apart from the liability of employers. If a friend or relative of the unconscious patient calls in a medical practitioner, the latter will naturally ask that friend or relative to guarantee his fee, or may ask for it in advance if he has any doubt about the ability of the patient to pay it. Of course, should the patient recover, and the guarantor have to pay the fee, he can in his turn recover it from the patient. Should, however, the patient die of the complaint or the injuries for which he has been attended, not only has the doctor (or the guarantor if he has already paid the doctor) a claim on the deceased's estate, but should the estate be insolvent that claim is preferent to all others save (1) costs of sequestration and administration; (2) necessary and reasonable funeral expenses. Of course this preference applies only to fees for attendance during the last illness, and it is shared equally by all the medical practitioners and by the chemist, should the services of more than one person have been required. They follow among themselves the rule "qui prior est tempore, potior est jure," not necessarily as to the total of their several accounts, but as to each separate item in each account as it was from time to time incurred.

The right of a practitioner, who, without being asked by anybody, attends an unconscious patient, might seem more doubtful, but reasoning on the Roman law by analogy, and this law does not seem to have been altered by the Dutch, it seems to me that if the layman can recover the medical fees which he has disbursed on behalf of his friend, so can the medical man who has himself attended the unconscious patient. And, to look at it from another point of view, "Jure nature equum est, neminem сит alterius detrimento et injuria fieri locupletiorem" (Digest 50-17-206). If a patient's life is saved, or even if his sufferings be alleviated, he is unquestionably "enriched" in a wide sense of the term. And the practitioner suffers by giving his services gratis cum suo detrimento et injuria." To him, especially if he has a large practice, time is money. And, surely, his knowledge and skill, acquired only at considerable cost, and by means of much mental toil, must count for something. It is a very valuable asset, his "capital," and a portion of this capital he places at the service of his patient. Here we have ample consideration for any reasonable fee.

66

(To be continued).

Dr. Rowan, an Australian practitioner, who, after having practised in Johannesburg since the close of the war, has now returned to Melbourne, has been pouring out the vials of his wrath to the representative of an English paper on South Africa in general. Besides discussing politics, he states, apparently in connection with medical matters, that Russian and German Jews are invariably preferred for appointments to Australians. This seems rather a sweeping assertion, of which, we imagine, it would be difficult to give proof.

Dr. Burghard, late of Bloemfontein, who left for England in August last, has decided to remain in that country permanently, He has, we understand, commenced practice in Leeds.

Hystero-Myomectomy for au adherent fibromyoma, weighing over 50 lbs. and of thirteen years' standing. RECOVERY.

By G. A. CASALIS, M.B., C.M., ED. Gynaecologist and Abdominal Surgeon to the Victoria Cottage Hospital, Wynberg, Cape Town.

Mrs. Y. a Scotswoman aged 38, nullipara, consulted me a few weeks since for an abdominal tumour, which had been diagnosed thirteen years ago, by a medical man in New York, U.S.A., as a fibroid of the uterus.

It was then, as far as she could remember not larger than a good sized orange, and she had been told not to worry about it, as it did not seem at the time to give much trouble. She was then 25 years old, her only complaint being painful and profuse menstruation.

Her sister, it is interesting to note, suffers from a similar growth, which has been allowed to grow and assume, she assures me, the same proportions as hers.

On examination the abdomen proved to be enormously distended by a huge mass, completely filling the pelvis proper and the whole of the abdominal cavity.

Mensuration of the abdomen at the umbilicus read 59 inches, and from pelvis to ensiform cartilage 35 inches. The woman looked exactly as if she was pregnant of a particularly large foetus (vide Photos No. I and No. II).

On vaginal examination the cervix was found drawn upwards and almost out of reach. It seemed to form

one whole with the mass above, and was smaller than normal, the cervical os being felt as a small dimple, which would not admit a sound further in than an inch and a half.

Two irregular irregular masses, apparently also closely connected with the tumour, were felt in the lateral fornices. One appeared somewhat softer than the other, but as bi-manual palpation was impossible, could not be otherwise examined.

(One of these masses proved at the operation to be a cystic ovary and the other a small sessile fibroid, the size of a goose's egg, in the left broad ligament).

General symptoms. Facies distinctly ovarian--skin yellow, emaciation of chest and legs very pronounced. The arms and hands alone being fairly nourished. Breathing purely thoracic, 30 to the minute. Pulmonary sounds normal, Cardiac dulness enlarged, heart sounds accentuated, specially second sound-pulse dicrotic running 90 to minute.

area

Edema, of lower extremities, from knees downwards. Urine normal at times, at others contains a trace of albumen. Digestion difficult, frequent attacks of diarrhoea.

Patient complains of being unable to sleep properly, she can hardly walk without taking frequent rests. Her legs after standing become painful and swell up, but go down at night when in bed.

She is generally free of pain, but has been seized at several periods with a sharp abdominal pain, which was diagnosed as "colic." One of these attacks was followed by fever, the pain being more particularly situated on the right side and she was then treated for "Influenza." Menses have for many years been profuse, but of late have been less so, probably because she had, by sheer weight, become less active.

She thought her size had materially increased within the last two years and she had consulted several doctors who declared her case too far gone for operation.

Diagnosis. Adherent fibro-myoma of uterus or possibly adherent ovarian cyst undergoing malignant degeneration and with solid contents?

Operation. The abdomen was opened in the middle line, at the most prominent part of the tumour, just below the umbilicus. The parietes were very thin, and the peritoneum found adherent to the anterior surface of the growth. It was carefully detached for a small distance round the incision, so as to allow room for a better examination of the tumour, several largely distended veins being clamped in the process.

Although the distinct fibroid nature of the swelling was now visible, I thought it advisable to plunge in its middle a trocar, hoping, as I had already found it to be the case in a similar growth I had operated upon a few years previously, that it might be cystic in parts, and thus easier to enucleate.

This proved a vain hope, a gush of blood being the only result of the puncture.

The abdominal incision was then rapidly enlarged, first downwards towards the pubis, then upwards within a couple of inches of the ensiform cartilage.

Using then both hands to separate the adhesions and the plexus of veins ramifying extensively over the anterior surface of the tumour, and consisting mainly of the omental vessels, which having greatly hypertrophied and anastomosed together, were running parallel with the long axis of the tumour, and from the parietal peritoneum to the growth itself, I worked upwards, clamping rapidly each blood vessel as it spurted, till the under surface of the liver was reached.

This organ was only loosely adherent to the tumour, but stretching right across its superior pole, from right to left and from the hepatic to the splenic flexures, the transverse colon was found adherent to it, by what remained of its very attenuated inesocolon.

These adhesions were rapidly clamped again, and the bowel being liberated, I was at last able, with both arms and hands embracing the growth, and by using a considerable amount of strength, to raise it from its bed and

hitch it, so to speak, on the pubic promontory (vide Photograph No. 3), where it was held in position by Drs. Claude Wright and Louis Beck, who were kindly assisting me.

The delivery of the tumour had taken exactly 25 minutes to perform.

The scene was here dramatic in the extreme and one not easily forgotten.

The patient. with an incision stretching from pubis to ensiform cartilage, the small bowels having long since been retracted under the diaphragm as the only place where they could find room, looked exactly as if her whole interior had been cleaned out.

The formerly overstretched abdominal walls, thin and relaxed, were hanging flap-like on both sides, while the whole abdominal vessels from cœliac axis to the bifurcation of the common iliac arteries, could be plainly seen pulsating along the spinal column up to the pelvic brim. The transverse colon limp and devoid of its peritoneum was tucked up partly below the liver and stomach surfaces, while the descending and ascending portions flattened and both empty, occupied their respective positions in the flanks.

If to this picture is added the presence of the towering fibrous mass still held over the pubis and the gory appearance of the field of operation, strewed over with forceps and clamps of all sizes, controlling but imperfectly the numberless veins and arteries which had just been severed, one can only wonder, the shock to the patient, was not such as to terminate life before the operation could be brought to a successful issue.

The pelvis being still obstructed by the lower part of the growth it now became necessary to get rid of the larger mass above so as to deal with the lower segment.

Fortunately at the junction of the upper and larger part of the tumour and of what was found to consist of the enlarged uterine body, there existed, just above the folds of the broad ligaments, a constriction, evidently the neck of the fibroid, which originally had budded out of the uterine walls (Vide Photo iv.) before it had invaded the whole of the abdomen.

Through this neck, I passed a strong mounted needle, carrying a stout silk ligature, which encircling the pedicle in the manner of an ecraseur, was tightly secured on one side and thus somewhat controlled the hæmorrhage when it was sectioned. This was carried out with a pair of curved scissors, several pairs of strong forci pressure forceps being further applied to the larger blood vessels as they were sectioned.

The larger part of the growth having thus been removed, the operation now resolved itself into an ordinary supra-vaginal amputation of the lower adherent segment, which consisted mainly of the fibromatous uterus and the two ovaries, one of which was manifestly cystic and had prolapsed low down in Douglas' pouch.

Before doing so, however the upper part of the incision was closed so as to diminish intra-abdominal shock by the undue exposure of the visceral organs. All the bleeding points on the parietes, on the remaining portion of the great omentum and on the transverse colon, were rapidly secured with cat-gut, the upper part of the abdomen carefully packed with hot aseptic compresses and the patient placed in the Trendelenburg position at an angle of 45 per cent.

Amputation of the remaining fibroid was then carried out in the usual way. The technic I generally follow being the one I have seen most of the French Surgeons, and Prof. Pozzi in particular, use in similar cases. It is essentially similar although differing in details from the one so admirably illustrated by Howard H. Kelly in His well-known book on Operative Gynaecology. The remains of both broad ligaments were clamped and divided close to their insertion on the uterus, the peritoneal flap and bladder dissected from the anterior uterine surface, the uterines secured and divided at the seat of election and the uterine pedicle severed just above the vaginal insertion.

The left cystic ovary was also excised and found to contain darkly stained serum. The right which was also fibro-cystic, was left in situ, the cysts having been punctured, and lastly a small pedunculated, almost sessile fibroid, apparently loosely connected with the parent growth, was removed from the left broad ligament

The peritoneal flap having been duly sutured after closure of the cervical stump with catgut. the abdomen was carefully cleaned out and closed in three layers, a large iodoform plug being left, Mickulick's fashion, in Douglas' pouch, so as to drain away the excess of serum and blood which would doubtless collect after such an extensive decortication.

The operation had been concluded exactly 1 hour and 30 minutes after its onset.

The patient very much collapsed, revived slowly under the stimulating effects of saline injections administered under the two breasts and in the rectum.

Ether, Strychnine and Adnephrin were freely injected hypodermically and undoubtedly greatly assisted to tide over the first hours of intense depression.

The iodoform plug was removed 48 hours after and the abdomen allowed to close.

In spite of the severe nature of the intervention, the extensive nature of damage done to the peritoneal surfaces, which could not be minimized in any way, the recovery was uninterrupted, the abdominal sutures being removed on the 10th day.

REMARKS.

The case presents many points of interest. First on account of the size of the growth and the solid nature of its contents.

Fibroid tumours of the uterus have of course been known to attain a much larger size and as Spencer Wells already pointed out in 1872, it is a mistake to imagine that the huge swellings distending to an unusual extent the abdomen are necessarily ovarian, and he goes on to state, that the largest abdominal tumours he had seen were either fibroid or fibro-cystic.

One of the larger tumours of this kind is one removed by Severanu of Bucharest and weighed 195 lbs. It was of a cystic nature and contained 17 lbs. of a coffee ground sediment.

According to W. R. Williams the abdominal distension was enormous, measuring 6 feet at the level of the umbilicus. Hunter of New York, quoted by Pozzi had removed a huge cystic myoma weighing 140 lbs., while the cadaver after its removal weighed but 95 lbs.

Stochard (Medica! Record, August 16th, 1884) found one in a multiparous negress, which weighed 135 lbs. and contained 9 gallons of a chocolate coloured fluid, the abdominal circumference being 5 feet, 8 inches.

Solid tumours are however generally of a smaller size. McIntyre removed one, which weighed 106 lbs., Platonof another of 90 lbs. and Howard H. Kelly in May, 1894 one which turned the scale at 59 lbs. and measured 51 inches round the abdomen. But although several solid myomata weighing from 40 to 70 lbs, have been reported, such enormous growths are very rare and the recovery after operation more exceptional still, the risks of their removal specially when complicated with extensive adhesions with adjacent structures being necessarily very great. These adhesions, in the case we operated upon, were not very largely distributed, but were concomitant with an abnormal peri-pheric development of adventitious blood vessels.

These, we have already noted, were evidently the omental veins and arteries, which undergoing hypertrophy and multiplication, had become, as evidenced by the comparatively small size of the vessels contained in the pedicle connecting the upper and large growth with the smaller uterine segment, the real feeders of the tumour proper.

The uterine and ovarian arteries were scarcely above the usual size, nor were the plexus of veins in the broad ligaments of any magnitude, so that the fibroid had practically severed its circulatory connection with the uterus and mainly depended upon the collateral network of vessels it had acquired first, with the omentum, and secondarily with the abdominal parietes.

There can be no doubt also that the adhesions with the under surface of the liver and which were also freely supplied with veins, had to a great extent relieved the portal system of the excess of blood flowing towards it. The vena cava flattened as it was between the tumour and the spinal column had its calibre greatly diminished, and thus the return of blood from the lower extremities had deviated from its usual channels, and was being returned to the central current by both the superficial and deep abdominal veins.

This is of course a constant phenomenon observed in hepatic growths, and specially those of a malignant nature.

Then as regards symptoms: one noted with some surprise the diminished amount of blood lost of late at the mentrual periods. This was partly accounted for, by the enforced rest taken by the patient, her weight having become such, as to prevent her taking any exercise.

But it is by no means an infrequent occurrence to find superitoneal fibroids, even if still actively growing, showing signs of diminished metrorrhagia and even of amenorrhoea, contrasting markedly in this respect with the intestitial and submucoid varieties.

We personally recollect a case where the presence of an ovoid, smooth, movable and manifestly cystic growth, co-existing with a history of amenorrhoea lead to the diagnosis of ovarian cystoma, and still, at the operation, the patient proved to be suffering from a fibro-cystic tumour, weighing 16 lbs. and containing 2 to 3 pints of a coffee-coloured liquid. Another, whose menstruation was irregular and scanty and presented all the symptoms of a solid ovarian growth, had a perfectly ovoid subperitoneal fibroid, adherent to Douglas' pouch and apparently loosely connected by an attenuated pedicle with the uterus proper. Most of its circulatory supply was derived from a bunch of vessels springing from an adhesive piece of omentum.

The cardinal point to observe, in assisting one to arrive at a correct diagnosis, is to locate, if possible, the body of the uterus, and specially that of the cervix and ascertain its relative position to the tumour itself.

But it is obvious, for more reasons than one, that it may be impossible to determine the relationship of one structure to the other, and specially so, with the larger forms of growths which fill the pelvis and part of the abdomen, as this proved to be the case with one of the patients mentioned above.

It then becomes a moot point of diagnosis to decide whether one is dealing with an ovarian or uterine tumour, a question, which indeed, the operation alone can decide. The presence of metrorrhagic symptoms or, on the contrary, of amenorrhoea do not therefore appear to us, to be the "criterion by which we may decide whether the growth is decidedly of ovarian or uterine origin, although they may assist in the differential diagnosis; nor is the diminished menstrual flow of a woman, manifestly suffering from a fibrous tumour, the sign that such a tumour is undergoing retrogressive changes and likely to disappear. It is an error only too frequently made and one which has prevented many a surgeon from advising an operation which would otherwise had been indicated and saved the patient from a more serious one later on.

The following appointments have been made at the Johannesburg Hospital:

Physician Dr. Currie.

Assistant Physicians: Drs. Pershouse, Lundie, Towert, and Johnstone Brown.

Assistant Surgeons: Drs. Temple Mursell, Ritchie Thompson, Heberden, and Daly.

House Physician: Dr. Sydney Pern.

Dr. A. Watt, a new arrival, has been appointed an Assistant Medical Officer at Valkenberg.

British Medical Association.

C.G.H. (EASTERN) BRANCH.

At a meeting of the Council, Sept. 10th, Mr. J. H. Wroughton, M.R.C.S., L.R.C.P., was elected a member. A meeting of the Branch was held at Steinmann's Hotel on the same day. Present, Drs. Purvis, Bays, Coutts, Dru-Drury, Greenlees, and R. C. Mullins, with Mr. H. Conder as a guest.

A letter was read from Dr. Richardson, enclosing one from Surg. General Evatt, on the proposed formation of a South African Council of the Association for dealing with local matters.

Resolved, "That this Branch will co-operate with the other South African Branches in any steps they may take towards the formation of a South African Council of the B.M.A.

A letter was read from Dr. C. J. Hill-Aitken, of East London, covering a self retaining vulsellum and vaginal speculum. Resolved to convey the thanks of the Branch to Dr. Aitken.

The report of the Branch Council on the draft report of the Committee of the Western Branch on proposed amendments to the Medical Act, was considered. Resolved That this Branch is of opinion that the time for a complete revision of the Acts has not yet arrived, but agrees with the amendment of Clause 13 of the Act of 1899, which would bring the Act more into line with the English Act of 1858. The Branch objects to the proposed deletion of words from Clause 36 of the Act of 1891, and understands that it is not proposed to delete Clause 60. The Branch will support the action of the Western Branch in seeking to amend the Act on these lines."

Dr. J. T. Bays then read a paper on "Some Disputed Points in Medicine" Dr. Bays discussed the use and abuse of midwifery forceps, routine douching, slop diet, and the administration of stout, satirising in an amusing manner the ritual of a modern antiseptic conduct of that pathological state, a confinement. He passed on to consider the value of lancing the gums of teething children, the practice of venesection, of feeding enteric patients more liberally than is usual, and dealt with the use of drugs in delirium treatment.

In the discussion that followed all took part, and a vote of thanks to Dr. Bays was passed.

C.G.H. (WESTERN) BRANCH.

The usual meeting was held on the 30th ult. Present Dr. Jane Waterston, Vice-President, in the Chair, and about thirty members.

Dr. Jasper Anderson read a paper on Infantile Mortality, in the course of which he invited suggestions with regard to a leaflet that he had drafted for distribution amongst the mothers in the poorer classes in the city, giving advice as to the dietary of infants.

Dr. Guillemard said that one thing which struck one was that there was less of that marked periodicity about the infant mortality in this country as compared with

England. We did not get that terrible fulminating diarrhoea which rendered certain months in England so fatal. And there was less of the gross forms of bad feeding in England. He had seen an infant sucking at a sauce bottle stoppered with newspaper, and filled with coffee without milk. You would hardly see anything comparable to that amongst the most ignorant classes in the Old Country. He thought that a good deal of trouble was due to the quality of the Cape Town milk. Very few of the cows had grass veld, and this was possibly the reason for the undoubted fact that many children could not digest cow's milk. Another point was that mothers did not see the necessity of the proportions in the food being the same at each meal. They mixed food in a big jug and left it to stand, the result being that the top portions differed materially from those at the bottom. He believed very much in always adding carbonate of soda to milk. He also thought that we could make a mistake by adhering too closely to exact measurements as to the quantity of food to be given. At the breast the child took a full swing till it was satisfied. Artificial foods also often differed in temperature. With reference to the suggested advice to add flour to the milk, he thought an improvement would be flour baked to a fawn colour. Another fault in this country was the frequent tendency of mothers to give animal food too early. For a child of twelve months old he had found the fat of fried bacon most useful.

Dr. Brown Lester, quoting from his experience at the Free Dispensary, said that there was always a large number of cases of gastro-enteritis from October to March. He found that, whatever one did, dispensary patients simply would not follow directions.

Dr. D. J. Wood asked Dr. Anderson whether he noticed any marked difference in the mortality of illegitimate as compared with legitimate children. The proposed leaflet would hardly reach the mothers of the former. He had noticed that eye affections in children bulked very largely in his practice at the New Somerset Hospital.

Dr. Ketchen would like to hear Dr. Anderson's views about a Municipal Milk Laboratory.

Dr. Kruger alluded to the "one cow" idea amongst mothers, which might be a good idea if the cow was a good one, but generally speaking was a very bad principle.

Dr. M. Hewatt believed that a large proportion of sore nipples was due to painting with spirit, and advocated simply keeping them clean and dry.

Dr. Reynolds pointed out that no mention was made in the draft leaflet of diluting the milk with barley. water. This often gave most excellent results. He would like to hear some opinions as to such Foods as the Allenburys. He had formed the impression that they were extremely useful.

Dr. Ketchen thought that malted Foods were harmful from their tendency to promote diarrhoea.

Dr. Darley-Hartley said that his experience of the Allenburys' Foods was most favourable. He had seen children who did no good on cow's milk pick up at once and thrive on these Foods. They had to consider human nature in the class whom they were advising, and that class simply would not attend to directions as