disturbance at any individual time that no crisis had been developed, yet the accumulated free blood, which had gravitated to the pelvis, had become considerable, since probably two quarts of old blood clots were removed in the course of the operation. The particularly interesting phases of this case, are, first, the mistaken diagnosis, and then the complete demonstration to the eye of a condition which is, undoubtedly, quite common, but almost never seen in the stage of development as shown in this case. There is no doubt that in the history of the case the confessed attempt at a procured abortion had been misleading.

The operation consisted in the removal of both tubes and ovaries, as well as the appendix, the latter having been drawn. into the adhesions. This case made an interrupted recovery.

The second case was that of a woman, 32 years old, who had had one child 10 years before. She had a hard time of it, was badly torn and repaired at the time. One and a half years after the child was born, and one year subsequent to that, she underwent two procured abortions, and was curetted after the

Fractured arm.

Plate IV.

first one. Ever since then the left ovary has been very sensitive for five or six days following menstruation. Menses were regular, lasting five days, and usually uncomfortable only on the first day. The left side, however, has been very tender, especially so to external touch, and she was obliged to give up all active duties. She became very low-spirited and depressed, and held herself aloof from companionship, which was very contrary to her nature. There was no leucorrhoea, except, during acute attacks, a watery discharge was noticeable on arising in the morning. Urination was very frequent and she was up at least once every night. Examination discovered a large fluctuating growth on the right side. The left side was so tender that nothing could be made out by palpation, and a diagnosis was made of cystomata ovarii, double; appendicitis, intercurrent.

At the operation, upon opening the abdomen in the midline, an ovarian cyst of the right side was easily demonstrable. This was tapped and fluid was drawn off to reduce its size so that

it could be brought through a comparatively small opening. The left side showed a very much enlarged and somewhat bound-down cystic ovary which, together with the tube, was so far damaged that it was decided to remove both tubes and ovaries on both sides, which was accordingly done.

This patient made an uninterrupted and satisfactory recovery.

The case was interesting as showing the earlier stages of what would have undoubtedly become a large ovarian cyst if left to itself, and as typical of a class of cases which cannot be adequately treated except by operation, and which, if taken at a proper time of election, prove very simple.

The third case was that of a woman, 45 years old, who had two children, then a miscarriage 13 years ago followed by another child, which was delivered very rapidly and forcibly, resulting in extensive lacerations. Five or six years ago she began to wear a support to keep up the parts beginning to protrude from the vagina, but with not much satisfaction. Up to

Shows the bone one month after operation. Although the arm and shoulder were immobilized all this time, something-perhaps the development of callus-has turned the free end of the wire downward through an arc of about 35 degrees. Functional and surgical result perfect.

two years ago she had lived in the country, but at that time came to live in the city. This resulted in increased activity on her part on account of the stairs, and led to a procidentia of the uterus which has now persisted for a year. Urination is very frequent when on her feet, but is relieved when lying down and the protuberant parts recede. All discomforts are worse when in an upright position. She has been told she has diabetes, although at the present time the urine is not excessive in quantity. Menses regular and without discomfort. Examination shows a large abdomen with the uterus lying completely outside the relaxed vaginal outlet when standing on her feet. When she lies down this partially recedes until only the elongated cervix lies without. This is eroded and irritated, has been extensively lacerated and subsequently inadequately repaired; it had been decided the best operation for her would be a vaginal hysterectomy with a narrowing of the vagina and a restoration of the perineum.

She came to the hospital in the afternoon of June 3, and an examination of the urine on the morning of June 4 (the day of the clinic) showed such a large quantity of sugar in the urine that her case was deferred for observation, since it has been well demonstrated that diabetic cases do not satisfactorily undergo operation. She was kept in the hospital eight days for observation, and then sent home for further observation and treatment, with the understanding that if the sugar be reduced sufficiently to make it safe, she should come back and the operation be undertaken.

This case is not without its lesson to the general practitioner inasmuch as the mechanical indications for operation were unquestionably clear and well defined, yet the patient's general condition proved absolutely prohibitive.

The fourth case was of the greatest interest to us and those about us, because we had her under observation for about a week, giving her unusual attention because we wanted to hold her over for this clinic as a typical case of its kind. The patient was a married woman, 22 years old, who had had three children and one miscarriage. Last March she had an abortion performed. and again on May 15, since which time there had been a vaginal discharge with epigastric pain extending to the right nipple and scapula, suggesting gall-stone colic. The diagnosis of gall stones, however, was not considered for a moment. The pain had been very severe for ten days preceding the time of operation, and on the Sunday before she had had a very severe chill accompanied by increased pain. Following this she was a little. better, although sometime in almost every twenty-four hours there would be a rather critical time of increased pain, with marked rise in temperature and pulse and a chilly sensation. This was so severe on the night of the preceding Thursday (48) hours before the operation) that the question of operating immediately was seriously considered; and the night before the

day of operation she again had a very severe chill, with increased pain. Several examinations demonstrated exquisite tenderness through the pelvis and lower abdomen, always much worse on the right side and over the appendix. There was no difficulty in recognizing the condition here as one of acute infection of the tubes following a procured abortion; and long ago the writer had solved the problem of what should be done in such cases. Nothing short of an abdominal operation will give safety. In the present case, again was it possible to demonstrate to the eye exactly what was taking place in the pelvis and lower abdomen. Upon opening the latter the pelvis was full of tissues adherent to each other. These adhesions were found to be recent; that is, they had undoubtedly taken place during the recent attack for the reason that they could be separated with the greatest facility. No force whatever was required to separate adjacent tissues, which were simply stuck together; and out of the mass of adhesions, the tubes were enucleated intact and brought into vision. In such cases, one is at first surprised at the comparatively slight evidence of the seriousness of what is taking place. The tubes are not much enlarged, nor are they actively inflamed. They are, however, rather flaccid, yet upon taking them into the hand and gently milking toward the fimbriated extremity, a thin, discolored fluid can be demonstrated exuding from the open end; and this fluid is the cause of the extension of the infection to the peritoneal cavity.

As the secretion within the tube accumulates it is retained until sufficient tension is created to force a portion of it from the open end of the tube. This causes an acute attack of localized peritonitis, shown by the sharp exacerbation of pain, nausea and vomiting, chill, etc., occurring at varying intervals. In the present case, one of these attacks occurred about once in every twenty-four hours. The result of these repeated attacks is to cause adhesions of all structures adjacent to the tube and parts affected by the exudate, thus walling off the infected area. Such a case, if left to itself, finally develops into the well-known chronic pus tube. In this case the operation took place before the complete isolation of the tube by adhesions, although the latter were in process of formation, and it could be demonstrated to the eye in the acute stage of development, which is rather an uncommon experience. Infection had undoubtedly been the result of the abortion. In the cases which so quickly threaten, and even cause the loss of life, the manner of infection is quite similar to this, the difference being that the form of infection is more virulent or the attempt at walling off is unsuccessful and a more rapid general peritonitis results.

Both tubes and ovaries were removed, together with the appendix, and the uterus was suspended.

The fifth case was of a child, ten years old, who had fallen backward from a seat on, and into the body of an ice-wagon a