622a greyish slough, which posteriorly looked quite black. Thepulse was 136, with tolerable volume; and the bowels relaxed.Wine, beef-tea, &c., were ordered; and Mr. Lloyd having like-wise seen the patient, suggested applications of nitrate ofsilver to the gangrenous part. On the eighth day after theappearance of the gangrenous stomatitis, the cheek was re-duced in size, and less red; in the centre a circle, about the Idiameter of a shilling, was noticed ; it was soft to the touch, Ithe parts around being firm and indurated. The slough within 1the mouth was of a grey colour, and the edges of the sore con-nected with it very slightly inflamed. Dr. Burrows now pre-scribed ammonia and bark, and a poultice to the face. On thetenth day an offensive slough of considerable size was detachedfrom the mouth; the cheek became much diminished in bulk,and presented a circumscribed patch of dusky redness, overwhich the skin appeared about to desquamate. The patienttook her food in the meanwhile, though with reluctance, asswallowing gave her much pain. The cheek gave the feelingof great tenuity at the affected spot; within the mouth wasseen a deep and excavated ulcer occupying the situation ofthe two last upper and lower molar teeth, with a small portionof slough remaining anteriorly.On the twelfth day the left commissiire of the lips became

much fissured. The patient now used, within the mouth, alotion of fifteen grains of chlorate of potash in decoction ofbark, and the wine and nourishing diet were continued. Theinterior of the ulcer was covered with a grey slough, and ofthe thickness of the cheek at that point nothing but the integument seemed to be left, the second bicuspid tooth havingdropped out. On the sixteenth day another tooth from theupper jaw fell out, and on the twentieth pain was complainedof; the gangrenous spot was darker externally, and the cuticledry and desquamating over it. The patient, however, openedher mouth with less difficulty, and the sores on the left angleof the mouth were healing.On the twenty-third day, after the accession of the gan-

grene, the dark spot on the face was situated at the base of a Iconsiderable depression on the side of the cheek; and aroundthe darkest portion a circular superficial crack had made itsappearance, enclosing a space about a quarter of an inch indiameter; and the part so enclosed resembled a scab. Fromthis time an improvement began to take place; the size of Ithe sore within the mouth diminished, and was covered witha white slough, resembling boiled albumen. Externally, the

I

superficial crack was a little deeper, and somewhat tender tothe touch.On the thirtieth day the patient’s appearance was much

improved. On the right cheek a depression remained, slightlydusky in appearance, tender to the touch, but not feeling sothin as formerly. Another of the upper teeth now droppedout. On the thirty-third day the cheek, externally, presenteda smaller depression, as well as a less dusky appearance; andinternally the ulcer was gradually contracting. On the for-tieth day the ulcerated surface within the mouth had regainedits mucous lining, and appeared healthy; though on its mar-gins, and in the alveolar depressions whence the molar teethhad fallen out, there was yet a whitish grey foul slough.Still the above-mentioned lotion has been used up to the pre-sent time. A complication of some importance, which occurredabout this period, consisted of pain, redness, and swelling inthe elbow of the right arm, as well as a certain amount ofdeafness: these symptoms were, however, removed by thellR1U..l n1AA.n<L

On the forty-third day there still remained a small sloughon the posterior portion of the original gangrenous sore, andthe alveolar portion of the upper jaw (the three molar teethof which were absent) became exposed, and the bone necrosed.On the fiftieth day the patient sat up, slept well, and enjoyeda good appetite. No trace of ulceration remained within the

mouth; the alveoli, however, were still in a necrosed state.An evident hysterical reaction now took place-a circumstance Ieasy of explanation at the patient’s age-and she would fre-quently burst into tears. She was discharged in a favourablecondition, but the change of scene and objects seemed, on herreturn home, to act powerfully on her debilitated frame; for,when with her friends, she became delirious, and was muchexcited. These symptoms continued for several days, andwere treated by purgatives, low diet, &c. The former tookfull effect; large quantities of scybala were passed, and thepatient rapidly regained full consciousness and tolerablehealth. A large portion of the superior maxillary bone cameaway about nine days after her discharge, and another loosepiece will have to be removed before the mouth can be pro-aonneed well.The favourable turn which this case has taken will show

that deterging and caustic applications, combined with tonicmedicine and stimulants, will conquer the fatal tendency ofthis dangerous affection. It will be perceived how close athand was the actual pe) foration of the cheek ; the phagedenic!process, however, was luckily arrested, but the osseous texturedid not escape; and the necrosis of the alveoli will bear %

lasting testimony to the severity of the morbid phenomena.KING’S COLLEGE HOSPITAL.

Recurrence of a Melanotic Tumour; Removal.

(Under the care of Mr. FERGUSSON.)MELANOSIS very frequently attacks the eye, and it is supposed

by some pathologists that the melanotic transformation isclosely connected with the peculiar nature of the choroidcoat. It is likewise thought that a melanotic tumour uncon-nected with encephaloid disease, when once extirpated is notlikely to recur, though the growth be certainly of a malignantkind. We lately noticed a patient of Mr. Fergusson withwhom the seat of the melanosis was not the eye, and who wasevidently suffering from a recurrence of the disease; we,therefore, beg permission briefly to put the same uponrecord.Mary Ann G-, forty-five years of age, married, a ivomaa

with dark hair, white eyelashes, and a melancholy appear-ance, was admitted Dec., 1850, under the care of Mr. Fergus-son, for a tumour in the right groin. This growth is aboutthe size of a small orange, oval, and is extending from theanterior superior spine of ilium to half way down Poupart’sligament. It is solid, unnattached to the skin, not lobulated,and has been considered by many practitioners to be hernia.On inquiry, it was found that two years ago, a small pendu-

lous tumour of a dark colour, had appeared on the right sideof the mons Veneris, it had a narrow pedicle by which it hung,and gave no pain for five weeks; the skin over it then ulcerated,and a substance like dark sponge protruded. This bled byoozing for a week, and as the patient could not stop the lossof blood, she went to a surgeon, who applied a ligature roundthe neck of the tumour. When this practitioner found thatthe latter did not separate, lie cut it off altogether with thescissors, and shortly after this operation, the skin around thecicatrix became of dark colour, and of a horse-shoe shape.Soon after this period, the patient felt pain down her thigh

and in the groin,alld the present tumour, which is deeper, andto the outer side of the above mentioned mark, was perceived.It was hard, painful, about the size of a marble, and remainedstationary until Feb., 18GO, when it grew rapidly and hascontinued to increase up to the present time. It appears tobe moveable in all directions, is unattached to the skin, butseems to have deep-seated connexions.During the first month of her stay in the hospital, the

patient felt more and more pain in the tumour, and after thislapse of time Mr. Fergusson removed it, the patient havingbeen rendered insensible by chloroform. Four or five vesselswere tied, one of which seemed to be a glandular branch ofthe femoral artery and of large size. The tumour turned ontto be a melanotic one; it was contained in a cyst of condensedcellular tissue, and was attached towards its inner margin tothe neighbouring glands, one of which was removed with thetumour. The latter was about the size of an orange, andwhen cut into, presented all the characters of melanosis. Mr.Fergusson, in addressing the pupils, remarked that some doubthad existed respecting the nature of this tumour, but it wasdue to Mr. Luxton, the house-surgeon, to state that he ( Mr.Luxton,) had expressed a belief that the growth was of themelanotic kind. The patient progressed very favourably, andwas discharged well about six weeks after the operation.

Varicocele treated by the -Needles and Twisted Suture.(Under the care of Mr. FERGUSSON.)

We have had frequent opportunities of seeing Mr. Fergussontreat varicocele by the twisted suture, and the success whichhas generally attended these operations induces us to acquaintthe readers of the " Mirror" with Mr. Fergusson’s mode ofprocedure. It seems pretty well agreed among surgeons thatall cases of varicocele do not require operative interference,and that proper and well-regulated support, where the affec-tion is not of a severe description, will generally afford suffi-cient relief. But the distended veins of the cord may causesuch painful dragging and disturbance of the general health,that it becomes the surgeon’s duty to propose remedial meansto his patient. We shall refrain from passing in review thevarious kinds of operations which have been resorted to, in

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order to obliterate the varicose spermatic veins; thesemethods are sufficiently well known; we would, however, justrefer to one lately advocated by 1B’1. Boyer. This gentleman,in the new edition of the work of his father (Baron Boyer),which he has just completed, advises in varicocele to make anincision over the external ring, to lay open the fibrous sheathof the spermatic cord, and to tie everything contained in itexcept the vas deferens and the artery. This method mustcertainly be very hazardous; and though the author cannotbring any number of facts to bear out his idea, he prefers hisplan to the ligature advised by M. Ricord, cauterization, orthe rolling up of the varicose plexus, according to M. Vidal’smethod.We beg permission to adduce the following case, as being a

fair sample of the various others in which we saw Mr. Fergus-son operate in the same manner:-W. J-, aged twenty-eight, admitted March 13, 1851,

with varicocele of the left side. He has had an aching painin the scrotum for the last eight or nine years. The veins ofthe left side are much enlarged and turgid, particularly aftera long day’s work; there is dragging pain at the cord, andsevere aching in the back and loins. The patient has beenwearing a suspensory bandage for the last two years; at

present, the skin on the left side of scrotum is very lax, theveins long and full, the left testis much smaller than theright, and there are also varicose veins on the left leg. Theman suffers a good deul of pain in the varicocele while stand-ing, but when he lies down, the swelling and uneasy sensationin the veins disappears. General health good.On the 15th of March, Mr. Fergusson passed three needles

under the scrotal veins, and twisted strong silk round them,as in the hare-lip operation. Two days afterwards the inflam-mation was rather severe in the scrotum, but the patient onlycomplained of heat in the part, and of a little cough. On theeighth day, the needles ulcerated out, and no pain or tender-ness of the cord was complained of. On the seventeenth day,Mr. Fergusson removed the needles, which were very nearlyout. On the twenty-second day, the sores left by the needleswere rapidly healing, and the patient was soon discharged,free from the very inconvenient affection for which he hadbeen operated on.The mode of operating illustrated by this case combines

many advantages, and does not seem, while it effectually obli-terates the veins, to inflict such violence upon the vessels asis done by a method newly introduced at Paris by Mr.)Tidal, Surgeon to the Hapital du Midi.

This latter method consists in passing a silver wire, held bya needle, behind the veins of the cord, these vessels and thevas deferens having first been separated. Another silver wireis then introduced in front of the vessels, this second wirerunning through the same apertures as the first. The veinsare thus situated between the wires, the ends of which areloose on either side, and the latter are now twisted upon them-selves. This tortion acts at first only upon the wires, thelatter forming a loop which becomes gradually diminished insize, and contains the veins. This first twisting movementtends to reduce the veins to a mere cord, and the wires to ametallic string offering a certain amount of resistance. Thismetallic string, in turning upon its own axis, must evidentlycarry with it the parts contained within the two wires of which

Iit is composed, and the veins are thus rolled upon this doublemetallic cord as the rope turns on the winch. ,

The vas deferens is not included in these displacements; itremains untouched behind the wires, and the testicle is carriedupwards towards the abdomen, where the veins have a fixedpoint; and the more turns are made the higher the testicle isdrawn. A small roller is then placed on the skin whichseparates the apertures of entrance and exit of the wires; thelatter are twisted upon the roller, and a probe being passedunder it, the parts are still more compressed by means of thiskind of packing-stick. The author states that this operativeproceeding is divided into three parts: 1, rolling of the veinson the wires; 2, compression of those vessels which are bothbetween and before the threads; 3, section of the veins atvarious points of their length; in fact, in as many points asturns have been made.

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ROYAL FREE HOSPITAL.Intestinal Obstruction; Amussat’s Operation; Death; Autopsy.

(Under the care of Mr. GAY.)WE had, a very short time since,occasion to refer to Amussat’s

operation, (THE LANCET, May 10, 1851, p. 512,) when report-ing a case of thyroid hernia, under the care of Mr. Stanley.

It will be recollected that the colon in Mr. Stanley’s patientwas found, on a post-mortem examination, empty and verymuch contracted; this state of things pointing to the littlegood which an artificial anus in the loin would have produced.We have now to relate’a case where the descending colonwas found in a somewhat analogous condition upon Amussat’soperation being performed; the opening of the lumbar regionbeing, however, fully justified by the peculiarities of thecase.

The instances of recovery after the above-named operativemeasures, published by Continental and English surgeons, arewell calculated to create a certain confidence in the operation;the two cases inserted in the last volume of the 3ledico-Cltirur-gical Transactions, being not the least important of the series.Intestinal obstruction is a subject of vast importance both tothe physician and the surgeon; we shall therefore seize everyopportunity of giving publicity to the facts derived from thepractice of the London hospitals which bear especially uponthis question. Several cases where no operation was per-formed, and where the autopsy disclosed the nature of theobstruction, lately came under our notice; we shall take anearly opportunity of recording them.Mr. Gay’s patient was a woman sixty years of age, who had

for some years been suffering from cancerous disease of thewomb. For the last two years, together with the advance ofthis disease, her bowels had become constipated, and shefound it difficult to procure regular evacuations; sometimesseveral days would elapse, and then the bowels would act,although but slightly. During this period she suffered little orno abdominal pain. For a fortnight before her admission to thehospital, no alvine evacuation had taken place, although theusual remedies had been pertinaciously resorted to.On admission Mr. Gay examined her. The abdomen was

much distended, and universally resonant on percussion, butnot tense. There was very little pain on pressure, and whatshe complained of, appeared to be from the manipulation of

over-distended bowels rather than from peritonaeal inflamma-tion. At times, however, for the last three or four days, shehad experienced paroxysms of forcing pain, accompanied withgeneral distress. Sickness had commenced about ten daysbefore, and now she vomited everything she took: but thematters vomited were not fsecal.On examining the rectum, the finger could be passed

easily to very nearly its own length; beyond that thereappeared to be no passage, but a uniformly hard mass wasfelt quite fixed in the pelvis and apparently pressing therectum so firmly against the sacrum as completely to close it.The mucous membrane, as far as it could be felt, was healthy; iland no indications could be found of the rectum itself beingdiseased. On passing the finger up the vagina, the os uteriwas felt to be very jagged and painful to the touch; a flowof blood and of ichorous matter left no doubt but that theos tincse had been destroyed by cancerous ulceration. Thebody of the uterus was further found to be densely indurated,very considerably enlarged, and almost immoveably wedgedinto the cavity of the pelvis.

Mr. Gay endeavoured to pass O’Beirne’s tube, but found itimpracticable: the efforts which had already been unsuccess-fully made, and the state of the contents of the pelvis, inducedhim to forego further attempts of the kind.The loins were now examined, and the left certainly gave

more resonance on percussion than the right, and this clearsound apppeared to take the line of the descending colon.There was considerable anxiety of face, with great prostra-

tion ; and as the state of the uterus appeared to be the causeof the obstruction, and there was no reasonable probabilitythat the patient would be able to pass faecal matter againthrough the rectum, Mr. Gay recommended the descendingcolon to be opened in the loins, and the advice was readilyassented to.The patient was speedily got under the influence of chlo-

roform by Dr. Snow, and Mr. Gay began the operation bymaking an incision about two inches in length, as nearly ascould be judged, parallel to the outer edge of the quadratuslumborum muscle. The skin, fascia, and superficial layer ofmuscles were now cut through, and the sheath of the quadratuslumborum reached without difficulty. This sheath was thenopened, and, avoiding the muscle itself as much as possible.an incision was made into the deeper layer of the sheath.Some fat, which was at first supposed to be the bowel, pre-sented itself; and after clearing away more than the usualquantity of adipose matter in this situation, the bowel wasdiscovered by the finger beneath the tract of the wound. Itwas, however, empty, to the surprise of the operator; a circum-