improvement, although the vomiting of large quantities of greenish fluid continued. On the 7th morning the patient appeared much better; but in the evening the pulse was 160, and she appeared almost moribund. Five grains of quinine were given every 3 hours by mouth and rectum. In 16 hours 35 grains had been given, and on the 8th day the pulse had fallen to 120. In the next 10 days she improved in many respects. There was no vomiting, but she suffered at times with abdominal pain and much flatulence. On the 19th day she appeared remarkably well; but at night, after a free watery motion, she suddenly became faint and sick, and died on the morning of the 20th day.

The wound was found firmly united. There were scarcely any traces of general peritonitis. No intestine was adherent near the wound, but one coil slightly adhered above the umbilicus. The uterus was small, and had a fibroid nodule the size of a marble projecting from its fundus. The left ovary was healthy. The pedicle of the tumour of the right ovary was closely surrounded-as shown in the accompanying engraving-by an

cavity. The canal of the adhering coil of intestine was almost completely obstructed, partly by the sharp curves at which it was fixed, and partly by the contraction of the adhering portion, the intestine above being much distended. There was neither blood, lymph, nor serum in the peritoneal cavity, nor could any tubercular deposit be found.

In all these cases the symptoms are exactly those of strangulated hernia. They may be relieved by opium or belladonna, but are almost certainly fatal if the obstruction cannot be overcome. More than once I have reopened the abdomen and separated adhering intestine from the abdominal wall and pedicle, with temporary relief, but new adhesions followed and ultimately death. I have seen several cases where symptoms of obstruction have gradually disappeared, and this has led me to wait too long in other cases before reopening the wound and searching for the seat of obstruction. In one case I might easily have saved life by separating a mere film of adhesion close to the wound, which held a piece of small intestine as sharply as a ligature. The preparation is in the Museum of the College of Surgeons.

Two woodcuts on the next page serve to make clear a point in anatomy which, from being overlooked or forgotten, has often led to difficulties in diagnosis and sometimes to dangerous proposals or mischievous practice. It will be seen by the representation of the perpendicular section of the abdomen, pelvis, and their contents, how under certain circumstances Douglas's pouch may become distended by fluid or by a mass of intestines gravitating into it. To be able to make sure of the nature of the tumefaction thus caused, and perceived during vaginal examination, requires tact and experience, and I have not been surprised sometimes to hear most erroneous speculations about it and to find myself consulted as to operative measures for its relief, under what was supposed to be the most urgent necessity. But a study of the relations of the parts will show how the presence of small intestines filled with fæcal matter and falling low down into Douglas's pouch between the uterus and rectum may simulate abscess or hæmatocele. The drawing also explains what a scope, when the expansion of the pouch has once begun, the space offers for the enlargement of a cystic tumour in that direction, and how by remaining

small intestines sinks down in the normal condition of parts between the uterus and the rectum. After ovariotomy, especially when the lower part of the ovarian tumour has pushed the uterus upwards and forwards, a considerable space is left between the rectum and uterus, and into this the small intestines fall down. I have often found them there when sponging out the pelvis. Now, supposing them to be more or less firmly fixed there by effused lymph, it is very probable that some obstruction may follow, and that a considerable swelling may be discovered behind the uterus on examining by the vagina. Rectal examination at once shows that it is between the rectum and the uterus, and probably that it is more towards the right than the left side. A glance at the second of these woodcuts shows why this is so. The rectum, containing fæces, fluid, or gas, occupies the left side before it reaches the middle line, and there is more vacant space towards the right of Douglas's pouch to admit the small intestines. There they may adhere and form a considerable swelling.

own.

Sometimes, long after recovery, more or less complete obstruction of intestine is followed by the formation of a fæcal fistula. Such cases are recorded by Lyon of Glasgow, Keith, and Bryant. Once the same thing happened in a patient of my In Lyon's case the operation was performed in February 1866, ' easily and favourably.' Hiccup and severe vomiting were present for a few days, and it was afterwards found that union of the edges of the wound was imperfect. A portion of intestine was to be seen adherent at the bottom of the wound. Pinlike perforations took place in this, and gave issue to fæcal matter and offensive gas. Various means were taken to obtain healing, but in August 1867 the wound, or rather the small exposed portion of perforated intestine, remained unchanged.

Dr. Keith operated on a patient in whom at the end of 6 weeks a pelvic abscess formed and pointed a little above Poupart's ligament. Some months afterwards there was a sudden escape of coagulated blood from the rectum, followed by a free discharge of pus from the opening in the groin. Fæcal matter soon made its appearance and continued to flow till July, when the fistula finally closed. This is the only case of the kind which has fallen to Dr. Keith, and it was also the only one

in which at the time he published the case he had returned the pedicle with the ligatures into the abdomen after ovariotomy.

Mr. Bryant's was a case of successful ovariotomy in 1867. The pedicle was transfixed and tied with whipcord; the ends of the ligatures being cut off they were allowed to sink into the abdomen with the pedicle. These ligatures were discharged some months afterwards through an artificial anus at the lower part of the abdominal wound, which in the end healed up completely.

The

The operation in my case was performed on March 10, 1864; the patient was 57 years of age. A large multilocular cyst of the left ovary was removed. pedicle was returned into the abdomen with the ligatures, the ends of which were cut off short, close to the knots. A portion of the cyst adhered so firmly in the left iliac fossa that it could not be separated, and it was left adherent, after transfixing and tying it, leaving the ends of the ligature hanging out of the lower angle of the wound. The patient recovered. But 5 weeks after the operation the ligatures still kept the lower part of the wound open, a little discharge daily escaping beside them.

On May 31 a ligature came away, the discharge gradually lessened, and the patient considered herself to be well. In May 1865 there was increase of discharge from the sinus attended with uneasiness, but not with severe pain, the odour of the discharge being offensive

not putrid, but faint or albuminous. Deep in the left iliac region was a general state of solidity of the parts, as contrasted with the opposite side.

It should be remembered that, although the ligature which had been left hanging out through the wound in the abdominal wall had come away in May 1864, there was no proof that the ligatures tied on the pedicle, and cut off short, had come away. It was thought they might be present and keeping up irritation.

After this the discharge became more abundant and decidedly fæcal, varying in quantity from day to day. But no solid fæces ever passed. She gradually became weaker, and died December 20, 1865, about 20 months after ovariotomy.

I am indebted to Mr. T. P. Teale for a report of the post-mortem examination. The fistulous opening on the surface of the abdomen was large enough to admit

moved a great many tumours of the breast and from other parts of the body every year; and I have performed a large number of plastic operations, such as closing vesico-vaginal fistula and restoring ruptured perineum, tetanus occurring only once. Then it followed the operation for ruptured perineum. In this case, and in 3 out of the 4 where it happened after ovariotomy, the patients themselves attributed the access of the symptoms to a chill. In the perineal case it was very remarkable, as the premonitory stiffness and spasms appeared soon after the removal of the patient's bed to a spot immediately beneath an open ventilating shaft. In 1 of the ovariotomy cases no note has been made as to chill; but in the 3 others it was distinctly observed that the tetanic symptoms came on after an exposure to a draught of cold air when the patients were incautiously uncovered. As preventive treatment, the necessity of protecting women after operation from currents of cold air, or chill in any way, is clearly shown. In regard to curative treatment, it is interesting to state that the only case of the 29 collected by Olshausen which recovered was that which I treated with woorara. Any one wishing to follow out this subject may refer to a paper of mine read at the Medico-Chirurgical Society in November 1859, and published in the Proceedings. In the other cases chloroform was given freely, woorara was again tried, but without any apparent good result, and opium was used. All treatment, however, was as ineffectual as it is generally found to be, except in the

very chronic cases. In 1 case I excised the remnant of the exposed pedicle and a portion of omentum which had been tied and brought out through the wound; hoping that, as injured nerves in the pedicle might be the origin of some injurious reflex action, when the cause of the mischief was taken away there would be some mitigation of the symptoms. Olshausen attributes the high mortality which he has tabulated partly to the irritation of hare-lip pins, but the greater proportion of it to insufficient tightness of the clamp, indicated by secondary hæmorrhage, so that the nerves of the pedicle were not so thoroughly crushed as to render them powerless in exciting marked reflex action. Messrs. Harris and Doran recently examined the spinal cord after the death of a woman in the Samaritan Hospital, and in their report to the Pathological Society state that they only found appearances which are seen after other diseases, such as exudations, dilated vessels, want of symmetry, and exuberant proliferation in the central canal; and they conclude that the clinical symptoms do not encourage us in the expectation of finding any specific change in the cord, though it is unquestionably the structure partly, if not chiefly, at fault. Here there was no apparent local morbid action, and, so far as my own cases are concerned, I have no reason to believe that any pathological condition connected with the operation had anything more to do with the disease than as giving the same prcdisposition which would come from a common wound.

OVARIAN tumours may not only be mistaken for pregnancy when they exist independently, but they are often complicated by its occurrence even in advanced stages of their growth. And though the diagnosis of this condition is generally to be made out by the usual order of examination, yet the complication may be revealed only at the time of the operation. Out of these circumstances several very important practical questions arise.

It may be asked, in the first place, whether in such a case it would be necessary to interfere at all, under the assumption that pregnancy and ovarian disease might go on together, and serious trouble arise only in a small percentage of cases. The early induction of premature labour has also been advocated on the grounds that rupture of the cyst, or its gangrene from rotation of the pedicle, might occur under the pressure of the