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NOTE ON THE RADICAL CURE OF HYDROCELE BY PERINEAL EXCISION OF THE GREATER PART OF THE SAC.
512 delivered in these
kingdoms." " You remember the child," preventing the publication of a second volume on conMay 20th, 1837, "which you saw in the stitutional disease which he tells us in the preface of with "primary" dispensary labouring under symptoms of syphilis. I mean his first published volume (1838) dealing the child which had the peculiar cry, the scaly lips, and the disease and its varieties would follow.a excoriated mouth, the bleared eyes, and the general Grosvenor-street, W. eruption of reddish brown stains. You also remember that I pointed out to you that the mother who nursed this wrote Wallace
on
"
child was free in appearance from all kind of disease. Her nipple had not suffered although the child’s mouth was so much affected. Now you know that such children are most apt to communicate disease to such sound women as OBSTETRICAL, AND nurse them. Why, then, did not this child communicate disease to its mother who nursed it and who seemed to be THERAPEUTICAL. sound ? I reply, because the mother was insensible to the action of the poison in consequence of her constitution being already contaminated. You may say she was sound. I NOTE ON THE RADICAL CURE OF HYDROCELE BY admit she was so to external appearance, but you have, in PERINEAL EXCISION OF THE GREATER my opinion, a proof in her having given birth to an unsound PART OF THE SAC. child that she was unsound. In fact, the mother of a child BY H. MILTON, M.R.C.S. ENG. congenitally syphilitic is not susceptible of having disease I her her own least so in child-at long produced by suckling as she remains in the same state as she was in when HYDROCELE is one of the most frequent conditions with she gave it birth. I have never seen a mother injured the surgeon in Egypt has to deal and its treatment by which by her own disordered child. This is a reason among and injection of iodine is of old standing in that others that such infants should be nursed puncture many by their mothers. But if a mother be separated for a country. In quite recent times this treatment was largely time from a child and cured and if the uncured carried out by barbers and I know a native hakeema (or lady child be brought into contact with her there is reason to of high standing who has a well-merited reputation believe that she would receive the infection. I have seen doctor) In my experience, howas regards this particular operation. cases which prove this." In explanation and support of ever, the results given by any form of injection are very these views he brings forward the results of inoculation uncertain and I have long abandoned this method entirely experiments on a man whom he calls " P. D " and on his and have treated all my cases by incision. In my earlier wife whom he calls " M. D." to whom the man had given operations I incised directly through the scrotal tissues on to obvious disease. The man was unsusceptible to auto- the hydrocele and I found very great difficulty in avoiding inoculation and the woman was unsusceptible to autoThis of infection is chiefly due to suppuration. inoculation. She was, however, susceptible to inoculation the nature of the danger and to the difficulty integument from the man from whom she had originally acquired the of a Later I adopted the satisfactory dressing. applying disease. "What, then," he asks, "was the cause that method recommended by Kocher of dislocating the hydrocele inoculation was not followed in P. D. by any effect? By into the abdominal wall and incising over the inguinal canal. his case and by many others of a similar kind I The results obtained were more satisfactory but thereby have been led to the discovery of an important law I frequently met with haemorrhage into the scrotum subserelating to the propagation of the venereal poison. quently to the closure of the wound. This risk of haemorrhage It is this : as soon as the constitution of any in- is due, in part at all events, to the pressure on to the cord dividual becomes contaminated with this poison all produced by the pad placed over the incision and owing to parts of his body are rendered insensible to inoculation the laxness of the scrotal tissue this hsemorrbage may go on with the matter of his own sores or of analogous sores of unperceived until a rise of temperature and pain necessitate another individual although such matter has the power of a change of dressing and disclose a scrotum as large and as producing disease in a sound person." With regard to the black as a hat. I have in all my recent operations adopted woman he writes, " We are authorised from this experia method which by providing perfect drainage obviates the ment to infer that M. D. was susceptible of the influence of of hasmatoma and which has given me a series of the poison of P. D. although insensible to her own poison, danger most excellent results with an entire absence of complicawhich had emanated originally from that of P. D. You must tions. This method, while adopting the principle of dislocaobserve that this conclusion corresponds with the general tion, changes the position of the incision from the inguinal conclusion already made-viz., that a system labouring under to the perineum. region a venereal disease is capable of being contaminated by a The operation is very simple. A purge and enema having less exhausted virus than its own. Now, although M. D. acted satisfactorily the patient is placed in the lithotomy originally received this infection from P. D., as soon as her position, the perineal and adjacent regions are shaved and disease became constitutional its virus was exhausted one well scrubbed with soap-and-water and rubbed down with grade more than that of P.D. and consequently she was still alcohol and sublimate, and the neighbouring parts are prosusceptible of the influence of the poison of P. D., although tected with -sterile cloths. An assistant seizes the scrotum insensible to her own." A case which he adduces as an and causes the hydrocele to project into the perineum, analogy to the reinfection of a mother by her own child is forcing it down as far as it will go. An incision is then remarkable and suggestive. It is that of a man who obviously made in the perineal skin over the lower part of the projecinfected his wife. Separated from her and undergoing tion from some two to three inches in length. A few strokes proper treatment his symptoms subsided, but on resuming of the knife expose the tunica vaginalis and an incision into cohabitation he acquired fresh disease of a primary exanthe- it allows its contents to As the sac contracts its matic character, followed in turn by constitutional symptoms. walls are seized with escape. and are gradually artery forceps Diday noted the manifestations reappearing in the mother in delivered through the incision. The hydrocele is then split subsequent conceptions. He regarded them as fresh aggra- from one end to the other and the larger portion of its walls vations of poison from the fcetus in utero. His apparent is removed with scissors, the portion over the testicle and forgetfulness of "Colles’s law," to which he had given his within half an inch of it being left untouched. The removal adhesion, led me to suggest relapse rather than fresh infec- of this of the hydrocele is quite useless and more portion tion under the stimulus of conception, in similar cases, as than that is harmful inasmuch as it leads to oozing and is well as in these local sores, often seen in men who have followed by orchitis. All bleeding points are nearly always previously suffered and who may or may not have exposed clamped and tied and the testicle is returned into the themselves afresh to admitted sources of contagion. scrotum. A small drain is introduced and the skin incision Not only does Wallace’s work throw light upon the nature closed with a fine suture. A perineal pad is applied and of immunity -in the mother, from inoculation experiments, but over this a large dressing which covers the scrotum and the also upon that of reinfection in exceptional and similar and by means of a T bandage or a sling from the neck cases. Moreover, light is thrown upon many other questions penis, holds them well up on the penis. The outside dressing is which at the present day are the subject of anxious inquiry removed for urination and the perineal pad is changed daily and controversy. It is a little remarkable that Wallace’s work should have remained "latent" for so long. This 5 Samuel Lane death refers, however, to his work and has arisen probably from the fact of his death in 1838 "Lectures on Syphilis," THE LANCET, June 18th, 1842.untimely
Clinical Notes:
MEDICAL, SURGICAL,
513 it tends to get soaked with perspiration. On the second seventeenth day which prevented the patient getting about day the tube is removed, on the fitth day the stitches are as quickly as she otherwise would have done. The result removed, and on the following day the patient can get up is very satisfactory, more especially as the operation had and if necessary go about his business but wearing a sus- been considerably delayed by the patient’s refusal to enter a hospital. It was, indeed, only undertaken to save her from pender and a perineal pad. Four points require attention. 1. Care must be taken not impending death. The operation was performed in a small to incise the testicle instead of the hydrocele sac. Usually room in a poor locality and the only nursing she had was inspection and palpation leave no doubt on the matter, but if from her neighbours. Since the operation the patient again for any reason, such as a thickened sac, the decision is became pregnant, but unfortunately miscarried at the fifth
as
difficult the passage of a hypodermic needle will settle the month. Stamford Hill, N. question without appreciable injury to the testicle. 2. Care must be taken to avoid any injury to the cord or testicle and the most delicate handling only must be practised. 3. All NOTE ON A CASE OF BRADYCARDIA. drainage must be arrested and a drain must be left for the BY CHARLES ORMEROD, M.D.BRUX., M.R.C.S. ENG., escape of any oozing. This latter precaution is, I think, of L R.C.P. LOND. great importance to prevent hasmatoma of the scrotum and the presence of a tube and its withdrawal on the second day offers no considerable inconvenience. 4. The scrotum must be A MAN, aged 83 years, well-nourished and extremely kept well up on the pubes during convalescence. phlegmatic in disposition, complained of feeling very cold Cairo. and of having occasionally what he called a"fit." At these times he turned white and felt faint. The attack was NOTE ON A RAPIDLY-GROWING OVARIAN TUMOUR evidently cardiac in character. These attacks occurred on any attempt to get out of bed. The family history of the COMPLICATING PREGNANCY; OVARIOTOMY; patient was unimportant. He had had two attacks of MISCARRIAGE ; RECOVERY. rheumatic fever, the second when he was a young man. He had been a non-smoker and had always been very BY DANIEL MOWAT, M.D.EDIN. No drugs had any effect on abstemious in his habits. the rate of the heart. On examination the heart THE following case of an ovarian cyst growing rapidlydulness was found to extend upwards to the third during pregnancy and its removal verifies the remarks madecostal cartilage. Its lateral limits were not markedly by Dr. W. Duncan in THE LANCET of Feb. 4th, but in thisincreased, the apex beat being in the fifth interspace just inside the nipple. There was a systolic murmur at the case the patient unfortunately miscarried about two hours inaudible at the back. The heart sounds at the base after the removal of the cyst, most probably from the too apex, were natural, but all the sounds were very faint and distant. free handling of the uterus. The pulse was extremely slow. On one occasion only 26 A woman, aged thirty-one years, who had had two beats and on another 29 beats per minute were counted, but children and one miscarriage, had suffered severely from throughout the year during which he has been under my metrorrhagia for several years. On examination in January, observation the pulse has ranged from 30 to 36 beats per 1890, I found the uterus enlarged and fibroid nodules minute. The liver dulness has not obviously increased. The ovaries were normal in size. There is no albuminuria and no epigastric pulsation. on the posterior wall. In January, 1892, she consulted me and stated that Probably the cause of the extremely slow pulse in this she was about three months pregnant but that she case is some degeneration of the cardiac muscle which is On examination I found the abdomen much possibly fatty in nature. was very large. on the side than on the left and dull on perLiphook. right larger cussion. Per vaginam the uterus was enlarged to the fifth month and was pushed to the left side. A cystic swelling somewhat larger than a cocoanut was felt towards the right of the uterus. This swelling was diagnosed to be an ovarian cyst and the patient was strongly advised to go to a hospital OF for operation as she only had three rooms in a small house and was unable to obtain skilled nursing. This, however, she steadfastly refused to do and she was therefore kept under observation, but the swelling increased so rapidly in BRITISH AND FOREIGN. size that she was soon unable to leave her bed. As her condition was now serious I asked Dr. Duncan of Stamford-hill to see her. This he kindly did and he confirmed my preNulla autem est alia pro certo noscendi via, nisi quamplurimas et vious diagnosis and expressed the opinion that an operation morborum et dissectionum historias, tum aliorum tum proprias must be performed at once. To relieve the immediate distress collectas habere, et inter se oomparare.—MORGAGNI De Sed. et Caus. lib. iv. Frooemlum. I tapped the cyst, but owing to the gelatinous nature of its contents nothing came through the cannula. ROYAL FREE HOSPITAL. On March 31st Mr. Reynolds of Highgate kindly gave the A CASE OF SARCOMA OF THE CORPORA CAVERNOSA; anoesthetic and Dr. Duncan of Stamford Hill assisted me in the operation. The usual incision in the central line was REMOVAL; REMARKS. made and the bleeding vessels were seized at once. The (Under the care of Mr. W. H. BATTLE.) great distension bad caused thinning of the integuments and IN two points the following case is remarkable. In the the cyst wall had ruptured at the point where it had prefirst also been Adhesions had taken round place the disease is one of extreme rarity, very few viously tapped. place this point spreading on the right side into the iliac fossa. cases indeed being recorded, and in the second place the These were separated and the tumour was emptied of its long duration of the case is noteworthy, for more than seven gelatinous contents which had to be scooped out with the and a half years intervened between the first appearance of hand. The tumour which was of the right ovary was then the disease and the death of the patient. Another point of withdrawn, several omental adhesions were separated, and the pedicle was tied in the usual manner and dropped into interest is the enlargement of the breasts ; it is said to occur the abdominal cavity. The pregnant uterus now gradually in cases of malignant disease of the lungs. The patient, a very tall man, aged 50 years, was first seen resumed the normal position in the centre of the abdomen where it immediately began to contract. The peritoneal cavity in November, 1892. Two years and six months previously he having been repeatedly washed with warm boric lotion the had noticed a difficulty in micturition and six months later a edges of the incision were brought together with silkworm very small swelling appeared in the middle of the perineum. gut. Two hours after the operation I found the patient in As it gave rise to no pain or inconvenience he took no further labour and she was shortly delivered of a fcetus six months notice of it. It increased in size and caused a sensation old. The after pains were very severe but were relieved with of weight and also some slight pain on walking. The patient morphia. The stitches were removed on the seventh day. was advised to go into the hospital but he declined ; howA slight attack of phlegmasia alba dolens developed on the ever, in January, 1893, he consented to become an in-patient _
A Mirror
HOSPITAL PRACTICE,
J)f0 &.,
-
kingdoms." " You remember the child," preventing the publication of a second volume on conMay 20th, 1837, "which you saw in the stitutional disease which he tells us in the preface of with "primary" dispensary labouring under symptoms of syphilis. I mean his first published volume (1838) dealing the child which had the peculiar cry, the scaly lips, and the disease and its varieties would follow.a excoriated mouth, the bleared eyes, and the general Grosvenor-street, W. eruption of reddish brown stains. You also remember that I pointed out to you that the mother who nursed this wrote Wallace
on
"
child was free in appearance from all kind of disease. Her nipple had not suffered although the child’s mouth was so much affected. Now you know that such children are most apt to communicate disease to such sound women as OBSTETRICAL, AND nurse them. Why, then, did not this child communicate disease to its mother who nursed it and who seemed to be THERAPEUTICAL. sound ? I reply, because the mother was insensible to the action of the poison in consequence of her constitution being already contaminated. You may say she was sound. I NOTE ON THE RADICAL CURE OF HYDROCELE BY admit she was so to external appearance, but you have, in PERINEAL EXCISION OF THE GREATER my opinion, a proof in her having given birth to an unsound PART OF THE SAC. child that she was unsound. In fact, the mother of a child BY H. MILTON, M.R.C.S. ENG. congenitally syphilitic is not susceptible of having disease I her her own least so in child-at long produced by suckling as she remains in the same state as she was in when HYDROCELE is one of the most frequent conditions with she gave it birth. I have never seen a mother injured the surgeon in Egypt has to deal and its treatment by which by her own disordered child. This is a reason among and injection of iodine is of old standing in that others that such infants should be nursed puncture many by their mothers. But if a mother be separated for a country. In quite recent times this treatment was largely time from a child and cured and if the uncured carried out by barbers and I know a native hakeema (or lady child be brought into contact with her there is reason to of high standing who has a well-merited reputation believe that she would receive the infection. I have seen doctor) In my experience, howas regards this particular operation. cases which prove this." In explanation and support of ever, the results given by any form of injection are very these views he brings forward the results of inoculation uncertain and I have long abandoned this method entirely experiments on a man whom he calls " P. D " and on his and have treated all my cases by incision. In my earlier wife whom he calls " M. D." to whom the man had given operations I incised directly through the scrotal tissues on to obvious disease. The man was unsusceptible to auto- the hydrocele and I found very great difficulty in avoiding inoculation and the woman was unsusceptible to autoThis of infection is chiefly due to suppuration. inoculation. She was, however, susceptible to inoculation the nature of the danger and to the difficulty integument from the man from whom she had originally acquired the of a Later I adopted the satisfactory dressing. applying disease. "What, then," he asks, "was the cause that method recommended by Kocher of dislocating the hydrocele inoculation was not followed in P. D. by any effect? By into the abdominal wall and incising over the inguinal canal. his case and by many others of a similar kind I The results obtained were more satisfactory but thereby have been led to the discovery of an important law I frequently met with haemorrhage into the scrotum subserelating to the propagation of the venereal poison. quently to the closure of the wound. This risk of haemorrhage It is this : as soon as the constitution of any in- is due, in part at all events, to the pressure on to the cord dividual becomes contaminated with this poison all produced by the pad placed over the incision and owing to parts of his body are rendered insensible to inoculation the laxness of the scrotal tissue this hsemorrbage may go on with the matter of his own sores or of analogous sores of unperceived until a rise of temperature and pain necessitate another individual although such matter has the power of a change of dressing and disclose a scrotum as large and as producing disease in a sound person." With regard to the black as a hat. I have in all my recent operations adopted woman he writes, " We are authorised from this experia method which by providing perfect drainage obviates the ment to infer that M. D. was susceptible of the influence of of hasmatoma and which has given me a series of the poison of P. D. although insensible to her own poison, danger most excellent results with an entire absence of complicawhich had emanated originally from that of P. D. You must tions. This method, while adopting the principle of dislocaobserve that this conclusion corresponds with the general tion, changes the position of the incision from the inguinal conclusion already made-viz., that a system labouring under to the perineum. region a venereal disease is capable of being contaminated by a The operation is very simple. A purge and enema having less exhausted virus than its own. Now, although M. D. acted satisfactorily the patient is placed in the lithotomy originally received this infection from P. D., as soon as her position, the perineal and adjacent regions are shaved and disease became constitutional its virus was exhausted one well scrubbed with soap-and-water and rubbed down with grade more than that of P.D. and consequently she was still alcohol and sublimate, and the neighbouring parts are prosusceptible of the influence of the poison of P. D., although tected with -sterile cloths. An assistant seizes the scrotum insensible to her own." A case which he adduces as an and causes the hydrocele to project into the perineum, analogy to the reinfection of a mother by her own child is forcing it down as far as it will go. An incision is then remarkable and suggestive. It is that of a man who obviously made in the perineal skin over the lower part of the projecinfected his wife. Separated from her and undergoing tion from some two to three inches in length. A few strokes proper treatment his symptoms subsided, but on resuming of the knife expose the tunica vaginalis and an incision into cohabitation he acquired fresh disease of a primary exanthe- it allows its contents to As the sac contracts its matic character, followed in turn by constitutional symptoms. walls are seized with escape. and are gradually artery forceps Diday noted the manifestations reappearing in the mother in delivered through the incision. The hydrocele is then split subsequent conceptions. He regarded them as fresh aggra- from one end to the other and the larger portion of its walls vations of poison from the fcetus in utero. His apparent is removed with scissors, the portion over the testicle and forgetfulness of "Colles’s law," to which he had given his within half an inch of it being left untouched. The removal adhesion, led me to suggest relapse rather than fresh infec- of this of the hydrocele is quite useless and more portion tion under the stimulus of conception, in similar cases, as than that is harmful inasmuch as it leads to oozing and is well as in these local sores, often seen in men who have followed by orchitis. All bleeding points are nearly always previously suffered and who may or may not have exposed clamped and tied and the testicle is returned into the themselves afresh to admitted sources of contagion. scrotum. A small drain is introduced and the skin incision Not only does Wallace’s work throw light upon the nature closed with a fine suture. A perineal pad is applied and of immunity -in the mother, from inoculation experiments, but over this a large dressing which covers the scrotum and the also upon that of reinfection in exceptional and similar and by means of a T bandage or a sling from the neck cases. Moreover, light is thrown upon many other questions penis, holds them well up on the penis. The outside dressing is which at the present day are the subject of anxious inquiry removed for urination and the perineal pad is changed daily and controversy. It is a little remarkable that Wallace’s work should have remained "latent" for so long. This 5 Samuel Lane death refers, however, to his work and has arisen probably from the fact of his death in 1838 "Lectures on Syphilis," THE LANCET, June 18th, 1842.untimely
Clinical Notes:
MEDICAL, SURGICAL,
513 it tends to get soaked with perspiration. On the second seventeenth day which prevented the patient getting about day the tube is removed, on the fitth day the stitches are as quickly as she otherwise would have done. The result removed, and on the following day the patient can get up is very satisfactory, more especially as the operation had and if necessary go about his business but wearing a sus- been considerably delayed by the patient’s refusal to enter a hospital. It was, indeed, only undertaken to save her from pender and a perineal pad. Four points require attention. 1. Care must be taken not impending death. The operation was performed in a small to incise the testicle instead of the hydrocele sac. Usually room in a poor locality and the only nursing she had was inspection and palpation leave no doubt on the matter, but if from her neighbours. Since the operation the patient again for any reason, such as a thickened sac, the decision is became pregnant, but unfortunately miscarried at the fifth
as
difficult the passage of a hypodermic needle will settle the month. Stamford Hill, N. question without appreciable injury to the testicle. 2. Care must be taken to avoid any injury to the cord or testicle and the most delicate handling only must be practised. 3. All NOTE ON A CASE OF BRADYCARDIA. drainage must be arrested and a drain must be left for the BY CHARLES ORMEROD, M.D.BRUX., M.R.C.S. ENG., escape of any oozing. This latter precaution is, I think, of L R.C.P. LOND. great importance to prevent hasmatoma of the scrotum and the presence of a tube and its withdrawal on the second day offers no considerable inconvenience. 4. The scrotum must be A MAN, aged 83 years, well-nourished and extremely kept well up on the pubes during convalescence. phlegmatic in disposition, complained of feeling very cold Cairo. and of having occasionally what he called a"fit." At these times he turned white and felt faint. The attack was NOTE ON A RAPIDLY-GROWING OVARIAN TUMOUR evidently cardiac in character. These attacks occurred on any attempt to get out of bed. The family history of the COMPLICATING PREGNANCY; OVARIOTOMY; patient was unimportant. He had had two attacks of MISCARRIAGE ; RECOVERY. rheumatic fever, the second when he was a young man. He had been a non-smoker and had always been very BY DANIEL MOWAT, M.D.EDIN. No drugs had any effect on abstemious in his habits. the rate of the heart. On examination the heart THE following case of an ovarian cyst growing rapidlydulness was found to extend upwards to the third during pregnancy and its removal verifies the remarks madecostal cartilage. Its lateral limits were not markedly by Dr. W. Duncan in THE LANCET of Feb. 4th, but in thisincreased, the apex beat being in the fifth interspace just inside the nipple. There was a systolic murmur at the case the patient unfortunately miscarried about two hours inaudible at the back. The heart sounds at the base after the removal of the cyst, most probably from the too apex, were natural, but all the sounds were very faint and distant. free handling of the uterus. The pulse was extremely slow. On one occasion only 26 A woman, aged thirty-one years, who had had two beats and on another 29 beats per minute were counted, but children and one miscarriage, had suffered severely from throughout the year during which he has been under my metrorrhagia for several years. On examination in January, observation the pulse has ranged from 30 to 36 beats per 1890, I found the uterus enlarged and fibroid nodules minute. The liver dulness has not obviously increased. The ovaries were normal in size. There is no albuminuria and no epigastric pulsation. on the posterior wall. In January, 1892, she consulted me and stated that Probably the cause of the extremely slow pulse in this she was about three months pregnant but that she case is some degeneration of the cardiac muscle which is On examination I found the abdomen much possibly fatty in nature. was very large. on the side than on the left and dull on perLiphook. right larger cussion. Per vaginam the uterus was enlarged to the fifth month and was pushed to the left side. A cystic swelling somewhat larger than a cocoanut was felt towards the right of the uterus. This swelling was diagnosed to be an ovarian cyst and the patient was strongly advised to go to a hospital OF for operation as she only had three rooms in a small house and was unable to obtain skilled nursing. This, however, she steadfastly refused to do and she was therefore kept under observation, but the swelling increased so rapidly in BRITISH AND FOREIGN. size that she was soon unable to leave her bed. As her condition was now serious I asked Dr. Duncan of Stamford-hill to see her. This he kindly did and he confirmed my preNulla autem est alia pro certo noscendi via, nisi quamplurimas et vious diagnosis and expressed the opinion that an operation morborum et dissectionum historias, tum aliorum tum proprias must be performed at once. To relieve the immediate distress collectas habere, et inter se oomparare.—MORGAGNI De Sed. et Caus. lib. iv. Frooemlum. I tapped the cyst, but owing to the gelatinous nature of its contents nothing came through the cannula. ROYAL FREE HOSPITAL. On March 31st Mr. Reynolds of Highgate kindly gave the A CASE OF SARCOMA OF THE CORPORA CAVERNOSA; anoesthetic and Dr. Duncan of Stamford Hill assisted me in the operation. The usual incision in the central line was REMOVAL; REMARKS. made and the bleeding vessels were seized at once. The (Under the care of Mr. W. H. BATTLE.) great distension bad caused thinning of the integuments and IN two points the following case is remarkable. In the the cyst wall had ruptured at the point where it had prefirst also been Adhesions had taken round place the disease is one of extreme rarity, very few viously tapped. place this point spreading on the right side into the iliac fossa. cases indeed being recorded, and in the second place the These were separated and the tumour was emptied of its long duration of the case is noteworthy, for more than seven gelatinous contents which had to be scooped out with the and a half years intervened between the first appearance of hand. The tumour which was of the right ovary was then the disease and the death of the patient. Another point of withdrawn, several omental adhesions were separated, and the pedicle was tied in the usual manner and dropped into interest is the enlargement of the breasts ; it is said to occur the abdominal cavity. The pregnant uterus now gradually in cases of malignant disease of the lungs. The patient, a very tall man, aged 50 years, was first seen resumed the normal position in the centre of the abdomen where it immediately began to contract. The peritoneal cavity in November, 1892. Two years and six months previously he having been repeatedly washed with warm boric lotion the had noticed a difficulty in micturition and six months later a edges of the incision were brought together with silkworm very small swelling appeared in the middle of the perineum. gut. Two hours after the operation I found the patient in As it gave rise to no pain or inconvenience he took no further labour and she was shortly delivered of a fcetus six months notice of it. It increased in size and caused a sensation old. The after pains were very severe but were relieved with of weight and also some slight pain on walking. The patient morphia. The stitches were removed on the seventh day. was advised to go into the hospital but he declined ; howA slight attack of phlegmasia alba dolens developed on the ever, in January, 1893, he consented to become an in-patient _
A Mirror
HOSPITAL PRACTICE,
J)f0 &.,
-