royal southern hospital, liverpool

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generally and percussion note normal; a few crepitantrftles at bases of lungs behind were alone heard ; there wasa slight cough; a systolic murmur heard all over the cardiacregion and slightly in left axilla; no venous hum heardabove the clavicles. Vaginal examination of the uterusshowed it to be balky and suspended below normal level inthe pelvis. The os uteri just admitted the index-finger, andwithin the uterine cavity was felt a smooth, dense fleshybody. The sound passed in beyond the normal depth, andcould be swept around the enclosed tumour. The uteruscould not be perceived above the pubes. Urine : sp. gr.1027, acid, slightly albuminous on submitting it to theaction of heat and nitric acid. Bowels constipated ; tongue,besides being blanched, slightly furred; some headache.To correct an offensive uterine discharge a solution of

Condy’s fluid was injected and an aperient given ; guaranawas administered at intervals with relief to the headache.On the 24th and 25tb, after washing out the uterus,

sponge tents were inserted within the neck of the uterus,between it and the polypus, and changed for fresh ones oflarger size at intervals of three or four hours.When the required dilatation had been effected the single

wire loop of an écraseur was adjusted around the polypus,and the wire gradually tightened till it crushed through itssubstance. On re-examination it was found that only aboutone-third of the growth had been removed. Therefore theloop was immediately again applied, pushed up over thetumour, the uterus being at the same time depressed, andthe wire was tightened close to the uterine surface, butbefore it had made its way half through the dragging on themass led to enucleation of the growth at the point of itsattachment, which appeared to be situated within theuterine wall, and presented at the site of its connexion aconvex surface. The patient was placed under anaesthesiaby ether during the second application of the ecraseur, asshe had become restless. The entire polypus, which provedto be a myoma, was of the size of a full-sized fowl’s egg.The uterus was afterwards washed out with a solution ofCondy’s fluid morning and evening as long as necessary, andthe patient made a good recovery under ordinary treatmentand a generous diet, completed by bitter and chalybeatetonic, being discharged convalescent on March 11th. Aboutfour weeks later she visited the hospital again with scarcelyany pallor, and had had a normal period. A few weekslater she again applied, but only to assure us of hercomplete recovery and thankfulness. The anæmic mur-murs had entirely vanished.

ROYAL SOUTHERN HOSPITAL, LIVERPOOL.RHEUMATIC FEVER WITH HYPERPYREXIA AND COMA;

COOL BATH ; CURE.

(Under the care of Dr. CARTER.)E-iNlTviA R-, aged thirty-three, married and the mothe

of a large family, was admitted on December 18tb, 1880suffering from her first attack of rheumatic fever. She hadhad slight pains for about ten days, but had only been con-fined to bed since the 13th. For the first three days thecase presented nothing special beyond the fact that slightnoise in the head was complained of before treatment wascommenced, and that she had not slept for several nightsowing to the intensity of the pain in the larger joints.Beyond this sleeplessness, which was easily accounted for,and the slight tinnitus there was nothing in her appearance,symptoms, or antecedent history leading to the anticipationof cerebral disturbance. She was a well-nourished, healthy-looking woman. Bowels regular ; heart’s sounds normal;pulse 104; respiration 28; temperature 100’2° at 11 A.M.A milk diet was ordered. The joints were wrapped incotton-wool, and at 2.30 P.M. she commenced taking amixture containing in each dose twenty grains of salicylateof soda and twenty minims of bromhydric acid. The first sixdoses were given at intervals of an hour, and the temperaturehad fallen from 101.8° at 2.30 P.M., to 99° at midnight.After the sixth dose the medicine was given every thirdhour. The pains, which had been so severe that all pressureof the bedclothes had to be taken off the inflamed joints,were greatly relieved, but it was noticed that with this reliefand the fall of the temperature which accompanied it therewas no corresponding decline in the pulse, which at midnightwas still 114, and during the next two days variedfrom 114 to 122, the temperature being generallylow, and only once for a short time reaching 101°.

After the ninth dose of medicine she complained of deaf-ness and giddiness; the respiration became somewhatsighing, and she vomited slightly at 4.30 P.31. on the 19th.Upon this the medicine was ordered to be given every fourthhour, and in soda-water. She again vomited at 10.15 P.M.,but afterwards passed a good night. During the day theface had been flushed, and she had perspired profusely. Onthe 20th she was quite free from pain, had less noise in thehead, but, as she had again vomited twice, and still com-plained of giddiness and deafness, the medicine was dis-continued at 2 P,M. At 5.30 she for the first time becamedelirious. Immediately after the commencement of thedelirium, which was at first mild, the temperature was only101°, but whether it rose during the next few hours is un-certain, as her violence soon became such as to prevent thepossibility of using the thermometer. To the hand, how-ever, the skin felt quite cool. As she obstinately refusedto take either food or medicine she was brought under theinfluence of chloroform, though with much difficulty,in consequence of her violence ; and while unconscious twoattempts were made to introduce enemata containingchloral hydrate and bromide of potassium into the rectum,but these were not retained a moment. Immediatelyon coming from under the influence of the chloroform shebecame as violent as ever; it was once more applied, there-fore, and a quarter of a grain of acetate of morphia in-jected hypodermically. Further attempts, made later on, tointroduce nutrient enemata into the rectum were unsuccessful.She slept well, but the temperature began quickly to rise,and by 2.10 A.M. of the 21st was found to be 105°, when thesurface of the body was sponged with tepid water. Thetemperature fell under the sponging, which was twice re-peated, to 100-6° at 5.30 A,M. At 6.30 she awoke, wheu thehouse-surgeon, finding her still delirious and refusing to takeeither food or medicine, again injected a quarter of a grainof acetate of morphia. At 7.45 the temperature was 1062°.By 10.50 it had fallen to 104’4°, but at 11.50 was 107°. Thepatient was then deeply comatose, and unable to be rousedby any external stimulus. It was not quite clear how longthis very high temperature had lasted, as an hour bad beenallowed to elapse between the last two observations, andduring that time an increase of nearly three degrees hadtaken place. She was immediately put into a bath at 90° F.,while cold water was steadily poured over her head, and thetemperature of the bath reduced by also running in coldwater. She was in the bath an hour. In about twenty-fiveminutes, her body temperature having fallen to 103°, shebecame conscious, and ten minutes before being taken outmade some rational observation and drank a little brandy-and-water-the first drink or nourishment of any kind thathad been taken for twenty hours. When removed from thebath her temperature was 99 G°, and fifteen minutes after-wards 98.4°. She then took some warm beef-tea, and duringthe afternoon plenty of warm milk. The pulse for the firsttime since her admission fell to below 100. After this therewas no difficulty. She slept well on the night of the bath;had slight pneumonia of the right base on the 22nd, whichran a very mild course and disappeared in a few days, to befollowed by a moderate return of her rheumatic symptoms.These in turn were easily subdued, apparently by the use ofsmaller doses of the salicylate, and after a few weeks’ resi-dence she was dismissed quite well, no cardiac complicationshaving been developed.There can be no question that but for the bathing at mid-

day on the 21st this patient would never have rallied fromthe state of coma, with hyperpyrexia, into which she had thenpassed.

STOCKTON HOSPITAL.

AMPUTATION BELOW THE KNEE IN WHICH NO LIGATURES

WERE REQUIRED ; RECOVERY.

(Under the care of Dr. Foss.)

FOR the notes of the following cases we are indebted toMr. Johu Hassall, M.B., house-surgeon.

J. H-, aged ten years, a school-girl, was admittedSept. lSth, 1SSO. The girl wa. crossing the railway, when anengine struck her on the ii,4ht side of the forehead andknocked her down. She rolled over to sa.ve her body, butwas unable to get her left leg away in time to prevent the

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whole train parsing over it. She was first removed home,and subsequently taken to the hospital. During this time aconsiderable amount of blood had been loa.On admission severe shock was present. The face was