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bent position, and, having done so, he sat up in order thathe might the better empty his bladder, which containedabout fifteen ounces-certainly not more. He now com-plained of feeling faint, which induced me to lay him downagain and to give him stimulants. In spite of this, he re-mained almost pulseless for more than an hour, and it wasquite two hours before he sumciently rallied to admit ofhis removal from my surgery.

c

Oct. 9th.-He has passed urine twice without difficulty.He has been sick several times. His pulse is very weakand intermittent. I gave him milk, beef-tea, and brandymixture, and ordered a sinapism to the epigastrium.10th.-Pulse scarcely perceptible. He had several con-

vulsive attacks, and died in the evening.I regret that no post-mortem examination was practicable.

I believe, however, that it would have revealed that theman had a fatty heart, and that during the syncope causedby the shock of passing the catheter a clot formed either inthe heart or aorta, which prevented his recovery. Nobodyaccompanied him except a little boy to drive him ; it istherefore fortunate that he rallied sufficiently to be removedhome.From this case, it seems to me that when there is reason

to suspect any weakness in the heart, it is advisable toenjoin the recumbent posture till after the removal of thecatheter, if not for a short time longer.Bere Regis, J3landford, Oct. 16th, 1871.

A MirrorOF THE PRACTICE OF

MEDICINE AND SURGERYIN THE

HOSPITALS OF LONDON.

Nullaantem est aliapro certo noscendivia, nisi quamplurimaset morborumet dissectionum historias, turn aliorum, tum proprias collectas habere, etinter se oomparaje.—Mo&A&Ni De Sea. et Oau8.Mof’b., lib. iv. Proteininm.

UNIVERSITY COLLEGE HOSPITAL.CLINICAL REMARKS ON A CASE OF TUBERCULAR CON-

SOLIDATION OF THE LUNG, COMPLICATEDWITH BRONCHITIS.

(By Dr. WILSON FOX.)

THE patient is a man of middle age, has a cough aCCQm-panied by free expectoration, and is rather wasted. Onexamination of the chest, the right side was found to beflattened at the apex and the base anteriorly. In the formersituation were observed the physical signs of a cavity; inthe latter, flattening, dulness, and absence of respiratorymurmur, indicated consolidation and shrinking. The leftside was prominent, dull on percussion in places, and yieldedthe sounds characteristic of chronic bronchitis. The heart’s

apex was felt to beat to the right of the sternum, but thesounds were healthy. It appeared that since the patienthad had H inflammation" of the right lung twc. years pre-viously, his health had gradually but steadily declined.Shortly before admission the left lung suffered an attackof bronchitis, of which, as just stated, it now presentschronic symptoms.Dr. Wilson Fox pointed out that this case afforded an

illustration of the truth that pulmonary phthisis is not adisease distinct and independent in its origin, but onewhich is liable to be grafted on to any affection which im-pairs the nutrition of the lungs, in virtue of a predispositionwhich consists in an irritable condition of the lymphaticsystem. Given this irritability, an individual is liable tobecome the subject of tuberculosis under any circumstanceswhich increase the vulnerability of his tissues; without ithe will probably enjoy immunity from that disease.Viewed in the light of the physical signs, the patient’s

history would be as follows:—Pneumonia of the right lungwas followed by tuberculosis, of which the present resultswere a cavity at the apex, due to softening and breaking

down of the lung-tissue, and consolidation of the base. Theleft lung, which probably became compensatively emphy-sematous, in consequence of the induration and contractionof the right one, had recently suffered from an attackof bronchitis, which had excited the same morbid processas that which followed pneumonia in the right, as shownby patches of dulness indicative of the existence of nodulesof consolidation. That the heart was found to beat to theright of the sternum was in the main to be attributed toits having been drawn over by the shrinking of the rightlung, though, in some small measure, it might also be dueto emphysema of the left lung and dilatation of the rightside of the heart produced by the pneumonia on the rightside. It did not follow from there being but little observ-able jugular pulsation that the right side of the heart hadnot undergone dilatation, for the tricuspid valve mighthave maintained its competence in consequence of the dimi-nution in quantity of the blood which might be expected toresult from prolonged deficiency of oxidation.

In reference to the treatment of the. patient, Dr. WilsonFox remarked that the word 11 expector&nv’ is made toapply to two classes of drugs which have opposite effects,and which therefore must be used with discrimination whereit is desired to act upon the bronchial mucous membrane.Lobelia and ipecacuanha are expectorants in the strictsense of the term, inasmuch as they promote secretion;squill, tolu, senega, and other remedies of this class, on thecontrary, have an opposite eJ1’ect. In the present case, heshould at first restrict the patient to a mild and nourishingdiet, and, with a view to checking the expectoration, orderhim to take a draught containing opium and ammonia, andto inhale the vapour of water medicated with one drop ofcreasote to the pint, and such a proportion of conium asmight be expected to -give repose to the bronchial tubeswithout interfering with the eexpectoration of their dis-

charge. After the lapse of a short interval he hoped togive him a full diet, with steel .and cod-liver oil.

GREAT NORTHERN HOSPITAL.OPERATION TO LIBERATE THE PENIS FROM A CURTAIN

OF SKIN DRAWN DOWN BY CONTRACTION OF THECICATRICES OF A BURN.

(Under the care of Mr. GAY.)THE operation we are about to describe was undertaken

for the cure of the following curious deformity. A boyabout nine years of age had sustained an extensive burnon the perineum and the inner aspect of the thighs, andthe contraction of the resulting cicatrices had not only socompletely appropriated the skin of the scrotum as to pushup the testes almost beyond the possibility of recognition,but also drawn the abdominal integument downwards infront of the penis, in the form of a tightly-stretched andarched curtain, which passed from thigh to thigh, andconcealed from view all but the tip of the prepuce. It alsointerfered considerably with the movement of the thighsin walking. The finger could be passed up to a distance ofabout one inch on the posterior aspect of this curtain,which thus was found to consist of a double fold of integu-ment, of which one surface looked forwards while the otherrested against the dorsum ’of the penis. With a view torelieving the tension of the integument and liberating thepenis, an incision about an inch in length was carriedthrough this curtain about half an inch on either side ofthe median line, and it was proposed to unite to each otherthe anterior and posterior lips of the divided portions ; butthe tension remained so great, and the adjoining tissuesseemed so inelastic, that Mr. Gay freely reflected on to thethigh and perineum respectively the divided flaps of skinon either side, and, by careful dissection, removed a con-siderable quantity of firm and unyielding subcutaneousfibrous tissue. Some healthy skin was brought up from theperineum to form a new scrotum, and the adjoining edges *of the divided skin were then brought into apposition bymeans of sutures on the right side; but this was accom-plished somewhat at the expense of the left side, wherethere remained a surface of about the size of a crown-

piece on the left groin, over which the skin could not bestretched with any prospect of union, it was therefore left

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to granulate with a view to covering it ultimately by skintransplantation.

Three weeks later we found that a little sloughing hadtaken place on both sides, where the tension was greatest;but the penis was quite released from its abnormal surround-ings, and there seemed every prospect of the granulationsbeing covered by skin-grafting in a manner which wouldobviate any further obstruction to the movements of thelower limbs.

EXCISION OF THE HEAD OF THE FEMUR.

On Wednesday last Mr. Gay excised the head of thefemur in a child five years of age, who had disease of the

hip of twelve months’ standing, and was admitted in a stateof exhaustion, with numerous pus-discharging openings inthe thigh and groin. The capsule had been opened by thedisease, but dislocation had not taken place. A smallpiece of necrosed bone was liberated from the upper part ofthe acetabulum at the same time.

MR. ADAMS’S CASE OF OSTEOTOMY.The general progress of this patient’s case is satisfactory.

With the exception of a rise of temperature on the dayfollowing the operation, there has been no constitutionaldisturbance. But only very limited movement of the femurindependent of the pelvis has as yet been obtained, althoughthe weight by which extension is being made has been gra-dually increased from three to eight pounds. This rigidityappears to be due, to a considerable extent, to insufficiencyof skin on the anterior aspect-a condition which is scarcelyto be wondered at when it is considered that, for ten yearsbefore the operation was undertaken, the femur had beenmaintained at such an angle that the trochanter major wason a level with the anterior inferior spine of the ilium. Onthe occasion of our last visit to this patient (the eighteenthday), there was no tenseness of integument at the pointwhere the incision had been made, nor thickening in itstrack, and not a drop of pus could be squeezed from theminute aperture in the skin.Mr. Adams proposes to attempt forcible extension under

chloroform on Wednesday next.

PROVINCIAL HOSPITAL REPORTS.

ST. MARY’S HOSPITAL, MANCHESTER.SEVEN CASES OF OVARIOTOMY.

Communicated by Mr. HENRY RUNCORN, House-Surgeon.(Under the care of Dr. LLOYD ROBERTS.)

CASE 1. Removal of the right ovary, with a fibro-cystic ittinouiof the uterus weighing twenty-threepounds; recovery.-1VT arg ar et11I aged thirty-two, single, noticed the enlargementtwenty-seven months before admission. It was not moremarked on one side than the other. She had never been

tapped. The abdomen measured forty-three inches in girthover the umbilicus, and from the ensiform cartilage to thepubes twenty-three inches. Fluctuation could be felt oveithe whole of the tumour. The uterus was movable, slightlyhypertrophied, and was raised with the tumour when thelatter was elevated by external manipulation.Ovariotomy was performed under the influence of bichlo-

ride of methylene, administered by Dr. Junker’s apparatus.An incision, three inches in length, was made down to thetumour, considerable haemorrhage arising from the dividedvessels of the abdominal wall, which was arrested by tor-sion. Some firm adhesions between the front of the tumourand abdominal parietes were separated, and a large syphontrocar was plunged twice into the tumour, but no fluidpassed through it. The primary incision was enlarged tothe extent of one inch above the umbilicus, and the tumourwas brought through the abdominal wound. The pedicle,which was three inches broad and very short, was securedby a circular clamp. Some blood-clots were removed fromthe abdominal cavity, and the wound was brought togetherby five deep sutures of silk, and dressed with carbolisedlotion and plaster, without the use of any abdominal band-age. With the exception of some dysuria on the sixth andseventh days, the patient had not a single unfavourablesymptom. The clamp was removed on the sixteenth day,

and a smaller one which was substituted was finally re-moved on the twentieth day. She left the hospital on theforty-sixth day.The tumour when examined was found to consist of the

right ovary in an early stage of cystic disease, with a fibro-cystic tumour of the uterus. It was pedunculated. Thediseased ovary and Fallopian tube, except its nmbriatedextremity, were firmly united to the tumour.CASE 2. 0’UCtftOOWM/; unilocular ovarian cyst of the left

side ; ligature cut short; pedicle returned.-Elizabeth P-, ,aged forty-nine, was a widow, and had had one living childand one miscarriage. The catamenia had ceased four yearspreviously. A year after that event she noticed a swellingin the left side of the abdomen. On admission the abdomenwas found to be large and prominent, yielding general fluc-tuation over the front a.nd sides of the tumour and reso-nance over both flanks. The girth at the umbilicus wasthirty-eight inches; from the ensiform cartilage to thepubes measured eighteen inches; the uterus was twoinches and three-quarters lower in the pelvis than normal.Fluctuation was felt in Douglas’s space on the left side.The patient had not been tapped.The tumour was exposed and tapped with a large syphon

trocar. The fluid withdrawn presented a dark grumous ap-pearance. The tumour was then drawn through the wound,and the pedicle, a broad and fleshy one an inch and a halfin length, was secured by a ligature which was cut short,and, the tumour having been separated, the stump wasdropped into the abdomen. No fluid entered the peritonealcavity. The abdominal wound was brought together by silksutures, and dressed as in the above case. The incisionwas three inches in length.With the exception of flatulence which troubled this

patient for a few days, she presented no unfavourable sym-ptom. The wound had healed by the seventh day, and onthe eleventh she was convalescent. The tumour was uni-locular, and with its contents weighed 191 lb.CASE 3. ]Iultilocular ovarian tumour of the left side;

ovariotomy with use of clamp; recovery. -Annie B-,aged twenty-four, was married, but had had no children.She first menstruated at twelve years of age, and had beenregular ever since. The swelling commenced five yearsbefore admission after a fall. The abdomen measured, overthe umbilicus, forty inches; from the sternum to the pubes,twenty-one inches. The globular fluctuating tumour in-clined to the left side. Fluctuation could be felt in bothflanks. The uterus was normal in size, with a small cervix.The tumour compressed the bladder and caused frequentdesire to urinate. She had never been tapped.The operation was performed under the influence of

bichloride of methylene. One large cyst was tapped infront, and a smaller cyst was then emptied. The two

emptied cysts, and a number of smaller ones unopened,were drawn through the wound, and the pedicle, two and ahalf inches in length, was secured by a clamp. The abdo-minal incision was secured by silk sutures. The incision inthis case was two inches in length. On the fourth dayafter the operation the patient had an urgent attack of dys-pncea with bronchial rgles, which was subdued by a linctus,sinapisms, and brandy and-water. The wound had healedby the eighteenth day, when the clamp was also removed.CASE 4. Multilocular ovarian tumour of the left side,

weighing i1venty-seven po2,cnds and a half; recovery.-MarthaH-, aged twenty-eight, was a. married woman. The ab-domen was much distended, irregular in shape, and bosse-lated. The fluctuation was localised; the swelling on theleft side was solid; the linea alba was drawn towards theleft side. The cyst on the right side reached to the ensi-form cartilage, was conical in shape, and fluctuated dis-tinctly. The girth at the umbilicus was forty-one inchesand a half ; from the sternum to the pubes measuredeighteen inches and a half. The uterus was slightly pro-lapsed, and the uterine sound passed to a distance of twoinches and a half. Owing to the extent to which thebreathing had been embarrassed by the tumour, the patienthad not been able to lie in bed for three weeks. She hadnot been tapped.The operation was performed under the influence of bi-

chloride of methylene. After the abdomen had been

opened in the usual manner, the bleeding which occurredfrom the vessels in the cut surfaces had been arrested, and