grains, and chloral hydrate, 10 grains, were exhibited, twenty minutes after which she was fast asleep. Hot irons and bottles were placed to feet and limbs, and heavy flannel shirt to body; ice pillow under the head reapplied. The bromide and chloral did their work well; she was no more troubled.

Monday, 10th, 8 o'clock A.M.: Temperature 1013° F., pulse 120, respiration 20. The spinal symptoms becoming prominent, spinal ice bags were put under her; keeping trunk and feet warm. Bromide and chloral to be kept up; Valentine's meat juice continued. Kidneys acting well; no movement from bowels, on account of morphine.

Evening, 8 o'clock: Temperature 101° F., pulse 90, respiration 18. Ordered same treatment continued.

Tuesday, 11th, 8 o'clock A.M.: Find patient rational; temperature, pulse and respiration normal; calling for chicken broth; patient very stiff; complaining of back; muscles of arms and shoulders and pectoral muscles exceedingly sore; gives her pain to move or be moved. Soreness gradually disappeared, as did all the other symptoms. Recovery was uninterrupted. Today, three months since, the patient has some eye symptoms, which might be corrected by properly fitting glasses. I had hoped to present a photomicrograph of the slide containing the meningococcus, but so far have heard nothing from the gentleman to whom it was sent.

REPORT OF SURGICAL CASES.*

Appendicitis with Hematoma of the Ovary; Suprapubic Lithotomy in a Child.

BY WM. D. SUMPTER, M.D.

NASHVILLE, TENN.

In a paper of this kind I must omit etiology, symptoms, complications, etc., other than those which bear upon the cases in question.

Case I. On October 10, 1898, I was called to see Mrs. E. History: Aged 24, married four years, sterile. Had always enjoyed good health. Never irregular in menstruation, and but little pain at any time; bowels had always been regular. I found her condition as follows: Menstruating, having begun two days before I saw her; bowels had moved on the day pre

* Read before the Tennessee State Medical Society, Nashville, April 14, 1899.

ceding my visit; vomiting for two days, but not severe; pain in right iliac region, also in umbilical, was present with chilly sensations; pulse below 80; temperature less than 100.5°F. Examination revealed no tympanites or rigidity of abdomen; pain on deep pressure at McBurney's point. The usual nonoperative treatment was followed, and on the next morning, the temperature being less than 100°F., pulse normal, was continued. Temperature was lower on the two consecutive days, and on the third normal.

As the attack proved so mild I considered it appendicial catarrh, and suggested to the family the possibility of operative treatment being necessary in the event of another attack.

I did not see the patient again until December 1, when she had a second attack, but little severer than the first. Menstruation in October had been free for nine days; in November was regular; on the 4th of December it returned, continuing, despite efforts to control it, until the first week of January. As there were no indications for an immediate operation just then, I advised removal of appendix later, between attacks. On December 11 the temperature was normal; and as patient preferred waiting until after the holidays, operation was postponed. During the first week of the year I saw her, menorrhagia was still present, suggesting the possibility of extrauterine pregnancy. Vaginal examination proved unsatisfactory on account of the rigidity of a well-developed abdominal wall. Singularly, the flow ceased two days later.

In consultation the patient was examined under an anesthetic. No appendix or tumefaction was felt on palpation of the abdomen. On vaginal examination the uterus was found to be infantile, about one-third the normal size, retroverted; and to the right side of it was a mass closely adherent, suggestive, before the fundus was felt, of latero-flexion.

At St. Thomas' Sanitarium, after usual preparations (the patient's temperature 99.8° F., pulse 68 to 90; flow had begun on preceding night), the pin-hole os of the uterus was dilated and gentle curettement employed. The abdomen was then opened by a median incision. The appendix was found to be four and one-half inches long, comparatively free from adhesions, and very much hypertrophied. At about the junction of the inner third with the outer two-thirds was a tumefaction. The distal end of the appendix was dark in color, from the defective circulation; the proximal, almost normal in appear

After completion of operation, examination by incision of appendix revealed scybalous particles in a thick exudate. At the point of enlargement was a hard concretion, containing in its center a nucleus, in consistence suggesting the much

slandered grapeseed or an enterolith, but exfoliating on washing, its structure was shown to be simply feces. After the removal of the appendix, in the right iliac region were found four tumors (replacing the ovary), three Graafian cysts, and a hematoma. The cysts were placed at the base of the hematoma, one being one and three-fourths inches long by one and one-fourth inches broad, the other two only one-fourth that size by actual measurement; they were removed. The hematoma was in no particular like the protruding, excisable variety, but involved the whole substance of the ovary, so that multiple follicular apoplexy had produced ovarian apoplexy; dimensions two inches long by one and a fourth broad. The stroma of the ovary held in its meshes, sponge-like, the collection of blood already beginning to break down on account of the twisting of the pedicle at its base. Consideration of the formation and results of hematoma, from the normal self-limited hemorrhage after rupture of a Graafian follicle to the tumefactions reported as large as a child's head, must be omitted. While ligating the base of this broad tumor, carefully held in the hand of an assistant, it broke off, leaving but a small portion to remove. The right tube was much distended, thickened, curled on itself with salpingitic closure of its ostium, held closely to the uterus by villimentous adhesions; these were easily broken down, and the tube removed. The left ovary and tube, although slightly enlarged, fortunately presented no indications for removal. The uterus was brought forward from its retroverted position and subjected to abdominal hysteropexia by Kelly's method of fixation, which he so appropriately calls suspension of the uterus. After inspection of right iliac region, the abdomen was closed.

The patient suffered but little shock. Vomiting and severe pain required attention. Temperature was never above 100.2° F.; pulse only twice above 100. Save an insignificant stitchhole abscess, recovery was uninterrupted, and patient returned home on the twenty-sixth day after operation.

In considering the case it but adds force to the importance. of preparation for complications in abdominal surgery. Suspension of the uterus by Kelly's method seems so far superior in its advantages to, and free from the dangers attendant in, those of Olshausen, Leopold, Czerny and others, that I believe it destined to replace them and to afford relief in many cases where the pessary was and is still used by a very few in fruitless attempts at reposition of the uterus.

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Case II. M. G., male, 3 years of age. October 23, 1898. History: At nine months of age his mother noticed unusual frequency of urination and high color of his urine, for which she at once placed him under treatment. When 13 months

old he had a number of spasms, continuing two days and one night; had never had one since. Under treatment the condition of his urine was but little changed; and during the first part of 1897 micturition became painful, and he would cry, even for some time after it was over. The physician in charge of him gave up the case to two other physicians, who, suspecting calculus, prepared for operation and anesthetized the child, but finding no stone the operation was abandoned. During the remainder of last summer and fall, in the hands of another physician, the child was given a prolonged treatment with Red Boiling Springs water. Save a copious deposit of brick-dust color, uric acid and urates, not much effect was obtained. His mother consulted me during January. The condition in which I found him, and one unchanged for over a year, was frequent micturition, every half hour or hour, or at any time on touching the penis; small evacuations from the bowel, simultaneous with urination in almost every instance; this I had opportunity to notice several times. It was accompanied by excruciating pain and shrieking. At that time his legs would flex on the thighs; his thighs on the rigid abdomen, and extreme adduction caused them to cross so tightly that it was with the greatest difficulty that they could be separated.

On examination of the penis I found an excessively redundant prepuce. Having made a diagnosis of vesical calculus, to be verified by examination of the bladder, and suspecting the necessity of operation for same, also because of the reflex nervous symptoms sometimes occasioned by a long prepuce, and possibly edema in case of operation, I circumcised the child. Then for several days examination was made of his urine; it contained traces of albumin, and was acid in reaction. Microscopic examination revealed shreds of mucous membrane, bladder epithelium, blood corpuscles and pus, triple phosphate crystals, uric acid and oxalate of lime crystals, the latter filling up much of the field, free or imbedded in the shreds of the membrane. Oxaluria continued, despite diuretics — the urine being thick, muco - purulent, and so jelly-like at times that if poured on a plate it would adhere to it, not dropping from it when inverted. Later, under diuretics and so-called solvents, the urine became thin, with heavy sediment.

Under anesthesia an examination of the bladder, by sound and bimanually-i. e., one finger of left hand in rectum, the other hand on abdomen-clearly demonstrated the presence

of stone. Calculus is not always easily found, and here let me insist on the value of bimanual examination. Loss of sleep and appetite had caused great emaciation, despite tonics; so immediate operation was decided upon.

On March 11, at the sanatorium, by the suprapubic method of lithotomy, the operation was performed. The bladder had been filled with three ounces of boric acid solution, and a catheter constricted the penis at its base. No rectal colpeurynter was used, because of no especial advantage and the great danger from it at times. On inserting my little finger into the bladder, the stone was located and easily removed with forceps. No incrustations of the bladder wall were found. The calculus weighed ninety-eight grains, and was oxalate of lime or mulberry variety. The bladder was irrigated and closed with fine silk; the abdomen was tightly closed with silkworm gut. A No. 5 rubber catheter could not be introduced into the bladder, but a No. 5 linen, after much difficulty, was passed and left in until night, when it was removed because of plugging of its eye, but was reintroduced and remained until the next afternoon. Reintroduction required anesthesia. On the removal of the catheter the child soon urinated. Urine on third day was clear, and has practically been so ever since.

The patient slept most of the night after operation, and all night of each succeeding day. There was no crying on urination after first time. Union by primary intention took place, and on the fifteenth day the patient was permitted to leave the sanatorium.

The formation of vesical calculus, varieties, symptoms, etc., must be omitted in this report; but I wish to call attention to some features of the last case. The spasms, occurring when the child was thirteen months old, were due no doubt to the passage of a nucleus of oxalate of lime or uric acid through the ureter; the baby had renal colic. Examination for vesical calculus cannot be too thorough, for even the most experienced have found post-mortem revelations. The bimanual examination is of great service, especially in children. The difficulty of introducing a catheter into a baby's bladder is due not only to the smallness of diameter, but also to the curve, of the urethra-different because of abdominal location of bladder in a child. The size of the stone was unusual, and last of all I believe the choice of operation was necessarily suprapubic lithotomy. It must still remain an unsettled question as to whether