matter was reduced to this, could a tube of so small a diameter, that an ordinary probe could not be passed along it, and in which there was no evidence of previous dilatation, permit of such a flow of fluid along it as to cause the rapid diminution which took place, especially on the last of the two occasions? His opinion was, it could not. He could see no other way in which it could be removed but by the kidney. He referred to the observations of Sir J. Y. Simpson, Hewitt, &c., on the removal of ovarian fluid from the peritoneal cavity, but remarked that their observations were not applicable to the case before the Society, for in it there was no account of such a train of symptoms as accompany the sudden rupture of a large ovarian cyst, and the extravasation of its contents into the peritoneal cavity; and what was even more important, there was no trace in the walls of the cyst of rupture having occurred. Dr. Thomas Keith had kindly examined the preparation, and was also of opinion that no rupture had oc curred. He had seen several cases of a somewhat similar kind to that of Miss M. O., and had observed decrease of size, and its subsequent increase. The conclusion Dr. Ritchie came to was, that the fluid had been in some way absorbed from the cyst directly, and without the intervention of rupture. In the cases in which Dr. Keith had observed a similar decrease, the fluid, as in Miss M. O.'s case, was clear and thin. Dr. Ritchie thought it was possible, and he might even say probable, that an endosmotic change had taken place by means of the large vessels, to which allusion was made among the post mortem appearances. This was favored by the extreme thinness of the posterior wall of the cyst, which was quite transparent, and by the limpid character and low specific gravity of the contained fluid. In such a view, it would be expected that when the distention of the cyst was greatest, the walls therefore thinnest, and the surrounding blood-vessels most stretched, that the transmission of the fluid would most likely commence; and referring to the case, it would be observed the decrease in size in the first instance began when the greatest distention had been attained, and the increase began when the reduction had reached sixteen inches. In the second instance the reduction commenced when the circumference had reached forty-nine inches; and when the lowest measurement of thirtyfive inches was arrived at, the cyst reversed the action, and again filled. It would be instructive to have his view, on the one hand, confirmed, or, on the other, to have a more satisfactory explanation of the phenomena. He had only further to add, he understood Dr. Keith to say he had rarely seen so small a pedicle, and that the case would have been an excellent one for operation.'

CASE OF EXTRA AND INTER-UTERINE FŒTATION OCCURRING CONJOINTLY; WITH OPERATION THEREFOR, RESULTING IN THE DEATH OF THE MOTHER, AND THE SAVING OF TWO LIVING CHILDREN. By DRS. JNO. W. MOORE and E. PAUL SALE, Aberdeen, Miss. Reported by E. PAUL SALE, M.D. (New Orleans Jour. Med., Oct. 1870.)

Dr. MOORE was called, February 11th, 1870, to attend Mary Ann, negress, æt. 22, unmarried, a cripple from atrophy of muscles of left leg; by occupation a seamstress. Herself and parents (with whom she lived) represented that she had been "tricked" by a negro man, and had a large snake in her abdomen, which was easily felt through the integuments. The

movements of this snake caused great pain, as though it were coiling around her "insides."

On examination, a large tumor was found extending over the lower part of the left hypochondriac, part of the umbilical and left lumbar regions, and encroaching somewhat upon the boundary of the hypogastric. Through the parietes of the abdomen the outline of a foetus could be felt, supposed to occupy the left ovary. She was suffering great pain, and her nervous system was seriously deranged. Pulse, 115; bowels obstinately constipated; appetite poor; she slept but little, and was much prostrated.

Dr. Moore visited her daily until March 2d, and her condition becoming alarming, he requested a consultation with me. (Here the report continues from my personal observation of the case.) I had heard of this patient some weeks before I saw her, from negro patients, who reported her being "voudoued" by a noted negro man in the country. I was requested by Dr. Moore, who purposely withheld his diagnosis, to go over and examine the case, and report my diagnosis to her parents to be compared with his. I did so, and concurred in toto with him.

The normal weight of the patient was about 110 or 115 lbs.; at the time of examination she was rather anæmic and slightly emaciated; her eyes sunken; respiration, 37 per minute, and not prolonged. Her tongue was small and dry, furred with a coating approaching brown. Pulse, 135, small and weak; temperature 971°. Her replies to questions were delivered in rather a faint tone, and were interrupted by paroxysms of pain, which surprised me in intensity, considering her exhausted condition. Upon exposure, I found the tumor situated as Dr. Moore described, except it occupied a position more towards the mesial line, the contour of the abdomen being prominently pointed and turned to the left side. Whilst viewing the shape, and determining the position of the tumor, I felt a contraction of it, and the outlines of a foetus could be distinctly felt. Examination per vaginam revealed a hot and dry vulva and vagina: the os not at all dilated, cervix elongated. I tried by conjoint manipulation, to get at the size of the uterus, which could be felt, but imperfectly, it appeared hard as far as felt, and its exact outline could not be determined.

I

She stoutly denied having had intercourse with a man, and a confession could not be extorted from her by any means. was informed by Dr. Moore and her mother that contractile pains had existed for four or five weeks, and that she had been

instructed by a negro midwife, whenever they came on, to stand, or sit if unable to do the former, and press upon the tumor from above, downwards, to prevent the snake crawling to her throat. This advice had been followed steadfastly by her until her strength failed her, and she was then assisted by sympathizing relatives and friends.

The next thing was the means of relief, and Dr. Moore and myself took into consideration the following points. The woman is evidently the subject of an extra-uterine fœtation. She had had contractile pains for at least four weeks. She is becoming rapidly exhausted, and if nothing is done, death must soon take place. There is no chance for the fœtus to be resolved into pus or a calcareous mass. The contraction cannot be controlled, and consequently there is danger of rupture and internal hemorrhage. Ovariotomy affords the only hope for saving either the mother or child. Another physician was called in consultation, but we failed in obtaining him. finally concluded to operate, and give the woman her only chance, and the possibility of saving the child. The necessary arrangements could not be made that day, and after seeing her again that evening, we concluded to operate next morning.

case.

We

Additional medical assistance was desired, but we again failed in obtaining it, and had to rely upon two intelligent unprofessional men, one of whom became suddenly indisposed in the midst of the operation. This inconvenienced us very much. At the request of Dr. Moore I performed the operation, selecting the method described by Prof. T. G. Thomas.* The incision was made more to the left to suit the individual After cutting through the abdominal walls by successive incisions, I came upon a hard, and somewhat glistening tumor. I then attempted to determine whether it was intimately connected to the uterus, by an assistant moving it up and down while my finger was in the vagina upon the os. It moved slightly, but not enough to consider it directly attached. Next, as to whether it was ovarian or tubal, and I must confess the emergency of the moment precluded my making an extended examination. Since thinking of it, though, my impression is that it was ovarian. I desired to cautiously incise the tumor, but the envelope was so thin and tense, that upon the first cut of the scalpel a gush of blood escaped, succeeded by a part of a sarcous mass, which was soon discovered to be a placenta. The opening was immediately enlarged, and the

* See his work on Diseases of Woman.

placenta, with a living child, extracted. The sac rapidly reduced itself in size, and allowed the uterus, which it had almost entirely overlain, to be felt. To our great astonishment it was found to be large and globular, as if impregnated. I stated to Dr. Moore my suspicions about it, and a hasty consultation was held whether to suspend the operation and try to deliver the child per vaginam by dilating the os, or make one operation do for both. The latter was deemed advisable, and hysterotomy was performed, which resulted in the extraction of another living child and placenta. The abdomen, cyst, and uterus were cleansed of all coagula, and the wound closed. A sound was passed with some difficulty through the os to allow the discharges to pass through. During the manipulation the hands were from time to time dipped in artificial serum, and all precautions were observed as best we could under the circumstances. I neglected to mention, in connection with the operation, one important item. Bearing in mind her extreme asthenic condition, and liability of sinking under the operation, we administered before operating 3iv. of brandy, and in the midst of the operation an injection of carbonate of ammonia, which was followed, after the patient was about to be placed in bed, by mxl Battley's Sedative in 3ij. more of brandy. As the result of it she was taken from the operating table with a better pulse than when she was placed on it. Reaction occurred, and she expressed herself as feeling pretty well, and her conversation almost approached a cheerful tone. Dr. Moore took charge of the after treatment, which was large doses of morphia, nutritious diet, stimulants, aud wound dress with a solution of carbolic acid; and reports as follows:

66

155:

66

66

7th, 9 A. M. Sanious discharge from wound: complains of severe pain in arms and breast. Died of supposed septicæmia, at 3 P. M., same day. At time of this writing, April 15th, children doing

well.

Her condition was so favorable on March 6th, when I visited her, in consultation with a surgeon of note, Dr. James M. Green, of Aberdeen, that we thought it more than possible that she would recover. On account of the degree of superstition which is held by freedmen in regard to their dead, no post mortem was allowed.

In presenting this case to the medical public, I regret very

much that more complete observations were not made; but the emergency of the moment, lack of competent assistants, lack of surgical conveniences, and entire inexperience in abdominal sections, are excuses I offer in extenuation of this seeming remissness; and I will also state that the patient as well as ourselves, lived in the country, and the subject of the operation lived three miles from Dr. Moore and ten from myself, over almost impassable prairie roads during the winter and spring months; and it so happened at the time of the occurrence, both of us were actively engaged in professional duties. It is greatly to be regretted that an autopsy was not allowed to reveal the anomalous and pathological condition of the parts.

Two CASES OF VAGINISMUS RELIEVED BY OPERATION.-By A. WOOD SMITH, M. D., Glasgow. (Glasgow Medical Journal, November, 1870.)

THE Condition of the vagina, to which the term vaginismus has been applied by Dr. Marion Sims, of New York, has hitherto been little noticed by obstetric writers, and yet there is reason to believe that it is not of unfrequent occurrence in a greater or less degree. The disorder may be shortly defined as a painfully sensitive state of the vaginal orifice, attributable to the hymen, and preventing by spasmodic closure either a digital examination or sexual congress.

An approach to vaginismus exists more or less in all virgins, and may not prove a barrier to impregnation, as accoucheurs must occasionally have discovered during the early stage of labor. A few weeks ago, in a primapara, I found the hymen unruptured and the vagina so sensitive and an ordinary examination 30 unbearable that I gladly desisted until chloroform was administered in a later stage.

It is often a considerable time after marriage before relief from this state is sought, as from motives of delicacy or artlessness the patient is apt quietly to endure the suffering, and attention is drawn to it generally through a train of nervous symptoms being engendered. Vaginismus is not inflammatory in its character, although it may create or be accompanied by this condition, acutely or in a chronic form, in the vagina, over the os uteri or in the ovaries. It is, however, always characterized by hyperesthesia of the vagina, chiefly limited to the orifice and hymen, and by a contracted condition of that canal, either structural or functional, produced by the presence, in whole or in part, of the hymen, or such spas