250 HOSPITAL MEDICINE AND SURGERY.

opium and aromatic spirit of ammonia were given frequently.On March 14th a line of demarcation was beginning to beformed along each series of metatarso-phalangeal joints ; theslough on the left heel had separated, leaving a small super-ficial ulcer, whilst the red patch on the right heel had com-pletely disappeared. On March 18th the phalanges of the littletoe on the left side were completely separated. On April 6thchloroform was administered and the remaining phalanges onboth feet were removed. The patient made an uninterruptedlygood recovery, except that on April 16th a small black spotwas noticed about the junction of the upper with the middlethird of the anterior surface of the right tibia. The childwas again ordered one-minim doses of laudanum and thespot disappeared in the course of a few days. On May 3rdshe was sent to the convalescent home at Broadstairs and shehas since been reported as being in London fat and well. Duringthe patient’s stay in the hospital her urine was repeatedlytested. It was usually neutral or feebly alkaline and it wasat all times free from sugar, blood and bsemoglobin. On,admission it contained some triple phosphates. On May 1st.it was acid and there was a faint trace of albumen.

Remarks by Mr. D’ARCY PowER.-This case of symmetri-cal gangrene appears to fulfil all the requirements of Dr.Raynaud. It affected simultaneously both lower extremities.It was limited to a small extent of the feet-viz., the toes.It affected many points all at once. The arteries supplyingthe affected feet continued to transmit blood. The case istherefore one of Raynaud’s disease and is of the rarer class,for it was a child, but not of the rarest class, for the patientwas a girl. In the light of Dr. Haig’s recent paper in thelast volume of the St. Bartholomew’s Hospital Reports it isinteresting to notice that the mother of the child volunteeredthe statement that before the attack the patient passed muchmore urine than usual. I did not notice any marbling ofthe skin and there was no intermittent pulse.

ROYAL INFIRMARY, NEWCASTLE-ON-TYNE.ACUTE PERITONITIS AFTER CONFINEMENT ; ABDOMINAL

SECTION ; DERMOID DISEASE OF BOTH OVARIES ;REMOVAL ; RECOVERY.

(Under the care of Mr. PAGE.)DBRMOID tumours of the ovary may be met with at all

periods of life, even beyond eighty years of age, but it is not

common to find both ovaries affected. In addition to the

cases mentioned in the remarks by Mr. Page, Dr. MatthewsDuncan has recorded a case in which dermoid cysts of bothovaries were removed by Mr. Langton. Dr. Montgomery 1removed a double dermoid ovarian cyst from a girlaged eleven; the tumour was known to have been

in existence for three years. Dr. Mundé2 operated forabdominal tumour and found a dermoid tumour of each

ovary, the right being as large as a pregnant uterusof six months. The patient was admitted with the sym-ptoms of acute peritonitis after confinement, and abdominalexamination does not appear to have shown the presence ofany new growth. The fact that such an acute inflammation,developing apparently as a consequence of parturition, maybe due to the rupture of a cyst, and not to septic infection,should be remembered. The case is encouraging to thosewho advise exploration in peritonitis after labour. For thenotes of this case we are indebted to Mr. W. H. Bishop,house surgeon.A woman aged thirty-three was admitted into the Royal

Infirmary, Newcastle-on-Tyne, on April 12th, under the careof Mr. Page, suffering from acute peritonitis with distension.The patient was confined on Feb. 1st, fourteen monthsafter marriage ; she was in labour forty-eight hours and wasultimately delivered with the forceps. Immediately afterthe birth she was seized with severe pain in the left sideand suffered from it more or less continuously for about a fort-night. One month after confinement she was able to leaveher room and a few days later went into the garden ; whilstout she had a rigor. The same day the pain in the left sidereturned as bad as ever " and the abdomen became muchswollen. Her previous history showed that she had been

1 Annual of the Universal Medical Sciences (Sajous), 1892, vol. ii.,G. 18.

2 Ibid.

exceptionally healthy and came of a healthy stock. ].struation commenced at fifteen years of age, but was irregnlaruntil she attained the age of twenty. Since then she b,1been quite regular ; the flow lasted three or four days atawas scanty. She had no pain and never passed any clots.On admission the patient, a tall woman, was somewhatdtli.

cate-looking and pale ; the face was pinched ; pulse 108, SD:!Iand thready ; respiration quiet and shallow. She had pain atitenderness all over the abdomen, but especially in the left i)3cregion. On vaginal examination a soft fluctuating swelJÌ!!gcould be felt in the left lateral fornix. The temperaturewa,1020 F. On April 13th the abdomen was opened and a quimtittof semi-purulent fluid escaped. The peritoneum was coveredwith lymph. The left ovary was about the size of a goose’seatand adherent to the intestines by recent adhesions ; it w;removed. The right ovary was about the size of a hen’s e.and was also removed. A pair of artery forceps were left on

a spurting vessel which was too deep to tie, a glass drainagetube was inserted and the wound closed. She made an uninter.rupted recovery, the wound healing by primary union through.out. The tube was removed the morning after the operationand the forceps twenty-four hours later. She left the hospih)on May 12th in good health. Examination of the ovarie,revealed an interesting condition. In the left no trace ofovarian structure was found. It was converted into a CIS!containing a large quantity of recent blood-clot and a msof coarse hair. The right contained hair, a plate of bone andfatty material ; a small portion of apparently healthy tissueremained. Both tubes were apparently healthy.Remarks by Mr. PAGE.-In Mr. Bland Sutton’s work on the

Surgical Diseases of the Ovaries " three cases are cited nyMr. Thornton, Dr. Bantock and Dr. Culling worth where bothovaries were removed in consequence of their being the seatof dermoid disease. Two of the women were pregnant at thetime of the operation, the third was the mother of twelvechildren. The case now reported is further interesting fromthe circumstance that the operation was performed with asuccessful result whilst the patient was suffering from asevere attack of acute peritonitis. I am of opinion that tnerecent blood-clot found in the left ovary was probably due to

injury during delivery.

BURTON-ON-TRENT INFIRMARY.PLASTIC OPERATION ON THE LEG

(Under the care of Mr. P. B. MASON.)THE plastic operation in this case, which was performed

after the method known as the Tagliacotian, appears to bavî

fulfilled in every way the object of the operator. The graitwas obtained from the opposite leg and the necessary qcif!ensured by keeping the limbs closely fixed by means of

plaster- of-Paris bandages. The patient, a young woman, waiunusually well-adapted for a plastic operation on the 10w(1extremities, much more so than the majority of those subjectto the formation of ulcers from the effects of injury sdisease, for her general health was good and the tissuearound were not affected by the results of chronic in8ammation. It was, moreover, possible to obtain asepsis fionthe first in a wound which was in both limbs entirely undrtthe control of the surgeon. For the notes of this case aare indebted to Mr. R. Meredith Littler, house surgeon,A servant aged twenty was admitted into the Burtot-

on-Trent Infirmary in November, 1890, suffering from .severe attack of typhoid fever, with at one time copior,bsemorrhage from the bowels. She was not finally dischargeduntil April 23rd, 1891. During her illness she suffered Mgreat swelling of the legs, which was supposed to be ?to obstruction of the lymphatic system, and cold abscessformed in various parts of the body which were opeCtdand drained. One in particular formed over the anterr’internal aspect of the right leg. This healed beforedischarge, but the scar has remained ever since, beir:prone to ulcerate and break down on the slightest ire"tion. Rest in bed always sufficed to ensure gradual hearwhilst just as surely the tension and irritation of wallérior getting about her occupation caused the scar ti z’

to break down again. Under these circumstances it ’decided to attempt the transplantation of a portion of .%from the calf of the opposite leg. This was done ,;

April lst, 1893. The old scar tissue was first of all cutscraped away from the site of the ulcer and for some ?’-’