Her temperature was 991° F.; pulse rather frequent and weak; no appetite; bowels regular, but pain with stools. She said she noticed lump in left side of abdomen shortly after supposed miscarriage in June, and this lump had been increasing in size since.

Examination of Abdomen.-A lump could be felt in hypogastric region, just above the pubes, extending from a little to right of median line outward on left side above Poupart's ligament nearly to crest of ilium, and upward in median line halfway to the umbilicus. It had something of the feel of a pregnant uterus displaced to left side, but not the regular outline of pregnant uterus. Keeping hand on lump for some time, distinct contractions could be felt, like intermittent contractions of pregnant uterus. Patient herself could feel a “hardening-up, of lump," as she expressed it, at intervals. The lump was close down behind pubes and Poupart's ligament, on left side. By dipping fingers down between it and pubes it could be lifted up and brought more toward median line. Pulsating vessels could be felt on its surface on pressure. It was tender on pressure and lifting it up caused pain. Auscultation negative.

Digital Examination per Vaginam.-Cervix pointing forward against anterior vaginal wall; soft feel; os open, admitting index finger nearly to os internum; body of uterus turned back and to left side. A little to right of body, low down, right Ovary could be felt quite distinctly, somewhat enlarged and tender on pressure, but movable. In front of cervix and body, separated by a narrow sulcus, a rounded, rather soft, somewhat elastic lump, which resembled somewhat in feel anteflexed body of pregnant uterus, projected downward close to anterior wall of vagina between pubes and cervix. Bimanually this lump could be felt extending outward to left and upward half-way to umbilicus. The entire mass appeared to have a close connection with uterus above and to left. It could not be separated from uterus. When lifted up, the uterus moved with it, cervix being tilted forward and body back. Mucous membrane of vagina and cervix was bluish in color, and bloody discharge oozed from os. Breasts were enlarged and contained milk.

From history and examination it was difficult to say whether the case was one of extra-uterine pregnancy or pregnancy in one horn of a double-horned uterus. Another question that required answering, if patient were pregnant, was whether

fetus was dead or alive. I urged her to enter hospital at once, where I could have her under observation for a time, but she said she could not do so for a week or two.

August 7th, with her physician, Dr. McNeill, I examined patient at her own home under anesthesia, but was not able to make out anything more definite than at previous examination. At this examination, however, I passed sound into uterine cavity and found that it went back and to left two and a half inches. I also passed sound into bladder and found that it lay under the mass in front. Pains and discharge had continued about the same since previous examination.

August 17th: Has been in St. Joseph's Hospital since August 14th; thinks abdomen and breasts have increased in size since last examination; thinks she has felt life. Examination.Lump larger; intermittent contractions distinctly felt through abdominal wall. Dr. Ferguson, who was with me at this examination, could also feel intermittent contractions distinctly. Breasts larger than at previous examination and contained milk. Discharge continues about the same. Pains less, and feeling much better generally. August 21st: Dr. Eccles, who was with me when I examined patient to-day, could also feel intermittent contractions distinctly. August 31st: Since August 21st has had occasional pretty strong pains, like labor pains,

accompanied and followed by some discharge. Breasts arė getting flabby. Lump has diminished in size, feels harder and less regular in outline, and has sunk lower in pelvis. Intermittent contractions not felt.. September 21st: Since last examination discharge less constant, but lochia-like odor and other characters the same. Occasional pains like labor pains. Very slight reduction in size of lump. No elevation of temperature, and general condition good.

Operation September 21st, 9 A.M. Long median incision. No parietal adhesions and no difficulty getting into peritoneal cavity. Came directly on mass in front and to the left side;

FIG. 2.-From plaster cast of tubal pregnancy. Posterior view.

adherent omentum and coils of intestine covering lump; some small blood clots amongst adherent coils of intestine and in front between lump and bladder. I separated adhesions down behind lump with fingers till I could feel fundus of uterus, which was retroverted and to the left side, lying under lump. I could then feel that lump was largely dilated, left tube twisted on itself and lying above and in front of uterus. I did not have much difficulty in shelling it out and bringing it up into abdominal wound. There was a very good broad-ligament pedicle, which I ligated with Staffordshire knot, and removed the lump without rupture. Right tube was apparently healthy, but right ovary was cystic, with only a thin shell of ovarian

tissue forming wall of cyst about the size of an English walnut. On account of diseased condition I removed it with tube also.

Examination after removal showed whole tube on the left side very much dilated, with wide, pouch-like dilatation of fimbriated extremity, and with ovary flattened out and plastered over fimbriated end like a cap, covering in and closing peritoneal orifice. The appearance of dilated tube with ovary plastered over fimbriated end is shown in illustration. The dilated tube, before opening into it, measured from uterine cornua to ovary twelve inches; wide, dilated pouch measured eight and one-half inches in circumference. On opening into dilated tube I found ponch-like dilatation filled with about ten ounces of liquid blood and soft blood clot, while that part of tube nearer uterus was filled with placenta and some tarry, jelly-like blood having the same appearance and odor as that discharged from vagina. No trace of fetus could be found; it had evidently been digested and absorbed.

It is quite probable that in this case the gestation sac in tube had ruptured and fetus had been expelled through peritoneal orifice of tube into peritoneal cavity about the end of second month and had been digested. Peritonitis with adhesions closed the fimbriated end and plastered ovary over it. Hemorrhage continuing at intervals caused dilatation of this end of tube into wide pouch shown in illustration. It was this pouch-like dilatation that could be felt from vagina behind pubes and Poupart's ligament. The uterine orifice of tube being open, some of the blood found its way into uterine cavity by peristaltic contractions of tube. This would account for the daily discharge of -jelly-like blood. The increase in size for a time after I first saw patient can be explained by exudation from peritonitis and slow hemorrhage going on in tube; the diminution in size later on, by absorption of exudation and effused blood.

Peculiarities.-1. Situation above and in front of uterus, between it and pubes, the usual situation being behind uterus.

2. Uterus being retroverted behind mass and on same side, instead of being displaced to opposite side.

3. The intermittent contractions, which were so like contractions of pregnant uterus as to lead one to think it a case of pregnancy in one horn of a double-horned uterus.

So far as I can find from literature at my disposal, the situa

tion of tube sac, above, in front, with uterus back and on same side, is unique.

Remarks. No flushing or drainage was used in operation. Wound healed by first intention, patient making an uninterrupted recovery, temperature never reaching 100° F. She left hospital, feeling quite well, between three and four weeks. following the operation.

331 QUEEN'S Avenue,

TRANSACTIONS OF THE

SOUTHERN SURGICAL AND GYNECOLOGICAL ASSOCIATION.

ABSTRACT OF THE PROCEEDINGS OF THE SIXTH ANNUAL MEETING, HELD AT NEW ORLEANS, LOUISIANA, NOVEMBER 14TH, 15TH, AND 16TH, 1893.

First Day-Morning Session.

The President, DR. BEDFORD BROWN, of Alexandria, Virginia, in the Chair.

An

ADDRESS OF WELCOME

was delivered by DR. ERNEST S. LEWIS on behalf of the local profession, which was responded to by President Brown. The first paper read was a memorial address on

EPHRAIM MCDOWELL,

by DR. L. S. MCMURTRY, of Louisville, Ky.

The author said that the galaxy of illustrious names would be incomplete without that of McDowell, the father of ovariotomy and the pioneer of abdominal surgery, which in modern times has grown to such grand proportions.

In the year 1852, twenty-two years after the death of McDowell, Prof. Gross, in his report on Kentucky surgery to the Kentucky State Medical Society, presented a sketch of the life of this eminent surgeon, with a detailed account of his original surgical work. This sketch was subsequently incorporated in Gross' "American Medical Biography," published in

1861.

After giving a sketch of McDowell's life, Dr. McMurtry then referred to his first ovariotomy, on Mrs. Crawford, and noted some points with reference to his operative technique. The