opportunity of examining again; and, indeed, she got on so well that there seemed no indication for further treatment, until a year later. In November, 1877, I saw, at some distance from London, a woman aged 47, who had had her last child ten years before. Since that time, she had suffered much from metrorrhagia, and this had lately much increased in severity. Being active in business-she was the wife of an innkeeper-she went on disregarding her condition until the losses told so much upon her that she was compelled to give in. She was very stout. I found a large, firm mass, rounded, filling the pelvis like a child's head. The hand passed in with some difficulty, surrounded the tumor, and traced its attachment by a broad pedicle to the uterine cavity. I adjusted a wire Another question arises: one which I put to myand cut it through by écraseur. A little bleeding self with especial point, because I acted in opposfollowed. The tumor was so large that it was with ition to rules upon which I have much insisted. difficulty brought through the vulva which had Might not reduction have been effected and ampupreviously admitted my hand. It was a fibro-my-tation avoided? Might not the resistance have oma of the size of a small foetal head. She ma e a good recovery, and resumed active work. In May 1879, I was summoned to her again. She had again been suffering from menorrhagia, alternating with offensive watery discharges stained with blood. She was very blanched and very prostrate, and had increased in stoutness. I found a pyriform tumor of the size of a Jargonelle pear, with a small pedicle in the vagina; the root quite continuous with the vaginal roof, leaving no passage beyond for the sound. Her condition made it imperative to remove it with the least possible delay. I applied a wire as before, thinking it was a polypus; but, on tightening the wire, the acute pain aroused the suspicion that it was the inverted uterus. This was verified by closer examination. Still we determined to persevere with ablation, knowing that her condition was too low to bear the tedious, painful, and probably forcible process of reduction by sustained elastic pressure. I therefore deliberately cut through the pedicle with the wire. Rather free bleeding followed; this was staunched by swabbing with tincture of iodine. Considerable pain in the abdomen followed; this was allayed by opiates, and she slowly recovered. My friend Mr. Turrell reported on July 6th that she had progressed favorably-had walked for more than half an hour the day before; and that, examined by the speculum a week before, the cicatrix appeared complete, and all constitutional disturbance had subsided. The temperature rose during the first week to 100.5° and 102°; the pulse to 104, and then fell to normal rate. This specimen is in the Museum of St. George's Hospital. It is laid open to show the interior. The yielded to sustained pressure, aided by taxis and the operation I have recommended and practised with success, of incising the neck of the uterus? It is impossible to answer this question in the negative. The attempt, I knew, would be attended by unusual difficulty, suffering, and danger; and, since the subject had reached the climacteric, the loss of organs which had already passed into decline could hardly be regarded in so serious a light as the loss of organs still in the plenitude of functional life. In these cases, then, of senile chronic inversion, the methods of ablation come into stronger competition with the methods of reduction than they ought to be permitted to do in cases of simple chronic inversion. Still I think that even in cases of senile chronic inversion, where the conditions are favorable to the attempt at reduction, the attempt ought to be made. I venture to conclude with the following propositions : The division of uterine inversions into three orders-namely, 1, recent; 2, simple chronic; 3, senile chronic-it will be seen, is based upon clear physiological distinctions; and this division carries clear therapeutical indications. In the recent cases, immediate reduction by taxis is almost always indicated. In the simple chronic case, taxis, aided or not by sustained elastic pressure and incisions of the uterine neck, is indicated, and will almost always be feasible. In the senile chronic cases, reduction by taxis, aided by every auxillary means, though still indicated, will be much more difficult of execution; and amputation, the last resource, will be less open to physiological objection, and at the same time less dangerous, than in the first two orders of cases. It must finally be borne in mind that, especially in the senile chronic inversions, tolerance may be acquired, and thus render all operative interference unnecessary. THE EXPERIENCE OF A SUCCESSFUL PRACTITIONER. [The following correspondence copied from the N. Y. Medical Record is an excellent hit at the patronizing airs assumed by some successful? practitioners when called in consultation by their confrères.-ED. LANCET]. When Mr. Smith urged me to see his child, after my consultation with Dr. White, I told him I could not do so, because Dr. W. was the regular attendant. Besides, I was overrun with work, and it was but fair that Dr. W. should have a start and make a living. I further said that I appreciated the feelings of a father who was anxious about his son, but under the Code I was forbidden to help him out of what he believed to be his difficulty. My assurance that the child would probably recover did not comfort him much; neither did he seem satisfied when I informed him that I would from time to time give Dr. W. such hints as occurred to me, as Dr. W. generally consulted me privately about his difficult cases. Such a trait, in my opinion, recommended him as a young man who was conscientious to his patients, and not afraid or ashamed to learn. Just then Dr. White dropped in the office, and was somewhat surprised to see Smith and I in conference. Smith was, however, astonished, and for the moment did not know what to do. This gave me my opportunity to put both at their ease by saying that Mr. S. was naturally much worried about his child, and, not knowing anything about the Code, had dropped in to talk over the case; and that I had comforted him by telling him that Dr. W. was just the man for the case, and that it was not proper for me to interfere by word or act. Dr. White was pleased, and the ice was broken for a general conversation. The latter ended by my promise to be present at a consultation on the morrow. After Smith left, Dr. W. and I had a frank conversation on the proper relations which should exist between patient and physician and between each other. At the same time he intimated that Smith seemed to be a little dissatisfied. White did not believe in keeping cases against the will of the patient, and became virtuously indignant | at the want of confidence in him. So incensed did he seem that I was fearful he might give up the case at once; however, I coaxed him to hold on, and he finally left in good humor. The following day I arrived at the patient's house before Dr. White, and waited for him at the bedside. While so doing I learned that Harry had three passages since the night before, and was The mother then showed me the medicine worse. that Dr. W. had ordered. I said that there must be some mistake; that in fact the remedy was the same as the child had been taking when I called, and signified my desire to see the new medicine. When informed the mixture was made by Dr. W. since the consultation, I at once smiled and changed the subject. The mistake arose from the fact that Dr. W. had repeated the rhubarb and soda instead of using the chalk-mixture. Although this annoyed me somewhat, I merely remarked that Dr. W. must have misunderstood me; that the medicine should be white instead of red, and that I would explain the matter to him when he came. In the course of the conversation I learned that each time after partaking of the medicine the child became worse; but I merely said that she should stop giving the remedy, and that we would make it right when the doctor arrived. Just then he came in. I had the bottle of medicine in my hand, and apologized for my apparent interference by remarking to him that he had misunderstood me, and that the child appeared to be worse. He blushed somewhat, and said that he had none of my medicine with him at the time; a remark which was very indiscreet in the presence of an anxious parent. However, I said that as I carried it around with me always, and used it a great deal, I would give him some. Accordingly I made the mixture upon the spot, administered it to the boy, and retired to consult. White agreed to continue with the chalk-mixture; and when we returned the boy said he felt good, wanted to sit up, and said he was hungry. I playfully remarked that he liked his medicine, and that he was getting better already. Dr. W. smiled also, and the mother seemed to be quite happy. Shaking hands with little Harry and patting his head, I took my leave, saying that the doctor had done every. thing necessary, and that I had nothing more to suggest. We left together, W. apologized for not using the chalk mixture the day before. I told him that it was a small matter, but was upon my part sorry I had alluded to the fact before the mother. The next morning White called on me to say that, although the child had improved, the family dismissed him, and urged me to see the case. I felt very delicate about the matter; but as I knew that my former partner would be called in, and as Dr. W. and the family were both willing, I consented, if sent for, to see the case through. After coming to such a conclusion, Dr. W. thanked me for what I had done for him, and assured me that he was willing to leave himself and his former case in my hands. Harry recovered in a day or two; but all I can do I can not persuade the mother to employ Dr. W. any more. Can I do more? I have often tried to impress on Dr. W. the importance of humoring his patients, and have many a time told him that he was too dogmatic. On several occasions I have been placed in an apparently false position by his obstinacy. To give |