denied syphilis and had always been moderate in his habits. In fact, there was no evidence anywhere of specific disease.

The appetite remained fair and bowels were in good condition. Kidneys free from trouble. Patient complained of a sense of constriction in the upper part of chest, comparatively little pain at the time of my examination, but claimed to have lost a great deal of sleep. The difficulty in breathing was most marked at night on attempting to lie down in bed. He complained, furthermore, of a feeling of congestion in the head and shortness of breath on exertion.

The examination, as above stated, showed the patient to be well developed and nourished, the face rather flushed and eyeballs slightly bulging. Pupils normal and use of external muscles of eye perfect. No involvement of cranial nerves. Special senses good. An examination of neck showed vessels on the surface overfilled and a decided increase in size of neck at its base. A marked bulging in the middle and upper third of the sternum was the special feature. The sternum above was pushed forward to a great degree and the distortion was slightly more marked on the right than on the left side of the median line. The veins over this prominent part of the chest were all very much dilated. Just above the sternum, on palpating in the suprasternal notch one was able to feel a distinct hard

mass.

On percussion there was an absence of pulmonary resonance over this large area which extended quite a distance to the right of the sternum above and to a lesser degree to the left of the sternum. The apex beat of the heart was practically in its normal position. The heart sounds were weak, rapid, regular and without bruits. The voice of the patient was a trifle husky, but there was no paralysis of recurrent laryngeal nerve on either side. The respirations, while patient was at rest, were practically normal in frequency. The pulse was regular, small, easily compressible and of rather low tension. No sphygmographic tracings were taken. The area of heart dullness merged into that of the tumor mass above. No breath sounds could be heard over this mass. There was at the time of the examination no special tenderness or pressure over the swelling, but slight edema of the skin with great increase in size of the superficial veins and a marked enlargement of the veins at the root of the neck. No bruits over heart or tumor mass. At this examination there was slight dullness over the lower portion of right lung posteriorly.

The patient, as I was told, gradually grew worse; the pressure symptoms became more

marked, the greatest difficulty being experi enced on attempting to lie down at night. However, patient continued to be about until four days before his death, which took place about the middle of July. The post-mortem revealed a small amount of serous fluid in the right pleural sac and a rather recent pleuropneumonia. The heart, lungs and tumor are here presented. The heart, as you can see, is rather smaller than normal for a patient so well built. A fresh fibrinous layer may be seen over the right lung below, and the whole lower lobe of right lung is the seat of a fresh pneumonia. That to which I wish to call special attention is the presence of a large tumor mass, separate and distinct from the heart, occupying the whole of the mediastinum from above down, slightly larger in width at the middle and tapering slightly above and below.

Because of the age of the patient, its rather sudden appearance and rapid growth, and because of the absence of any evidence of syphilis and owing to the small, hard mass palpable in the suprasternal notch, not pulsating in character, I felt that we had to deal with a sarcoma of the mediastinum. The post-mortem examination, with microscopic examination of the tumor mass, shows the correctness of the diagnosis. It proves to be a lympho-sarcoma.

Ligation of the Femoral Artery.

DR. W. D. HAINES: A young man, a patient of Dr. Emmet Fayen, while cutting meat with a very narrow blade accidentally plunged the knife into his right thigh at a point over the sartorius, four inches above the knee joint. The patient had bled furiously at the time of the accident, but this had been arrested by the application of an improvised tourniquet. On freely exposing the parts, the small stab-wound of the skin was found to continue through the inner side of the sartorius and to have severed the anastomotica magna a short distance below its origin and the femoral artery just above the upper end of Hunter's canal. The vessels were so badly mutilated that restoration of continuity by suture was deemed inexpedient, and simple ligation with catgut for control of hemorrhage was adopted instead. A small drainage was introduced, and with the exception of this point primary union followed. The patient was put to bed with the limb slightly elevated, the thigh abducted and the leg flexed. The foot and leg became warm, and have remained so since the operation. Pulsation in the posterior tibial and peroneal arteries was present on the third day after the

injury. The function of the limb is seemingly unimpaired, although the patient is still in the hospital, having developed typhoid fever.

Animal experiments for the restoration of severed blood-vessels have been numerous and results encouraging, in that large vessels have been completely divided and successfully united by suture. Jassinowsky, in 1889, sutured wounded vessels, and is usually given credit for the first success in this work. Shede attempted arterial anastomosis in 1882, but did not meet with encouraging results.

The technique of arterial anastomosis is not difficult. With a surgical field the vessel to be sutured is lightly clamped and two or three tension-sutures introduced to steady the divided ends of the artery while the sutures are being introduced to maintain the parts in apposition. Very fine silk or celluloidin may be used, and a mattress suture reinforced with an occasional interrupted suture which does not include the intima within its grasp have proven satisfactory.

The dangers of secondary hemorrhage, thrombus, aneurism and sepsis have deterred the extensive employment of the suture of the blood-vessels, but in view of the vast amount of experimental research now doing in this field and the report of an occasional successful case in actual practice, leads one to hope for the realization in the near future of great possibilities in blood-vessel surgery. A Case of Precocious Menstruation.

DR. A. E. OSMOND: Patient a perfectly normal white female child, aged six, born in Ohio, and having two sisters aged eight and eleven, who have never shown any sign of abnormal condition. Mother dead, yet history seems to show that she first menstruated at age of fourteen. On examination the child was normally formed, except that the hips were a trifle broader than would be expected at that age and a reddish fur was present on the pubes. Breasts were negative. Child was brought by her grandmother, who stated that the child first showed menstruation in May, 1906, which lasted from the second to the seventh. I first saw her in June, 1906, when the second flow was present, and contined from the second to the tenth. Have kept in correspondence with her grandmother for a year, and learn that the child has continued to menstruate regularly. At present the breasts have enlarged, the hips are broader, and the pubes are well covered with hair.

Inasmuch as over a year has elapsed since menstruation first began, and that the child's body shows those signs and changes which

take place at puberty, I think we may safely report a case of precocious menstruation at the age of six.

Two Cases of Placenta Previa.

DR. MAGNUS A. TATE: I know of no class of cases in the whole domain of surgery and obstetrics that will present such evident marked and alarming symptoms as are present in a placenta previa, and especially so when it is centrally implanted. Placenta previa is not classified as common, occurring only once in 500 to 1,000 cases of labor, and that when it is of that variety known as the centrally implanted it is indeed a rare affliction. It was my fortune to encounter two cases of central implantation last winter, and I give you brief histories of each.

Case 1.-Dr. J. S. Caldwell asked me to see the first case. Patient, a primipara, about twenty-five years old, was seen on the night of February 6, 1907, by Drs. Caldwell, Rowe and Blizzard. The latter physician. had charge of the case, and stated that the patient had been bleeding profusely. Immediate delivery was first advised, but the hour being late and patient exhausted, it was finally decided to tampon vagina and wait. This case was watched almost night and day until February 12, or one week after the first consultation, when labor pains came on and I was then called into the case. Upon examination I found the woman of slight build and child in an L. O. A. position. The os dilated about the size of a dollar, and inserting the finger very carefully I found the placenta immediately over the os; in other words, I was dealing with a central implantation. The bleeding at this time was not very severe, and after thorough preparation I hurriedly delivered by going directly through placenta and made a version. A full-time child was delivered, the fundus firmly grasped and the hemorrhage was soon checked. Subsequent history shows mother and child both living and well.

Case II.-In March, 1907, Dr. Raphael Miller called me by telephone, saying that he had a very bad case of placenta previa on hand, and asked me to see the case with him. He had tamponed and had temporarily succeeded in controlling the hemorrhage. I advised sending the patient to Christ Hospital, which was done, and I saw her immediately upon arrival. Mrs., a multipara, had been bleeding off and on for one month, but as she was extremely anxious to save the child the doctor temporized, constantly watching her; but the time had now arrived when further waiting could no longer be countenanced.

Patient was very pale and her clothing saturated with blood. After a careful external examination I found we had an R. O. P. presentation to deal with, and upon vaginal examination (after removing tampon) the os was found to be dilated to the size of a dollar and the placenta immediately over os. Delivery was followed out as in first case. The child was resuscitated with difficulty and lacked about a month of being full time. The subsequent history of woman was that of a perfect recovery, but the child died on the morning of the third day.

When we consider the mortality of women in marginal placenta previa to be about 25 per cent., and that of the infants 50 to 75 per cent., and that more than half of those children born alive die within the first ten days, it seems that in these two cases we were somewhat fortunate in our results, having saved both mothers and one child (the second being premature), and especially so does it seem we were fortunate since both placenta were centrally implanted, and this of itself always gives a greater mortality than when marginally situated.

DISCUSSION.

DR W. D PORTER: I would like to ask what was the length of time between the turning of the child and delivery?

DR TATE: The first took three minutes and the second five.

DR. WM. GILLESPIE: Does the doctor regard these placentae as centrally implanted?

DR. TATE: In the marginal placenta previa there is no difficulty in making a diagnosis; but in this case I was able to run my hand entirely around the margin. The placenta was unattached on all sides It must have been centrally implanted.

DR W E. KIELY: I would like to ask a question about Dr. Tate's cases. I do not know of any greater type of a dangerous condition than a case of placenta previa. Did I understand you delivered the woman in a few minutes? Were the patients multiparæ?

DR. TATE: The first was a primapara, the second was a multipara. The second case had been bleeding a few months, the first a few weeks

DR. KIELY: I have never seen reported nor have I ever read of such a rapid and successful delivery in this class of cases, and I still retain an interest in the subject.

I recall a case in which a lady had given birth to a dead child and had eclampsia at time of birth About ten years later she became pregnant again, and the husband, with the memory of the previous labor still fresh in his mind, engaged a physician early in the pregnancy and requested him to decide upon some physician to come to his assistance should complications arise. The pregnancy was in every way normal, but the patient thought she was carrying the child beyond time. One day the physician was called to come as soon as possible. Within fifteen minntes he was at the patient's home, and found that things had been going along just as usual,

until a terrific hemorrhage came on just as the patient was leaving the dinner table. The amount of blood lost was very great, but the bleeding had stopped when he arrived, and the patient was lying on bed and very comfortable. An examination revealed very little dilatation and the examining finger encountered the placenta.

I was called by telephone and responded at once. Found the vagina plugged, there was no bleeding, no pain of any consequence, temperature normal, pulse 100, patient cheerful. As there seemed no indications for immediate delivery and things were going along well, we waited for about three hours. I had her brought under the influence of chloroform, using two drachms. by measure, during the term of delivery. I had no difficulty in dilating the cervix; tore the placenta at left side of uterus; when a slight rent was perceptible, introduced my hand, turned and delivered a dead child. Time, from beginning to completion of delivery, about twenty minutes. While going under chloroform she had twenty-four ounces of salt solution transfused under breast. After delivery hypodermic of ergot, strychnine and digitalin, together with strong coffee and brandy by the mouth, and hot intrauterine douche. She was very weak after the delivery, no hemorrhage, uterus contracted well. She suffered constantly from air-hunger. Trausfusion repeated three-quarters of an hour after delivery. Pulse would not respond, continued dicrotic, breathing irregular, and she passed away three hours after delivery.

In my next case of placenta previa I was more fortunate I was called late one night about a year after my first case. My neighbor, Dr. Kuntz, had been called, and sent for me. He found an Italian woman in a pool of blood, a multipara, mother of four living children. She had been losing blood in small quantities for some time This night a severe hemorrhage induced them to send for a physician The doctor had done a beautiful job of packing, using his fingers for a speculum and strips of sheet for packing. The surroundings were wretched and dirty. I had the woman brought across the bed. packing removed, and with it sharp hemorrhage. I introduced my had without an anesthetic, tore the placenta, turned and made a rapid delivery, the woman all the time screaming at me in Italian. Fortunately, I did not understand. We brought a living child, and it and the mother did remarkably well. The woman was up and about in twelve days.

Primary Cancer of the Vagina.

DR. JOHN MILLER: Mrs. L. J., colored, married, aged thirty-eight years, was referred to me by Dr. S. Smith. Father dead; cause of death unknown. Mother died in labor. Two brothers and one sister living and well. Patient has had measles and whooping-cough as a child, and severe attacks of malaria. Had typhoid fever when twenty-five years old. She began to menstruate between the age of thirteen and fourteen years; was always regular, lasting three days, without pain. She has had two children born at term and two abortions.

In May of this year she began to com

plain of pain in the back and in the left leg. The leg became considerably swollen, so that she was unable to walk. This subsided in about two weeks and she was again able to be about. She has been getting weaker, and says she has lost twenty pounds since May. In August she noticed a bloody discharge from the vagina, between the menstrual periods. This discharge continued until the day she consulted me, October 15. The function of the bowels has always been regular, also the kidneys. Urinalysis negative.

On examination of the pelvic organs I found a mass on the posterior wall of the vagina about a fourth of an inch from the introitus, extending up into the vagina for a distance of two inches. The edges of the mass were hard and infiltrated, and the surface, crater-like, bled from the slightest touch. The discharge in the vagina was watery and foul-smelling. The cervix was small and the uterus in normal position. No disease of the adnexa. Inguinal glands were not palpable. Digital examination of the rectum showed no thickening of its walls.

The patient was sent to the Good Samaritan Hospital for operation, and operated on October 18. A curettage of the uterus preceded the operation. An incision was made around the entire mass, including a collar of apparently healthy mucous membrane of the vagina. The connective tissue and muscles of the vagina down to and exposing the rectum were removed. The wound in the vagina was closed with cat-gut sutures.

A microscopic examination of the tumor was made by Dr. Baker, and his report confirmed the clinical diagnosis of a primary squamous-celled carcinoma of the vagina. I report this case because of its rarity.

Specimens of Multinodular Fibroid Tumors of the Uterus with Pus Tubes.

DR. RUFUS B. HALL reported a case and showed specimens of large pus tubes and a multinodular fibroid tumor of the uterus, which he had removed that day. He said that he wished to show the specimens while they were fresh, and it would be necessary to give a short history of the case for a better understanding.

The patient was a married woman, aged forty-nine years; mother of two children, the youngest about twenty years of age. She had always enjoyed exceptionally good health until about one year ago, when her menstrual periods became irregular, sometimes too close together and too profuse, with a discomfort in her abdomen and pelvis, ac

companied by a leucorrheal discharge. She thought all these symptoms were due to the approaching menopause and complained of them just as little as she could. Otherwise, her health was excellent. She consulted her family physician three or four times during the year, principally because she had a little bloody discharge at irregular intervals between her periods. No physical examination was ever made.

On Saturday night, October 27, she took what she described as a severe hemorrhage. She must have lost about a half pint of blood. This was not enough to injure her in any way, but greatly alarmed' her. She sent for her physician and would not let him leave the house that night. Early that morning I was asked to see her. The hemorrhage had stopped, but she was nervous and suffering a good deal of pain. Her temperature was about 101° and had been that since the doctor's visit. The abdomen was rigid and tender upon pressure. The patient was a large, fleshy woman, making the examination more difficult. I could determine that she did not have cancer of the cervix, but the uterus was enlarged and hard nodules could be palpated in the lower segment of the uterus. There was a distinct enlargement to be made out and extending into her abdomen. I had no hesitation in advising an early operation, but as to whether it was cancer of the body of the uterus or not, I was not willing to qualify. The family was not satisfied, and asked that another surgeon be called to see if he would agree with me and her doctor; four o'clock P. M., Monday, was set for the consultation, and Dr. Charles Bonifield saw the patient with us. He concurred in the diagnosis of the psesence of a tumor and urged an early operation. Tuesday, the 29th, she went to the hospital, but her abdomen was distended largely by gas, the temperature remained constantly above 100°, she was more comfortable on her back with her knee drawn up, we were not able to get the bowels thoroughly moved and get rid of part of the gas until Saturday, and she was prepared for the operation, which was made Monday morning.

On

When the abdomen was opened, to her left side was a walled-off abscess holding about a pint of pus, just as we have a walled-off abscess in appendicitis. You will notice the Fallopian tube on that side was part of the wall of the abscess. It must have leaked a little, as the nidus for the abscess. After clearing this up, the left tube was removed without rupture, and you will notice it was about two inches across it and five inches long. The right

tube was then liberated. It measured nine inches long and two and a half inches across its broadest point. We removed it without rupture, and as there was quite a number of small fibroid tumors in the uterus, making it about the size of a cocoanut, and a suspicion of malignant disease, a total extirpation was made. The total extirpation was the operation of selection in this case because one of the tumors, much larger than a black walnut, was post-peritoneal, and to remove that we had partial extirpation of the cervix. completed, and by removing the entire cervix we would have ample drainage by the vagina and we could protect the soiled field by gauze carried out through the vagina.

The history is an unusual one for such pathology as presented in these specimens. Patients usually with such large pus-tubes present are in bed half of their time for months preceding the operation.

THE OBSTETRICAL SOCIETY OF

PHILADELPHIA.

Meeting of October 3, 1907.

THE PRESIDENT, DR. WILMER KRUSEN, IN THE CHAIR.

Observations Upon the Sarcomatous Metaplasia of Uterine Fibro-Myomata.

DR. EDW. A. SCHUMANN: Whether that form of uterine sarcoma affecting the parenchyma of the organ is usually primary or is always secondary to the presence of a degenerating fibro-myoma is still an open question. No case yet recorded in which the actual transition of fibromatous elements into sarcoma cells may be demonstrated. Many pathological reasons exist why sarcomatous degeneration of uterine fibroids should be a fairly common phenomenon. Three cases were reported, in all of which such transition of pure fibro-myoma into spindle-celled and round-celled sarcoma seemed to be established. The subject was reviewed from a pathological standpoint.

DISCUSSION.

DR. C. C. NORRIS: The following statistics may be of interest in this connection: In going over our cases at the University I found that we have had thirteen malignant tumors of the uterine parenchyma of connective tissue origin. Of these five were spindle-celled sarcoma, five small round-celled sarcoma, one large roundcelled sarcoma, one of mixed type, and one endothelioma. Of these thirteen tumors, three were undoubtedly due to so-called degeneration of a fibro-myoma, although the actual metaplasia from a muscle to a sarcoma cell could not be demonstrated. A fourth case was somewhat

doubtful. A. Martin, in a paper on this subject, said that 3 per cent of all fibro-myomata underwent a sarcomatous degeneration. From a study of the recent statistics on this condition this proportion seems a little high. Our thirteen cases of malignant connective tissue tumors question is, can a sarcoma arise from a degeneroccurred as against 207 cases of fibro-myoma. The ation of a fibr -myoma, or is the sarcoma a malignant growth from the first and simply accidental in the fibro-myoma? Opinions on this subject vary. But, as Dr. Schumann has said, the actual transformation is still to be proved From a clinical standpoint it is of but little importance. It should, however, be remembered that a sarcoma may closely resemble a fibrospecimen and in the symptoms. This was true myoma in the gross appearance of the gross in two of our cases, the condition not being suspected until a microscopic examination had been made. For this reason all uterine fibromyomata should be subjected to a careful histological examination and sections should be taken from various portions of the neoplasm.

DR. STEPHEN E. TRACY: The consideration of malignant degeneration of fibro-myomata uteri, and of associate malignant disease, is of great importance. Dr. Noble, of this city, has called attention many times to malignancy in connection with fibro-myomata uteri, and more espe cially to carcinoma corporis uteri. In a series of between three and four thousand consecutive cases of fibro-myomata uteri which I have collected from the literature, it was found that sarcoma was recorded in 1.5 per cent. of the cases, carcinoma corporis uteri in 1.7 per cent, of the cases, and carcinoma cervicis uteri in 0.7 per cent of the cases. In the same series malignant degeneration of the tumor and associate malig. naut disease was recorded in 4.1 per cent of the In consideration of the frequency with which degeneration takes place in the fibromyomata uteri, and also of the comparative frequency of associate malignant disease. I would recommend that all fibro-myomata uteri removed at operation be subjected to a thorough microscopical examination.

cases.

DR SCHUMANN closes: I have only to add that although there have been so many cases, apparently sarcomatous degenerations of fibroids, reported, no one has been able to demonstrate the direct transition of the two tumors, although many able pathologists have been at work upon the subject. We often find the sarcomatous nodules in and about the myomatous cells, but the place where the fibroid becomes sarcoma has proven most elusive. It is that which makes the subject of great interest.

Report of A Case of Ovarian Cyst with Twisted Pedicle Complicating Pregnancy and Labor.

DR. EDWARD P. DAVIS reported the case of a married Polish woman, thirty-two years of age, who was in her third pregnancy and in labor when admitted to the Jefferson Maternity. External conjugate 18 cm. As the two previous labors were instrumental, with death of the fetus, permission was secured to deliver the patient by any method which seemed most likely to save her life and that of the child. Celio-hysterectomy was done.