ment. tion we decidedly changed our opinion. There is no doubt in my mind that the cause of the patient's death was bad judgWe thought at the time that symphyseotomy offered a chance of delivering a living child, and it was not found to be bad procedure until it was too late to turn back. As to the infection, that is a question of interest. I do not think the patient was infected by the operation. She had been in the hospital, was not examined by any one except Dr. Russell and myself, and she did well for the first day or so. She was considerably shocked, and I think developed from this an intestinal apathy, for we had difficulty to get the bowels to move, and I once thought of opening the pelvic colon to relieve the distension. I have never before seen such great distension, and in order to get a movement we went through considerable manipulation-for instance, we put her upon the Trendelenburg table and gave a high enema, which had to be repeated several times before we got movement. When we did succeed, however, it was very decided and feces came in contact with the womb. Of course it is only surmise that she was infected in that way. The operation was performed with strict aseptic technique. DR. DAVIS.-I would like to suggest the possible infection by bacilli coli communis, which may give just such symptoms as those Dr. Dobbin has described. Do you recollect the condition of the intestinal walls? DR. DOBBIN.-Owing to delays that could not be prevented, autopsy was not performed until the fourth or fifth day after after death, and we could not say what the condition had been. DR. B. B. BкOWNE exhibited a SARCOMA OF THE VAGINA IN A CHILD THREE YEARS OLD. DR. KELLY.-I have been very much interested in hearing this report of an exceedingly rare case. We all know how nomadic our patients sometimes are. This case happened to come to my clinic, and I found a somewhat different, a more advanced condition than Dr. Browne describes. These cases are among the gynecological rarities. I very well remember one of my earliest experiences was with one of these grape-like sarcomatous masses projecting down from the posterior lip of the cervix. I did not know what it was at the time and amputated the lip of the cervix, but the growth returned and the patient finally died of the disease. The growth was grape-like, made up of delicate vesicles, and was of a sarcomatous nature We have to consider two different classes or species of the sarcoma in these cases. We have in the first place a class not found elsewhere. Those that are found in connection with the uterus are of vesicular nature and similar to, but not to be confounded with, those observed in children. The first class of cases, for example, begin as vesicular sarcoma by forming these grape-like masses. They sometimes contain a cartilaginous tissue never found in children. I think there are about thirty cases on record of sarcoma of this kind. In the second class there are, perhaps, only fourteen or fifteen on record as occurring in children. They begin as more or less irregular, flat, sessile tumors, in the anterior wall of the vagina, and as they advance or grow larger they take the form of vesicular tumors. They generally occur in the very young, though one case has been reported in a girl of 15. In one case the patient was born with the tumor, and it seems to have some relation to the Cohnheim theory, though it would be difficult to say that it proves it. In another case the child was presumably born with it, though it existed five years before it took on any signs of malignancy. It is peculiar in the child, too, in this respect, that it has been found on the anterior wall in 9 out of 14 cases, with 3 on the lateral walls and 2 on the posterior wall. It is further extraordinary in this, that the disease does not spread by metastasis, as the term is generally used, but is regional, the metastasis being local and only a short distance from the area of infection. In one other respect they are somewhat peculiar, that is, that they contain striped muscle fibres. This tissue is not found in every case, but occurs with great frequency. As to the clinical symptoms these cases mostly turn out just as described by Dr. Browne. In this case hundreds of little masses have been removed, only to return again and show evident malignant nature. They choke the vagina and pelvis, may subsequently invade the uterus, and the patient is apt to die from interference with the urinary function; for as infection very readily takes place in these cases, the child may die of purulent peritonitis, pyometra, or nephritis. The question as to what to do with these cases is a very important one. If seen early enough the operation ought to be an exceedingly radical one. I believe only two cases that have been operated upon have lived any length of time afterward. The practical point is early removal of all vaginal tumors, careful microscopical examination; and if we find this disease and our first operation has not been a very radical one, we should do a second operation and let that be a decidedly radical one. DR. CULLEN-I would like to ask why it would not be possible in this case, with the child in good condition, to remove the whole growth, divert the rectum, take out the entire vagina from below, and then from above complete the operation. DR. KELLY.-That is exactly what was done in one of the only two successful cases. DR. BROWNE.-I would call attention to the great distensibility of the vagina in young children. In this case it was very much distended. The manner in which this growth was expelled was very similar to the way in which the placenta is expelled from the uterus. DR. W. W. RUSSELL, Secretary. TRANSACTIONS OF THE ST. LOUIS Meeting of February 16, 1899. The President, W. B. DORSETT, M.D., in the Chair. DR. FRANK GLASGOW presented a specimen of SARCOMA OF THE OVARY. A young woman came three weeks ago complaining of pain and a swelling in the abdomen dating from the last part of October. Before that she had felt perfectly well. There was an irregular mass, like a soft myoma, extending up to the umbilicus, most prominent on the right side, which was exquisitely sensitive. I concluded that it was a soft myomatous mass developed from the ovary, because I could outline the uterus in front. This seemed to be normal in size and was a little increased in depth. She had been having fever, sometimes as high as 102.5° F. This occurred every day, it being a little higher in the evenings. She was not emaciated, but a little pale; apparently her health was not very much interfered with. She was 24 years old, strong, and well built. She had been a clerk in a large lumber concern, and she continued to work, I believe, up to a month ago. The tumor, when the abdomen was opened, had the appearance of a pregnant uterus, was of dark red hue, smooth; did not look like an ovarian cyst at all. It was irregular in shape and was not at all movable. There were no adhesions. In trying to lift it out of the abdomen my hand went into the tumor-into a mass of blood and broken-down débris. I had now no doubt it was a sarcoma. I removed it and found it was from the ovary. I tied off the broad ligament and closed up the peritoneum and abdomen by tier suture. She went along without any inconvenience or disturbance from the operation. The fever continued for six days, gradually getting less and less. She never had any sensitiveness of the abdomen nor the slightest reaction. I let her go home three weeks after the operation. I did not remove the right ovary, as it was healthy. I hardened the specimen in alcohol and formol. The sections which I have made show that the tumor is sarcomatous. There was no involvement of the uterus. The tumor is of special interest, inasmuch as it shows a change in the ovary, which is as large as two fists and looks like fibrous tissue, not only to the naked eye but under the microscope; there is fibrous tissue, with epithelial tissue scat tered through it. We notice that this large ovary is intimately connected with the mass of sarcoma. Whether we have a fibroma gradually changed into a sarcoma I cannot say until I have made more careful study. This fibroma is not joined by a pedicle to the ovary, but is a part of the ovary, and yet the mass of the ovary is distinct. The prognosis is bad. In my opinion there is no danger of its returning in loco, but it was attached to the anterior abdominal wall and I ruptured it in removing it, so of course the cells are scattered through the abdomen; they could not all be wiped out, and in this way I expect a recurrence. DR. F. J. LUTZ.-Fibroids of the ovary are comparatively rare. We should not be surprised to find almost any kind of tissue in an ovarian tumor or resulting from an ovarian tumor, because the ovary itself is the foundation of the development of all kinds of structures. You have there the possibility of the development of any tissue. These tumors as a rule present a very unfavorable prognosis, nevertheless I have had a case of spindle-celled sarcoma of the ovary which did not return. The patient was a woman about 28 years of age, the mother of two children. It is twelve years since I removed that tumor, and she has since given birth to three children; she herself has remained perfectly healthy. This is, however, only a rare exception to a general rule. DR. NEVILLE.-The doctor spoke of fibromata of the ovary as rare. The stroma of the ovary is fibrous tissue. DR. LUTZ.-If you stop to think of the cases of fibroid of the ovary, you will find that in proportion to other degenerative conditions, such as cystic, carcinomatous, and sarcomatous changes, they are rare. DR. DORSETT.-Do you not think the absence of glandular enlargement is a favorable factor in the prognosis? DR. LUTZ.-Yes; but, as a matter of fact, ovarian tumors, even carcinomata, are relatively rarely attended with glandular involvement. When you have a distinct capsule over the carcinomatous or sarcomatous growth you comparatively rarely have glandular involvement, and when you have glandular involvement the case is inoperable. DR. FRANK GLASGOW.-There is one thing about this specimen that speaks for itself: the sarcomatous mass is separated from the pedicle by the whole of the fibroid ovary. CANCEROUS UTERUS REMOVED BY VAGINAL HYSTERECTOMY. DR. W. B. DORSETT.-The patient, 52 years of age, came to me about three months ago suffering with pain in the uterus and a slight discharge simply tinged. She had no history of hemorrhage. She ceased menstruating at 45 years of age and enjoyed good health until about two and a half years ago, when she noticed that there was a little trickling now and then, a stain, a leucorrhea. She was a fleshy woman, and there was nothing to be ascertained so far as an examination was concerned; nothing could be felt out of the way. When the case came to me I tried to make up my mind as to what was the best thing to do, as well as to make a diagnosis. From the experience gained in similar cases I suspected cancer, and accordingly I made a vaginal hysterectomy. The patient survived the operation and went home in three weeks, to all intents and purposes well. She was out of bed in two weeks. She has not had an ache or pain since. The specimen shows the growth coming down to the internal os and involving the posterior wall of the uterus. This second specimen is A MYOMA from a trained nurse, an Englishwoman 38 years old. Five years ago she began to have hemorrhages from the uterus, and she went to a physician in Kansas City and was treated by electricity for myoma. She claims that the tumor was materially decreased in size, but, the pain and hemorrhage continuing, she concluded to have the uterus removed. She came here without consulting a physician as to the propriety of the operation. simply to have the uterus removed. In making bimanual examination the tumor did not seem to be very large, but I was particularly impressed with the prominence of the tumor in the anterior wall of the uterus. My experience with these myomata is that they grow most frequently in the posterior wall. This pushed forward the bladder so that there was vesical irritation and tenesmus. I removed the tumor by abdominal hysterectomy. The greatest obstruction was the mass that was directly in front between the cervix and bladder. After removing the uterus I found this submucous tumor, which was in all probability the cause of the hemorrhage. The tumor shows not only the submucous but also the subperitoneal and intramural varieties of myomatous growth. The patient from whom the second specimen was removed sat up four weeks after the operation. This patient had an idiosyncrasy against morphine; and, while it is not well to administer morphine after an operation of this character, the pain was so intense that I gave her an eighth of a grain, and as a consequence she vomited for four days. I was called three or four times to see the patient, and the question came to my mind whether or not there was a kink or adhesion or something causing obstruction of the bowel. It is a serious question to make a diagnosis between an obstruction and an idiosyncrasy against a drug, and I admit that I should have inquired into this matter before giving the morphine. She told me afterward that she could not take morphine and never could, that it always made her vomit for two or three days. There is something peculiar in the vomiting of obstruction. The material thrown up seems to come up easily, by a sort of regurgitation rather than a vomiting. I believe this gives some insight into the true condition of affairs. Dr. Ameiss will no doubt remember a patient that we operated on two |