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out to the Blue-jackets on the morning this hap-pened, at different distances on cloth &c. The boy’strousers were used and on firing at a distance of two inchesthere was an irregular tear produced in the cloth with nocharring ; at a distance of three inches the fabric was charredand at twelve inches it was fired. On placing a piece of the clothin front of a turnip and firing at a distance of two inches atear was produced in the cloth and a cone-shaped hole in theturnip, some two inches in depth, with traces of uncharredpowder round about, very similar to the hole produced in theboy’s thigh. I have no doubt that the wound was caused bythe firing of a blank cartridge from a Martini-Henry rifle, thenozzle of the rifle being within two inches of the boy’s body.Government Civil Hospital, Hong Kong.

A PEBBLE IN THE EAR FOR EIGHT YEARS WITH-OUT THE PATIENT’S KNOWLEDGE.

BY W. R. H. STEWART,AURAL SURGEON TO THE GREAT NORTHERN CENTRAL HOSPITAL, &c.

A SINGLE lady, kindly sent by my colleague, Mr. Macready,consulted me for deafness on the left side, which had lastedoff and on for some years. It had become much worse

the week or two before coming to me and there was arather distressing " hammering " noise in the ear. I foundthe left meatus plugged with a mass of hardened wax. On

using the syringe for its removal out dropped a pebble,evidently from the sea beach. In shape it might be calledan irregular cube, measuring on its longest side five-sixteenthsof an inch, the other sides being three-sixteenths and one-eighth. The patient had no idea the stone was in the earand as she had not been to the seaside for over eight years itmust have been in the ear all that time. The case is, I think,interesting, for it is strange that so large a pebble had re-mained all those years in the ear without the patient’s know-ledge. It also confirms the opinion that a foreign body maylodge in the meatus for a considerable time without producingmischief, provided no injudicious instrumental attemptshave been made to remove it.Devonshire.street, W.

A MirrorOF

HOSPITAL PRACTICE,BRITISH AND FOREIGN.

ST. THOMAS’S HOSPITAL.CASES ILLUSTRATING THE TREATMENT OF RECURRENTPELVIC PERITONITIS BY ABDOMINAL SECTION ; REMARKS.

(Under the care of Dr. CULLINGWORTH.)

Nulla. autem est alia pro certo noscendi via, nisi quamplurimas et mor-borum et dissectionum historias, tum alioium tum proprias collectashabere, et inter se compare.—MORGAGNI De Sed. et Caus. 3fof6.,lib. iv. Procemium.

WE commence this week a series of cases recently underthe care of Dr. Cullingworth, in which it was necessary toperform the operation of abdominal section. The cases

described had a number of points in common which renderthem of very great interest ; in all there was a history ofattacks of abdominal pain due to pelvic inflammation and itsconsequences and in all there was much disease, whichcould only be cured by the removal of the diseased structures.It is worthy of note that in nearly all of them the operationwas one of considerable difficulty and it was necessary to

employ drainage of the pelvis afterwards. The results of thetreatment are most satisfactory.CASE 1.-P. B-, aged twenty-five, single, a dressmaker,

was admitted into the Adelaide ward on March 2nd, 1892, com-plaining of abdominal pain and swelling. She had enjoyed goodhealth till three years ago, when she was laid up for three monthswith an attack of rheumatic fever. Two years and a half agoshe was confined to bed for several days by an attack ofpelvic inflammation following gonorrhoea. She has since beenliable to similar but less severe attacks of pelvic pain.Menstruation has been regular and normal till the first week

in December, 1891, when her last period occurred. A fort-night later-i.e., in the third week of December last-shewas suddenly seized at midday, while at work, with severepain in the abdomen and legs. She left her work and went.home to bed. The pain in the abdomen continued. Adoctor was called in and discovered a swelling in the lower-half of the abdomen. The patient had not been conscious of’the presence of a tumour in the abdomen till it was noticed!

by her medical attendant. She has remained in bed eversince ; poultices and leeches have been applied with littlerelief and hypodermic injections of morphia have beenadministered every night or very often in the morning, onaccount of the pain and restlessness. She has lost a good !deal of flesh and her bowels have been very constipated.On admission the patient, a thin, highly intelligent, anaemic;

woman, complained of continuous abdominal pain and swelljmgof eleven weeks’ duration. On examination the abdomen was.somewhat resistant and considerable pain and tenderness.were complained of, especially in the left iliac region. A.smooth tense swelling was defined occupying the left lowerhalf of the abdomen, extending upwards as high as the.umbilicus. On the right side was a smaller swelling, its

upper limits reaching a point midway between the pubes and)umbilicus and extending outwards as far as the outer thirdof Poupart’s ligament. A distant sulcus could be feltbetween the two swellings superiorly. Both were absolutelyfixed and on the left side there was indistinct fluctuation.On bi-manual examination the lateral and posterior forniceswere found depressed. The cervix was high up and almost.obliterated and the external os closed. Two rounded swell-

ings could be felt through the vaginal roof separated by adistinct sulcus ; the smaller one on the right was smooth,soft and rounded and apparently continuous with the cervix,any movement imparted to it by the external hand being-directly appreciated by a finger placed on the cervix. The-.uterine sound was not passed. A hard crescentic mass wasfelt in Douglas’s pouch.On March 10th, eight days after admission, abdominal

section was performed. There had been no material altera-tion in the physical signs, except that fluctuation had become.more evident in the swelling in the left side. Maximum

temperature since admission 99° F. On opening the abdomentwo suppurating ovarian cysts were discovered; the larger’one on the left side contained over a pint of greenish-yellow,inoffensive pus, which was withdrawn by trocar and caiinula..The contents of the smaller cyst on the right side were of asimilar character. Both cysts were intimately adherent to>

surrounding parts and especially to the rectum. The bodyof the uterus, normal in size, was pushed forwards behind!the pubes. The broad ligament partially enveloped the-cysts anteriorly. There was no cellulitis. The Fallopiantubes were thickened and elongated, but otherwise normal..The operation was somewhat protracted and rendered!

extremely difficult by reason of the number and densityof the adhesions. The right cyst was ruptured during’its separation from the neighbouring parts and its puru-lent contents escaped into the peritoneal cavity. The.abdomen was freely douched with boracic-acid lotion, a glass.drainage-tube inserted and the wound sutured with silkworm-gut sutures. The patient was returned to bed in a.

collapsed condition. Temperature 95 6°, pulse almost imper-ceptible at wrist ; cardiac pulsations 154. She graduallyrallied and convalescence was afterwards rapid. The sutures.were removed on the seventh day; the indiarubber tube,which had replaced the glass tube, was discarded on thetwelfth day. The patient got up on the sixteenth day and leftthe ward on April 22nd, the wound having been healed forten days. She reported herself a month later in good health-CASE 2.-E. C-, aged thirty-two, married, was admitted!

into the Adelaide ward on March 8th, 1892, complaining of*severe pain and swelling in the lower part of the abdomen.She was married at the age of nineteen and had never been

pregnant. She had menstruated regularly till six weeksago, when her present illness began. Up to this time"she had enjoyed good health. No history of gonorrhoea.Six weeks ago the patient was suddenly attacked in the*early morning, while lying in bed, with acute pain in the’lower part of the abdomen. She got up for an hour or so,,but was compelled to go back on account of the increasing-severity of the pain and tenderness of the abdomen. No-

rigor or vomiting. The pain gradually diminished, but aweek later she began to vomit and this has continued moreor less severely up to the present. She has also complainedof difficulty and pain in micturition. Three weeks ago the;

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patient first noticed a swelling in the lower part of theabdomen and this has progressively increased in size andbecome more painful and tcndcr. She has grown muchthinner during the last few weeks and has kept her bed upto the time of her admission.On admission the patient, a pale, emaciated woman with

sunken eyes and looking extremely ill, complained of abdominalpain of six weeks’ duration. Thoracic organs normal. Thelower half of the abdomen is somewhat prominent and

asymmetrical, the fulness being more marked on the right.The walls are somewhat rigid. On palpation a smooth,tender swelling can be definecl reaching in the middle line tothe umbilicus and laterally for a distance of three inchesfrom the middle line. Indistinct sense of fluctuation wasobtained. There is resonance over the upper half of thetumour. On bi-manual examination the uterus was found

pushed forwards and to the left by two tense cysts, the

larger one occupying the right posterior quarter of the pelvis,the smaller a similar position on the left, a distinct sulcus alittle to the left of the median plane intervening. Tempera-ture 101° to 1028°. Urine normal.On March 14th, six days after admission, the patient having

been steadily losing ground and with a temperature rangingffrom 99 ’4° to 103 ’6°, abdominal section was performed. On !,the right side was found an inflamed ovarian cyst universallyadherent and partly covered in front by adherent intestine.During the separation of the adhesion the cyst wall wasruptured and pus escaped freely. Sixteen fluid ounces of

very offensive pus were drawn off by trocar and cannula.The vermiform appendix was so firmly adherent to the cystwall that it was torn across during the separation of thecyst. It was thickened and inflamed, the lining membranebeing denuded of epithelium and covered with lymph. Onthe left side there was a smaller cyst also intimatelyadherent to surrounding structures, especially to therectum, and containing offensive pus which escaped inconsiderable quantity during its separation. The Fallopiantubes were normal. The peritoneal cavity was thoroughlydouched with hot boracic lotion and two glass drainage-tubes inserted and the wound sutured with silkworm-gutsutures. The operation lasted nearly two hours and the

patient was returned to bed in a somewhat collapsed condi-tion and an injection of brandy administered subcutaneously.The patient rallied well from the operation. The tempera-ture rose the same night to 101°, but with that exception themaximum temperature during the convalescence, which wassingularly rapid and uneventful, was 99’6°. One glass tubewas removed the following morning and twenty-four hoursaater the other tube was replaced by an indiarubber tube, thedischarge being purulent and offensive and containing small- sloughs. Stitches were removed on the seventh day, theindiarubber tube on the fourteenth day, the discharge beingvery slight and non-offensive. She got up on the sixteenthday and left the ward well on April 13th. She presentedherself a month later perfectly well.CASE 3.-M. S-, aged forty-six, married, was admitted

into the Adelaide ward on Feb. 27th, 1892, complaining ofattacks of abdominal pain of five years’ duration. The

patient has been married twenty-five years and has neverbeen pregnant. Catamenia began at the age of fourteen,twenty-eight days’ type, the flow lasting from three to!four days and accompanied with pain. Since 1887 thepatient has suffered from paroxysmal attacks of pain inthe lower part of the abdomen and left side. She also’suffers from winter cough. The attacks of pain recur

very frequently and last generally for two or three days.and always start in the left iliac region. During theattack she says she feels very ill and sick and is obliged totake to her bed. The longest interval that she has had freefrom pain during the past five years is five weeks. Betweenthe attacks she feels quite well. She was in the ward undertreatment for pelvic inflammation, chiefly cellulitic, twelvemonths ago and greatly improved whilst under observa-tion, but from the time of her discharge she had sufferedfrom recurrent attacks of pelvic pain more frequently thanever.

On admission the patient, a stout, robust-looking woman,complained of pain in the lower part of the abdomen and theleft side. The abdominal wall was soft, thick and flaccid,lesonant all over ; nothing abnormal detected on palpation.On vaginal examination the uterus was found retroverted anddisplaced to the right. The sound passed normal distance.Occupying the left posterior quarter of the pelvis was a hard,irregular mass, quite fixed and somewhat painful. There wasno evidence of fluctuation. The temperature was normal and

the urine contained a trace of albumen. The thoracic organswere normal. After seventeen days’ complete rest in bed, therebeing then no alteration in the physical signs, abdominalsection was performed. The left posterior quarter of thepelvis was found occupied by a tense, inflamed ovarian cystroofed in by adherent intestine and omentum and partlycovered in front by the thickened and inflamed left broadligament. The uterus was displaced a little to the right of themedian plane. Posteriorly, there were dense adhesionsbetween the cyst and rectum. With considerable difficultythese adhesions were broken down and during the manipula-tions the cyst was ruptured and the purulent and highlyoffensive contents escaped into the abdomen. The collapsedcyst was then removed, a portion of its wall being lefton the distal side of the ligature ; the lining membraneof this was afterwards dissected away. The abdo-minal cavity was thoroughly douched with boracic lotion,a glass drainage-tube inserted and the wound suturedwith silkworm-gut sutures. On subsequent examinationthe cyst showed signs of intense inflammation ; the wallwas dense, a quarter of an inch in thickness and glisteningwhite on section ; it measured three inches and a half by fourinches. Internally it presented a red, ulcerated and shreddysurface. At one part of the wall there was considerablethickening, which on section had the appearance of ovariantissue rendered dense by chronic inflammation. It provedon further examination to be inflamed connective tissue, withthe slightly thickened but otherwise normal Fallopian tubeembedded in its midst. The convalescence was satisfactoryin every respect. The patient got up on the fourteenth dayand left the ward a fortnight later in good health, the woundhaving been completely healed for a week. The patient hadsince menstruated normally. There have been two attacks ofsevere pain of short duration, but the general health con-tinues to improve. Some induration can still be felt on theleft side of the pelvis.CASE 4.-M. S——, aged twenty-seven, married, was ad-

mitted into the Adelaide ward on Feb. 20th, 1892. She wasmarried in 1880 at the age of sixteen and has had two children.She dates her illness from an abortion in 1885, after which shesuffered from violent pain in the lower part of the abdomenwith haemorrhage and sickness for some months. During thepast seven years the catamenial function, which had previouslybeen regular and normal, has become very irregular, occurringat intervals varying from three to six weeks. She describesthe flow as being like ’’ dirty water.

" No dysmenorrhcea.She has not been pregnant since the abortion seven years ago.During these seven years she has been subject to attacks ofabdominal pain. The last and most severe attack commenceda fortnight before admission. The pain was of a sharp burningcharacter, situated chiefly in the right iliac region and to a lessdegree on the opposite side and radiating down the thighs.The patient had been in bed on account of the severity ofthe pain for one week before her admission.On admission the abdominal wall was so rigid that a

satisfactory examination could not be made. A few dayslater an examination was made under an anæsthetic ; theuterus was found displaced to the left and freely movable.Occupying the right posterior quarter of the pelvis and

depressing the right fornix was a tense, smooth, fluctuatingswelling the size of a fist, separate from the uterus, whichcould be moved independently of it. The thoracic organswere normal. Urine contained a decided trace of albumen.

Temperature 98° to 102°.On March 18th abdominal section was performed. The

uterus were found displaced to the left and the appendages onthat side were normal; on the right side was found a globulartense cyst adherent to the surrounding parts and to the smallintestine. The cyst burst during its separation from theadhesions and its purulent contents escaped partly into theabdomen and externally. The broad ligament was consider-ably thickened by cellulitis and the Fallopian tube was alsothickened and inflamed. The tube, with the collapsed suppura-ting ovarian cyst, was removed and the abdominal cavitydouched with boracic lotion at 110°. A glass drainage-tubewas inserted and the wound sutured by silkworm-gut sutures.On the following morning the glass tube was replaced by an

, indiarubber tube, the discharge being considerable in quantityand of offensive odour. The stitches were removed on theseventh day. The tube was left out on April 11th, therebeing less discharge of a purulent non-offensive character.The patient got up two days later and left the ward onApril 29th, well, in all respects, except for the presence of asmall discharging sinus at the lower angle of the incision.

(To be concluded.)