CASE OF OVARIOTOMY IN ROME.

1089 Bronchitis and CASE 6.-H. P-,aged sixty-seven. dilated right heart, with tricuspid regurgitation ; atheromatous radials. The urine passed daily amounted to forty-two ounces ; sp. gr. 1025, with a quarter of a column of albumen coagulum ; no casts were found on careful examination. At the necropsy the kidneyswere cirrhotic. The same difficulty in finding casts is useful in discriminating recent subacute cases of Bright’s disease from that class of cases where an acute attack supervenes on old intertubular nephritis. CASE 7.-E. V-, aged thirty-two. General oedema of body; ursemic convulsions ; death. The urine passed was ten ounces; acid reaction; sp. gr. 1010; one-third of a column of coagulum ; no casts could be found. At the postmortem examination there was general anasarca ; the heart weighed 24 oz., and the valves were competent; kidneys

CASE

emphysema ;

and cystic, weighing together7 oz.; microscopically, most of the tubes were blocked with swollen epithelium, the matrix was much increased, and the

markedly granular arteries

were

thickened.

Although granular kidney advanced life, it occasionally

is

properly

a

disease of

in young people or In the following case, which is of sufficient children. interest to be given in extenso, the general character of the symptoms resembled chronic or subacute nephritis, with this notable difference, that no casts could be found on careful examination of the urine. The kidneys proved to be extremely cirrhotic, and the disease must have been of old occurs

standing. CASE 8.-P. S-,domestic servant, aged twenty-six. Had scarlatina when a child. Noticed symptoms fourteen

Fig. 4.

days before admission. Illness began with backache, cramp and swelling of the eyelids and feet, and the body has become gradually swollen. There is a mitral regurgitant bruit. On the second day after admission she had headache and vomiting. The urine was alkaline; sp. gr. 1010; nearly solid on boiling; no casts were found.-Third day: From 5 A.M. till 9 A.M. she had eleven convulsions; did not speak during the day; semi-comatose; no oedema of limbs ; she resents interference. Evening pulse 120; respiration 36. No physical signs in lungs.-Fourth day: Same condition of stupor ; pulse l-1-8. In the afternoon she recovered a little from stupor. Tongue dry ; sordes on lips ; restless.-Fifth day: Restless and noisy.---Sixth day: Cough; restless; no physical signs in lungs; involuntary micturition; violent purgation with three grains of compound powder of elaterium.-Seventh day: Itespiration 36; chest full of coarse, loose crepitations; coughs up copious frothy sputum, having a striking uniform pink colour, which the microscope shows is due to blood. This lasted till death, which occurred in the night. At the necropsy the lungs were cedematous; bronchi contained pink mucus. There was hypertrophy of the left ventricle; the mitral valve segments were small, probably allowing regurgitation. There was notable pallor of the brain and meninges; on section the brain looked bloodless. The kidneyspresented the characters of cirrhosis, except that the capsule peeled well; each weighed 2oz. (See Fig. 4.) Birmingham.

OF

OVARIOTOMY

BY J. H.

IN

ROME.

THOMPSON, M.D.

THE LANCET of June 20th, 1885, contained a report by of a case of ovariotomy in Rome ; the sequel, of which the following is the history, I believe to be unprecedented in the records of ovariotomy. On reference to the original article, it will be noticed that I did not cut off the ends of the ligatures embracing the pedicle, but left them outside the abdominal wall; and that after several weeks, finding them still firmly attached, I resorted to continuous gentle traction, using an elastic ring, to one side of which the ligatures were attached, and the other side made fast to the abdominal wall by strips of adhesive plaster. At the end of eleven weeks, there being no sign of separation, I cut them off as short as possible and let the attached ends drop into the abdominal cavity. My patient continued perfectly well until February of this year, when she sought advice on account of a throbbing and dragging pain at the lower part of the abdomen, with frequent and painful micturition. She had missed her periods for two months, and believed herself to be pregnant. Upon examining the cicatrix, the lower part was found to be markedly contracted; pressure gave slight pain. The urine was carefully examined, and found to be normal. Under these circumstances I thought the pain might be due to traction made by the gravid uterus upon adhesions between the stump and the cicatrix. In the iirst week of March she aborted, losing a considerable quantity of blood. From this she quickly recovered, but the discomfort about the bladder continued. In May she had a smart attack of fever, and complained of intense pain. Poultices, hot sitz-baths, and opium were prescribed. On the fourth day after the commencement of this exacerbation she experienced sudden relief, and voided about eight ounces of urine loaded with pus and some blood. For several days a large quantity of pus was passed with the urine. The pain It -was was much diminished, and no longer pulsating. evident that an abscess had formed in the abdominal cavity, and had evacuated itself into the bladder. From this time until the middle of June there was steady improvement, but then the pain returned with increased violence, and it was only after long-continued efforts that she could succeed in passing urine. As I was leaving Rome for the summer vacation, 1 recommended her admission into St. Giacomo Hospital, the attending surgeon of that institution being familiar with her history. On my return to Rome in October, Prof. Pandolfi kindly furnished me with a written report of her case whilst under his charge, which I have translated, and of which the following is a synopsis :— Niargherita i1I-- came under my care on July 6tl-l of this year. She was then suffering great pain, accompanied by fever. On examination I found the bladder much distended, the fundus reaching to the umbilicus. Immediate relief was necessary, but, to my surprise, 1 was unable to pass the catheter, the urethra being blocked by a hard resisting body. I tried to seize the foreign substance with the ordinary forceps, but found it impossible. Having provided myself with Serey and Etoilles’ extractor, I succeeded in removing the mass, which upon examination proved to be a number of ligatures encrusted by the urinary salts. As soon as the impediment was removed she passed a large quantity of fetid turbid urine. For some days her urine remained turbid, but gradually improved, and at the end of twenty days she was discharged, being perfectly restored to health. " I think, my dear colleague, the explanation is clear. The threads removed from the bladder were evidently the ligatures placed around the pedicle of the ovarian tumour you removed from her in March, 1884. Yow I think that at some distant time after the operation a slow flogosi set in, caused by disturbance of the adhesions, or by the presence of the unencapsuled ligatures, which eventuatedin an abscess which ulcerated through the corresponding wall of the bladder. It is clear how the rest happened. This interpretation explains the pain and fever which accompanied the evolution of this interesting, rare, and fortunate case.GAETANO PANDOLFI, M.D." The accompanying illustration is taken from a photograph of the specimens. In removing the mass, the incrustation me

1090 broken off excepting one thread, around which they are still in situ. Figs. 1 and 2 are the parts which encircled the pedicle, Figs. 3 and 4 the ends of the ligatures which have become separated from the knots ; around Fig. 4 will be seen a mass of incrustation. Remarks.-The long-continued traction upon the ligatures, as before described, prevented the stump falling downwards and backwards to its natural position, and at the same time drew the uterus upwards and forwards. The relative position of the parts when subjected to the traction of the ligatures will be readily appreciated if reference be made to " Savage’s was

Anatomy of the Female Pelvic Organs," Plate 8, Fig. 1. Imagine a ligature placed around the posterior folds of the broad ligament between the uterus and left ovary, and the distal part divided.

Traction forward would flex the uterus

wanted to go to stool, and sat up in bed. A violent pain came on, and a second foetus, female, and much smaller than the first, was expelled with its membranes and placenta into the " chamber." The event was so unexpected that she fainted and remained unconscious for some time. Her recovery was slow, and she did not leave her bed for a month. Since the miscarriage she has suffered from menorrhagia, pain in the lower part of the abdomen, backache, and bearing down. Leucorrhoea has been constant for some months, and coitus causes much pain and a bloody discharge. The patient is a well-built woman of medium height, with fair complexion and good features; the mammae are well developed and nipples natural; heart and lungs sound; urine healthy; nothing unusual about the external pudenda ; no malposition of the viscera or arteries of the body or limbs can be made out; and there is no history of twins or congenital deformity in her family. Physwal examination.-The vagina is divided into two unequal parts by a thick septum extending from the situation of the hymen to the fornices, being attached to the anterior and posterior vaginal walls. The septum is onethird of an inch thick, and is marked with rugse on both sides. It extends into the fornices and passes down in a groove between the cervices on the anterior and posterior surfaces. Immediately below the cervices there is a perforation, where the septum seems to have been torn from its uterine attachments, the cervical portion being plainly visible. The left vagina is rather more developed than the right, a No. 2 Fergusson’s speculum passing easily into the former, but with difficulty into the latter. A cervix can be felt presenting into each vagina, that on the left being round, that on the right broad and flattened. Both cervices are lacerated and eroded. Two ora can be distinctly seen, the right being more patulous than the left. Two sounds introduced through them into the cavities pass outwards, each towards its own cornu, the right measuring two inches and a half, the left two inches and three-quarters. A glairy discharge can be seen exuding from both ora. instead of the fundus uteri, a deep sulcus can be felt with two cornua spreading out, one on either side, the left cornu being larger than the right. Treatment.- The vaginal septum was so thick that I decided to cut out the middle portion with Paquelin’s cautery knife, and thus relieve the dyspareunia and gain more space in order to treat the erosion existing in both uteri, and at the same time remove all risk in case of future pregnancy. There was no difficulty about the operation, and the patient

Bimanually,

antero-laterally and bring the stump into immediate contact with the wall of the bladder. At this point firm adhesions must have been formed, which gavethe patient no trouble so long as they were undisturbed. But the backward and upward traction caused by the enlarging uterus, or their possible disturbance by too frequent coitus, provoked the inflammation which eventuated in an abscess. Too long time passed (eleven months) between the operation and the first appearance of pain and discomfort for the in- reports herself " quite relieved." flammation to have been excited by the presence of the unaided by any other factor. This is the first case in which I have elected to leave the ends of the ligatures outside instead of cutting them off short. I certainly shall not try the experiment again. ,

ligatures

,y

Rome.

TWO CASES OF DOUBLE UTERUS AND VAGINA. BY A. C. BUTLER-SMYTHE, F.R.C.S. ED., SENIOR SURGEON TO THE 6ROSVENOR HOSPITAL FOR WOMEN AND CHILDREN, WESTMINSTER; SURMEOX TO THE FARRINGDON SEVERAL DISPENSARY AND LYIXU-IN CHARITY.

CASE 1. Double uterus and vagina, 10itk pre,qnancy of twins. L. N--, aged twenty-three, married, was first seen by me in 1884. She was born in Wales, and is the elder of two sisters. Has always enjoyed good health. Shemenstruated first at the age of sixteen, and was regular for some months, but says the flow usually stopped on the second or third day for about twenty-four hours, and then came on again very freely, lasting in all about eight or ten days. She was married at seventeen, and after that event suffered greatly from dyspareunia, though at times she experienced no pain whatever during intercourse. Two years later she became pregnant, and when about seven months advanced was frightened and hurt by a donkey running against her. She was seized with pains in the abdomen and vomiting, but managed to get home and went to bed at once. Her sufferings continued till the fifth day, when she miscarried of a seven months foetus, male, being attended by a midwife, who delivered her and got away the placenta. The labour pains continued for two days afterwards, when she suddenly felt as if she

;

CASE 2. Uterus septus, with remains of double vagina.C. M-, aged thirty-four, came under my notice in 1884. She is the third of a family of five children, and has one sister, who is married and has had children. Her father is alive and in good health, but her mother died of "tumour of the pelvis. Patient’s health has always been good, and for the last few years she has acted as a monthly nurse. Menstruation appeared at the age of sixteen, and she has been regular ever since, the flow lasting five or six days, but the quantity lost at each period being small. Her condition was discovered after marriage, when it was found that attempt at coitus caused great pain, and penetration was impossible on account of a broad band stretching across the vagina. Sloe sought medical advice, and had the septum split, and at that time it was thought she had a double uterus, but the patient cannot give any information on the point, and her doctor is dead. She is a strong, well-made woman, five feet eight inches in height, dark hair and eyes, sallow complexion, and melancholy expression of features. Mammse and nipples small; heart and lungs sound; viscera and arteries of the body and limbs natural. There is no history of any malformation in her family. She has been married eight years, but has never been pregnant, and her chief anxiety is her sterile condition. Physical examination. Bimanually, the fundus uteri seems to be very broad, and spreads out on either side, but more so on the right than on the left. The cervix is enlarged and flattened, and nothing unusual can be felt at the external os. The remains of a vaginal septum can be seen in the fornices and along the vaginal walls. A fibroid about the size of a plum is situated in the anterior wall of the uterus, about the junction of the body with the neck. Per speculum, the septum can be seen nearly flush with the external os, running antero-posteriorly and dividing the uterus into right and left cavities. Two sounds introduced on each side of the septum pass upwards and slightly -