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it, and seldom passed a whole day or night without suffering.Her urine was pale and limpid, specific gravity 1006, slightlyacid, and contained no albumen. Her pulse was not accele-rated ; tongue clean; chest-sounds good. Dr. Hall Davis exa-mined the uterus with a uterine sound, and thus ascertainedthat it was small and freely movable, independently of thetumour, and in its natural position. She was ordered by Dr.Davis a generous diet with two ounces of port wine daily, anda quinine mixture with sulphuric ether.

Jan. 7th.-Has passed sixty ounces of urine in the twenty-four hours, of the specific gravity above indicated, and quiteclear. She says she feels stronger and better than when shefirst came into the hospital.

13th.-Complains of much pain at the lower part of theabdomen, particularly towards the left iliac and inguinalregions. The patient has, on account of her bad nights fromfrequent pains in the lumbar, iliac, and inguinal regions, andtotal inability to work for her livelihood, expressed a strongwish to have the tumour removed. Believing that the tumourwas ovarian, and concluding that, from its great mobility andthe absence of adhesions, its removal would be easy, an ope-ration was promised ; but its dangers were very fully explainedto the patient, both by Dr. Davis and Mr. Lawson, and shewas recommended to leave the hospital for a week to considerthe subject well over with her friends. She was accordinglydischarged on Jan. 16th.24th.-The patient again presented herself for admission

and expressed a strong determination to have the tumour removed, urging that in her present state she was quite incapableof work, and was thus unable to maintain herself. It wa,therefore arranged that an operation should be performed.26th.-An empty, well ventilated, and well warmed ware

was prepared, and supplied with warm vapour. The patienthaving been placed under the influence of chloroform, a cathetewas introduced, and the small quantity of water in the bladderdrawn off. Mr. Lawson then opened the abdomen by an incision, about four inches in length, below the umbilicus, wherthe tumour, with the pressure merely of the weight of thEhand, immediately presented itself, lying in front of the intes-tines, and looking very like a small ovarian tumour. It wasevidently covered by a layer of peritoneum, which had not theappearance of omentum. Mr. Lawson then introduced his twofingers to explore round the tumour and ascertain the extentof its pedicle, if it had any; but he found that it had no pe-dicle, and that its peritoneal covering was continuous with theperitoneal lining of the abdominal walls. The tumour was notwithin the true abdominal cavity, but behind the peritoneum,which it had carried forwards, and now formed one of its

coverings. A small incision was made through the peritonealcoat on the surface of the tumour to examine its nature, anda dark-coloured elastic mass presented itself. This he punc-tured with a fine exploratory trocar, but only a drop of bloodescaped. It was now a question what was the nature of thetumour ? It was suggested that it might be a movable kidney,completely altered by disease ; and as this supposition seemedto be the most probable, Mr. Lawson determined to proceedno further, and at once closed the wound, having first, how-ever, satisfied himself that the uterus and ovaries were in situand normal. The edges of the wound were now brought to-gether with harelip-pins, and the wire suture between them.One of Mr. Salmon’s obstetric bandages, lined with flannel,was placed round the abdomen, and the patient returned tobed. Ordered one grain of opium every four hours. The

operation was performed at nine o’clock in the morning, and,the report at six o’clock states that she had been quiet, andslept a little since the operation. She has no pain or tensionof the belly; pulse 96.27th.-She passed five ounces of urine during the night, and

vomited once ; has no pain or tenderness of the abdomen;pulse 108. During the morning she vomited several times,and in the afternoon the sickness increased in frequency.She was ordered soap pill with opium, ten grains, as a sup-pository. After the suppository she slept for two hours ; buton waking the vomiting again returned. Without quotingverbatim from the hospital notes, it is sufficient to say that thevomiting continued more or less until she expired. The abdo-men became tense and tympanitic on the afternoon of the 28th,and she died on the evening of the 29th. From the time ofthe operation she suffered but little pain, and maintained con-sciousness to within two or three hours of her death.The following is an extract from the report of the post-

mortem examination by Dr. C’ayley:-Abdomen: There was slight general peritonitis; a little soft

yellow lymph was smeared over the coils of intestine and the

abdominal walls. It was most abundant near the incision.On the left side of the abdomen was a large oval tumour, at-tached to and apparently forming part of the left kidney, fromthe outer and lower part of which it appeared to project. The

kidney and tumour were enveloped on both sides by peri-toneum, which formed a kind of mesentery for them, so thatthey were freely movable upwards to the diaphragm, down-wards as far as the brim of the pelvis, and inwards to themesial line. The left renal artery was much elongated, andran obliquely downwards and outwards. The tumour had a

fluctuating feel. The kidney was turned so that its hiluslooked backwards and to the left, and its convex border for-wards. On making a section through the tumour and kidney,the former was found to be of the consistence of very softbrain-matter, of a pinkish-white colour, with large venoustracks running through it. It was enveloped in a fibrous cap-sule continuous with that of the kidney, from the substanceof which organ it was quite separated. The posterior surfaceof the kidney was hollowed out by the tumour, and its greatestmass lay in the hilus, which was much altered in shape; itformed a projection into the pelvis of the kidney, which wassomewhat dilated. The ureter was normal. The supra-renalcapsule was distant an inch and a half from the kidney. Thedescending colon and sigmoid flexure lay behind the tumourand kidney. The long diameter of the tumour was four inchesand a half, and the short diameter three inches and a half ;the circumference nearly twelve inches. The ovaries weresmall and tough, and much cicatrized. The uterus was ofmoderate size. The walls of the lower part of the body werevery flaccid, and the fundus was bent backwards, so as toform an angle with the lower part of the body. The rightkidney was normal. The liver also was normal. The spleenwas of moderate size, and very soft. The lumbar glandson the left side were somewhat enlarged, and infiltrated withmedullary matter. On microscopical examination, the tumourwas found to consist almost entirely of round and oval nuclei,about the size of blood-globules, with a small quantity of verydelicate fibres and long slender fibre-cells. There was no markof the tumour having been punctured.In this case the extraordinary nature and position of the

tumour are sufficient to account for the error of diagnosis.Certainly the last thing one would have expected to find onopening the abdominal cavity, would be the kidney lying asit did on the surface of the intestines. The only way in whichthe unusual position can be accounted for is, that the weightof the tumour gradually bore the kidney downwards and for-wards, and that the continued rolling movements of the intes-tines on it gradually urged it forwards, and, dragging on theperitoneum, it formed for itself a mesentery, which becameelongated as the tumour increased in size and weight. It

might be said that the mobility of the tumour upwards wouldhave determined that it was not ovarian ; but during lifemotion in this direction was limited by the transverse colonand stomach, and it was only when these were removed at thepost-mortem examination that it could be made to reach theliaphragm. So far from the kidney being suspected as theeat of the disease, the urine examined on two or three occa-sions was ascertained to be healthy, with the exception ofbeing of a low specific gravity. There was no cachectic ap-)earance nor wasting of the tissues to suggest a malignantgrowth, but the woman was well nourished and appeared inair health and well suited for an operation. The case is

mportant as it adds another fact to the history of the diffi-mities in the diagnosis of ovarian disease, and it is recordedvith the sincere hope that it may be an aid towards elucidatinghe diagnosis of tumours apparently within the cavity of the,bdomen.

Provinical Hospital Reports.SOUTH DEVON AND EAST CORNWALL

HOSPITAL.

COMPOUND COMMINUTED FRACTURE OF THE SKULL, WITHDEPRESSION OF BONE ; TREPHINING ; RECOVERY.

(Under the care of Mr. WHIPPLE.)THE following case, forwarded to us by Mr. George Miles,

the house-surgeon, is remarkable, in the first place, for thegreat height from which the patient fell without being killedon the spot; and, in the second, for the good recovery made

287

after trephining and the removal of so many fragments of bone. The fall must have been broken in some way, and thepatient thus saved.

J. M-, aged thirty-one, admitted September 25th, 1863.Family history good, yielding no evidence of any hereditary

diathesis. Patient says he has never been laid up by any ill-ness ; he is a healthy, robust-looking man. For some years Ipast he has led a very debauched and dissipated life. On the

night of the 24th he had been drinking up to a late hour, and, Ireturning home in a state of intoxication, he wandered from the road into aai adjacent field, and walked over the edge of astone quarry, falling a distance of eighty feet. He was dis-covered some hours afterwards, and brought to the hospital.On admission, a large lacerated and contused wound was

found, slightly above the left frontal eminence. On intro-ducing the finger through this wound, an extensive comn-ii-nuted fracture was detected in the frontal bone, near thecoronal suture, and somewhat to the left of the vertex, en-croaching upon the left parietal. The fragments were firmlyimpacted and considerably depressed. The patient was per-fectly conscious, there being no sign whatever of compressionof the brain. About six hours after the accident the patient,at his own request, was placed under the influence of chloro-form, and Mr. Whipple twice applied the trephine, subse-quently removing eighteen fragments of bone, which in theaggregate weighed four drachms. These pieces of bone, whencollected and accurately placed in sit-u, covered a space mea-suring 3 in. by 1 in. in diameter. The longitudinal sinus wasopened, from which a rather profuse hæmorrhage ensued. No isutures were used to the wound, a simple water-dressing alonebeing applied to it, and the shaven scalp kept cool by meansof a damp cloth. Ordered to have milk diet; perfect quietudeto be enforced; and a purge to be administered in the morning.

Sept. 26th. - Passed a comfortable night ; no noticeableheadache; face quite natural; tongue somewhat furred; pulse66, full.27th.-Some twitchings of the upper extremity were noticed

by the night nurse during sleep. Pupils natural. No sign ofparalysis. Appetite moderately good; complains of thirst. iPulse 76. Ordered an effervescing mixture of citric acid andpotash.28th.-Complains of severe pain in the head; tongue much !

furred; pulse 68. He is rather more drowsy than usual;pupils somewhat torpid on exposure to a strong light. Bowelsfreely acted upon by an aperient, affording him great relief. !

30th.-Going on favourably. Wound suppurating; dischargerather offensive. To be cleansed with a solution of Condy’sfluid, and a poultice to be applied.

Oct. 20th. -No untoward symptom has occurred; the woundis granulating healthily. Appetite good. To have the ordinarydiet of the hospital. Allowed to leave his bed.

Dec. 20th. - The wound is now healed, and the patientdeclares himself " quite well."

STOCKPORT INFIRMARY.ENTRANCE OF A PIECE OF LEAD, TWO OUNCES IN WEIGHT,

INTO THE CENTRE OF THE BRAIN ; DEATH RESULTINGTWENTY-SEVEN HOURS AFTER THE RECEIPT OF THE

INJURY.

(Under the care of Mr. J. T. PEARSON.)

THE following case is one of much interest. The particularswere forwarded by Mr. J. Peek Richards, the house-surgeon.A. B-, aged fourteen, was admitted into the infirmary

on Oct. llth, 1864, with a compound comminuted fracture ofthe skull, caused by the passage of a piece of lead through theforehead in the following manner. It appears that the fatherof the boy had taken a piece of iron piping into the smithy,and in order to seal one of its ends had poured some moltenlead down to the bottom. When his back was turned the boyplaced the piping in the fire for the purpose of melting thelead, when by some means or other the leaden plug was pro-pelled along it as if from a gun, and struck him on the fore-head. He was brought to the infirmary five hours after the acci-

dent, when, on examination, it was found that there was awound over the right eye communicating with the interior ofthe skull through an aperture in the frontal bone. A con-siderable quantity of cerebral matter had exuded from, andtwo or three small pieces of bone were found lying in, the

wound. He was semi-conscious, and when spoken to sharpl3-answered. When in bed, if the clothes were drawn offhim he quickly replaced them ; and any examination of thewound seemed to cause him considerable pain. There was no

paralysis, and the breathing never at any time became sterto-rous.

The loose fragments were removed, the head shaved, and apledget of lint applied to the wound and evaporating lotion tothe head. C’roton oil was administered, without effect ; butafter the use of two enemata his bowels were freely opened.He continued very restless during the night, continually sit.ting up and attempting to fight some imaginary foe. He onceor twice succeeded in removing the coverings over the wound,so that during the night a considerable quantity of brain-matter escaped. In the morning well-marked symptoms ofencephalitis set in; and about six o’clock P.M., or twenty-seven hours after the receipt of the injury, he died; hisrespiration for the last few hours being principally affected.His friends strenuously objected to his head being opened ;

but on examining the seat of injury, a cleanly-cut circularaperture (with no staining round about), about the size of aflorin, was found in the right side of the frontal bone, abouthalf an inch above the supra-orbital ridge. On passing a probethrough the opening to the extent of about four inches in adirection backwards, inwards, and a little downwards, a

foreign body could be felt, which on extraction proved to bethe plug of lead in question; it weighed two ounces, and wasof a cylindrical shape, a little over an inch long, with a dia-meter of nearly three-fourths of an inch, both ends being flat

like those of a drum.

Medical Societies.PATHOLOGICAL SOCIETY OF LONDON.

DR. PEACOCK, PRESIDENT.

DR. DICKINSON showed two specimens ofENTERITIS OCCURRING WITHOUT KNOWN CAUSE.

The complaint in this form, he said, is very rarely seen inpractice. One patient was a boy who was admitted into hos-pital for retention of urine, and who died with obscure swell-ing of the belly, constipation, and vomiting. On post-mortemexamination the whole mucous membrane of the large intestinewas found sloughing; there were several perforations in theintestine and pus in the peritoneal cavity. The other case,that of a young woman, was similar : the last two feet of thesmall intestine were sloughing.

Dr. DICKINSON also showed a specimen ofPERFORATION OF THE STOMACH,

occurring in a young woman who died from the effects of irri-tant poison eight days after taking it. After death, the con-tents of the stomach were found in the peritoneal cavity, anda hole as large as a sixpence was found in the stomach; butthe absence of any morbid action around the hole, and therelative extent and shape of the rupture of the serous andmucous coats, showed that the rupture had occurred afterdeath. The case was brought forward on account of its im-portance in a medico-legal point of view.

Dr. WILKS remarked that Dr. Dickinson’s first cases werealso important in legal medicine, since the occurrence of acuteidiopathic enteritis had been denied at the trial of Dr. Smethurst.Mr. H. LEE mentioned an instance in which he had found

the mucous membrane of the rectum sloughing, in a case ofsecondary syphilis.The PRESIDENT remarked that the late Dr. Baly, in his lec-

tures before the College of Physicians, had described cases ofenteritis similar to those brought forward by Dr. Dickinson.

Dr. QUAIN observed that the stomach displayed by Dr.Dickinson could not have given way by the generation of gas,had it not been previously softened by the irritant poison.Mr. HOLMES exhibited a

MALFORMATION OF THE BLADDER,in which there was a congenital cyst attached to a bladderwhich was otherwise malformed.

Dr. WILxs showed a specimen ofLOSS OF THE PULMONARY VALVES.

A man, aged thirty-one, came amongst his out-patients suffer-ing from phthisis. He had at the same time a double bruit

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