crowded against the bladder and pubic bones by the tumor. The whole pelvic cavity is filled with two tumors, the larger representing the left and the smaller the right ovary. These growths press against the uterus but do not grow from it. The growth arising on the left side is distinctly determined to be the same as the tumor distending the abdomen. On palpation and percussion the tumor is found to be cystic excepting in the left iliac region, where it is hard and nodular. There is no change in the percussion note whether the patient sits or lies down. The abdomen gives a dull note from the pubes to the ensiform cartilage, and from side to side. Fluctuation wave from side to side is distinct. The note is tympanitic just underneath the diaphragm only.

Diagnosis-Dr. C. E. Jones had made a diagnosis of ovarian cystoma before he brought the case to the hospital. His diagnosis I confirmed.

Operation. After carefully preparing the patient for several days we operated June 3, 1903. I was ably assisted by Drs. Jones, Kobicke, Day, Stark and Huntley, and our staff of operating-room nurses. Chloroform was administered by Dr. Hodghead. A median incision three inches long was made between the umbilicus and pubes (see Figs. 2 and 3). The tumor was found to arise from the left broad ligament. The left Fallopian tube, measuring 10 inches in length, is attached on the left side of the growth. The tumor occupied the entire abdominal cavity, it was attached closely to the parietal peritoneum, to the under surface of the liver (bile stains are clearly visible), to many coils of small intestines above, and to the ascending, transverse and descending colon behind. The great omentum and small intestines had been pushed upwards, and were lying just beneath the diaphragm with the stomach and liver. On tapping the cystoma, 10,000 c. c. of sero-mucous fluid was removed. This enabled me to dissect the tumor from the peritoneum and the abdominal viscera, to which it was attached everywhere. These firm adhesions to the parietal peritoneum prevented the bowels from descending to give us our usual tympanitic note in the flanks. There were also at least 1,000 c.c. of peritoneal fluid in the peritoneal cavity, and several thousand cubic centimeters more in the tumor, which contained not less than 12,000 c.c., or over three gallons. On the left side of the tumor a number

of daughter cysts were found (see Fig. 4), which were opened from within the growth and partially evacuated to enable us to remove the collapsed tumor through our threeinch incision. The pedicle was short. The tumor was removed in the usual way. On the right side we found a small ovarian tumor about the size of one's fist which was also removed. The large tumor measured 35 by 32 inches in circumference. The appendix vermiformis was found to be in a state of chronic catarrhal inflammation, so we removed that also at the same sitting. The patient made an uninterrupted recovery, and was allowed to go home after the third week.

Pathology. Our specimen (Fig. 4), has been turned inside out to show the daughter and granddaughter cysts. It has also been stuffed with cotton to distend it to nearly its normal size. It belongs to the largest ovarian growths found, and is classified with the variety known as proliferating cystadenomata. Next in size we find the variety known as multilocular cystomata. Both are of ovarian origin. In the proliferating adeno-cystoma, there is commonly one large cyst and a number of daughter cysts on its inner surface. The germinal epithelium dips down and grows into the ovarian stroma, and there develops a cyst very similar to the Graafian vesicle. Proliferation of cells from the walls of the tumor occurs, growing into the cyst walls, producing new or daughter cysts. From these again grand-daughter cysts develop, and in this wise the proliferating adeno-cystoma grows. The growth secretes a large quantity of serous or sero-mucous fluid, which is usually thinner in consistency than the glandular or multilocular variety of ovarian cystoma contains. These large cystadenomata are usually round or oblong, having a dense, smooth, glistening surface of opalescent color. Growths of this kind are most frequently found between the ages of 30 and 45. They develop comparatively rapidly, and are generally painless except from pressure.

The multilocular variety is usually glandular, with one or more large cysts and several smaller ones separated by well defined and strong septa. The inner surface is covered by a simple layer of epithelium containing many beaker cells. Cysts of this character generally contain a viscous

material or a thick colloid substance composed of pseudo-mucin. Multilocular cysts are due to cystic dilatation of new glandular acini by secretion from the epithelia, or they may be due to inversion of the germinal epithelium. Many authorities claim that these tumors are merely enlarged follicles, which have failed to rupture on account

of inflammatory thickening of the outer covering of the Ovary a very plausible theory.

The above case is one of proliferating cystadenoma, as shown by the photographs, and of special interest from a diagnostic point of view, the growth having attached itself

to the entire parietal peritoneum, under surface of liver and to a great extent of the small and large intestine. There was no change of dullness by position. It is also interesting from the fact that the patient is only 17 years old, and yet the tumor had developed to a large size. An examination of the urine three weeks after the operation shows it to be about normal. The albumen has practically disappeared, and the urea is up to 1.8 per cent. The small intestines adjusted themselves readily to their normal position again, as will be seen by the photographs taken three weeks after the operation. It will also be noticed that the mammary glands are beginning to develop again.

EXCISION OF THE SUPERIOR MAXILLARY UNDER MEDULLARY NARCOSIS.

By A. W. MORTON, M. D.

(Read before the San Francisco Clinical Society, May 20, 1903.) Mr. G. H., American born; aged 39; family and personal history good; he gave history of excessive smoking, and use of alcoholic stimulants, until five years ago, since which time he has abstained from both. He received an injury to the right jaw two and a half years ago which penetrated the mucous membrane internally, which never healed. Within a short time the parts became ulcerated, and a cauliflower growth involved the mucous membrane of the superior maxillary (occurred at the seat of injury). September, 1902, a lower incision was made and part of the growth removed. The patient was referred to me by Dr. H. W. Taggart, and a section removed from the mucous membrane of the mouth, which proved to be carcinoma.

He entered the City and County Hospital December 3, 1902, was prepared by removing decayed teeth, and cleansing the mouth. Sterile cocaine hydrochlorate .032 gram ( gr.) was injected into the third lumbar space, after dissolving it in the cerebrospinal fluid, following the usual technic for procuring complete analgesia of the body. The pulse before injection was 100°, from the patient being slightly excited by going before the class in the operating room. The pulse during the operation varied from 90 to 100; respiration remained normal; the patient remained conscious, and was not nauseated, and expressed himself as free from pain many times during the operation. The