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Ne» York 14609 USA as (716) 482 - 0300 - Phone = (713) 288 - 5989 - Fax \&mN pasi.s vmM REMAIlks ON OVARIOTOllY WITH Ax\ APPENDJX. COXIAlNhNa TliR HISTORY OF SEVERAL TYPICAL CASES ,- Ji'T MKT WITH IK PRACnuE. By J. W. KOSEBilUGH. M.I) (OF IIAMILTOX, ONTAttlO) ri;sl,l^n/ <>/(/„■ Malkal Fncxlhj of til. l!a„ulionV!t>i 11, Prrsid'-nt of ihf HamUtmi :,t,d.ral and !ii >J /Iv.^intal ; let'.- riftnii Sochly^.itc BEAD nV Xm.^'AT Tilt lEN'^ A.Yii^'tjAL .MEKTf^rc; (CANADA l^DICAL ASSOCTATJoY .AIONTHEAL, SEl'T , I,s77. HAiiijo!^ PUBLIC imm ( Reprinted from T«E; Canada LAxcfcx, April, 1S7S.) ■V- ^- T.^ '-1 ! 1 '*', L' ' ■Bp'. -.^. ^I^^R^^^A Wm mm 4 < r Yi •f j,>i -irr*'^^' i \ H 1^' M M REiVIARKS OX OVARIOTOMY; WITH AN APPKNUIX, lOVfAlMXIl TIIK > HISTORY OF SEVERAL TYPICAL CASES, MKT WITH IN IM{ACTICE. Bv J. W. UOSEHIU^GH, iM.D., (itK HAMilTOX, ONTARIO) Prfmlffit of the MiUical Futility of t/ii: Hamilton City Hoxpital ; lu(« Prfnutfnt of the Hamilfon M(d'irn1 and Simjicnl Society, etc. HEAD IIV TITr.K AT TIIK TKNTH ANNUAL MEETING of- TIIK CANADA MEDICAL ASSOCIATION, MONTREAL, SEPT, 1877. mM,!..TaN-panus library ( Jteprhited from The Canada Lancet, Afml, 1S78.) HAMILTON : RoBKRTt & Gniniy, Strim Pristerb, 16 Kixe Willwm Stbiet. 1878. t. 'I M 1 REMARKS ON OVAIUOTOMY. iR/ The oi)emtion entitled Ovariotomy, first suggested by William Hunter, firat taught by John Bell, and first performed by Ej)hrHim MoDowe'l, has 8i)eedily come to be recognized as a legitimate and establishe.' procedure for the radicil cure of ov-rian disease; and, indeed, ofler^ a more favorable prognosis than most other capital si.r- gical ojierations. Never has any medical procedure risen mou rapidly into favor, nor gained a stronger hold upon the professional mind, nor been more frequently resorted to by eminent practitioners throughout the civilized world, than has ovariotomy during the pHst ipiarter of a century. Seeing that to the investigation of the etiology and pathologv of ovarian disease have recently been brought the best thought and expe- rience of the age, and that ovariotomy has in so short a period accom- plished BO grand a career, rescuing many valuable lives from a premature death, this operation is justly entitl.d to be regarded as the monarch of gynecology. Considering the growing frequency of the operation in the Dominion, it is desimble that the profession should discuss the lifferent methods now practiced, with the view to arrive, if possible, at some definite con- clusions as to the best means of completing the several steps thereof. In this, as in every new development of science, the advance is not uncontested. There are to be found those who, with equal honesty and tenacity, hold opposing convictions. Ovariotomy has not won its final triumph, though destined so to do ; its progress has been a succession of brilliant victories, and ere long we may hope ^o see it coming out of the strife, its last opposition overcome, and having accorded to it a place chief among capital operations — " Like some tali oliif, wiiosts awful form Swells from the vale, and midway leaves tlie storm. Though round its base the threatening clouds be spread Eternal sunshine settles on its liead." w l>& When about to perform this operation for the first time, being anxious to find some definite rules for guidance at certain points, great was the sense of disappointment upon finding that the acknowledged authorities did not supply the information required by a beginner. To remedy this defect, I was obliged to consult the record of cases published by different operators, in the several medical journals, and decide upon the plan to be adopted under certain circumstances. Recently, however, abundance of information on the several unsettled questions has been supplied, and though we have neither the literature, the tradition, nor the sobered reasons of centuries to guide us in this, as in the better known capital operations, fortunately some of tiie greatest modern lights have sufiiciently explored this hitherto unknown realm, with such brilliant results as startle the world, while supplying data, that to the reflecting mind will furnish rules for guidance in further operations — rules that may, as in all practice, from time to time, be amended, as new discover- ies are made. Though ovariotomy! is of only recent date, there have been attracted to its investigation numbers of men eminent in the profession — the peers of the men of the past -who have pursued their researches from widely different points of observation, and with so impressive results, that already from the muss of testimony thus supplied, we may glean such important facts as will enable us to reach conclusions, which we venture to predict, experience will but confirm. True, some of the most experienced authorities have expre.ssed the opinion that we are only on the threshold of knowledge respecting the etiology, pathology, and treatment of ovarian disease, and in their modesty refrain from making any deductions. Tlie wisdom of such a course is open to question. On the other hand, is it not their privilege, aye, and duty, to classify and utilize the knowledge already gained ? Many things may be true which are compaiatively valueless. To know the facts is important, but a further effort and patience in the piirsuit of truth are required to ascertain their relative value. The line must be drawn somewhere. Probably were we to attempt, at present, to distinguish between the difierent methods practiced in ovariotomy, no two investi- gators would be found agreeing in every i)articular. This supposition justifies the expectation now indulged, that the subject chosen for discussion this morning will prove interesting and profitable! to all present. The discuHHion of oviiriii'i dihease — its diu"UOi^Ls uud vuriouii methods of treatment, is not designed in this paper ; but the diagnosis having been made, and ovariotomy decided upon, it is pioposed to ascertain svhich are the most successful, and consequently the most [•^1 nae, being nts, great lowledged iner. To published Bide upon however, has been n, nor the er known gilts have I brilliant reflecting rules that ' discover- ittve been profession researches nipressive I, we may mn, which me of the at we are pathology, Tain from s open to and duty, my things le facts is truth are be drawn tistinguish vo iuvesti- iipposition ihoseu for l.l(' to nil d vurioiis diagnosis oposed to the most useful methods of accomplishing the various steps of the operation. The plan proposed is to give a resuim of what the writer believes to be the best methods now practiced, and to assist in eliminating a mass of rubbish, which at present encumbers the literature of this procedure. A desire for brevity, and the intention to avoid, en passant, a discussion of those points which may be more advantageously considered at the close of the paper, must excuse the peremptory manner in which the writer's views are occasionally expressed. PKEPARATIONS FOH THE OPERATION. The operation should be undertaken only by that surgeon who realizes the full weight of the responsibility he-assumes, and determines to be thoroughly prepared for eveiy step of the procedure, as well us any emergency that is liable to occur ; for, unquestionably, success greatly depends upon the prejjarations previously made, the care and skill exercised during each stage of the operation, and particularly the vigilant supervision given to the mirutiie of the after-treatment. When possible, choice should be made of a plea,sunt and healthy locality, and of a large and cheerful m, capable of boing heated and ventilated. The room should be thoroughly cleansed, the ceiling whitened, the walls calcirained or newly papered, and the woodwork and floor well washed, using plenty of soap and water. The carpet and furniture should be new, and the bedding clean. It will be found convenient to have two beds, as nearly alike as possible, in the room, so that the patient may be easily lifted from the one to the other. The patient having, after a full and candid explanation to her of the possibilities of the operation, voluntarily decided to avail herself of this prospect of a radical cure, this question ought to bo regarded as .settled ; and from that hour all discussion on that point entirely avoided, while every means should be employed to inspire her with hope and courage. In the absence of urgent symptoms, time .should be taken to improve her physical condi- tion, and elevate her vital powers. She should be kept free from excitement, her food nutritious and easily digestible, the bowels regular, and the kidneys secreting a proper "4-lii'*-I/» "~ — ^'.'il ^/\---' -l.«..1J 1— -.1! 1 « I--"- 1 ;_i.-ii; A liie aiiiO.-)iiil.-viv, ti\j auiitt luuti .-iiiuilut uc ;iiiu".TCu. .v Kllltl, IIlLfllJirt; III and experienced nuree should Ije secured — one who will faithfully and tenderly attend the paticiut, and maintain a Arm yet gentle discipline in llic room. It is obviou.Hly impracticable to decide, with absolute m certainty, upon a fine day for the operation, as has been recommended, with the wind in a certain quarter. The choice has to be made some days provioiusly, and no ordinary weather prophet can calculate with much certainty the state of the weather two or three days hence. The patient prepared, the nurse and assistants on hand, and everything being in readiness, it would be exceedingly inconvenient to postpone the operation on account of a miny day or an east wind. The operator should have a written list of all the instruments and utensils usually needed, including those rarely required in any emergency ; this list should be checked, and the instruments properly arranged on the table, convenient to his hand. One hour previous "to the operation, the patient should receive thirty drops of laudanum, and immediately before the antesthetic, a little bi-andy and water. The anaesthetic administered, the assistants enter the room, the temperature of which should be maintained at about 80°, and all liability to drafts from the opening of doors and windows prevented. The patient is then lifted from the bed and placed upon a narrow table, made comfortable with folded blankets and sheets, in front of a large window, transmitting an abundance of light. Her feet and legs should be kept wai-m by means of woollen stockings, flannel drawers and a light blanket. The feet rest upon a stool or chair at the fcot of the table. It is necessaiy to have five or six skillful, cool-headed assistants, free from, all taint or suspicion of contamination, arising from dissections, post mortenis, suppurations or contagious diseases. The nurse must have in readiness, in the room, plenty of hot and cold water, carbolized water (1 to 100), a tub, several pails, wash bowls, soap, towels, soft flannels and cotton cloths, napkins, etc. She should have three pairs of new sponges, readily distinguishable from each other : one paii- for the external wound ; the second, a large pair, for the contents of the tumor ; and the third pair, extra soft and fine, for cleansing the peritoneum. Care must be taken to keep each pair in separate dishes, and the assistant who sponges the contents of the tumor must be careful not to touch the sponges reserved for the peritoneum. The operator takes his place on the right ot the patient, with his chief assistant directly opposite. The one in charge of the instruments should be familiar with his duties, and ready to anticipate the wants of the operator. The a.ssJstant in charge of the anaesthetic shoula be accus- tomed to its administration, and one who could be relied upon to faith- fully discharge his duties, regardless of the progress of the operation. The ami'sthetic should be given in such quantity only as is necessary to maintsin quietude. This is important, owing to the tendency to pro- longed sickness and vomiting after ovariotomy. When chloroform — »mmended, made some culate with lence. The everything ostpone the be operator sils usually ' ; thia list I the table, uld receive etic, a little tants enter about 80°, d windows ced upon a sheets, in Her feet Qgs, flannel ihair at the 3ool-headed rising from ises. The t and cold ash bowls, 3he should from each ;e pair, for td fine, for ch pair in the tumor toneum. ;, with his istruments e wants of i be accus- i to faith- operation, scessary to icy to jiro- oroform — which I pi-efcr— is used, it is astonishing how little is rwiiunnl to k«ep up complet anrosthesia, esijccially when sprinkled guttiitim upon one thicknett r ,he napkin covering the nose and mouth, and held closoly around th„ chin to prevent the loss of vajwr, while the air is ftwlv admitted from above on either side of the nose.* All things being in readiness, the bladder should be evacuated with a catheter by an assistant, before commencing the operation. TlIK ABDOMINAL INCISION. The abdominal section is now always made in the median line between the umbilicus and symphysis pubis, the length required depend ing somewhat upon the nature of the contents of the tumor. Even for exploratory purposes the incision should be about five inches long which will usually bs found sufficient to allow of the extraction of the tumor after its size has been reduced ; but, if not, the incision can after- wards be lengthened. The section is made with a strong scalpel, commencing below the navel, at a i>oint which will make a proper length of wound ending an inch above the pubic symphysis. Care must be taken to make the dissection along the median line, through the skin, areolar and adipose tissue, down to the I'uiea alba. When this tendinous line has been reached, and uncovered throughout the extent of the external wound, it is picked up by a tenaculum, openeliciitions are very embarrassing to some operators in the exciteinoiit of tlie hour, Imt a cool, quiet investigation will Hoon serve to clear \\\) th»" perplexity, anil the experienced siirgeon will prove hiujself equal to the emergency. ADHESIOXS. Tlie tumor having been exposed to view, search is made for adhe- Kions. The hand is wasl\id, plunged into warm carbolizcd water, and two or three fingers are passed around between the tumor and the abdominal parietes. If slight adhesions are met with, they are gently broken down v/ith the fingei-s. I have found the large curved steel sound, recommended by Professor Thomas, an excellent instrument for a more extended search for atlhesions. It is warmed, dipped in the disinfectant, and passed gently around the tumor as far as the pedicle. With tiie aid of this harmless instrument the operator can satisfactonly ixssure himself of the presence or absence of adhesions around every part of the tumor excepting posteriorly. The most serious adhesions met with are strong attachments to the bladder, litems, omentum and intes- tines. These bands must not be cut, unless first secured by a silk ligature ; and this I believe to be a good and safe method. But it is usual to enucleate them from the tumor by the fingers or the handle of the knife. Another excellent method of separating strong adhesions, is by iuaking use of the temporary clamp and actual caiitery. When, how- ever, the cyst is firmly adherent to the bladder, intestine, or uterus, a small portion of the cyst wall should be cut out aud left adherent to the viscus, the secreting membrane being dissected away. In such cases great care must be exercised to avoid perforating the intestine or ruptur- ing the fragile wall of the cyst. TAPPIX(i THE CYST. The operator having confirmed his diagnosis, and ascertained that the removal of the tumor is possible, proceeds to diminish its size by removing the fluid contents. The cyst is seized at the upper end of the abdominal incision by strong toothed, or deeply grooved forceps, and steadied, while the large trocar is plunged into it. An excellent instrument for this purpose is the trocar known as Spencer Well's. It is an ingenious contrivance, self-retaining, and has a flexible tube attached, through which the fluid is conveyed into the receptacle below the table. When one of these trocars cannot be obtained in a country town, a large tube, sloped and pointed at one end, may be improvised for the occasion, an opening being made for it by a scalpel. In such an event, and indeed ... all cases where there is danger of the contents escaping into the peritoneal cavity, it is beat to turn the patient on her ; exciternont to clem- up Keif cqUiil to le for adlie- l water, and iior and the y are gently }ui'ved steel itrument for pped in the the pedicle, satisfactonly d every part Ihesions met m and intes- jd by a silk L Bnt it is 16 handle of adhesions, is When, how- or uterus, a xerent to the a such cases ne or ruptur- jrtained that h its size by e upper end wed forceps, An excellent jncer Well's, flexible tube sptacle below in a country le improvised In such an the contents latient on her [«1 left side, while the fluid is flowing away, and every precaution must bo taken with sponges and fla'-nels to prevent the contents getting into the peritoneum. In the mean time, t';e assistant is keeping the cyst wpII into the wound, by steady traction with the forceps, while anothei' compresses the abdominal walls against the tumor by one hand on each side of the incision. In compound tumors, after the parent cyst has boen evacuated, others come into view, and are, one after another, tapjjed and emptied. The contents of some cysts are very gelatinous and tenacious, passing out through even a large tube very tardily. Under such circumstances, the patient being on lun* side, I have exjjedited their evacuation by laying them open freely with a scaljiel. In otlier cases, the contents are semi-solid, or composed mostly of small cysts — honey-combed, which have to be incised, broken down with the hand inside, and scooijed away before the cyst can be sufficiently reduced to be extracted through a fair sized opening. REMOVAL OF THE Tl'MOU. As the cyst is being emptied of its contents, the assistant, by continued traction with the forceps, gradually withdraws the lessened tumor through the incision, assisted, in most cases, by the hands of the operator. Care is now taken to have the tumor well supported by the assistants, to prevent its falling, or dragging injuriously ao the pedicle. When the lengtli of the pedicle will permit, it is good practice to tie it tightly with whip-cord, near the tumor, make a loop with the cord with which to manipulate the pedicle, and cut away the tumor. This may now be entrusted to a skillful and experienced assistant, who will attend to any unruptured adhesions according to the methods previously described, while the operator gives his attention to the pedicle. SECURING THE PEDICLE. We come now to the most important step of the operation — the treatment of the pedicle. The most effectual methods of securing the pedicle is certainly the most importani, and the most anxious question the operator has to consider. He is impressed with the recollection that in his management of this step of the operation, he is required not only to eflectually and permanently secure the stump against hemor- rhage, but this must be done so delicately as not to drag or twist the uterus, nor inflict the slightest injury upon the parts which are to remain within tiie pexitoneai eavity, so that tlicir oliull be iio tis.sne likely to decompose or give rise to septic absorption ; for it is obvious the success of the operation in no small measure depends upon how these objects are accomplished — what '•i.jk is run of hemorrhage, shock, [10] peritonitis, and septica-rria-tho four great sources of mortality after ovanotorny. It ,s, therefore, not surprising, nor to be deprecated, that this question has been anxiously discussed among ova.iotomists, and various mot hods of procedure warmly advocated. The various methods practiced and recommended by their advo- cates, may be classified thus : 1. The Extra Peritoneal. 2. Tim Intra Peritoneal £^tra:p^rit,,neal ("without" the peritoneum). _ Under this dmsion may be includM the various modes of securing the pedicle on sido of t.H: peritoneum. This object is generally accomplished by either bringi.;. the pedicle through the lower part of the incision, and hxing it outsice with a clan.p before dividing it, or first ligaturing the pedicle with ..Ilk, catgnt, wire, or some other agent, and then etther fixing It ouuside, or with the abdominal parietes while closing the wound. The various plans resorted to for this purpose, have the same object in view-to keep the stump of the pedicle securely in or outside of the abdonnnal wound so that it cannot drop into the peritoneal cavity, and tliere become the source of mi.schief. For the sake of brevity I shaU include all methods having the above objects in view, under the designation of the clamp method, as I believe the fixation , of the pedicle externally can best be accomplished by a good, stron.. clamp-such as used by Mr. Spencer Wells. It should be borne in mind that some pedicles are very large and vascular, two or three inches in breadth, and containing the following structures : the broad ligament, the Fallopian tube, the ovarian ligament, sometimes the round ligament, several very large arteries, and a number of greatly developed veins ; and all this mass must be firmly and effectually secured, if possible, against the perils already mentioned. The clamp method consists in embracing the whole pedicle, outside the aodominal wound, with a strong metallic constricting instrument, capable of being screwed together very tightly, and cutting away the tumor about half an inch outside of the clamp. .The abdominal wound IS then neatly closed around the pedicle, under the clamp, and the stump thus firmly held is so treated as to prevent any septic matter Irom finding its way into the peritoneal cavity. This, it is claimed, possesses advantages over the intra-peritoneal metho.l, where the stump of that large vascular mass, whether severed by the actual cautery, "tied and dropped," or Teated by any other l)lan, remains witJiin tho nprit'^p»"i ^tx^u,, „.i . • ,. , , . , \ . '- i-i-i^ I" ." vRriv,;, ytuar; ii IS liable to become the source of septic decomposition, and hazard the patient's lif^ The clamp method has been, and still is, the one most geuemlly of mortality after e deprecated, that •variotomists, and 'd by their advo- • — Under thiw uring the pedicle accomplished hy the incision, and I'st ligaturing the and then either diilo closing the e, have the same 3ly in or outside the jjeritoneal For the sake of objects in view, eve the fixation ■ a good, strong uld be borne in ■1', two or three ures': the broad sometimes the mber of greatly and effectually pedicle, outside ng instrument, itting away the idominal wound clamp, and the y septic matter intra-peritoneal i'hether severed 1 by any other able to Ijecorae t's life. most generally . practiced ; it was introduced by Mr. Jonathan Jlutchinson, and is nea.ly always employed by Mr. Spencer Wells -that prince of ovari otonusts, who himself has performed the operation nearly one thousand times, thus adding, according to the calculation of Lord Selborne 20,000 years to the lives of European women. Intra-peritoneal ("within" the peritonetim).— ITnder this shall be included all modes which leave the stump of the pedicle within the peritoneal cavity : the actual cautery, the galvano-cautery, the ecrcsevr acnpres.sure, dcligation by various ligatures, toreion and enucleation. ' .Several members of this Association, in attendance at the Interna tional Medical Congress, in Philadelphia, had the pleasure of hearinc. Dr. Miner, of Buffalo, describe in plain, lucid language, his plan of performing "ovariotomy by enucleation," and were deq.ly impresse.l • with the conviction that his procedure is a capital method, in some cases at least, especially where the pedicle is so broad and short that it IS impossible to apply a clamp, and hazardous to attempt to secure it bv a ligature, or divide it -by the actual cautery. In a recent operation where the pedicle was of this descrij.tion, I availed myself of the method of enucleation, to separate the i)edicle several inches from the tumor in order to get sufficient length to allow ot securing it by a double ligature. This process enabled me to complete the operation satisfac- torily, and the result was successful.* I therefore feel indebted to Dr. Miner for giving his valuable discovery to the profession. Dr. Miner's remarks were reported in the Transactions of the International Medical Congress, and may be abbreviaVd as follows : "It is well known that the ovarian tumor ia surrounded by a peritoneal covering; tliat the pedicle, proper, usually divides into three or four parts passing up over the walls of the tumor in bands of variable width, which contain vessels, often of large size, and which gradually diminish in thickness and in the size of the contained vessels, until finally they are lost in simple, thickened portions of peritoneal covering. The peritoneal investment is not closely attached to the cyst, but separates readily, just as the peritoneum separates e'sewhere in the pelvic cavity, being immediately lined by the subserous cellular tissue ; thus no vessels of any considerable size enter the cyst. The tumor separates from its attachments with remarkable readiness, so much so that, in sex eral instances, it 13 reported to have escaped the grasp of the operator, and fallen spontaneously from the pedicle by accident, thus plainly indicating the natural and proper method of removal. My surgical friends who have seen the operation, unite in regarding it as i.- r ""■""'.,." — '^o'''- i-f^e(UUc puasiWc. To sec It, 18 to bo convinced of its entire feasib.hty and safety, while its advantages are too apparent to rcnuire a moments consideration. * Sec Appendix, Gxse III. [12] cedurc. The finL^ers of th7oZ ?''**'"«' ^'" «'^'' « ^ery fair idea of the pro- or .„.pea,e,e. 4^^^ Z^S ."13^:1^ "^ " ™™'" ^°'"°" lliis separation is to be carefullv mirlo n.,+;i *v,' their termination. To make tl,P Hi, 7 . 1 *^^ ''''•^'^ """^ *'*<=ed *« raised from the abdoZa eaX^ ^^^^ ""'iT.' *'^ *"™- - -P-sented as but. of course whe eTtensiv-l !^'/ '"^'^'°'*''^ ''^ *^^ ^^"^ ^^ -'^ -«««tant ; risks of remo;aUr;e:tr;n?n::r ''' ''''-'''' '''' '' '-'-''''- -' «'« exiHtXt'\oir"*::rd" ^r;r"""" '^'^""•^'''^"'- ^^^^- ^<^^--- capil ary veils thLTT: T *^' P'"'"'' '=°"*'""'^'J *» '^'^ P^'«''l«- The foT he band . ! T ^ '^"""« ''^'^ P^°^^«« °^ enncleation ) ^o not bleed rpibrie^ L^?SL; ^°^^'"-™°^*- *'- Wer trunks, while the broken oft- short ^.TlnthaUs'^^^^^^^^^^^ '' *^"' ^^^ ^ '^ -P'^^". »PP^i^^l ^or « .,„. t.trth""V'' '"'"'' '' '"'^ ^"^ ^"^"^'^^ methods-acupre. s ne,,.or«...r,, tL.galvano-caiUery, or by twisting and torsion, I shall not take „p your tune in discussing, as tLey possess no advantages ; * Kindly loaned by Dr. Miner. » i i N. Brush, who idea of the pro- vascular portion i are traced to s represented as of an assistant ; Jossible, aud the Vhen adliesions e pedicle. The 1 ) do not bleed, the broken oft" u, applied for a 3tls — acujnos- on, I shall not advantages ; • [13] but ll.e remaining two methods-the actual .Mutory and the ligature- (lennind esjiecial consideration. ne Actual Cautery—lhiH nietho,!, introduced l.y Mr. John Clav a celebrated ovariotomist, of Birmingham, England, for the purpose of arresting hemorrhage from parietal and visceral adhesions, was seized by Mr. Laker Brown, for the treatment of the pedicle also; an.l with most excellent results. It consists in compressing the pedicle with a ten.porary clamp, while being divided, or rather sawed off, bv a wedge Bhaped cautery iron, heated only to a white heat, so as to bum its way slowly through the structure. The clamp is then unscrewed, and after wai ,Dg a short time, to secure if necessary any bleeding vessel by a ligature or another touch of the cautery, the stump is allowed to recede into the peritoneal cavity, and the abdominal wound is completely closed Al hough this plan of dividing the pedicle yielded unparalleled results in the hands of the late Mr. Baker Brown, very few since his lamented death have adopted his procedure, except in cases with very short pedi- cles and hen only as a dernier ressort. Recently, however, one of the most brilliant ovariotomists of the day-Mr. Thomas Keith, of Edin burgh-has practiced this method in over fifty cases, " and, out of '>41 oi.erations (by various methods), has .saved 206 lives-a success hitherto unequalled in the history of any capital operation.* But most operators seem anxious to avoid this mode, except in cases where neither the clamp nor hgature is applicable ; appearing to think that the danger of secondary hemorrhage, decomposition, and septic absorption is increased thereby. For instance, take the following quotations : that 7?h.T'°'7^; *^' ^.T '^^^ " ^^^""*y ''S'''^"^* hemorrhage; and hat, I think, ,8 best gamed by the use of the clamp or the ligature" Dr rtir""- ^'•«"^«^""«'*'''^'"« International McaicalL,jre.., ofZLlpZ sa-s-"^'"'^' ^^'""^''" ^'' excellent work on the Diseases of Women, "^'■- f *ker Brown introduced the plan of amputating the tumor by means of the actual cautery, and claimed the astonishing results of twenty-nine cuTes Tn thrty-two operations. The insecurity against hemorrhage attendant uZtl^^ m hod w,)l probably prevent its competing with those already mentioned but in :^:W aXirge^'^i" ''' '-' *° '' -^"-- ^« ^-P ^^*^^" tHe p;^- ! t Schnuder, in his recent work, page, 422, remarks as follows • t..t :^;:z::'zr::2:i7^^^ ^^-^-^ peHtonitis. see.s to hnve liUle-..„ndaW " The ::;:2\:^2:^:^^ •IcnmnU." Or. Alt.vmder K. Sinnwrn of Kah/burih V'L^ f any method timt the case may VoHyniu, Philadelphia, l'»se 807 ^.^""'"'■b'li. Iranmctwnto/ the Jntemational Medical [in I !i that caiiturizfttii)ii tice done it since ice, iicaily all eat Htlvantagi's ilioit and deep me, dediiciblo s great ad van - a better in all securing the ouble ligature, ts root, with a lalf separately, tightly around rt, the pedicle p dropped into This method lie of the best roik over fifty e honor, at all iig had a series lemp ; Marion as horse-hair-, ling an animal ;l(tal lliau any lip and becoino o Dr. T.lcr Smith's h all olhci's will, in [ir,] untied an.l consequently it failed to meet the expectation of it« •idvocateH. Gradually the good, old fashioned silk ligature^- itnelf an -n.al product has become the favorite for this purpose; „fange to ■say, however, whatever ligatures are used, it is impos.sible to fi.ui then. u few months afterwards, and the question is, what beconu-s of them i It has been suggested that they become partially if not entirely absorbed • .nt the expenments of Spiegelberg, Waldeyer, and Maslowiy, on the' Lorns of the uteri of animals, prove that not only the ligatures but also the stump beyond them, become encapsuled by effused lynud.: It « claimed for Uus utra-peritoneal method, that ic is simp'e. asy lo u of the abdonunal wound in its whole length. That the " tyin-. and dropping method is a good and successful one, and gradmilW ormng into favor, it is needless to dispute ; indeed, it is easy to foresee that It IS destined, ere long, to become the favorite procedure Having given as much space to the consideration of the best nethods of securing the pedicle, as a paper of this kind will permit it draw the lines" a little closer than has heretofore been attempted We have seen that there are two methods worthy of commendation • TA e.tra^rUoneal, and the intra perito.^,ul. We have seen that the extra-peritoneal method is best accomplished by means of a Inir socured e.teriial to the abdominal wound, and'the intra-periton IJ ncithe method appearing to possess advantages superior to the oilier methS'weU "r ^'f/""" ^'"'^ "^^^^ '^' ""*- -' ^'^'^t either method, well-performed by a painstaking and skillful operator who gives personal and great attention to the details of the preparl^ lid after treatment of his patients, will yield about equal Lsults and consequently, it does not matter much to which method recou il had m-ovided . .s well executed and receives the same vigil.nt ::;r:i In' It s highly important, therefore, that the operator should be unprojudiced-not wedded to any particular plan ; buT that he houM proceed to each case prepared and desirous to adopt that method w il "nd<.r the circumstances, seems best adapted to that particular case CLEANSING TIIK I'EHITONEAL CAVITY. ....r!:^'J7i!^;' external incision the opposite ovary must .. should" h« 'J— —generation l.ave commenced there, the ovary Hl.ould be removed and the peritoneal cavity thoroughly cleaiised every pai tide of debns remaining is liable to decompo.se. Alter the [I.ij hemorrhage* huH coaHOut HO Boon as igh tlie tub(?, valesenc*' wum •oin obsoiving that city in le privilege of ;;las8 durinage- ns, I had tlio and assisting tomy patients. >minal wound, r tube passing Through the njected, which )f pus with it. d clear. The f low indeed, aarked to Dr. er end." He convalescing )f ovariotomy the followin<' I with considerable r. iti su'_'h cases I rnational Medical ifter the sundering writers attribute to bert Uarne«. Ibid. I [«7] the empty.ug o p„„ nto the per.ton.U.n from inrtamn.atory ac i«„ Thr"m 1T ance of not only preventing the entrance of «..uh elen.e„L into ho , riZ um a«d of re„.ov.ng thorn before closing the abdominal .,„ uing , bu i o^S them free vent during thn i.i., ,/i.i ,.f „ i . K'^>"g of ovariotomil t • '^ / '-"°^'»'"'=«°*--«' »"« attractMi the attention o ovar.oto.n.8t8. It ,a « my unif„nn habit to inaert .. gla-sa ,lrai.i«^...tube ght mohes long and varying in diameter fron. half to th^....;rt T o "a„ C be e tt h 17 '"• ,' "'''^ "" ""'' '*''* '■" ^''^ P-i'o««u.n. Should no nui.l be left m the abdominal cav.ty, this tube ahouKl not be in,erted or if Z operator be .„ doubt, it ahoul.l be placed in position an.l kept tig^ry lid I flu.d accumulation exist, or its occurrence bo rendered probable by sllhtlinl Tsor^ b:^ nothin ^ °° •""''"'' "' temperature mark the occurrence of septic nas passed away. Shoul.l septica-mia show itself, a gun. elastic catheter cut ofT S 'andl si "'' )' ""'**'' ^ '"' "' ^^-"•'^«' *•-« «'-^ *"»>« draw ; < „ inch, and a stream of warm water containing one dra. hm .( ddoride of sodium and sixteen grains of the crystal, of carbolic acid to the p.. t, gently inj Id Z means o a Davidson's or fountain syringe. No foi^e Ih^tevL Cia be employed, but a free supply „f water should be thrown . , until the return current comes forth clear. When the temperature or pulse ses Ind tl- , tor symptoms of sopticmia develop, such an i^oction should be ^iSd on ' „ e ght hours, tut without the tube is left from the time of tl. opera on Tt U d fficult and sometimes impossible to reach the most depen lent pa Hf ho " Septicemia, which I believe will in time be admitf^.l K„ *i. zriuT iiirtrr'-^?' ■■• -■»■ "^^ -•""• -- "»• gerous state. It is ushered m by dizziness; excessive rauscuL.- prostratbn ■ anorexia ; great pallor ; high temperature ; small, rapid and ve^ weak pulse '■ sometimes a low delirium ; a dry tongue ; and a sweetish odor of «, Teath it' .8 probably this condition which is so often alluded to as a ' tvpho . .tTto • afte ^t: TdT orvVS"' 'VT'' '-'' '"'^"^' " '^"^ '"-'•- ^^- -- qn tea in Dr. Clay s tables as shock or collapse, occurring as late th« fifn, B.xth seventh and tenth days, were really !nsLces of this le on The U-.elopment o pentomtis and Beptic^mia should be carefully lookc for All the vital and physical signs which mark them should be constLtwt ■ t Ltej result, first, of the decomposition, and second, of the absorption of flui Is in the orr:iirirL'« ---.?- — » ^^y- ^-^ ^^ -y take ;::: ;: :t: « -^^de^iy ;d;a;s:r i, ^rriorrx^tjtir rs:: St rallies from he immediate efiFects of an.-osthesia and operation, fears si uld S! entertained that peritonitis or septicmia is developing. ' If it o'ccur wUL n fo^ C - , ^ [18] days after the operation, it is likely to be the former. If after that time, the probabilities are greatly in favor of the latter. The puUe will usually become rapid at the same time, whichever morbid condition is developing, and it must not be forgotten that the tw o are often combined. Let no one suppose that septicemia once established becomes irremediable. Experience disproves this ; it is the prolongation of exposure to absorption of septic elements that constitutes the great danger of the condition. This method of meeting in an efficient and satisfactory manner the most fruitful source of danger after ovariotomy, I regard as second in importance to no other improvement which has been introduced since the discovery of the operation itself. It emanated from Dr. E. R. Peaslee, and has even now, I think, not assumed its legitimate position in the scale of importance." This practice has not been veiy warmly accepted in Great Britain. English surgeons, proverbial for their slowness to adopt any new recouimendation, have practiced drainage only in cases regai-ded as desperate, or likely to prove sucli. On the continent, however, it has been received with considerable enthusiasm, especially by the thoughtful German, But it is due to Prof. Carl Schroeder, to say, that he doubts the utility of resorting to the use of the drainage tube in many cases where it is now used.; In a recent article upon this subject he remarks : "Let me once more state my views precisely, that the exudation after ovariotomy is not in itself the cause of the septicemia, but it is on the contrary periectly harmless unless it decompose ; but that decomposition only occurs after infection, and that consequently the important point is not the removal of the exudation, but the avoidance of the infection. I should therefore decide upon drainage during the operation, only in case I believed— a state of things which should of course not happen— that the patient had become infected, or, in case decomposing masses from some suppurating cyst, e. g. , had found their way into the abdominal cavity. Drainage of the abdominal cavity assumes a very different position as a therapeutic measure, against a septic peritonitis which already cxisiis. For, although the exudation be neither the original cause nor the only symptom of the septic condition, it must still be conceded that its removal is highly desirable. It is true, this is then difficult to accomplish." CLOSING THE ABDOMINAL WOUND. This is generally effected with both deep and superficial sutures. Almost every variety of suture material has been employed for this purpose. The result of the operation, however, does not appear to depend upon the kind chosen. Most operators prefer silver wire, but Spencer Wells, and some others, nearly always employ Chinese silk. As the deep sutures are placed about an inch apart, the numl)er to be used will depend, of course, upon the length of the incision ; when tlic '{rjiiiinge-tube is insevtett, ana tiie peaiCiC i» biouglit uutsiuc, fchcy slimld be placed between the last stitch and the last bat one. The threads should be about eighteen inelies in length, with a long, straight needle affixed to either end. Each needle is passed from within out- ker that time, the ill usually become ig, and it must not se that septicajinia 58 this ; it is the it constitutes the > an efficient and riotomj', I regard been introduced Dr. E. R. Peaslee, tion iu the scale I Great Britain, idopt any new es regarded as however, it has r the thoughtful that lie doubts ! in many cases act he remarks : e exudation after is on the contrary only occurs after e removal of the sfore decide upon 3 of things which cted, or, in case nd their way into J8 a very different lis which already luso nor the only that its removal h." Grficial sutures, ployed for this not ajipeai to silver wire, but y Chinese silk. numljer to be ion ; when the : outside, they bat one. The a long, straight om within out' [19] wards including a narrow margin of the peritoneal membrane, through he entn-e tlnckness of the abdominal walls, emerging at a point abm,t hree-quarters of an inch from the edge. All the deep sutur s sho u M be thus mscrted before they a. tied. The wound is^ norelmim ' and 11 any fresh oozing of blood have taken place, this must b Z " d away. An assistant now, with one hand on either side of the wo^ buges up, as it were, the redundant walls, while the stitches ai bg tied or twisted. Then n order to secure a nicer coaptation of the edge! of the womul, superficial sutures are placed between the dee, ont which include only the skin and areolar tissue. All ex,,erienced one. stit h, as It IS found when the two edges are thus brought together thev unite quickly by first intention ; and this is desideratld in'o^e tt.t If suppuration take place outside, pus and other septic fluid mly be prevented entering the peritoneal cavity ^ The wound should then be covered with dry lint, or lint soaked in carbohzed oil ; over this and the whole abdomen should be placed a lik pud of dry cotton-wool, and several folded napkirs, whil broad st.t of,adhesive plaster should be passed nearly around the body, to su ' the abuomen in case of vomiting. Lastly a wide flannel bandage si o^ secui. he whole. The patient should now be placed in a comfo ab ' bed between blankets, and warmth for a time, even in hot wea he :Snt 1 /'' ;f ': '" '^^' ^^^^ ™^"^ '^ *^- ^i--^--''. ^^ patient left quietly alone with her nurse. THE AKTEK-TREATMENT. As this is a matter of the greatest importance, the o,>erator must 'z^rrTu ^"^"*^^" '' ^'^ '"^""^^^ ^et^u^o^z r : ZZ . : ""'''"'' '^' ''''''''''' °^ ^ ">«'^--J f-"^' to super- use the case in his temporary absence, and a con.petent nurse must 1 -..e.d hyp^l ^^ httle ce may be allowed, but no food or drink. If" the powers of If" seem to be flagging, a little brandy and iced water must bcgiven by he mouth or an enema of milk and brandy. The room must be kept irt; 1 i"r:_^,\^" r." '^^^'^^^' '^"* -" ventilated. This sn !.. ..,,ij_, ,^.,,.^ i,^. ^ .,,j,^ ^^^ ^^^ j^^^ gratG-the best of all venti- lators for a s,ck-room. or a gas jot can be kept burning in the fireplace The bladder must be emptied by a catheter every six or eight hou.s • the bowels should be kept constipated .even or eight days, it.t in J II' m§ [20] the intostl: s become distended with gas, they may be unloaded by a simple enema of warm water, as early as the fifth day. Should vomiting persist after the effects of the anfesthetic have passed away, neither food nor drink should be allowed by the mouth — absolutely nothing, excepting ice to suck, and perhaps a dessert-spoonful of lime-water and milk, in equal parts, at stated intervals. Life must be sustained by rectal alimentation.* Enemata of nutritive materials already prepared for assimilation, as beef-essence, beef-tea, muuon, oyster or chicken broth, or egg beaten in milk, may be administered every three or four hours, in quantities of about four ounces at a time. Brandy and medicines, when necessary, may be added to the injections. The nutritive material should be strained and warmed previous to being adminis*^ored, after which the anus must be supporteil for a time by firm pressure with a napkin. After three or four days, when all tendency to vomiting has ceased, or as soon as the stomach begins to crave food, small quantities of light nourishment may be tried. A spoonful of milk, beef tea, or oyster broth, may be given at frequent intervals, and if such nutriment agree with the stomach, other articles of similar diet and small portions of solid food can be permitted. If the patient appear to be doing well, as indicated hy the general symptoms — pulse, temperature, respiration, and freedom from pain — the wound need not be examired till the third or fourth day, when it should be cleansed and dressed with fresh materials. Should suppuration bo then commencing in any part of the wound, or around the pedicle, this must be carefully sponged twice or thrice a day, after which, the wound is each time dressed with lint soaked in carbolized oil. The upper part of the incision usually unites immediately by first intention, and the whole wound in four or five days ; but the sutures are not removed until the seventh or eighth, unless some of them become a source of irritation. When the clamp has been employed, it is left undisturbed until it becomes loose and ready to be removed without any traction ; the time varies with the thickness of the pedicle, but it usually falls off about the eighth or tenth day. After the sutures and clamp have been removed, the abdomen must be supported by adhesive plaster, pads of cotton wool and an abdominal bandage. Even when the patient leases for home, she should be enjoined to continue the support by an elastic Viandage, coi-sets, or some other abdominal supporter. * That life can be sustained, with nutritive injections, by the rectum, is proven in cases 1 and 5 of the Appendix. It is only within the past few years that the imnortanitn of thla moan, nf «n;. lttiiiin({ nutrition has been recognized by the profession. Of late, recourse is more frequently had to this method of nourishing the patier.t, not only in persistent vomiting after ovariotomy, but hIbo in the various diseases in which food cannot be swallowed nor diRested by the stomach • and recently cases have been reported in which life had been sustained, by this means during periods varying from three months, to three, and even Hve, years. The question remains to bo deter- mined : whether the nutritive material thus atinilnlstered Is digested or merely aV.sorbed . e unloaded by a anesthetic have by the mouth — I. dessert-spoonful vals. Life must tritive materials a, mutton, oyster ministered every ; a time. Brandy injections. The revious to being )r a time by firm n all tendency to 3 to crave food, spoonful of milk, ■vals, and if such limilar diet and I by the general •m from pain — th day, when it )uld suppuration md the pedicle, after which, the olized oil. The ' first intention, sutures ai-e not them become a loyed, it is left emoved without } i>edicle, but it e abdomen must id an abdominal she should be corsets, or some proven in cases 1 and of tbi? niORTis of sus- more frequently had ifter ovariotomy, but by the stomach ; and iieans. during periods remains to be dcter- ly absorbed . [21] SHOCK. Occasionally, however, ovariotomy cases do not get on so favorably as above indicated. It not unfrequently happens that the nervous pros- tration we are accustomed to speak of as exhaustion, shock, or collapse continues after the usual time expected from the effects of anesthesia and the operation. The patient does not rally, but gradually sinks, in spite of our best endeavora to revive her failing powers. With this depression of the vital forces most of us ai-e familiar, as occurring after capital operations, and railway and other severe accidents. In reference to this condition, Dr. Barnes makes the following original and pertinent obficrvations : •< A considerable proportion of all the deaths, I am convinced, occurs from W^tn haT? Z *^'\'tr '"^ ** ^l"<^«t'°° °f '-^di^dual power of endurance. flJT. ^ ? ''^'* *'"' P"^'"' '' '" ''"y P"^*''^"'^^ <^-««- Women recover LZ f Tr :r"'*r' '"'"'^'^ ^y ■*" "^^ complications considered the most formidable ; others sink after the easiest and simplest operations. Women comparatively robust succumb, whilst the apparently fragile recover. In Zy cases the unexpected result is not due, at least appreciably, to difference in skill. It can only be referred to innate power of resistance. This is an unknown quantity and ,s the chief cause of the uncertainty which surrounds the operation, ^o doubt the shock can be lessened by care and skill during the operation, and the patient can be to some extent supported through it." Vigilant supervision and good management by the operator, per- sonally, at this critical time, may succeed in reviving the sinking powers. Warmth, even ir. hot weather, must be kept constantly to the feet, legs, axillae, and cardiac region. When the stomach will retain stimulants, iced brandy or iced chamf)agne can be given by the mouth. But, when obstinate vomiting pei-sists, the stimulants must be adminis- tered per rectum ; and, if necessary, ammonia hypodermically. The patient must be kept quiet on her back, and free from pain by morphine subcutaneously, or laudanum added to the enemata. In other desperate cases, ^hen the patient does not sink from exhaustion, we scarcely expect she will survive the secondary dangera of hemorrhage, peritonitis and septicaemia. HEMORRHAGE. Should internal hemon-hage occur, indicated by progressive faint- ness, and a feeble, frequent pulse, the wound must be re-opened, the bleeding vessel secured, and the peritoneal cavity again cleansed. This 7^^ — 'r.-.c^..,. an«ci ,.aa.ing, uui lac conauiou is an extreme one, as the patient, if left alone, will bleed to death. The above procedure offers the only hoi^e of arresting the hemorrhage. During all this time the operator must be on the constant watch for untoward symptoms HAMILTDN POBLi is LiP^ [22] rKuno.NiTis. Thomas says : "The evils which are chiefiy to be feared as sequels of the operation are, v ithin the first twenty four hours, hemorrhage ; from second to fourth day, peritonitis ; from completion of operation to third or fourth day, nervous prostration ; and from fourth to fourteenth day, septica'mia, " Wells says : " After ovariotomy, the most frequent cause of death is peritonitis, or some form of fever or blood poisoning, so often associated with peritonitis." Barnes says : "A more serious form of peritonitis is one that seems analo- gous to the puerperal form. Here there is commonly septiciumia, or inflammation is propagated from the seat of the pedicle, in which some unhealthy action is going ""•*** SepticcX'mia may occur, although not commonly, without much peritonitis. The symptoms then are very similar to those of septicemic puerperal fever, and should be treated in a similar manner." FEVER. Very recently, Mr. J. Knowsloy Thornton, of London, read a pajwr before the Royal Medical and Chirurgical Society, asserting that there is a fever foll6wing ovariotomy. For many of his data he was indebted to Mr. Wells, whom he had assiated in the greater number of his last 300 operations. He believed there was a simple fever distinct from tJiat caused by peritonitis or septicemia, but liable to lead to serious lesions in important organs, if not checked ; attributed this form of fever chiefly to the sudden increase in the volume of blood, circulating in the body after the removal of the large circulating area contained in the tumor ; and indicated the various organs which might suffer, draw- ing special attention to the braifi as receiving a large blood-supply. Mr. Wells, who was present, coincided with Mr. Thornton, and stiid he had noticed that the chief cause of death after ovariotomy was not peritonitis as much as fever. This new theory, sustained by the authority of Mr. Wells, must, I presume, be accepted, and /etw— pywmic fever— added to the sequelse following ovariotomy. This condition, separately, or in conjunction with peritonitis, would certainly make the symptoms, as suggpsted by Barnes, analogous to those heretofore known as " puerperal fever." But this makes " confusion worse confounded," ;>,s the great discussion ot the Obstetrical Society of London, in 1875, decidod, if it decided anything, that there is no such disease as puerperal iavQv, per se. This opens a wide field for discussion, which we cannot here enter. Tlic practical question which concerns the ovariotomisr,, is ; Are the scjii'ilai fnUowin'r oyariotomy analogous to those following p.irturition— be they fever, peritonitis, pyiuniiii, septicanuia, or icoi'rha>uiia? We must, 1 fear, leave these 4uei>tious to be settled Ijy invcstigutors having the opportu- HAMILTON ?mu% DBMP^ .■ ] 1 <^4 \i I d as sequels of the go ; from second to lird or fourth day, ca'inia. " cause of death is ;en associated with that seems analo- ., or inliammation is Ithy action is going igh not commonly, similar to those of manner." London, icad a !y, asserting that hia clatti he was I'oater number of ph fever distinct to lead to serious ted this form of blood, circulating rea contained in jht suffer, draw- ge blood-supply, iton, and said he •iotomy was not 1". Wells, must, I I to the sequelae ' in conjunction as suggested by sral fever." But discussion ol the ecided anything, . This opens a . The practical LquelfiB following -be they fever, e must, 1 fear, ng the opportu- [23] nityof pursuing their inquiries on a large scale; and, in the meiintime - treat (he case under our c tre according to tlie light and knowledge in our possession. Since the symptoms of peritoniti.s, and the condition designated sep ica^nua are so graphically described in recent works, it is unnecessary to detail tliem in this paper. The operator must be constantly on the watch, and should, at any time, the temperature advance one or two degrees above the normal condition, while at the same time the pulse and respirations become more frequent, he must immediately take steps to control the circulation and lower the temperature. The wound, and drainage-tube, if employed, must be examined and carefully cleansed. A full dose of fluid opium mu.st be given at once, and repeated every three or four hours, or so often as neces.sary to keep the patient free from pain. In addition, I would give ten grains of quinine, in powder, mixed with two grains of aromatic powder, every two or three hours, by the mouth, if the stomach will retain it, and if not, then in enamata with the brandy which must be now increased, as well as other sustaining nourishment! Locally hot fomentations and turpentine stupes, or dry heat with soft flannels, are useful, and sometimes afford great comfort. The head should be somewhat elevated, and kept cool by means of the iced-water cap, or with bladders partially filled with pounded ice constantly applied to every part of it and the nuchal region. I have seen this treatment arrest a violent attack of puerperal peritonitis, and also a pretty high fever following ovariotomy.* Some reso;-t to blood-letting and the administration of aconite, and veratum viride, as a means of reducing the febrile temperature, but I must confess that I have no faith m such therapeutics ; indeed, in a case of an asthenic type, I believe they do positive harm by unduly depressing the vital forces. Dry cold applied to the head, however, by means of the ice-cap or the coiled tubing conveying iced water-as first practiced in Glasgow for injuries to the head, employed by Mr. Thornton to reduce the febrile temperature following ovariotomy, and approved by Mr. Wells— I doubt not-will prove useful for that object, as I have observed its beneficial efi-ects for injuries of the head in the Hamilton Hospital. Others have recouT-se to the use of the ice-collar to the neck, the ice-bag to the spine or the iced-bath for the same purpose, and with astonishing results. SEPTIC.KMIA. 'The existing peritoniti.s, if not speedily checked, especially if the inflammation has been set up by decompowtion and .septic absorption, will quickly develop or result in that more formidal>le condition-septicromia. * Vide Appoiulix. Ciiso III, jl j! [24] Not unfrequently the two are combined, or run concurrently, at least, it is impossible to define where the one ends and the other begins. Some assert that septiciemia may occur without any previous perceptible peri- tonitis. Usually, however, septicscmia is the result of peritonitis, which has been started by septic absorption. The symptoms by which it is ushered in are well portrayed in the quotation from Thomas's work con- cerning this condition, and the use of the drainage-tube. The topical treatment of the peritoneal cavity by means of antiseptic injections through the drainage-tube must be resorted to, and in case the tube has not been employed, the cavity must be boldly tapped, all turbid serum withdrawn, and then thoroughly cleansed by antiseptic injections through the canula. CONCLUSION. * In conclusion, permit me to say that ovariotomy is an onerous undertaking. The conscientious surgeon finds, from the moment he takes the case in hand, tha,t, in addition to the anxiety he must feel, it makes a demand upon his time, thought, nerve and skill, for which no merely financial remuneration can possibly recoup him. It is the conviction of the writer that no practitioner should undertake this formidable opera- tion, who has not had considerable experience as a surgeon, and who has not a penchant for such practice ; who cannot transfer his patients with contagious diseases to another, and surround himself with skillful and cool-headed assistants ; and who will not devote himself almost exclu- sively to the after treatment ; for, unquestionably, it is by strict attention to the preparation, and the totality of the little circumstances connected with the operation, as well as, and more particularly, the after-treatment, that success so much more frequently is now the result of the operation. m m jiiii ently, at least, it p begins. Some perceptible peri- )eritonitis, which 8 by which it is omas's work con- be. The topical iseptic injections !ase the tube has ill turbid serum ijections through J is an onerous moment he takes ist feel, it makes ?hich no merely ;he conviction of armidable opera- eon, and who has lis patients with rith skillful and !lf almost exclu- j strict attention tancea connected I after-treatment, of the operation. APPENDIX CONTAININO THE HISTORY OF SEVERAL TYPICAL CASES MET WITH IN PRACTICE. Case I.— OwnW disease, of four years' duration.— Ovariotomy ~ Sm '^*'-~^'''''^' *'''"'*^'^ ^y '''« Extra-peritoneal method.- M. H., Canadian, aged 23, single; a smart, active, dark-complox- loned, healthy-looking young woman ; but presents the appearance of a pregnant female at full terra. Has always enjoyed good health ; men- struates regularly, and her appetite and digestion are goo childhood, but never had any severe illness. Digestion had always been good until within three or four months, when she noticed that she felt full and uncomfortable after meals. This caused her to seek the advice of Dr. Corson, who discovered , that her abdomen was considerably enlarged, due to the presence of an ovarian tumor. For about a year she had been aware that she was gradually becoming stouter, and at Christmas (1876), her dressmaker remarked it, but this did not occasion any surprise, on the contrary, she congratulated herself, as she presumed she was " growing out " of her former delicate condition. Present State. — Of medium size, sandy complexion ; fairly well nourished. All the organs and functions of the body appear to be in a normal condition. Her friends i"emark that she does not look so well in the face as she did two or three months since. Vh'tioi/.rti .^o/ivto Tn fVio af-Qn/liTirif r»naiftrir» a\\a annaat^a \-nr\r mnnli like a woman seven months gone in pregnancy. The tumor is not very rotund and prominent ; it is rather flat, but entirely fills up the hypo- gastric, both inguinal, and the umbilical regions, extending three inches o[)ii. weio clayH. Tho n. During iib'loniinal t Haturattid ) Otli day), l)on oxanii- ient on her pulBc, tho During tlio turned on ;od, and on inging waa ) remainder rhe patient self feeling licle treated "Tied ami less of Dr. Her health any severe reo or four rtablo after ) discovered sence of an 3 gradually emarked it, ngratulated ler delicate fairly well r to be in a ook so well verv much is not very ) the hypo- /hree inches [29] above the navel. Undnr pressure, it resistH like a f.ill mic, but dorn not feel solid like a fibroid. Tho whole surface yields dull.H«H under IHircussion, and deep-seated fluctuation is obscurely elicited, with the exception of a largo {.ortion occupying tho right iliuc region, whore tho t.mior IS har.l ancf uneven. Sin.imon's sound passed 2^ inches int., tho uterus, in tho left lateral direction. The tumor is felt by the linger on the right side of the uterus. The measurements are as follows : ' (iirth at umbilicus 33 inches. *rom umbilicus to ens. cartila"e na «« " " pubes .■.■.■.■.*.■.■.■.■.■.■.■;;.■.■; 5I " " " right a, s. s. process 7] <« " left a. 8. 8. process Q « Taj,ped with a hypodermic syringe, tho cyst yields a thin straw, colored fluid, which is not spontaneously coagulable. Diagnosis : Ovarian tumor-multilocular, springing from tho richt ovary. " . Nov. 24.— Miss N. having been in tho city several days, getting accustomed to her lying-in room and other surroundings, the menses having ceased five days since, and being in all respects in a pretty good and hoiKjful condition, the operation was proceeded with. Tie patient having been chloroformed, and tho abdominal section, ive inches in length, made in the usual way, tlio tumor was readilv brought into view ; the patient having been turned on hor left side, the cyst was tapped with an ordinary trocar, and the contents being thin it was rapidly emptied of about twelve pints of thin straw-colored fluid llie tumor was then brought through the incision without further enlargement, and found to bo composed of an aggiegation of small cysts, somewhat resembling the honey-comb, filled with a similar fluid to that of the parent cyst. The weight of the tumor and contents was eight pounds. The pedicle was very short, and had to be enucleated according to Dr. Miner's process), several inches from the tumor, before suflicient length was obtained to permit of manipulation. The sound part was then ascertained to be too short for the application of a clamp, and recourse was had to "tying and dropping." A double silk ligature was passed by means of a large needle through a thin part near the centre of the pedicle, and each half first secured separately, and ben as an extra precaution one of the ligatures was tied tightly around tJie whole. The oozing enucleated portion waa then amputated by the actual canterv. The pedicle, contrary to the diagnosis-ba-sed upon tho fact that he uterus was in the left side of the pelvis, while tho lower part of the tumor was felt on the right side-was found to have sprung from the [30] f left ovary. Tins anomaly wuh accouutod for, when it waH fotiml that tho solid portion of the tamor had sent a projection downwardH into tho pelvis, whioli had crowded tho utoniH over to the left. Ah bonim con- tinued to accumulate in tho jMjlvic cavity, afXor it had l»een thoroughly sponged, drainage was provided for, by inserting a tube, hofoi closing tho wound. After this had been accomplished in the usual way, the patient was placed in a good comfortable bed, with warmth to tho feel. She (juickly rallied from tho cliloroform, and as she complained of some pain, 40 drops of laudanum with a little brand> and iced wattu- were administei-ed. Tho pulse waw now 72 and tho respiration 38. An hour Bubsecpiontly the pulse was 75, and in two hours 80. As she still com- plained of pain, 50 drops of laudanum were given in a littlo brandy and iced water. She is now thirsty, and is allowed ice to suck, but nothing to drink. At seven o'clock the same evening, reaction was found thoroughly established. Fulso 100 ; respiration 22 ; skin warm and moist ; feels " too warm," notwithstanding the hot bottles and some of the bed clothing had been removed ; vomited a small (quantity, once only, about 4 p.m. Took away, \)Qr catheter, about seven ounces uriuo. Said she felt some pain, and was given another dose of laudanum with brandy and water, iced. 11.30 r. M.— Has not vomited sinco 4 p. m. ; has slept a coujtlo of hours ; feels but very little pain. Pulse 9G ] respiration 20 ; tempera- ture 100^°. Took away six ounces of urine ; gave enema — beef essence 5ij., tr. opiL, 5s8., brandy 5ij. To have nothing excepting ice by tho mouth. 25th, 8 A. M. — Had a very good night ; vomited once this tnorning " u littlo greenish fluid ;" slept nearly all night, waked occasionally, and had a piece of ice ; pulse 82 ; respiration 18 ; temperature 99J°. Took away the urine, and repeated the enema. 1 P_ M. — Has been comfortable during tho forenoon ; vomited again about 8.30, but not since ; pulse 88 ; respiration 16 ; temperature lOOJ^ Took tho urine, and repeated the enema. As the drainage-tube was nearly full, it was emptied by sucking 5iij of reddish fluid out, with tho bulb of a syringe having a small flexible tube attached. The tube was then washed out by injecting a small quantity of warm water, slightly carbolized, and containing a few grains of table salt. This solution was immediately withdrawn by means of the syringe, and the process was repeated several times until the fluid returned clear. G i>, M. — Has not vomited since morning; aicpt about two hoai-ss ; pulse 96; respiration 16; temperature lOlJ" ; took away the urine; repeated the enema ; withdrew about 5iij reddish serum from the pelvic cavity, and washed it out as previously. U:3( ''omfortab "hot;" pi mine, and tuouth exc 2Gth, morning ; ha.s not voi .skin moist re[)eated tli the draina^ G I'. M skin is drj Kemovod t Ins., tinctui 8:30 i«. she awoke dry ; begs ( temi^eraturt opiate ; con MirNK p. m.; no p lOlf^ Too sulphate qui tho head, an 27th, 8 time, but wl ice was com gradually ah temperature vomit the m complains of see well. Pe which she re] is to be allow drainage-tube came away w little iced bra 1 P. M. - Passed her ui 17; temperat morning. E egg and milk [31] 11:30 P. u.~V ■ «'opt conHi.hirublo since soven o'clock; f.-eU comfortablo; Hkin .n.«t; no pain; no headache, but ntateH nho feel, hot; pulHo 104; .oHpimtion 17; t<,mi,emture 101". Took uwny tho ..nno and repc=«tocl tl.o onoma. Hho haH had tlum far nothing by the mouth excepting ice. 20th, 8 A. M.-Ha.i a conifortabh, sloop up to three o'clock this inornmg ; since that tin.o she has been restlosH with a deHiro to u.inate • ha.s not vomited since yentonlay morning, and the stomach feels settled ; Hkm nunst; pulse IOl'; tem,H,r«ture 100. Took away ^iij urine, and rciK^ated the enema. Brought away ^ii reddisJi scrum 'and washed out the drainage-tube. G p. M._Nurse states, patient has had a fever since 1 p. m. The skm 18 dry and hot; pulse 123; respiration 17; tera,H)rature lOlf. Komovod the urine, and gave per oncum : mutton broth, ^vj., bmndv 3.S., tincture opii. 5, ,, sulph.to of quinine grs. xv. Ice to t"he head. «:J0 V. M.-Has slept soundly, and i)erspired freely; as soon as Hhe awoke the perspiration ceased an.l the skin again became hot and Jry; begs constantly for ice when awake; pulse 113 ; respiration 17- temi^raturo lOr Repeated the l.st enema, .ith tho Exception f ,0 opiate ; continued ice to the head. MirNioHT.-Has rested well, and slept most of the time since 9 mn' "!,Pr '.'^^'^ "'"'«*' P"'«« 12G; respimtion 17; temperature .,lLf ^'".\""^«^ fi'^^« "^"tton broth-per enema; and by mouth, Sl^,^^ £:::: '-'^ ^- ^-^ --5iu.; continuL ice to h-n,« T^' \ ""■ f ~^^^' ^'^'^ "■ eood night, and slept the most of the time, but when she wakened occasionally, wanted the ice as usual The ice was continued to the head during the whole night. Tho fever gradually abated towards morning; ske is no. free from fever. The tempemture IS normal (98^). Pulse 100; respiration 17. 7)id n^I eew 11 p/T/r 'rH ''""«" '' the quinine, and inability to wUr ; , . 7 *° ^"'' '^ ^^"^^ ^^''^ -^«' -ith cream and sugar winch she r^hshed, and as the stomach now begins to crave for food, she 18 to be allowed some fluid nourishment by the mouth. Washed ou the chainage-tube with the syringe, but only two or three pieces of 1^2 ^Z:^^' ''^^-'^' '^^' '-^^^^'^ «-i"«of .ninineina 1 p. M.-_She appears much better, has neither fever nor p«in Pa«.cd nor uvaio without the aid of the catheter. Pulse 75; respiration ZZLu^o !"" opiate since yesterday evening. Has taken some egg and milk containing a little brandy. [32] 10 p. M.— Contiftiies to improve, she ia cool, moist, and perfectly free from fever. Pulse 85 ; respiration 14 ; temperature dl}°. 28th, 8. A. M.— Still improving, states she feels hungry. Tlie menses came on this morning. As flatus was becoming troublesome, the bowels was relieved by an enema of warm water. Daring the next few days the drainage-tube was frequently eniptiod and syringed out ; on one occasion half an ounce of offensive pus was brought away, and several times debris of broken down tissue. But from the above date she continued to improve, with the exception of the 7lli, 8th, and 9th days, when she did not feel so well, as considerable suppura- tion occured in the sheath of the right rectus muscle. This, however^ soon ceased, and her recovery was rapid. REMARKS.—The chief interest, in this case, centres in the fact that the operation was followed by a fever, unaccompanied by any inflammatory symptoms whatever; and that this fever was controlled and arrested by the prompt administration of quinine, in large doses, bringing the temperature down from r^^arly 102°, to below the normal (DTJ), within 24 hours. Tlie case also de? istrates the usefulness of the drainage-tube, through which the pelvis was cleansed from decomposing materials, and septic absorption probably averted. Case IV. — Multilocular Ovarian Tumor. — Extreme condition. — Tap- ping.— Rectal aliiiientation.— Peritonitis.— Ovariotomy.— Extensive adhesions. — Pedicle ligatured and secured with the wound. — Exliaustion. — Fatal Result. Mrs, McA, aged 42, married, the mother of six children, consulted me on March 10th, 1872, for an enlargement of her abdomen. Ten months previously she fii-st noticed "a swelling low down on the left side," which increased rapidly during the next three months, and this she concluded was due to pregancy. Her size then remained stationery for some time and she became doubtful as to the nature of her condition. During the winter months, however, the enlargement agaift gradually increased. V\Km examination, the abdomen presented the appearance of an eight months pregnancy. It was protuberant, irregularly uneven, and everywhere dull under pei;cussion. Fluctuation was very distinct at the upper and right side of the tumor, while the left side and lower portion were hard and unyielding. I informed the woman and her husband that I believed her enlarged condition was due to the presence of an ovarian tumor of a compound nature; ana propoauu :i uuiiaiututiun lui inc j- ti|-r^T!-j ^.m „,„„,!.„.» .,!..u. critical examination. This they considered, postponed, and declined ; and shortly afterwards placed the case under the treatment of a notorious itinerant charlatan, hailing from Buffalo. 1(1 perfectly 1° r> • igry. Tlie jlesome, the itly emptied vo pus was !. But from I of the Till, ble suppnra- is, however^ he fact that iflammatory rested by the temperature hours. The rough which absorption ition. — l^ap- . — Extensive 3 woimd. — in, consulted Ten months side," which lie concluded 3r some time Daring the oased. Upon ?ight months rywhere dull ler and right 3re liard and her enlarged a compound ilr 111 r» v.ctvp) leclinedj and f a notorious ■ [33] On Feb. 3rd, 1873, eleven months from the former time, I was agam requested to visit the patient. They then informed me tliat the cliarlatan had continued his treatment three months with positive assur- ances that he would cure her of the "dropsy," but finding she was losing flesh and strength she discontinued his treatment. In September, having contracted a cold, she became very poorly and took to the bed, where she had been confined all winter. While her health has been failing, tlic tumor has been increasing in size, so chat now it completely fills the abdominal cavity, pressing «p against the liver, stomach, .spleen and diaphragm so as to seriously obstruct the respiration. The girth of the abdomen at the umbilicus is 46| inches, and measurement from the ensiform cartilage to the pubes is 26 inches. She is now in an extreme condition; pulse feeble; respiration 42; face pallid; lower extremities very cedematous; and vomiting frequently. She begs me to do something quickly for her relief. "You may do anything," says she, " for I can't live. I explained to her that she was too weak to bear the operation of ovariotomy, and that, under the circumstances, the only procedure admis- sible wa« that of tapping. This she then urged me to do immediately. Iherefore, during the afternoon, assisted by Dr. Malloch, I performed that operation with acommon large sized trocar, in the median line midway between the umbilicus and symphysis pubis. The contents, which camo away very slowly, were of a dark color, and of the consistence of syrup. When thia cyst ceased to flow it was evident, from the enlargement and fluctuation still existing above the umbilicus, that one or more cysts remained to be emptied. Withdrawing the canula, a long curved trocar was directed, through the same orifice, obliquely upwards and pushed into another cyst, the contents of which proved to be thicker and more gelatinous than those of the former. These resembled soft soap in consistence and appearance. The contents of the cysts being so tenacious, notwithstandin-r the discharge was expedited by pressure with the hands on either side of the abdomen, two hours were occupied in emptying them. The matter thus discharged measured twenty-two quarts, or five and one-half gallons. 1 he operation of tapping was very exhausting in the patient's weakened condition, but nevertheless as the size of the tumor was diminished, she several times expressed herself as feeling much relieved, and the pale anxious/«cte« improved in color and appearance. The respiration decreased to 26 and the pulse to 90. The tumor was now reduced to about the size of, and felt very much like, the womb containinir „ 1ar.r« >.io..„t,a after child-birth; but owing to adhesions, as we presuined, it could not be pressed down into the pelvis. The vomiting which had l.een so distressing previous to the operation, persisted for the three subsequent days, notwithstanding the fact that we K [34] administered neither antesthetic nor medicines. During this time nothing but morsels of ice could be taken into the mouth, and for two weeks life was sustained by rectal alimentation. Enemata of beef-essence and other nutritive materials were administered in quantities of about two to four ounces at a time, every three or four houra. At the end of a fortnight her stomach began to bear a little milk and lime water, and by and by> two or three raw oysters sprinkled with lemon juice, and other light easily digested food. On the 25th of this month she had a sharp inflammatory attack, attended with acute pain in the right side, between the illium and the liver, which fortunately was alleviated in a few hours. From that time she slowly improved, and with the improvement came an increasing desire to have the tumor removed. At each occasional visit during the month of May, she urged me to make up my mind to perform ovariotomy. During this month she had been up and about the house, much impi-oved, but still weak and pale. The cysts had been gradually refilling, so that she now measured 40 and 20 inches respectively, instead of 46£ and 26 previous to the tapping. Keeping in mind the existence of strong adhesions and her unfavor- able condition, I explained to her, and her friends, the great danger, and uncertainty of the operation under the circumstances. To this she quietly remarked that they fully understood all this, and again calmly argued that she could not live but a short time if the tumor was not removed, and said she ardently wished that this should be attempted. Seeing that the hot weather was fast approaching, and it being more than probable that she would not survive the summer months in that condition, I determined to yield to the patient's solicitations .nd make the attempt to remove the tumor. Accordingly on June 3rd, 1873, ovariotomy was with difliculty accomplished. Chloroform having been administered, the abdominal walls being thin, the tumor was quickly exposed through an incision about six inches in length, which was afterwards lengthened to eight inches. On attempting to pass a couple of fingers between the tumor and abdominal parietes, firm adhesions were found in every direction. These, as far as they could be reached, were slowly separated with the fingers. The patient was then turned upon her left side and the tumor tapped with a large trocar and canula, improvised for the occasion ; but as the contents were thick and came away very slowly, a free incision was made into the cyst with a bistotiry, when the thick gelatinous matter escaped rapidly. The tumor* was then slowly withdrawn through the incision, when two broad bands were brought into view. One of these was tlie pedicle *Tho tumor, when laid open after removal, was seen to cunsiit of one larKe cavity sur- rounded ty an a););reicatlun of small cysts in its walls, and bt^re evidence of broken down cysts in its interior. ime nothing weeks life 36 and other two to four a fortnight by and by» ■ light eiisily iflammatory e illiura and From that n increasing t during the ovariotomy, h improved, ling, so that 46f and 26 ler unfavor- danger, and ) she quietly Imly argued ot removed, being more [iths in that s .nd make li difficulty >minal walls >n about six nches. On 1 abdominal se, as far as gers. The pped with a ;he contents ade into the )ed rapidly. I, when two the pedicle nrxe ctvity 8ur- II down oysU tn [35] reaching from the right ovary to the superior part of the tumor, while the other—a very broad band— proved to be the bladder adherent by its posterior surface and elongated upwards. Considerable difficulty was experienced in separating the adhesions between the bladder and the tumor. A piece of whip cord was tied around the pedicle and the tumor excised ; a loop of the whip-cord served as a convenient handle with which the iiedicle was held by an assistant until it was properly secured. Oozing of bloody serum continued from the ruptured adhesions, and it was some time before the abdominal walls could be closed. The pedicle was securely ligatured with whip-cord, at a suitable length from its root, and transfixed in the lower part of the wound by a large needle passing through the centre below the ligature. The abdominal cavity having been very carefully sponged, the wound was closed with silver wire sutures and dressed in the usual way. The patient was then placed in a comfortable bed, and an anodyne administered per rectum. She rested very well that night .; remained very quiet ; did not vomit ; complained of nothing, and received small pieces of ice when they were put into her mouth. The next day it was apparent that she was not rallying from the effects of the operation, and notwithstanding the efforts made to revive her sinking powers, she gradually failed until she quietly and easily passed away about nine o'clock in the evening. Thus ended what seemed a hopeless undertaking ; but cases appar- ently equally hopeless had recovered, and as my patient urgently requested that the attempt should be made, I was unwilling she should bo left to her fatal disease without an effort being made for her rescue. Case Y .—Multilocular Ovarian Tumor.— Peritonitis.—Obstruction of the Bowels.-^ Ovariotomy.— Adhesions to Ommtum.— Clamp. ~ Drainage.— Septicaemia . — Recovery. Mrs. W., widow, aged 40, sterile, came from Ohio, and was admitted to the Hamilton City Hospital under my care June 10th, 1876. States that she has never been a strong person ; has had a cough several years ; catamenia have been regular ; never has been pregnant ; four yeara ago had an attack of pneumonia, which lasted ten weeks ; last summer had typhoid fever and was ill five weeks. Her husband died in February last, and immediately after his death she Avas taken with nausea and vomiting, which continued about two months, at the same time she noticed that her abdomen was enlarging rapidly and she did not know but that she might be pregnant. Present State.— Hhe is of medium size ; sallow complexion ; ema- ciated ; feet and ancles (Edematous ; abdomen considerably enlarged and presents the appearance of a seven months' pregnancy. Skin cool J [36] tongue coated brown ; constipated ; pulse 106 ; tempoi-aturo 99° ; respi- rations 25 to 28, irregular. Physical Signs. — The abdomen is rotund, a decided protubemnco existing anteriorly, and very little flattening out by sagging of fluid to the flanks. Under palpation the tumor resists like a full sac. The fluctuation elicited is of a deep-seated character, and can be made out over the whole tumor, with the exception ot a space of about four inches in diameter, situated midway between the umbilicus and right anterior superior spinous process of the illicum ; this region yields the sensation of hardness under percussion, and in it she has suffered severe pain for three or four weeks. By vaginal and rectal touch the lower margin of tlie tumor can be felt and obscure fluctuation elicited. The uterus lies high up behind the tumor, and measures the normal two and a half inches'. Simon's recommendation of examining the tumor posterioily by means of the hand in the rectum was not enforced. The measurements were as follows : Circumference of abdomen at umbilicus 32i inches. From ensiform cartilage to pubes 15" » II umbilicus to pubes 71 „ II It ens. cartilage 7i n M H r, a, B, s, process , . 7i n II 11 1. a. s, s. process 7| u The tumor was tapped with the hypodermic syringe, and about half a drachm of thick, syrupy, straw-colored fluid withdrawn. This was not spontansously coagulable. It was subsequently examined by the microscope, but the presence of the disputed cell was not discovered. Diagnosis : Ovarian tumor, which is probably polycystic. On the afternoon of the 13th she was suddenly attacked with a sharp lancinating pain in the solid portion of the tumor to the right of the umbilicus, which rapidly extended over the whole abdominal region, accompanied with vomiting, fevor, and frequent pulse. In the course of two hours the pulse ran up to 140, became small and thready, and the vomiting very frequent. The bowels had been constipated since her admission to the Hospital. Ordered hot turpentine stupes to the abdo- men, and I gr. morph, sulph. hypodermically every three hours, if neces- sary ; also a little brandy and iced water. June 13th. — The medicines and hot fomentations gave great relief and after getting the second hypodermic injection she passed a compara- iivoly comfortable night, but vomited aevemi times through the course of the night and this morning. The pulse is now 140, but softer and fuller. Tongue brown, furred. Bears slight pressure over the abdomen without complaining. Bowels not moved. y ; rospi- ituberanco >f fluid to sac. The made out bur inches t anterior sensation pain for margin of iterus lies nd a half Kjsterioily ichos. M II It II II md about 'n. This mined by iscovered. >d with a le right of al region, course of , and the since her the abdo- 1, if neces- eat relief compara- iie course lofter and abdomen [37] EvENiNo.-Condition imj.roving. P«]ao 140. Tongue moist, and not so thickly furred. Does not complain of pressure over the abdomen except in tne right hypochondrium. Ordered a turpentine enema, and the hypodermic injection of morphia to be repeated if necessary. Continue the iced brandy. 16th.-Improving. Had a good night after the morphia, but the bowels were not moved by the enema. Pulse 130, softer and fuller Skin moist and cool. Considerable tenderness in the right hypochondrium and has paroxysms of paiii three or four times a day. Ordered beef tea' milk and brandy, and the hypodermic injection to be administered when necessary to relieve pain. 1 7th.— Continues much the same. No movement of the bowels R^t disturbed by attacks of pain on the right side of the tumor; has' had the morphine three or four times in 24 hours. The menses appeared during the night — scanty. 20th._Rather more comfortable. The stomach bears nourishment a little better; the bowels remain obstinately constipated. The cedema of the feet and legs has subsided. Pulse 120; temperature 98°; respiration 22. 22nd.-At a consultation of the Hospital staff, the critical condition of the patient, the existing peritonitis, the probability of disorganizing changes taking place within the tumor, and the sure and certain end i-apidly approaching having been recognized, and a free interchange of opinion expressed, ovariotomy was decided upon. The operation was commenced at noon, in the presence of the faculty and a number of pmctitioners and medical students. Dr. Mullin administered the chlo- roform m his usual careful and attentive manner, and Dr. Malloch kinc^'y acted as chief assistant. The abdominal section was made five inches in length, but this was afterwards increased to seven inches On opening the peritoneum some ascitic fluid flowed away, and through this u r^u .^ 1'*"''^°^ *""^°' ^^ recognized. As no adhesions could be felt with the fingers the patient was now turned on her left side the presenting cyst seized at the upper end of the incision by a pair of strong, long-toothed forceps and steadied while being tapped with a large trocar; but through the canula of this instrument the jelly-like contents, assisted by pressure with the hands, came away so slowly that considerable time was occupied in evacuating the cyst. After the parent cyst was thus lessened, similar smaller ones came into view, and were one after another laid onen freelv with <. K,-»*«„.„ „^j „..:.,_, The contente of each of the smaller cysts was found to differ from the other, both in color and consistence. Though about one^Mrd of the tumor proved to be solid it was thus sufliciently reduced in size to permit ite being extracted threugh the [38] enlarged incision, by traction with the forceps, assisted by the hands of the operator. Now it was seen that the omentum was closely adherent in several places to the superio-posterior part of the tumor. Consider- able difficulty was experienced in separating these adhesions, which, on being accomplished, bled freely. The omentum was then turned up and carefully laid upon a soft napkin placed across the abdomen, and the bleeding points were secured by the use of a number of small silk ligatures. The ligatures were all cut short and the omentum was imme- diately returned to the peritoneal cavity. While Dr. Malloch was thus arresting the hemorrhage of the omentum, the operator was engaged in securing the pedicle. This was found attached to the right side, and being of moderate length it was first tied with whip-cord, near the tumor, and the latter cut away and removed. A loop was then made with the cord, aflfording a convenient handle with which to manipulate the stump. This was treated by the extra-peritoneal method — fixed external to the wound by means of a Spencer Wells's clamp. Portions of the intestine appeared inflamed and deeply congested. After the peritoneal cavity had been thoroughly sponged, it was found that some oozing of bloody serum continued, and as a number of ligatures had been left upon the omentum it was deemed advisable to provide for drainage, therefore, a large glass drainage-tube was inserted, above the pedicle, reaching down into Douglas's space. The abdominal wound was then closed and dressed in the usual manner, and the patient was placed in a clean, warmed, comfortable bed, with warm applications to her feet. She slept two hours from the efiect of the anaesthetic, waking two or three times, when she was given a little iced water. The following notes are abbreviated from the Hosjntal record : 4 p. M. — Complaining of some pain; morph. sulph. gi*. J was administered hypodermic ally, 4:30 p. M. — After taking a small quantity of beef-essence she almost immediately vomited — the first since the operation. 9 p. M. — Pulse 140; temperature lOOj" ; respiration 12 ; about five ounces urine taken away by the catheter. Wishing some drink, she was allowed a little brandy and water, directly after which she vomited nearly a pint of greenish-tinged fluid. Dr. Rosebrugh ordered small pieces of ice at frequent intervals instead of drink, and to have very little fluid during the tight; urine to be taken by the catheter every eight hours ; morphia hypodermically occasionally, to keep the patient at rest and free from pain. 23rd, 8 A. M. — Had a pretty comfortable night. A hypodermic injection was administered at 10 p. m. and another at 6 a. m. Consid- erable reddish serum has escaped around the drainage-tube and pedicle, saturating everything about the patient. 98f. ' rsiiSfeaiiiia*! he hands of ly adherent Consider- ), which, on :ned up and en, and the small silk I was inimc- ch was thus engaged in it side, and r the tumor, de with the the stump, jmal to the lie intestine >neal cavity g of bloody ift upon the therefore, a ching down and dressed m, warmed, B slept two hree times, •ecord : gi-. I was : she almost ; about five drink, she the vomited lered small 1 have very heter every the patient hypodermic 1. Consid' nd pedicle, [39] No°o']!i'!'!*? ..'. "^"'^° ^^^ ' temperature lOQi". Evening loc " ^^i- ^4th. Moning jj, „ 100 Evening...... ]\l " ^Sf- 9p.m_.... ?2 „ ioo|°. Ti.^ „„,. , '**,' " ^*" " not recorded. llie patient appeared to be doing so well during the forenoon that no particular restrictions as to fluid were mentioned to the at3' ants, but on visiting the Hospital at 9 o'clock in the evening we fid warm, and too much iced water, milk, etc., had been allowed, and she ha^ had frequent attacks of vomiting during the afternoon and evening Ihe pulse had increased in frequency from 112 to 140. Gave peremptorv lit: of ilt fT 'r ^°''^"^ ''''^' ''' -'^'^^ excepTng TS ineces of ice to suck, and occasionally a dessert spoonful of lime water and milk, in equal parts, iced-nothing else. a ,f W ^ \ ''r^^''^ '^ P''"^ ^""'^ '^'S^*' "^^'^^"g'^ «^« remained in of i.VniIh7 P r?//? "^ did not vomit after the restrictions of i^t night. Pulse 124; temperature 99r. Ordered the restrictions to be continued. When thirsty may suck ice, but to have no wateT Nutri ive enemata, consisting of beef-essence to be administered every three hours This was continued five or six days until nourishmen w2 craved and digested by the stomach. Noon -Pulse 126 .'r"''"*^^ 992° Vv^r,ir,r, -D I lo/, , -^'"""u. -ruise iJb ; temperature JS*o . Jiivenmg.— Pulse 126 ; temperature 100^°. 26th.-Improving. Has not vomited since' being confined to the hme water and milk. The beef-essence per .ctum is'retained comfo^ The catheter has been used every eight hours; and the morphia hypodermically has had to be repeated three or four «mes a day 7uJ e 120; temperature 992°. Evening. -No change to thf bulb" f "'" ' '' ' ^-P«-t"re lOr. A small flexible tube attached to the bulb of a syringe, was inserted into the drainage-tube, and about Ijalf an ounce of fluid withdiuwn, after which, by means of tiis syrt" he pelvic cavity was washed out with a solution of warm water, contJn xng two drachms of common salt and a few drops of carl die acid to the 98- '■ T^ K r '^" '"' P"''' ^'" *° ^^^' ^"'^ '^' tempemture to for' ihZ I ^'T^X" """"""^ '"^^''^ ''"^ afternoon-the first motion for hree weeks. At her urgent request the patient was allowed half a small cup of t.a, which she relished very greatly, and it agreed with her 28th.— Pulse 120; temperature 98^°. 29th.— „ 104 „ 990 30th.— M li2 „ 990, [40] On the 20 th the bowels wore moved three times ; on this day several stitches were removed, also the clamp, which had become loose. The pelvic cavity was daily washed out, a little serum and broken down tissue coming away. The stomach digesting the nourishment very well, a more liberal allowance of food was permitted. July Ist. — Pulse 124; temperature 100^°. The patient is not looking 80 well — has a sunken appearance. About half an ounce of very offensive pus was found in the drainage-tube, also some pus about the tube in the wound; withdrew the pus, cleansed the wound, and washed out the pelvic cavity, after which the patient appeared much l)etter, July 2nd.— Pulse 102 ; temperature 99f . July 4th.— II 100 .1 99''. The drainage-tube having been forced nearly out of the wound, was removed. The remaining stitches were also removed. The aid of the catheter from this date was discontinued. Bowels moved by the aid of an enema of warm water. From this date she gradually and continuously improved, yo that by the 16th she began to leave the bed for a short time, and on tlia 30 th left the Hospital. The measurements taken a few days previously, were as follows ; Circumference at umbilicus 23 inches. Umbilicus to ensiform cartilage 6 n II II pubes 5J II II II r. a. s. s. process 4| n II II 1. a. s. s. process 5 n For some days she had been wearing well-fitting abdominal corsets, with cotton padding underneath, for the purpose of affording support, and preventing hernia through the recently healed cicatrix. She remained in the city a few weeks before leaving for home. During this short time she improved rapidly, and subsequently wrote that she was gradually getting stronger and stronger and fleshing up again. Reuabks. — The special points of interest in this case were — the low condition of the patient and the desperate nature of the case, owing to the existing peritonitis; the probability of disorganizing changes taking place in the tumor ; the obstinate obstruction of the bowels, due to pressure and inflammation ; the extensive adhesions met with during the operation ; the difficulty in arresting the hemorrhage ; the number of ligatures left in the peritoneal cavity, and the provision made for drainage. In the after-treatment, the exhausted condition resulting from frequent vomiting; the fortunate result of restricting the fluid taken by the mouth ; sustaining niitrition by rectal alimentation ; and the beneficial effect of establishing drainage, in first permitting the escape oi a large quantity of serum, subsequently affording an outlet for the [41] offensive pus ; and lastly, providing a channel througli which the pelvic ivity could bo washed with disinfectants, on the advent n/ the symptoms -f septicaemia. Above all, the pleasing knowledge that the woman is now m excellent health-her disease radically cured-and that she bids lair to enjoy many yean ,.. health and happiness. I have given the history of this unusually interesting case in pretty full detail, hoping that by thus showing under what truly desperate circumstances valuable lives may be rescued from a premature death the benefits the operation has already conferred may be yet further extended by encouraging other surgeons to give the poor sufferer the only hope remaining of escaping the inevitable result, should the tumor be left to finish its deadly work. In c'osing the appendix for the present, I cannot with too much emphasis reiterate my conviction that not a little of the success which has rewarded the efforts of the opemtor, must be attributed to the careful attention given to the minutest particulars, which could even remotely effect the result. In this connection, I desire to return my warmest thanks to my medical friends, who so ably assisted me in bringing this and other difficult operations to a successful termination. That operator is indeed fortunate, who can surround himself on such occasions with good anatomists, skillful surgeons, and learned physicians, with cool heads, alert minds, and ready bands, anticipating every want of the operator, and prompt to meet any emergency. Such medical gentlemen, I am proud to acknowledge, have always kindly and cheerfully rendered me their valuable assistance.