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CASE 6. Polycystic ovccriccn tumour; ovariotmy; rapid re-covery.-Margaret C-, aged twenty-two, was admitted,under the care of Dr. Oldham and Mr. Bryant, on April 20th,1866, having been sent in by Mr. Francis Toulmin, of Hackney,for operation. The patient was a single woman, and had

always had good health. She had observed her abdomen toenlarge for three months. On March 2lst she was seen by Dr.Oldham, who suggested tapping, when seven pints of a thickfluid were drawn off. She rapidly refilled. When admittedshe was larger than ever, and measured thirty-six inches incircumference. On May 16th ovariotomy was performed, a Imoderate incision being made. Some parietal adhesions ex-isted, and were torn through. The tumour was readily re-moved, and the pedicle ligatured in two portions, the ends ofthe ligatures being cut off, and the whole dropped in. Thewound was closed with silk sutures. Rapid recovery followedthe operation.CASE Monocystic proliferous cyst; ovariotomy; rapid re-

covery.-Harriet B-, aged nineteen, a single woman, wasadmitted, under the joint care of Dr. Oldham and Mr. Bryant,on Nov. 29th, 1866, with ovarian dropsy. She had observedthe tumour for about nine months; her catamenia having beenirregular and profuse for that time, and much pain having ex-isted in her right groin. Her abdomen had steadily increasedin size. On Dec. 12th, 1866, ovariotomy was performed. Amoderate incision was made. No adhesions existed. The cystwas readily drawn out, and its pedicle ligatured in two por-tions. The wound was then closed and secured by silk sutures,the peritoneum having been touched only by the scalpel. Nosingle bad symptom followed. On the fourth day the sutureswere removed, rapid recovery having taken place.

ST. MARY’S HOSPITAL.CASE OF SEVERE LACERATION OF THE PERINEUM AND

RECTO-VAGINAL SEPTUM; OPERATION; CURE.

(Under the care of Mr. JAMES LANE.)THE following case illustrates a rupture of the most severe

kind. Mr. J. Lane insisted, in such cases, on the necessity of adouble operation: the first to unite the recto-vaginal septum, thesecond to restore the perineum. Simple wire sutures were suffi-cient for the first ; but for the second the quill suture was re-quired. If the attempt were made to unite the whole by oneprocedure, there was great risk that an aperture would be leftbetween the rectum and vagina behind the new perineum, andthe patient’s condition would be but little, if at all, improved.He had frequently performed this double operation in similarcases of extensive rupture, and always with satisfactory results.It was necessary to divide the sphincter at the second opera-tion, otherwise its action would tend to separate the partsand prevent union at the lower angle of the wound, which wasthe most important point. He believed, however, it was suffi-cient to divide the muscle on one side, and not on both, assometimes practised.M. S-, aged thirty-three, was admitted Oct. 27th, 1866.

She had been married thirteen years. The laceration took

place on the occasion of the birth of her first child, elevenyears ago, when she was attended by a midwife. From thattime to the present she has had no control over her motions.She has had three children since. On examination, the peri-neum was found to have been torn completely through into therectum, and the recto-vaginal septum had also given way tothe extent of more than an inch in the upward direction. Alaceration of this extent necessarily involved not only theexternal sphincter, but also the internal sphincter and lowercircular fibres of the bowel, so that any control over the fæceswhen once they had descended into the rectum was obviouslyimpossible.

First operation (Oct. 31st) : The edges of the rent in therecto-vaginal septum were pared and brought together, in thelongitudinal direction, by six sutures of silver wire. In this

way the intsgrity of the two canals was restored down to theperineum, but the union of the latter part was delayed for asubsequent operation. The sutures were removed on theninth day. The bowels were kept confined by opium, andwere not allowed to act till the eleventh day. Complete andfirm union was then found to have taken place, and she statedthat she had regained considerable power over her motions.

Second operation (Nov. 21st) The sides of the vaginal out-

let corresponding to the original situation of the perineumwere denuded and brought together after the manner of thequill suture, perforated ivory bars being used to represent thequills, and strong silver wire being employed for the sutures.In addition to this, four superficial sutures of silver wire wereinserted to retain the cutaneous edges in contact. After the

parts had been thus brought together, the sphincter wasfreely divided. The quill sutures were removed at the end offorty-eight hours ; the superficial ones were retained till theseventh day. The bowels were again kept confined for elevendays. Union by first intention was obtained throughout,complete control over the rectum was restored, and the patientleft the hospital quite well, and greatly pleased by the result,on Dec. llth.

MIDDLESEX HOSPITAL.SEVERE COLIC AND CONSTIPATION; BENEFICIAL EFFECT

OF BELLADONNA.

(Under the care of Dr. MURCHISON.)BELLADONNA is much more frequently had recourse to in

the treatment of constipation abroad than in this country.The beneficial effects which appeared to result from its use inthe following case were very remarkable. For information re-

specting the patient we are indebted to Dr. Murray, house-physician.

Ellen L-, aged twenty-seven, married for three years,but without any family, and catamenia regular, was admittedinto the hospital on the 28th of December, 1866. She statedthat she had always enjoyed good health, with the exceptionof an attack similar to the present one about two years before.On that occasion she had been ill for nearly three months; shehad taken enormous quantities of purgatives, and yet for threeweeks she had passed nothing from her bowels. She had neverhad jaundice or passed blood in her urine, and no one living inthe same house had on either occasion suffered from similar

symptoms. The present attack commenced ten days beforeadmission, with severe pains in the abdomen, of a paroxysmalcharacter, and always worse at night. From the first the at-tacks of pain had often been accompanied with violent vomit-ing ; but for seven or eight days the bowels had acted daily.For at least two days before admission the bowels had notacted.On admission, the patient was in great distress with pain in

her abdomen and back, which bent her up double. The painwas paroxysmal, but the paroxysms followed one another inrapid succession. She described the pain as shooting from theabdomen down the anus as well as the legs. The urine con-tained no blood. There was not a trace of jaundice, and notenderness of abdomen; but the paroxysms of pain were ac-companied by violent retching and bilious vomiting. The pulsewas 72 ; the skin felt cool; no external hernia could be dis-covered ; and there was no blue line along the edge of thesums. The natient on admission was ordered a warm bath.poultices with laudanum to the abdomen, a large castor-oilenema twice a day, and a draught every four hours containingtwenty minims of laudanum and of chloric ether in an ounceof peppermint water.On Dec. 30th she had taken in the course of two days nearly

half an ounce of laudanum, besides having a quarter of a graininjected into the skin; and she had had five copious injectionsof gruel and castor oil, and two warm baths. But there hadbeen no action whatever of the bowels, and the vomiting andpain continued as urgent as ever, so that she had had no sleepsince admission. In addition, the pulse had risen to 108, theskin felt hot, the patient was more depressed, and there wasdecided tenderness in the left groin. Twelve leeches were nowordered to be applied to the abdomen, followed by linseedpoultices : and a mixture was prescribed, consisting of castoroil, half an ounce; liquor potassæ, twenty minims; tincture ofopium, twenty-five minims; and peppermint water, an ounceand a half : to be taken every sixth hour.The tenderness of the abdomen was considerably relieved by

the leeches ; but on Jan. 1st the patient had taken eight dosesof the mixture, or four ounces of castor oil and nearly threeand a half drachms of laudanum, which had been retained, butwithout any action of the bowels, and with but little relief to

the pain or vomiting. The patient was now ordered a pillcontaining half a grain of extract of belladonna every fourhours, with belladonna ointment to the abdomen, a warm bathat night, and a castor-oil enema twice a day.On the following morning, after taking four of the pills, and

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the pupils being moderately dilated, the patient had a copiousfeculent motion. This was the first action of the bowels forat least a week, and from that moment the pain and vomitingsubsided. The pills were repeated twice daily, and the bowelscontinued to act regularly and copiously. On Jan. 8th thepatient was discharged well.The most probable cause of the colic in this instance Dr. li

Murchison believed to be the accumulation of fæcal matter inthe bowel, and for the following reasons. Before the bowels acted a doughy mass could be felt between the umbilicus andthe left groin, which, on Dec. 30th, was the seat of consider-able tenderness, and when the bowels began to act, largequantities of feculent matter were passed. It is well knownthat enormous accumulations of fasces may take place in theintestine, notwithstanding that the bowels act daily. A re-markable case of this sort is recorded by Frerichs, in whichthe accumulation was mistaken for pregnancy or an enormoustumour of the liver.* #

Although the pain was referred to the back as well as theabdomen, the absence of blood or albumen from the urine, andthe immediate cessation of the pain on the bowels acting,negatived the idea of nephritic colic.The situation of the pain, the age of the patient, and the

complete absence of jaundice, were opposed to the notion thatit was biliary colic.The fact that the patient had both attacks in the same

house raised the suspicion that the symptoms might havebeen due to lead ; but opposed to this view were the followingconsiderations :-

1. No other person in the same house had suffered fromsimilar symptoms.

2. In the interval between the two attacks the patient her-self had not suffered from colic.

3. The characteristic blue line of lead was absent from themargin of the gums. The edge of the gums was tumid andunusually red, but there was no blue tint.

CLINICAL RECORDS.

NOVEL METHOD OF DEALING WITH LIGATURESAPPLIED TO ARTERIES.

MR. CAMPBELL DE MORGAN has been adopting of late, at theMiddlesex Hospital, a plan of dealing with ligatures applied tovessels during a cutting operation, which merits notice. Whenthe vessels have been tied, instead of following the usualcustom and leaving the ligatures hanging out of the wound,Mr. De Morgan, by means of a needle, passes them throughthe skin close to where they are tied. They remain quitequie and come away without the slightest pain or troublewhen their work is done. The wound consequently hasnothing to irritate it, and enjoys every opportunity of healingby the first intention. The plan leaves the parts as quiet as ifacupressure had been applied. There is now in the hospital acase in which Mr. Moore tried the method at Mr. De Morgan’ssuggestion, on Wednesday week, after removing a breast.

DISLOCATION OF THE RADIUS AND ULNA FOR-WARDS AT THE ELBOW WITHOUT FRACTURE.

A CASE of this very rare dislocation occurred at UniversityCollege Hos_pital the week before last, during the frost. A

strong young man, of twenty years of age, slipped down onthe pavement, falling on his left elbow. On getting up hefound he could scarcely move the elbow, which was so painfulthat he applied immediately at the hospital. On examininghim about twenty minutes after the fall, Mr. J. W. Langmore,the house-surgeon, found that there was some swelling and aslight bruise over the prominence of the elbow, with but littleswelling elsewhere. The arm was bent at an angle of about130°, but could be flexed to a right angle and straightened toabout 160°, although all movement gave the patient great pain.The forearm was about three-quarters of an inch longer thanits fellow. The condyles of the humerus were nearly on alevel with the olecranon, which was displaced forwards, thetendon of the triceps muscle being very tightly stretchedround the end of the humerus. The sigmoid notch could befelt. The head of the radius could also be felt in front of thelower end of the humerus. Mr. Langmore replaced the ulnaby bending the elbow across his knee, and then, as the radius

* Diseases of the Liver, Sydenham Society’), Translation, vol. i. p. 69.

was still dislocated, he reduced it by pressure on its headwhilst good extension was made by assistants. The arm wasthen put on a straight splint and an evaporating lotion applied.A certain amount of heat and swelling ensued, but by thefourth day this subsided and the joint was quite movable.

Medical Societies.ROYAL MEDICAL AND CHIRURGICAL SOCIETY.

TUESDAY, JAN. 8TH, 1866.

DR. JAMES ALDERSON, F.R.S., PRESIDENT.

A rAPER was read with a peculiar title, and of such asingular character, that we only refer to it in order to saythat it was admitted into the programme of the Society’s pro-ceedings by mistake. It was not properly introduced to theSociety, and had been read contrary to law. The consequenceis an abstract of it will not appear in the Society’s " Trans-actions " nor in the journals.SEQUEL TO A CASE OF COLOTOMY RECORDED IN THE LASTVOLUME OF THE " TRANSACTIONS," THE PATIENT HAVINGDIED OF AN AFFECTION IN THE CECUM SIMILAR TO THATIN THE SIGMOID FLEXURE OF THE COLON, FOR WHICH THEOPERATION WAS PERFORMED.

BY T. HOLMES,ASSISTANT-SUEGEON TO ST. GEORGE’S HOSPITAL.

The patient remained in good general health, passed all thefasces through the artificial anus, and was in a state of comfortfor several months. He still continued occasionally to passurine from the anus, and complained occasionally of pains inthe pelvis. About fifteen months after the operation the fæcesagain made their appearance in the water. Soon the faecaldischarge from the artificial anus ceased, and he began to be ingreat distress from pain and difficulty in passing water, whichwas as much loaded with fasces as before the operation. Infact he fell again into the condition from which he had beenrelieved, and in this condition he died in the month of October,1866. The parts were removed for exhibition to the Society.They show that the original opening was between the sigmoidflexure and the bladder; that it was not caused by malignantdisease, but, as far as can be determined, by ordinary ulcera-tion ; that the same action had taken plaoe in the cascum, bywhich it had become adherent to, and had been ulcerated into,the bladder, and thus the operation was from that time ren-dered nugatory. But for this fresh affection he might haveenjoyed a long life, as the original diagnosis was correct, andthe operation was calculated to afford complete relief from the

The paper is accompanied by the preparation, and a drawingof the parts by Dr. Westmacott.Mr. CURLING agreed in the remarks which had been made

by Mr. Holmes in his paper, and which, though this case endedbadly, showed the correctness of the diagnosis, and justifiedthe operation. In these cases, however completely the opera-tion might be performed, it was not always possible to preventsome of the faecal matter from escaping into the intestinebelow. He related a case in point. It was curious in Mr.Holmes’s case that two adhesions existed in different parts,and ulcerated into the bladder in two places. In this respectthe case he believed was unique.Mr. JOHN WooD inquired whether any signs of an abscess

having existed in the peritoneal cavity between the peritoneumand bladder could be detected.Mr. CHARLES HAWKlNS said that cases of this kind were

not necessarily malignant, and referred to the instance of aman who, without any previous illness or symptoms of dis-ease, was startled at finding faecal matter mixed with hisurine. A stone in the bladder was found, which was removedby lithotrity; after this the urine made its way into therectum, but no fsecal matter passed with the urine. The open-ing had evidently contracted to such an extent that fsecalmatter could not escape from the rectum. The man did notdie from this disease, which was evidently not malignant.

,

Mr. T. HOLMES regretted that the preparation of the partshad, by accident, not been brought before the Fellows. Itwas, however, in the museum of St. George’s Hospital, whereany gentleman who took an interest in the case might inspectit. He had not been able to find any trace whatever of an