chief. In all operable cases, therefore, at whatever month of pregnancy they may be recognized, immediate radical operation should be undertaken. Whether this operation should be vaginal or abdominal the next ten years may be expected to show.

DR. G. E. HERMAN expressed his appreciation of Dr. Spencer's able paper. He thought the general rule of treatment in all forms of cancer, viz., to remove it as soon as possible, applied to cancer of the cervix in the later months of pregnancy. He considered that vaginal hysterectomy immediately after delivery should be easy, because the vagina was then so relaxed that the uterus could easily be pulled down to the vulva. He could not agree with Dr. Spencer in advising Porro's operation with the serre-noeud where delivery through the natural passage was impossible. He had only once performed Cesarean section for cancer; he sewed up the uterus in the usual way and the patient recovered.

DR. AMAND ROUTH thought that conservative Cesarean section was the correct treatment in operable cases, and gave details of one case where the woman recovered, but died in three months, a healthy child surviving.

DR. HANDFIELD-JONES, DR. BRIGGS and DR. W. S. A. GRIFFITHI expressed the opinion that in Dr. Spencer's three successful cases the cancers, being all of the squamous-celled variety, were of the less virulent type of disease, and that the fact of non-recurrence after a lapse of years depended more on the type of the disease than on any detail of treatment.

DR. SPENCER, in reply, said that his objection to vaginal Cesarean section was due to risk of local inflammation. The growth of cancer in pregnancy was sometimes rapid, but not always; in his own case it was very slow. He believed that the old Porro operation with the serre-noeud was safer than the conservative. operation.

DR. J. H. DAUBER showed a

DOUBLE SYMMETRICAL CYSTOMA

of unusual origin and connections which, on the motion of Dr. Cullingworth, was referred to the Pathological Committee. DR. W. W. H. TATE showed a

DERMOID CYST OF OVARY

removed by abdominal section. It contained several beautifully formed teeth. The cyst, which at the time of removal was as large as a fetal head, had been the source of obstruction during labor five years previously, and had been associated with subsequent attacks of abdominal pain.

MRS. BOYD showed the uterus removed by

ABDOMINAL PAN-HYSTERECTOMY

from a patient of forty, who was the subject of squamous carcinoma of the cervix of the uterus. She and her colleague at the New Hospital for Women had, contrary to what had hitherto

been the more general practice, followed the plan of operating by the abdominal method in all cases of cancer of the body of the uterus, and in most cases of cancer of the cervix. They had now had in all twenty-one cases without a death, so that she claimed that the patient was not exposed to any more risk by adopting this method than by removal through the vagina. MRS. BOYD also showed a

FIBROID OF THE BROAD LIGAMENT

removed from a patient sixty-three years of age, who had had copious hemorrhages and increase in size of the growth for five months. The uterus was enlarged and was removed by pan-hysterectomy. Its walls were thick and fibroid and the cavity was occupied by a tongue-shaped polypus, consisting of fibrin attached to an adenomatous base. The section showed a benign adenoma. The section of the fibroid showed ordinary fibroid structure. DR. CUTHBERT LOCKYER showed a

CARCINOMA OF THE OVARY

of unusual type. The growth resembled in its structure the columnar cancer so common in the rectum, and as bowel symptoms had existed in this case for fifteen months, it seems highly probable that the solid mass in the hilum of the left ovary was secondary in origin to carcinoma in the rectum.

DR. HERBERT R. SPENCER showed a new

GALVANO-CAUTERY

which he had used many times for amputation of the cervix and for hysterectomy. The handle itself forms an insulator, and the whole instrument can be easily sterilized by boiling.

BRIEF OF CURRENT LITERATURE.

DISEASES OF CHILDREN.

The Infective Nature of Rheumatic Fever.-F. J. Poynton (Brit. Med. Jour., May 14) illustrates his remarks by the study of a fatal case of rheumatic fever in a child. In July, 1902, a girl of 9 was brought suffering with chorea.. Attack was moderate, general in distribution and ordinary in type. The mitral valve was damaged and heart rapid and excited. This was the first attack of rheumatism. It had commenced six weeks before, with vomiting, pains in limbs, swelling of wrist joints and then chorea. She stayed in hospital fourteen weeks. The chorea was cured but heart was unsatisfactory, rapid with distinct systolic murmur. By May, 1903, bruit had disappeared and at apex only a short first sound and normal second sound were heard. August 17th she was admitted to hospital. Fourteen days before she had pain over heart and in all limbs, looked cyanosed, had felt cold and shivery, and had suffered with attacks of vomiting. Her temperature was 103.8°, pulse 140 and respirations 40 on admission. Great cardiac distress. Although heart was greatly enlarged there were no signs of pericarditis. A loud systolic murmur in mitral area. Lungs showed nothing. definite. The spleen was enlarged and tender, liver enlarged, and urine albuminous. While in hospital the symptoms were rapid anemia, sweating and abdominal pain. Temperature showed in the four hourly chart a continuous and moderate pyrexia. Ten days after admission she died suddenly.

The writer recognizes three types of endocarditis: 1. Simple endocarditis. In this the micro-organisms in the valve either cease to be active or are destroyed by the living cells of the tissues. 2. The fibroid type as in mitral stenosis. In this the infection is persistent, but the resistance of the tissues is great. 3. The malignant type. In this the micro-organisms grow in countless numbers in the valve; the vegetations may be either large or small, and the resistance of the tissues is feeble.

At the post-mortem the mitral valve covered with blood clot was removed and cultures were taken from the lungs, kidneys, spleen and gall-bladder. Bacteriological results from the cultures were: 1. Pure cultures of the diplococcus were found in the tubes inoculated from the valve, the spleen and the kidney. 2. The culture from the lung was not pure but the diplococcus was present among other micro-organisms. 3. Pericardial fluid and the blood gave negative result. This last negative result from pericardial fluid emphasizes the fact that these microorganisms, when they grow in the body, grow best in the local lesions, and though often present in the blood do not thrive in it. Practical applications of the infective view of rheumatic fever:

Early diagnosis is of extreme importance and physicians should educate the laity to the importance of gradual failure of health, wasting, vague epigastric and other pains, nervousness, night terrors, and anemias. There are certain facts, formerly uncertain, now rest on a sure basis: 1. The existence of a true rheumatic broncho-pneumonia and a rheumatic pleurisy. 2. Of a true renal rheumatism. 3. Of a true rheumatic peritonitis. The relation of tonsilitis to rheumatic fever has been recognized for more than a century. It is certain that one channel of infection is through the damaged tonsils in which the micro-organism is deposited. Almost as complete is the proof of the existence of a true rheumatic iritis and chorea. It is now possible to produce experimental heart disease. Our practical knowledge has profited, for it has shown: 1. That simple and malignant endocarditis can be stages in the same process, that they are not always essentially different, and that the malignant form does not always premise a secondary affection. It follows from this that if rheumatic endocarditis is infective it can be both simple and malignant in type. 2. It has shown that ante-mortem thrombosis may occur in the heart in rheumatic fever without any severe valvular damage. 3. Accurate knowledge can now be obtained upon the rapidity of the formation of vegetations and upon their actual structure. 4. It throws light upon the formation of infarcts in rheumatic fever, which experiment shows may form without the presence of any visible valvular disease or clotting of blood in the chambers of the heart. The bearing of this fact on the pathology of chorea is manifest. 5. The myocardial changes in rheumatism which were suspected by the clinician and elucidated by the pathologist are absolutely proved by experiment, for they can be produced by this micro-organism.

Subcutaneous Angioma in Infants. Considerations on the Treatment.-Adrien Besson (Jour. des Sci. Méd. de Lille, June 4) gives two cases and outlines treatment in general. Ist case. Infant 20 months. In center of middle frontal region a violaceous erectile tumor, size of small walnut, presents all the appearances of a simple cutaneous angioma. Mother always noticed it. Has grown perceptibly during last eight days. Swells visibly when child cries or is angry. Extirpated on the spot. Dressing taken off in eight days. Cured entirely; fifteen days afterwards there is only seen a light scar.

2d case. Infants 16 months. Presents on outer part of right side of neck at level of sub-clavicular region a subcutaneous angiomatous tumor size of a hazelnut but with a large base and a rather diffuse extension. Solution of Piazza employed. Injections every eight days with a Pravaz syringe. Compression at first made at the periphery of the tumor, needle driven into the angiomatous tissue and 5 or 6 drops injected, waiting from a half to one minute before withdrawing the needle. A reaction occurred during the day, variable, but might be intense. The infant received 7 injections. The tumor visibly sank down and

grew pale, presenting indurated islets, scattered corresponding to the injected zones and giving the sensation of grains of lead encapsulated. The mother, judging the result sufficient, did not return. The three methods of treating these tumors are: Coagulating injections, electrolysis, extirpation. I. Injections. There have been used nitric acid, chloride of lime, alcohol, wine, tinct. iodine, acetic and citric acids, chloral hydrate, and, above all, perchloride of iron. Unfortunately, the use of these has given rise to very grave accidents, even death from detached clots. The solution of Piazza avoids these; the composition is as follows: Chloride of sodium 15 gr., perchcloride of iron 25 gr., distilled water 60 gr. 2. Electrolysis. The results are very good. Often there is no cicatrix left. It is painful, but cocaine may be used or chloroform. 3. Extirpation pure and simple. Procedure of choice. Great care in hemostasis and asepsis. Indications for use of different methods:

1. Extirpation. Where tumor is limited, or where loss of blood is not feared (very young infants), or where cicatrix is not exposed. 2. Electrolysis. Where the tumor is exposed, and has a large base (especially in the face). 3. Injections of solution of Piazza in intermediary cases circumscribed tumor, extirpation refused, tumor still circumscribed, but with a more extensive and diffuse base (in other regions than the face).

Koplik's Spots in the Diagnosis of Measles.—J. C. Muir (Lancet, June II) publishes eleven cases from Plaistow Hospital, all showing the Koplik's spots, occasionally within twentyfour hours of the onset and never delayed beyond the third day of the pyrexia. The interval from their appearance to that of the rash was from one to three days. In almost all of the cases the prodromal catarrh was very slight, a fact which enhanced the value of the spots. In some of them a certain diagnosis at that date was impossible except for their presence. Other symptoms which will usually be present and may occur before the pyrexia must not be neglected. It is where these other symptoms are slight and inconclusive that the presence of the spots may decide the diagnosis. They are absent in, roughly, 10 per cent. of recorded cases.

The Treatment of Hernia in Young Children.-P. Lockhart Mummery (Brit. Jour. of Children's Diseases, June) says that the number of cases of hernia in infants and young children is considerable and the treatment by trusses is unsatisfactory. It is not easy with a fat baby to obtain a truss to remain in position and keep up hernia without having one with a strong spring, which will make skin sore. The old wool or worsted truss, if it were capable of keeping up the hernia, does not cause sufficient pressure on the neck of the sack to obliterate it. Under most favorable circumstances the child must wear a truss constantly for a period of probably two years, and even then may fail to cure the hernia. If the hernia is cured in the sense that it no longer comes down the child is left with a condition which often