were patches of softened, cheesy, yellowish-white material (like smegma). The opening in the cyst wall was held up to the abdominal incision, and the contents evacuated by means of the hand and ovum forceps. The cavity was then irrigated with boric acid solution, and dried with sponges on holders, the wall of the adventitia being at the same time cleaned of the softened deposit by means of the sponges. The cyst was about eight inches-vertical measurement—and contained ninety-two ounces altogether. After the pseudo-cyst had been well cleaned, it was dropped back, no sutures being introduced to bring the edges of the opening together. The sponges were then removed from the surrounding area, vessels secured by torsion and ligature (catgut), and the abdominal wound closed by means of seven sutures of silkworm-gut passing through skin, muscle, and peritoneum, inserted with a straight French needle, and superficial horsehair sutures. The part was then dressed with boric powder and perchloride gauze. A couple of strips of Mead's plaster were fixed over the gauze, to take off some of the strain in the event of the patient vomiting, and cotton wool (absorbent) and a binder applied over all.

September 3.-Temperature 98.4°; pulse 112, small and compressible; tongue dryish and brown. Vomiting commenced seven hours after operation and continued at about hourly intervalsprincipally bile. Very thirsty; has some pain at the site of incision; abdomen generally soft and flaccid, no distension; abdomen heaves with respiration; urine was passed naturally immediately after operation, but has had to be drawn off since; bowels not open. Fed by enemata of brandy and beef-tea every three hours, and milk suppositories. B Ac. carbol. 1 gr., chlorof. m. iv, S.V.R. 3 ss., aq. ad 3 ss.

8 p.m.--Vomiting had been less from 11 o'clock to 3.30 p.m., then commenced again, vomited three times before 7 o'clock, once severely. Vomit comes up without effort on the part of the patient, and still bilious in character. Temperature 98.6°; pulse 116, volume fair; respiration 18; tongue dry, brown; very thirsty; no distension; no general tenderness; knees not drawn up.

12 p.m.-Distended; abdomen tympanitic; in great pain; tenderness well marked, principally confined to left side; knees drawn up. Temperature 98:4°; pulse 120; respiration 33. Tongue very dry. Has not vomited since 5 o'clock. No discharge coming through the dressings. To have turpentine enema.

September 4.-Temperature 99.4°; pulse 130, small; slight amount of fæces and flatus came away after enema. Vomited twice this morning before 10 a.m., dark fluid not offensive; distension increased; urine drawn off, good quantity secreted— twenty-four ounces in twelve hours, clear, and quite free from albumen.

12 a.m.-Temperature 97°; pulse 130, better volume; pain and tenderness on right side as well as on left; distension less; an enema of turpentine administered; rectal tube inserted and large amount of flatus escaped. B Hst. mag. sulph, acid 3iij, hourly. 4.30 p.m.-Temperature 98.8°; pulse 140; not complaining; has vomited after medicine twice, large quantity of dark fluid; distension increasing; bowels not yet open; champagne ordered, and hypodermic of strych. gr., and morph. gr. †, administered; turpentine enema repeated.

September 5.Temperature 98.4°; pulse 146, and weak; has been vomiting everything; vomiting has taken gushing character, dark fluid, not offensive. Abdominal distension increasing, not relieved by rectal tube or enemata; slept very little; hyp. of strych. gr.; R Cerii. oxal. gr. v, ft. pil. Wound examined— edges look fairly healthy, although not united; very little dark discharge present on the dressings, but no further escape on introduction of a probe and separation of the edges; no pus; no dulness to be obtained-note being every where tympanitic. R Hydrarg. subchlor. gr. x, ss.; powder not retained. Died at 6-p.m.

Post-mortem by Dr. C. H. Mollison, Assistant Pathologist. On opening the abdomen, the intestines were found greatly distended and coated with recent lymph. The peritoneal cavity contained a quantity of grumous-looking fluid. The sac cavity, left after the removal of the cyst, lay at the back of the abdomen, the edges of incision showed no signs of union either to each other, or to other structures; the incision communicated with the general peritoneal cavity, and was not near the parietal wall, but in apposition with intestine. The cyst-cavity contained some bloody fluid which did not completely fill it. There was no pus present. No trace of any other cyst could be found in the liver. The chest was not examined.

4

NOTE. At the August meeting of the Medical Society of Victoria, and at the last meeting of the Victorian Branch of the British Medical Association, the intra-peritoneal method of

treating hydatid cysts was discussed, and difference of opinion was expressed as to what happened when the cyst was dropped back. The above case has therefore been reported at some length. The peritonitis was apparently septic, and the same result might have followed any method of operating, but the case shows that the cavity left after removal of the cyst may contain fluid, and yet need not come into apposition with the abdominal wall.

ST. VINCENT'S HOSPITAL, MELBOURNE. Two Cases in which an Erroneous Diagnosis of Ascaris Lumbricoides was made.

Reported by S. D. READ, M.B., Resident Surgeon.

In view of the numerous symptoms that are variously ascribed to the presence of the ascaris lumbricoides in the intestinal tract, the following two cases, the one of intestinal obstruction, the other of hydatids, are of interest in exemplifying how an erroneous diagnosis may be made by attaching too much importance to the discovery of the presence of this parasite, when it may be merely coincident with the malady which is really causing the symptoms.

CASE I.

G. M., æt. 20, admitted June 3, 1895, under the care of Dr. Morton. The patient, while on a visit to her sister, who was a surgical in-patient of the hospital, was seized with sudden violent abdominal pain, and after a little while became somewhat collapsed. On the evening of admission, in addition to the pain, she suffered from a good deal of vomiting. She passed a very restless night, and the following day, during one of the attacks of vomiting, she threw up a large round worm. The condition of the patient was then ascribed to ascarides lumbricoides. Purgatives and santonin were administered, but did not result in any relief, and though the administration of copious enemata was added to that of the purgatives, no action of the bowels was effected. On the day following a second worm was ejected during the vomiting, and the patient complained of a sensation as if a worm were present in her throat, in addition to the abdominal pain. On the fourth day the vomiting assumed a fæcal character, and it was decided to wash out the stomach, which was accordingly done with a

solution of boric acid and bicarbonate of soda; the washings being very offensive. Subsequent to this procedure the patient obtained some relief, and passed a much better night, and the night nurse in attendance also reported that the bowels acted after an enema, which had been administered to supplement purgatives. The irrigation of the stomach was continued on the two following days, the washings still being of an offensive character. There was no in further action of the bowels, and on the sixth day the abdomen, addition to the tenderness which had previously existed, now began to distend. On the seventh day the tenderness and distension had increased, and it was resolved to resort to surgical interference, but the patient now began to sink rapidly, and died on the morning of the eighth day.

At the necropsy, the retro-peritoneal glands were found to be enlarged and, in some cases, caseous. A large loop of the ileum had been forced through a small band of adhesion of apparently considerable standing, and had become completely strangulated with consequent intestinal obstruction.

No history of any preceding attacks of peritonitis could be obtained from the sister, who said that the patient had always been healthy, though of late she had appeared somewhat pallid, and had complained of a somewhat voracious appetite. A point of some interest in connection with this case, though as yet it fails to throw any light on the obscurity of origin of this parasite, is the prevalence of the ascarides in several members of the family of the patient. The mother, two of the sisters, and a child of one of the sisters have, at various times, either vomited or passed by the bowel round-worms, one of the sisters having thus got rid of a large number of them at different times. The family live about seven miles from the sea, in a hilly locality. Rain water is used for drinking; there are not many dogs in the neighbourhood, nor, as far as can be ascertained, are the family in the habit of consuming vegetables grown in water, such as cress.

CASE II.

Mrs. W. W., admitted to the hospital, August 9, 1895, under the care of Dr. O'Sullivan. She complained of severe pain in the epigastrium and inter-scapular region, more severe at some times than at others. When the pain was most severe, it was accompanied by vomiting of greenish, bitter, gelatinous fluid. The urine was very dark coloured.

On examination, the patient was found to be well nourished, but deeply jaundiced; just below the region of the gall bladder was a hard spherical tumour, and to the left of this, on a somewhat higher level, a second somewhat smaller tumour.

Previous history.-Was healthy up till a short time previous to marriage, seven years ago, when on one occasion she suffered from a severe attack of pain, attended with vomiting, but which attack, she said, lasted for a few minutes only, was then quite free from pain for about three years. During the three years following, she suffered from occasional slight attacks of pain in the same regions (epigastrium and between the scapula). Has had three children, the youngest being seven months old. During the third month of the last pregnancy, she was attacked with similar pains. There were several very severe attacks which lasted for periods varying from a few hours to three or four days. She said that there was no pain in the lower abdomen, though the abdomen used to swell. In the sixth month of pregnancy, during one of the paroxysms of pain and vomiting, a large ascaris lumbricoides was vomited, and from that time the patient obtained relief. The condition was accordingly ascribed to the presence of the ascarides. However, about three months after confinement the attacks returned at intervals, and it was in the one preceding her admission to the hospital, when she said that she became jaundiced for the first time, that the tumour in the right hypochondrium was discovered by her medical attendant.

Operation revealed a large hydatid cyst, with an hour-glass constriction dividing it, the adventitious wall of the smaller sac being calcified. Evidences of former attacks of localised peritonitis were present, in the form of thickening of the peritoneum and adhesions between it and the cyst. The latter was opened through one of the peritoneal adhesions (the peritoneum being closed by suture where it had been opened at a non-adherent site), the contents thoroughly evacuated, the endo-cyst removed, and the ecto-cyst treated by Lindemann's method. The patient made a good recovery, and was discharged a month after operation, when the cavity had almost granulated up.

Dr. A. H. Horsfall, M.B., of Melbourne, late of the Melbourne Hospital, has been appointed resident medical superintendent of the Newcastle Hospital.