CASE II.-R. D., aged 32, six children, the youngest six years old; never free from menstrual flow for longer than a week at a time; constant pelvic pain, for which she has been treated without success for more than two years. Operation, January 5, 1884. Since then all pain has ceased, and her menstrual periods have become regular.

CASE III.-J. D., aged 29, six children, the youngest a year old; constant pelvic pain, but no menorrhagia; ovaries prolapsed and tender, but not much enlarged. Operation, February 14. Complete relief from pain. In February 1885 she had another child. She suffered no pain during pregnancy, but had a "cross-birth," and has now a slight attack of pelvic cellulitis.

CASE IV.A. K., aged 29, three children, the youngest a year old; constant pelvic pain and dysuria; an unhealthy looking woman; uterus measured 4 inches, ovaries tender but not enlarged. Operation, February 26. A fortnight later the whole of the sloughing mucous membrane of the bladder was removed per urethram, and she finally left hospital relieved of her pain, though without restoration of her health.

CASE V.-A. M., aged 31, single, a schoolmistress sent to me by Dr Grimsdale; dysmenorrhoea; ovaries prolapsed and considerably enlarged. Operation, March 17. Relieved, but still suffering so much that she has been obliged to give up her school, though she has not yet made up her mind to removal of the ovaries.

CASE VI.—A. G., aged 31, six children, the youngest nearly two years old. Menstruation had not recurred since its birth until a month before entering hospital, when "a flooding" commenced, which still continued. For three months she had been in bed with pain. Operation, March 31. Menorrhagia and pain both cured, but she is now (twelve months later) under the care of Dr Harvey of Wavertree for some renewal of the pain.

CASE VII.-J. T., aged 27, married sixteen months, no child. From June to September 1883 menstruation ceased, and then there was a "flooding," which she does not think was a miscarriage. Dysmenorrhoea both before and after marriage. April 4, shortening round ligaments, no relief of symptoms. Ovaries removed, a large chronic abscess being found in each. Since then all pelvic pain has disappeared.

CASE VIII.-C. F., aged 31, two children, the youngest seven years old, suffered from sickness and backache. Hyperplasia and retroflexion of uterus with small prolapsed ovaries. Operation, April 25. Painful symptoms quite cured.

CASE IX.-J. E., aged 24, three children; was in bed with pelvic pains for four weeks before entering hospital. Operation, August 29. A most gratifying cure.

CASE X.-M. R., aged 24, two children; constant pelvic pain. Operation, September 5. Little relief, and her uterine appendages will probably have to be removed.

CASE XI.-S. F., a virgin, aged 18, suffering from menorrhagia, which had persisted for five weeks, and had troubled her for two years. Ovaries prolapsed and tender, uterus retroflexed but mobile. Operation, December 13. Menorrhagia and pain completely cured.

This operation, then, has yet to find its level. In simple prolapse and painless retroflexion or version of the uterus it is eminently successful. But when there is also cystocele or rectocele it is practically useless, and these complications are generally found amongst the most troublesome cases of prolapse. In painful retroflexion the ovaries and tubes are often diseased, though it is not always an easy matter to detect this condition by physical diagAnd while shortening the round ligaments will never cure pyosalpinx or ovarian abscess, after removal of the diseased appendages the flexion ceases to trouble. In over fifty cases in which I have removed the uterine appendages there has been more or less retroflexion in fully one-half of them. Yet I have never had occasion to treat the flexion afterwards. Still, one operation is undoubtedly less grave than the other, and when the tubes are healthy and the ovaries only swollen, the round ligaments should, in the first place at least, be shortened. The cases above narrated amply justify this position, and they have not been overstated. In no instance, I believe, has abortion occurred after operation, though frequent miscarriages were common before it. instances there has been parturition at full term. In both, pregnancy was easy and the children were born alive, but in both also a slight attack of pelvic cellulitis followed parturition. In one, the inflammation having subsided, I am able to state that the uterus retains its normal position and has not again become retroflected. It is too early to know its condition in the second case, as the woman has not yet risen from her bed. Two or three others are now pregnant, and I hope to be able to make a favourable report at a later date upon pregnancy and parturition subsequent to shortening the round ligaments. Gynecologists will certainly find a use for this operation which Mr Rivington and, no doubt, many others suggested long ago, but which Dr Alexander first patiently evolved in its practical bearings in the Liverpool Workhouse, and Dr Adams first demonstrated in the dissecting-rooms of the Glasgow University. But, as indeed with every other operation, it should only be tried in suitable cases.

V.-CASE OF CYSTIC DEGENERATION OF THE KIDNEY. By T. W. M'DOWALL, M.D.

ALTHOUGH cystic degeneration of the kidney is frequently enough seen in the bodies of the insane, it was never my fortune to meet with such a remarkable example as is represented in the accompanying illustration. It was obtained from the body of an old man, whose history is briefly as follows:

J. M., æt. 65, was admitted in July 1875. His mental symptoms were a combination of melancholia and dementia. He was in somewhat feeble bodily health, stooped very much, and was ruptured in the right side.

During his nine years' residence his mental symptoms varied considerably. Occasionally melancholia predominated; more frequently dementia was most marked; at intervals there were short periods of excitement, when his language was obscene, and sometimes he was so well that he could converse with his neighbours and interest himself with newspapers.

His bodily health continued distinctly feeble, but there were no prominent symptoms. In the earlier period of his residence he used to complain that he never had passage in his bowels. For years he complained of itching of the anus, and that he passed worms. Although his stools were frequently examined none were found; but that his complaints were well founded was proved at the post-mortem examination, when thousands of the common seat worm (Oxyuris vermicularis) were found in the intestines.

In March 1877 he had an attack of bronchitis, from which he never completely recovered. In March 1884 he was seized with pneumonia, and sank rather rapidly. The skin of the left leg became of a purple colour, as might occur in thrombosis of the main vessel, but the patient sank too rapidly for the condition of the limb to be exactly determined.

Concerning his history previous to admission here, it is only necessary to refer to an accident he met with many years ago. He more than once stated that having fallen asleep in a cart, he fell before the wheel, which passed over his body. Unfortunately, the details of this accident and his subsequent symptoms were not inquired into, a fact I much regret, seeing that the accident and the condition of the kidney probably stood in the relation of cause and effect.

The post-mortem notes are as follows:-Examination made 5 hours after death. Weather mild. P.M. rigidity is well marked. There is slight oedema and mottled redness of the lower two-thirds of left leg. The glands in left groin are slightly enlarged. There is a large irreducible hernia in right groin. There are no bed-sores, bruises, or other marks of injury.

The skull-cap is unusually thin and of moderate density.

About 2 oz. of serum escaped during the removal of the brain. The membranes are thickened and opaque in the frontal and parietal regions, the convolutions are atrophied, and there is a corresponding amount of subarachnoid effusion. The vessels at the base are markedly atheromatous. On section the brain is watery; the gray matter very pale and atrophied. The lateral ventricles contain four drachms of serum. There is no trace of softening or clot.

On opening the abdomen there is a large cyst, exactly like a distended bladder, reaching from 1 inch above the pubis to the umbilicus.

The heart weighs 9 oz. The aortic valves are incompetent. The coronary arteries are atheromatous and hypertrophied to an unusual extent. The muscular substance is somewhat pale and very soft. The mitral valves are markedly atheromatous. The right lung weighs 31 oz., adherent posteriorly and to the diaphragm. The anterior margin is emphysematous. The whole inferior third of the lung is in a condition of red hepatization passing into gray. Left lung weighs 17 oz., in the same state.

The liver equals 44 oz., soft and friable.
The left kidney equals 45 oz.

It consists of the usual structure in the middle, but its ends are expanded into immense cysts. It is 11 inches long, nearly 5 in breadth, and 15 inches round the larger end. On evacuating the urinous fluid, the organ weighs only 101 oz. The right kidney weighs 8 oz. It is fatty, contains a number of small cysts, and the capsule is adherent here and

there.

The accompanying illustration gives a fair idea of the shape of the organ after removal from the body. Whilst in the abdomen the lower cyst pressed forwards to the anterior wall, and the upper one lay deeply in the left hypochondrium and immediately in contact with the diaphragm. Besides the large cysts there were a few smaller ones in the organ, but chiefly about the pelvis and in the neighbourhood of the large ones.

In the way of remarks very few are necessary. The whole interest is in the unusual development of the abnormality. Clinically the case is of no interest, as the condition was not discovered till after death, but it can be easily understood that the tumour in the hypogastric region might have formed a most difficult problem of diagnosis.

As to the mode of development of such cysts nothing need be said. All that is at present known on the subject is contained in two excellent articles-one by Dr Frederick T. Roberts, in Reynold's System of Medicine, vol. v. ; the other by Ebstein in Ziemssen's Cyclopædia of Medicine, vol. xv. It is important to note that both authors admit that large cysts of the kidney are occasionally due to accidental violence.