decided but not obstructive. The greatest inconvenience was from the weight of the abdominal mass causing some disability in walking. About the 1st of June symptoms of prostration and extreme dyspnoea set in, accompanied by excessive emaciation. On the 4th of the month, the symptoms still increasing, Dr. Pepper again saw the case with Dr. Smith. An apparent sense of fluctuation gave rise to the hope that the removal of fluid, should any be found to exist, might lessen the sufferings from pressure, and on the following day Dr. W. Pepper saw the case with them. The child being thoroughly etherized, an exploring trocar was plunged into the most prominent portion of the mass but no fluid escaped. The point of puncture was acutely painful the next day, but anodynes gave prompt relief. He continued to sink until the 14th, when he died. The urine flowed freely until the 12th when total suppression occurred; before death a considerable quantity of blood was voided from the bladder. Slight cedema of the left leg was present for a few days before death. The duration of the disease from the first attack of hæmaturia was nine months; from the first discovery of the tumor, about six.

The autopsy was made twenty-four hours after death by Dr. W. Pepper, who furnished the following notes of the naked eye and microscopic appearances:

The right kidney was hypertrophied to a moderate degree, weighing 2 ozs.; its tissue presented normal appearances.

The left kidney occupied the entire left side of the abdomen; the intestines being pushed over to the right side. The descending colon was quite tightly adherent to its inner aspect, but the walls of the bowels were healthy, and their calibre not permanently obstructed. The adhesions which bound the kidney to its place were unusually dense and strong, but there were no adhesions between its capsule and the anterior wall of the abdomen. The kidney was enormously enlarged, weighing 3 lbs., and presented a nodulated exterior. The capsule was thickened, and tensely filled by the contained mass, which imparted a sense of elastic vibration. Upon section, the normal appearances of renal tissue were entirely absent, the mass presenting throughout typical encephaloid characters. The section was generally of a whitish-gray color, mottled with patches of pink and red of various shades, and, in one or two places, presented effusions of blood. All parts of the cut surface exuded abundant cancer-juice on pressure. Microscopic examination showed an entire absence of the elements of renal tissue, the mass being composed of very numerous nucleated cells, with a scanty stroma of small fusiform cells. The major

ity of the cells were about the size of a white blood-corpuscle, rounded or oval in shape, and containing one, or, in a few instances, two nuclei. A few cells were seen which were larger than the above, and contained multiple nuclei. Many of them presented highly granular contents, and the tissue also contained free oil in granules or small globules, and some crystals of cholesterine. The upper part of the ureter was much enlarged, its walls thickened and rigid, and its calibre obstructed by a firm, reddish-gray plug which projected downwards about 1 inches from the pelvis of the kidney. This plug was not attached to the ureter for a short distance above its lower extremity, but near the pelvis the mass gained firm adhesion to the mucous membrane. On microscopic examination it was found to be a firm, partially decolorized blood-clot, which was continuous with a softer clot occupying the pelvis of the kidney. Its presence entirely occluded the ureter and prevented the escape of any discharge whatever from the left kidney into the bladder. The lower part of the left ureter was quite healthy. At the point where the puncture with the needle had been made there was marked discoloration of the capsule, and the morbid tissue around the track of the needle showed more advanced degeneration than elsewhere. Corresponding to this point of the capsule was a patch of discoloration with a thin layer of lymph on the peritoneal covering of the anterior abdominal wall. No extension of the inflammation had occurred.

DR. A. II. SMITH made some remarks upon the propriety of exploratory punctures in such cases, and stated that, from the results of the post-mortem examination in this case, he had no doubt but that, had the child been in better condition, death would have been materially hastened by the inflammation and degenerative tissue changes set up around the point of puncture. The great difficulty in always positively recognizing the presence of fluctuation in such cases was alluded to by Dr. William Goodell and illustrated by a case of

OBLITERATION OF THE FALLOPIAN TUBES, ACCOMPANIED BY

AMENORRHEA AND STERILITY.

DR. R. G. CURTIN read the following history: C— W, a stout, robust, middle-aged Irish woman, was admitted August 28, 1866, to the insane department of the Philadelphia Hospital, laboring under an attack of acute mania brought on by intemperance. After her admission, in a lucid interval, she informed Dr. Curtin that she had never menstruated, but that periodically she had pains in the head and back, with all the

other symptoms usually accompanying the performance of this function, and attributed her mental condition, in a measure, to the absence of the flow. She had been married and living with her husband for ten years, and had never conceived. The maniacal symptoms returned, and she died, very suddenly, three days after admission.

On post-mortem examination no abnormal condition of the brain could be discovered; the immediate cause of death was an extensive pulmonary apoplexy. The external sexual organs were normal, the uterus undersized, but with all its appendages complete. On both fallopian tubes, about midway between their extremities, were bead-like prominences. On laying them open two calcareous nodules were found, each one about the size of a pea, and completely obstructing the calibre of the tubes, which, above these points, were dilated and distended. by fluid. The ovaries were marked with numerous cicatrices of ruptured graafian vesicles-one apparently being only three weeks old. No evidences of pelvic peritonitis.

DR. WILLIAM PEPPER remarked that cretaceous nodules appeared to him to be the remains of old blood-clots which had originally formed in the fallopian tubes. In the great majority of cases, at least, calcareous formations occur as the sequelæ of former plastic exudation or of coagula. The transformation is effected by the disintegration and absorption of the organic constituents, while the inorganic calcareous portions remain as an amorphous mass. The symmetrical disposition of the nodules in the present case seems to render probable the view of their being transformed coagula. In this connection Dr. William Pepper alluded to a series of morbid conditions of the fallopian tubes which he had observed, in which different stages of this process appeared to be present. In one instance both fallopian tubes were distended with firm, partially-decolorized, but not as yet disintegrated clots. In a second, both tubes were much enlarged and filled with a soft, cheesy substance of yellowish color, apparently caused by the disintegration of clots. In several other cases, the free opening of one tube was closed, and the distal portion of the tube itself distended with a clear, serous fluid (pseudo-cystic disease of the fallopian tubes). In the latter cases, it is most probable that the condition was the result of inflammatory obliteration of the free opening of the tube, and the subsequent accumulation of fluid in its extremity thus closed. But it might be that here also a clot was the starting point of the process, and the complete removal of its solid portions was followed by a pseudo-cystic condition, such as is found in the subarachnoid or arachnoid

space after meningeal hemorrhage. The present specimen would seem to present still another of the sequela which are well known to result from the formation of coagula, and from their subsequent degenerative changes.

An animated discussion arose on the relationship existing between menstruation and ovulation. Dr. F. G. Smith defended the view that, though frequently coincident, yet they did not bear the relationship of cause and effect, and illustrated his remarks by cases. The opposite side was espoused by Drs. A. H. Smith, William Goodell, and others.

DR. J. G. ALLEN related a case where a woman conceived before menstruation.

DR. O. P. REX had also seen a case where a woman bore her first child at the age of 21, and menstruated, for the first time, only several years after the birth of her third child.

Other similar cases were related.

DR. F. G. SMITH spoke of a case of sudden death which recently occurred in his practice. A middle-aged lady had had seven or eight pregnancies, and, with the exception of one living child, had always miscarried, when well advanced in gestation, the cause probably being albuminuria, as that condition had invariably been present. At the time of her death she was about 4 monthis advanced in utero-gestation, and, although presenting evidences of albuminuria, was apparently doing well. While talking with some friends, she suddenly expired, with all the symptoms of heart clot. No post-mortem examination could be obtained. Dr. Wm. Pepper had examined the urine, and had found a considerable amount of albumen, associated with hyaline and faintly granular tube casts, and suggested that the case had been one of latent Bright's disease with cardiac degeneration.

MEETING OF AUGUST 4, 1870. DR. HARRIS IN THE CHAIR.

CASE OF POST-PARTUM HEMORRHAGE CAUSED BY A DISTENDED BLADDER, ARRESTED BY THE INJECTION OF THE PERCHLORIDE OF IRON.

DR. W. GOODELL related this case as follows:-The woman had been previously delivered of a small infant, after a tedious labor, in which "forcing powders" were used. In the present labor-after suffering for three hours only-the membranes broke; the head descended in the R. O. P. position, and soon rotated to the ilium, where it became arrested. After waiting about an hour, and finding the pains inefficient, Dr. G. applied the forceps, and, without much trouble, delivered her of a child

weighing not quite nine pounds. Previous to the application of the forceps he had not passed the catheter, because he rarely did so, unless the head was at the brim, or the patient had been long in labor. In accordance with his invariable custom, he gave one drachm of the fluid extract of ergot so soon as the head had cleared the perineum. The placenta was presently cast, and the womb contracted firmly. No accumulation of urine was at that time observed, although the hand carefully followed down the womb into the pelvis.

In about three hours he was summoned to the bedside of his patient to arrest an alarming hemorrhage. Upon removing the binder, and applying his hand to the abdomen, it came in contact with a soft, yielding body, which he at once commenced to knead, on the supposition that it was the flaccid uterus. Whilst thus engaged, the back of his hand accidentally touched a circumscribed tumor, high up at the epigastrium, far more dense than the other, and apparently quite isolated from it. For a moment he thought it was a fibroid tumor, attached to the womb by a long pedicle; but he very soon discovered it to be the womb itself, and that he was compressing a distended bladder. He at once drew off thirty-three ounces of urine. The womb contained no clots, but a large mass of them was turned out of the distended and greatly elongated vagina. This caused the womb to descend again into the pelvis, but it refused to respond perfectly to compression, ergot, and to ice. Free bleeding continued, either from the uterine cavity or else from some lacerated point in the cervix, and the woman soon began to sigh, yawn, retch, and toss about. He therefore introduced the nozzle of a syringe within the os, and slowly injected a solution of two ounces of the liq. ferri perchloridi to eight of water. The effect was immediate, and so persistent, that the napkin, applied to the vulva directly afterwards, did not require to be changed for five hours. For several days the lochia contained minute and intensely black clots, which became quite fœtid. The convalescence of the patient was slow, but perfect.

Dr. G. remarked, that few obstetrical writers allude to postpartum hemorrhages arising from an accumulation of urine; although, from its anatomical relations, a distended bladder would carry up the womb, and thus stretch its walls, as well as those of the vagina, when paralyzed by over distention, as after labor. He had, however, met with two other examples, but they had occurred respectively on the third and ninth day following delivery. In neither of these had he mistaken the distended bladder for the flaccid uterus; probably because the